Stephen Koch, M.D.*
Associate Professor
Joseph L. Nates, M.D.
Assistant Professor
Departments of Anesthesiology* and Neurosurgery
Memorial-Hermann Hospital
University of Texas Medical School-Houston
Houston, Texas
The correct citation of this article for reference is:
Koch S, Nates J: Answer to Case of the Month; Case 2. The Internet Journal of Emergency and Intensive Care Medicine 1999; Vol3 N2: http://www.ispub.com/journals/IJEICM/Vol3N2/answer2.htm. Published July 1, 1999; Last Updated July 1, 1999.
The question was:
No need for words.
1. What abnormalities are demonstrated by the cardiac silhouette?
2. What is your differential diagnosis of this chest x-ray?
3. How does this chest x-ray findings relate to the Brooklyn Bridge in New York City?
The answer is:
This case represents a 45 year-old diver found washed ashore on the coast. The deceased
was in
complete diving gear and no evidence of trauma was noted. An autopsy was performed and
this
radiograph was obtained at the start of that examination.
The chest radiograph demonstrates complete filling of the heart with air due to massive
gas
embolism. Blood has been forced out of all chambers of the heart by the coalescing
bubbles. The
differential diagnosis would include nosocomial injection of air such as with placement of
a central
line. The findings of this radiograph relate to the Brooklyn Bridge in New York
historically. During
the construction of the bridge the engineers worked on the supports under the water of the
East
River. In order to work at depth they entered into chambers, called caissons, which were
then
lowered to the river bed where construction work was performed. Unfortunately, these
caissons
were not pressurized. Upon returning to the surface many of the workers suffered
debilitating injuries
that only years later were recognized as results of decompression illness. Hence the term
‘caisson’s
disease’ is synonymous with the ‘bends’ or more accurately, decompression
illness. In fact,
explosive decompression occurred on several occasions leading to death from asphyxiation,
drowning, and decompression. Such explosive decompression could have produced radiographic
changes as seen in our case.
Figure 1: Chest Xray with complete filling of the heart with air due to massive gas embolism
Please e-mail any comments to : jnates@anes1.med.uth.tmc.edu
© Internet Scientific Publications,
L.L.C., 1996 to 1999.
First Published: October 1996
