The question was:

No need for words.

1. What is the abnormality?

2. What is your differential diagnosis of this CT of the brain?

3. Based on this CT what would the bronchoscopy show?

The answer is:

A 50 year-old woman presented in coma following removal from a house fire. She was intubated at the scene and transported via helicopter to our facility. Admission carboxyhemoglobin concentration was 15.7%. A head CT obtained in the emergency center showed bilateral hypodensities in the globus pallidus. These lesions have been regarded as a pathological hallmark of CO poisoning, but they have been seen in non-CO hypoxic/ischemic injury as well.

Figure 1

Figure 1: Head CT showing bilateral hypodensities in the globus pallidus

The patient underwent emergent hyperbaric oxygen therapy without a change in her neurological condition. She was admitted to the ICU and a bronchoscopy was performed and demonstrated excessive amounts of soot throughout all airways examined. Some erythema was noted as well. See chest x-ray and photograph below. Despite aggressive positive pressure ventilation she expired the day following admission from progressive hypoxemia.

Figure 2

Figure 2: Chest X-Ray

Figure 3

Figure 3: Trachea in endoscopy

Figure 4

Figure 4: Carina in endoscopy

Figure 5

Figure 5: Small airways in endoscopy

Suggested Literature:

Tomson LF, et al. Management of the moribund carbon monoxide victim. Archives of Emergency

Medicine 1992;9:208-213.

Starkstein SE, et al. Psychic Akinesia following bilateral pallidal lesions. International Journal of

Psychiatry in Medicine. 1989;19:155-164.

Please e-mail any comments to : jnates@anes1.med.uth.tmc.edu