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Emergency Medicine

Emergency Medicine. Radiology Chest X-rays: Introduction Andrew Coggins. Routine for CXR Interpretation 1. Demographics (Name, Time Taken) Film Quality ( A dequacy/Rotation/Penetration) A pparatus A irway (Trachea) B reathing Mediastinum (>7cm) Hilum (Left Should be Higher than Right)

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Emergency Medicine

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  1. Emergency Medicine Radiology Chest X-rays: Introduction Andrew Coggins

  2. Routine for CXR Interpretation 1 • Demographics (Name, Time Taken) • Film Quality (Adequacy/Rotation/Penetration) • Apparatus • Airway (Trachea) • Breathing Mediastinum (>7cm) Hilum (Left Should be Higher than Right) Lungs (Lung Fields, Fissures) Angles (Costoprenic, Cardioprenic)

  3. Routine for CXR Interpretation 2 • Circulation Cardiomegaly • Diaphram • Extra Things Bones Soft Tissues Subtle Findings (especially Pneunothorax) Step Back – Overall Appearance

  4. Film Quality: Adequacy • Film Quality is important • A rotated film can be confusing and make one lung look darker • Penetration is evaluated by looking at the vertebral bodies (are they easily seen) and looking at the ‘blackness’ of the film • PA v AP (see next slide) • This should be considered in terms of the size of the heart and mediastinum

  5. AP v PA

  6. Film Quality: Rotation and Penetration • Angulation / Rotatation • Clavicles should project over posterior 3rd Rib • The spinous processes should lie half way between the medial ends of the clavicles • Penetration (less relevant with Digital Imaging) • Under Penetration (too white): loss of lung base detail, increase hilar markings • Over Penetration (too black): reduced subtle findings

  7. Adequacy of Patient Inspiration • Films are generally taken on inspiration • Occasionally inspiratory and expiratory films are taken (pneumothorax) • In the Right hemithorax at least 6 anterior ribs should be seen • Incomplete inspiration can lead to exaggeration of lung markings and heart size • Lung hyperexpansion is a sign of obstructive lung disease

  8. Lateral Films • Useful in Right Sided Lesion • Hemidiaphram is Seen Well • Stomach Bubble aids with orientation • NB – Labelled side is closest to cassette • The left oblique fissure is more vertically orientated • The lateral ‘Decubitus’ film is occasionally used for evaluation of pleural effusions and pneumothorax (use of gravity)

  9. Terminology • Lung Zones (Upper (2 ribs) Middle (3rd and 4th Ribs) and Lower (Below 4th Rib)) • Silhouettes – border of two densities, significant findings may be suggested by obliteration of a distinct border - ‘silhouette sign’ • Opacity (white) versus Lucency (black) • Radiological Densities

  10. Apparatus • Central Lines • Position Varies but Ideally Should be in the Proximal SVC • Endotracheal Tubes • Should be around 4cm above the Carina • Other Devices

  11. Airway • Look at this Position of the Trachea

  12. Airway • Look at the Mediastinum • Enlargement may be due to projection (AP), a vascular problem (Aortic Dissection) or Mass in the Mediastium (Thymoma, Metastatic Cancer) • Aortic Dissection is a consideration if the patient has typical chest pain and the mediastinum is widened (see later)

  13. Mediastinum • Mediatinal Masses (Lateral helpful) • Increased Density • Change in Mediastinal Contour • Stripe Abnormal

  14. Pneumomediastinum on the CXR • Pneumomediastinum • Lucency Surrounding Heart • Tubular Artery Sign • Continuous Diaphragm Sign • Subcutaneous Emphysema

  15. ‘Tubular artery sign’ in a 28-year-old man who sustained blunt trauma.

  16. Breathing • Lungs on the CXR • Start with Hilum

  17. The Hilum • Hilum • 99% of the normal Hilar Shadow is Pulmonary Vessesl and Bronchial Lymph Nodes • Position – Left is 2cm above the Right (Left NEVER below Right) • Shape – smooth margins, V-shaped, symmetry • Normally see ‘convergence’ and ‘overly’ • Density – Typically Symetrical

  18. Breathing • Lung Zones • Describe abnormalites as Lower, Middle or Upper Zone • White = Opacity/Opacification/Shadowing • Describe Shadowing as Consolidation, Reticular or Nodular • Distinict Masses are often described as ‘Coin Shaped’ Lesions • Look Very Carefully for Pneumothorax (see next slide)

