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Case Report of an Empyema Identified on Lung Ultrasound

Michelle Brown, DO*, Carly Heffernan, BS* and Alisa Wray, MD, MAEd*

DOI: https://doi.org/10.21980/J8SH2N Issue 6:4 No ratings yet.
Using a curvilinear ultrasound probe, images of the patient were obtained from the left mix-axillary line. These images demonstrate a loculated left-sided pleural effusion (outlined in the attached ultrasound image in blue) that was moderate in size, concerning for an empyema. The diaphragm on the right (red) of the image outlines the inferior margin of the collection of pus, which is seen in the inferior aspect of the left lung. Unfortunately, rib shadows on the left side of the image prevent the full empyema from being captured in this single image. As a result of the bedside ultrasound, however, the patient was rapidly diagnosed with an empyema and was initiated on antibiotics, which is further discussed below. After his bedside ultrasound was completed, his chest x-ray revealed the expected left-sided pleural effusion. Additionally, a CT angiogram of the chest was ordered to rule out a pulmonary embolism, which was negative for an embolism but does redemonstrate the left-sided loculated pleural effusion (outlined on the CT axial and coronal images in blue).
RespiratoryVisual EM

Modified Manikin for Tracheoinnominate Artery Fistula

Emily M Tarver, MD*, Gina D Jefferson, MD, MPH ^, Patrick Parker‡, Kristina Readman‡, Susana M Salazar Marocho, BDS, PhD** and Anna A Lerant, MD, CHSE‡^^

DOI: https://doi.org/10.21980/J8Z93H Issue 6:3 No ratings yet.
By the end of this educational session, learners will be able to: 1) perform a focused history and physical exam on any patient who presents with bleeding from the tracheostomy site; 2) describe the differential diagnosis of bleeding from a tracheostomy site, including a TIAF; 3) demonstrate the stepwise management of bleeding from a suspected TIAF, including cuff hyperinflation and the Utley Maneuver; 4) verify that definitive airway control via endotracheal intubation is only feasible in the tracheostomy patient when it is clear, upon history and exam, that the patient can be intubated from above; and 5) demonstrate additional critical actions in the management of a patient with a TIAF, including early consultation with otolaryngology and cardiothoracic surgery as well as emergent blood transfusion and activation of a massive transfusion protocol.
InnovationsProceduresRespiratory

Tracheoinnominate Artery Fistula

Emily M Tarver, MD*, Anna A Lerant, MD, CHSE^, Jeffrey D Orledge, MD*, Benjamin P Stevens, MD‡, and Gina D Jefferson, MD, MPH, FACS‡

DOI: https://doi.org/10.21980/J8K05R Issue 6:3 No ratings yet.
By the end of this simulation, learners will be able to: 1) perform a focused history and physical exam on any patient who presents with bleeding from the tracheostomy site, 2) describe the differential diagnosis of bleeding from a tracheostomy site, including a TIAF, 3) demonstrate the stepwise management of bleeding from a suspected TIAF, including cuff hyperinflation and the Utley Maneuver, 4) verify that definitive airway control via endotracheal intubation is only feasible in the tracheostomy patient when it is clear, upon history and exam, that the patient can be intubated from above, 5) demonstrate additional critical actions in the management of a patient with a TIAF, including early consultation with otolaryngology and cardiothoracic surgery as well as emergent blood transfusion and activation of a massive transfusion protocol.
ProceduresRespiratorySimulation

A Pediatric Emergency Medicine Refresher Course for Generalist Healthcare Providers in Belize: Respiratory Emergencies

Adeola Adekunbi Kosoko, MD*, Alicia E Genisca, MD^, Marideth Rus, MD†, Shreya Ramayya**, Lisa Johnson, MD^^ and Joy Mackey, MD††

DOI: https://doi.org/10.21980/J84063 Issue 6:2 No ratings yet.
This curriculum presents a refresher course in recognizing and stabilizing pediatric acute respiratory complaints for generalist healthcare providers practicing in LMICs. Our goal is to implement this curriculum in the small LMIC of Belize. This module focuses on common respiratory complaints, including asthma, bronchiolitis, pneumonia and acute airway management.
CurriculaRespiratory

Pulmonary Arteriovenous Malformation in a Patient with Suspected Hereditary Hemorrhagic Telangiectasia: A Case Report

