1 X-rays, from www.icufaqs.

org Mark Hammerschmidt, RN

Its just my opinion, but I think that ICU nurses should have some basic (really basic) idea of how to look at x rays of some of their !tools of the trade"# $% tubes, central lines, &' lines, maybe a couple of others( )bviously you arent *oin* to be tryin* to compete with physicians in readin* them, but still I think its useful to be able to look at a stat film and say !+ee, it looks like that $% tube is in the ri*ht main stem(" )r !,ow, no wonder the &' line is stuck in wed*e, look how far in it is-" %hin*s like that( .o I went out on the web and surfed around, and I found some film ima*es that may be helpful( 's usual# please remember that this material is not meant to be an official reference of any kind / its supposed to reflect the experience and knowled*e of a preceptor as it is passed on to a new 01 orientee( 'lso please let me know when you find errors or omissions / well put them in ri*ht away( ' word about the x ray ima*es# film ima*es can be impenetrably hard to read, even if you have, as radiolo*ists are said to have# x ray vision( (2a-) ' lot of these ima*es are clearer on the computer screen, I *uess because the resolution is lots hi*her than whats produced by most printers( 3ine, anyhow( %ry a laser printer, or try lookin* at the pictures on your monitor and adjustin* the contrast sometimes it helps( 4 6 7 8 9 : ; < = 4> 44 46 47 48 49 4: 4; 4< 4= 6> 64 66 ,hat is an x ray5 ,hat are some common x ray procedures that my patients may have in the 3ICU5 ,ho takes x rays5 ,ho reads them5 ,hat is a stat film5 2ow stat should stat be5 Can I stay in the room if my patient is bein* x rayed5 ,hat are those clip thin*s that the x ray techs wear5 It seems like my patient has been x rayed twelve times today / is that safe5 ,ho was 0oent*en5 Is it true that 3arie Curie *lowed in the dark5 ,hat about &ierre5 ,hat is a C'% scan5 ,hat is a spiral C'% scan5 2ow lon* to C% scans take5 ,hat is a C%'5 ,hats the difference between a C% scan and an 30I5 ,hat is an 30'5 ,hy do some tests use contrast5 ,hats the connection between I? contrast and renal failure5 ,hat is this I hear about mucomyst5 @o we *ive contrast in the 3ICU5 ,hat kind of I? access does my patient have to have to *et I? contrast5 ,hat about +astro*rafin5 ,hat is the problem with +lucopha*e (metformin)5

Aist of B ray Ima*es# a 1ormal chest film with markers b Chest film with a really clear trachea and carina( c Chest film with $%% and 1+% d $%% in the ri*ht mainstem( e %he same $%% pulled back to proper position f Chest film with $%%, and C?& line, and maybe an 1+ tube * Chest film with a trach in place, and old sternotomy wire sutures(

2 h i j k l m n o p D r s t ' non tension pneumothorax( %ension pneumothorax with a really neat mediastinal shift( 'nother tension pneumo( 'n 1+ tube causin* a pneumothorax( ' bi* pleural effusion ' chest film with two chest tubes# ones in position, the other isnt( ' &' line ' &' line with an interestin* object nearby 'n I'C& tip (you sure5), and a &' line, probably not in far enou*h( 'n abdominal film with dilated bowel loops )ne patient, two films, before and after developin* tamponade( ,ho is this, and what happened to him5 %he first ever C?& line(

