MIDI II Module 2 Exam--Neuroimaging & ACLS
Check for reversible causes (H's & T's)
After trying many initial measures to return patient during a code, what should you consider?
Make sure EKG is on patient and it is being monitoring for any arrhythmias
After establishing airway, compressions, and evaluated for shock, what should you make sure is on and monitoring?
-Nasal cannula—low flow supplemental O2; rates 1-6 lpm & 24-44% O2; -High flow nasal cannula—heated & humidified device; capable of 60 lpm & 21-100% O2; -Simple face mask—delivers low to moderate amounts of oxygen; has holes on the side of the mask to let air in and out; 6-10 lpm 40-60% O2; -Venturi face mask—adjustable flow oxygen concentration; 2-15 lpm; 24-60% O2 (frequently used for chronic lung disease patients); -Partial-rebreather face mask—face mask and a reservoir bag with 2-way valve; 10-15 lpm 60-80% O2; -Non-rebreather face mask—face mask and a reservoir bag with a one-way valve; 10-15 lpm 100% O2
Describe the following oxygenation devices: nasal cannula, high-flow nasal cannula, simple face mask, Venturi face mask, partial-rebreather face mask, and non-rebreather face mask. How much oxygen do they deliver?
Water (CSF areas or edema)--will be dark on T1 and bright on T2
How can you differentiate between T1 and T2 MRIs?
T1: -Hyperdense (bright)—vertebral bodies and subcutaneous fat -Hypodense (dark)—CSF, disks, and cortical bone T2: -Hyperdense (bright)—CSF and subcutaneous fat -Hypodense (dark)—vertebral bodies, disks, and cortical bone
How do T1 spinal MRIs differ from T2 spinal MRIs?
One hand applies downward pressure to the forehead while the fingers of the other hand lifts the mandible; Should not use if there is suspected cervical spine injury
How do you perform a head tilt-chin lift? When can this not be used?
Nature of calcification usually can be determined by its pattern & anatomic location
How is the nature of a calcification seen on x-ray usually determined?
Intubating because it could be hypoxic issue
If coding patient has been unresponsive to measures, what should you consider?
Immediate analyze for rhythm and shock if possible--do not wait until end of the 2 minute compression cycle
If doing chest compressions and another person comes with AED, what should you do next?
Should give breaths every 5-6 seconds and check pulse every 2 minutes
If patient has a pulse but not adequate breaths, what should you do?
Should look for presence of stool because that marks the large bowel's location (usually rectosigmoid area but can back up into descending or transverse); Stool should appear like multiple small bubbles of gas present within a semisolid-appearing soft tissue density
If you are having trouble locating the large bowel on x-ray, what is something you can look for? What should it appear like?
If stable, give Atropine IV 1 mg bolus if patient is stable and in bradycardia rhythm (if unstable, pace them); Can repeat every 3-5 minutes with a max of 3; Consider Dopamine or Epi if that does not work
If your patient is showing a bradycardia rhythm and are stable, what should you give them? How often can this be repeated? What else should you consider if this does not work?
T1 because the CSF areas (ventricles) are dark and water is always dark on T1
Is this a T1 or T2 MRI and how do you know?
T2 because the CSF areas (ventricles) are bright and water is always bright on T2
Is this a T1 or T2 MRI and how do you know?
Those are mastoid air cells which suggests we are near the ears in this image; This is the 4th ventricle and it is dark because it is filled with CSF (normal finding)
On this CT image of the brain, what are the small hypodense (dark) spots on the right (mostly) and left of the cerebellum and what does that suggest? What is the hypodense area in the middle of the cerebellum and why is it dark?
IUD
What abnormality is seen on this x-ray?
Should use the jaw-thrust maneuver; Grasp the angles of the lower jaw and lift with both hands, moving the jaw upward then maintain cervical spine immobilization while opening the airway or have another provider assist you
What airway technique should be used if there is suspected C-spine injury? How is this performed?
1. Suspected cervical spine injury 2. Severe arthritis of the neck 3. Significant trauma of the mouth, face, or neck 4. Decreased mouth opening 5. Obesity 6. Anatomical variants (receding chin, large overbite, short neck) 7. Pediatric patients (they have short necks & large head)
What are 7 indications of a potentially difficult airway?
Eye opening can give 4 points if spontaneous -If just responds to verbal command—3 -If just responds to pain—2 -If no opening—1; Verbal response can give 5 points if person responds oriented -If response is confused—4 -If response has inappropriate words—3 -If response has incomprehensible sounds—2 -If no response—1; Motor response can give 6 points if obeying commands -If there is movement with localized pain—5 -If there is just withdrawal to pain—4 -If there is just flexion to pain—3 -If there is just extension to pain—2 -If there is no motor response—1
What are all the possible scores for the Glasgow Coma Scale?
Ventricle fibrillation and pulseless ventricular tachycardia are shockable but pulseless electrical activity and asystole are not shockable
What are shockable rhythms and which are not?
Nasal cannula, high-flow nasal cannula, simple face mask, Venturi face mask, partial-rebreather face mask, and non-rebreather face mask
What are six different oxygenation devices that we use?
1. Disk herniation 2. Degeneration 3. Arthritis 4. Diffuse idiopathic skeletal hyperostosis (DISH) 5. Compression fractures 6. Spinal stenosis 7. Malignancy 8. Infection 9. Trauma 10. Muscle/ligament strain
What are ten causes of back pain?
