Wednesday, January 25, 2006

Abnormal CXR

91 yo female admitted to the ICU for hypotension. This is her CXR the following morning...




What would be your next step?

15 comments - CLICK HERE to read & add your own!:

Jennings said...

Low resolution but looks like haziness RLL and maybe a retrocardiac as well; would treat for CAP or if she's in a nursing home, HAP. Then supportive care for the sepsis, with fluids etc.
High mortality for 91 y/o with multilobar pneumonia and hypotension, without even knowing the other parameters (ala PORT)...

Baleeiro said...

There are so many shadows overlying the CxR (I love ICU films) that I am having trouble identifying them all (like the curved wire on the R). From my cheap monitor it looks like the ETT might be a little low with some LLL collapse... maybe pull the ETT a bit and ABTx?

Jennings said...

wow and I thought that was an NG tube. I'm blaming it on the resolution.

Baleeiro said...

It might be a NGT and I'm just overreading because of the resolution. It just seems to end at the carina but with all the sternotomy wires I am not sure...

Jess said...

Yeah, I thought that tube went further down, and if you look at the top of the film it doesn't look like it's overlying the trachea at the very top.
If the patient was vigorously resuscitated with fluids, could she have been over-resuscitated and have some pulmonary edema? There's no way I'm gonna see Kerley B lines on this monitor though!

Jeff H said...

That looks like an NG tube to me. I keep looking at that wire/catheter/something or other on the right. I can't think of how a catheter or wire could end up in that position, so I wonder if it's extrathoracic.

Otherwise, I agree with Jennings.

Mike L said...

Ok, you are perseverating on the NG tube.
The thing I was hoping to create discussion is that "wire/catheter/something or other on the right"

What do you think that is?

Jennings said...

Oh ok, that is a central line wire that got lost as a result of placing a femoral line. Needs interventional radiology to get it out.

Baleeiro said...

It looks like a lost guidewire such as from a cardiac cath gone awry...

Jennings said...

hah I beat baleeiro

Jennings said...

by 22 seconds

Baleeiro said...

That's why we tell people in training to hold on to the guidewire...

Mike L said...

Jennings is correct... that is a guidewire from a fem vein line placed during a pseudocode.

Strangely, it was discovered when her lines were being removed before being sent to the morgue. Yes, it came out when the line (in the fem vein) was discontinued.

Baleeiro said...

So somebody placed the line over the wire and left the wire in?

Jeff H said...

Unfortunately, I've seen a similar case in the past--a resident placed the catheter and never removed the wire. Fortunately, it never migrated and came out easily.

For those fellows out there, there was a very similar radiograph on pulmonary medicine boards a few years ago. The point is, make sure you can explain all of the lines/tubes/catheters etc. that you see on an ICU chest film. If it looks wrong, and it's not extrathoracic (of course, we never have laterals), than it probably is wrong.