Archive | June, 2013

Rasmussen’s aneurysm (a.k.a. massive hemoptysis is bad)

28 Jun

RAGING HYPOTHETICAL:

Your next patient is a 40 year old male who comes in because he is coughing up blood. Your differential is broad, and you eventually send him for a CTA of his chest.  

On the way back from CT, he starts having severe respiratory distress thanks to the massive amount of blood he is spraying into the air with each labored breath/cough.  

As you are intubating, the clerk says the radiologist is on the phone saying something about Rasmussen and an aneurysm….what does this mean?

 

WHAT THE !%^@$ IS RASMUSSEN’S ANEURYSM?

Rasmussen’s aneurysm is a pulmonary/bronchial artery aneurysm adjacent or within a tuberculous cavity.

occurs in up to 5% of patients with such lesions

slowly expands because of inflammatory erosion of the external vessel wall until it bursts (this is bad)

(hemoptysis with active TB more commonly from bronchiolar ulceration with necrosis of adjacent blood vessels and distal alveoli)

MASSIVE HEMOPTYSIS differential includes:

  • Bronchiectasis
  • Tuberculosis (+/- rasmussen’s aneurysm)
  • pneumonia/other lung infections (e.g. fungal)
  • carcinoma
  • Bronchitis
  • vasculitis
  • pulmonary embolism
  • coagulopathy
  • trauma
  • tracheo-inominate fistula

 

MANAGEMENT OPTIONS:

ABCs (airway comes first)

blood products

bronch

embolization/IR

thoracic surgery

 

BOTTOM LINE:

TB + massive hemoptysis, worry about Rasmussen’s aneurysm.

ABCs. 

 

Submitted by J. Stanton.

 

References: uptodate.com: Massive hemoptysis: Causes, Initial Management, Clinical manifestations and evaluation of pulmonary tuberculosis; picture

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subclavian steal (quick review)

27 Jun

rare cause of brainstem ischemia

abnormal narrowing of the subclavian artery proximal to the origin of the vertebral artery

with exercise of the ipsilateral arm, blood is shunted, or “stolen,” from the vertebrobasilar system to the subclavian artery supplying the arm muscles.

 

more common on the left.

 

Physical examination

  • decreased pulse volume and diminished blood pressure in the affected arm.
  • Turn head to other side OR raise arms up (can replicate syndrome).
  • BP difference between 2 arms (significant pressure difference of 40-50 between arms more commonly associated with symptoms and likely needs treatment) — don’t forget other scary things (e.g. aortic dissection) can do this, too.

 

Other causes of brainstem ischemia include vertebrobasilar atherosclerotic disease and basilar artery migraines.

 

Study showed that most are asymptomatic (93%) 

 

IMAGING:

Carotid duplex US or CTA chest

 

RAPID RECAP:

keep subclavian steal in your differential for odd neuro complaints (e.g. syncope, cerebellar issues, etc), particularly with exercise

RARE but need high index of suspicion

imaging: CTA, vascular ultrasounds

 

Submitted by J. Andrick.

 

References: Labropoulos N, Nandivada P, Bekelis K. Prevalence and impact of the subclavian steal syndrome. Annals Surgery. 2010.; picture

anisocoria

26 Jun

Just 6 slides. Rapid fire. High yield. click away.

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Submitted by F. DiFranco.

 

Post LP Headache

25 Jun

90% headaches within 3 days.

Postural.

Keep in mind that could be intracranial hemorrhage causing repeat headache.

 

The incidence is:

  • ∼40% with a 22G needle;
  • 25% with a 25G needle,
  • 2%–12% with a 26G Quincke needle,
  • <2% with a 29G needle. (i.e. smaller is better)

Risk factors for post–lumbar puncture headache 

  • use of a large needle size (>22 gauge),
  • use of a cutting (Quincke) needle,
  • multiple attempts,
  • failure to replace the stylet when withdrawing the needle.

 

Prevention:

Smaller needles (if possible, may need at least 22G to measure pressure, obtain CSF).

