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IDEA Series: Ultrasound-capable, 3D-printed central line trainer

Problem: Central venous line (CVL) placement is a key skill for emergency medicine providers. Sites for central line placement include the internal jugular vein, subclavian vein, and femoral vein. Indications include, but are not limited to fluid resuscitation, medication administration, central venous pressure monitoring, pulmonary artery catheter introduction, and transvenous pacing wire placement. Procedural complications can include catheter-associated infection and arterial puncture. Success rates for CVL placement vary based on location and provider experience [1-3]. Point-of-Care Ultrasound (POCUS) increases both success rate and patient safety when used to guide CVL placement [4].

central line trainer 3d idea

Figure 1. Setup for ultrasound-capable, 3D-printed central line trainer

The Innovation

The ultrasound-capable, 3D-printed central line trainer was created to facilitate realistic training of POCUS-guided CVL placement, specifically utilizing the internal jugular vein. The trainer uses a ballistic gel insert that is ultrasound-capable and replaceable, as needed.

The Learners

The model can be utilized by anyone needing practice and training on central line placement. This includes medical and physician assistant students, residents, and fellows. It will be particularly useful with students familiar with POCUS basics.

Group Size

In our experience, 4-5 students were able to utilize the model before the wear from repeated use began to impact the imaging and structure of the model, necessitating replacement of the insert. The dilation step of the Seldinger technique can be skipped or simulated in order to prolong the life of the gel insert.

Equipment

Description of the Innovation

  • The initial head model was designed using 2 common 3D modeling software systems: Tinkercad and  Meshmixer
  • A generic head and neck model was imported into Meshmixer. Using the available tools in Meshmixer, the head was rotated to the side and the neck was manipulated to enhance the appearance of an extended neck with close attention to the sternocleidomastoid muscle and clavicle.
  • The model was then imported into Tinkercad and a section of the neck was removed, inverted, and manipulated inside of a box to create a negative (mold).

central line trainer tinkercad

Figure 2. Screenshot of head being edited in Tinkercad software

central line trainer tinkercad neck

Figure 3. Screenshot of neck mold being edited in Tinkercad software

  • The head was printed with Polylactic acid (PLA) filament in 2 sections that were then glued together with superglue. The seam was sealed and smoothed with latex caulk. The files for both the head and the mold can be found in this Google Drive folder.
  • A hole was drilled from the base of the neck through the top of the head. A second hole was drilled in the base of the model.
  • To make a suitable tray for the ballistic gel insert, a thin plate was printed and then cut to fit the shape of the neck. Finally, that piece was glued to the bottom of the model.
  • The model was painted using matte spray paint.

central line trainer spray paint

Figure 4. Use of matte spray paint to paint the model

  • The mold was printed next. Two holes were drilled on either side to allow for insertion of latex tubing.
  • The ballistic gel was heated according to the directions on the box. The gel can be colored using dye or acrylic paint. Caution should be practiced when using acrylic paint. The heated gel can foam up, increasing the possibility of injury from burn.
  • While the gel was heating, the mold was prepared. The bottom was coated with a thin layer of dish soap to assist with gel release. Two sections of latex tubing, approximately 2 feet each were inserted into the mold. Modeling clay was used to fill the gaps.
  • Once colored and thoroughly heated, the gel was poured into the mold.

central line trainer mold internal jugular vein

Figure 5. Preparation of the mold in which the heated gel will be poured

central line trainer mold pour

Figure 6. The heated, colored gel is poured into the mold

  • After curing, the latex tubes were removed. The gel neck model was then removed and placed into the accompanying space on the 3d printed trainer.
  • The latex tubing was fished back through the available holes, and filled with water. As an optional step, a 30 cc syringe was attached to one end of the thicker tube. Tube stoppers can also be printed and used in place of hemostats. Pumping the syringe plunger simulates the appearance of arterial flow on ultrasound.

Video Demonstration of Final Product

Lessons learned

We are currently investigating how best to research this model. The model is inexpensive compared to available commercial CVL trainers. We estimate the cost at approximately $80 per model in materials. This, of course, does not include the price of a 3d printer, 18v drill, or drill bit. Two comparable models available for purchase are both listed for over $1000 [5, 6]. The build time is approximately 1 week with time spent printing, glue-drying, and ballistic gel setting. The model can be used repeatedly and the insert remade many times over.