1- What is an x-ray 2eres what I know / I mean, I could look up all sorts of information, but this is supposed to be what your preceptor knows, ri*ht5 Is your preceptor a medical physicist5 1o- Cut can your preceptor work an intra aortic balloon pump, a C??2 machine, and a Eoll pacin* box (how about one at a time, okay5) 2opefully.o# x rays are a kind of dan*erous but useful ioniFin* radiation( %hey produce ima*es on silver coated film that lives in the x ray plates that were forever puttin* behind one part of our patients or another( %he dan*ers in exposure to x rays are two# how much power they use to shoot, and how close you are to the shot( !%he exposure varies inversely with the sDuare of the distance from the source(" 3eanin*# that your risk of exposure drops a whole lot when you *et away from where the machine is pointin* at( .o stand way back( I usually stand behind the tech shootin* the film (*rin-)( !- What are some common x-ray "rocedures that my "atients may ha#e in the M$%& )ur patients *et !ima*ed" a lot( 3ost of our ima*es are portables, shot in the bed, althou*h all too often patients will have to travel to the radiolo*y suites for C% or 30I studies( .ome common situations# !&lain films"# 'fter intubation( 'fter the insertion of any central line in the neck or chest, or after repositionin* a line( 'fter the insertion of a chest tube( 'fter the insertion of a soft naso*astric tube / in fact, I hear that nowadays theres a push on to *et a film after the insertion of .alem sump tubes as well, which to me doesnt seem to make sense if youre *ettin* *astric materials from it, althou*h it mi*ht just be in the distal esopha*usG ,henever your patient looks like theyre in worsenin* respiratory distress( %o help evaluate !before" and !after" treatment of pulmonary edema( @aily to evaluate chan*es in, say, pneumonia, or any other developin* disease process(

0arely, well have bone fracture films to shoot, but usually fractures in our patients are stabiliFed in the most basic way by orthopedics, and then left to be resolved once the more life threatenin* problems are settled(

C% scans and 30Is# (startin* from the top and workin* south, and only listin* the ones that come readily to mind) 2ead# 'ny kind of acute neuro event, or symptoms of a neuro event, will often buy your patient a head C%( In C?'s, the critical Duestion is# is it embolic, or hemorrha*ic5 1eck and spine# usually a traumatic neck injury can be !cleared for c spines" with plain films, but now and a*ain youll see a C% or 30I for these( $ncephalitis and menin*itis also show up nicely on C%s, I understand( Chest# lots of reasons for chest scans / traumatic injuries, bleeds, tumors, fluid collectionsG 'bdomen# also lots of reasons / specific or*an disease, fluid or air collections, retroperitoneal bleeds (we see our share of these / lots of our patients *et !hardware iFedH in one fem or the other)( &elvis# 'lso for lookin* at retroperitoneal bleeds, I believe / in the 3ICU anyhow( .ICU patients mi*ht have an unstable pelvis after a car crash(

'- Who takes x-rays B ray techs shoot all our films( %here are specialty techs who run the C% scanners and the 30I machines( I believe that there is a sin*le tech who does all the portable C% scans( @ont for*et thou*h, that on trips to the scanners you are the person in char*e of the patient clinically( If you think theres a problem, or the chance of a problem / speak up- %he techs are used to this, and are more than willin* to help you *et the patient throu*h the scan safely( %heres a detailed !trip to the scanner" section in the !1ew in the ICU" I'J( (- Who reads them )ur house officers do Duick reads on stat films, but if they have any Duestions about what theyre lookin* at, theres always a radiolo*ist available in the house to help them out( 'll the films are reviewed on radiolo*y rounds within 68 hours( )- What is a stat fi*m How stat shou*d stat +e %his can vary a lot, dependin* on how busy the techs are( .tat in my mind really ou*ht to be within 7> minutes at the most( .ometimes it just takes lon*erG ,- %an $ stay in the room with the "atient if my "atient is getting x-rayed I find that I rarely need to / the only time I can think of is if the patient is havin* lateral decubitus films shot (side lyin* / theyre usually lookin* to see if a collection of fluid moves downwards with *ravity and !layers out")( It can be hard to keep a patient in this position

