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Case- Ingested Foreign Bodies- Coins | OMG: Interesting Cases in Pediatric Radiology
Case- Ingested Foreign Bodies- Coins | OMG: Interesting Cases in Pediatric Radiology
chapterRemoval of penny from esophagus endoscopicallysuspected possible reflux disease
Case- Vaginal Foreign Bodies- 10 year old female | OMG: Interesting Cases in Pediatric Radiology
Case- Vaginal Foreign Bodies- 10 year old female | OMG: Interesting Cases in Pediatric Radiology
chapterMRI showed a smooth image in upper vaginaobject foundvaginal adhesion hiding the cervix
Case 2: Upper GI Bleed | Emoblization: Bleeding and Trauma
Case- Ingested Foreign Bodies- Magnets | OMG: Interesting Cases in Pediatric Radiology
Case- Ingested Foreign Bodies- Magnets | OMG: Interesting Cases in Pediatric Radiology
chapterday 3 pain reappearsdischarged with instructions that object would pass in stoolfeverguardingIV fluidsobservationpalerebound tendernessrigid abdomensurgical consult obtained.vomiting
Case- Ingested Foreign Bodies | OMG: Interesting Cases in Pediatric Radiology
Case- Ingested Foreign Bodies | OMG: Interesting Cases in Pediatric Radiology
bowel restchapterIngestion of a piece of wire bristle from BBQIV antibioticslaparoscopic explorationPain continuespain palliationsurgical removal recommended
Case- Vaginal Foreign Bodies- 11 year old female | OMG: Interesting Cases in Pediatric Radiology
Case- Vaginal Foreign Bodies- 11 year old female | OMG: Interesting Cases in Pediatric Radiology
chapterHysterotomy finds golf tee in uterusobject foundsuspicious of UTI
Case 1: Lower GI Bleeding | Emoblization: Bleeding and Trauma
Case 1: Lower GI Bleeding | Emoblization: Bleeding and Trauma
chaptercoilscolonoscopyembolizationLower GI Bleed
Case 3b: Splenic Laceration | Emoblization: Bleeding and Trauma
Case 3b: Splenic Laceration | Emoblization: Bleeding and Trauma
chaptercoilsembolizationSplenic Laceration
Case 6: Pelvic Fracture | Emoblization: Bleeding and Trauma
Case- Not all wheezing is asthma | OMG: Interesting Cases in Pediatric Radiology
Case- Not all wheezing is asthma | OMG: Interesting Cases in Pediatric Radiology
antibioticschapterminimal peribronchial thickeningneb treatmentsno pneumonia or air trappingpost tussive emesissteroids
Case- Ingested Foreign Bodies- Magnets | OMG: Interesting Cases in Pediatric Radiology
Case- Ingested Foreign Bodies- Magnets | OMG: Interesting Cases in Pediatric Radiology
Abdominal US suggests appendicitischapterGastroenteritisrebound tendernessWorsening pain
Case 7: Retroperitoneal Hematoma | Emoblization: Bleeding and Trauma
Case 7: Retroperitoneal Hematoma | Emoblization: Bleeding and Trauma
chaptercoilsembolizationmicrocatheterRetroperitoneal hematoma due to a transverse process fracture
Case- Stroke - 64 year old male | Neuro-Interventions
Case- Stroke - 64 year old male | Neuro-Interventions
balloon catheterchapterstent retrieverstroke
Transcript

one is a little bit more rare in that

this is a farm body that migrates so migration of the foreign body towards abdominal organ and it is rare but it can and does happen so here we have a 2 year old with a sewing needle ingestion who they followed for three months

without evidence of expulsion but this kid continued to have intermittent abdominal pain fussiness just overall crankiness and the parents decided that they were tired of just following this so they went for a second opinion and

they awry when they got for their second opinion they did indeed get more x-rays and it showed this and I'll show you in a minute they it showed the sewing needle in the lower abdominal quadrant they could not see it by practice Coupee

excuse me but what they did which in as you read along it didn't look like they had done anywhere else was they did a complete hands-on physical exam as well and they could actually palpate by rectal exam and then determined that it

had migrated and maybe you know maybe the migration had occurred over time and was not there when it was looked at earlier so this child ended up with a mini laparotomy do to the concerns of the migration out of

the lumen the needle was found in the meso : he had a significant recovery and three month post procedure follow-up showed no complication here this one's a little harder to see sorry I'm pointing problems it's the long straight can you

guys say it so again our take-home points although they are rare make em migrate outside if not removed early radiological follow-up as well as physical examination is important to identify potential complications and any

foreign body suggested to have migrated outside of the lumen should be considered for removal without delay because of the potential for traumatic complications okay alright she swallowed

so these are collections of indigestion material that can get stuck in the GI tract and they're usually either plant material or it can also be hair and the ones that I've seen the most are hair the most common one for the plant one is

actually rhubarb I don't know who's eating rhubarb but apparently there's some really bad things that can happen from it there's several cases of that but I'm going to talk about trickle but B sores which are hair balls so it's

pretty rare but it is more common in girls and it's secondary to the ingestion of hair this is a hairy tale so there are hair balls and that's because the surface of the hair is so smooth it can be difficult for it to be

digested and move through the intestinal tract it'll get caught in the gastric mucosa and then food and mucus will also accumulate in there and they can become quite large and this will be over time so it's like an impact

that can occur there is something called Rapunzel syndrome not that common but that's where this hairball can actually extend into the jejunum into the lower parts and parts of it could break off and actually obstruct the intestine so

not a lot of symptoms we do look for some psychiatric comorbidity so the child that is pulling their hair or Piko or other kinds of things can be indicators some complications as this enlarges there's been episodes where

there's been obstructive where there's perforations and ulcerations so in this case this was a nine year old female who had no chronic abdominal pain just vomiting and weight loss she had no alopecia so that's something if you see

somebody and you want to know whom where's that hair going if they're pulling it out but she had a big palpable mass and you can see it right there she did have a history of a psychiatric comorbidity and they tried

to do an endoscopy it was unsuccessful and that you see why so you can see the size of what they removed from her stomach look I purposely left the image there of the hand so that you could see this and this is what Rapunzel's sink

syndrome is so you can see how long this can be and how it could be very obstructive so these are rare they're difficult to recognize consider this in children with pica or other psychiatric illnesses consider alopecia without a

medical cause as a possibly on assessment and then remember that they need a referral for psychiatric follow-up so in conclusion detailed assessment and history are very critical and identifying potential

presence of foreign bodies radiological imaging is helpful but you need to know that it is not a hundred percent accurate all the time and then just think about some evidence-based practices and what I wanted to leave

with you and this is here BMJ hopefully you can see the website this is actually a very nice algorithm that helps in deciding what to do depending on where the object is and what types of objects could possibly be coming through thank

you very much

with a kind of a cool case that this is this is a non-contrast CT of the head and if you look in the center this is one we call a hyper dense sign so this is that basilar artery the vertebral

it's brighter than the rest of the brain that's a cute clot so that's when we say hyper dense sign I've never seen one this big in and in the basilar artery so this was a case he was a 35 year old guy he just had a knee replacement surgery

he was doing his PT on post-op day - and he just fell he just became comatose with either the CT and so we immediately took them you know now to talk about these maps again cerebral blood volume is normal but you can see the MTT is all

increased in the cerebellum and cerebellum whatever not that big of a deal but your brainstem your brainstem carries everything so you can become locked in locked-in syndrome or pretty much died with the basilar stroke so he

ended up taking him and oops sorry let's see if this will play you can see sorry can you play in the back both yeah there if you just go forward one it should play yeah so you can see there's no blood flow going to the back of the

brain that's an injection of the left vertebral artery and there's no flow going up there and so you get your catheter past the clot so that's that caught that catheter is in the posterior cerebral artery PCA and in this one we

dropped a stent retriever and did the trap technique which is removing it as a unit you can see it kind of being removed and he goes into the catheter on the back and then you do this so this is

what the clock looks like so that clock came out in one big piece like a femoral vein right there and he had it out happening was he had a patent foramen ovale at a PF Oh and he developed a blood clot post arthroplasty and this

went straight to his brain and but he was fine and we ended up opening his his basilar artery he literally woke up like 20 minutes later and he was fine so again that's when you you see there was a little bit

of a stroke in his cerebellum but that was totally asymptomatic and so you know that's why I find these cases really satisfying you know not all of them go like that and I quote about 30% of cases doing well and then the other 70% not

going so well but it's still pretty good and so I mentioned Twitter I am on it and pretty active on it a lot of people I learned so many things and and these are some good accounts for neuro but I've really learned so much and now I

met the process where I I'm like teaching techniques to my guys who taught me and I'm like learning these off of Twitter so it's kind of interesting I always hated on Twitter when I when I feels like who who signs

up for that like it's all about Instagram but it's it's pretty it's it's an amazing platform and you can learn a lot so I definitely recommend to sign up for it and that's it and you can email me or contact me any questions Thanks

