Tutorial: Imaging in the ICU Ben deBoisblanc, MD, FCCP & Trish Kritek, MD, FCCP © 2014 American College of Chest Physicians A 50 y/o woman presented to the ED with septic shock She was given empiric antibiotics, insulin and IV fluids Due to her obesity, a left subclavian venous catheter was placed using landmarks without ultrasound Norepinephrine is infusing through the catheter The above x-ray was obtained on admission to the ICU Which of the following should be done now: a) pull back the central venous catheter cm b) remove the catheter since it is in the aorta c) advance the catheter cm d) leave the catheter alone and continue to use it e) place a chest tube in the left hemithorax © 2014 American College of Chest Physicians A 65 y/o woman was admitted to the ICU with acute pulmonary edema following a STEMI She was intubated & had a PICC placed in the left arm This chest x-ray was obtained on admission Dark blood can be aspirated from the PICC & it was visualized within the axillary vein on U/S Which of the following should be done now: a) Place a chest tube in the left pleural space b) Check an arterial blood gas on the blood aspirated from the PICC c) Pull back the ETT cm cm d) Connect the PICC to a pressure transducer e) Perform CPT on the left hemithorax with the patient in a right lateral decubitus position © 2014 American College of Chest Physicians The above M-mode thoracic ultrasound image was obtained at the right posterior T9 intercostal in a proned 25 y/o man with ARDS due to H1N1 influenza The findings in this image: a) exclude pneumothorax with a high level of certainty b) are diagnostic of pneumothorax c) demonstrate a densely consolidated right lover lobe d) should be confirmed with a chest CT e) demonstrate a large pleural effusion adjacent to normally aerated lung © 2014 American College of Chest Physicians A 45 year old woman with metastatic breast cancer was admitted to the ICU with progressive shortness of breath over week Her blood pressure is 85/40 & neck veins are distended A screen capture of a parasternal short-axis echocardiogram is shown Appropriate next steps should include: a) right-sided EKG leads b) dobutamine c) pericardiocentesis d) thoracentesis e) anticoagulation © 2014 American College of Chest Physicians A 49 y/o alcoholic man was admitted to the ICU with severe abdominal pain days after ingesting raw oysters Both his hypotension and oliguria have responded to fluid boluses Blood cultures are growing a gram-negative rod He is currently receiving a carbapenem and vancomycin A CT scan of his abdomen is shown The next step in his management should be: a) add empiric doycycline b) percutaneous transhepatic biliary drainage c) therapeutic colonoscopy d) surgery e) metachlopromide © 2014 American College of Chest Physicians A 32 y/o gravid woman (gestational age 32 wks) is admitted to the ICU with headache, nausea & visual disturbances Her BP is 220/110 Creatinine is mg/dl Shortly after admission she has a generalized tonic-clonic seizure T2 weighted MRI of the brain is shown above True statements about this condition include: a) blood pressure reduction increases the risk of brain herniation b) low magnesium is a risk factor c) focal neurologic signs are common d) there is a predilection for younger patients e) aneurisms are found in 40% © 2014 American College of Chest Physicians A 38 y/o HIV-infected man was admitted to the ICU days ago with acute respiratory failure due to PJP His fever has persisted in spite of high dose TMP/SMX He now has RUQ tenderness He is normotensive and he has adequate urine output Correct management at this time should include: a) operative cholecystectomy b) addition of vancomycin for enterococcal cholecystitis c) percutaneous transhepatic biliary drainage d) emergent ERCP with ampulotomy e) ursodeoxycholic acid © 2014 American College of Chest Physicians A 60 y/o man developed nausea and vomiting after hours eating potato salad at a crawfish boil Eight hours later he presented to the ED with extreme prostration BP 70/40, P 130, RR 38, SpO2 85% A chest x-ray in the ED is shown Treatment of this condition is focused on: a) low tidal volume ventilation b) tube thoracostomy c) open surgical drainage d) NG tube drainage e) oral vacomycin © 2014 American College of Chest Physicians A 22 y/o HIV-positive woman with ARDS due to PJP had a CT scan performed for the evaluation of hypoxemia The pathogenesis of her pneumomediastinum and left pneumothorax are most likely related to: a) ruptured visceral pleura with followed by tracking into the mediastinum b) esophageal rupture from her NG tube c) misplaced central venous catheter d) development of interstitial emphysema e) ruptured intra-abdominal viscous © 2014 American College of Chest Physicians 34 y/o restrained driver in a head on collision Awake but remains hypotensive after L of crystalloid & units PRBC in the ED Based on the image above, you would recommend: a) emergent left posterolateral thoracotomy b) esophagram c) tranexamic acid d) CT scan of abdomen & pelvis e) Measurement of bladder pressure © 2014 American College of Chest Physicians ... position © 2 014 American College of Chest Physicians The above M-mode thoracic ultrasound image was obtained at the right posterior T9 intercostal in a proned 25 y/o man with ARDS due to H1N1 influenza... metachlopromide © 2 014 American College of Chest Physicians A 32 y/o gravid woman (gestational age 32 wks) is admitted to the ICU with headache, nausea & visual disturbances Her BP is 220 /11 0 Creatinine... alone and continue to use it e) place a chest tube in the left hemithorax © 2 014 American College of Chest Physicians A 65 y/o woman was admitted to the ICU with acute pulmonary edema following a