  19. Circulation • Cardiomediastinal Contours • Right heart border – SVC, Right Atrium, IVC • Left Heart Border • Aortic arch, Pulmonary artery, Left auricle, Left ventricle • 1/3 of heart should be R of Midline, 2/3 to L • Pericardial Fat pads are normal: Triangular, always at the cardiophrenic angle, progressively less dense

  20. Heart Chambers and Pericardium • Left Atrium • Increased Subcarinal Angle, Double shadow Sign • LV Enlargement • Prominent Left heart Border • LV Aneurysm • Localised Bulge, Calcification • RV Enlargement • Filling of Retrosternal Space • Pericardial Effusions • Globular Outline of Heart, Rapid Onset

  21. Cardiac Failure • LV Failure • Increased Heart Size (Cardiomegaly) • Calibre Changes – Upper Lobe Vessel Enlargement • Parenchymal Change – Reticular Linear Changes and Interstitial Changes. Airspeace Opacification • Pleural Effusions (Rigth>Left) • .

  22. Aortic Dissection • Classified into Stanford and De Bakey Classification Systems • Stanford A is proximal and Stanford B is distal to the Subclavian Artery • CXR SIGNS: • Wide Mediastinum (>8cm) • Changes in the Smoothness of the Aortic Knuckle • Left Pleural Effusion, Pericardial Effusion • Internal Change • Normal CXR

  23. Unfolded Aorta • An Unfolded Aorta may be Misinterpretted as a dissection – it tends to have a very smooth contour • This is common in elderly patients

  24. Case 1 • A previously well 23 year old man is brought to your Emergency Department acutely short of breath after developing left sided chest pain at work. • On arrival, he appeared pale and sweaty and was hypotensive. • A CXR was taken immediately after a procedure was performed to stabilise his condition. His vital signs are now normal. - Describe and interpret his CXR - Outline your treatment options

  25. Answer • Chest X-ray showing a pneumothorax • Needle thoracostomy catheter in situ • No evidence of radiological tension

  26. Case 2 • A 57 year old female car driver presents following a head on collision with a bus at 60Kph. • Her observations are listed: HR98, BP130/90mmHg, Resp 24, SpO2 98% - Describe and interpret her X-ray - Outline your management options

  27. Answer(s) • Widened Mediastinum • Clavicle Fracture • Rib Fractures • ?Right Haemopneumothorax

  28. Case 3 • An 80 year old male pedestrian is brought to your emergency department 30 minutes after being struck by a motorcycle at high speed.

  29. Answer(s) • Chest X-ray of trauma patient showing multiple rib fractures and underlying area of pulmonary contusion or haemothorax

  30. Case 4 • A 20 year old man presents to your emergency department with central chest pain that commenced after recreational drug use at a party two hours earlier. • His observations are:

  31. Questions • Describe and interpret his Chest X-ray • Outline your management.

  32. Answer(s) • Mediastinal emphysema, Subcutaneous emphysema. • Pneumothorax may be due to attempted subclavian or jugular vein puncture in IV drug users, rupture of drug-related bullae or rarely rupture of peripheral pulmonary abscesses • The large airway pressure changes involved in inhalational manoeuvres employed in crack or cannabis use may also lead to rupture of distal airways. Air may then track into the pleural space or mediastinum, manifesting as pneumothorax or pneumomediastinum (Roszler MH et al)

  33. Case 5 • A 52 year old woman presents to your emergency department with gradually increasing breathlessness over the preceding three days. It is one week since her last chemotherapy treatment for cancer. • His observations are:

  34. Questions • Describe the CXR findings • Outline your Differential Diagnosis

  35. Answer(s) • X-ray showed • Large left pleural effusion • Multiple discrete lung parenchymal lesions typical of metastatic lung disease • Portocath • ?Mastectomy ?O2 Mask

  36. Pleural Effusions • According to Light's criteria a pleural effusion is exudative if at least one of the following exists: • The ratio of pleural fluid protein to serum protein is greater than 0.5 • The ratio of pleural fluid LDH and serum LDH is greater than 0.6 • Pleural fluid LDH is greater than 0.6 times the normal upper limit for serum. (i.e 0.6 of 200)

  37. Pleural Effusions - Causes • Transudates • Congestive Heart Fauklrue, lvier Fauirleu, Renal Faiulre, Nephrotic syndrome, Hypoalbuminaemia, Enteropathy, Dialysis • Exudates • Lung Ca, TB, Infections (Bacterial), RA, Pancreatitis, Subphrenic Abscess, Meig’s Syndrome, Dressler’s Syndrome, SLE, Lymphoma, Hypothyroid, PE, Mesothelioma, Yellow Nail Syndrome, Vasculitis

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