Vogel, J. et al. Is long-axis view superior to short-axis view in ultrasound-guided central venous catheterization? Crit Care Med 2015 Apr;43(4):832-9.

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40 year-old male sustains a blunt force injury the left side of his lead. What's the diagnosis and what structure was injured?

Epidural Hematoma with mid-line shift from middle meningeal artery injury; see image below for comparison of subdural and epidural

Epidural hematoma

• Blood accumulates between dura and calvarium secondary to trauma; concurrent skull fractures are common
• Middle menial artery is usually involved in the temporal region; other arteries may be involved depending on which area of the skull receives the impact
• Up to one-third of cases present with the "classic" lucid interval from injury and loss of consciousness to a decline in mental status. Diagnosis should be suspected, however, based on mechanism
• Treatment is surgical evacuation, however aggressive medical management of increased intracranial pressure should not be delayed:
  • Head of bed elevated and keep neck mid-line
  • Anti-emetics and analgesics
  • Osmotic agents such as mannitol or hypertonic saline
  • Avoid hypoxia, hypotension, and hyperthermia

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• Aggressive fluid and vasopressor support
• Early intubation and airway protection should be considered in severe cases; minimize BVM given the risk of gastric distention.
• NG tube decompressing of the stomach will help the ventilation/oxygenation process.
• ECMO may be considered if conventional therapy has failed and any one of the following criteria is met:

1. Inability to maintain pre-ductal PaO2 saturations >85 percent or post-ductal PaO2 >30 mmHg
2. Peak inspiratory pressure >28 cm H2O or mean airway pressure >15 cm H2O
3. Hypotension that is resistant to fluid and inotropic support
4. Inadequate oxygen delivery with persistent metabolic acidosis

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Acalculous cholecystitis

Acalculous Cholecystitis

• Acalculous cholecystitis is due to gallbladder (GB) wall ischemia and GB stasis (i.e., from reduced GB contraction secondary to reduced PO intake).
• The result is gallbladder "sludge" (A), thickened GB walls (B), and pericholecystic fluid (C).
• Risk factors for acalculous cholecystitis include
  • critical illness (especially sepsis)
  • acute cholecystitis
  • chronic immobility
  • total parenteral nutrition
  • diabetes and immunosuppression
• Treatment includes antibiotics covering enteric / biliary pathogens and cholecystectomy (if a surgical candidate) or percutaneous cholecystostomy if unsuitable for the OR.
• Complications include perforation, GB gangrene, and extra-biliary abscess.

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Severe hypokinesis with anterioseptal wall motion abnormality.

• A: Anteroseptal wall (perfused by left anterior descending)
• B: Inferolateral wall (perfused by left circulmflex artery and variable contributions from posterior descending artery)
• Click on the links to read more about cardiac wall segments and their coronary distribution
  • Parasternal view and Apical four chamber view

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Tricks to distinguish the RV from LV in apical four-chamber view

• The right ventricle (RV) is normally smaller in size (2/3 the size) as compared to the left ventricle (LV).
• When scanning critically ill patients you may encounter patients with right ventricles that are dilated secondary to acute or chronic illness. This enlargement may make the RV appear similar to a typical LV on an apical four-chamber view.
• If you are new to ultrasound or just get confused by the probe marker, screen orientation, or just unsure, there are some tricks that you can use to quickly identify the LV and the RV on the apical four-chamber view.
  • The tricuspid valve is more "apically" displaced when compared to the mitral valve
  • The RV is heavily trabeculated as compared to the LV
  • The RV has the moderator band, while the LV lacks such a structure
  • The LV has the "fifth" chamber (i.e., the left ventricular outflow tract); you can identify this by tilting the probe slightly anteriorly after finding the apical four-chamber view.