If another model were to be designed, the top of the head could be sacrificed in favor of an elongated neck section. The top of the head provides no value and consumes 3d printing filament. Furthermore, an elongated neck may be preferable for a new learner by allowing more room to practice probe and hand placement.

Theory behind the innovation

Simulation as a means of teaching has been a firmly established practice across the landscape of medical education. The model in question is high-fidelity and offers the user a realistic experience in a low-stress environment. The model is small enough to be portable and can be used with little preparation, making it an ideal tool for just-in-time training in the emergency department.

Tools that allow the learner to practice multiple steps of a skill during one exercise are invaluable for skill development, competency-based medical education and mastery learning.

Idea Series Logo debriefing

Led by series editor, Dr. Mary Haas, the IDEA series showcases examples of what programs worldwide have been doing to make residency conference more entertaining, engaging, and most of all, educational for residents. Read more publications from the series.

References

  1. McGee DC, Gould MK. Preventing complications of central venous catheterization. New England Journal of Medicine. 2003;348(12):1123-1133. doi:10.1056/nejmra011883
  2. Schummer W, Köditz JA, Schelenz C, Reinhart K, Sakka SG. Pre-procedure ultrasound increases the success and safety of central venous catheterization. British Journal of Anaesthesia. 2014;113(1):122-129. doi:10.1093/bja/aeu049
  3. E Portalatin M, Fakhoury E, Brancato R, et al. Factors contributing to unsuccessful central line placement in the neck and chest. Surgery: Current Trends and Innovations. 2019;3(2):1-5. doi:10.24966/scti-7284/100015
  4. Saugel B, Scheeren TWL, Teboul J-L. Ultrasound-guided central venous catheter placement: A Structured Review and recommendations for Clinical Practice – Critical Care. BioMed Central. Published August 28, 2017. Accessed September 21, 2022.
  5. Life/form Central Venous Cannulation Simulator. Universal Medical. . Accessed September 21, 2022.
  6. Blue Phantom internal jugular Central Line Ultrasound manikin. 3012495 – Blue Phantom – BPP-060 – Ultrasound Trainers. Accessed September 21, 2022.
By |2026-06-16T16:18:09-07:00Sep 30, 2022|IDEA series, Medical Education, Ultrasound|
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PEM Pearls: An Approach to Infant Apnea

infant

A 2-day-old female born at 41 weeks presents to the Emergency Department (ED) for an episode of apnea. Her parents noticed she stopped breathing, went limp, and turned blue. They are not sure for how long. The infant has had decreased urine output but is otherwise well without any other symptoms. Mom has an unspecified autoimmune condition and is taking hydroxychloroquine. The pregnancy and birth were largely uneventful. Mom was positive for Group B. Strep, had prolonged rupture of membranes, and was appropriately treated with antibiotics.

Vitals: The infant’s vital signs in the ED are within normal limits except for mild tachypnea.

Initial Exam: Her exam is nonfocal.

Background

Apnea among infants occurs when an infant stops breathing for 20 seconds or longer or stops breathing, for any amount of time, with bradycardia, cyanosis, pallor, and/or hypotonia. The overall incidence of apnea is 1 in 1,000 full-term infants. Infants who are premature (<37 weeks) are at increased risk for apnea; the incidence is almost 100% in infants born less than 28 weeks. Apnea is more common in premature infants due to their immature respiratory systems and physiologic stressors often manifest as respiratory depression in infants [1].

For infants that are actively apneic, the approach is similar to any pediatric resuscitation: ABCs (see ED approach below for management). 

For infants who had an apneic episode that has since resolved, one has more time to think about the differential. 

Differential Diagnosis

Apnea can be benign and physiologic, typically lasting between 5-10 seconds and more often occurring between 2 weeks to 6 months of life. Because physiologic stressors can manifest as respiratory depression in infants, the differential for pathologic apnea is broad. The following are broad categories to consider (similar to “the misfits” mnemonic for the crashing neonate).

  1. Sepsis: UTI, pneumonia, necrotizing enterocolitis, meningitis/encephalitis 
  2. Pulmonary disease: pneumonia, pneumothorax, viral illness  
  3. Congenital heart disease 
  4. Metabolic disease: glucose, inborn errors of metabolism, electrolytes 
  5. Intracranial abnormalities
  6. Non-accidental trauma 
  7. Toxins: carbon monoxide, botulism, maternal opioid use 

It’s important to note that apnea in infants may qualify as a BRUE (brief, resolved, unexplained event). However, in this case, the infant is less than 60 days old. This is NEVER a low-risk BRUE [2]. 

