Point-of-Care Ultrasound: A Vital Tool for Anesthesiologists in the Perioperative and Critical Care Settings.

Point-of-care ultrasound (POCUS) is an essential skill in various specialties like anesthesiology, critical care, and emergency medicine. Anesthesiologists utilize POCUS for quick diagnosis and procedural guidance in perioperative and critical care settings. Key applications include vascular ultrasound for challenging venous and arterial catheter placements, gastric ultrasound for aspiration risk assessment, airway ultrasound, diaphragm ultrasound, and lung ultrasound for respiratory assessment. Additional utilities of POCUS can include multi-organ POCUS evaluation for undifferentiated shock or cardiac arrest, ultrasound-guided central neuraxial and peripheral nerve blocks, focused cardiac ultrasound, and novel applications such as venous excess ultrasound. This review highlights these POCUS applications in perioperative and intensive care and summarizes the latest evidence of their accuracy and limitations.

Katz-Wachtel phenomenon in an adult with dilated cardiomyopathy.

Katz-Wachtel phenomenon is an electrocardiogram (ECG) sign demonstrating large equiphasic precordial QRS complexes indicative of biventricular hypertrophy. This sign is most commonly seen in children with congenital heart disease and is rarely described in adults. We report a case where this ECG sign was noted in an adult with dilated cardiomyopathy and discuss the possible mechanisms for this unusual finding.

Axillary Vein Spasm During Permanent Pacemaker Implantation.

This case example illustrates the challenging nature of managing axillary vein spasm. Once axillary vein spasm has been diagnosed, unnecessary attempts at venous puncture should be avoided as this can result in worsening of the spasm. Intravenous fluids should be infused from the ipsilateral venous access. Intravenous nitroglycerin from the ipsilateral access in incremental doses of 100-200 µg can help in relieving the spasm. It is imperative to wait for 5-10 minutes before re-attempting puncture. A repeat venogram should be performed to demonstrate resolution of spasm and guide the puncture. If spasm persists, puncture may be attempted in the medial part of the axillary vein or the subclavian vein. In refractory cases where the above measures fail, contralateral venous access may be required.

A Case With Inferior Wall Myocardial Infarction and Conduction Abnormalities: Addressing the Diagnostic Challenges.

Conduction disturbances are an important complication of ST-elevation myocardial infarction (STEMI). Conduction disturbances such as fascicular blocks and bundle branch blocks are associated with alteration of QRS morphology and secondary ST-T wave changes that can influence the diagnosis of acute myocardial ischemia. We report an interesting case where a patient presented with inferior wall myocardial infarction (MI), right bundle branch block (RBBB), and left anterior hemiblock (LAHB). We discuss the challenges in diagnosing MI in such patients, including the impact of QRS changes in RBBB and LAHB, their influence on diagnosis of STEMI, and differentiation of combined first-degree AV block and bifascicular block from trifascicular block.

Vieussens' Arterial Ring.

The Vieussens' artery is an anastomotic communication between the conus branch of the right coronary artery and the left anterior descending (LAD). Vieussens' ring is so named because it circles around the great vessels in the form of a partial ring. The course of the artery can be best understood in 2 orthogonal views. In the left oblique view, the artery appears coursing upward to the left. In the right oblique view, it courses anteriorly across the right ventricular outflow tract. The clinical significance of Vieussens' arterial ring lies in it being a major source of collateral blood flow to an occluded LAD. The presence of this large collateral may explain preserved ventricular function in our patient, despite severe triple-vessel disease.

Intramural Hematoma Burrowing Behind a Coronary Stent: Optical Coherence Tomography Findings.

A 47-year-old patient underwent elective percutaneous coronary intervention for two separate lesions in left circumflex artery with a intervening normal segment. After completion of the procedure, there was abrupt vessel closure in the intervening normal segment. Intracoronary imaging using optical coherence tomography (OCT) demonstrated a large intramural hematoma (IMH) extending distally behind the stent. We describe the OCT findings of IMH using cross-sectional, longitudinal and stent-rendered images, and discuss its management.

Longitudinal Stent Deformation: Insights Provided by Optical Coherence Tomography.

Longitudinal stent deformation is defined as shortening or elongation of the stent along its longitudinal axis after deployment. It is under-recognized on angiography, and imaging- based studies have reported an incidence of up to 1%. The etiology includes damage by the guiding catheter or secondary devices such as postdilation balloons, imaging catheters, additional stents, or wire entanglement. Deformation can occur with all stent platforms. In the present case, forceful removal of the trapped guidewire led to the guide being sucked into the LAD and deforming the stent.

Cardiac Gunshot Injury: A Serendipitous Miss!

Penetrating cardiac injuries carry a grave prognosis. We present a rare case of thoracic gunshot injury where the bullet ricocheted and lodged in the pericardium without causing damage to the adjacent cardiac structures. Multimodality imaging helped in localizing the bullet, assessing damage, and planning safe surgical removal without cardiopulmonary bypass. (Level of Difficulty: Beginner.).

Sudden unexpected improvement in the atrioventricular conduction. What is the mechanism?

The 12-lead electrocardiogram (ECG) of a 79-year-old male patient with recurrent pre-syncope showed irregular sinus rhythm with constant PR interval and left bundle branch block (LBBB) with intermittently blocked P waves. The beat following the blocked P wave had a narrower QRS with a shorter PR interval. The phenomenon of bilateral bundle branch block explains the sudden improvement in the atrioventricular conduction.