[Applause] [Music]

five-year-old with excessive vaginal bleeding bleeding has no other symptoms

her she had a normal ultrasound of the lower abdomen there was no evidence of trauma or sexual abuse again very very important part of your history to obtain so they get a decide to do an MRI of her abdomen to see what's going on because

then ultrasound was negative and the metal detector went off when she went in the scanner so they pull her out and they get an x-ray a plain abdominal film that was done later and see a foreign body anybody want to take a guess at

what that might be metal so it definitely definitely shows up whoops those are actually keys to her diary so she was writing in her diary and she didn't want her mother to find that she

was writing so she stuck the keys inside and I guess never took them out again so that was those were two keys so very interesting cases okay let's talk about

similar but similar story an older patient who presented for a biopsy of a right renal mass now sometimes it's a skiing accident sometimes it's a car accident sometimes it's us that causes

these problems so here's a patient who came in for a biopsy of a renal mass here's the CT scan hopefully you can appreciate that the patient is face down or prone on this scan this by the spine is on the top side you can see our

biopsy needle going into a mass in the left kidney excuse me the right kidney and now this is the she comes back later because of some pain and now in a manner that's similar to what you said earlier on that first CT scan you can now see

the right kidney is pushed forward by a very large retroperitoneal hematoma so this is probably a post biopsy bleed this doesn't happen very often in fact as someone who does kidney biopsies once or twice every day I'm shocked that this

doesn't happen more often we're sticking big needles into vascular organs or vascular masses it's amazing that we don't have more patients come back for this it only happens about 2% of the time and usually people who have these

types of risk factors are at risk for this type of bleeding after a biopsy but we can do is we can go in do an angiogram and again I want you to just appreciate look at the picture I think everyone hopefully can see on the bottom

of the picture there's this active extrav enough contrast from the lower pol renal arteries all right lo pol renal artery and that's bad if it's great in a lecture because it's very easy for everyone to see but the reality

is it really signifies very significant bleeding and that's what everyone here should appreciate if you're managing the trauma patient or the bleeding patient if you see if this Cleary this clearly means everyone's got to move a little

faster to address it because this is a bad bleed but the great news is that we have the technology now to go all the way into the renal arteries or frankly the arteries of any organ get very far distant land just embolize it and so

look how far we got here for this patient we took care of it this patients kidney function didn't pump an inch because the reality is there was very little impact on the normal parts of the kidney so that's the goal if you guys

work with people who say oh we don't have to get that far out just throw some coils you know near the origin it's fine it'll accomplish the same goal but at the same time they will have killed half of the patients kidney so it is always

worth making some effort to get as far as you can into the organ that you're treating but at the same time you don't want to take an hour to do that because the patient's bleeding pretty heavily and you have to address it so that's our

goal during these procedures next case

and then one more example just to sort of illustrate the idea of a heat sink or

a cold sink right so this patient has a mass in their left adrenal gland right next to the aorta it's just anterior to the kidneys so the problem here is if you put a microwave ablation probe right next to the aorta you're likely to burn

the aorta and if you want to point the microwave ablation probe directly at the aorta well there isn't really a good window for that right you would have to go through the kidney you'll go through bowel and on route to getting there so

really I elected to do cryoablation right so that's the mass that's the aorta so you're obviously worried about injuring any order you place two probes into the lesion they obviously are streaking us out right now but that's

the aorta right there so we are four millimeters away from the aorta with these two probes you would think you'd be concerned about damaging it but using that cold sink effect you can see how the ice boss actually carves around the

aorta so you can get a really nice ablation on to that structure with that Waring that you're damaging the aorta or any nearby big vascular structure now that doesn't happen with pancreas if you freeze into pancreas you're going to get

a pancreatitis and if you freeze into bowel your bowel is going to have a perforation so that really just is with blood vessels that you can do that

know if they know more how to work an iPhone than I do so they also know how to disconnect things as well kids with attention-seeking behavior and

that will come into play a little further in our presentation forty percent of all foreign body ingestions are unwitnessed so which is kind of scary so history is important but sometimes we don't always have a history

of what happened and diagnosing and treating early and disposing of used batteries because even the used batteries can still cause damage so kids less than age three years have with a vague history of foreign body ingestion

where they've been to the ER before force ingesting something and if they have a suggested suggestive chest x-ray should be presumed to have a foreign body of a lithium button battery and treated managed very quickly and those

patients with the button batteries often get IV steroids before and after and that can help to improve the outcomes but obviously that we need more research okay I'm gonna pass the mic over to Michelle who's gonna move on further

we're gonna move on to coins and other metallic objects so coins are the most commonly ingested for our body in children other things that we see pretty often are needles safety pins straight pins earrings keys screws and toys keys

obviously we've already seen here and toys the signs and symptoms can vary a lot of times we'll see vomiting drooling dysphasia difficulty swallowing the feeling of having a lump or stump something lodged in their

throat and then the respiratory symptoms of coughing choking and stridor but what we really need to remember is sometimes there are no symptoms at all especially initially so our first case today is a four year old who comes into the

emergency room for the third time she has vomiting of undigested food an Associated weight loss she's been to the this is her third visit the first two she was giving fluid challenges tolerated those and was sent home with a

GI visit scheduled for the future to work her up for possible reflux disease one physical exam now this has been going on for months she is now severely wasted she's three years old she weighs ten kilos she's below the point four

percentile she is on the threshold of severe malnutrition although she has no other physical signs that would lead to an underlying disease process but in all of this the only imaging they had gotten in the prior edie visits was abdominal

injury imaging nobody ever thought to do a chest x-ray because she didn't have any respiratory symptoms so lo and behold here's the circular dense object just below the clavicles and it as Laurie talked about with the button

batteries they can tell or highly suspect that this is a coin because there's no rim around it so on further evaluation and talking to this child and really asking her she did admit to swallowing a coin in the summer but

hatton told anybody because she was afraid she would get in trouble so as Laurie said they're often 40% unwitnessed so we don't know that it's happened and even when you ask they may be apprehensive to share that

information with you so a lot of times it's about the verbage you know making it friendly and it's okay we just want to know what's making you sick or we want to make you feel better so have you you know

eaten anything unusual did you accidentally swallow something that maybe you shouldn't have so that we're not scaring these kids she had this removed and escaped eclis without complication she had a great

recovery and there are before-and-after pictures it's pretty amazing that it could actually have gotten that far without a further evaluation with that kind of weight loss the take-home points for this would be that retained

esophagus foreign bodies are common in the emergency room Department but most often they present with little diagnostic difficulty however the signs and symptoms you're seeing may not reflect what's actually happening and in

young children they may not be forthcoming with the history it may not be witnessed they may not be willing to share so you really have to dig and there is a need for a low threshold of suspicion to avoid diagnostic delay and

potential complications with timely treatment so we're going to move on to

but at button batteries and I say yikes because these are scary scary things

button batteries or disk batteries are made of lithium are very popular now they are they are popular because they have a very high capacity for energy and voltage they are very resistant they have a longer shelf life and they're

very stable at cold temperatures and they are pressing in watches these fobs remote control devices hearing aids calculators keychains and electronic toys so they the great thing is a lot of advantages but they have a lot of

potential for injury because of all of these you know all these benefits of them they are smooth and shiny very attractive to children especially the average age being two years 56% of cases are unwitnessed when kids ingest them

and they represent approximately 2% of all ingested foreign bodies but they probably are the most dangerous things that kids can ingest and 36% of patients are initially asymptomatic so it's very challenging to diagnose and even if they

ingest a battery that's already a bit spent meaning that it's a dead battery they are still at risk to cause injury if they swallow okay so these batteries generate an electric current when it meets the moist environment of the GI

tract and the battery contents leak and even though the outside casing remains intact the contents are still leaking there's a heavy metal toxicity burning burning burning and aside the symptoms of ingestion if

missed the child will choke or gag you'll see bloody saliva may have chest pain a new onset of wheezing or stridor and they may have a history of a viral syndrome so they've been coughing but coincidentally have ingested something

in the meantime they may have dark stools because of the bleeding or a rash and obviously the the worst case scenario may cause tracheal esophageal fistula media cyanide Asst and may erode major blood vessels and may actually

cause hemorrhage so button batteries can about 60 to 70 percent can become lodged in the esophagus and the more likely ones there's different sizes there's 20 millimeters and 15 millimeters and even though that doesn't sound like a lot of

difference the 20 millimeter ones are the ones that are more likely to become lodged and the duration of the lithium button battery the LV bfb the lit lithium button battery foreign body ingestion ingestion really has no

correlation with the length of how when it happened with the chances of its impaction it's kind of random where it gets stuck along the way so one of the treatments for suspected foreign body with button battery is that Children's