Approach for the ED Provider

For the emergency provider, considering all of this can be overwhelming. Our job is to collect pertinent data, stabilize the infant, and start empiric treatment in order for the inpatient teams to further investigate the exact cause of the apnea. The following is a simplified ED approach: 

Key history questions:

  1. How was the delivery: Was meconium present? Was there prolonged rupture of membranes? 
  2. How was the pregnancy: Did mom get prenatal care? Were there any abnormal results with prenatal testing? What are mom’s medical conditions? Did mom get any treatment during her pregnancy (e.g. PCN for syphilis)?
  3. How is the infant feeding, stooling, and urinating? Are there any other symptoms? 

Key workup to initiate (in bold are items we wouldn’t typically send for adult workups and may be forgotten by ED providers who do not primarily care for children):

  1. VBG, CBC, CMP, ammonia (for metabolic conditions), blood culture, urinalysis, lumbar puncture (if concerned about sepsis)
  2. Respiratory viral panel, pertussis (if endemic and/or area with low vaccination rates)
  3. ECG, chest X-ray (if hypoxic or abnormal clinical exam)
  4. Pre and post-ductal oxygen saturation and four-point blood pressure (for heart disease, primarily coarctation of the Aorta)

Key physical exam findings (undress the patient fully):

  1. Are there bruises or other signs of abuse? 
  2. What is the fontanelle size? How do the pupils appear?
  3. Is there wheezing, rhonchi, or rales on lung auscultation? Are breath sounds equal? Is there increased work of breathing?
  4. Is there abdominal distension or guarding?
  5. Are there rashes? Is there edema in the extremities?

Management for infants currently apneic: ABCs.

  1. Establish access, connect to monitors, and get a full set of vitals (including rectal temperature).
  2. Support the airway. Start with oxygenation and ventilation. Utilize noninvasive pressure ventilation with continuous positive airway pressure (CPAP) or High Flow Nasal Canula (HFNC). Consider intubation if there is no improvement, however, do not jump immediately to intubation as an infant’s respiratory status can quickly change with respiratory support. 
  3. Start CPR if there is no pulse or the pulse is less than 60 beats per minute.
  4. Begin intravenous fluids at 10-20ml/kg (be careful if you have concerns about heart failure). 
  5. Obtain a point of care glucose (and if available, venous blood gas). Consider naloxone if opioid ingestion is possible.

Management for the infants who are not currently apneic: 

  1. Monitor vital signs and support respiration as needed (e.g. nasal cannula, CPAP).
  2. Give empiric antibiotics if there is a concern for sepsis. Remember, avoid ceftriaxone in neonates less than 28 days due to concern for kernicterus. Instead, use ampicillin and gentamicin. Add vancomycin if concerned about MRSA.
  3. Nutritional support – remember that infants have low glucose stores. Start maintenance fluids (D10W (if <28 days) or D5NS +/- KCl).
  4. The NICU may want you to start caffeine and/or theophylline in the ED for treatment for apnea of prematurity.

Disposition is mainly to the Neonatal Intensive Care Unit (NICU).

Case Resolution

While in the ED, the infant desaturates to the 80s with improvement on HFNC. She has a full sepsis workup and is started on empiric antibiotics (ampicillin/gentamicin) and antivirals (acyclovir). The infant is found to have hypoglycemia and metabolic acidosis. Her neurologic, cardiac, and infectious workups are unremarkable and she doesn’t have any apneic/cyanotic episodes while hospitalized. She is discharged home with suspected hypoglycemia from poor feeding as the cause.

Conclusion

  • The workup for apnea in infants is broad and not limited to pulmonary pathology.
  • Remember your ABCs, ask key history questions (prenatal, intrapartum, postpartum), send key diagnostics (including ammonia and pertussis), and collect key physical exam findings (including pre and post-ductal saturation and four-point blood pressure).
  • Call your NICU team early.
  • You will likely not arrive at the cause of the apnea in the ED, but your early workup and empiric treatment (e.g. CPAP, antibiotics) are critical in caring for these infants.

Read more pediatric emergency medicine topics as part of the PEM Pearls Series on ALiEM.

References

  1. Kondamudi NP, Khetarpal S. Apnea In Children. [Updated 2022 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK441894/ .Accessed September 21, 2022.
  2. Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants [published correction appears in Pediatrics. 2016 Aug;138(2):]. Pediatrics. 2016;137(5):e20160590. PMID 27244835 

Read more pediatric emergency medicine topics as part of the PEM Pearls Series on ALiEM.