4 when theyre hooked up to lots of hardware / check with the tech you may find yourself wearin* lead and holdin* the patient up( Cy all means, use appropriate measures to safely, briefly sedate your patient if she needs it for the x ray( If youre takin* your patient off the floor for C% or an 30I, check with the team / if your patient cant be accurately scanned because of a*itation, theres no point in makin* the trek if you cant safely *ive them sedation to help them hold still( -- What are those c*i" things that x-ray techs wear .hou*d we wear them %he techs all wear film dosimeters / *ad*ets that measured their cumulative exposure to radiation over some *iven period of time( 's for nurses wearin* them / I need to ask around about this( (Update / the techs said no() /- $t seems *ike my "atient has +een x-rayed twe*#e times today 0 is that safe Its obviously a Duestion of priorities# will the patient benefit more from havin* the x ray studies, or from not havin* them5 Aookin* around on the web I found an interestin* way of lookin* at the problem# you compare the amount of radiation from the x ray study with the amount of normal !back*round" radiation the patient mi*ht receive just by lyin* still in bed, bombarded by cosmic rays, and radon from the rumpus room in the basement( %hey call this the !Cack*round $Duivalent 0adiation %ime" / or C$0%( 2ere are some of the numbers# @ental x ray# 4 weeks worth of normal back*round radiation( Chest film# 4> days( Upper +I series# 4(9 years (uh ohG) Aower +I series# 6 years I understand myself that KUCs use a lot more radiation than chest films do / I always stood way back when we were havin* our kidsG

%he website *ivin* this information went on to say that !no studies of radiation to humans have demonstrated an increase in cancer at the doses used in dia*nostic radiolo*yG"( Im obviously not tryin* to do a comprehensive review here / but as far as I went, the information was reassurin*( Lour mila*e may varyG 1- Who was Roentgen ,orth mentionin* / he discovered that these stran*e rays *enerated by his vacuum tube could pass throu*h certain materials, make interestin* ima*es on silver coated photo*raphic plate( 1ot knowin* what the rays were or where they came from, he called them !B" like the unknown Duantity in an al*ebra formula(

2ere he is#

%he second picture is of 3rs( 0oent*en / part of her, anyway / maybe the first or second x ray ever taken( 12- $s it true that Marie %urie g*owed in the dark 1eat rumor, huh5 3y dau*hter did a report on 3arie in hi*h school, and says that to this day they still cant handle her diaries / theyre too radioactive( 11- What a+out 3ierre I have no idea, but my dau*hter says theres an old joke# &ierre# (*oin* to bed at ni*ht) 3arie, turn the li*hts out( 3arie# %hey are out, dear( 1!- What is a %45 scan What is a s"ira* %45 scan How *ong do scans take 1urses have a pretty *ood idea of what C% scans are / they produce a series of !cuts", ima*es across the body workin* upwards or downwards throu*h the body section in Duestion( .piral C%s are a newer kind of scan / the scannin* tube rotates continuously as the patient moves alon* throu*h the scanner / the result is better ima*in* with lower radiation exposure( 3ost scans nowadays take less than half an hour / its transportin* your possibly unstable patient to the scanner and back that makes for all the stress( %heres a full description of how you mi*ht plan and carry out a trip to the scanner in the !1ew In the ICU" I'J( 1'- What is a %54 C%' stands for C% 'n*io*raphy / the idea is to do a spiral C% scan while I? contrast is injected( C%' can apparently reDuire a lot of contrast / 4>> 49> ml( %his may be a bad thin* for your patients kidneysGC%' seems to be the scan of choice when evaluatin* &$s and vascular aneurysms of one kind or another(