Hospital of Philadelphia we have adopted is to give that they suggest that the kids take honey on the way to the hospital if that's suspected and what the honey does is provides a protective barrier for the throat and helps to

neutralize the alkaline levels so even though it's they're not NPO for this impending surgical removal they find that there's a benefit of ingesting honey so even after removal by endoscopy of button batteries the injury can occur

days two weeks later and that's because of the leftover alkali the alkaline environment and the weakened tissues that are occurred so it takes a long time for this for these injuries to heal so in foreign body ingestion should

really be treated as button battery ingestion unless they're proven otherwise okay so in terms of imaging AP and lateral chest films are obtained along with neck and abdominal films because we

don't know where that button battery is along the pathway so it may look like a coin on x-ray but the difference we should treat it as a button battery and less proven otherwise and assume that there's some acid leaking and try to

remove that foreign body as quickly as possible so what you see on x-ray is you look for the halo it's a little bit hard in the lighting of this room but there's actually kind of a halo around that round object that's gonna differentiate

it from a coin and sideways it's not quite completely round like a coin would be there's a step off because if you notice that a button battery has a little bit of a lip on it so there's a step off sign that's seen on the lateral

film here and here are some other images so here's a button battery that's in the esophagus and you could see on close-up that there's a double ring and that is it's in the esophagus just above the Carina and that it's a little bit hard

to see on that image and here's another image where it's in that this is a 2.0 millimeter one and it's stuck in the mid esophagus okay and this is the step off so it's not quite it'll look a little bit different than a coin the step off

on the lateral view hence the reason to get ap and lateral films and then this is actually a child that swallowed magnets and so that magnets have all kind of stuck together okay and here's a lateral film of a button battery and

here's a more focused view where you could actually see the rim so you see in this these images a rounded radio-opaque foreign body with a double rim and the halo sign by the arrow and that's concerned for a button battery that's

overlying the stomach

good morning everybody and I'm always excited when there's pediatric content anywhere so when Nancy Michelle and I were we're talking we were trying to figure out a topic and I had some experience with some foreign bodies in MRI and such in my experience so we

thought it would be interesting to talk about interesting cases in pediatric radiology okay our objectives for today are to identify potential risk factors that present in Pediatric Radiology patients discuss some pre screening

assessments for common pediatric comorbid conditions using a case base case based methodology and reviews and radiologic images of unique pediatric cases so we know that kids have a tendency to put things into small

objects into their mouths and other or orifices their nose their ears their vaginas so we are going to be discussing some cases throughout this presentation and we know that kids not only ingest objects but they also insert them and

they may actually inhale them as well most of these objects will pass spontaneously 10 to 20 percent of those that they swallow will require removal by endoscopy and about 1% require surgical removal and why is this a

problem with kids we know that kids are in the oral phase of development so they their teeth are not formed so they have inadequate dentition so they can't chew things so those pieces of hotdog those peanuts and and such are difficult for

them to chew which we know is the first phase of digestion their epiglottis is higher so it can make it more difficult for them to swallow and they have immature swallowing coordination so hence things are more likely to get

stuck so the incidence of foreign bodies is about six months to four years of age makes sense there's a slight predominance of males I can tell you I have a son and a daughter my daughter never put anything in her mouth or nose

or whatever but my son was certainly broke that record there's a slight predominance of males the most common objects are coins earrings marbles barrettes and rocks and objects that are typically longer than five centimeters

or greater than two centimeters in diameter are less likely to pass through the pylorus which makes sense and most pass within four to six days but some take up to four weeks of ingestion so why do we need radiologic imaging so

x-rays we know that the object would have to be radio opaque to be visualized on x-ray we know there's a challenge in cooperating for expiratory films and I'll talk about that in a couple of more slides we want to avoid CT scan if

possible because of the radio the exposure but ultrasound is really up and coming in terms of determining the location and the status of the object and provides dynamic imaging when you're thinking about foreign body foreign body

ingestion so ingestion versus aspiration foreign body aspiration is the fifth leading cause of death among one to three year olds and the primary cause of unintentional death in infants so the initial choking episode may be

unwitnessed it doesn't take very long for it for a six-month-old who's sitting up to grab something and put it in his mouth and toys pieces of toys account for ninety percent of these cases there's often a delay in diagnosing

these cases in patients that have a history of asthma croup or pneumonia because they always COFF so when they have an episode of coughing say oh it just must be the start of an asthma flare not thinking about foreign body

aspiration in the mix and of course early and up too late complications maybe it's fixing cardiac arrest dis Nia and laryngeal edema because as I said the epiglottis is high those Airways are narrow so there can be swelling

they swallow or ingest something and not

here we have a MRI that shows a lesion in the left kidney sorry I don't have a

pointer here really but you can see the lesion in the medial part of the left kidney there couple probes are placed under CT guidance you can already see the beginning of the formation of an ice ball there this is the second probe you

can see the ice ball forming and there's a good example of the ice ball it's got good coverage of the the lesion as well as a good margin around that cryoablation tends to be less detrimental to the collecting system of

the kidney so some of the concerns when you do renal ablation is that you're gonna cause your read or strictures or urine leaks because you're burning the collecting system essentially with cryoablation you tend not to see that

you don't have to use something called pilar profusion is often right the idea with pilo profusion is you put a small catheter into the ureter and you infuse the kidney with cold saline so that the collecting system stays cold while you

while you burn the tumor well you don't often times have to do that with cryoablation so that's one benefit of it and then this is a one month later scan this is the normal appearance you can see the ablation zone that and the

resolution of the tumor will follow these up for a few years to make sure that all that tissue goes away and this

okay all right let's go over another case we have a ten-year-old with smelly

and bloody leukorrhea itching and vulva irritation always want to rule out sexual abuse of course when there's any vaginal discharge or any vaginal bleeding as well okay they're on trans abdominal ultrasound

there was an echogenic image that was noted in the upper part of her vagina and she had a badge on ah Skippy under general anesthesia and what that noted was a vaginal adhesion that was hiding the cervix so they decided to do an MRI

and the MRI showed a smooth image in the upper vagina so here's a couple of our images here on the Left we have a coronal MRI t2-weighted images sequence in the upper part of the vagina they can see a foreign body okay on that janaki

right here on the right you can see an adhesion that's kind of hiding the cervix and there's a flap on the side a flap of tissue that's how that's hiding a small orifice which is leading to the cavity of the foreign body and this is

the foreign body that was found it's a plastic dolls house glass and they suspect that it had been present there for several years okay next case a

right now here's a different case is a 49 year old male who presented to the emergency department after vomiting a lot of blood vomiting was the key word there it's going the other direction so that's an upper GI bleed all right and

when we talk about upper GI bleeds there's a lot of different causes for upper GI bleeds the most common are ulcers but there's mallory-weiss tears of the esophagus there's just esophagitis or gastritis

there's different cancer vascular malformations fistula is varices which I'm not going to talk about but varices on the venous side in a patient with portal hypertension these are all causes of upper GI bleeding now

once again we might treat them medically we might look at them with endoscopy and potentially cauterize something embolization usually is used when and when endoscopy is not successful all right or certainly surgery but an upper