By |2022-09-21T15:16:27-07:00Sep 26, 2022|Pediatrics, PEM Pearls|
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SAEM Clinical Images Series: My Eye is Swollen

eye

A 56-year-old male presented to the Emergency Department with a chief complaint of painful eyelid swelling and itching upon waking up. He reported no history of trauma or fever. He had one similar episode in the past which was self-limiting. The patient denied vision loss, diplopia, pain with extraocular movement, and ophthalmoplegia.

 

Vitals: T 37.4°C; BP 129/73; HR 91; RR 16

General: A/O x 3; well nourished in NAD

HEENT:  Extraocular movements intact in both eyes. Pupils are equal, round, and reactive to light and accommodation bilaterally. Visual Acuity: OD 20/20, OS 20/25.

Left eye: Diffuse swelling and erythema to the left upper and medial lower eyelids with minimal purulent discharge from the lacrimal puncta. Tenderness localized to the medial canthal region.

Right eye: Normal.

Complete blood count (CBC): within normal limits

Comprehensive metabolic panel (CMP): within normal limits

Acute dacryocystitis. Dacryocystitis is defined by inflammation or infection of the nasolacrimal sac. Whether acute or chronic, acquired or congenital, inflammation is caused by obstruction of the nasolacrimal duct usually from infection, trauma, or a space-occupying lesion. The most common infectious organisms are Staphylococcus and beta-hemolytic streptococcus species. The classic clinical presentation is a sudden onset of swelling, erythema, and tenderness in the medial part of the orbit. Conjunctival injection and swelling around the entire orbit can suggest the development of preseptal cellulitis. Complications of dacryocystitis include orbital abscess, orbital cellulitis, vision loss, ophthalmoplegia, and eyelid necrosis. The differential diagnosis includes dacryoadenitis, lacrimal sac or sinonasal tumor, ethmoid sinusitis, and infected sebaceous or dermoid cyst.

Treatment for dacryocystitis depends on the severity and clinical manifestations of the disease. In mild cases, symptoms will resolve with the application of warm compresses, lacrimal sac massage (Crigler technique), and topical antibiotics if indicated. Severe cases may require oral or parenteral antibiotics and surgical decompression.

Take-Home Points

  • Dacryocystitis is inflammation of the medial nasolacrimal sac preceded by obstruction and may be acute or chronic, congenital or acquired.
  • Dacryocystitis exhibits a bimodal age distribution. The common congenital form is found in infancy, and in adulthood at age of 40 years older.
  • Dacryocystitis is occasionally mistaken for dacryoadenitis (inflammation of the nasolacrimal gland with superolateral eyelid edema). Far less common, dacryoadenitis is associated with systemic inflammatory conditions such as malignancy, Sjogren syndrome, sarcoidosis, Crohn’s disease, and other autoimmune diseases.
  • Proper recognition and prompt treatment may prevent serious complications including orbital cellulitis, vision loss, and sepsis.

  • Alsalamah AK, Alkatan HM, Al-Faky YH. Acute dacryocystitis complicated by orbital cellulitis and loss of vision: A case report and review of the literature. Int J Surg Case Rep. 2018;50:130-134. doi: 10.1016/j.ijscr.2018.07.045. Epub 2018 Aug 9. PMID: 30118963; PMCID: PMC6098209.
  • Carlisle RT, Digiovanni J. Differential Diagnosis of the Swollen Red Eyelid. Am Fam Physician. 2015 Jul 15;92(2):106-12. PMID: 26176369.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2022-09-11T10:08:30-07:00Sep 19, 2022|HEENT, SAEM Clinical Images|
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SAEM Clinical Images Series: Unilateral Facial Pain

swelling

A 78-year-old male with a past medical history of Lewy body dementia, hypertension on bisoprolol, hypothyroidism, COPD, chronic lower extremity edema on furosemide, and overactive bladder on oxybutynin presented to the emergency department for evaluation of three days of progressively worsening left-sided neck and facial swelling. Associated symptoms included poor oral intake, a nonproductive cough, and one week of sore throat.

The black arrow represents the left parotid gland.