Air-fluid levels because of the turtle-shell appearance
What are the black arrows pointing to and how do you know?
Showing renal calcifications
What are the black arrows pointing towards?
1. Maintain good airway/support breathing--might need advanced airway if not already established 2. Keep an eye on blood pressure--treat if systolic is less than 90 or MAP is less than 65 with fluids 1-2 L normal saline or LR then vasopressors (Norepinephrine, Epi, or Dopamine as continuous infusion) if necessary; Once airway & BP are stable, get EKG to look for signs of MI; If signs of MI, get to Cath lab; If no signs of MI, see if they can follow commands & if not we want to manage targeted temperature & get CT; If no signs of MI & following commands, transfer to ICU for ongoing management
What are the initial two things you are looking at once patient has received return of spontaneous circulation (ROSC) and how do you treat this? After these are taken care of, what is your next step and how do you treat it?
Phleboliths--small, rounded calcifications which represent calcified venous thrombi occurring with age; Most commonly seen in the pelvis of women
What are the radiopaque structures seen near the pelvis? What are they from? Who is most common to have them?
1. Hypovolemia--High temperature can be a clue; Give fluids or blood depending on the cause 2. Hypoxia--Check airway, O2, ABGs; Give oxygen, intubate & ventilate; Might need ECHMO; 3. Hydrogen Ions--Acidosis from sepsis, toxin, or DKA; Get ABG; If determined to be respiratory, ventilate to blow off CO2; If determined to be metabolic, give bicarbonate; 4. Hypo/Hyperkalemia--Was patient vomiting/diarrhea or are they in renal failure/rhabdomyolysis; Look at EKG for T-wave & get stat labs; If hypokalemia, give potassium; If hyperkalemia, give calcium to protect cardiac then insulin, albuterol treatment, or Lasix; Patient may need dialysis 5. Hypoglycemia--Should be getting glucose quickly in code; Give D50% quickly 6. Hypothermia-- Temperature less than 35 C; Passive or active rewarming (bear hugger or warm fluids) 7. Toxins--CCBs, beta blockers, Digoxin, TCAs, opioids, and cocaine are common overdoses causing this; Look at EKG for prolonged QT, pinpoint pupils, & history; Give supportive care & antidote if available 8. Tamponade--Is patient post-cardiac surgery, penetrating injury, or aortic dissection; Can check for muffled heart sounds, hypotension, or ECHO; Do pericardiocentesis or thoracotomy 9. Tension pneumothorax--Unequal chests rise/fall, tracheal deviation, unequal breath sounds; Do needle decompression and place in a chest tube 10. Thrombus--Chest pain/SOB or ST changes on EKG; Go to cath lab if possible, thrombolytics, stat surgery; 11. Trauma--dependent on issue
What are the six H's and 5 T's you should know? What should be checked to rule these causes out? What can be given if these are found to be issues?
Needle cricothroidotomy--Locate the cricothyroid membrane with nondominant hand then insert needle through skin at 45-degree angle caudally & aspirate the syringe as you advance (to see air bubbles once in the trachea) then remove the needle, keeping the hub in & attach oxygen supply; Surgical cricothyroidotomy--Palpate depression over cricothyroid membrane with nondominant hand and make a 1.5 cm stab incision then pick up cricoid cartilage with tracheal hook & insert 5-6 sized tracheostomy tube through opening
What are the steps in a needle cricothyroidotomy? What about surgical cricothyroidotomy?
1. Patient is fully monitored 2. Disconnect ventilator 3. Pre-oxygenate with 100% O2 4. Establish baseline Arterial Blood Gas (ABG) 5. Observe for any signs of respirations for 8-10 minutes (abdominal or chest rise) 6. Draw second ABG, looking at their PaCO2 and reconnect ventilator; When looking at the final PaCO2, if it is greater than 60 mm Hg that is a positive test, which supports the diagnosis of breath death
What are the steps in performing the apnea test? What is a positive test for this and what does that mean?
1. Proctoscopy—allows evaluation of anus and rectum 2. Sigmoidoscopy—allows for evaluation of anus, rectum, & sigmoid colon 3. Colonoscopy—allows evaluation of entire colon to the ileocecal value
What are the three different types of GI endoscopes and how do they differ?
Black--right kidney White--left kidney; Showing how the left is much more enlarged when the right
What are the white and black arrows pointing to and what is that displaying?
1. Pediatric Emergency Care Applied Research Network (PECARN)--Utilized if there is a pediatric head injury to guide if imaging is necessary or not; Would consider if there is AMS, vomiting, severe headache, if severe mechanism of injury, or if sings of basilar skull fracture; 2. National Emergency X-Radiography Utilization Study (NEXUS)--Used to decide which trauma adult patients do not require cervical spine imaging; Cannot have neuro deficits, midline tenderness, altered loss of consciousness, or be intoxicated; 3. Canadian C-Spine Rule (CCR)--Also used to decide which trauma adult patients do not require cervical spine imaging; Alert, stable trauma patients under 65 go to CT
What are three algorithms used to evaluate head trauma patients and how do they differ?
-Ridged "Yankauer" suction catheter: Put to the side of the mouth but if someone bites down on it, can dislodge the piece of plastic and get stuck in their airway; Soft suction catheter: Can either thread down nose or ET tube and suction endotracheal (has to be fairly sterile)
What are two different types of suction devices used and how do they differ?