GI bleeds embolization is a lot more attractive of an option all right so here's another picture what do you think you up for it nope you turned me down all right who wants to who wants to tell me what they see how about you how about

you guys you can team up together what do you think so what do you seeing so let's look at that together so this is a seal EF is an anagram of the celiac axis you want to think it through you want to volunteer you see a filter we don't care

about that yeah all right that's fair so you see the catheter going up right in the middle and it's going right into the celiac axis all right what I want to draw your attention to is right in the middle of the screen a little bit over

to the left is again a blobby thing all right that's extravagant of contrast and the vessel that that's coming off of is the gastroduodenal artery so I want you to see that if you look at the catheter you

can see the shadow of the catheter right up going up from the bottom that's going into the celiac axis and the big vessel going over to the left side of the screen is the proper hepatic artery that the common hepatic artery excuse me and

the first vessel heading south from there is the gastroduodenal artery that blood vessel is supplying the end of the stomach and the beginning of the small intestine and what you see is the extravagant coming off now what it's

very important if you're dealing with bleeding patients whether it's in dusky whether it's hemoptysis or GI bleeding anything like that we're looking for that type of blob appearance which just mean the contrast is no longer

constrained by the artery it's free into space okay usually the way we were built is that the blood vessels the biggest they ever are near the heart as they leave the heart they get progressively smaller until they reach

the tips of your fingers and the tips of your toes if there's any place that you see where it gets big small then big again that's not normal okay that's not normal and now we just got to figure out what's

the abnormal part is it the small part or the big part all right in this particular case it's that big blob that's big it doesn't belong there all right but in the upper GI system there's lots of collateral vessels so we can

just go in and we can put coils right in the gastroduodenal artery and we can embolize that and we can do it safely because we know that there is alternative routes for blood to flow now the one thing we have to do here and

this is an important concept for any abnormal bleeding whether it's trauma or other causes is we always look for the backdoor so in this particular patient we did an angiogram of the superior mesenteric artery there's another vessel

going to the intestines and it's nice cuz we have the coils there you can get a sense that it's possible for blood to flow from a branch of the superior mesenteric artery backwards into the GDA and so we just want to make sure that

that's not happening because we can do the best job ever with an embolization procedure but if we don't get the front door and the back door we're gonna fail patients will come back with recurrent bleeding and at least in my experience

that's a big reason why people do come back so we think we do a great job in two or three days later people come back with abnormal bleeding it's weak because we didn't address both sides of the pathology all right so here's another

case I can make up the ages anyway so it doesn't matter so 43 year old patient on a motorcycle that collided with a deer all right presents with left upper quadrant abdominal pain and now we're looking at a cat scan all right who

wants to look at a cat scan you look like you're up for it what do you think what do you see no no you're not sure so we're looking so the key is the left upper quadrant pain right the patient presented with left-sided pain you

should know that whenever we're looking at a study like this we're looking as if we're talking to the person so the right side is on the left the image the left is on the right side and so if you look on the these are two

images if you look at the right side of the image you can actually see the spleen that's like that beam shape thing towards the back of the patient and what we should see is a homogeneous appearance of the organ but what we're

seeing are some kind of dark grayish lines going through it that's essentially a laceration of the screen that's what we're looking at that's the pathology that will prompt us doing a procedure like this and when we ever we

see a patient with splenic trauma we try and grade the trauma so one thing you're going to hear about is it's a patient with a grey 2 laceration or a great 4 laceration or something like that and that basically just describes the extent

of the laceration through the spleen the further through the spleen it goes the higher the number is the worse it is for the patient okay we tend to get involved with patients who who essentially have grade 3 or higher lacerations and are

hemodynamically stable so in this particular patient this was thought to be a grade 3 splenic laceration but there was not a whole lot of blood around the spleen so we thought this patient had some time to come to

angiography and embolization so here's the angiogram lo and behold what we see is again a blobby thing which is the theme of this lecture remember this is bleeding so we're looking for blobby things and all the way on the right side

of that image you can see that cloud of contrasts that black contrast that's extravasated of contrast that's not normal all the way to the right you guys see it are you good so going all the way to the right that's

what we're trying to do now when we do splenic embolization there's two ways we think about this do we want to go all the way to where the bleeding is all the way out into the screen and embolize one little branch that's injured or do we

want to do something called the proximal splenic embolization we would just put like some coils or plugs right at the origin of the splenic artery with the goal of being to slow down the flow and allow the spleen to heal a lot of it is

just what's possible maybe what time it is how tired we are things like that all factors that weigh into it but here's a little bit of a better view you can see the area of extravasation now here's another picture now we put

our microcatheter out there now you're getting a bit more of a sense of what's going on there you can see the extravagance II the vessel that it's coming from and then we put our catheter all the way out there and now we're

right at the source of the bleeding so our philosophy is if we see bleeding we want to go as far as we can towards the source of the bleeding keeping in mind that whenever we don't get as close to the bleeding as possible we're

sacrificing normal parts of the organ that we're treating and that's the philosophical leap that we make during these procedures so we were able to get out there and then we embolize leaving a lot of flow through the rest of the

spleen and the patient was able to survive like we never did anything alright that's our goal now here's a

something some case examples of where I use cryoablation right so this is a

patient who has a nodule in the in the back of their lungs in the right lower lobe and basically I'll place two probes into that notch on either side of Brackett the lesion and then three months later fall up you can see a nice

resolution of that nodule so when it comes to lung a couple things I'll mention is if the nodule is greater than eight millimeters I'll immediately go to two probes I want to make sure that I cover the lesion whereas microwave it's

pretty rare depending on what device you're using for you to put more than one probe in so some people's concern with cryo in the lung is more probes means more risk of pneumothorax but you can also see surrounding and proximal to

where we did the place you can see the hemorrhage that you see so if those of you out there that are doing the lung ablations you probably have physicians that are using something called the triple freeze protocol right so the

double freeze protocol is the idea that you go ten minutes freeze five minutes 30 minutes freeze five minutes thought well what we saw was lung early on in the studies was a very large ablation a freeze to start with caused massive

hemorrhage patients were having very large amounts of hemorrhage so what we do now in lung is something called a triple freeze protocol we'll do a very short freeze about three minutes and that'll cause an ice ball to form and

then we'll thaw that in other three minutes three minutes of thawr and as soon as that starts to thaw we'll freeze it again and we've shown us a substantial decrease in the amount of hemorrhage so if you're doing long and

you and you you're told to do a double freeze protocol perhaps suggest the triple freeze is a better idea so that's three months later so another example

so on to case number two so this is a three-year-old child and you can see

very clearly he comes to the IDI and he said 24 hours of pain vomiting he's a febrile doesn't look like he's ill at all and in this case the mother recognizes this this is a little stick magnetic stick from a construction type

of toy so so it's one single piece so he's admitted for eight hours of observation just to be conservative they give him IV fluids he begins to improve he's not vomiting he's not having any pain anymore he sent home with

instructions letting them know that this should pass eventually through his stool and two days post-op on follow-up he's back at baseline as far as playing he's eating normally and everything seems fine then on day three he started to

have abdominal pain again and you can see his white blood Khaled cell count went up he's now has a rigid abdomen he's guarding and he's having a lot of pain so they decide to do a surgical consult

okay so now we see this same object right it's moved which is what should happen but there's all this free air now all around it which is different so they begin to do some IV fluid resuscitation and he's emergently taken to the or so

he had two perforations in the jejunum and what had happened was those pieces of magnet were actually covered by this outside covering and that piece that looked like it was one piece was actually five individual magnets so

inside of the GI system the whole covering basically II rotate and then these little magnets some of them stuck together but they started moving and you can see how small they are and so that's why he had those major

complications so this is one situation where we thought that there was just one magnet but in reality they were multiple so in a sense you know this has come up as an issue there's not a lot of big Studies on this because it doesn't

happen that frequently but there was one good review that was done and this was done a few years ago where looked at 80 some odd cases and they used to children's hospitals and they just tried to find out so you know what happens in

terms of the progression of the the ingestion so again 56 percent were males not a surprise that that happened and I want you to note the age so about eight years old you know you kind of start thinking maybe they would know better

but I guess not so the age I never really think too much about age as much I had some really bad ingestions with people that were developmentally normal that were 14 and 15 years old and then the other thing you need to note 67% had

multiple magnets or they had a magnet and also ingested another metallic object so there's a CO ingestion there and those definitely were the situations where they were more likely to have to have some surgical type of procedure

because there were difficulties so 39 not many presented with symptoms and the most common one was abdominal pain and that could be just about anything and so 53% initially did not have operative management and of those 38 of them 37

percent failed it and then they've 47% had an endoscopy or they would have endoscopy and surgery combination so the take home the ingestion think about magnet ingestion a lot of people don't just because the magnets are hidden in a

