Imag|ng

8r|an k. Geh|bach, MD
D|v|s|on of u|monary, Cr|nca| Care, &
Cccupanona| Med|c|ne
Un|vers|ty of Iowa


D|sc|osures
none
Cb[ecnves
uescrlbe how Lo eva|uate suspected L |n pregnancy
uslng Lhe A1S Cllnlcal racuce Culdellne.
Lxplaln Lhe uses and llmlLauons of beds|de
u|trasonography.
uescrlbe Lhe evldence supporung Lhe use of an on-
demand strategy to chest rad|ography ln lCu
pauenLs.
uescrlbe Lhe advanLages and dlsadvanLages of
dlerenL approaches Lo Lhe d|agnos|s of suspected
esophagea| perforanon and suspected aornc
d|ssecnon.
ClLe rlsk facLors for Lhe developmenL of contrast
nephropathy and nephrogen|c system|c hbros|s, and
llsL sLraLegles for Lhelr prevenuon

uesnon #1
A 28 yo prevlously healLhy woman, C21, presenLs aL
10 weeks' gesLauon wlLh 2 days of lnLermluenL rlghL
pleurluc chesL paln and mlld shorLness of breaLh.
uenles leg paln.

hyslcal examlnauon
1 37.3 ulse 90 8esp 16 8 90/60 SpC2 98
8reaLhlng comforLably. Lungs C1A. ChesL wall
nonLender. normal S1 and S2. Mlld le pedal edema.
Wh|ch of the fo||ow|ng |s the next best
step |n eva|uanng th|s panent's
symptoms?
A. u-dlmer Lesung.
8. laln chesL radlograph (wlLh shleldlng)
C. C1 pulmonary anglography
u. 8llaLeral compresslon lower exLremlLy ulLrasound
L. venulauon/perfuslon lung scan
1he d||emma:
L accounLs for 20 of maLernal deaLhs ln uS
Slgns & sx of L overlap wlLh physlologlc A's of
pregnancy
ueslre Lo llmlL radlauon exposure Lo moLher & feLus
Leung eL al. A!8CCM 2011.
Work|ng up V1L |n pregnancy
kad|anon exposure: 2 at-r|sk |nd|v|dua|s
leLal radlauon doses dellvered !" $%&'( by properly
performed dx LesLs presenL no measurably ^ rlsk of
prenaLal deaLh, malformauon, or lmpalred menLal
developmenL.
Carclnogenesls ls consldered Lhe ma[or rlsk for feLus and
moLher (lung, breasL).
8oughly equlvalenL feLal exposure wlLh C1 vs v/C
MaLernal radlauon exposure: C1 > v/C
8oLh C1 & v/C valuable sLudles ln approprlaLe conLexL
Leung eL al. A!8CCM 2011.
Iod|nated contrast agents |n pregnancy
CaLegory 8
osslble lnducuon of neonaLal hypoLhyroldlsm,
however, reLrospecuve sLudy of 344 pregnanL pLs
who underwenL C1A for L found nl Lhyroxlne
levels ln all aL blrLh (8our[elly C 2010).
no LeraLogenlclLy noLed ln anlmal sLudles
In s|tuanons |n wh|ch the panent |s unstab|e, or
when certa|n stud|es are unava||ab|e or
|mpracnca|, emp|r|c therapy or a|ternanve
d|agnosnc approaches may be |nd|cated.
GUIDLLINL CAVLA1S