1(- What6s the difference +etween a %5 scan and an MR$ 30I stands for 3a*netic 0esonance Ima*in* / it uses radio freDuency waves instead of ioniFin* radiation to *enerate an ima*e( %he machine involves the use of very powerful ma*nets / they will pull anythin* made of ferrous material (ironMsteel) ri*ht off of you into the machine, and you will not be able to *et it out until the techs shut the ma*nets down / this usually makes them very unhappy( %here was a famous story from somewhere about a code cart *ettin* whipped entirely up off the floorG Aikewise, takin* a patient with implanted objects can be very dan*erous / how about pacemakers5 2ip replacements5 Cerebral aneurysm clips5 %hink about this every time you take a patient to the 30I suite / check with the team, and check with the scanner techs to make sure the scan is safe( 30I scans take much lon*er than C%s / *et orders for appropriate sedation (I find a little propofol in my coffee is very helpful / ow- )h, you meant the patient-) before you *o( 2ere are a couple of nice ima*es to show the difference in Duality#

%his is a C'% scan of what5 'nd whats that thin* over there on the left5 't least its not pushin* everythin* over to the other sideG

Aook a little clearer5 .ame patient( %his is an 30I with *adolinium contrast( %he difference is that this is a much more expensive study( I know which one I want my brain sur*eon lookin* atG

1)- What is an MR4 30' is !3a*netic 0esonance 'n*io*raphy" / which is to say, 30I lookin* at blood vessel flow, probably usin* contrast( 30I studies use a contrast material called !*adolinium" youll hear the techs say thin*s like# !,ith or without *ado5" +adolinium turns out to be an element / heres what I could find out about it# !+adolinium, chelated to a carrier molecule, is an intravenously injected 30 contrast a*ent which Gnormally stays in blood vesselsGit has the effect of makin* vessels, vascular tissues, and areas of blood leaka*e appear bri*hter(" (%hanks 0ay 2su, ,ashin*ton U( .chool of 3edicine-) .o this is what youll probably see them *ive when youre lookin* for a bleed somewhereG !+adolinium is excreted throu*h the kidneys, with a half /life of 4(69 / 4(: hours(" +ado has the reputation of bein* very low on the aller*ic reaction list( 1,- Why do some %5 tests use contrast %hey help li*ht up the structures that youre tryin* to see( In C% scannin*, the contrast dye is iodine based / which is why patients with aller*ies to shellfish arent supposed to *et them( %hese dyes definitely have dan*ers associated with them# obviously, some people are *oin* to have severe aller*ic reactions( %he other problem, and we see this one more often than wed like to, is the fact that a dye load can really, seriously hurt a patients kidney function, especially if theyve *ot some de*ree of renal failure already( 2ere are some of the main points# I? contrast dye can cause reaction that is about the same anaphylaxis, and is treated the same way( If a patient reacts it has nothin* to do with previous exposure to the dye( 0eactions occur in less than 9N of the patients who *et I? contrast dye( %heres an alternative !low molecular wei*ht" dye that lowers the risk of reaction to less than 4N( 2ives is what most people show as a reaction to contrast( %he risk of a fatal reaction is somethin* less than 4 in 4>>,>>>( &retreatment helps( 'ntihistamines and corticosteroids, as well as usin* !non ionic, low molecular wei*ht" contrast dyes means lower rates of anaphylactoid reactions( %he reaction may not be related to previous exposure, but people who have reacted before may react a*ain / the rate is 4; :>N( 'sthmatics and people with multiple aller*ies are at *reater risk for reaction( .evere reactions are very rareG 4 in :69> exams usin* A3, contrast(

1-- What is the connection +etween iodine-+ased contrast and rena* fai*ure 2ere Im *oin* to summariFe one of a really neat series of clinical pearls from the U. 'rmy &harmacy website, edited by 3ajor @ave 'ndersen( %his one was comprehensive yet succinct, and extremely clear( %hanks, 3ajor 'ndersen( ' :6 year old patient with diabetic nephropathy is booked for a C% scan with contrast( 'll labs are normal except for a *lucose of 479, and a creatinine of 6(8( (Uh ohGIve been in too