lot of different toys and it is definitely a problem and that could become emergent so based on that study there's now an algorithm that basically has you be somewhat watchful but to go ahead and basically unless you're a

hundred percent certain assume that there's more than one magnet there and they're more likely to actually take them to have a procedure to remove it another thing to think about there's a few articles about

this about using handheld metal detectors not just for magnets but for other metallic objects and this it can be used in the emergency department so this is just a commercial type of handheld detector and this could be

maybe the parent is refusing to have an x-ray or the child is you know really difficult to get you know any sort of cooperation to do it or it's gonna take a really long time to get this x-ray so a few places have used this to be able

to just do a quick identification and localization of whether or not there's a metal object so I don't know if any of your places are using this but if you do some things to know first of all it is not fda-approved for this purpose but

they are medical grade because they're the same ones that are approved to be used when you go through TSA so it's not going to be harmful so you want to put the child in the center of the room away from metal objects they can't have any

zippers or clasp or anything like that and you want to ask them to put their hands up in this way and then we're wandering from the top all the way down to the pubis looking for any type of sounds okay it's bizarro or bizarro

a what this is a 16 year old who

presented to the GI clinic with a 2-day history of sharp abdominal pain and I know we all think oh my gosh a teenager with abdominal pain how often do we see that it was accompanied by sweats she'd had one episode of non bloody vomiting

decreased oral intake and some diarrhea although she no longer has vomiting and diarrhea denies fever or trauma she does have a history of irritable bowel and chronic constipation and an ovarian cyst rupture so again you have a lot going on

with the abdomen with this kiddo and you know somewhat broad symptoms so on further examination she describes this pain as clearly different from any of her pain associated with IBS and constipation she specifically said it

feels like there is a bubble that is about to burst it was exacerbated by eating coughing and sneezing her she appeared a mild distress but her vital signs were stable and her tenderness was localized to and to the right upper

quadrant with palpation and percussion so the x-ray shows a your object 13 millimeters in length adjacent to the large bowel and liver she was transferred to the emergency department where her pain continued to

intensify they got a CT the IDI doc dug for some more history this goes just you know history history is important keep digging you know as long as you don't know what's going on keep digging and then

finally when talking about food and anything that she could have eaten different they did figure out they had just gotten the grill out about a week ago and the dad had cleaned it real good and they'd been eating barbecue so they

suspected a wire ingestion from the cleaning brush for the grill surgery was consulted there was no signs or symptoms of sepsis or peritonitis so she was admitted for observation this is the CT so you well it's got a narrow good so

you can see and then down here she got to the floor they decided on bowel rest pain control and antibiotics however the pain continued to intensify again feels like a needle poking me she was very specific about the pain where

it was how it felt so surgical removal was recommended and here you see the wire brush or bristle that they removed post-op uneventful discharged after two days with no complications she did continue to be treated for her IBS again

this really just highlights a really common outpatient IDI complaint with a really uncommon diagnosis keep in mind you know we've talked about unwitnessed and kids that you know don't want to tell well this was really you know a

whole different story it was an unknown ingestion take-homes in the last decade there has been a huge increase in reported incidence of this type with wire bristle detailed history preceding the onset of acute and focal

symptoms should prompt physicians to consider unintentional foreign body ingestion and continue digging for that history and

tip and I'll show an example of that so

right so this is that same lady actually with the malignant melanoma she has a lesion in her liver it's sort of the circumscribed structure we're in right next to the gallbladder there so we placed the probe actually under

fluoroscopic guidance with combi Ct we have a catheter in the hepatic artery so we're gonna inject some contrast and see what the ablation zone looks like but as you can see with injection of contrast very well

delineated margins on that ablation so I could tell with a lot of reassurance like I said that that we're not burning anything that we're worried about I'd say here's an example we've burnt right up towards the gallbladder but didn't

injure the goal though so that's very very nice to know so that's the benefits of microwave ablation in essentially you can use microwave nearly anywhere people are using a lot in renal and and liver nowadays you can use it in lung although

some issues with microwave is it is painful so if you burn the chest wall with microwave you're gonna know about it afterwards whereas cryo you can do near nerves like in a costal nerves and you do just fine so just a quick summary

let's move on here is another patient who took a fall skiing we see a lot of these patients up in upstate New York and they presented with severe left-sided abdominal pain and here's the cat scan

all right who's up for it what do you think what looks bad you look like you're into it what do you think yeah the right the bottom right-hand side of the picture should be spleen and it just looks like a big pool of blood that's

pretty good you did pretty good spleens a little higher so we're gonna presume spleen is there Graham this is just one image one slice through the picture through the body so we're just not at the level of the spleen but that's the

kidney that's exactly right that white thing on the right side of the image of the patient's left side is the kidney and the one thing I'd like everyone who appreciates that doesn't look at all like the other side all right so when

you look at a cat-scan like this you want to look for symmetry that's really important all right that's the cool thing is we're kind of meant to be similar looking on both sides of our body and in this particular

case you can see that the left kidney has been pushed way forward in the body compared to the right side and there is a kind of a hematoma sitting in the retroperitoneum posterior behind the kidney that's bad

the other thing you should notice is if you look at that left kidney you notice that white squiggly line that doesn't belong there okay that's contrast that's not really constrained inside an artery that's extravagant of

contrast that's bad all right we don't want to see that all right again there's a grading system for renal trauma and you're gonna hear people talk about grade 1 2 3 4 injuries all right obviously as the number gets higher the

extents of the injury gets more significant all right so again here's that picture think you can appreciate that it's at least a grade 4 laceration of the kidney so we went in and we did an angiogram now we can watch these

patients we can surgically manage them by taking out their kidney in some ways that's the easy part excuse me it's a lot more elegant to try and embolize these patients if they're hemodynamically stable and can take you

know getting to angio and doing the case now in general we do embolization for patients with lower grade injuries and usually penetrating injuries a penetrating trauma that's seen on CT I think this is something that's changing

I if any of you work at high-volume trauma centers the reality is that we're doing more and more renal angiography for trauma than we used to because it's just becoming a more accepted thing for us to

be doing that all right so here's the angiogram and again I think you can notice it really correlates very well to what we saw on the CT scan you see that first image on the left and on the delayed image you see that that kind of

poorly constrained contrast going out into space now we were never really quite sure what this was if it was extravasation or if it was potentially an arteriovenous fistula with early filling of a renal vein regardless of

which it's not normal all right so what we did was we went in and we embolized and I only included this picture because I'm a big drawer during cases so when I'm working with a resident or a fellow I like to really

lay out our plan on a piece of paper and try and stick to the plan and this particular picture look really good so I included on the lecture but basically you can see that the coils the goal here for any embolization procedure

when it comes to trauma is to preserve as much of the normal organ as we can and to simply get you know to the source of the bleeding and to get it to stop and that's what we did there so what you can appreciate on this is kind of the

renal parenchyma or the tissue of the kidney is largely maintained you can see the dark black kind of blush within the kidney and all that really stands for properly working kidney all right and yet we embolize the pathology so that's

our goal here's a similar patient not

go through some more cases foreign body aspiration 20 month old has a two-day history of fever fussiness non-productive cough and he's not eating quite so much his Pio intake is

decreased chest x-rays is obtained and it's unsure if it's left lower lobe atelectasis versus pneumonia and his condition gets worse so they decide to do a CT scan of the chest and note that there's a point 5cm by 0.4 cm object

obstructing the left mainstem bronchus so the next step is wrong kosgeb II to see what's in there and you could see on the let's see we could see an uncooked pinto bean was removed on bronchoscopy so so obviously uncooked being a little

harder than it being soft being cooked and softer and these I thought these were very interesting images the one on the left is a CT scan of the paranasal sinuses and you could see on the arrow that there's a button battery which I'm

going to talk about in a few moments button battery in the right NER and a used eraser piece of eraser in the left narrow our middle picture here is a raid there's a radiopaque foreign body in the left mainstem bronchus which is a peanut

right here in the airway and here is a fish bone that's in the hypopharynx and that's just on a plane neck x-ray so you could see all different foreign bodies

in there okay so foreign bodies she put it where so females may present with

abdominal pain and what we think about with females with abdominal pain we think about constipation gastritis UTIs pyelonephritis or renal stones and we but what about a vaginal foreign body four percent of cases of girls with

genital complaints in the emergency room have been found to have a vaginal foreign body those bought foreign bodies include toilet paper hair ties safety pins pencils candy and more common in three to nine year olds of course in

history you would ask about tampon use but these foreign bodies can my great all the way up through the cervix and the signs and symptoms that they present with our vaginal bleeding dysuria hematuria foul odor and lower

abdominal pain okay so when you're looking at diagnosing vaginal foreign bodies x-rays are really less sensitive to objects that are made of wood and plastic you may not see it on an x-ray ultrasound and MRI are sensitive to

differences in water content and inflammation and again ultrasound can provide dynamic imaging so you may be able to see as that object has migrated CT scan is less sensitive especially if the objects been there for a while and

has retained fluid and the clinical picture and the imaging may not exactly reveal the diagnosis so this case is an 11 year old with menarche she has a history of ADHD she's been complaining of abdominal pain 7 on a scale of 1 to

