Pearl for 12/21

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    Pearl for 12/21

    A 25 yo male with no PMH walks into your ED complaining of right neck pain, right shoulder stiffness,  and cough x 1 month, no fevers chills. On exam his vitals are all within normal limits, exam is notable for right sided swelling and asymmetric neck. CXR as below:

     

     

     

    What are you concerned for? What should be your next imaging modality?

     

    SVC syndrome, CT+ of chest to evaluate SVC/IJs, and for mediastinal mass.

     

    This patient had clot in his b/l IJs, SVC, Rt axillary vein, pericardial effusion and a mediastinal mass found to be lymphoma. Still undergoing treatment.

     

    SVC syndrome is basically the manifestations of blocked flow back to the heart from either SVC compression from outside source, or from obstruction from within (clot). You will see swelling in the neck, face and possibly arm. You can see facial flushing especially when you ask the patient to raise their arms (see comments). You will see distended neck veins and cough.  The other fact to know about it is that people with SVC syndrome develop collaterals to allow bloodflow back to the heart, principlally the azygos vein.  

     

    From Deja Review:

    What are some important things to know about superior vena cava syndrome (SVCS)?

    Gradual compression of the SVC; SVCS is associated chiefly with malignancy; Bronchogenic CA accounts for more than 80% of cases of SVCS

     

    What are some other causes of SVCS aside from malignancy?

    Thrombosis (central venous instrumentation); Infectious causes (i.e., tuberculosis/syphilis); Lymphoma

     

    What are some clinical features of SVCS?

    Venous distension of face/upper extremity, facial flushing, headache, JVD, cough, and dyspnea

     

    What are some important diagnostic tests to consider in SVCS?

    CXR: Mass or widened mediastinum; Thoracic CT: test of choice; Histological sample: important for therapy

     

    What are some key points in the management of SVCS?

    ABCs: rarely present acutely; Tissue diagnosis for palliative therapy; Elevation of head provides some relief

     

    Jang, David. Deja Review : Emergency Medicine.

    Blacklick, OH, USA: McGraw-Hill Medical Publishing Division, 2007. p 172.

    http://site.ebrary.com/lib/nyulibrary/Doc?id=10210127&ppg=188

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