This week's COTW is a two-part special. This is a 70-year old man who presented with several days of diarrhea. Firstly, here are his abdominal images. What can you conclude based on these clips?
This is a case of a 52 yo F trauma patient with severe traumatic brain injury. She was intubated and transferred to the ICU where, given the severity of her TBI, an intraparenchymal ICP monitor was placed by neurosurgery. The ICP monitor was initially showing an ICP of 10. Overnight, however, despite no apparent clinical change, the ICP waveform was inconsistent and the readings were now showing values around 40-50. We thus performed a point-of-care TCD to help determine whether her ICP was truly elevated or whether the ICP monitor was giving spurious information. Have a look at the following images. Do you think the TCD spectral waveform is consistent with markedly elevated ICP?
This is a 40-year old man status post-liver transplant (several months prior) who has had a complicated hospital course. He is now re-admitted with presumed septic shock (query HAP) and has been intubated for respiratory failure. He's also had a formal abdominal ultrasound commenting on periportal hepatic edema and signs of congestion. Based on the images below what interventions might you make to the team in addition to antimicrobial therapy? The team is particularly worried about right heart failure and elevated right-sided pressures - what do you tell them based on your findings?
This is a 54 yo M who presented with acute hypoxic respiratory failure necessitating intubation and ICU admission. Post-intubation he had a P/F ratio of 54 despite a relatively unremarkable CXR. The PEEP was increased to try to improve oxygenation. A CTPA was ordered which was negative for PE and showed just a small right lower lobe consolidation. Given that the refractory hypoxia seemed discordant with the pulmonary pathology, concern was raised for an intracardiac shunt. A point-of-care TEE was performed including a bubble study. Have a look at the selected clips below and see what you think!