10 and she's had a fever for two days her pain is worse with activity it's improved when she takes a warm bath she's not as active as usual and her Pio in takis is down a little bit but she has no sore throat no congestion no

coughs s pain nausea vomiting diarrhea no hematuria no dysuria no headache and no rash she's had vaginal bleeding for about two days and suspicious of a UTI her abdominal ultrasound she notes some free fluid in the pelvis and they do a

history t'me and find a golf tee found in her uterus which created an abscess and required a washout and dream and I'll show you some of that okay so we could see here you could see the foreign body noted here on CT scan and here's

the piece of the golf tee so you're able to see that I'm glad I'm doing this before lunch instead of after lunch right

patient who presents with rectal

bleeding he's had a transfusion and this is the angiogram so it's gonna be a lot easier people volunteer so who wants to say what they see what do you say what do you say show me tell everyone what you say well there's two

slides the first one you see just a little bit of blood and on the second slide you can see where he's really bleeding all right so these are the same the same patient same angiogram so one thing you guys should realize if you

don't know this already about an angiogram is an angiogram is a series of pictures over time good job by the way so a series of pictures over time so it's not just one image and the analogy I like to give is if I take my kids to

Disney World right I can have that picture of all of us in front of the castle with the Mickey hats and everyone's smiling but like one second before this one kicked that one and one second after this one smacked the other

one in the head and they're all crying but I got that one picture an angiogram is that situation it's a series of pictures over time so while you may look at that first picture on the left and maybe not see so much going on what you

should appreciate on the right is that big blobby thing of contrast over on the right side all right now what that means is that there is blood pouring out of that person's vessel all right this is a mesenteric angiogram it's a superior

mesenteric artery angiogram we put a catheter in by the groin from the groin we went into the SMA and we took some pictures and this is what we're seeing and we're appreciating hopefully that big blobby thing on the right all right

so this is what we'll call a lower GI bleed all right the patient's essentially crapping blood that's a lower GI bleed all right so given that just another hint this kind of implies that we're gonna talk about upper GI

bleeding later all right just so you know so there's lots of different causes for lower GI believes there's diverticular disease there's angiodysplasia switch our small malformations of the blood vessels

there's a ski mcdowell there's patients who maybe had radiation therapy for different cancers can be predisposed to bleeding cancer itself can cause bleeding and different inflammatory diseases like either infections or other

diseases can as lower GI bleeding now how do we work these patients up well usually I would think that most of the time these patients have hit an ir suite they've probably had a colonoscopy first and a

colonoscopy is really the first line used to assess what's going on with a lower GI bleed it's not that easy to do it's difficult to prep those of you who resolve this I am and have had a colonoscopy know that it's better when

you prep before the colonoscopy and if someone comes in with a lower GI believe they haven't been adequately prepped that makes the colonoscopy very difficult the other thing is remember you're going from the bottom up into

colonoscopy and you have blood coming at you in someone who is experiencing a lower GI bleed and that essentially means it's difficult to see so many times the colonoscopy is not really able to tell us what we need to know I would

say the next thing that usually happens is some type of imaging now of a sudden the patients are coming to radiology and what you may have is any one of three different options you might have a nuclear medicine bleeding scan you might

have a CT angiogram you might have a regular old conventional angiogram and for those of you saying who cares what's the difference just take some pictures the big difference is that the amount of bleeding that it takes to see it is

different for each of those exams so the most sensitive exam is the nuclear medicine scan that's going to pick up the lowest rates of bleeding a conventional angiogram is the worst scan we can do for GI bleed or worse imaging

we can do because you need a lot of bleeding to see it so when we saw when my friend here picked up the the blobby thing on the right would that bleed that's a big bleed like we can look at it and say aren't these really pretty

pictures but when we see it and you see that kind of bleed you have to realize that's a lot of bleeding to see it like that so our antenna has to go up and we have to start moving a little bit CTA is kind

of right in the middle and actually a lot of people are turning now to see TAS I'm not personally a huge fan of that because I think it's a waste of time and contrast in my opinion I think a CTA for GI bleeding is a way if I can translate

it is I don't feel like doing that case right now so I'm gonna get a CTA and we'll figure it out later all right that's that's my language for a CTA but in my opinion you know it has some value how do we treat them well if

you can see on colonoscopy then you can potentially treat it with colonoscopy and there's different things that they can do with their scopes obviously if there's more diffuse disease they can remove part of

the bowel that's that's a problem and then of course the answer is embolization exactly so here is the picture from our embolization procedure and what do you see all right I won't pick on anybody yet basically what we

did was you can see over there you can see the shade of our angiographic catheter there's a micro catheter now passing all the way into the actual vessel that's bleeding and now when we do an angiogram you can actually see the

vessel that's bleeding now conventionally in the old days for those of you that have been doing this for a while you probably are used to living in a world where it's not great to embolize lower GI bleeds it's better to embolize

upper GI bleeds and lower GI bleeds and the reason why is because there's less collateral flow so if we block up a blood vessel we essentially kill everything beyond where we blocked it up because there's no alternative routes

for blood to flow all right in this particular case you can actually see that long stringy thing going right to the bleed and here we were able to get into that single vessel and kind of see it right there the long think heading

towards 4 o'clock and when we embolize it you can see we put coils in there and blocked it up so the only thing we embolize there is the blood vessel going to the abnormality the risk of ischemia is low and the clinical efficacy is high

but if you can't make it all the way out there if we embolize let's say right there that entire loop of intestine would be infarct it and that would be bad so we always have to think about that when we're embolizing GI bleeds all

different patient this is an unrestrained passenger in a motor vehicle accident now that you are all

experts in looking at this CT you can see on the right side of both of those images is the spleen you can see that darker grey areas within the spleen that's bad it should look more like the the the lighter parts

and actually all the grey are on the outside is all blood or fluid in the abdomen so this is a bad laceration probably at least a grade four splenic laceration but again this was a hemodynamically stable patient all right

and here's what we saw this is the angiogram you can see the splenic artery and you can see they're kind of diffuse abnormality of the spleen it just doesn't look right under normal circumstances it just look like branches

on a tree and what we're seeing here is just kind of splotchy looking splenic ranked them up so that's not normal we just want to give it a chance to heal this is the scenario we might do a proximal splenic embolization where

we'll go in and we'll basically put a plug or some coils right at the origin of the splenic artery and I love this picture because what it shows is why we do this philosophically what I want you to notice is on the image to the left

you can see the coil right there right if you see the abrupt stopping of the splenic artery and then what you see are all those vessels going up towards the top of the picture those are arteries that are supplying

the stomach it's the left gastric artery some other vessels that then go through vessels we call the short gastric arteries and what you get is is the reconstitution of the splenic artery so on the image to the right all the way on

the right side of the picture those branches that you see are within the spleen so even though we plugged up the splenic artery right at its start the spleen is able to get blood flow through those collateral vessels all right so

that's our goal that's what a proximal splenic embolization is trying to do we just want the spleen to heal a little bit and reality what we want to do is these patients are usually fine we just don't want them to go home and have a

delayed rupture of their spleen because that's something many of us probably don't appreciate if someone has a splenic artery injury or splenic injury and they're doing fine and then we send them home there is an incidence of

delayed rupture of the spleen and what we know through lots of good papers is doing these proximal embolization procedures helps to reduce that risk of delayed splenic rupture so that's what we're trying to do there all right so

is example as I mentioned about doing very large ablation so this is a lady who hadn't malignant melanoma and she

had metastases to liver we basically placed six probes into this mass as you can see there on that CT the image on the right is the appearance of those six probes it's all excited about how many probes I placed in this patient

