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Chest x ray Interptetations
- 1. Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff Doctors Medical Center
- 4. We went from surface anatomy to being able to look under the skin
- 6. How Are X-rays Made?
- 9. Metal : Dense Nothing goes through Bone: Somewhat dense whiter than tissue, darker than handcuffs
- 11. Systematic Approach to Chest X-rays • Lots of methods • Learn any one, then stick to it • Most errors are made because of poor viewing conditions, no method, and going too fast
- 12. A B C D S
- 13. For all X-Rays, check the 4 R’s…. • Right Person? • Right/Left? • Rotated? • Radiation?
- 14. 25 yo Male with complaint of pleuritic chest pain on the right side.
- 22. Airway - Aorta Breathing - Bones Circulation - Cardiac Diaphragm - Deformity Soft tissues - Shoulder
- 23. Airway - Aorta
- 24. What we are looking for with.. • Airway – Position • Is it mid-line? If not: ?Rotation ? Pathology ? Tension? – Corina • Helps with placement of ET tube depth – Caliber • Steepling – hints towards croup as Dx
- 25. What we are looking for with.. • Aorta – Location • Helps Identify Left vs Right on x-ray • Helps you find left mainstem bronchus – Calcifications • Nice but not particularly significant – Size (Mediastinum) • Despite current media: size matters • Big -> possible aortic pathology
- 29. Airway - Aorta Breathing - Bones
- 30. What we are looking for with.. • Breathing – Look at the lung fields – Hazy/White = pneumonia/infiltrate or mass – Too Dark (or absence of markings) • Possible Pneumothorax • Possible Bulla
- 32. What we are looking for with.. • Bones (Focus on Ribs) – Fractures • Points towards degree of injury/mechanism • Gives us clues of possible underlying injuries
- 34. Airway - Aorta Breathing - Bones Circulation - Cardiac
- 35. What we are looking for with.. • Cardiac – “Big” or “Not Big” – Well defined Margins – Subtle bumps (RV enlargement)
- 39. Airway - Aorta Breathing - Bones Circulation - Cardiac Diaphragm - Deformity
- 40. What we are looking for with.. • Diaphragm – Configuration • 2 rounded humps – Sharp Margins – Sharp Sulci – Look underneath • Gas where it should or shouldn’t be • NG tube
- 41. What we are looking for with.. • Deformity (All the other Bones) – Clavicle fractures/Dislocations – Humeral fractures/Dislocations – Scapula • Follow the curve of the tip • Look for Fracture
- 44. Airway - Aorta Breathing - Bones Circulation - Cardiac Diaphragm - Deformity Soft tissues - Shoulder
- 45. What we are looking for with.. • Soft Tissues – Air – Foreign Bodies (Including chest tube placement)
- 49. What we are looking for with.. • Shoulder – Fracture – Dislocation
- 55. Chest X-ray • Pneumothorax • Effusions • Pneumonia
- 62. Looking for love in all the wrong places • On all films, look for air where it shouldn’t be • Air in the wrong place => pathology!
- 63. Beware of the “straight line” • In nature (and with x-rays), straight lines are unusual • In X-rays, if you see a straight line, think about an air-fluid level
- 68. FINAL EXAM
- 69. Airway - Aorta Breathing - Bones Circulation - Cardiac Diaphragm - Deformity Soft tissues - Shoulder
- 70. 65 yo male, c/o SOB
Editor's Notes
- X-rays are everywhere; Flying here, I passed through security, and my bags were x-rayed. X-rays give us a completely different perspective of everyday objects. We can use x-rays to see inside a keyboard, or a frog. The applications of x-rays are myriad, in aviation, electronics, as well as medicine.
- As a quick review, x-rays are simply part of the electromagnetic spectrum, and is a shorter wavelength than the ultraviolet light that gives us a tan, or me a sunburn. X-ray radiation was discovered by Roentgen in 1895.
