imaging in the icu
TRANSCRIPT
Nov 2006 Kishore P.Critical Care Conference
Imaging in the ICU
Nov 2006 Kishore P.Critical Care Conference
Modalities
• X-Ray
• CT scans
• MRI
• Ultrasound examinations
• Angiography
• Flouroscopy
Nov 2006 Kishore P.Critical Care Conference
X-Ray
• Most common
• AP view
• Centering difficult
• Exposure equalization difficult
• X-Rays other than chest difficult
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Nov 2006 Kishore P.Critical Care Conference
Case 1
• 70 year old diabetic reverend admitted to the ICU for Urosepsis. Intubated for poor sensorium and labored breathing. On treatment gradually getting better.
On day 5, being weaned from ventilation when he desaturates with no hemodynamic instability.
On examination has decreased breath sounds on right side and crackles bilaterally
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Nov 2006 Kishore P.Critical Care Conference
Collapse
• Humidification
• Suction
• Chest physiotherapy
• Position
• PEEP
• Bronchoscopy
Nov 2006 Kishore P.Critical Care Conference
Case 2
• 30 yr old man with AML on chemotherapy develops bilateral fungal pneumonia. He is intubated for persistent hypoxia in spite of CPAP. His lung infiltrates worsen on Amphotericin and antibiotics and he requires high peep, low tidal volumes and prone position ventilation to maintain saturations of 88-92%. He is also on high inotropes. On Day 15, he develops a sudden deterioration of oxygenation and hemodynamics.
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898326C• 20 yr old primi with scrub typhus
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Nov 2006 Kishore P.Critical Care Conference
Pneumothorax
• Deep sulcus sign
Nov 2006 Kishore P.Critical Care Conference
Hemodynamic compromiseSuspected tension
Hemodynamically stable
Needle aspiration and chest tube
placement
FiO2 100%Reduce PEEP to 3
FiO2 100%Reduce PEEP to 3
Chest X-Ray
Clinically suspected pneumothorax
Chest X-Ray
Mechanical ventilationSymptomatic
Self ventilatingasymptomatic
Chest tube/pigtailConservative management
Nov 2006 Kishore P.Critical Care Conference
Case 3
• Patient with Multiple Myeloma on mechanical ventilation for respiratory failure due to bilateral pneumonia.
• FiO2 100%, PEEP 15cm H2O, TV 360ml
Rate 35/min.
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B
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16 year old girl with ITP,autoimmune thyroiditis and medium vessel vasculitis on mechanical ventilation with high PEEP for ARDS due to viral pneumonia
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Nov 2006 Kishore P.Critical Care Conference
Causes of pneumomediastinum in mechanical ventilation
• High tidal volumes
• High PEEP
• “fighting” the ventilator
• Auto PEEP
Nov 2006 Kishore P.Critical Care Conference
Case 4
• 35 yr old lady with SLE and lupus nephritis and mild CRF on steroids is intubated for severe hypoxia when she presents to the emergency department with breathlessness.
Examination reveals bilateral crackles. She is started on cover for bacterial, fungal and PCP etiologies.
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Ely, E. W. et al. Chest 2002;121:942-950
The VPW is measured by (1) dropping a perpendicular line from the point at which the left subclavian artery exits the aortic arch and (2) measuring across to the point at which the superior vena cava crosses the right mainstem bronchus
Vascular Pedicle Width
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Nov 2006 Kishore P.Critical Care Conference
• Patients with a VPW > 70mm coupled with a cardiothoracic ratio >0.55 are more than three times likely to have a Pulmonary Artery Occlusion Pressure > 18mm Hg compared to those without these findings.
Wayward Lines
Nov 2006 Kishore P.Critical Care Conference
Review
• Collapse
• Deep sulcus sign for pneumothorax
• Pneumomediastinum
• Fluid overload-VPW
• Pleural effusion
• Wayward lines