Vitals: Afebrile; normal room air saturation

HEENT: Firm, tender, warm and erythematous swelling over the left mandibular ramus that extended to the cheek, left neck, and spread caudally into the supraclavicular region and anterior chest. There were no identifiable hard masses or areas of fluctuance. Further inspection of the oral cavity revealed dry mucous membranes, poor dental hygiene without identifiable dental abscess, tonsils were normal size and equal bilaterally, and uvula was midline. Direct pressure externally over the area of concern revealed purulent discharge from Stenson’s duct.

White blood cell (WBC) count: 22.15

Comprehensive metabolic panel (CMP): Na 131; BUN 39; Cr 3.3

Lactic acid: 2.9

Acute suppurative parotitis (ASP) is a serious bacterial infection of the parotid gland that occurs in patients with diminished salivary flow, increased susceptibility to infection, and poor oral hygiene. Our patient had multiple risk factors for this disease which can include dehydration, advanced age, sialolithiasis, medications (diuretics, beta-blockers, antihistamines, phenothiazines, tricyclic antidepressants, anticholinergics), and certain disorders including diabetes, HIV, hypothyroidism, Sjogren’s syndrome. The most common organisms responsible for ASP are Staphylococcus aureus and oral flora anaerobes.

The most feared complications include supraglottitis, cervical necrotizing fasciitis, and other deep neck space infections which can be surgical emergencies and rarely cause impending airway obstruction. Further central and vascular complications include brain abscess, central venous thrombosis, and Lemierre’s syndrome

Take-Home Points

  • The role of bedside ultrasound in acute suppurative parotitis can help to rule out a superficial abscess or sialolithiasis. CT scan is beneficial in ruling out deep space infections as a complication from this disease process or other causes of head and neck swelling.
  • ASP-associated complications are rare but can lead to significant morbidity and mortality secondary to the parotid gland’s proximity to vital structures and ability to spread to adjacent deep spaces.
  • Emergency medicine physicians will manage acute suppurative parotitis and must be aware of the potential complications when determining safe disposition and appropriate treatment.

  • Markovich A, Ronen O. Factors predicting length of stay in patients hospitalized for acute parotitis. J Investig Med. 2021 Feb;69(2):388-392. doi: 10.1136/jim-2020-001506. Epub 2020 Oct 21. PMID: 33087427.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2022-09-11T10:03:16-07:00Sep 12, 2022|HEENT, SAEM Clinical Images|
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Trick of the Trade: Winging It with External Jugular Cannulation

external jugular

Sankoff J, et al. WJEM (2008)

Imagine yourself caring for a patient that needs urgent vascular access, but several attempts at peripheral intravenous (IV) cannulation have been unsuccessful. You aren’t quite at the point where emergent intraosseous or central venous access is indicated. Maybe those options aren’t even available where you’re working. From across the room, though, you can see a very prominent external jugular (EJ) vein. Sadly, you remember the last EJ line you placed falling out almost immediately.

Patients with challenging peripheral intravenous access in the extremities may require and benefit from cannulation of the EJ. Often done in the setting of resuscitation, securing these angiocatheters on the neck can be difficult. Tape and dressings may not stick due to sweat and anatomical limitations. Rotation, flexion, and extension of the neck can displace the catheter.

Trick of the Trade

If available, modify a winged angiocatheter to allow suturing to the skin of the neck.

angiocatheter

  • Create two small holes, one on each wing of the angiocatheter, using a sharp instrument such as scissors, scalpel, or needle.
  • Place EJ line and secure to the skin using sutures, similar to stabilization of central or arterial line.

Winged angiocatheters may not be available in all clinical institutions. International readers of ALiEM may be more familiar with their use.

However, this trick introduces the idea of finding creative modifications of available catheters to allow for suturing and securing of alternative IV lines. Modifications similar to this Trick of the Trade can be considered when placing “deep” peripheral IVs or pseudo-midline IVs such as when using extended-length angiocatheters or repurposed arterial catheters where suture can be wrapped around the hub. This approach may also be useful in peripheral cannulation of the internal jugular vein. 

Tip: Be careful not to pierce the catheter or compress it down when suturing.

More from ALiEM on EJ cannulation:

Interest in other tricks?

Read more articles in the Tricks of the Trade series.

By |2022-09-08T15:18:30-07:00Sep 9, 2022|Tricks of the Trade|
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ALiEM AIR Series | Neurology 2022 Module

Welcome to the AIR Neurology Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online content related to neurological emergencies in the Emergency Department. 5 blog posts met our standard of online excellence and were curated and approved for residency training by the AIR Series Board. We identified 2 AIR and 3 Honorable Mentions. We recommend programs give 3 hours (about 30 minutes per article) of III credit for this module.

