Cardiology/Vascular

Saddle Pulmonary Embolus

Colin Therriault, MD^*, Daniel Natkiel, DO^* and Megan Stobart-Gallagher, DO^{^}

DOI: https://doi.org/10.21980/J8N63P Issue 4:2 No ratings yet.

An electrocardiogram (ECG) showed evidence of right heart strain with an incomplete right bundle branch block, S1Q3T3 (see red arrow [S1], blue arrow [Q3], and black arrow [T3]), and ST-segment elevation in the septal leads (green arrows). Bedside echocardiography showed a dilated right ventricle with ventricular wall akinesis (red arrow) sparing the apex (purple arrow), which is known as McConnell’s Sign. It also showed a mobile hyperechoic mass (yellow arrow). These ultrasound findings were concerning for pulmonary embolism (PE), so computed tomography (CT) angiogram of the chest was ordered and confirmed massive bilateral obstructive filling defects (red arrows) consistent with saddle pulmonary embolism. Additionally, noted is flattening of the interventricular septum (blue arrow) consistent with right heart strain. Laboratory studies were notable for a troponin-I of 0.29 ng/mL, a B-type natriuretic peptide of 792.3 pg/mL, lactic acid of 5.30 mmol/L, and a creatinine of 2.0 mg/dL, consistent with end organ dysfunction. All other lab work was within normal limits.

Visual EM Cardiology/Vascular Respiratory

Pericardial Clot on Point-of-Care Ultrasound

Rame Bashir, BS^*, Esther Kim, BS^*, Shadi Lahham, MD, MS^* and John C Fox, MD^*

DOI: https://doi.org/10.21980/J8ZH1TIssue 4:2 No ratings yet.

Focused assessment with sonography in trauma (FAST) scan was positive for a clinically significant pericardial effusion as evidenced by the hypoechoic fluid around the myocardium, indicated by the blue arrow in image 2. Findings are also consistent with tamponade process as evidenced by restricted expansion and collapse of the right ventricle during diastole. The hyperechoic floating structure between the pericardium and myocardium, adjacent to the right ventricle, represents a pericardial clot, indicated by the white arrow.The density of the pericardial clot differs from that of the myocardium, thus serving as an additional variable to avoid confusing this as part of the myocardial structure.

Cardiology/Vascular Ultrasound Visual EM

Wellens’ Syndrome

Brittany Perry Hoffstatter, DO^* and Brian Walsh, MD^*

DOI: https://doi.org/10.21980/J8FS8KIssue 4:1 No ratings yet.

Initial electrocardiogram (ECG) revealed the classic biphasic T waves in V2 and V3 of Wellen’s syndrome (see red outlines). A second EKG demonstrated an evolving deeply inverted T wave (see blue outlines).

Visual EM Cardiology/Vascular

Arteriovenous Graft Pseudoaneurysm

Erik Madsen, MD^*, Lauren Sylwanowicz, MD^{^} and Alisa Wray, MD, MAEd^{^}

DOI: https://doi.org/10.21980/J8B06ZIssue 4:1 No ratings yet.

A bedside ultrasound of the mass demonstrated a large compressible hypoechoic structure (see purple outline) above the arteriovenous graft (see red outline). The contents demonstrated movement of fluid within the structure. This was confirmed with Doppler mode, which allowed for visualization of flow communicating between the structure and the underlying vessel, which is diagnostic for a pseudoaneurysm.

Visual EM Cardiology/Vascular

Guilty as Charged: Jailed Coronary Vessel Presenting as Wellens’ Syndrome Type B

Aderonke Susan Akapo, DO^*, Ryan Fashempour^*, Mohamad Moussa, MD^* and Patrick Bruss, MD^{^}

DOI: https://doi.org/10.21980/J8DS6H Issue 4:1 No ratings yet.

