Lines, Tubes and ICU CXR - Smith
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This document provides guidance on interpreting chest X-rays in the ICU setting. It discusses how to image patients properly with positioning at least 6 feet from the tube at 40 inches. Key areas to evaluate include lines and tubes like ET tubes, central lines, and feeding tubes. The heart, lungs and potential effusions should also be examined. Interpretation is most useful considering clinical context as findings can be subtle. Overall it aims to provide a systematic approach and checklist for ICU chest X-ray interpretation.
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This document discusses Doppler ultrasound of the carotid arteries. It begins with an introduction describing how carotid artery disease can cause strokes and how ultrasound is used to diagnose stenosis to determine surgical candidates. It then describes the anatomy of the carotid arteries and outlines the normal ultrasound appearance. Key points of a carotid ultrasound exam are described including using grayscale, color Doppler, power Doppler and spectral analysis. Different types of carotid plaques are defined as well as how they appear ultrasonographically. Methods for evaluating stenosis and differentiating true from pseudo-spectral broadening are also covered.
Adult Chest X-Rays Of The Month - #46
Drs. Angela Pikus, Alex Blackwell, Mark Baumgarten, Rosa Malloy-Post are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
• Abnormalities of the Thoracic Aorta
o Traumatic aortic disruption
o Thoracic aortic aneurysm with acute dissection
Cxr revised 24 11-91
1. The document provides a detailed overview of normal chest x-ray anatomy, including labeling structures such as the trachea, heart, lungs, diaphragm, and bones.
2. Key points covered include normal sizes and positions of anatomical structures, differences between inspiration and expiration films, and examples of pathological changes.
3. Recommendations are provided for techniques to ensure quality chest x-rays as well as a systematic approach to reading chest x-rays starting from the abdomen and progressing to the lungs.
Similar to Lines, Tubes and ICU CXR - Smith (20)
Chest x ray quality - how to interpret chest x-ray (1)
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Noon conference specialty talk ccu 5-7-19
Critical care involves managing organ system failures while considering the overall clinical picture of the patient. Less invasive interventions are preferred when possible to avoid iatrogenic harm. Prognostication is difficult, and outcomes depend on the individual patient's values and preferences. Family meetings require skilled communication to make difficult end-of-life decisions. The goal is providing humane care that aligns with patient priorities through a team-based approach.
Jgk noon conference 5.7.19
This document summarizes a bioethics case discussion involving a 68-year-old female patient with metastatic lung cancer. The patient was admitted for pneumonia and influenza and experienced a complex clinical course involving recurrent infections, malnutrition, and declining functional status. Discussions with family focused on unclear goals of care and difficulty accepting a transition to comfort measures. An ethics consult recommended a one-week trial of aggressive care with clear outcomes to help guide decision making. After the trial failed and a deathbed visit from her son, the family agreed to transition to comfort care, where the patient later passed away. The document reviews key challenges, outcomes, and bioethics considerations around medically appropriate treatment and incorporating patient perspectives when decisional capacity is lacking
Organism potpourri 5 6-2019
The document summarizes several infectious disease cases presented at a noon conference. The first case discusses a male presenting with cough and fever who was diagnosed with blastomycosis after cytology found Blastomyces dermatitidis. The second case involves a pregnant woman from Nigeria with malaria diagnosed on peripheral smear after visiting a rural village. The third case is about a man returning from Saint Martin with joint pains and fever, possibly due to arboviral infections like chikungunya or dengue. The last two cases discuss a man with L4-L5 osteomyelitis and sacroiliitis diagnosed with brucellosis, and a woman with cervical lymphadenopathy possibly having toxoplasmosis
Noon conference 2 caballero
Meghan Caballero presented a noon conference on factitious disorder. The objectives were to review definitions, epidemiology, pathogenesis, clinical features, diagnosis, and treatment options for factitious disorder. Factitious disorder involves patients deceiving doctors by misrepresenting or inducing medical symptoms without an obvious reward. It affects about 1% of clinical settings and usually presents in adults in their 30s or 40s following hospitalization. Diagnosis requires falsified symptoms and deception according to DSM-5 criteria. Treatment focuses on psychotherapy but many patients refuse or do not follow up with psychiatric care.