Laryngeal mask airway--Do not have to visualize anything (blindly inserted) & then just inflate balloon; cusps around the epiglottic opening; Intubating Laryngeal Mask Airway--Again, do not have to visualize to put this in; These are not definitive airways; They cannot be used in conscious patients or those with a gag reflex
What are two examples of supraglottic airways and how are they inserted? Are these definitive airways? Can these be used on conscious patients?
Doll's eye reflex--abnormal result occurs when tilting the head from side to side and the eyes remain in a fixed position in the skull; Caloric stimulation--abnormal result occurs when ice water is applied inside the ear & eyes do not deviate toward that side
What are two tests used when performing oculocephalic testing and how do they differ?
Can view these either directly by visualizing the edges of the structure or indirectly by seeing an enlarged organ with displacement of the bowel
What are two ways you can view soft tissue masses on x-ray?
Causes: rupture of air-containing loop of bowel or trauma; Signs of this on x-ray: Air beneath the diaphragm, visualization of both sides of the bowel wall, visualization of the falciform ligament (usually only with large amounts)
What can cause extra luminal air (pneumoperitoneum)? What are three signs of this on x-ray?
Could be from mass, narrowing/stricture (diverticular disease), twisting (volvulus), or intraabdominal adhesions
What could potential causes for colonic obstruction?
If oxygen is set too low, can suffocate patient
What do you have to be careful when using non-rebreather face masks?
Placing end-tidal CO2 detector on endotracheal tube will ensure it is ventilating patient—positive color change indicates good positioning
What do you place on the endotracheal tube once you place it and why? What would indicate this?
Delivers electrical activity one way then switches and goes the other way; Seen on most AED devices now
What does biphasic mean? Where is this seen?
Epinephrine 1 mg IV push with 10-20 mL flush; Can be given every 3-5 minutes until ROSC is achieved
What drug should be your first go to for an unresponsive patient without a pulse? What is the dose? How often can this be given?
The shearing or tearing of the brain's nerve fibers (axons) that happens when the brain is injured as it shift and rotates inside the skull; Also called Diffuse Axonal Injury (DAI); Most commonly involves high-speed motor vehicle collisions with an accelerating/decelerating motion that creates shear forces to the white matter tracts of the brain; Will see loss of grey-white interface on head CT
What has occurred in a traumatic brain injury? What is this also called? What is often the cause of this? What will you see on CT with this?
This is a lateral view x-ray; It is showing degenerative disk disease with vacuum-disk phenomenon of narrowing of the disk space seen with black arrow and then osteophytes seen on the anterior vertebral bodies; Progressive loss of height of the intervertebral disk space from dehydration of gelatinous nucleus pulposus
What imaging tool is used here? What is it showing us and how do you know? What occurred in this disease
Sacroiliac joint; It should appear black; If not black, that could indicate, ankylosing spondylitis; This is AP view
What is #4 indicating? How should this appear and if it does not, what does that indicate? What view is this?
Self-inflating bag attaching to a non-rebreathing valve and face mask; Opposite end of the bag is attached to 100% supplemental oxygen; Requires: Adequate mask seal, proper ventilation technique, PEEP valve to improve oxygenation
What is a bag-value mask? What is the opposite end attached to? What three things are requirements for this device?
Functional ileus--One or more loops of bowel lose their ability to propagate the peristaltic waves of the bowel; 1. Localized ileus (sentinel loops)—affects only 1 or 2 loops of small bowel 2. Generalized adynamic ileus—affects all loops of large & small bowel
What is a functional ileus? What are the two types?
They are talking without issue
What is a good indication that there is an established airway for a patient?
Porcelain gallbladder--hyperechoic shadowing of gallbladder wall with hypoechoic nondependent mass inside
What is a sign of gallbladder cancer on ultrasound?
Use of 3D imaging with a CT scan; Tube is inserted into the rectum and air is inserted & used as contrast, allowing for adequate visualization; No sedation is required but still needs bowel prep; If abnormalities are found, conventional colonoscopy is then required
What is a virtual colonoscopy? How is the procedure done? How is this different from a endoscopy colonoscopy and what might still be needed?
Sound beam cannot penetrate bone or gas or deep into structures so deep organs like the pancreas are not well-visualized
What is a weakness of ultrasounds?
Gallstones in the right upper quadrant
What is abnormal on this abdominal x-ray?
Contrast enhanced (barium) x-ray study provides visualization of the lower esophagus, stomach, and duodenum
What is an upper GI series?
Cholecystitis—gallbladder inflammation; Best seen on gallbladder ultrasound; Signs of this on ultrasound: presence of gallstones, thickening of gallbladder wall, pericholecystic fluid (fluid around it), positive Murphy sign (pain with compression of gallbladder by probe)
What is cholecystitis? What tool is best to diagnose this? What will you see?
Can include supine view, upright or left lateral decubitus view, chest radiograph, and prone view (sometimes); Also called 3-way abdomen view or obstruction; Supine view--good for to look for masses, bowel gas patterns, and calcifications; Upright or left lateral decubitus view—good for pneumoperitoneum (perforation) and determining air-fluid levels; Chest radiograph—free air beneath diaphragm, pneumonia, pleural effusions; Prone view (sometimes)—identifying gas in the rectum, sigmoid, ascending, and descending colon
What is included in an acute abdominal series? What is this also called? What are each specific view in the series good to see?
