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Adolescent admitted for sepsis found to have DVT and diffuse PE
Serena P. Kelly MS, CPNP-AC, CCRN, CPEN

- Bilateral diffuse septic emboli are present, with increased patchy consolidation. 
- Trace bilateral pleural effusions.

Stages of Cardiogenic Pulmonary Edema

Stage 2:  Interstitial Edema

Debra Siela, PhD, RN, CCNS, ACNS-BC, CCRN, CNE, RRT Associate Professor of Nursing

- PCWP rises to between 18 and 25 mm Hg, interstitial edema begins
- Kerley lines are due to thickening of intralobular septra caused by increased tissue or fluid. Kerley lines are a radiographic sign with interstitial pulmonary edema. They are thin linear pulmonary opacities caused by fluid or cellular infiltration into the interstitium of the lungs.
- Kerley B lines or horizontal lines no more than 2 cm long that appear in the lung periphery near costophrenic angles now become evident on chest radiographs. 
- Kerley A lines are oblique lines approximately 2 to 6 cm in length that appear in the upper lobes near the hila. Kerley A lines are caused by distension of channels that connect the peripheral and central lymphatics of the lungs.
- Butterfly pattern may occur due to fluid engorgement of the interstitium adjacent to the hilar blood vessels
- Normal bronchial walls appear as pencil-point thin when viewed end-on. Interstitial edema  widens the bronchial walls and makes their margins appear indistinct, which is termed peribronchial cuffing. These appear as small doughnut denisities.

ECG Characteristics of Acute Pericarditis 

Hannibal, Gerard B.

The acute pericarditis electrocardiogram can easily be mistaken for ST segment elevation MI (STEMI).ST segment elevation and the computerized interpretation of “Acute MI” both favor a diagnosis of STEMI. However, the ST segment elevation of MI is regional while the ST segment elevation is global (most leads as seen above) in acute pericarditis . Another clue that favors acute pericarditis is PR segment depression, seen here in leads II, III, aVF, and leads V4 through V6. ECG changes related to pericarditis are seen in most leads because the pericardium surrounds the heart and the surface ECG detects a variance between normal cells and damaged sub-epicardial cells.

AACN Advanced Critical Care. 23(3):341-344, July/September 2012.

Chest Trauma CT Scan 

Debra Siela PhD, RN, CCNS, ACNS-BC, CCRN-K, CNE, RRT Associate Professor of Nursing

See a chest CT scan of a pedestrian hit by a truck. 
A FAST scan could not be done because of the subcutaneous emphysema. Air is present in the mediastinum (pneumomediastinum) and in the subcutaneous layer (subcutaneous emphysema) besides the bilateral  pneumothoraces. The left pneumothorax is not distinct in this view. Contusions are present in the posterior lungs. The patient also had pneumatoceles (air filled pockets in the lung from lacerations) and rib fractures, which are not visualized on this scan.

Surface ECG rhythm of a patient with an ICD 
Hannibal, Gerard B

The patient developed ventricular tachycardia and  the device appropriately attempted overdrive pacing, which failed. The cardiac rhythm deteriorated to ventricular fibrillation and the patient received an appropriate shock. The electrophysiologist turned off the overdrive pacing function of the device.

Rhythms with changing P-wave morphology in a single electrocardiographic lead

Hannibal, Gerard B.

Wandering Atrial Pacemaker - Note the transitional P-wave morphologies in beats 3 and 4, which suggest fusion of competing pacemakers or simultaneous activation via alternate SA nodal exit sites. Patients with this rhythm are usually symptom free, and treatment is not required.

Multifocal Ectopic Atrial Tachycardia - Note the multiform P- waves with a clear return to the isoelectric line. Beat numbers 10 and 12 show aberrant conduction. This rhythm is associated with stress conditions such as acute pulmonary and cardiac conditions. Treatment of the underlying condition usually eliminates the rhythm.

Subtle changes in the electrocardiogram related to hypocalcemia 

Hannibal, Gerard B.

Pre-treatment ECG of a patient with tumor lysis syndrome. Calcium level 4.6mg/dl , ionized calcium 2.4 mg/dl, ST segment measures 200 ms and QT is 500 ms with QT corrected of 558 ms.

Post-treatment ECG of patient with tumor lysis syndrome. Calcium level is 6.8 mg/dl, ionized calcium 3.7 mg/dl, ST segment measures 160 ms and QT is 412 ms with QT corrected of 438 ms.

Inferior Wall Myocardial Infarction 
Hannibal, Gerard B.

12 lead ECG of a 91 year old male presenting with inferior wall  myocardial infarction.  Note the ST segment elevation in leads II, III,and aVf along with reciprocal changes.  Also note the QT prolongation (QT= 516 ms and QTc=494 ms), a common feature of ischemia that is under appreciated.

Surface ECG Demonstrating Anti-tachycardia Pacing 

Hannibal, Gerard B.

The 12-lead rhythm strip demonstrates anti-tachycardia pacing (ATP) in a patient with an internal cardiac defibrillator. Programmed ATP is the preferred method of device treatment as an alternative to a shock. Most modern 12 lead ECG machines allow the operator to run a 12 lead rhythm strip such as the one shown in the figure. Note the presence of “positive concordance” in the tachycardia portion of the ECG. All precordial leads (V1-V6) show upright wave forms.

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