Clinical osa evaluation (residents)
This document discusses obstructive sleep apnea (OSA) in women. It notes several anatomical factors that can contribute to OSA in women, such as a smaller airway size, elongated airway, and micrognathia. It compares the costs, convenience, accuracy, and comfort of different diagnostic tests for OSA, including home sleep tests, in-lab polysomnography (PSG), and PSG with positive airway pressure titration (PAP). The document also images several CPAP mask options and oral appliance therapies that can be used to treat OSA. It concludes by providing contact information for a sleep physician.
Noon conference opheim 050219
A 38-year-old woman presents with abnormally heavy menstrual bleeding. Her periods are now 10 days long compared to her normal 5 days. She has lower abdominal cramping and mild dizziness. Exam is normal. Initial testing shows a hemoglobin of 10.5 (down from 12 six months ago). Pelvic ultrasound reveals a left-sided submucosal fibroid. The patient is prescribed a course of progesterone which does not fully resolve her bleeding. She is referred for hysteroscopic or laparoscopic myomectomy to treat her symptomatic submucosal fibroid.
Tb answer sheet
The document discusses guidelines for tuberculosis (TB) testing and treatment. It provides criteria for positive TB test results based on induration size and risk factors. It notes that interferon gamma release assays (IGRAs) are at least as sensitive as the tuberculin skin test (TST) for detecting TB infection. Both tests detect exposure to TB but cannot differentiate between active disease and latent infection. IGRAs are preferred in those with BCG vaccination or nontuberculous mycobacterium infection history. Treatment options for latent TB infection include various combinations of isoniazid and rifampin administered for 3-9 months, depending on medications and patient risk factors such as HIV status.
Latent tb worksheet
A 42-year-old healthcare worker presents for follow-up of a recent tuberculin skin test (TST) which showed 12mm of induration. He has no symptoms of active tuberculosis such as cough, fever, or night sweats. The next most appropriate step in management is to start isoniazid treatment for latent tuberculosis.
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This document provides guidance on performing and interpreting CT head scans. It outlines the basic search pattern for a CT head, including examining for hemorrhage, signs of infarct, brain parenchyma, and other structures. It also lists some blind spots on CT head scans. The document then describes several case examples of acute stroke, subdural hemorrhages of different ages, epidural hematomas including a special venous type, subarachnoid hemorrhage, fat embolism after injury, and interpreting gunshot wound head CTs.
2019 04-30 noon conference [stephen slade]
This document summarizes information about subacute granulomatous (De Quervain) thyroiditis and compares it to Adult Stills disease. Subacute thyroiditis is often caused by a viral infection and presents with neck or jaw pain, a tender thyroid, and elevated inflammatory markers. It follows a path of varying thyroid hormone levels and typically resolves with follicular regeneration. Adult Stills disease has an unclear trigger but presents with quotidian fevers, arthritis, and an evanescent rash, requiring immunosuppression for treatment. Key differences between the conditions are highlighted regarding epidemiology, clinical presentation, diagnostics, and therapeutics.
Noon conference banta
This document summarizes a noon conference on cerebellar infarcts. It discusses the cerebellum's anatomy and circuitry, the clinical presentation of cerebellar infarcts including limb ataxia and gait imbalance. Physical exam techniques like HINTS are covered. Diagnostic tests like MRI are discussed as the gold standard. Treatment options like tPA are mentioned. An illness script compares cerebellar infarct to vestibular neuritis, outlining their differences in pathophysiology, epidemiology, clinical presentation, diagnostics and therapeutics.
