CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School,...

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CXR in CXR in Emergency Department Emergency Department By : O. Ahmadi, MD. By : O. Ahmadi, MD. Professor Assistant of Professor Assistant of Esfahan medical School, Esfahan medical School, Emergency Department of Emergency Department of Al-Zahra Hospital Al-Zahra Hospital

Transcript of CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School,...

Page 1: CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital.

CXR in CXR in Emergency DepartmentEmergency Department

By : O. Ahmadi, MD. Professor By : O. Ahmadi, MD. Professor Assistant of Esfahan medical Assistant of Esfahan medical

School, Emergency School, Emergency Department of Al-Zahra Department of Al-Zahra

HospitalHospital

Page 2: CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital.

Normal CXRNormal CXR

Page 3: CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital.

Features that are Features that are typically examined on a typically examined on a

chest X-raychest X-ray Every doctor will have a different Every doctor will have a different

approach to examining chest X-approach to examining chest X-rays. A commonly used mnemonic rays. A commonly used mnemonic for what to look for on a chest X-for what to look for on a chest X-ray is: ray is:

IIt t MMay ay PProve rove QQuite uite RRight ight (but) (but) SStop top AAnd nd BBe e CCertain ertain

HHow ow LLungs ungs AAppearppear

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II = Identification (name, age, = Identification (name, age, sex, indication for X-ray)sex, indication for X-ray)

MM = Markers (differentiate left = Markers (differentiate left from right )from right )

PP = Position - the = Position - the spinousspinous process process of T4 should be of T4 should be between the heads of the between the heads of the clavicleclavicle (if it isn't the body is (if it isn't the body is rotated) rotated)

Page 5: CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital.

QQ = Quality - is the film = Quality - is the film penetrated properly. In a properly penetrated properly. In a properly penetrated film the vertebral penetrated film the vertebral interspaces should be visible interspaces should be visible behind the central (cardiac) behind the central (cardiac) shadow shadow

RR = Respiration - chest X-rays are = Respiration - chest X-rays are typically done with full inspiration typically done with full inspiration

(but) (but)

Page 6: CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital.

SS = Soft tissue - look for = Soft tissue - look for subcutaneous emphysemasubcutaneous emphysema (suggestive of trauma), soft tissue (suggestive of trauma), soft tissue swelling swelling

AA = Abdomen - look for free = Abdomen - look for free abdominal air (suggests penetrating abdominal air (suggests penetrating trauma, peritonitis, or recent surgery) trauma, peritonitis, or recent surgery)

BB = Bone - look for fractures (these = Bone - look for fractures (these tend to be at the lateral aspects tend to be at the lateral aspects because of the mechanics because of the mechanics

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CC = Central shadow (cardiac = Central shadow (cardiac silhouette) - greater than 50% of silhouette) - greater than 50% of lateral distance in frontal view at lateral distance in frontal view at the diaphragm suggests cardiac the diaphragm suggests cardiac enlargement (usually secondary enlargement (usually secondary to heart failure) or a pericardial to heart failure) or a pericardial effusion . A widened effusion . A widened mediastinum may suggest aortic mediastinum may suggest aortic dissectiondissection

Page 8: CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital.

HH = Hila (of the lungs) - can be = Hila (of the lungs) - can be affected in lung disease, malignant affected in lung disease, malignant processes and infection (hilar processes and infection (hilar lymphadenopathy). lymphadenopathy).

LL = Lungs - for consolidation, = Lungs - for consolidation, interstitial lung disease (reticular, interstitial lung disease (reticular, nodular or reticulonodular), nodular or reticulonodular), honeycombing, miliary pattern, honeycombing, miliary pattern, granulomas, lung masses granulomas, lung masses

AA = Absent structures/Apices of the = Absent structures/Apices of the lung (for pneumothorax) lung (for pneumothorax)

Page 9: CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital.

Technique tipsTechnique tips

Sometimes the film may Sometimes the film may have been taken at an anglehave been taken at an angle

The silhouette sign The silhouette sign To identify PA or AP film To identify PA or AP film

Page 10: CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital.

Effect of over- Effect of over- and and underexposure underexposure on a chest x-ray.on a chest x-ray. Overexposure Overexposure (A)(A)

Underexposure Underexposure (B (B

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Nipple Nipple shadows.shadows. midclaviculamidclavicular line over r line over the lower the lower half of both half of both the right and the right and the left lung the left lung (arrows)(arrows). . These should These should be bilateral be bilateral

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Effect of Effect of position position on the on the chest x-chest x-rayray

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Normal Normal Anatomy Anatomy

and Variantsand Variants

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Page 15: CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital.