- X-rays are produced when electrons strike a metal target. The electrons are liberated from the heated filament and accelerated by a high voltage towards the metal target. The X-rays are produced when the electrons collide with the atoms and nuclei of the metal target. Emitted X-ray has a characteristic wavelength depending upon which metal is present
- Soon after their discovery, scientists were putting different parts of their body in front of x-rays to make pictures, and from there the science of medical radiology began. It is important to realize that, at its roots, the radiographs that you and I look at every day are just…. Shadows… When we were children, we often made shadow figures from a bright light. The x-ray pictures we use today, and the ones we will be studying next, are just shadows.
- This last x-ray is a fairly common one in my emergency department, and I bet in some of your departments too. So x-rays are everywhere, but what are they?
- Here is what you will learn today – x-ray findings that you can’t afford to miss before you transport a patient. Now, there is incredible minutia in radiology. You have to be a special person to even become a radiologist. To emphasize that point, let me tell you a story a fellow doctor told me. A young woman, who had not been feeling well for months, went to her doctor. After a careful examination and several tests, the doctor sat down with her. “I have some terrible news for you. You have a terminal illness, with less than 6 months left to live.” The woman was distraught, and pleaded with the doctor, “what should I do?” The doctor pondered the question, then answered, “I think you should go out and marry a radiologist.” “Marry a radiologist?”, she asked. “Will that make me live longer?” . “No” the doctor answered, “but it will make the next six months seem like an eternity.” So parents, don’t let your children grow up to be radiologists.
- Check the 4 R Right Patient? Right vs. Left? Rotated? Radiated?
- Right Person? Check the name and the date Right/Left? Orient the film correctly, the same way every time Rotated? Be aware that it alters the way everything will look Radiation? It the film overexposed? Underexposed? Just Right? 1. Verify patient information and date on both films and position of LEFT or RIGHT marker on frontal. 2. Note adequacy of penetration and any technical defects. (Should be able to see intervertebral disc space through the heart shadow. Vertebral spinous process should be midway between medial heads of both clavicles.) 3. Look briefly at the entirety of both films for obvious abnormalities.
- What side is the patients right side? You want to orient the x-ray correctly, with the patient’s right side being here. Often times there is a marker placed on the film by the radiology tech, but sometimes they are wrong too. I also look for 3 other clues about the x-rays orientation. First, look for a stomach bubble, then check the heart’s position (usually on the left), and look for the aortic knob. The knob is where the aorta goes up and over the left mainstem bronchus.
- Let’s look at this in real life. Here is a trauma patient with increasing difficulty breathing. The chest xray taken, and the tech has run back to you with the film, yelling tension pneumo!! It’s easy to see, the pneumothorax is shifting everything over. No problem, you say to yourself, I’ll just put a chest tube on the right, and we will be done. Since this is a class, you know its not that easy. Lets check for orientation. Well, there is not Left or right marker placed, so that’s no help. The is no gastric bubble, so that’s no help. So lets look at the aortic knob.
- This is the correct orientation, and you needed to decompress the left side. Many chest tubes have been placed on the wrong side by this error. Don’t let it catch you.
- Underpenetrated
- Overpentetrated
- Now we add to our checklist; A B C D S;
- Now we add to our checklist; A B C D S;
- The C our our checklist is Circulation & Cardiac. The first part, C, can be a challenge. It requires looking at the smaller blood vessels, and making a judgement call as to whether or not they look prominent or congested. To be honest, that takes a long time to master, and I can safely say I still don’t have it mastered. Often times my interpretation will vary from the radiologist’s report in regards to the caliber of the smaller vessels. So I propose we leave that behind, and focus on Cardiac.
- The C our our checklist is Circulation & Cardiac. The first part, C, can be a challenge. It requires looking at the smaller blood vessels, and making a judgement call as to whether or not they look prominent or congested. To be honest, that takes a long time to master, and I can safely say I still don’t have it mastered. Often times my interpretation will vary from the radiologist’s report in regards to the caliber of the smaller vessels. So I propose we leave that behind, and focus on Cardiac.
- Now we add to our checklist; A B C D S;
- The C our our checklist is Circulation & Cardiac. The first part, C, can be a challenge. It requires looking at the smaller blood vessels, and making a judgement call as to whether or not they look prominent or congested. To be honest, that takes a long time to master, and I can safely say I still don’t have it mastered. Often times my interpretation will vary from the radiologist’s report in regards to the caliber of the smaller vessels. So I propose we leave that behind, and focus on Cardiac.
