Chest in emergency medicine

Basic CHEST X ray interpretation By Subin solomen MPT(manipal) Professor Subin Solomen MPT Manipal

CHEST RADIOGRAPH  

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Most common modality of imaging Simple and inexpensive If properly interpreted - can provide valuable clues. - can avoid further unnecessary investigations.

Subin Solomen MPT Manipal

STANDARD VIEWS 

POSTEROANTERIOR VIEW ( PA)

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ANTEROPOSTERIOR VIEW ( AP )

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LATERAL VIEW


Patient Identification Name, Age, Sex  Date of examination  Clinical information 

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SIDE MARKER


TECHNICAL ASPECTS PA / AP view  CENTERING  PENETRATION  DEGREE OF INSPIRATION 


POSTEROANTERIOR (PA) VIEW The standard frontal view of the chest  Refers to direction of x-ray beam  Positioning of the patient  Taken at a distance of SIX FEET  In deep inspiration at suspension  Breasts to be compressed against film 


PA VIEW Subin Solomen MPT Manipal

PA VIEW


ANTEROPOSTERIOR (AP) VIEW Patient in supine position  Used in very sick patients,infants,one who is unable to sit or stand  Direction of x-ray beam  At a distance of 100 cm {4 feet}  Greater magnification  Less sharpness of images 


AP VIEW


AP VIEW


PA vs AP VIEW PA 1.

2.

3. 4.

5.

AP

Scapulae not 1. overlapping lung fields Clavicle is oblique 2. Heart border clear 3. Cardiac magnification 4. not seen Fundic air bubble seen 5.

Scapulae overlapping lung fields Clavicle is horizontal Heart border not clear Cardiac magnification

Fundic air bubble not seen


1) Scapular border

PA

VS


AP

3) Heart border

PA

VS


AP

4) Heart size

PA

VS


AP

5) Fundic shadow

PA

VS


AP

6) Companion shadow

PA

VS


AP

7) Counting of ribs

Rt PA 6th

VS


AP 5th

8) Inverted V shadows In PA View


PA vs AP VIEW PA

AP

9)Tear drop not present 9) Tear drop sign 10) Overriding of clavicle  Absent or prominent and first rib 11)Vertbral bodies square shaped


CENTERING


CENTERING



PENETRATION


NORMAL

UNDER PENETRATED Subin Solomen MPT Manipal

OVERPENETRATED

NORMAL


EXPIRATORY

INSPIRATORY Subin Solomen MPT Manipal

VIEWING PA VIEW   

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Soft tissues Bony cage Lung fields Heart and mediastinum Hilum Trachea Diaphragm Costophrenic angles Cardiophrenic angles Infradiaphragmatic areas




THE LUNG FIELDS 

DIVIDED into 3 Zones: UPPER MID LOWER

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COMPARE both the lung fields

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DISTRIBUTION of lung markings Subin Solomen MPT Manipal

TYPES OF DENSITIES GAS – BLACK  WATER (soft tissue & fat)- GREY  MINERAL(CALCIFIC)- WHITE 



PA VIEW

HEART AND MEDIASTINUM

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RIGHT MEDIASTINAL BORDER

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LEFT MEDIASTINAL BORDER

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AORTIC KNUCKLE

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SIZE OF HEART: CARDIOTHORACIC RATIO Subin Solomen MPT Manipal


CR

CL

T

CT RATIO = CR + CL / T

CR + CL = TRANSVERSE CARDIAC DIAMETER Subin Solomen MPT Manipal T = TRANSVERSE THORACIC DIAMETER

HILUM Components of Hilar shadows  Left hilum higher than the right in 97% of subjects  At the same level in 3% of subjects  Should be of equal density and similar size on either sides 


LEFT HILUM

RIGHT HILUM


Subin Solomen MPT Manipal TRACHEA

DIAPHRAGM 

LOCATION

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RELATIVE LEVELS of the right and left hemidiaphragms

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SHAPE


Diaphragm tenting Collapse Hepatomegaly Sub dia abscess

Diaphragm flattened COPD

A

Diaphragm tenting


DIAPHRAGM

COSTOPHRENIC ANGLES

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Look for VISIBILITY and SHARPNESS

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BLUNT angles


Cardio phrenic angles

LV hypertrophy

PA view – there is an increase in the diameter of the heart, and elongation and increased convexity of the left heart border. The apex extends downwards and out into the diaphragm. Subin Solomen MPT Manipal