8 many of these situations myself( Can you spell C??25) %he radiolo*ist is concerned about *ivin* contrast to a patient with a creatinine over 6(>( Is there anythin* that can prevent or minimiFe further kidney dama*e5 'cute renal failure from I? contrast / this they define as a rise in creatinine of more than >(9 within 8< hours after the dose / ran*es from = 8>N in diabetics with mild to moderate renal insufficiency, to 9> =>N in diabetics with severe chronic renal insufficiency( ('ck- I take my *lucopha*e, dont I5 'nd the doc says my feet tin*le because I stand up all ni*htG) .ome summary points#

Aots of thin*s have been tried(# CaO6 channel blockers, mannitol, lasix, dopamine, others, with little or no success( !3annitol and furosemide actually worsened renal function more than saline alone(" %he problem is that C% scans of many areas are basically worthless without contrast( (2ow about *oin* strai*ht to 30I instead5 )r is there no advanta*e5) 1on ionic, A3, contrast may cause less kidney dama*e( I? hydration before and after a contrast dose is shown to limit kidney dama*e( 1ormal or half normal saline at a rate of 4mlMk*Mhour for 46 hours before, and 46 hours after the contrast seems to be effective(

1/- What is this $ hear a+out mucomyst ' recent study (1$P3 6>>> 87# 4<> 8) showed that a :>>m* dose of 3ucomyst (acetylcysteine) on the day before and the day after the contrast dose si*nificantly lowered the incidence of contrast induced acute renal failure( 'nybody know how this works5 11- 7o we gi#e contrast in the M$%& ,e *ive oral contrast in the form of *astro*rafin( %he C% orders have built in dosin* orders to tell you what to do / usually its somethin* like ;(9cc of *astro*rafin in 6>>cc of water either orally (ack-) or throu*h an 1+ tube, repeated several times( Check with the team if youre worried about your patients kidneys( !2- What kind of $8 access does my "atient ha#e to ha#e to get $8 contrast ,e take patients with all sorts of I? access to the scanners, but for some reason the techs down there want the patient to have a plain, *arden variety heplock in one arm or the other( 'nybody know why they dont use a central line5 3ake sure the I? is patent, and in a siFable vein / that contrast *ets injected pretty fastG !1- What a+out 9astrografin 'ppaarently this stuff is very safe to use( It is iodine based( !!- What is the "ro+*em with 9*uco"hage :metformin;

9 (I took a personal interest in this oneG) +lucopha*e has the rare but unhappy ability of provokin* a severe lactic acidosis, especially in renal failure situations( If the I? contrast dose were to push a patient from, maybe, C0I to '0I, then the presence of *lucopha*e in that situation would be a bad thin*( It appears that the routine is to hold *lucopha*e for a day before the exam, and for two days afterwardsG *ood to know(

a 1ormal Chest Iilm with 3arkers 2eres the trachea, nicely at midline( %he carina ou*ht to be around here( I was tau*ht that a line is !central" if the tip is inserted beyond the third rib( Is this the third or fourth, behind the clavicle5 If the C?& tip is this far down, it needs to be pulled back to the .?C( 1ot much of a bubble( .ometimes they look like a bi* clear volleyball( Lou can decompress a bi* stomach bubble with an 1+ tube(

((

%hese are the two !hemi" diaphra*ms( .ometimes one or the other is pushed down, or pulled up, for one reason or another(

@ont you think that arrows and text boxes are just the most artistic thin* since Aeonardo5 (3y son showed my how to make them() Ima*ine what they could do for the 3ona Aisa- 2ey, yo, Aouvre, what do you say5

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b Chest film with a really clear trachea and carina( %his film shows the trachea, carina, and main stems very clearly / theyre not always so easy to see( 2eres the carina( 'n $% tube thats too far in may poke the carina / this may be why your patient is hackin* and chokin* all the time( %he ri*ht main stem is where patients often aspirate to itQs more in a strai*ht vertical line downwards than the left one( $% tubes that are advanced too far also usually wind up here(

