September 2016 Critical Care Case of the Month

Clement U. Singarajah, MD

Samir Sultan, DO

Phoenix VA Medical Center

Phoenix, AZ USA

Critical Care Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours 

Lead Author(s): Clement U. Singarajah, MD.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

Clinical History

A 66-year-old man was admitted to the ICU in complete heart block with borderline hypotension. After cardiology consultation, a decision was made to place an urgent transvenous pacer. The transvenous pacer was place without use fluoroscopy from an right internal jugular venous (IJV) approach using real time ultrasound by two very experienced operators. The ultrasound confirmed right  IJV placement and the pacer was found to capture and pace appropriately without any complications. A post placement CXR was obtained (Figure 1).

 Figure 1. Portable chest x-ray after RIJV transvenous pacer (TVP).

What does the chest x-ray show? (Click on the correct answer to proceed to the second of five panels)

1. A persistent left SVC
2. Normal placement of the RIJV TVP
3. Right pneumothorax
4. TVP pacer passing from RIJV and then into the aorta and left ventricle
5. TVP pacer passing outside heart and pacing epicardially

Cite as: Singarjah CU, Sultan S. September 2016 critical care case of the month. Southwest J Pulm Crit Care. 2016;13(3):108-13. doi: http://dx.doi.org/10.13175/swjpcc079-16 PDF