2. CASE 1
A 50 YEAR-OLD MAN,INTUBATED AFTER HE PRESENTED IN
STATUS EPILEPTICUS.
POST-INTUBATION CXR SHOWN.
FINDINGS IN CXR ??
3. WHAT ABNORMAL FINDINGS CAN YOU SEE ON
HIS CXR?
Tip of the ET tube being less than 2cm from the
carina
Important abnormality is an injury affecting the
right glenohumeral joint and proximal humerus.
4. MANAGEMENT ??
This man’s dislocation was reduced while he was
intubated and sedated
Subsequent operative repair.
8. WHAT IS THE COMPLICATION?
The chest drain is in the left ventricle.
9. MANAGEMENT…???
Identified by the presence of pulsatile bright red
blood coming from the drain.
Clamping the drain !
Not taking the drain out.
Cardiac surgery to remove the drain and repair
the heart.
Appropriate reporting and follow-up.
11. 56 YEAR OLD WOMAN WITH SEVERE PNEUMONIA IN THE
ICU.
HER LEG HAS SUDDENLY TURNED BLUE:
12. WHAT IS THE DIAGNOSIS?
Phlegmasia Cerulea Dolens
(Painful blue edema)
Manifestations of venous thrombosis .
Result from acute massive venous thrombosis and
obstruction of the venous drainage of an extremity.
15. 18-YEAR OLD MALE IS BROUGHT BY EMS FOLLOWING A
GENERALISED SEIZURE AT HOME. ON ARRIVAL HE IS
COMATOSE WITH A GCS OF 3 AND POOR RESPIRATORY EFFORT.
PUPILS ARE SYMMETRICALLY DILATED. BLOOD SUGAR IS
NORMAL. BP IS 70/40. HIS ECG IS SHOWN BELOW:
16. DESCRIBE THE ECG FINDINGS…???
Regular broad complex tachycardia
Rate 130 bpm
Right axis deviation
Very broad QRS complexes (160ms)
Terminal R wave in aVR > 3mm;
RBBB
Markedly prolonged QTc 590 ms
Non-specific T wave abnormalities with T-wave
inversions in V1-2 & lead III
17. WHAT IS THE LIKELY DIAGNOSIS…???
TCA Poisoning.
The degree of QRS broadening on the ECG is
correlated with adverse events:
QRS > 100 ms is predictive of seizures
QRS > 160 ms is predictive of ventricular arrhythmias
18. MANAGEMENT…???
IV, O2 and Monitor.
IV sodium bicarbonate 100 mEq (1-2 mEq / kg); repeat every few
minutes until BP improves and QRS complexes begin to narrow.
Intubate.
Hyperventilate to maintain a pH of 7.50 – 7.55.
Activated charcoal.
Crystalloid bolus (10-20 mL/kg).
Consider vasopressors
If arrhythmias occur, the first step is to give more sodium
bicarbonate.
Lidocaine (1.5mg/kg) IV is a second line agent once pH is > 7.5.
Treat further seizures with IV benzodiazepines.
20. 65-YEAR M,90 MINS OF CENTRAL CHEST PRESSURE AWOKE HIM
FROM SLEEP. HE THINKS HE HAS ‘INDIGESTION’. NON-RADIATING,
WITH MILD SOB, NO NAUSEA, VOMITING OR DIAPHORESIS. EX-
SMOKER .THERE IS NO PREVIOUS MEDICAL HISTORY. PULSE= 54
BPM, BP-127/86 AND O2 SAT 98% ON RA. PAIN IMPROVED SLIGHTLY
WITH SL NITRATES, ALTHOUGH HE STILL HAS SOME ONGOING
CHEST DISCOMFORT.
21. DESCRIBE THE ECG…???
Sinus rhythm at 54 bpm
Normal axis
Normal intervals
Borderline left atrial enlargement with a bifid P
wave in lead II
Normal ST segments and T waves, except for
some non-specific T-wave flattening in aVL
22. INVERTED U WAVES IN THE LATERAL LEADS I, V5
AND V6 (AND POSSIBLY ALSO IN LEADS II AND III)
23. SIGNIFICANCE OF THESE ECG
FINDINGS…???
Very specific sign of myocardial ischaemia
Earliest marker of unstable angina and evolving
MI
May be observed during attacks of Prinzmetal
angina
Left ventricular dysfunction
With this patient’s history, the U wave
inversion would be strongly suggestive of
an acute coronary syndrome (unstable angina
or NSTEMI).
24. HOW WOULD YOU MANAGE THIS
PATIENT…???
Manage as an ACS
Serial ECGs and troponins.
No indications for thrombolysis or emergent PCI
Admitted - Angiography
26. A 76 YEAR-OLD MAN PRESENTS WITH SPREADING
VIOLACEOUS RASH OVER MOST OF HIS BODY. HE
NOTICED IT ON HIS FEET WHEN HE WOKE UP. HIS
OBSERVATIONS ARE UNREMARKABLE.
NO FEVER, AND THE RASH IS SLIGHTLY ITCHY.