The positioning of the transverse colon--it appears lower than it should be; The colon was displaced by the enlarged liver above it; Might prompt us to get an ultrasound around the liver
What is irregular in this picture? Why has this occurred? What might this prompt you to do next?
Abdominal plain films (x-rays) because it is simple to obtain, low cost, readily available in most medical centers, causes no discomfort to the patient, and may provide important diagnostic info; This covers the kidneys, ureters, and the bladder; Can display intraperitoneal free air, bowel obstruction (initial signs), organomegaly, masses, calcifications, or foreign bodies
What is often the first imaging obtained in evaluating an abdominal complaint and why? What organs does this cover? What can it be helpful in displaying?
Combitube--Has two tubes within one airway device that can be used for suctioning as well
What is one example of a Multilumen Esophageal airway device? What is special about it?
39--3rd ventricle; Yes because it looks like a thin slit; if it is larger, could suggest back-up of CSF
What is represented by the number "39"? Is this a normal presentation and how do you know?
Diverticulosis
What is shown by the arrows on the right?
Determines the size of the airway opening in the mouth with Class I having the largest area and Class IV having the smallest amount; Most likely needs to be intubated if going through surgery because of the smaller area
What is the Mallampati classification used for and what as the classes? What should you consider if you are Class IV during surgery?
"S" is the suprasellar cistern; White arrows--cerebral peduncles; Black arrow--interpeduncular cistern; They are darker because they are filled with CSF
What is the S signifying in this picture? What about the white arrows? What about the black arrow? Why are they darker?
Cricoid pressure performed during intubation when establishing definitive airway; This reduces the risk of aspiration and may aid in visualizing the vocal cords; Can use the BURP procedure (back, upward, rightward pressure) but cannot let go until definitive airway is established
What is the Sellick maneuver and when is it utilized? Why is this helpful? What procedure is done with this and what must you not do?
Calcified leiomyoma--calcified fibroid in the female pelvis
What is the abnormality in this abdominal x-ray?
Porcelain gallbladder; Calcified gallbladder wall that occurs with chronic inflammation & stasis associated with gallstones; These individuals have an increased risk of carcinoma of gallbladder
What is the abnormality in this abdominal x-ray? What occurred for it to present this way? What is this patient at risk for?
Psoas muscle; This can be helpful to see if anything in way obstructing this border
What is the arrow pointing to on this abdominal x-ray? Why is this a landmark to look for?
Arachnoid mater; Blood vessels are supplied from Pia mater; Together the Pia and arachnoid mater are called leptomeninges
What is the avascular layer of the skull? Where does it get its blood supply? What are these called?
CT because it can show the bone window and if there is tissue damage; Types: linear, depressed, basilar skull fractures; Basilar skull fracture is the most serious skull fracture
What is the best imaging of choice for skull fractures and why? What are three types of skull fractures and which is the most serious?
MRI--Best for: chronic headaches, seizures, vertigo/dizziness, masses CT--Best for: detect blood/hemorrhage, trauma, acute/severe headaches, stroke; X-ray cannot be used to look at the brain because it is not sensitive enough
What is the best use for MRI when imaging the brain? What about CTs? Can x-ray be used to image the brain? Why or why not?
Pneumoperitoneum; Most likely in the upright view because the air will rise to the highest part of the abdomen (right under the diaphragm) in this view
What is the black arrow pointing to? What view is this patient most likely in and why is that important?
Gas in the colon
What is the dark circle on the right-side of the patient?
Definition—a tube placed in the trachea with a cuff inflated below the vocal cords; 1. Endotracheal intubation—either orotracheal or nasotracheal 2. Surgical airways—either tracheostomy or cricothyroidotomy; Criteria for establishing definitive airway · A—Inability to maintain a patent airway · B—Inability to maintain adequate oxygenation · C—AMS resulting in cerebral hypoperfusion · D—AMS in the presence of a head injury (GCS < 8)
What is the definition of a definitive airway? What are two different types of definitive airways and what are examples of them? What is the criteria for establishing a definitive airway?
Hypersensitivity reaction—idiosyncratic & largely independent of the dose & infusion rate; will have flushing, pruritis, angioedema; Chemotoxic reaction—related to the chemical properties of the RCM & are dependent on the dose and infusion rate; can have seizures, vasovagal reactions, arrhythmias, renal toxicity
What is the difference in hypersensitivity and chemotoxic reactions with radioconstrast media?
Small bowel -Will see air in 2-3 loops of non-dilated small bowel -Diameter is smaller at 2.5cm and has ability to extend to 5cm -This will be centrally placed in the abdomen with valvulae conniventes markings across the lumen & spaced closer together -Looks like a stack of coins Large bowel -Almost always has air in the rectum or sigmoid -Diameter is larger at 6cm and has the ability to dilate 2-3x its size -Peripherally placed and has haustral markings that do not extend completely across & are more widely spaced apart
What is the difference in small bowel and large bowel on imaging?
Non-contrast CT; If this was an acute ischemic stroke (less than 24 hours since symptoms began) usually will see a normal CT; If this was an acute hemorrhagic stroke (less than 24 hours), will have hyperdense (bright area) that will become darker as the clot forms
What is the first imaging step if a patient is having a suspected stroke? What would you expect to see if this was an ischemic stroke? What about a hemorrhagic?
