《放射医学艺术》PPT课件.ppt

1、Medical Arts Radiology,Barry R. Morgenstern, M.D.,Tubes and LinesWhat, Where and Whoops,Format of Lecture,For each device What they are and what they do Where they belong Whoops malpositioning and complications,Airways,Endotracheal TubesWhat They Are Used For,Indications for Assisted ventilation Iso

2、late trachea to permit control of airway Prevents gastric distension Direct route for suctioning Administration of medications via ETT,Endotracheal TubesWhere,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 Ba

3、lloon should never distend tracheal walls; if 2.8 cm, suspect laceration,Endotracheal TubesWhoops,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,R3,Tip of endotracheal tube (ye

4、llow arrow) lies well above the carina (green arrow),TracheostomyWhat,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,TracheostomyWher

5、e,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,TracheostomyWhoops,Immediately after Subcutaneous emphysema Pneumomediastinum Pneumothorax Cuff should not be 1 times diameter of lumen Tracheal stenosis,Tracheos

6、tomyTracheal 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,R3,Tip of tracheostomy tube (yellow arrow) lies about mid

7、way between the stoma (blue arrow) and carina (green arrow),Intravascular Lines,Central Venous CathetersWhat,Used in critically ill patients For venous access Measurement of central venous pressure Intravascular blood volume,Central Venous CathetersWhere,Subclavian joins brachiocephalic vein behind

8、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 CathetersWhoops,Most often malpositioned in RV or internal jugular Arrythmias in RV; inaccurate CVP readings elsewhere Occasionally outside b

9、lood vessel Look for sharp bends in catheter Arterial placement suggested by pulsatile flow,Central Venous CathetersComplications,Air embolism Pneumothorax (5%) Hemothorax Cardiac perforation Sepsis Venous perforation,Central Venous CathetersTwo or more attempts,Should initial placement fail, get a

10、chest x-ray before trying other side to avoid bilateral pneumothoraces,R3,Tip of central venous catheter (yellow arrow) curves gently downward into superior vena cava,PICC LinesPercutaneous Intravascular Central Catheters,What Used for long-term access Small size catheters (4-5F) Single or dual lume

11、n Inserted through antecubital or basilic/cephalic vein Where Tip should lie within SVC Whoops Tips may become malpositioned over time,Pulmonary Artery - Swan-Ganz Catheters What,Swan-Ganz catheters Aid in differentiating cardiac from non-cardiac pulmonary edema,Pulmonary Artery - Swan-Ganz Catheter

12、sWhere,Tip should lie within right or left pulmonary artery 2cm from hila Balloon inflated only when measurements are made,Pulmonary Artery - Swan-Ganz Catheters Whoops,Most common significant complication is pulmonary infarction From occlusion by catheter From embolization off of catheter Uncommon

13、Cardiac arrhythmia Pulmonary artery perforation Intracardiac knotting,R3,Tip of transabdominal Swan-Ganz catheter (yellow arrow) lies in right pulmonary artery,80 y/o male s/p MI, intubated, 2 episodes of massive hemptysis after Swan-Ganz catheter placement,Pleural Drainage TubesWhat,Used to remove

14、either air in or fluid in the pleural space,Pleural Drainage TubesWhere,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 TubesWhoops,Bleeding 2 lacera

15、tion 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,R3,Tip of thoracostomy (pleural) drainage tube (yellow arrow) lies in the apex of the right hemithorax. The side ho

16、le (blue arrow) is well within the chest.,Cardiac Devices,Used for cardiac conduction abnormalities Catheter should have gentle curves,PacemakersWhat,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

17、(s) in right atrium and/or coronary sinus,PacemakersWhere,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

18、subcutaneously,PacemakersWhoops,Two-lead pacemaker (red circle) shows one lead in right atrium (green arrow) and the second in the right ventricle (red arrow).,Implantable DefibrillatorsWhat,Automatic implantable cardiac defibrillators (AICD) AICDs used to prevent sudden death from ventricular fibri

19、llation,Implantable DefibrillatorsWhere,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 DefibrillatorsWhoops,Leads may fracture or migrate,Two-lead automatic implantable cardiac defi

20、brillator. You can differentiate this from a pacemaker by the fuzzy leads” (red arrows) on an AICD.,Intraaortic Balloon PumpWhat,Intraaortic counterpulsation balloon pump (IACB or IABP) Used to improve cardiac output following surgery or in patients with cardiogenic shock Inflated in systole and def

21、lated in diastole Increases O to myocardium and decreases LV workload,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,www.CTS,Tip of intra-aortic balloon p

22、ump (red arrow) lies just below top of the aortic arch (green arrow) and heads slightly to the right.,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,

23、Tip of intra-aortic balloon pump (yellow arrow) lies about 2 cm from top of aortic arch (blue arrow),GI Tubes and Lines,Indications for a NGT Feeding Gastric sampling and decompression Administering medication,Nasogastric TubesWhat,Tip should be in stomach At least 10 cm of tube should extend into s

24、tomach Many have side holes that extend up to 10cm on tube,Nasogastric TubesWhere,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 c

25、ause esophagitis and stricture,Nasogastric TubesWhoops,Tip of nasogastric tube (yellow arrow) should lie at least 10cm into the EG junction,Feeding TubesWhat, 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,The tip of the feeding tube (green arrow) lies in the region of the duodenal bulb. Ideally the t