%his is a pretty unpleasant lookin* x ray( Compare these fluffy lookin* lun* bases to the nice clear ones in the first picture / probably pneumonia( .ee how the left hemidiaphra*m has been pulled upwards5 %hats a pneumonia thin*(

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c Chest film with $%% and 1+%

&retty sure this is the carina( 2eres an electrode wire with a connector at the end(

I may be seein* thin*s, but Im pretty sure this is the end of an $% tube( ' little too hi*h, I think(

%his looks like the radio opaDue line on a naso*astric tube( It looks just like the $K+ monitorin* wires, but it has no electrode connector at the end, and its in the typical place(

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d $ndotracheal tube in the ri*ht main stem(

%his is the .omethin* definitely wron* with this picture( @oes carina( I think( this patient have lun* sounds on the left after bein* intubated5 1o5 I wonder why her sat is so lowG 2eres the left main stem( 'ny air *ettin* into this lun*5

14

e $% tube pulled back to the proper position(

%he web site said that this was the same patient, after the tube had been repositioned (pulled back() Im not sure( Cut anyhow this persons $% tube isnt in either main stem, and the left lun* looks nicely aerated( (I cant see the carina either() ,hat kind of central line does this patient have / meanin*, is this in the internal ju*ular, or the subclavian, or (hey, lets be creative) is it maybe a femoral line5 Is the tip where it ou*ht to be5

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f Chest film with $%%, C?& line, and maybe an 1+ tube(

I have no idea why this ima*e came out reversed, but there are a couple of thin*s for you to try to find# $% tube look all ri*ht to you5 ,hat kind of central line does this patient have5 %ip position okay5 Is there an 1+ tube5

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* Chest film with a trach in place, and old sternotomy wire sutures(

2eres a short trach tube( .ee the sternal wires5 .M& C'C+ or valve(

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'll the normal fuFFy stuff here on the left are what they call !vascular markin*s"( 're there any vascular markin*s here5 ,hered they *o5 ,hy is this whole area very clear5 (%he word is !hyperlucent" / which I believe translates as !very clear")( h ' non tension pneumothorax(

18

i %ension pneumothorax with a really neat mediastinal shift( (I *uess the patient doesnt think its so neatG)

@oes everybody know the procedure for insertin* an I? catheter into the chest to decompress a pneumothorax5 ,here does it *o5 ,ho puts it in5 2ow far in should it *o5 ,hat should you hearR and then maybe see the patient do5 Ily around the room backwards5

Aots of vascular markin*s on this side(

,hered the markin*s *o5

%his is definitely a much more dan*erous situation than the one before it( %his time, the pressure on the pneumo side has steadily increased, and now the heart is *ettin* shoved forcibly over to the other side / definitely classed as a !bi* bad thin*"( ,hich service would you stat pa*e to come see this patient5 $verybody knows how to set up a chest tube, ri*ht5 'nd you all know what an air leak is5 ,hat maneuver could you make before the sur*eons arrive5 If this patient had an arterial line, you mi*ht see a nice example of !pulsus paradoxus" / blood pressure that drops with inspiration, and rises with expiration / in fact, this mi*ht be your first clue that a tension pneumo mi*ht be developin*( %ake a look at the !Chest %ubes" I'J for more on this G

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j 'nother tension pneumo(

@efinitely havin* too much fun with the arrowsG

,hy is this hemidiaphra*m bein* pushed downwards5

k an 1+% causin* a pneumo( Aooks like a @obhoff( 'nother really nice ima*e from the ?irtual 2ospital( 1ot a pretty picture, however( .ee the pneumothorax down there at the bottom5 'ctually, is there one on each side5 .o, uh, did they never hear the phrase# !.top when you feel resistance-"5