Diffuse Tensor imaging (DTI) MRI; Clinical diagnosis: -GCS has to be less than 8 for over 6 hours while off sedation -Clinical picture is related to the severity of the DAI; Treatment: -Prevent secondary brain injury -Hypoxia, hypotension, cerebral edema, increased intracranial pressure
What is the imaging modality of choice for a traumatic brain injury? What are the clinical requirements to make this diagnosis? How is it treated?
Non-communicating (due to blockage in ventricular system) is the most common cause; Will see ventricular dilation and the temporal horns are the most sensitive to dilation; The 4th ventricle is dilated in communicating hydrocephalus and normal in size in non-communicating hydrocephalus
What is the most common cause of hydrocephalus? What will you see on imaging with hydrocephalus and which area is most sensitive for this? What is a way to tell the difference between these two potentially on imaging?
Metastasis from the lung; Primary malignant brain tumor--glioma; Primary non-malignant brain tumor--meningioma Glioma--glioblastoma multiforme which is common in frontal and temporal lobes; Gliomas will enhance with contrast; Metastasis will appear as multiple, well-defined round masses near the gray-white junction that are hypodense & enhance with contrast giving ring pattern
What is the most common malignant brain tumor? What the most common primary malignant and non-malignant brain tumors? What is the most common type of glioma and where are they common? How will these all appear on imaging?
Duration of suctioning should be no more than 15 second; Unless there is airway compromise
What is the number one rule when suctioning an airway? When is the only time this rule can be broken?
Venturi face mask
What is the only oxygenation device that you can determine the percentage of oxygen the patient is getting accurately?
Tracheotomy
What is the only surgical airway that can be permanent?
Targeted temperature management (TTM)
What is the only thing shown to improve neurological functioning post-cardiac arrest?
ABCS: Adequacy & Alignment, Bones, Cartilage, Soft tissue/Spaces; Views: AP, Lateral, Odontoid (open mouth view—good for dens process)
What is the pneumonic we use to evaluate spinal x-rays and what does each mean? What are three views used in spinal x-rays?
Large bowel because the lines do not go all the way across the lumen (haustra)
What is the predominant organ you see on the right picture and how do you know?
Gallbladder ultrasound; Gallbladder normally should appear as a fluid-filled sonolucent lumen surrounded by an echogenic wall about 3mm thick
What is the primary study of choice for abnormalities of the biliary system? What should you see on this?
Enlarged spleen because it has projected past the 12 rib
What is the red arrow pointing to and how do you know?
Red arrow is pointing to the calcified pineal gland in the brain; This is considered hyperdense; Hypodense U-shaped areas are the lateral ventricles
What is the red arrow pointing to? How would this be described? What are the large hypodense U-shaped areas above it?
-X-ray—great for bony abnormalities -CT—great for bony detail (trauma, DDD, spinal tumors) -MRI—great for soft tissue evaluation (bone marrow)
What is the role of x-ray, CT, and MRI on imaging of the spine?
MRI; Pros—gives excellent visual of bone marrow, spinal cord, and intervertebral disks and there is no radiation involved; Cons—expensive, not always available, time-consuming, claustrophobic patient difficulties, cannot put in patients with metal (pacemakers, clips)
What is the study of choice for most diseases of the spine? What are some pros and cons of this study?
Unenhanced CT
What is the study of choice in acute head trauma?
Endoscopic Retrograde Cholangiopancreatography (ERCP); Allows visualization of the bile or pancreatic ducts & indicated for evaluation of jaundice patient & patients with unexplained upper abdominal pain or pancreatitis; An endoscope is placed through the mouth and travels to the duodenum & a small catheter is passed through into the common bile duct or pancreatic duct, injecting radiographic dye while x-ray images are taken; Yes, sedation is used; Complications: perforation, gram negative sepsis in patients with jaundice, pancreatitis, aspiration, or oversedation leading to respiratory distress
What is the tool used for this patient? What is it used for and indicated in? What is the procedure for this? Is sedation used? What are complications seen with this procedure?
MRI Cholangiopancreatography (MRCP); Noninvasive way to image the biliary tree without requiring injection of contrast material; Fluid-filled structures will appear bright & everything else is dark (as shown in picture); Helpful for depicting biliary strictures, dilation, CBD stones, gallstones, choledochal cysts, and pancreas divisum
What is the tool used for this patient? What is this used for? What will you usually see? What is it helpful for detecting?
Nuclear scanning (HIDA scan); Main use is diagnosing acute cholecystitis or biliary dyskinesia; -Normal result—visualization of gallbladder in 60-120 minutes -Abnormal—failure to visualize after 60-120 minutes
What is the tool used for this patient? What is used to diagnose? What are normal and abnormal results for this?
This is lateral view and best for X-ray but CT better shows this; Displaying Hangman's fracture; Fracture of posterior aspect of C2, separating it from anterior aspect that is caused by hyperextension-compression injury seen in car accidents, diving, or contact sports injuries; Usually there are no neurological deficits
What is the view and is it the best? What kind of fracture is it displaying? What occurred in this injury and what can commonly cause it? Will there be neurologic deficits?
3 is the worst score; 15 the best score; Composed of 3 parameters: eye opening, best verbal response, and best motor response
What is the worst score you can get on the Glasgow Coma Scale? What is the best? What are the three parameters it looks at?
