Critical care clinics
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Critical care clinics · Apr 1994
Review Comparative StudyComputed tomography of the abdomen in the critically ill.
In one's attempt to arrive at the most accurate diagnosis in the critically ill, the selection of the most efficacious and rapid imaging modality can be problematic to clinicians, especially if the clinical presentation is confusing. The selection most often, is between US and CT. In general, US is advantageous in that it can be performed at bedside and is a faster and less costly examination. ⋯ This can be accomplished best by direct communication between clinicians and radiologists before and after the examination. Radiologists who understand the clinical problems and are familiar with all diagnostic modalities should be consulted for the selection of the modality best suited to answering the question at hand. Similarly, critically ill patients should benefit most if clinicians and radiologists review the examination results together in light of the clinical presentation for more accurate and meaningful diagnosis.
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The plain film of the abdomen usually is the first radiographic examination ordered to evaluate the abdomen in the ICU patient. It is inexpensive, universally available and may be done at the bedside in the ICU. This article details and describes what to look for when interpreting a plain radiograph of the abdomen.
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Nuclear medicine techniques yield unique physiologic information about many organ systems. These types of studies can be extremely useful in the acutely ill patient. Pulmonary scintigraphy is the procedure of choice for screening dyspneic patients for pulmonary emboli. Hepatobiliary scintigraphy has a definite role in the evaluation of patients with abdominal pain and those with postbiliary tract surgical complications.
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Ultrasonography plays an increasingly important role in the evaluation of the vascular system. It is especially useful for the intensive care patient because of its ability to be performed at the patient's bedside, as well as the relatively high frequency of vascular complications in the ICU. Ultrasonography is the method of choice for evaluation of deep vein thromboembolic disease of the lower extremity in all patients, demonstrating excellent sensitivity and specificity for this condition. ⋯ It may be limited in this assessment, however, because it does not reliably demonstrate the central subclavian and innominate veins, and therefore may be inadequate for evaluation of malfunctioning central venous catheters. Ultrasonography can reliably identify the presence of abdominal aortic aneurysms, although computed tomography is better able to demonstrate location and extent of these lesions. Finally, ultrasonography can be used to diagnose complications of arterial catheterization and, in selected patients, may direct compression of pseudoaneurysms, resulting in thrombosis and thereby averting surgical repair.
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In summary, ultrasonography and its recent advances appear ideally suited to a number of conditions common in the critically ill patient and the ICU setting. Depending on the clinical situation, and, providing appropriate technical expertise is available, ultrasonography can both gather diagnostic information and, where indicated, guide therapeutic intervention.