1here |s no We||s score for the pregnant pt w|th poss|b|e L

Loca| pracnces & expernse shou|d be taken |nto account

Cvera|| qua||ty of ev|dence |s weak


Gu|de||nes for eva|uanng suspected L |n
pregnancy
1. u-dlmer should noL be used Lo excluded L (weak
rec).
2. auenLs wlLh suspecLed L & slgns/sx of uv1 should
undergo bllaLeral CuS rsL, II Lhe LesL ls avallable &
Lhe pL ls sLable, followed by furLher Lesung lf Lhe
resulL ls negauve (weak rec).
3. auenLs wlLh suspecLed L & no slgns/sx of uv1
should undergo sLudles of Lhe pulmonary
vasculaLure raLher Lhan CuS (weak rec).
Leung eL al. A!8CCM 2011.
Gu|de||nes (cont)
4. 1he Cx8 ls recommended as Lhe rsL radlauon-
assoclaLed procedure ln Lhe dx workup (sLrong rec).
3. ln pLs wlLh suspecLed L and a normal Cx8 Lhe nexL
LesL ls lung sclnugraphy, followed by C1A lf
nondlagnosuc (sLrong rec).
6. ln pLs wlLh suspecLed L and a nondx v/C scan,
furLher dx Lesung ls rec over cllnlcal mgmL, and C1A
ls recommended over pulmonary anglography (sLrong
rec).
7. ln pLs wlLh suspecLed L and an abnormal Cx8, C1A
ls recommended over lung sclnugraphy (weak rec).
SuspecLed L ln pregnancy
CuS
Leg sympLoms?
1reaL
Cx8
C1A v/C
SLop 1reaL SLop CuS,
C1A
?e
s
no
Abnl nl
nondx
-
+
1echnlcally
lnadequaLe
+ + -
D|agnos|s of suspected L |n pregnancy
llgure adapLed from Leung eL al. A!8CCM 2011.
-
uesnon #2: Wh|ch of the fo||ow|ng statements |s true
regard|ng c||n|c|an-d|rected u|trasonography (assum|ng
adequate exper|ence)?
A. locused AssessmenL wlLh Sonography for 1rauma (lAS1)
ls superlor Lo C1 for Lhe evaluauon of solld organ ln[urles.
8. uS has noL been shown Lo lmprove Lhe raLe of success for
LhoracenLesls or paracenLesls.
C. uS ls more sensluve Lhan Cx8 for Lhe deLecuon of
pneumoLhorax.
u. 8eal-ume uS guldance of CvC lnseruon has noL been
shown Lo lncrease Lhe raLe of successful cannulauon.
L. lluld responslveness can be assessed wlLh Lhls Lechnlque
only when pauenLs are noL recelvlng mechanlcal
venulauon.
C||n|c|an-performed u|trasonography
Llkely Lo be LesLed as popularlLy lncreases