- The C our our checklist is Circulation & Cardiac. The first part, C, can be a challenge. It requires looking at the smaller blood vessels, and making a judgement call as to whether or not they look prominent or congested. To be honest, that takes a long time to master, and I can safely say I still don’t have it mastered. Often times my interpretation will vary from the radiologist’s report in regards to the caliber of the smaller vessels. So I propose we leave that behind, and focus on Cardiac.
- Frontal view: Airway: Follow trachea to carina and main bronchi. Aorta: Follow contour of aorta on left from arch to descending Breathing: Study the lungs, both up and down and side to side. Include lung volumes and symmetry of markings. Check periphery of lungs for pneumothorax and effusions. Bones: Trace periphery of the chest - neck, chest wall, bones, diaphragms. Circulation: Look at both hila for enlargement and abnormal bulges. Cardiac: Evaluate mediastinal contours, edges and shape. Diaphragm: Check the upper abdomen for free air and abnormal air collections Deformity: Look at spine for deformity, asymmetry of pedicles/ spinous processes Soft tissues: Trace periphery of images - forward through abdomen Shoulder: reminder to look at bones and periphery
- The C our our checklist is Circulation & Cardiac. The first part, C, can be a challenge. It requires looking at the smaller blood vessels, and making a judgement call as to whether or not they look prominent or congested. To be honest, that takes a long time to master, and I can safely say I still don’t have it mastered. Often times my interpretation will vary from the radiologist’s report in regards to the caliber of the smaller vessels. So I propose we leave that behind, and focus on Cardiac
- The C our our checklist is Circulation & Cardiac. The first part, C, can be a challenge. It requires looking at the smaller blood vessels, and making a judgement call as to whether or not they look prominent or congested. To be honest, that takes a long time to master, and I can safely say I still don’t have it mastered. Often times my interpretation will vary from the radiologist’s report in regards to the caliber of the smaller vessels. So I propose we leave that behind, and focus on Cardiac.
- Now we add to our checklist; A B C D S;
- The C our our checklist is Circulation & Cardiac. The first part, C, can be a challenge. It requires looking at the smaller blood vessels, and making a judgement call as to whether or not they look prominent or congested. To be honest, that takes a long time to master, and I can safely say I still don’t have it mastered. Often times my interpretation will vary from the radiologist’s report in regards to the caliber of the smaller vessels. So I propose we leave that behind, and focus on Cardiac.
- S
- Now we add to our checklist; A B C D S;
- S
- S
- Close-up view of Right Upper Lobe of Lung and Right Shoulder demonstrates streaky lucencies overlying the shoulder and upper chest (blue circle) characteristic of subcutaneous emphysema with muscle bundles of pectoralis muscle becoming visible. The red arrow points to subcutaneous emphysema in the supraclavicular area.
- Left pneumothorax-deep sulcus sign., Lucency at left costophrenic angle which projects well below the costophrenic angle on the opposite side is the "Deep sulcus sign" indicating the presence of a pneumothorax on a supine radiograph of the chest (Bullet is seen overlying the heart)
- Trachea
- On the lateral view, you can look for proper penetration and inspiration by observing that the spine appears to be darken as you move caudally. This is due to more air in lung in the lower lobes and less chest wall. The sternum should be seen edge on and posteriorly you should see two sets of ribs.
- Look for the straight line. Can you see it? It right here, and this is the stomach. We are seeing a fluid collection in the stomach, with a pocket of air above it. This is a normal finding with an x-ray taken with the patient upright. You will not see this if they are laying down
- So what do we see here? Any straight lines? Sure, there are several. It is not normal to see these; it would mean a possible intestinal illeus or obstruction. What do you think will happen when you transport this patient in a non-pressurized aircraft? The air will expand, and I would suspect the patient will be more uncomfortable as a result.
- The is a lung abscess or empyema. Most often, it will need to be drained, often with CT guidance by the radiologist.
- Check the 4 R Right Patient? Right vs. Left? Rotated? Radiated?