What is the optimal position to intubate an obese patient?

click image to enlarge

Source

Image source: http://bentollenaar.com/_MM_Book/Ch.43.htm

Mattu, A.  Emedhome.com.  EMCast.  January 2012.

Is this right IJ central line correctly placed as noted on chest x-ray?

Blue dot marks tip of IJ.   Contrast adjusted to maximize clarity of IJ and tracheobronchial angle.  Click on image to enlarge.

IJ should be pulled back 1-2 cm.  Ideal location is at the superior vena cava/atrial junction which is located  3-5 cm below the tracheobronchial angle, a distance which is reproducible in patients despite gender and body habitus. 


Source

Emedhome.com.  Clinical Pearls: "Proper Position of a Central Line."  7 April 2010.

Marcucci, L. Avoiding Common ICU Errors.  "Place the Tip of a Central Venous Catheter at the Junction of the Superior Vena Cava and Atrium"  Lippincott Williams & Wilkins.  2007.

29 y/o male has left sided chest pain which started after falling off a ladder. Identify the pathology on the chest and rib x-rays.

What pathology are the red arrows pointing at? Orange? Green?

PA chest x-ray.  Click on image to enlarge.

Left rib x-ray

Oblique left rib x-ray.

Red arrows denote the two rib fractures.  Orange arrows, subcutaneous air.  Green arrow, small apical pneumothorax.

The rib fractures and subcutaneous air are pretty easy to identify.  Finding the pneumothorax is a little more difficult but here are a couple tricks to picking it up.

1. Blunt (not penetrating) trauma + rib fracture + subcutaneous air = pneumothorax.  Find it.  
2. First place to look for a pneumothorax on an upright chest x-ray is in the upper hemithorax as air in the pleural space will rise.   Most common appearance is an area adjacent to the ribs where no lung vascularity is seen and where a very thin white line represents the visceral pleura.

Source

Mettler: Essentials of Radiology, 2nd ed.

Can a 5 month old have a simple febrile seizure?

No.  By definition "simple" febrile seizures occur in children 6 months - 5 years old.  A seizure is a 5 month old is, by definition, complex.


Peer VIII: Physician's Evaluation and Educational Review in Emergency Medicine, American College of Emergency Physicians

24 y/o female presents with throat pain which developed while eating chicken wings at a holiday party. Identify the abnormality, if any, on this soft tissue neck x-ray.

Click image to enlarge.

scroll down for answer 

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Arrow denotes chicken bone.

Name two circumstances when a selective serotonin reuptake inhibitor (SSRI) overdose may be potentially dangerous.

1. massive overdose 
2. citalopram (Celexa) overdose which can cause QT prolongation and seizures 

Otherwise, SSRI overdoses are generally benign. 


Source

Peer VIII: Physcian's Evaluation and Educational Review in Emergency Medicine, American College of Emergency Physicians

Even the best in emergency medicine can't avoid medical malpractice lawsuits ....

Peter Rosen MD reveals in Bouncebacks! Medical and Legal that he has been sued about "half a dozen" times.  Fortunately for him he never had to settle or go to court as he was eventually dismissed from all cases.