8r|ef overv|ew
lAS1
rocedures
lluld responslveness
lnLro Lo Lhoraclc lmaglng
normal ndlngs
neumoLhorax (pLx)
leural euslon
Consolldauon
Alveolar-lnLersuual syndrome
US bas|cs: the producnon
& detecnon of echoes
8eecuon produced aL
boundary beLween 2
ussues wlLh dlerenL
acousuc properues
1radeo beLween
resoluuon (hlgh freq) and
peneLrauon (low freq)
ArufacLs: plualls and
opporLunlues
Aldrlch !L. CrlL Care Med 2007.
Large d|erence |n acousnc
|mpedance = strong echo
keecnon &
refracnon of
ob||que beam
Iocused Assessment w|th Sonography for
1rauma (IAS1)
Lxamlnes 4 areas for free uld:
erlhepauc & hepaLo-renal
erlsplenlc
elvls
erlcardlum
Pas supplanLed uL ln many
cenLers & clrcumsLances
8apld, nonlnvaslve, repeaLable
CperaLor-dependenL
LlmlLed lnformauon
www.Lrauma.or
g
IAS1 recommendanons
SulLable for a rsL look" as an ad[uncL Lo Lhe A1LS prlmary
survey
lalrly sensluve and hlghly speclc for free uld, low
sensluvlLy for ln[ury Lo solld organs
Not as sens|nve as C1!
US ! the success & " the comp||canons of beds|de
procedures
kea|-nme uS use wlLh
cenLral llne lnseruon
Slmllar resulLs wlLh
LhoracenLesls,
paracenLesls
V|sua||z|ng w|re |n
ve|n pr|or to d||anon
nypovo|em|c pt on MV w|th s|gn|hcant IVC var|anon
No IVC var|anon: not a cand|date for u|ds
Lung |mag|ng w|th u|trasound
leural euslon
neumoLhorax
Consolldauon
Mass
Lung abscess
ulmonary edema or brosls
PaklmlsefaL eL al. 1he Cpen Crlucal
Care Medlclne !ournal 2010.
Norma| |ung hnd|ngs
osLerlor shadowlng from rlbs
Lung pulse
Pyperecholc, slldlng llne (pleural llne)
A llnes" (a reverberauon arufacL represenung Lhe
horlzonLal repeuuon of Lhe pleural llne)
8 llnes" (a few are normal): verucal narrow llnes
exLendlng from pleural llne radlally Lo edge of
screen
M-mode: seashore slgn
Norma| exam w|th |ung s||d|ng & A ||nes (and a
||u|e b|t of |ung pu|se)
Conso||danon & p|eura| eus|on and asc|tes
A|veo|ar-|ntersnna| syndrome |nd|cated by
abundant 8 ||nes ("|ung rockets")
Detecnon of pneumothorax by US
More dlmculL Lhan oLher aspecLs of ulLrasonography,
wlLh experlence, however, Lhe uS ls vL8? sensluve
(and fasL!)
Slgns
! A-llnes vlslble and lung slldlng absenL, C8
! Lung polnL slgn (parual pneumoLhorax)
! 8arcode slgn" on M mode
normal lung slldlng or 8 llnes exclude dx
8|ke vs tree: |ung po|nt
Seashore S|gn 8arcode S|gn (ptx)
8|ke vs tree, part 2: r|b fractures
uesnon #3: Wh|ch of the fo||ow|ng statements |s
true regard|ng esophagea| perforanon?
A. 8arlum conLrasL ls Lhe preferred agenL when orderlng a
conLrasL esophagram because lL ls more sensluve Lhan
waLer-soluble conLrasL.
8. CreplLus and neck paln ls suggesuve of Lhoraclc
esophageal perforauon.
C. Lsophageal dlssecuon and/or hemaLoma may be
dlagnosed by C1 scan.
u. MosL cases are sponLaneous and due Lo eorL
rupLure".
L. An enurely normal chesL lm excludes Lhe dlagnosls.
Lsophagea| perforanon
Spontaneous: eorL rupLure (8oerhaave's syndrome),
plll esophaglus, 8arreu's ulcer, lnfecuous ulcers, causuc
lngesuon
1raumanc: posL-dllauon or posL-sLenL, followlng
Lraumauc lnLubauon
8orhaave's syndrome:
uescrlbed ln 1724 by Perman 8oerhaave
usually le posLerlor-laLeral aspecL of dlsLal esophagus
Plgh cervlcal also occurs
lncompleLe crlcopharyngeal relaxauon
31 yo wlLh pneumomedlasunum.
Po eL al. A!8 2009.
Chest rad|ograph hnd|ngs |n esophagea| perforanon
I|nd|ngs depend on
nm|ng
neumothorax or
pneumomed|asnnum
may be so|e ear|y hnd|ng
May have p|eura|
eus|on (usu |eh) or
hydroptx, subcutaneous
emphysema
D|agnosnc stud|es for suspected