Evolving changes to electrocardiograph (ECG) were noted during serial ECG monitoring involving leads V2 and V3, along with some T-wave inversion in V4 and V5 that were concerning for a Wellens’ syndrome type B on second ECG. She was admitted and subsequently taken to cardiac catheterization suite where it was revealed that the previously placed stent in the left anterior descending (LAD) artery was patent. Unfortunately, the stent blocked off an adjacent side branch vessel off the LAD in proximal two-third region of the stent (as seen in the cartoon).

Visual EM Cardiology/Vascular

Intramural Hematoma with Type B Aortic Dissection

Ronald Goubert, BS^*, Robert Rowe, MD^* and Alisa Wray, MD, MAEd^*

DOI: https://doi.org/10.21980/J81M03Issue 4:1 No ratings yet.

Computed tomography angiography of the chest and abdomen revealed a 9.5 cm thoracoabdominal aneurysm (red outline) with intramural hematoma (yellow shading) and large left pleural effusion versus hemothorax with old blood (blue shading).

Cardiology/Vascular Visual EM

Cocaine-induced Myocardial Infarction and Pulmonary Edema

Dae-won Lee, MD* and Timothy J Koboldt, MD*

DOI: https://doi.org/10.21980/J8ZS87Issue 3:4 No ratings yet.

By the end of this simulation session, the learners will be able to:1) Determine appropriate diagnostics in a patient with likely cocaine toxicity. 2) Identify and manage respiratory failure. 3) Identify and manage a ST-elevation myocardial infarction (STEMI) and pulmonary edema. 4) Identify and manage cocaine toxicity with benzodiazepines. 5) Determine appropriate disposition of the patient to the cardiac catheterization lab and an intensive care unit (ICU). 6) Demonstrate effective communication and teamwork during resuscitation of a critically ill patient.

Cardiology/Vascular Simulation Toxicology

Prehospital Cardiac Arrest Management Simulation

Nicklaus P Ashburn, MD^*, Bryan P Beaver, MD^*, Robert D Nelson, MD^*, Michael T Fitch, MD, PhD^* and Jason P Stopyra, MD^*

DOI: https://doi.org/10.21980/J8V057 Issue 3:4 No ratings yet.

At the end of this simulation learners will be able to: 1) Perform team-focused CPR using effective leadership and communication skills during prehospital resuscitation. 2) Employ high-quality CPR with an emphasis on compressions and early defibrillation. 3) Demonstrate appropriate airway management utilizing an oropharyngeal airway and bag-valve-mask, blind-insertion airway device, and/or endotracheal intubation during cardiac arrest. 4) Recognize and appropriately defibrillate pulseless ventricular tachycardia and ventricular fibrillation. 5) Formulate an appropriate differential diagnosis for pulseless electrical activity.

EMS Cardiology/Vascular Simulation

Endocarditis

Sara Arastoo, BS^* and Sari Lahham, MD, MBA^*

DOI: https://doi.org/10.21980/J8JP73Issue 3:4 No ratings yet.

Upright frontal radiograph of the chest demonstrated large pleural effusion on the left and moderate pleural effusion on the right as shown by the visible menisci on both sides (red arrows) with diffuse bilateral nodular densities (yellow dotted lines), consistent with septic pulmonary emboli. Computed tomography (CT) of the chest demonstrated multiple scattered lung nodules bilaterally containing internal foci of air cavitation (green dotted lines).

Infectious Disease Cardiology/Vascular Visual EM

Clinical Evaluation and Management of Pediatric Pericarditis

Sharona Hariri, BA^*, Alisa Wray, MD, MAEd^{^} and Lauren Sylwanowicz, MD^{^}

DOI: https://doi.org/10.21980/J8HP85Issue 3:4 No ratings yet.

An electrocardiogram (ECG) was concerning for ST segment elevation in leads II, III, aVF, and V4, with subtle ST elevations in V5 and V6 (see black arrows). There is also ST segment depression in aVL (see blue arrows).

Cardiology/Vascular Visual EM