Cardio phrenic angles

RV Hypertrophy

PA view – enlargement of the RV produces elevation of the apex; if there is gross dilatation there is forward bulging of the RV outflow tract with increased convexity. Subin Solomen MPT Manipal

THE HIDDEN AREAS 

THE APICES

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RETROCARDIAC AREA

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RETRODIAPHRAGMATIC AREAS

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PARTS OBSCURED BY BONES



VIEWING THE LATERAL FILM THE CLEAR SPACES  VERTEBRAL TRANSLUCENCY  DIAPHRAGM OUTLINE  THE FISSURES  THE TRACHEA  THE STERNUM 



PULMONARY VASCULAR PATTERNS

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GOOD ERECT PA CHEST FILM.

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SIZE AND DISTRIBUTION of vessels is of major importance.


BRONCHOVASCULAR MARKINGS


NORMAL VASCULAR PATTERNS


PULMONARY ARTERIAL HTN HALLMARK: 

Enlargement of main and central pulmonary arteries.

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Pruning of peripheral pulmonary arteries

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Normal sized heart/right heart enlargement.



SUPPORT DEVICES 

Endotracheal tube / Tracheostomy tube

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Nasogastric tube

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Central venous catheter

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Pulmonary artery catheter

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Cardiac pacemaker

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Pleural drainage tubes Subin Solomen MPT Manipal

ENDOTRACHEAL TUBE


MISPLACED ETT Subin Solomen MPT Manipal


RYLE’S TUBE


RYLES TUBE


Naso-gastric Tube in Right Main Bronchus. Subin Solomen MPT Manipal

CVP


SWAN GANZ CATHETER Subin Solomen MPT Manipal

PACEMAKER

PACEMAKER TIP IN APEX OF RV. Subin Solomen MPT Manipal

ICD TUBE


Collapse ( Atelectasis) 

Lobar signs  

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Shift of fissures Crowding of vessels and airways Increased opacity -Silhouette sign

Extralobar signs  

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Elevation of hemidiaphragm Mediastinal shift Hilar shift and distortion Compensatory hyperinflation Ribs are close together Tracheal shift Subin Solomen MPT Manipal

Silhouttes sign

RML

Lingula

Rt border

Lt heart

Asc aorta


Apico posterior LUL Aortic knuckle


Anterior segment RUL


Atelectasis Following ET Intubation


Atelectasis – LLL- PA


Atelectasis – LLL- Lat.


Atelectasis – RML- PA



Aspiration Pneumonitis 

Radiographic appearance appears within few hrs of aspiration , progresses for 24-48 hrs and regresses by 72 hrs .Complete clearing is within a week or two.

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May be patchy or diffuse , usually bilateral, mainly right sided, most often lung bases or superior segment of lower lobe.


Pulmonary edemaperihilar.


Kerley B lines




Pulmonary embolism

WESTERMARK’S SIGN Subin Solomen MPT Manipal

ARDS


PNEUMOTHORAX Chest Radiograph:  Supine signs  Hyperlucency Of Hemithorax  Deep sulcus sign 


DEEP SULCUS SIGN


PNEUMOTHORAX



Tension Pneumo thorax

Lt

Rt


HYDROPNEUMOTHORAX


Lung abscess


COPD

Solomen MPT Manipal HypeSubin inflated

Giant Bullae


Large Bullae


PNEUMOMEDIASTINUM Causes  Bronchial perforation  Esophageal perforation  Pharyngeal perforation MACKLIN EFFECT.  Chest radiograph : lucent streaks outlining mediastinal structures, elevate the pleura and extends in to the neck or chest wall.  Continuous diaphragm sign Subin Solomen MPT Manipal

Subcutaneous emphysema Subin Solomen MPT Manipal

PLEURAL EFFUSION Erect radiograph • Blunting of costophrenic angles • Homogenous increase in density over the lower lung fields


PLEURAL EFFUSION



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Detection of small pneumothorax is important as it may increase in size as patient receives positive pressure ventilation.

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TENSION PNEUMOTHORAX: CHEST RADIOGRAPH:  Absent lung markings  Mediastinal displacement  Eversion of diaphragm Subin Solomen MPT Manipal

PSEUDOANEURYSM Subin Solomen MPT Manipal

PNEUMOPERICARDIUM Subin Solomen MPT Manipal

Upper Airway Obstruction Foreing Body Aspiration


MV Replacement


Dextrocardia- situs inverses


Bronchogenic carcinoma


THANK YOU