Nadia Zuabi, MD*, Sean Ryan Thompson, BS*, Alexa Lucas, BS*, Alisa Wray, MD*

DOI: https://doi.org/10.21980/J8M353 Issue 6:1 No ratings yet.
Initial vital signs were unremarkable, including oxygen saturation of 98% on room air. The patient did not exhibit any signs of respiratory distress, and the lungs were clear to auscultation bilaterally. Labs were obtained, which showed normal hemoglobin at 15.8. Computed tomography (CT) of the chest (Video 1) showed a large left upper lobe arteriovenous malformation (AVM) with large feeding arteries and tortuous dilated draining veins (red arrow) measuring up to 3.8cm. Imaging also demonstrated nonspecific multifocal ground-glass opacities, which may have represented pulmonary hemorrhage (blue outline) from AVM without evidence of contrast extravasation to suggest active bleeding.
Cardiology/VascularRespiratoryVisual EM

Case Report: Traumatic Tension Pneumothorax in a Pediatric Patient

Zachary Tritsch, MD*, Gayle Galan, MD*, Gary Oates, MD* and Janelle Thomas, MD*

DOI: https://doi.org/10.21980/J8ZD1S Issue 6:1 No ratings yet.
Chest X-ray demonstrated significant right-sided pneumothorax (with red outline showing border of collapsed right lung) with cardio mediastinal shift to the left (shown by blue arrows) indicative of a tension pneumothorax
PediatricsRespiratoryTraumaVisual EM

Hemoptysis Due to Diffuse Alveolar Hemorrhage

Zoltan Buchwald, MD* and Amrita Vempati, MD*

DOI: https://doi.org/10.21980/J8ZP86 Issue 5:3 No ratings yet.
By the end of this simulation session, learners will be able to: (1) recognize worsening respiratory status of a patient with hemoptysis and intervene appropriately, (2) manage a patient with severe hemoptysis and perform appropriate ventilator management, (3) manage sinus tachycardia with QT prolongation on the ECG caused by cocaine and hypomagnesemia, (4) address various etiologies of hemoptysis, (5) discuss the causes of massive hemoptysis and management options, and (6) review ventilation strategies in an intubated hypoxic patient.
RespiratorySimulation

Improving Emergency Department Airway Preparedness in the Era of COVID-19: An Interprofessional, In Situ Simulation

Keiran J Warner, MD*, Ashley C Rider, MD*, James Marvel, MD*, Michael A Gisondi, MD*, Kimberly Schertzer, MD* and Kelly N Roszczynialski, MD, MS*

DOI: https://doi.org/10.21980/J8V06M Issue 5:3 No ratings yet.
At the conclusion of the simulation session, learners will be able to: 1) Understand the need to notify team members of a planned COVID intubation including: physician, respiratory therapist, pharmacist, nurse(s), and ED technician. 2) Distinguish between in-room and out-of-room personnel during high-risk aerosolizing procedures. 3) Distinguish between in-room and out-of-room equipment during high-risk aerosolizing procedures to minimize contamination. 4) Appropriately select oxygenation therapies and avoid high-risk aerosolizing procedures. 5) Manage high risk scenarios such as hypotension or failed intubation and be prepared to give push-dose vasoactive medications or place a rescue device such as an I-gel®.
Infectious DiseaseProceduresRespiratorySimulation

Low Fidelity Trainer for Fiberoptic Scope Use in the Emergency Department

Garren Giles, DO*, Dominic Diprinzio, DO* and Jordana Haber, MD*

DOI: https://doi.org/10.21980/J8764B Issue 5:3 No ratings yet.
By the end of this training session, learners will be able to 1) list indications, contraindication, and complications in performing fiberoptic intubations, 2) know how to use and maneuver a fiberoptic scope, and 3) be able to successfully intubate the trainer model.
InnovationsProceduresRespiratory

A Case Report on Miliary Tuberculosis in Acute Immune Reconstitution Inflammatory Syndrome

Erica Concors, MD*, Hamid Ehsani-Nia, DO* and Michael Mirza, MD*

DOI: https://doi.org/10.21980/J81H02 Issue 5:3 No ratings yet.
A portable single-view radiograph of the chest was obtained upon the patient’s arrival to the ED resuscitation bay that showed diffuse reticulonodular airspace opacities (red arrows) seen throughout the bilateral lungs, concerning for disseminated pulmonary tuberculosis. Subsequently, a computed tomography (CT) angiography of the chest was obtained which again demonstrates this diffuse reticulonodular airspace opacity pattern (red arrows).
Infectious DiseaseRespiratoryVisual EM
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