AIR Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

Take the AIR Neurology Quiz at ALiEMU

Interested in taking the AIR quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.

Highlighted Quality Posts: Neurological Emergencies

Site Article Author Date Label
EMDocs Cauda Equina Syndrome: Why do we miss it? How to improve? John H. Priester, MD and Mark Bisanzo, MD 13 Jun 2021 AIR
EMCrit Spinal Epidural Abscess Josh Farkas, MD 25 Feb 2022 AIR
Clinical Monster Must Be Blood on the Brain Molly Piccione, DO 3 June 2021 HM
EMCrit Neuro emergencies in pregnancy Josh Farkas, MD 23 Feb 2022 HM
EMCrit Neuro-onc emergencies Josh Farkas, MD 2 June 2022 HM

(AIR = Approved Instructional Resource; HM = Honorable Mention)

If you have any questions or comments on the AIR series, or this AIR module, please contact us! More in-depth information regarding the Social Media Index.

Thank you to the Society of Academic Emergency Medicine (SAEM) and the Council of EM Residency Directors (CORD) for jointly sponsoring the AIR Series! We are thrilled to partner with both on shaping the future of medical education.

By |2026-06-16T16:18:05-07:00Sep 2, 2022|Approved Instructional Resources (AIR series)|
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SAEM Clinical Images Series: Breast Swelling

A female in her 50s with a past medical history of coronary artery disease, pacemaker placement, hypertension, and ESRD presented to the emergency department with the chief complaint of missed dialysis, breast engorgement, and an increase in vascularity in her chest and abdomen. The patient reported an increase in breast swelling and increased vascularity in her belly over the past three months. Additionally, she woke up short of breath on the morning of presentation and reported dyspnea at rest. She denied chest pain, diaphoresis, breast pain, fever, rash, trauma to the breasts, or drainage.

 

Vitals: T 36.9°C; HR 105; BP 109/74; RR 20; O2 sat 97% on nasal canula @ 3L

Neck: JVD

Lungs: Bilateral crackles

Chest and abdomen: Increased vascularity

Breast: Bilateral breast swelling and redness

Lower extremity: Bilateral pitting edema and varicose veins

Basic metabolic panel (BMP): K 6.9; Cr 9.53

Brain natriuretic peptide (BNP): >35,000

Troponin I: 0.1

DDX: Inflammatory carcinoma, mastitis, superior vena cava syndrome, portal hypertension, pulmonary hypertension, pulmonary embolism.

Superior vena cava (SVC) syndrome results from any condition that leads to obstruction of blood flow through the SVC. Our case was caused by complete occlusion from a thrombus and the patient presented with bilateral breast swelling, skin changes (peau d’orange), and an increase in vascularity in the abdomen and chest (caput medusa). Breast tissue largely drains into the axillary veins, and more proximally into the subclavian veins. Due to occlusion of the SVC, a complete backup of venous flow occurs, resulting in all of the noted collateral hypervascularity.  Often SVC occlusion is caused by malignancy obstructing the superior vena cava or invading the vein.

The CTA demonstrates occlusion of the superior vena cava. There are multiple varices in the chest wall and the imaged upper abdominal wall. There is also diffuse subcutaneous edema with diffuse soft tissue swelling and skin thickening of the bilateral breasts.

Take-Home Points

  • Consider superior vena cava occlusion in patients undergoing hemodialysis who present with the above physical exam findings.
  • Consider occult malignancy as the source or cause of thrombosis.
  • Be sure to fully expose your patient when appropriate and keep your differential broad.

  • Corduff N, Rozen WM, Taylor GI. The superficial venous drainage of the breast: a clinical study and implications for breast reduction surgery. J Plast Reconstr Aesthet Surg. 2010 May;63(5):809-13. doi: 10.1016/j.bjps.2009.02.055. Epub 2009 Apr 3. PMID: 19345164.
  • Friedman T, Quencer KB, Kishore SA, Winokur RS, Madoff DC. Malignant Venous Obstruction: Superior Vena Cava Syndrome and Beyond. Semin Intervent Radiol. 2017 Dec;34(4):398-408. doi: 10.1055/s-0037-1608863. Epub 2017 Dec 14. PMID: 29249864; PMCID: PMC5730434.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2022-08-28T22:47:29-07:00Aug 29, 2022|Heme-Oncology, Radiology, SAEM Clinical Images|
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