Mm 4 29-19
This document summarizes a case presentation of a patient with recurrent diabetic foot infections and osteomyelitis leading to multiple amputations over several years. Despite aggressive treatments including multiple debridements and long-term IV antibiotics, the patient continued to experience complications from non-adherence to wound care and medications. A discussion of the case highlighted potential errors like lack of standardized treatment protocols, fragmented care coordination, and challenges providing consistent care for a patient in a rural area with psychiatric issues. Lessons focused on the need for multidisciplinary teams and addressing both medical and social factors to best manage these complex cases.
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Noon conference Lobaton
This document discusses Wernecke's encephalopathy, a neurological condition caused by thiamine (vitamin B1) deficiency. It begins by outlining the objectives and importance of thiamine. The classic triad of signs includes encephalopathy, oculomotor dysfunction, and gait ataxia, though this full triad is only seen in about 33% of cases. Diagnosis is clinical but may include MRI showing lesions in the thalamus, mamillary bodies, and periaqueductal region. Treatment involves high-dose intravenous or intramuscular thiamine supplementation. Wernecke's encephalopathy is commonly associated with chronic alcoholism but can occur in other conditions involving malnutrition
Noon conference kaylee park
1) The objectives of the noon conference were to review warm autoimmune hemolytic anemia (AIHA), including diagnostic criteria, clinical presentation, and treatment.
2) A case study was presented of a 27-year-old woman with systemic lupus erythematosus (SLE) and new onset fatigue and shortness of breath. Her lab results were consistent with warm AIHA.
3) Warm AIHA was discussed in detail, including diagnostic criteria of anemia, elevated LDH, low haptoglobin, positive direct antiglobulin test; clinical presentation of anemia, hemolysis, associated conditions; and first-line treatment of high dose corticosteroids.
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Upper Respiratory Tract Infections: Pharyngitis, Epiglottitis, Deep Infections in Head and Neck
The document discusses various upper respiratory tract infections including pharyngitis, epiglottitis, and deep neck space infections. It provides guidelines for evaluating and diagnosing pharyngitis using the Centor criteria to determine if testing for Group A streptococcus is needed. It also discusses non-streptococcal causes of pharyngitis and outlines considerations and workup for dangerous deep neck space infections like epiglottitis and peritonsillar abscesses. The goal is to appropriately diagnose and treat conditions like streptococcal pharyngitis while excluding
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This document summarizes a presentation on Cyclic Vomiting Syndrome (CVS). It discusses the clinical manifestations of CVS including stereotypical vomiting episodes, intervals of good health between episodes, and absence of an organic cause. It outlines the diagnostic criteria per Rome IV as having stereotypical episodes of vomiting at least 3 times in the past year, with varying intervals of good health in between. The pathogenesis of CVS is unknown but has been associated with migraines. Treatment involves abortive medications like sumatriptan for mild episodes and prophylactic tricyclic antidepressants for more frequent/severe episodes. An illness script compares CVS to Cannabinoid Hyperemesis Syndrome.
Crc talk for residents 2019
Colorectal cancer screening aims to detect cancer early and prevent cancer by removing precancerous polyps. Screening decreases colorectal cancer incidence and mortality in those over 50 by finding cancer at earlier stages. However, incidence and mortality have increased in younger adults in recent decades. Current guidelines recommend starting screening at 45 or 50 depending on risk factors, but starting at 45 is controversial due to costs and potential strain on resources. The main objectives of screening are detecting cancer early and removing polyps to prevent cancer.
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This document discusses multiple myeloma (MM) and monoclonal gammopathy of undetermined significance (MGUS). It defines MGUS and describes its three distinct types. It outlines the workup, disease course, and monitoring for MGUS. Complications of MGUS discussed include anemia, fractures, and thrombosis. MM is then reviewed, including typical presentations and complications like renal disease. Renal disease in MM is further explained, focusing on light chain cast nephropathy.