It is pointing to stool which is alarming just in the location/backup of it (ascending colon)--it should not be over here
What is the yellow arrow pointing to? What is alarming about this?
Spinal stenosis and MRI is the study of choice; Narrowing of the spinal canal due to soft tissue or bony abnormalities; Most commonly seen in the cervical and lumbar spines; X-ray can show AP diameter of spinal canal less than 10mm, facet joint arthritis, or spondylolisthesis; Patient will have intermittent pain and paresthesia radiating down the leg worsened by standing or walking and relieved by flexing the spine by lying supine or squatting
What is this MRI showing and is this a study of choice? What is occurring in this? Where is this most commonly seen? What would an x-ray show? How would this patient present?
Falciform ligament (which is not normally visualized); Visualization of this indicates pneumoperitoneum
What is this arrow pointing to? What does it indicate?
Ankylosing spondylitis because of the bamboo-spine appearance; Sacroiliitis is the hallmark of ankylosing spondylitis—fusion of the SI joints that appears as a thin, white line instead of a joint space; Inflammation and fusion of the SI joints and spinal facet joints with involvement of the paravertebral soft tissues; Typically, will ascend the spine starting at the SI joints; X-ray usually is first line
What is this diagnosis and how do you know? What is the hallmark of this disease? What is this occurring in this? How do this typically develop? What is imaging of choice?
Aydnamic ileus because the entire bowel is aperistaltic or hypoperistaltic & completely air-containing & dilated; Also there is not air seen in the rectum or sigmoid; This is the result of abdominal or pelvic surgery or severe electrolyte imbalance (hypokalemia)
What is this diagnosis and how do you know? What is this usually the result of?
This is lateral x-ray but can also use CT for this as well; Shows naked facet sign—superior articular facet is no longer covered by the inferior facet above it Displaying Locked Facets; Bilateral locking of the facets caused by hyperflexion mostly at cervical spine; Almost always has neurological deficits
What is this imaging tool and is it the best? What is the sign shown in this x-ray? What kind of fracture is it displaying? What occurred in this injury and what can commonly cause it? Will there be neurological deficits?
CT scan shown here which is the best imaging tool for this fracture; Displaying Burst fracture; Comminuted compression fracture of vertebral body causing bowing of it toward the spinal canal that can occur in cervical, thoracic, and lumbar spine from high energy axial loading seen in car accidents & diving injuries; There are usually neurological deficits seen
What is this imaging tool and is it the best? What kind of fracture is it displaying? What occurred in this injury and what can commonly cause it? Will there be neurological deficits?
This is an x-ray; Showing Diffuse idiopathic skeletal hyperostosis (DISH) because of the thick bridging/flowing calcification (white line) of 4 contiguous vertebrae with preserved disk spaces and normal SI joints; Bony proliferations (enthesophytes) develop at sites of tendon and ligament insertion following ossification of the anterior longitudinal ligament; Generally, occurs in lower cervical and lower thoracic spine; These patients generally have back stiffness but none or mild back pain
What is this imaging tool? What is it showing us and how do you know? What is occurring in this disease? Where does it often occur? How do these patients typically present?
This is an x-ray; Showing compression fracture of the wedge-shaped deformity & height difference between anterior and superior parts of the vertebral body; Generally, occurs in mid-thoracic and upper lumbar areas & affect women more than men; MRI will differentiate between a fracture due to osteoporosis and malignancy
What is this imaging tool? What is it showing use and how do you know? Who does this generally affect more and where? Why would someone also suggest getting an MRI with this if you can make diagnosis from x-ray?
CT scan; Displaying Chance fracture; Transverse fracture through the entire vertebral body, pedicles, and spinous process usually in the lower thoracic and upper lumbar areas caused by a shearing force; These patients will have a high incidence of intraabdominal injuries
What is this imaging tool? What kind of fracture is it displaying? What occurred in this injury and what can commonly cause it? What should you specifically watch out for with patients of these injuries?
Herniated disk; When soft internal portion of disk bulges out through degeneration of outer annulus fibers; MRI is the study of choice for evaluating this (which is what this picture is); Most common position is at L4-L5; Not often in thoracic spine because those disks are very stable in part because they are protected by the rib cage; Can lead to back pain and sciatica if affecting lumbar spine & radiculopathy and myelopathy if affecting cervical spine
What is this picture showing? What occurs in this? What is the study of choice for this? Where is this most commonly see and where is it not commonly seen? What can this lead to?
Osteomylitis/diskitis because of the disk space abnormalities and destruction of adjacent vertebral body endplates if involved; This is an infection of the disk (diskitis) or vertebrae (osteomyelitis) that is most often caused by infection in another organ that spreads hematogenously, typically Staph aureus; The lumbar region is the most commonly involved; MRI is more sensitive than CT for diskitis
What is this showing and how do you know? What is occurring here and what is the most likely cause? What area is typically involved? Which imaging is more sensitive?
Thromboelastography (TEG); R—how quick the clot forms K—how strong the clot gets over time MA—how strong the clot is A60—how quick the clot lysis; We should not see shape narrow on the left side--want it to stay straight
What is this tool used? What does the R, K, MA, and A60 stand for? What should we not see with this?
This is odontoid view & best but can confirm with CT; Displaying Jefferson fracture; Bilateral fractures of both anterior and posterior arches of C1 that is caused by axial loading injury (diving into shallow pool or football injury); No neurologic deficits
What is this view and is it the best? What kind of fracture is it displaying? What occurred in this injury and what can commonly cause it? Will there be neurologic deficits?
