放射医学艺术课件

,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Medical Arts Radiology,Barry R. Morgenstern, M.D.,Medical Arts RadiologyBarry R.,1,Tubes and Lines,What, Where and Whoops,Tubes and LinesWhat, Where a,2,Format of Lecture,For each device,What,they are and what they do,Where,they belong,Whoops, malpositioning and complications,Format of LectureFor each devi,3,放射医学艺术课件,4,放射医学艺术课件,5,Endotracheal Tubes,What They Are Used For,Indications for,Assisted ventilation,Isolate trachea to permit control of airway,Prevents gastric distension,Direct route for suctioning,Administration of medications via ETT,Endotracheal TubesWhat They A,6,Endotracheal Tubes,Where,Tip should be 2 - 5cm above carina,Between clavicles and carina,Carina usually at level of T4,Tip may change by 2cm with flexion/extension,Balloon should never distend tracheal walls; if 2.8 cm, suspect laceration,Endotracheal TubesWhereTip sh,7,Endotracheal Tubes,Whoops,Most common malposition: tip in right mainstem bronchus,Leads to atelectasis, or,Right-sided tension pneumothorax,Tube in larynx or pharynx,Damage vocal chords,Aspiration,Endotracheal TubesWhoopsMost,8,R3,Tip of endotracheal tube,(yellow arrow),lies well above the carina,(green arrow),R3Tip of endotracheal tube (ye,9,Tracheostomy,What,Indications for,Airway obstruction at or above level of larynx,Respiratory failure requiring long-term intubation (21 days),Obstruction during sleep apnea,Paralysis of muscles that affect swallowing or respiration,TracheostomyWhatIndications f,10,Tracheostomy,Where,Tip half-way between stoma and carina,About T3,Tip placement not affected by flexion/extension,Width of tube about 2/3 width of trachea,TracheostomyWhereTip half-way,11,Tracheostomy,Whoops,Immediately after,Subcutaneous emphysema,Pneumomediastinum,Pneumothorax,Cuff should not be 1 times diameter of lumen,Tracheal stenosis,TracheostomyWhoopsImmediately,12,Tracheostomy,Tracheal Stenosis,Most common late-occurring complication of tracheostomy tube,May occur at stoma, level of cuff or at tip of tube,Most common at stoma,Fibrosis with destruction of cartilage,At cuff site, usually 2 to circumferential scar,TracheostomyTracheal Stenosis,13,R3,Tip of tracheostomy tube,(yellow arrow),lies about midway between the stoma,(blue arrow),and carina,(green arrow),R3Tip of tracheostomy tube (ye,14,Intravascular Lines,Intravascular Lines,15,Central Venous Catheters,What,Used in critically ill patients,For venous access,Measurement of central venous pressure,Intravascular blood volume,Central Venous CathetersWhatU,16,Central Venous Catheters,Where,Subclavian joins brachiocephalic vein behind medial end of clavicle,Catheter should reach this point before descending,Catheter should descend lateral to spine and,tip should be in the SVC,Central Venous CathetersWhere,17,Central Venous Catheters,Whoops,Most often malpositioned in RV or internal jugular,Arrythmias in RV; inaccurate CVP readings elsewhere,Occasionally outside blood vessel,Look for sharp bends in catheter,Arterial placement suggested by pulsatile flow,Central Venous CathetersWhoop,18,Central Venous Catheters,Complications,Air embolism,Pneumothorax (5%),Hemothorax,Cardiac perforation,Sepsis,Venous perforation,Central Venous CathetersCompl,19,Central Venous Catheters,Two or more attempts,Should initial placement fail, get a chest x-ray before trying other side to avoid bilateral pneumothoraces,Central Venous CathetersTwo o,20,R3,Tip of central venous catheter,(yellow arrow),curves gently downward into superior vena cava,R3Tip of central venous cathet,21,PICC Lines,Percutaneous Intravascular Central Catheters,What,Used for long-term access,Small size catheters (4-5F),Single or dual lumen,Inserted through antecubital or basilic/cephalic vein,Where,Tip should lie within SVC,Whoops,Tips may become malpositioned over time,PICC LinesPercutaneous Intrav,22,Pulmonary Artery - Swan-Ganz Catheters,What,Swan-Ganz catheters,Aid in differentiating cardiac from non-cardiac pulmonary edema,Pulmonary Artery - Swan-G,23,Pulmonary Artery - Swan-Ganz Catheters,Where,Tip should lie within right or left pulmonary artery,2cm from hila,Balloon inflated only when measurements are made,Pulmonary Artery - Swan-G,24,Pulmonary Artery - Swan-Ganz Catheters,Whoops,Most common significant complication is pulmonary infarction,From occlusion by catheter,From embolization off of catheter,Uncommon,Cardiac arrhythmia,Pulmonary artery perforation,Intracardiac knotting,Pulmonary Artery - Swan,25,R3,Tip of transabdominal Swan-Ganz catheter,(yellow arrow),lies in right pulmonary artery,R3Tip of transabdominal Swan-G,26,80 y/o male s/p MI, intubated, 2 episodes of massive hemptysis after Swan-Ganz catheter placement,80 y/o male s/p MI, intubated,27,放射医学艺术课件,28,放射医学艺术课件,29,放射医学艺术课件,30,Pleural Drainage Tubes,What,Used to remove either air in or fluid in the pleural space,Pleural Drainage TubesWhatUse,31,Pleural Drainage Tubes,Where,Ideal position is anterosuperior for PTX and posteroinferior for effusion,Usually work well no matter where positioned,None of the side holes should lie outside of the thoracic wall,Pleural Drainage TubesWhereId,32,Pleural Drainage Tubes,Whoops,Bleeding 2 laceration of intercostal artery,Laceration