CT - the prime instrument for the critical. Critical Decisions & Critical Bleeds

Transcription

1 Critical Decisions & Critical Bleeds Bertil Leidner, MD Karolinska University Hospital Huddinge Stockholm, Sweden CT - the prime instrument for the critical patient t

2 The critical patient Traumatized In shock bleeding Life threatening illness Identify the critically ill patient» Referral; personal contact» Tech Shortcut the diagnostic process» Prepare: review clinical facts + previous exams» Be exam; refering doc + radiologist» Monitor reading The critical patient HESITATIONS Radiation (young patient) Pregnancy Breast feeding Contrast & Renal insuffiency Allergy

3 Case: Female 66 y o Diarrhea, vomiting + abd pain 2 days KOL, Mb Crohn longstanding Exam without iv contrast due to non- defined allergy towards contrast media

4 Radiology report No free air. Dilated small bowel loops with suspicion of distal obstruction. Oedema in mesentary & distal ileal wall inflammmatory reaction?? Air in intrahepatic bilary ducts or in peripheral portal branches but not in central porta. No air in bowel walls Status post ERCP/papillotomy? Follow-thru exam started

5 12 h later 2nd exam with iv contrast

6 2nd radiology report (iv contrast +) Suspicion of thrombus in proximal a mes sup & coeliac trunc. Air in portal vein + intestinal wall Patchy hepatic necrosis Acute laparotomy reveals no pulsation in these arteries & extensive tissue necrosis No further actions. Patient dies in ICU Discussion Limits of non-contrast exam» Clinical hesitation, delay!» Make it easy to diagnose!

7 Don t forget YOU have to make a medical decision» Pro vs Con The patient comes for a diagnostic exam No patient comes to radiology in order to» get a low dose of radiation» get a low dose of contrast media 50 y o man Motorbike accident Case GCS 13, slightly tender abdomen, no shock What if» Earlier heavy skin reaction after iv iodine CM» Known renal disease; P-creatinine 200 Trauma CT with iv CM? Or not?

8 No iv contrast FAST neg + CT + No fluid Standard in the scans abdomen. + iv Injury ruled out?? No iv contrast Standard scans + iv

9 Questions? To postpone or refuse an examination» May kill the patient?» May save the patient?» Maybe tomorrow a good choice? Not using iv contrast» May kill the patient? t?» May save the patient?» Maybe tomorrow a good choice? Pre-examination Judging the referral Read between the lines Be a doctor

10 Pre-examination WHEN TO BE CONCERNED? Radiation young age Contrast old age, renal disease, contrast allergy Prophylaxis hydration» Drinking water» 0.9% NaCl iv 100 ml/h» 4-12 h pre h post exam (US-1 h pre- + 4 h post exam)» Acetylcysteine unclear - new metaanalysis? Critical Examination CT-angiography &no peripheral iv line? When may you use the contrast power injector? IV lines» Central venous catheter» Port-A-cath» Pick-line

11 Outline l Critical cases & Critical bleeds» Head imaging emergency findings» C-spine imaging soft tissue» Thorax critical cases» Abdomen hypovolemia yp critical cases

12 Dx? l l l l l l MVA Findings? Mixed density lesion Trapped fluid in ipsilateral ventricle DX? Hyperacute subdural hematoma» Unclotted blood

13 Motorcross-accident 25 y o female thrown off bike hit the bushes Findings? Wood wide window

14 C - Spine soft tissues Fracture/dislocation» What about the spinal cord? Bony injury is ruled out Remaining problems» Neurological defecit?» Unconscious patient Ligamentous injury? MRI drawbacks» Patient factors Badly injuried metal» Not always available for the patient CT Acute Spinal Canal Imaging Spinal Cord threats» herniating disc» epidural hematoma» ligamentous injuries 64x0.625 mm (or 4x1 mm)» 25% recon overlap» bone algorithm» mprsag6mmthick mm» 50% overlap» WW 400 WL 100 C 7 T 2

15 Bechterew Epidural hematoma

16 Thorax Thorax» You are called to the CT suite by the tech.» Now what? How to deal with a tension pnthx?! Make a quick report? Call for an anesthesiologist? Call for a surgeon? or...

17 How to deal with a tension pnthx?! l l or... Puncture» 2-3 intercostal space» Medio-clavicular line» Large needle (venflon)» Keep until drainage cath is placed

18 28 y old female Severe abdominal pain since 30 min. Tender central abd Blood from rectum since yesterday BP 90/50, pulse 95

19 Findings > fluid density Sentinel clot, Ongoing bleed Shock bowel IVC, aorta

20 Case discussions Critical patients 32 year old female; 4-12 h post partum Abdominal pain Tachycardia, low blood pressure DIC? Ongoing bleed? P-krea 150 CT? Angio-embolization?

21 32 year old female; 12 h post partum P-krea 150 CT? Angio-embolization? CT PROTOCOL» Native series To define earlier contrast, sutures etc» Arterial phase - 25 sec after 160 HU in aorta abd» Venous phase + 25 sec» Late phase sec Contrast protocol» 0.75 g Iodine/kg bodyweight» 25 sec injection time (max 8 ml/sec)

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23 32 year old female; 4 h post partum P-krea 150 CT PROTOCOL» 160 ml Visipaque 6 ml/s DIC injury to liver + kidneys Follow up I Anuria 2 weeks Polyuria phase Renal recovery

24 Discussion Lifesaving procedures Amount of iv contrast high» Lower dose vs find the bleeding source Rescan after 2 weeks for abscess?» Iv contrast or not? 5 weeks post partum Still in dialysis Polyuric phase Judged to regain renal & liver function 2 years later limited renal impairment

25 Thank you for your attention!