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Magnetic Resonance Imaging in the Pediatric Patient

Introduction The demand for pediatric magnetic resonance imaging (MRI) is steadily increasing because MRI is radiation free, has exquisite soft tissue contrast, and provides quantitative structural, functional, and vascular information for diagnosing a wide spectrum of diseases. Furthermore, the advent of genomics has led to improvements in understanding the genetic basis of a variety of heritable disorders associated with childhood neoplasms, so serial laboratory and radiologic…

Contrast-Enhanced Magnetic Resonance Imaging

Introduction Contrast agents used in magnetic resonance imaging (MRI) can be either endogenous or exogenous. The most common type of endogenous contrast-enhanced MRI is arterial spin labeling (ASL) techniques, which use a dynamic labeling of internal water to measure brain perfusion. ASL is noninvasive, and the sequences needed to acquire this type of imaging are included on most major vendors' platforms. However, ASL still suffers from…

Imaging Principles in Magnetic Resonance Angiography

Introduction Magnetic resonance angiography (MRA) enables noninvasive assessment of vascular disease in both the arterial and venous circulation. Owing to the availability of volumetric data sets without the need for ionizing radiation exposure and facilitated by technologic and methodological advances in hardware, data sampling, and image reconstruction approaches, MRA has become a powerful tool for the diagnosis of a variety of vascular pathologies. MRA techniques explore…

Imaging Principles in Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is based on spatially encoding a nuclear magnetic resonance (NMR) signal. Therefore an understanding of the basics of NMR is critical for understanding MRI, and this information is given in the first section of this chapter. Magnetic field gradients are used in MRI to spatially encode the NMR signal to obtain the raw MRI data, or k-space. Images are reconstructed from k-space…

Computed Tomography Imaging Operation

Protocol Management and Optimization Protocols are the turn-by-turn instructions that allow the computed tomography (CT) operator to get from point A—registering the patient on the scanner from the order in the radiology information system (RIS)—to point B—sending a complete set of images to the picture archiving and communication system (PACS) for a radiologist to interpret. To comply with the National Electrical Manufacturers Association (NEMA) XR-29 standard,…

Imaging Principles in Computed Tomography

Computed tomography (CT) has grown quickly from an innovative specialized tool to a mainstay of medicine in every healthcare setting. Hospitals, outpatient clinics, and physician offices find CT to be an essential tool for patient diagnosis and management. Every year brings new advances in CT technology and applications. This chapter is dedicated to the basic principles and physics of CT operation. The practicing radiologist who can…

Ultrasound training in critical care medicine fellowships

Overview Critical care ultrasound (CCU) is a noninvasive tool used for diagnostic evaluation and for guiding procedures in critical care patients. Ultrasound improves success and lowers complication rates when used to guide procedures such as vascular access and fluid drainage. Despite these advantages, formal training in CCU has not been incorporated into many fellowship programs, and training in this skill remains heterogeneous. The American Board of…

Training in critical care echocardiography: Both sides of the atlantic

Overview Echocardiography provides intensivists with a means of rapidly assessing the anatomy and function of the heart in intensive care unit (ICU) patients with hemodynamic failure, thus guiding management. Since echocardiography is a key skill for frontline intensivists, developing effective training programs is essential to ensure that clinicians have competence in the field. This chapter discusses some issues related to training in critical care echocardiography (CCE)…

Training and competence in ultrasound-guided vascular access

Overview Despite well-established evidence on the use of ultrasound for placement of any vascular access, a formal training program on how to perform ultrasound-guided vascular access (UGVA) and how to certify adequate competence has not been clearly defined. , According to recommendations by the National Institute for Clinical Excellence, those involved in UGVA should undertake appropriate training to achieve competence. Defining a competent practitioner in objective…

Integrating ultrasound into critical care teaching rounds

Overview Significant advancements have been made in the use of ultrasound technology since its inception in the early 1950s. These advances have revolutionized the practice of critical care medicine. Currently, clinicians in the intensive care unit (ICU) have at their disposal a tool at the bedside that augments the physical examination and is safe, portable, noninvasive, and readily available. Safety Ultrasound technology uses sound waves, and…