of liver or spleen on insertion,Insertion into the lung may lead to,Lung laceration,BP fistula,Rapid expansion of lung may lead to pulmonary edema,Pleural Drainage TubesWhoopsB,33,R3,Tip of thoracostomy (pleural) drainage tube,(yellow arrow),lies in the apex of the right hemithorax. The side hole,(blue arrow),is well within the chest.,R3Tip of thoracostomy (pleural,34,Cardiac Devices,Cardiac Devices,35,Used for cardiac conduction abnormalities,Catheter should have gentle curves,Pacemakers,What,PacemakersWhat,36,Tip positioned at apex of right ventricle,Tip may have slight bend as it abuts wall of right ventricle,Not a sharp bend,Some pacers may also have lead(s) in right atrium and/or coronary sinus,Pacemakers,Where,Tip positioned at apex of righ,37,Fracture of leads at pacer, tip or site of venous access,Leads can perforate heart,cardiac tamponade,Look for sharp bends in leads 2 perforation of blood vessel,Leads may be ectopically placed, e.g. hepatic vein,Pacemaker battery may migrate subcutaneously,Pacemakers,Whoops,Fracture of leads at pacer, ti,38,Two-lead pacemaker,(red circle),shows one lead in right atrium,(green,arrow),and the second in the right ventricle,(red arrow).,Two-lead pacemaker (red circle,39,Implantable Defibrillators,What,Automatic implantable cardiac defibrillators (AICD),AICDs used to prevent sudden death from ventricular fibrillation,Implantable DefibrillatorsWha,40,Implantable Defibrillators,Where,Usually can be recognized by short, wider electrode on one or both leads,One electrode usually in SVC or brachiocephalic vein,Other is in right ventricle,Implantable DefibrillatorsWhe,41,Implantable Defibrillators,Whoops,Leads may fracture or migrate,Implantable DefibrillatorsWho,42,Two-lead automatic implantable cardiac defibrillator. You can differentiate this from a pacemaker by the fuzzy leads”,(red arrows),on an AICD.,Two-lead automatic implantable,43,Intraaortic Balloon Pump,What,Intraaortic counterpulsation balloon pump (IACB or IABP),Used to improve cardiac output following surgery or in patients with cardiogenic shock,Inflated in systole and deflated in diastole,Increases O,to myocardium and decreases LV workload,Intraaortic Balloon PumpWhatI,44,Intraaortic Balloon Pump,Where,Tip identified by small, rectangular metallic marker,Should lie distal to left subclavian,Metallic marker should point slightly to right in region of arch,Intraaortic Balloon Pump Wher,45,www.CTSnet.org,Tip of intra-aortic balloon pump,(red arrow),lies just below top of the aortic arch,(green arrow),and heads slightly to the right.,www.CTSnet.orgTip of intra-aor,46,Intraaortic Balloon Pump,Whoops,If catheter is too proximal, balloon may occlude great vessels,leads to stroke,If balloon is too distal,leads to,decreased effectiveness,Aortic dissection may occur,Intraaortic Balloon Pump Whoo,47,Tip of intra-aortic balloon pump,(yellow arrow),lies about 2 cm from top of aortic arch,(blue arrow),R3,Tip of intra-aortic balloon pu,48,GI Tubes and Lines,GI Tubes and Lines,49,Indications for a NGT,Feeding,Gastric sampling and decompression,Administering medication,Nasogastric Tubes,What,Indications for a NGTNasogastr,50,Tip should be in stomach,At least 10 cm of tube should extend into stomach,Many have side holes that extend up to 10cm on tube,Nasogastric Tubes,Where,Tip should be in stomachNasoga,51,Most commonly malpositioned of all tubes and lines,May enter trachea and bronchi or curl in esophagus,Perforation usually involves cervical esophagus,Can also perforate stomach,Indwelling tube leads to G-E reflux,May cause esophagitis and stricture,Nasogastric Tubes,Whoops,Most commonly malpositioned of,52,Tip of nasogastric tube,(yellow arrow),should lie at least 10cm into the EG junction,Tip of nasogastric tube (yello,53,Feeding Tubes,What, Where and Whoops,What,Used for nutrition,Where,Tip of feeding tube should be in duodenum,Most are in the stomach,Whoops,Perforation by guide wire,Too proximal,aspiration,Feeding TubesWhat, Where and,54,The tip of the feeding tube,(green arrow),lies in the region of the duodenal bulb. Ideally the tip should be in the duodenum.,The tip of the feeding tube (g,55,Tubes and LinesThat HaveLost Their Way,Tubes and LinesThat HaveLost,56,R3,Feeding tube,(green arrow),enters right lower lobe bronchus, loops on itself then crosses over to LLL bronchus,(red arrow).,R3Feeding tube (green arrow) e,57,R3,Tip of central venous catheter coils back on itself in right brachiocephalic vein,(red arrow).,R3Tip of central venous cathet,58,Tip of endotracheal tube is in right mainstem bronchus,(red arrow),so right upper lobe and entire left lung are atelectatic because they are not being aerated.,Tip of endotracheal tube is in,59,R3,Swan-Ganz catheter enters left pulmonary artery,(red arrow),then loops back on itself with tip in region of right ventricular outflow tract,(green arrow),R3Swan-Ganz catheter enters le,60,R3,Tip of Swan-Ganz catheter lies too peripherally in right descending pulmonary artery,(red arrow),R3Tip of Swan-Ganz catheter li,61,R3,Tip of pleural drainage catheter (thoracotomy drainage tube) enters on right and crosses mid-line to the opposite side,(red arrow).,R3Tip of pleural drainage cath,62,放射医学艺术课件,63,