Situs Situs inversus.inversus. The heart, The heart, stomach, and stomach, and liver are all in liver are all in reversed reversed positions. positions. Before you Before you make this make this diagnosis, diagnosis, make sure make sure that the that the technician technician has placed has placed the right and the right and left markers left markers correctly.correctly.

Page 16: CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital.

Lung volume can be estimated Lung volume can be estimated by observing the point where a by observing the point where a posterior rib crosses the dome of posterior rib crosses the dome of the diaphragm. Normal for PA the diaphragm. Normal for PA film - 9film - 9thth or 10 or 10thth posterior rib. posterior rib.

This point is at the 8This point is at the 8thth or 9 or 9thth ribs ribs in older patientsin older patients

Page 17: CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital.

Free gas Free gas under the under the diaphragm diaphragm indicates indicates

bowel bowel perforation. perforation.

Note that Note that this sign is this sign is only likely only likely to be seen to be seen if an erect if an erect

film is film is takentaken

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PericardiPericardial al

effusioneffusion

Page 19: CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital.

The right lung has 3 lobes: Right The right lung has 3 lobes: Right upper lobe, middle and lower upper lobe, middle and lower lobe. lobe.

The left lung has 2 lobes: Left The left lung has 2 lobes: Left upper lobe (the lingula upper lobe (the lingula anatomically corresponds to the anatomically corresponds to the middle lobe on the right) and middle lobe on the right) and lower lobelower lobe

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Page 21: CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital.

Pulmonary infiltratesPulmonary infiltrates

Atelectasis/collapse    Atelectasis/collapse    Loss of lung volume Loss of lung volume Anatomy shifts towards atelectasisAnatomy shifts towards atelectasis Linear, smooth, wedge-shapedLinear, smooth, wedge-shaped Apex of opacity starts at hilumApex of opacity starts at hilum   Consolidation Consolidation  Normal lung volume Normal lung volume No anatomical shift No anatomical shift ConsolidationConsolidation   Air bronchograms can occur in both. Air bronchograms can occur in both.

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Page 23: CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital.

PneumoniaPneumonia

Severe pneumonia is classically Severe pneumonia is classically manifested by airspace disease and manifested by airspace disease and consolidation (alveoli and consolidation (alveoli and bronchioles that are completely filledbronchioles that are completely filled

Air bronchograms may occur (air in Air bronchograms may occur (air in larger bronchi, outlined by larger bronchi, outlined by consolidated surrounding consolidated surrounding parenchyma) parenchyma)

Other radiographic features include: Other radiographic features include: interstitial infiltrates that may be the interstitial infiltrates that may be the

only manifestation or may coexist with only manifestation or may coexist with consolidative changes. consolidative changes.

± associated parapneumonic effusion ± associated parapneumonic effusion

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Air BronchogramAir Bronchogram

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PneumoniaPneumonia

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Pulmonary edemaPulmonary edema

A A hallmark hallmark of of pulmonarpulmonary edema y edema is it’s is it’s ability to ability to clear clear rapidly – rapidly – within within hourshours

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Page 28: CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital.
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PneumothoraPneumothoraxx

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HemothorHemothoraxax

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ContusionContusion

Page 33: CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital.

Aortic DissectionAortic Dissection

Page 34: CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital.

Pulmonary Embolism Pulmonary Embolism

CXR Findings:CXR Findings: NormalNormal AtelectasisAtelectasis Increased size pulmonary artery, azygos, SVCIncreased size pulmonary artery, azygos, SVC Elevated hemidiaphragmElevated hemidiaphragm Edema away from site of PEEdema away from site of PE Westermark's sign Westermark's sign

Oligemia of lung beyond occluded vesselOligemia of lung beyond occluded vessel May be localized, unilateral, or widespreadMay be localized, unilateral, or widespread Usually associated with increased size of pulmonary Usually associated with increased size of pulmonary

artery (Fleischner's sign)artery (Fleischner's sign) Hampton's Hump Hampton's Hump

Associated with PE with infarctionAssociated with PE with infarction Triangular or rounded density at periphery or pleural Triangular or rounded density at periphery or pleural

basedbased Best seen 12-24 hours after eventBest seen 12-24 hours after event

Page 35: CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital.
Page 36: CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital.

What`s wrong with this x ray?