esophagea| perforanon
Lsophagram
WaLer-soluble conLrasL (CasLrogran) preferred
8arlum superlor for small perforauons buL causes
lnammaLory response (Lherefore performed only lf
Lhe waLer-soluble sLudy ls negauve)
C1
Also excellenL and may reveal alLernauve dlagnoses
May deLecL lnLramural dlssecuon, hemaLoma
8oerhaave syndrome |n 2 m|dd|e-aged men
?oung eL al. 8adlographlcs 2008.
Cra| contrast & a|r ad[acent to
esophagus, a|so w|th |eh
eus|on
A|r, debr|s, & ora| contrast
ad[acent to esophagus
Lsophagram |n a young man w|th emetogen|c
esophagea| perforanon
?oung eL al. 8adlographlcs 2008.
Lsophagram
show|ng |eakage
of mater|a| from
cerv|ca| esophagus
uesnon #4: Wh|ch of the fo||ow|ng
statements |s true regard|ng the |mag|ng of
panents w|th suspected aornc d|ssecnon?
A. 1LL ls Lhe LesL of cholce for Lhe evaluauon of pauenLs
wlLh conrmed or suspecLed chronlc aoruc dlssecuon.
8. C1A provldes useful lnformauon abouL Lhe presence or
absence of aoruc lnsumclency ln 1ype A aoruc
dlssecuon.
C. Medlasunal wldenlng ls presenL on Cx8 ln over 90 of
dlssecuons.
u. M8A ls Lhe safesL LesL ln Lhe unsLable pauenL.
L. 1he overall accuracy of C1A, M8A, & 1LL ls slmllar.
Vocabu|ary of aornc d|sease
Aneurysm: locallzed dllauon of a vessel due Lo weakened wall
seudoaneurysm: a hemaLoma around a leaklng hole ln an
arLery
D|ssecnon: Lear ln Lhe wall of a vessel
1rue |umen: self-evldenL
Ia|se |umen: Lhe abnormal channel wlLhln Lhe wall of Lhe
dlssecung arLery
Innma| ap: a layer of lnumal ussue separaung Lrue from false
lumen
Mura| thrombus: Lhrombus ln conLacL wlLhln Lhe endoLhellal
llnlng
Intramura| hematoma: hemaLoma wlLhln Lhe wall of Lhe
dlssecung vessel
kupture: self-evldenL
www.radpod.org
Aornc d|ssecnon w|th |nnma| ap
1LL show|ng descend|ng aornc d|ssecnon
LvangellsLa eL al. Lur ! Lchocardlogr 2010.
1wo [ets from true
|umen (1L) to fa|se
|umen (IL) |dennfy
the presence of
secondary
commun|canons.
Cho|ce of test
Cvera|| accuracy of C1A, MkA, & 1LL |s s|m||ar for
dx of aornc d|ssecnon
C1A ls wldely avallable & able Lo evaluaLe Lhe aorLa
& lLs branches ln lLs enureLy
1LL allows funcuonal evaluauon (lncludlng presence
or absence of aoruc lnsumclency)
M8A useful when C1 nondx, alLernauve Lo C1A when
Lhere are conLrasL concerns, however ls slower
Lxper|ence w|th the techn|que
Lect of da||y Ckk on hosp|ta| morta||ty
Iavors on-demand Iavors rounne
Cba eL al. 8adlology 2010.
revennng comp||canons from contrast
adm|n|stranon
Lnsure adequaLe hydrauon/renal blood ow
0.9 nS 1 ml/kg for 12 hrs prlor Lo and followlng Lhe
procedure
LowesL posslble dose of conLrasL
Avold nSAluS and CCx-2 lnhlblLors
Lvldence on n-aceLylcysLelne ls mlxed.lf deslred:
1200 mg orally Lwlce dally u-1 and u0
l/u Lesung ln aL-rlsk lndlvlduals
Nephrogen|c system|c hbros|s
AvCluAnCL of C8C
admlnlsLrauon ln
hlgh-rlsk lndlvlduals
(Cl8 < 30)
CAu1lCn wlLh Cl8
30-39
Conslder Lemporary
Pu lf C8C consldered
essenual
Sx onseL < 2 monLhs of
C8C exposure
Skln leslons, Lhlckenlng,
conLracLures
May lnvolve vlscera
Pellman. Semln nephrol 2011.
Summary
1he A1S guldellnes provlde a useful sLarung polnL for
Lhe evaluauon of suspecLed L ln pregnancy
1he lncreaslng popularlLy of cllnlclan-dlrecLed
ulLrasonography means LhaL baslc prlnclples may be
LesLed
1he selecuon of Lhe besL LesL for evaluaung Lhoraclc
emergencles llke esophageal perforauon or aoruc
dlssecuon depends on Lhe pauenL and semng
ConLrasL nephropaLhy ls besL prevenLed by ensurlng
adequaLe hydrauon/renal blood ow
C||n|c|an-d|rected
u|trasound