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Chest X-ray Interpretation for Critical Care Transports
Focusing on what matters…
Robert Donovan MD FACEPMedical Director PHI California
Chief of Staff Doctors Medical Center
We went from surface anatomy to being able to look under the skin
How Are X-rays Made?
Metal : DenseNothing goes
through
Soft Tissues: L
east Dense
Grey color
Air: Not d
ense at
all
all x-ra
ys pass
through
Bone: Somewhat densewhiter than tissue,
darker than handcuffs
X-Ray Findings you
can’t afford to miss!!
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
Checklist A B C D SCheck 4 R’s
For all X-Rays, check the 4 R’s….
• Right Person?
• Right/Left?
• Rotated?
• Radiation?
25 yo Male with complaint of pleuritic chest pain on the right side.
If this is a 25 yo Male, then what are these?
Rightside
ChecklistAirway - Aorta
Breathing - BonesCirculation - Cardiac
Diaphragm - DeformitySoft tissues - Shoulder
Check 4 R’s
ChecklistAirway - Aorta
Check 4 R’s
A
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
A
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
ChecklistAirway - Aorta
Breathing - Bones
Check 4 R’s
B
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
What we are looking for with..
• Bones (Focus on Ribs)– Fractures• Points towards degree of injury/mechanism• Gives us clues of possible underlying injuries
ChecklistAirway - Aorta
Breathing - BonesCirculation - Cardiac
Check 4 R’s
C
What we are looking for with..
• Cardiac– “Big” or “Not Big”– Well defined Margins– Subtle bumps (RV enlargement)
ChecklistAirway - Aorta
Breathing - BonesCirculation - Cardiac
Diaphragm - Deformity
Check 4 R’s
D
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
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
Style Points
often lost h
ere
ChecklistAirway - Aorta
Breathing - BonesCirculation - Cardiac
Diaphragm - DeformitySoft tissues - Shoulder
Check 4 R’s
S
What we are looking for with..
• Soft Tissues– Air– Foreign Bodies (Including chest tube placement)
What we are looking for with..
• Shoulder– Fracture– Dislocation
Chest X-ray
• Pneumothorax• Effusions• Pneumonia
Spontaneous Pneumothorax
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!
Air
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
FINAL EXAM
ChecklistAirway - Aorta
Breathing - BonesCirculation - Cardiac
Diaphragm - DeformitySoft tissues - Shoulder
Check 4 R’s
65 yo male, c/o SOB