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Proximal fibula fracture; have a high-clinical suspicion for a Maisonneuve fracture and consider CT scan of the ankle

Maisonneuve fracture

• Fracture of proximal third of the fibula with associated injury of the tibiofibular syndesmosis and interosseous membrane; there is typically an associated fracture of the medial malleolus or ruptured deltoid ligament.
• This patient had a normal ankle X-ray, but the proximal fibular fracture and the persistent ankle pain lead to an ankle CT scan demonstrating a non-displaced fracture at the medial aspect of the posterior malleolus, extending into the tibiotalar joint (see below). 
• The take home point is to always look for an associated ankle injury when a proximal fibular fracture is discovered and Xray above and below the fracture. If Xrays are negative but there is still high clinical suspicion consider advanced imaging such as CT scan.

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• This is an ultrasound of the kidney demonstrating moderate to severe hydronephrosis seondary to an obstructing renal stone (not shown)
• The areas that are anechoic (or black) are the blocked ureter, renal pelvis, and calyces

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Ludwig's angina

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http://www.nejm.org/doi/pdf/10.1056/NEJMoa1500896

Phlegmasia cerulea dolens; there was extensive clot found in the left external iliac, common femoral, superficial femoral, and popliteal veins.

• Phlegmasia alba dolens (literally: swollen, white, and painful) is a thrombosis of the major deep veins of the lower extremity. No collateral veins are involved so venous drainage of the leg is reduced but not completely compromised.
• Phlegmasia cerulea dolens (literally: swollen, blue, and painful) thrombosis of major deep veins with extension to collateral veins. The result is venous congestions, edema, and can progress to gangrene when arterial flow is compromised.
• Anticoagulation with heparin is recommended, although catheter directed thrombolytics or surgical thrombectomy may be recommended when circulation is threatened.

• Multiple rib fractures, bilateral clavicle fracture, and hemothorax.
• This child was ultimately diagnosed with osteogenesis imperfect, but child abuse should be quite high on your differential.

First described by Dr. Aubrey Hampton in 1940, hampton hump is a peripheral (pleural) based opacification found on chest X-ray; it occurs secondary to infarction of the lung

Although commonly associated pulmonary embolism it may occur secondary to other causes of lung infarction

Here are some other infrequent, but not rare signs, of pulmonary embolism on chest X-ray:

• Westermark sign: area of vascular cutoff distal to a pulmonary embolism
• Fleishner sign: an enlarged pulmonary artery
• Pleural effusion

http://radiopaedia.org

As the cold and snow rips through the United States, hypothermia is a major concern because each year approximately 1,300 Americans die of hypothermia.

Classification of hypothermia:

• Mild (32-35 Celsius): shivering, hyperventilation, tachycardia, but patients are usually hemodynamically stable.
• Moderate (28-32 Celsius): CNS depression, hypoventilation, loss of shivering, risk of arrhythmias, and paradoxical undressing
• Severe (<28 degrees Celsius): increased risk of ventricular tachycardia/fibrillation, pulmonary edema, and coma

The risk of cardiac arrest increases when the core temperature is less than 32 Celsius and significantly rises when the temperature is less than 28 Celsius. Rapid rewarming is required as part of resuscitation should cardiac arrest occur.

A rescue therapy to consider (when available) is extra corporeal membrane oxygenation (ECMO). ECMO not only provides circulatory support for patients in cardiac arrest, but allows re-warming of patients by 8-12 Celsius per hour.

Some studies quote survival rates of 50% with hypothermic cardiac arrest patients receiving ECMO versus 10% in similar patients who do not receive ECMO.

As winter lingers in the United States, consider speaking to your cardiac surgeons now to plan an Emergency Department protocol for hypothermic patients that may require ECMO.

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Anterior shoulder dislocation

Cunningham Technique

• A technique for shoulder reduction that typically does not require sedation.
• Relies on proper positioning of the patient and gentle massage of the biceps muscle while gentle traction is applied to the antecubital fossa
• Click here for a step by step tutorial on the technique and click here for videos on the technique

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Severe ecchymosis from coumadin overdose

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Barnard, et al. Rapid sequence induction of anaesthesia via the intraosseous route: a prospective observational study. Emerg Med J. 2014 Jun 24. pii: emermed-2014-203740.