like it's a game and then I just watched an ablation talk with a guy put 16 in so that didn't really make me feel much better so so we have six probes here and you can see what we what you do when you have lesions that are in the soft

tissues and you're worried about freezing to the skin you can have injury to the skin right essentially frostburn and so frostbite sorry and so what you can do is you can take either a warm glove fill it up with saline and put it

with the fingers amongst the probes so it keeps the skin warm because you don't want to freeze the skin or what people are doing sometimes as well as they've just put some gauze around all the probes and they spray that goes with

warm saline I just take one of those leader bags of saline put it in the microwave for a couple minutes and then just fill fill the bowl up with it and just spray the gauze on that or you can do the glove technique the main idea

here once again is you don't want to get skin injury when you do these and as you can see a pretty sizable ablation around that entire tumor you can even see the lightening sign which is the low attenuation sort of lightening looking

structures within the ice ball which is cracking of the ice ball as you form but you will see what this is immediately after the procedure the patient will have a very hard ice ball under their chest and it takes about an hour

for that to melt so if you notice bleeding off towards or what is perceived as bleeding before you panic you should realize that that ice pole is going to melt and it's going to come out the holes seep out of the holes that you

created so oftentimes if it's sort of a blood tinge fluid that's really just the ice ball melting in the fluid coming out of the the sites that you've punctured

patient 40s year-old patient again car accident lower abdominal pain and bruising so it sounds like you guys can appreciate that's an injury alright so we'll move past that so here's a CT scan these are four separate images from the

same patient CT scan and it is a bit more subtle I'm not suggesting it's easy to see you know we can appreciate the injury but one thing that you should be able to notice again is that concept of symmetry so when our residence or even

myself or anybody reads a cat scan we always want to kind of appreciate all the differences in the symmetry that we're seeing and so what you can see here is especially on that upper left hand side you can see the penis coming

out of the patient almost coming out of the patient and if you just draw a line straight back from there you should notice that there's a bit more tissue on the left side of the patient than the right side of the patient but that's

what we're looking at and if you go to the image over to the right the top right image right at that same area there's a little bit of a white blush which just shows that there is some bleeding going on there and if you look

at the third image which is the one on the bottom left right below one of the bones or there's another area of a white contrast collection or bleeding all right you can maybe see that again on the fourth image so that's what we're

looking for on the CT that asymmetry or the thickening of the tissue and we're looking for an escape of some contrast from where we should expect it to be all right so many of these patients will be

unstable those are the patients that probably need to go right to the or but for the patients who are really you know doing okay we have a chance to intervene on them and the reason why that's important is the more unstable they are

the higher the chance of mortality especially with the pelvic fracture so pelvic fractures are a big deal if you have a hemodynamically unstable patient with a pelvic fracture that's something to take very seriously

all right many of these patients will get CTS or C if we see extravasation they often come to us for angiography so here's the angiogram again a great example if you only look at one picture or two pictures

you're not going to see the problem all right so if you look at the first two pictures you really don't see anything I would I would argue it looks normal but as you get to that third picture you see that kind of collection of contrast

on the bottom right-hand side of the picture all right that's why you need to look at all the pictures of the and reom not just one picture you watch them it's like watching a

little movie now you just stand there and watch it over and over again I get a sense of what it looks like at the beginning middle and end of the angiographic run or set of images the other thing is it's very hard to see

extravasation of contrast when you're in the aorta so many times we do an aorta gram we take some pictures and we may or may not see anything but if we know there's a pelvic fraction we know it's more on the left side we'll go into the

left internal iliac artery and do a more selective angiogram and here's a picture of that selective angiogram and now you can see the extrapolation even more clearly hopefully you can all see it the bottom kind of leftish part of the image

all right here's a more selective now we say okay we definitely see something now we're going to get a little bit further into the system here's a picture now it's very clear you can go if you don't see it all right so you should see it on

the bottom all right and now our goal is to just get as close as we can and so we got all the way down then we put some coils there and again our goal is to make sure that we get just into the vessel that we treat and embolize it now

people will say what agent should we use do we use gel foam do we use particles do we use coils do we use glue or onyx the truth is you can you can really use anything but the thing with the most control so for trauma we tend to use

coils for trauma alright because our goal is to deposit an embolic agent right at the site of the injury that's our goal if we use particles we don't have as much control or a liquid we don't have

as much control they could go somewhere we don't want it to go all right here you're dealing with the blood supply of the penis the rectum the bladder other things which you know most of us would prefer not be injured during an

angiogram all right so we don't want to do something that we don't have complete control over and coils give us that type of control

all wheezing is asthma I'm going to start with some interesting cases so a six-year-old has a one-month history of a cough URI and it progresses to wheezing chest x-rays obtained and

you see minimal peribronchial thickening but there's no pneumonia or air trapping he's treated with antibiotics and nebulizers and steroids and he gets better in a couple of days but about two weeks later he returns for similar

symptoms so while he's being worked up two weeks later he has post tussah emphasis and expels a tooth so this is okay this is the x-ray that was done at the initial start of his coughing where foreign body was not suspected in the

initial workup and so the foreign body was missed but in hindsight the mother recalls and I teach a physical assessment course and I always talk about it's all in the history it's all in the history it's all in the history

but in hindsight the mother stated that just before the child started with the coughing episodes a few weeks prior he had lost a tooth and he guessed when it fell out they never found the tooth and they just assumed that he had swallowed

it but in fact he had actually aspirated the tooth so the incidence of foreign body aspiration it's most common again those boys in boys less than 3 years of age with the peak age being one to two years it's usually noted in the right

mainstem because that's the path of least resistance but it can get lodged in the larynx or the trachea the most commonly aspirated objects are peanuts legumes seeds popcorn hardware marbles and balls so infants and toddlers would

be food tends to be the culprit older children coins and paper clips have also been implicated with foreign body aspiration and inflatable objects are the most dangerous so hence stay away from those latex

balloons because kids can aspirate and though objects in the airway expand even further and can cause more obstruction of their Airways and complete airway obstruction in cases where they're in

there eating uncut hotdogs grapes or gel candies and in my experience in the pediatric ICU at Children's Hospital of Philadelphia I've taken care of several children who had air complete airway obstruction and subsequent demise and

hot dogs on autopsy pieces of hotdogs you know being removed from the airway so I could certainly speak to that so there should always be a high index of suspicion and a low threshold for radiologic studies look in the nose

first you'll be amazed at what kids can fit up there plain x-ray films anterior posterior and lateral views the objects are seen in about 62% of the cases an expert Ori films chest films help with a diagnosis so there was a study down back

in 1979 that looked at expert ory films that which correctly diagnosed 47 out of 50 cases of kids with foreign bodies in their airway so it's difficult if the if the if the foreign body is in the trachea because you would have the

changes would be bilateral but what expiratory films helped to do is eliminate the need for fluoroscopy CT and bronchoscopy so you could see in the picture on on your left and the picture on the right it's you could see that

there is a the either the tack or the physician wears a lead glove and applies epigastric pressure to prevent lung expansion and to help visualize a foreign body so you could see the picture on the right where there's

actually hyperinflation that seen let's

we're gonna move on I have Nancy for the

final piece good morning everybody so I'm going to start with attraction the attraction of magnets that children seem to have so you can see here on the right that the incidence of these types of ingestion is relatively low but what you

need to know is that there's been a major increase in the number of times that we see this because there's so many toys and other objects that contain magnets in them and the magnets that are in there are extremely high-powered so

just because it's a small magnet doesn't mean that it's less of a problem so as you can see there are packaged warning labels on them but a lot of people still don't really actually I think believe that ingesting a magnet can be fatal but

there have been several fatalities and children from magnet ingestions and this is just really cool-looking puzzle I would be attracted to it if I was a child but this contains over 200 magnetic balls in there so I like x-men

so I'm calling this the case of magneto so this is a ten year old boy with a one-day history of recurrent vomiting who basically had some abdominal pain which is you've heard multiple times this is a very common presentation and

he had some abdominal tenderness so they started treatment for gastroenteritis which seemed totally appropriate but then his pain got worse and he started to have rebound tenderness so of course they're thinking

maybe appendicitis they did in a abdominal ultrasound and then they got the x-ray and then they got the x-ray there we go any guesses on what this is like a bracelet right like a little small brace

that's what I thought when I saw this so when you see that what type of material do you think this could be if you're thinking it's a bracelet yeah like a hard plastic right so obviously we're talking about magnets so here you go