Ultrasonography: A basic clinical competency

Overview Ultrasonography has undergone a transformation in the past 2 decades that is fundamentally changing the way that medicine is taught and practiced. Technologic advances have taken ultrasound to the bedside or point of care in the form of laptop and pocket-sized devices that produce high-quality digital images that can be saved in multiple formats or sent anywhere in the world for review. Because of the…

The holistic approach ultrasound concept and the role of the critical care ultrasound laboratory

Overview The approaches to examination of patients by clinical providers has evolved with the growth of medical knowledge and expectations of quality care. Though still primarily relying on their senses, physicians have been adding basic equipment (e.g., scale, stethoscope) and more complex devices (e.g., scopes, sphygmomanometer) to patient evaluation standards. In the intensive care unit (ICU), the diagnostic process is rather complex and continuous, and physical…

Integrating picture archiving and communication systems and computerized provider order entry into the intensive care unit: The challenge of delivering health information technology–enabled innovation

Overview This chapter presents research evidence on the effective utilization of picture archiving communication systems (PACSs) and computerized provider order entry (CPOE) systems in the intensive care unit (ICU). PACSs provide a centralized communication repository for all imaging data that replaces previous film-based systems by delivering diagnostic images electronically to clinicians. CPOE systems allow clinicians to place orders (e.g., medication, imaging, and pathology) directly into computers…

Ultrasound in animals

Overview In 2004, in the first historical translational study of focused assessment with sonography for trauma (FAST) from humans to small animals, 101 dogs with severe blunt trauma after being hit by cars were evaluated. The authors reported that intraabdominal injury, specifically, hemoperitoneum, was more common than previously identified (pre-FAST rate of 12% to 23% versus a post-FAST rate of 45%). By imaging the thorax via…

Ultrasound in reconstructive microsurgery: (CONSULTANT-LEVEL EXAMINATION)

Overview Recent innovations in local tissue rearrangement and free tissue transfer have altered surgical approaches from simple wound care or amputation to optimal functional and aesthetic repair. Survival of transferred tissue remains a concern in trauma patients. , Apart from the surgical technique, various factors may influence microsurgical operations, such as defect location and size, functional characteristics and underlying disorders, types of affected tissue, anatomic variants,…

Ultrasound-guided regional anesthesia in the intensive care unit

Overview Peripheral regional anesthesia and neuraxial anesthesia are well established in postoperative pain management following major orthopedic, thoracic, and abdominal procedures. Benefits include pain control superior to that achieved with systemic opioids, improved lung function after thoracic and abdominal procedures, and decreased stress/inflammatory responses. Ultrasound (US) guidance for regional anesthesia has been used increasingly over the last decade because it allows precise positioning of the catheter…

Ultrasound-guided percutaneous tracheostomy

Overview Percutaneous tracheostomy (PT) is a common bedside procedure in the intensive care unit (ICU). Successful outcome requires midline needle puncture between the second and fourth tracheal rings and avoidance of posterior wall and vascular trauma. Kearney et al reported rates of perioperative morbidity of 6% and procedure-related mortality of 0.6%. Placement complications include hemorrhage, accidental extubation, pneumothorax, formation of a false passage, damage to tracheal…

Soft tissue, musculoskeletal system, and miscellaneous targets

Overview Besides encompassing specific focused techniques, the holistic approach (HOLA) ultrasound concept, introduced in Chapter 1 , promotes generic scanning of any body part (head-to-toe ultrasound imaging) as modulated by current clinical indications. Any ultrasound view obtained through the skin contains some information about soft tissues. While serving as an imaging window and as anatomic reference structures in focused techniques (e.g., the chest wall in lung…

Ultrasound imaging in space flight

Throughout the 5 decades of human space flight, the space medical support systems provided for onboard treatment of minor medical events and evacuation of the seriously ill or injured to Earth. In the absence of adequate objective information, however, it may be difficult to weigh the risks of onboard management against those of emergency return. A case of substantial trauma or illness would pose a serious…

Use of ultrasound in war zones

Overview War zones are unpredictable and austere environments that present unique challenges to medical providers. The hazards of combat as well as common nontraumatic pathology must be cared for in a diverse range of settings, from the combat medic caring for a wounded casualty while under enemy fire to the physician caring for critically ill patients in a forward-deployed temporary field hospital. During previous conflicts, as…