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Imaging in the ICU

Imaging in the ICU. Modalities. X-Ray CT scans MRI Ultrasound examinations Angiography Flouroscopy. X-Ray. Most common AP view Centering difficult Exposure equalization difficult X-Rays other than chest difficult. ??. Case 1.

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Imaging in the ICU

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  1. Imaging in the ICU Kishore P. Critical Care Conference

  2. Modalities • X-Ray • CT scans • MRI • Ultrasound examinations • Angiography • Flouroscopy Kishore P. Critical Care Conference

  3. X-Ray • Most common • AP view • Centering difficult • Exposure equalization difficult • X-Rays other than chest difficult Kishore P. Critical Care Conference

  4. ??

  5. 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 Kishore P. Critical Care Conference

  6. 876308A

  7. 876308A

  8. 918121C

  9. Collapse • Humidification • Suction • Chest physiotherapy • Position • PEEP • Bronchoscopy Kishore P. Critical Care Conference

  10. 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. Kishore P. Critical Care Conference

  11. 864620C

  12. 864620C

  13. 864620C

  14. 864620C

  15. 864620C

  16. 898326C • 20 yr old primi with scrub typhus

  17. 898326C

  18. 898326C

  19. Pneumothorax • Deep sulcus sign Kishore P. Critical Care Conference

  20. Clinically suspected pneumothorax Hemodynamic compromise Suspected tension Hemodynamically stable FiO2 100% Reduce PEEP to 3 FiO2 100% Reduce PEEP to 3 Chest X-Ray Needle aspiration and chest tube placement Mechanical ventilation Symptomatic Self ventilating asymptomatic Conservative management Chest X-Ray Chest tube/pigtail Kishore P. Critical Care Conference

  21. 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. Kishore P. Critical Care Conference

  22. A

  23. A B 16 year old girl with ITP,autoimmune thyroiditis and medium vessel vasculitis on mechanical ventilation with high PEEP for ARDS due to viral pneumonia

  24. A B

  25. Causes of pneumomediastinum in mechanical ventilation • High tidal volumes • High PEEP • “fighting” the ventilator • Auto PEEP Kishore P. Critical Care Conference

  26. 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. Kishore P. Critical Care Conference

  27. 890403C

  28. 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 Ely, E. W. et al. Chest 2002;121:942-950 Kishore P. Critical Care Conference

  29. Vascular Pedicle Width

  30. 890403C

  31. 278680A

  32. 832720C-malaria

  33. 839892C

  34. 801557C-scrub

  35. 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. Kishore P. Critical Care Conference

  36. Wayward Lines

  37. Review • Collapse • Deep sulcus sign for pneumothorax • Pneumomediastinum • Fluid overload-VPW • Pleural effusion • Wayward lines Kishore P. Critical Care Conference

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