Osteoarthritis because of the formation of osteophytes near the joint spaces with narrowing & sclerosis of facet joints; This is oblique view--best to see it; Get CT because can easily see facet arthritis better with it GET MRI because can easily see nerve compression with it
What is this x-ray showing us and how do you know? What view is it? Why would you use CT and MRI on this patient as well?
Special test used in the evaluation of critically or potentially critically ill patients that looks at how hypercoagulable you are—how fast clot is initiated, forms, & how strong the clot is; Can be used to guide treatment and resuscitation as well as monitoring blood transfusion therapy
What is thromboelastography (TEG)? What can it be used for?
Appearance of air density in disk space from the dehydrated disk causing release of nitrogen; seen in late degenerative disk disease
What is vacuum-disk phenomenon and what is it seen in?
Determine if they are stable or not--if unstable, do synchronized cardioversion with sedation prior; If stable, then have to look to see if QRS is wide or narrow; If patient is stable with wide QRS, try a vagal maneuver then Adenosine 6 mg IV push with flush (2nd dose would be 12 mg); If patient is stable with narrow QRS, only give Adenosine
What is your next step if your patient is showing a tachycardia rhythm on EKG? What is the next step after that? How does this determine what you will end up doing next for the patient?
Would show a darker collar on the Scottie dog image on the oblique x-ray view
What might indicate a pars interarticularis fracture? Which view can you see it best in?
Maxillofacial trauma--distortion of anatomical landmarks and airway compromise; Neck trauma--vascular injury in penetrating trauma; fractures/dislocations of cervical spine requiring stabilization before, during, and after securing the airway; Laryngeal trauma--might hear stridor or hoarseness with this injury; might have subcutaneous emphysema
What might you consider when trying to establish an airway in the following situations: with maxillofacial trauma, neck trauma, or laryngeal trauma?
Liquid is inserted into the large intestine through anus & uses x-rays to visualize the colon; Rarely done unless person cannot do a colonoscopy; No sedation is needed; Contraindications: perforation of colon, megacolon (can worsen this), and ischemic bowel disease; Potential complications: perforation and barium fecal impaction
What occurs in the barium enema? How often is this utilized? Does this person need to be sedated? What are contraindicated to getting a barium enema? What are potential complications?
Will hear high-pitched, hyperactive bowel sounds on auscultation from peristalsis still continuing; On imaging, will see multiple dilated loops on small bowel—usually more than the large bowel
What on physical exam gives idea that patient has a small bowel obstruction? What is the clue to look for on imaging with this?
Gallbladder, pancreas, and bladder (can see it when filled)
What organs are not usually visible on x-ray unless there is associated calcification?
Upper GI endoscopy--Esophagogastroduodenoscopy (EGD); Can also be used therapeutically by taking a biopsy of tissue, controlling of active GI bleeding, or dilation of strictures; Contraindications--Severe upper GI bleed, esophageal diverticula, suspected perforation, recent upper GI surgery; Potential complications—perforation, bleeding from biopsy site, pulmonary aspiration of gastric contents, or sedative medication reaction
What procedure is more sensitive specific than upper GI x-ray series? Besides visualization of the lumen in the upper GI, what can this be used for? What are contraindications to this? What are potential complications?
Amiodarone 300 mg IV push; If patient remains unresponsive and indicating another Amiodarone dose, give 150 mg IV; Lidocaine 1 mg IV push is also an option here
What should give after giving 3 shocks to a patient? What if you have to give this a second time? What is an alternative in this situation?
Assume all AMS patients are due to hypoxia until proven otherwise and establish airway; AMS patients may require a definitive airway because their tongue can often fall backward and obstruct the hypopharynx
What should you consider an altered mental status patient has when you first arrive on scene? What could they require specifically?
-On AP view, want to make sure we can see T1-T12, pedicles go all the way down on each side of vertebral bodies, & the vertebral bodies are rectangular -On lateral view, want to make sure we can see T1-T12 (although T1 might be difficult to see because it can be obscured by the arms)
What should you see to indicate adequacy on AP and Lateral views for the thoracic spinal x-rays?
-On AP view, should see L1 through L4 and the sacroiliac joint -On lateral view, should see L1 through L4 -On spot view, want to see a zoomed-in image of L5-S1 looking for spondylolisthesis -On oblique view, want to be able to see the facet joint and pars interarticularis
What should you see to indicate adequacy on AP, Lateral, Oblique, and Spot views for the lumbar spinal x-rays?
-On AP view, want to see C3 through T1 -On lateral view, want to see C1-T1 & make sure they follow the imaginary lines (spinolaminal line, posterior spinal line, and anterior spinal line) -On odontoid view, want to make sure the lateral masses of C1 line up over the masses of C2
What should you see to indicate adequacy on AP, Lateral, and Odontoid views for the cervical spinal x-rays?
This is a barium swallow showing corkscrew esophagus so the patient will have intermittent problems with swallowing; Have patient drink liquid barium before and during exam and then do x-ray to examine esophagus at GE junction; Can add in gas producing agent with the barium to improve mucosal visualization; Contraindicated in acute colitis or if GI perforation is suspected; Inform patient that stool will be white until all the barium has been eliminated
What test is being utilized here and what is this displaying? What are the steps for the patient in this procedure? What can aid in visualization during this test? When is this contraindicated? What do you inform patient after that procedure?