THE DAY PREVIOUSLY HE HAD RECEIVED CHEMO
FOR DUKE’S B STAGE BOWEL CANCER. NOT
TAKING ANY OTHER MEDICATION. HE HAS HAD A
DRY COUGH WHICH HE HAS NOT TOLD HIS
ONCOLOGIST ABOUT.
28. WHAT IS THIS SKIN MANIFESTATION..???
Palpable purpura
29. WHAT UNDERLYING PATHOLOGICAL PROCESS
DOES THIS IMPLY…???
leukocytoclastic vasculitis —
histopathologic term used to denote small-vessel
vasculitis.
30. WHAT IS THE MOST IMPORTANT CAUSE
TO EXCLUDE AND/OR TREAT IN THE
EMERGENCY SETTING..???
Sepsis — especially meningococcemia
32. 71 YEAR-OLD MAN TRIPPED AT HOME AND BUMPED HIS
FOREHEAD ON THE WALL. NO LOC. SUSTAINED A MINOR
BRUISE ON HIS FOREHEAD .HIS ONLY COMPLAINT IS
MARKEDLY BLURRED VISION IN HIS RT EYE..HAD
PREVIOUS CATARACT SURGERY ON BOTH EYES.
33. WHAT IS THE DIAGNOSIS…???
Anterior dislocation of an intraocular lens
34. MANAGEMENT OF THIS CONDITION…???
Immediate ophthalmology consultation
Rx options vary from observation to surgical
removal and replacement.
36. 21 YEAR-OLD F, PRESENTS WITH ACUTE ONSET ABDOMINAL
PAIN AND VOMITING FOUR YEARS AFTER A MAJOR MOTOR
VEHICLE ACCIDENT.
A CHEST X-RAY IS PERFORMED:
37. WHAT IS THE LIKELY DIAGNOSIS…???
Traumatic rupture of the diaphragm with strangulation of
viscera in the chest.
Ambroise Paré, in 1579, described the first case of
diaphragmatic rupture diagnosed at autopsy.
38. CHEST X-RAY FINDINGS INCLUDE:
Presence of bowel or stomach gas in the chest
NG tube that passes through or finishes in the
chest
Irregularity of the diaphragma
An elevated hemidiaphragm
Mediastinal shift without pulmonary or
intrapleural cause
44. A 27 YEAR OLD M, WITH HEAD AND EXTENSIVE FACIAL
TRAUMA IS ADMITTED TO THE ICU AFTER A
NEUROSURGICAL INTERVENTION FOR AN ACUTE
SUBDURAL HAEMORRHAGE.THERE HAS BEEN DIFFICULTY
WITH OXYGENATION IN THE OR.
CXR 1 was performed at the time of admission to ICU
45. CXR 2 WAS PERFORMED AFTER A THERAPEUTIC
INTERVENTION.
46. DESCRIBE CHEST X-RAY 1…
ETT in appropriate position
Orogastric tube in an appropriate position.
Right upper lobe collapse.
Left lung is significantly hyperinflated due to the
provision of a large amount of PEEP.
47. WHAT IS THE DIAGNOSIS…???
Right upper lobe collapse
history provided likely to be due to a blood clot in the
right upper lobe bronchus.
52. CASE 12
5 year-old male with developmental delay presents with
non-bloody and non-bilious vomiting over 10 days;
bowel movements are normal. Four weeks ago he was
placed in a hip-spica cast following a motor vehicle
crash.
54. DIAGNOSIS…???
CAST syndrome
Also known as Superior Mesenteric Artery Syndrome
Caused by extrinsic compression of the SMA with
ensuing partial gastric outlet obstruction
Commonly seen in the second decade of life when there
is increased spinal flexibility and truncal casting
increases lumbar lordosis.
55. TREATMENT …???
IV replacement therapy
NG tube to decompress the stomach and
duodenum and
Replacement of the cast.
58. MANAGEMENT…???
Non-displaced fractures:
RICE therapy, gutter splint, and Ortho follow-up.
Displaced, rotated, or angulated fractures (>40 degrees):
Closed reduction may be attempted
Surgical fixation usually required.
59. CASE 14
WHAT MIGHT THIS FINDING BE A
CONSEQUENCE OF…???
Elevated methaemoglobin levels
Intra-abdominal haemorrhage
Congenital melanocyte proliferation
Immunosuppression with concurrent
human herpes virus 8 infection
62. 26 YEAR-OLD MAN PRESENTED TO THE ED WITH
CHEST PAIN. TRIPPED ON SOME STEPS AND THE
RIGHT-SIDE OF HIS CHEST COLLIDED WITH THE
HANDRAIL.
63. WHAT ARE THE CHEST RADIOGRAPH
FINDINGS…???
There is a right-sided aortic arch.
The trachea is deviated to the left rather than
the right.
There is no evidence of traumatic injury or situs
inversus.
About 1 in 100,000 people have a right-sided
aorta.
Right-sided aortic arch can simply be mirror
image of a normal left-sided arch.