Orientation – perpendicular orientation of bevel (‘split the fibers’)

 

Treatment:

Caffeine (300-500mg PO or IV daily or BID)

Blood patch

 

Submitted by J. Andrick.

 

References: Post‐dural puncture headache: pathogenesis, prevention and treatment. Turnbull DK. Brit J AnesPostgrad Med J. 2006 Nov;82(973):713-6.Post lumbar puncture headache: diagnosis and management. Ahmed SV, Jayawarna C, Jude E.; picture

 

blind rotation technique for mainstem intubation

24 Jun

RAGING HYPOTHETICAL:

Your next patient is a middle aged man who is at first spraying a fine red mist with each cough, then starts bubbling rivers of bloody goodness with each attempted breath.  Your laryngoscope (and hopefully suction and a Bougie) are already in your back pocket.   As you go to intubate, is there anything else you can do here?

 

You can intubate one lung (nonbleeding lung–if you know which one that is)

RIGHT mainstem bronchus is easy —  just advance standard ETT.

 

LEFT mainstem more difficult – often requires special equipment.

TRY THIS: Rotate tube to the left (90 degrees) after through vocal cords and advance until resistance met.

 

You can use this for the RIGHT mainstem, too (rotate 90 degrees toward right lung, and advance until resistance)

 

The rotation technique successfully intubated the right side 94% and the left 72% of the time (n = 25 in cadaver trial)

 

Similar results with a directional-tip ET tube (if you have it)

 

Submitted by J. Andrick.

 

References: An evaluation of a blind rotational technique for selective mainstem intubation. Bair AE, Doherty MJ, Harper R, Albertson TE: Acad Emerg Med 11: 1105, 2004.; picture

ischemic pancreatitis

21 Jun

Review article with 11 Case reports of ischemic pancreatitis (rare) by Hackert et al.

 

WHY DOES IT HAPPEN?

  • vessel occlusion or poor output state (sepsis, cardiogenic, hemorrhagic)
  • typically POSTSURGICAL (pancreas transplant) or setting of Cardiopulmonary bypass

 

Diagnosis

requires elevated lipase in combination with abdominal pain with some form of hypoperfusion or vessel occlusion and exclusion of other causes of pancreatitis.

Lactate will be elevated as well.

celiac trunk and the superior mesenteric artery are the major vascular supply of the pancreas — pay attention to these areas on imaging

 

Triggers for ischemic AP:

  • hypotension and shock of any origin,
  • macro- or microvascular occlusion,
  • pharmacologic interventions such as catecholamine therapy,
  • cold ischemia during pancreas transplantation.

 

Treatment

standard pancreatitis treatment (IV fluids, analgesics, etc).

Also if vessel occlusion then can revascularize (controversial given high periop complication rates unless other organs are affected).

– only one case report of revascularization.

Mortality rate high — 64% (7/11) in this small review

 

Submitted by J. Andrick.

 

References: Ischemic acute pancreatitis: clinical features of 11 patients and review of the literature. Hackert et al. Amer J Surg.; picture

 

Kawasaki Disease (30-second review)

20 Jun

Sensitivity of physical exam findings:

Fever x 5 days plus at least 4/5 of:

1. Conjunctival injection (bilateral)

2. MM changes (eg. Fissured lips, strawberry tongue)

3. Polymorphous rash

4. Extremity changes (edema, desquamation)

5. Cervical LAD

 Sensitivity 90%, specificity 54%

 

20-25% develop coronary aneurysms, typically clinically silent until sudden death

 

IVIG reduces aneurysms to only 2-4% cases

 

MIMICKERS – GAS pharyngitis (scarlet fever), measles

 

Med-school mnemonic: CRASH & BURN

  • Conjunctivitis
  • Rash
  • Adenopathy/Aneurysm
  • Strawberry tongue
  • Hand/foot induration/desquamation

&

  • BURN – fever x 5 days

 

 

Submitted by J. Andrick.

 

References: Kawasaki Syndrome, Burns, Glode review Lancet 2004; Kawasaki Disease II Yim et al. J Ped Child Health.; picture