foreshadowing not really it's a magnet but when you would first look at it I think you would think maybe hard plastic or some sort of jewelry some sort of that type of metal so they took him to the operating room and this is the

segment that they took out he had one of those rainbow magnet puzzles that I showed you at the beginning so when they removed it they found 16 separate little magnet balls so what people don't understand about the magnets is when

they travel through the GI system they continue to attract each other so in this situation you can see here that there is a fistula that's developed and that's because two magnets were on the opposite side of bowel and so they

attract each other and they pressed together this can cause perforations this can cause fistula x' and this can cause necrosis of those parts of the intestine and so in this case he had seven

fistulas several perforations and they had to actually remove part of his ileum because he had so many of them and then just because this poor child he's never gonna or he or she he will never do this again he had a wound

infection afterwards so this became a very complicated thing so he's in the hospital for quite a while but was able to be discharged successfully so the question comes up about well if the problem is that there are two magnets

that attract each other and that's what causes a problem then if there's a single magnet then in theory that shouldn't be an issue it should be able to pass so when you look at some of the algorithms for treatment of magnets

it'll say that if you believe that it's a single magnet that we should attempt to let it pass so that's sort of the conventional wisdom for it

all right another patient 52 year old patient ATV accident we get a lot of

lunatics on ATVs in our area and they presented with severe back pain here's the cat scan you see that white thing kind of in the back on the right side it almost looks exactly like that liver one I showed you two patients ago the

difference is that that's not conscious that's a part of the patient's bone that's the spine that fractured off and is now sitting in the middle of a big hematoma so that's why my kids don't have ATVs all right so basically that's

a big retroperitoneal hematoma due to a transverse process fracture all right in light of an ATV injury here's the angiogram now look at the picture on the left first that's an aorta gram you see the renal

artery at the top you see the bifurcation of the aorta kind of in the middle going down to each side and maybe just on that first image you see a hint of maybe some cloudy extravasated on the left side of the spine excuse me the

right side of the spine the left side of the image now remember I just I know I keep hammering this point home but you need the delayed image to make the diagnosis that's normally going to tell you if there's a real problem and on

that image on the right which is a bit more delayed you can see the extravagant Rast next to where the spine was that's an injury that's a lumbar artery injury and as we get closer all right we put a micro catheter in that lumbar artery now

you see the extraction and the question always comes up how much of that space do we need to fill that's an abnormal space that's just receiving all the blood that's leaking out of the artery and basically we don't have to fill all

of it we try we try to but it takes a lot to fill that up so we'll go in there you can see we put a lot of coils in this space and then we started packing coils back into the artery that was injured and I know it looks really big

on that image but if you go back into a finally orna gram you can appreciate that we were in a very small artery there but the technology that we have now allows us to get very far into very small arteries and that I think is

what's changed over the 20 years that I've been doing this at the very beginning of my career we wouldn't think about doing any of these things since we didn't have the tools to get that far out we had to

embolize these vessels very close to their origin and that led to a failure rate and an adverse injury rate that we don't see now that we can get this far out keypoint another case we have an older

long sharp objects up to 90% and I think Laurie mentioned that to of ingested foreign bodies passed through the GI tract without complication however there

are exceptions to that and foreign bodies greater than four centimeters by two centimeters are those most likely to get caught up either in the constrictions of the esophagus in the pylorus or

the ileocecal Junction so our second case today is a nine-year-old who presented to the emergency department with the history of swallowing a pin ten hours ago again he did this at school doing a project but was afraid to tell

anyone but then when he came home he was afraid that something would happen so he finally confessed and he was he was asymptomatic but the parents decided to follow up just to make sure because it was a pin

he had an unremarkable exam they did do the x-rays so you can see there so there's the pin and if something to notice here is right now it is going with the point side down on the blunt side up and here it is here luckily

these show no evidence of impaction or perforation so they decided to just admit him with serial x-rays to follow through and hopefully it would pass most of the time they do pass and most of the time watch this pin they will go blunt

side down which decreases your risk of injury perforation or impaction so here we are moving so that those images were ten hours and now we're at about fifteen hours and you can see well on this one first of all it's starting to rotate

you'll see that looks a little concerning to me just the way it's facing but the blunt side is actually starting to go down and then over here were further down into the colon and then when we move on four hours later 26

hours after he initially ingested this he passed spontaneously past this with no complications was discharged to him the following morning so pretty amazing and that was just about the blunt end so the take homes here is that

you really can have spontaneous passage wait watchful waiting is okay to do as long as there are no signs or symptoms to be concerned about at that point however anything sharp or cutting does need an urgent examination because there

is a high risk of serious complications so there's complications most likely to occur with long sharp objects mucosal abrasions bleeding GI perforations peritonitis and medius tinnitus so this

then real quick just mercury ingestion again they're not selling the mercury

the liquid mercury thermometers anymore but there's still a lot of them out there and we do still occasionally in the DDC some of these come in the mercury is a dense silver white odorless heavy metal it can penetrate cell

membranes and accumulate in several organs and become toxic in several systems including the urinary CNS endocrine and Gi it's unusual to cause toxicity if the integrity of the mucosa is intact

and it does not enter further into the system if ingested from like a single thermometer 500 to 700 milligrams of Elemental mercury it's virtually non-toxic other sources are barometers batteries and sigma m-- fig manometers

you think after 30 years in nursing I could say that better so this is a two-year-old and the mother noted the broken thermometer with no evidence of mercury so he didn't have any symptoms that he wasn't complaining of pain he

wasn't coughing no breathing or swallowing but the mom brought him in anyway because it was mercury and she knew that it could be toxic he was stable vital signs stable no oral cuts abrasions glass particles but this

is what his x-ray looked like so it's just multiple scattered round densities throughout they did admit him for observation they repeated the x-ray in a serial course on day two he had complete clearance of the densities and was

discharged without complications so again our take homes usually it is with small amounts of mercury that have not gotten further into the system it's rarely toxic so you need to know the dose and the

the level of exposure the really important thing here is do not induce emesis or administer activated charcoal and do not use glass mercury containing thermometers in the home that's it and

well I'll kind of show you a case just to kind of show you what what it looks like and so when are you doing it an angiogram you can see that there's a

clot that that little vessel there's no pointer up here is there okay so the vessel that's going going to the right of the image that's the MCA and so there's a big clot there you should see all these other vessels that you kind of

see start filling in later those are the collaterals so that's what you see on the first image when you see those collaterals you know that okay that brain is probably still alive so let me get this clock so this is what happens

you basically get that little micro catheter up there and this is deploying the stent so in the middle that's deploying the stent and you just is basically pin pulls is pretty amazing a little tiny device so that's the stent

across the clot into the middle cerebral artery and then what you do and I labeled it here so you can see so you have that solitaire stent Retriever and then you have a base catheter intermediate catheter and then you have

that balloon guide so you can see all that work near there and this technique is when you pull the stunt retriever into the catheter so you literally pull it in now more people don't pull the whole thing

in they take it out as a unit called the trap or sandwich but this just shows you something like that and then you you do another image and there you go so that now you have the blood flow into the middle cerebral artery and it's pretty

it's a good feeling when you sit like okay you know obviously you're not how the woods get you're pretty much banking that that patient's brain is gonna be okay but usually it is and so say for this patient this was the perfusion map

so you see everything that's at risk there at the end of the case this was an MRI done the next day the the white area is what infarcted and that's okay that's your basal ganglia the patient will be asymptomatic because you just need one

so the whole other part of the brain which controls speech controls movements everything that is back so you know that's a good feeling this patient you know went home in two days and was fine versus before they were gonna you know

probably not be able to maintain independent lifestyle so here here this video is a little bit long when it shows you the ADAP technique which is just getting that catheter to the clot and we don't have to show it this one's like a

minute long but you just get the catheter to the clot and aspirate people are now trying to look at the data what's better using a stent Retriever or not and surprisingly it shows that the adaptor the aspiration technique is

working as well then you save a lot of money cuz those stent retrievers are really expensive technically it's kind of hard to get that clot the catheter up there at times but we're always mentioning Tiki scores

once we do a clot retrieval and the Tiki score just means perfusion we want three we're happy with A to C which is a new one or a two B anything below to be not that great and we consider it a failure even though all of these start off at

zero so we really want a to B or higher and grade three just means you have completely normal perfusion um so you'll see these people kind of all the docs I was like screaming like a tiki to to III that's what that

stuff means and just for a little

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