Colonoscopy; Patient will be sedated for colonoscopies Contraindications—coagulopathies, suspected perforation, toxic megacolon, recent colon anastomosis, or recent diverticulitis; Potential complications—bowel perforation or persistent bleeding
What tool allows for direct visualization of the entire colon? Will the patient need to be sedated for this? What are contraindications to this procedure? What are potential complications?
-Hyodense area (dark)—fat (not usually present), air (sinuses), water (CSF), chronic subdural hematomas -Isodense area (gray)—normal brain, forms of protein (subacute subdural hematomas) -Hyperdense area (bright)—metal (bullet, aneurysm clips), iodine (after contrast), calcium, hemorrhage; If sinuses are filled with mucus or blood, will not appear dark
What will appear hypodense on brain CT? Is this dark, gray, or bright? What will appear isodense on brain CT? Is this dark, gray, or bright? What will appear hyperdense on brain CT? Is this dark, gray, or bright? What specific area can change on imaging that we talked about?
Used in unconscious patients without a gag reflex (like when using BVM); It is inserted into the mouth with point towards roof of mouth, twisted, then lies behind the tongue; Process is different in children since they do not have hard palates—need to just go in straight; Measured from the angle of the jaw to the corner of the mouth
When is an oropharyngeal airway utilized? How is it properly inserted? When is this process different? How is it properly sized?
Recommended for semi-conscious or unconscious patients with an intact gag reflex (ex: postictal patients or drug overdoses); This is contraindicated in patients with facial trauma or suspected basilar skull fracture; Potential complications include epistaxis, gagging, vomiting, and aspiration; Sized from the tip of the nose to the earlobe; Should be inserted into the largest nare & lubricated—should abort if there is resistance felt
When is insertion of the nasopharyngeal airway recommended? When is it contraindicated? What are potential complications from it? How do you size it properly & how is it properly inserted?
Used in bradycardia and all heart blocks for unstable patients; Sedation should also be used for these patients as well; Have to set the heart rate of the patient (can be 80-100) and then increase the output until you achieve capture; Turn down the output at the minimal level that it still achieves capture on the patient then put it up another 10%
When is pacing used? What should be used before performing this? What do you have to set the device to when pacing? What should you do once you achieve capture?
Delivery of electrical energy to the heart to terminate tachycardiac arrhythmias in unstable patients; Used in SVT, A-fib, atrial flutter, and V-tach with a pulse; If these patients are stable, should try to be adjusted with medications first; Cardioversion is synched with the R-waves of the patient's rhythm before delivering a shock; Usually starts with 50-100 J; Right after, check rhythm and see if it has converted; Important to sedate patient prior to shock because it can be painful
When is synchronized cardioversion used? Which specific rhythms is it used in? What if these patients are stable? What is this synched to? How much energy is usually used initially? What should you immediately do after delivering shock? What is important to use before performing cardioversion and why?
Contraindicated on anyone under age of 12; This is preferred over tracheostomy because it is easier, there is less bleeding, and faster; Must remember to watch for recurrent laryngeal nerve that goes right across the thyroid
When is using surgical cricothyroidotomy contraindicated? What is this preferred over and why? What do you have to be careful about with surgical cricothyroidotomies?
If in code, use 100% through BVM; If not, adjust until O2 saturation stats are at 94%
When oxygen levels should you be using through the BVM while in code? What about if you are not in a code?
Should start at 120 J then go to 150 J at the next should then try 200 J & continue at 200 J for any shocks after that
When shocking patient in V-fib or V-tach, what should we start the electricity levels at? What should it be increased to?
Occurs at the base of the skull will cause tears in the dura mater with CSF leakage; Will see CSF rhinorrhea or otorrhea, hemotympanum (blood behind TM), Battle sign (bruising behind ears), raccoon eyes (bruising around eyes); CT findings--Will have traumatic pneumocephalus (air where there is not supposed to be), fluid in the mastoid air cells, and air-filled level in the sphenoid sinus
Where does a basilar skull fracture occur and what does it cause? What will you see on physical exam with these patients? What are CT findings suggestive of a basilar skull fracture?
The majority of bowel gas comes from swallowed air & the rest is from bacterial fermentation of food; Will see dilation of bowel loops beyond their normal size; Stomach—almost always has air in it except if patient recently vomiting or if they have an NG tube in place & attached to suction
Where does the majority of bowel gas come from? Where does the rest? What would indicate bowel gas on x-ray? How should the stomach look on x-ray?
Colonoscopy, EGD, Barium Enema, and ERCP (Endoscopic retrograde cholangiopancreatography)
Which GI imaging procedures require informed consent?
They are usually in the posterior portion of the vertebral bodies; Multiple myeloma; Can lead to compression fractures but tend to destroy the posterior aspect of the vertebral body; Screening study of choice for these are radionuclide bone scan--they are highly sensitive to the presence of metastatic deposits but they are not very specific.; Prostate and breast will have osteoblastic lesions metastasize to bone & breast, kidney, thyroid, and lung will have osteolytic lesions metastasize
Which part do metastasis to the spine typically develop? What is the most common primary bone malignancy? What can metastasis in the spine lead to? What is the screening study of choice and what is its downfall? Which metastasis are osteoblastic (build-up bone) and which are osteolytic (destroy bone)?