19 im resident future of rectal cancer
The document summarizes recent developments in the treatment of rectal cancer. It notes that standard therapy involving total mesorectal excision and chemoradiation leads to permanent ostomy in 25% of patients and late toxicity. New studies are exploring non-operative management for patients who achieve a clinical complete response after neoadjuvant therapy, with similar survival outcomes but higher rectal preservation rates compared to surgery. Biomarkers such as dMMR status and neuroendocrine histology may help personalize treatment approaches for rectal cancer patients.
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Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
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10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
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Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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Lines, Tubes and ICU CXR - Smith
- 1. Lines, tubes, and the ICU Chest X-ray Phil Smith Radiology Resident
- 3. ICU Chest X-ray • Who and how to image • Image interpretation basics – Lines and tubes
- 4. What does a single view chest x-ray cost?
- 5. • Professional charge $9.36 • Technical charge $12.96
- 6. Who and how to image?
- 9. How to image? 6 feet (72 in)
- 10. 40 inches
- 11. Chest x-ray findings are extremely non-specific and of significantly more value when interpreted in light of clinical information Significant findings can be extremely subtle or impossible to see by CXR “Screening Test” Limitations
- 12. Have a system • Overall assessment • Lines and tubes • Heart/Vessels • Lungs • Effusions • Other: Mediastinum and hila, pneumothorax, upper abdomen, bones
- 13. Overall Assessment • Will I be able to get useful information from this image? – Quality of image – Positioning – Inspiratory effort
- 14. Inspiration
- 15. Lines and Tubes • ET tube • Central venous catheters • Nasoenteric tubes • Not discussed: chest tubes, IABPs, among others
- 16. ET Tube • Optimally 5 cm above carina (at least 2 cm) • Tube position changes with head – “hose goes with the nose” Godroy MCB. Chest Radiography in the ICU: Part 1, Evaluation of Airway, Enteric, and Pleural Tubes. AJR 2012; 198:563–571.
- 19. Central Venous Catheters • Optimal position is in lower third of SVC to cavoatrial junction • VM Institutional Standards: – Tip location for all centrally located vascular access devices: • Optimal tip location: Lower superior vena cava/upper right atrium • Acceptable tip location: Mid-superior vena cava. • Unacceptable tip location: Brachiocephalic, upper superior vena cava, innominate vein.
- 22. Post-placement checklist • Line course and tip position • Complications? – PTX – Hematoma or other significant change
- 23. Problematic central lines • Approximately 10% of the chest radiographs obtained immediately after insertion demonstrated malpositioned catheters • Pneumothoraces were present in only a small percentage of patients. • Complications were twice as common with subclavian catheters (17% versus 8%), although unsuspected complications were infrequent. Literature review from ACR Appropriateness Criteria
- 36. Nasoenteric Tubes Dobhoff feeding tube (“weight enteric feeding tube”) Nasogastric decompression tube
- 37. Nasoenteric tubes • Optimal position depends on intended use – Feeding tube – distal stomach or duodenum – Decompression – both tip and side port below GE junction
- 38. Anatomy
- 42. Heart/Vessels • Normal cardiac silhouette up to ~55% of thoracic width on a portable (AP) exam • Also an increase in size of cardiac silhouette such would considered potentially abnormal • Vessels to the lung bases should be more numerous and larger than those to the upper lung • Vessels should not be easily visible in the periphery of the lung
- 43. Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 12334
- 47. Heart/Vessels • PA Pressures: • 10 mm Hg: Normal • 15 mm Hg: Vascular recruitment • 20 mm Hg: Interstitial edema • >25 mm Hg: Alveolar edema
- 48. Lungs • Volumes – Inspiration – Symmetry • Look for normal borders • Look for opacity – If volume loss -> atelectasis – If no evidence of volume loss -> not atelectasis • Look at recent priors to determine timing of onset
- 53. Lungs
- 54. Effusions • Can be difficult to see on a portable CXR – Need 500 cc of effusion to reliably see on a portable exam • Blunting of costophrenic angles • Fluid in minor fissure • “Gradient” of opacity with obscuration of the diaphragm