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l( ' bi* pleural effusion(

&retty bi* effusion over there on the patients ri*ht( ,hat should we do5

m( ' chest film with two chest tubes# ones in position, the other isnt( Aookin* at the chest tube on the left / see the break in the line that travels alon* the side of the tube5 %hats where the draina*e port is( .uppose that chest tube is hooked up to suction throu*h a pleurevac box / what mi*ht you hear while standin* close to the patient5 ,hat could you do about it as a temporary fix5 ,hat team would you call if you found this situation, and what would you have ready for them when they came5

@oesnt look ri*ht( ,hat noise mi*ht you hear when you *et close to this patient5 2ow could you use sterile vaseline *auFe to put a temporary fix to this situation5 ,ho needs to be called5

%he break in the line shows where the suction tube has a side port( ,hat happens if the tube *ets pulled on, and the port *ets outside the skin5

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n a &' line(

'wful picture, but you can see how the &' line curls around as it *oes throu*h the 0', the 0?, and up around into the &'( 3y arrow is pointin* to where I think the tip is I think this line is probably not Duite far enou*h in, and wont wed*e( If the &' line were to slip back, say, to the 0? / how mi*ht you know5 ,hat would you do about it5

o( ' &' line with an interestin* object nearby(

%hats more like where a &' tip ou*ht to be( I had to play with the contrast in this ima*e to make the line a little clearer, so its very dark( 'ny *uesses as to what the white arrow is pointin* at5 ,hat if I were to tell you that maybe the laryn*oscope operator was a little hasty durin* intubation5 .hould we call the dentist if the patient codes5

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p 'n I'C& tip( (0eally5), and a &' line, probably not in far enou*h(

%he story here was that the black arrow is pointin* at the tip of an intra aortic balloon pump( I think I see sternal wires, and my arrow I think maybe is pointin* to the really misplaced end of a &' line, but I dont see any balloon tip( ,hich doesnt mean it isnt thereG

D( 'n abdominal film with dilated bowel loops(

,e dont spend all our time lookin* at the chest, you know( 2as your patient been on a fentanyl drip5 +as collection can cause the bowel to distend for all kinds of reasonsGtime for 0e*lan5 )r a sur*eon5

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r( )ne patient, two films, before and after developin* tamponade(

,hat a difference two months makes- Cet this patient had some rub- %hatll teach you not to for*et your Indocin- %here are three situations where you mi*ht see a clear pulsus paradoxus on your a line wave, and this is one of them# pneumothorax, pericardial tamponade, and really severe dehydrationMhypovolemia( ,hich one is this5 %he other clue is somethin* you only mi*ht see now on the $K+ monitor# !electrical alternans" / the J0. complexes are alternately bi*, then small, then bi*, then small( %hey may *et a liter (-) out of this patients pericardiumGthats a portacath, ri*ht5

2eres a little sample of electrical alternans#

http#MMec*library(comMelecSalt(html

'nd heres a sample of what pulsus paradoxus looks like on an a line tracin*#

24 s( ,ho is this, and what happened to him5

'ny ideas5 %his turns out to be the !Iceman" / the poor *uy that was found after bein* froFen for so lon* on that *lacier in .witFerland( %he pointed object in the yellow rin* turns out to be the arrowhead that killed him( I thou*ht the .wiss were neutralG

Copyri*ht materials used with permission of the author and the University of IowaQs ?irtual 2ospital#

www(vh(or*(

%hanks Iowa- (!Is this heaven5", !1o, its ?irtual IowaG")(

t %he first ever C?& line(

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.ee it there, in white, comin* up the left arm5 %his is apparently the ori*inal famous photo*raph taken by ,erner Iorssmann, back in 4=6=( 'pparently in the *rip of enthusiasm, he threaded a urolo*ic catheter upwards into his own arm, then ran downstairs to the x ray room where he *ot into a scuffle with a collea*ue who thou*ht he was *oin* nuts, kicked him in the shins to *et by, and then shot this film( %he rest, as they say, is / !2ey, would you just throw in a central line already5 I cant keep this *uy on peripheral neo forever, yknow-"