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

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Presentation on theme: "CXR in Emergency Department By : O. Ahmadi, MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital."— Presentation transcript:

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

2 Normal CXR

3 Features that are typically examined on a chest X-ray Every doctor will have a different approach to examining chest X-rays. A commonly used mnemonic for what to look for on a chest X-ray is: Every doctor will have a different approach to examining chest X-rays. A commonly used mnemonic for what to look for on a chest X-ray is: It May Prove Quite Right (but) Stop And Be Certain How Lungs Appear It May Prove Quite Right (but) Stop And Be Certain How Lungs Appear

4 I = Identification (name, age, sex, indication for X-ray) I = Identification (name, age, sex, indication for X-ray) M = Markers (differentiate left from right ) M = Markers (differentiate left from right ) P = Position - the spinous process of T4 should be between the heads of the clavicle (if it isn't the body is rotated) P = Position - the spinous process of T4 should be between the heads of the clavicle (if it isn't the body is rotated)spinous processclaviclespinous processclavicle

5 Q = Quality - is the film penetrated properly. In a properly penetrated film the vertebral interspaces should be visible behind the central (cardiac) shadow Q = Quality - is the film penetrated properly. In a properly penetrated film the vertebral interspaces should be visible behind the central (cardiac) shadow R = Respiration - chest X-rays are typically done with full inspiration R = Respiration - chest X-rays are typically done with full inspiration(but)

6 S = Soft tissue - look for subcutaneous emphysema (suggestive of trauma), soft tissue swelling S = Soft tissue - look for subcutaneous emphysema (suggestive of trauma), soft tissue swellingsubcutaneous emphysemasubcutaneous emphysema A = Abdomen - look for free abdominal air (suggests penetrating trauma, peritonitis, or recent surgery) A = Abdomen - look for free abdominal air (suggests penetrating trauma, peritonitis, or recent surgery)free abdominal airfree abdominal air B = Bone - look for fractures (these tend to be at the lateral aspects because of the mechanics B = Bone - look for fractures (these tend to be at the lateral aspects because of the mechanics

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

8 H = Hila (of the lungs) - can be affected in lung disease, malignant processes and infection (hilar lymphadenopathy). H = Hila (of the lungs) - can be affected in lung disease, malignant processes and infection (hilar lymphadenopathy).Hilahilar lymphadenopathyHilahilar lymphadenopathy L = Lungs - for consolidation, interstitial lung disease (reticular, nodular or reticulonodular), honeycombing, miliary pattern, granulomas, lung masses L = Lungs - for consolidation, interstitial lung disease (reticular, nodular or reticulonodular), honeycombing, miliary pattern, granulomas, lung masses A = Absent structures/Apices of the lung (for pneumothorax) A = Absent structures/Apices of the lung (for pneumothorax)pneumothorax

9 Technique tips Sometimes the film may have been taken at an angle Sometimes the film may have been taken at an angle The silhouette sign The silhouette sign To identify PA or AP film To identify PA or AP film

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

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

12 Effect of position on the chest x- ray Effect of position on the chest x- ray

13 Normal Anatomy and Variants

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

16 Lung volume can be estimated by observing the point where a posterior rib crosses the dome of the diaphragm. Normal for PA film - 9 th or 10 th posterior rib. Lung volume can be estimated by observing the point where a posterior rib crosses the dome of the diaphragm. Normal for PA film - 9 th or 10 th posterior rib. This point is at the 8 th or 9 th ribs in older patients This point is at the 8 th or 9 th ribs in older patients

17 Free gas under the diaphragm indicates bowel perforation. Note that this sign is only likely to be seen if an erect film is taken

18 Pericardial effusion

19 The right lung has 3 lobes: Right upper lobe, middle and lower lobe. The right lung has 3 lobes: Right upper lobe, middle and lower lobe. The left lung has 2 lobes: Left upper lobe (the lingula anatomically corresponds to the middle lobe on the right) and lower lobe The left lung has 2 lobes: Left upper lobe (the lingula anatomically corresponds to the middle lobe on the right) and lower lobe

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

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23 Pneumonia Severe pneumonia is classically manifested by airspace disease and consolidation (alveoli and bronchioles that are completely filled Severe pneumonia is classically manifested by airspace disease and consolidation (alveoli and bronchioles that are completely filled Air bronchograms may occur (air in larger bronchi, outlined by consolidated surrounding parenchyma) Air bronchograms may occur (air in larger bronchi, outlined by consolidated surrounding parenchyma) Other radiographic features include: Other radiographic features include: interstitial infiltrates that may be the only manifestation or may coexist with consolidative changes. interstitial infiltrates that may be the only manifestation or may coexist with consolidative changes. ± associated parapneumonic effusion ± associated parapneumonic effusion

24 Air Bronchogram

25 Pneumonia

26 Pulmonary edema A hallmark of pulmonary edema is it’s ability to clear rapidly – within hours A hallmark of pulmonary edema is it’s ability to clear rapidly – within hours

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29 Pneumothorax

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31 Hemothorax

32 Contusion

33 Aortic Dissection

34 Pulmonary Embolism CXR Findings: CXR Findings: Normal Normal Atelectasis Atelectasis Increased size pulmonary artery, azygos, SVC Increased size pulmonary artery, azygos, SVC Elevated hemidiaphragm Elevated hemidiaphragm Edema away from site of PE Edema away from site of PE Westermark's sign Westermark's sign Oligemia of lung beyond occluded vessel Oligemia of lung beyond occluded vessel May be localized, unilateral, or widespread May be localized, unilateral, or widespread Usually associated with increased size of pulmonary artery (Fleischner's sign) Usually associated with increased size of pulmonary artery (Fleischner's sign) Hampton's Hump Hampton's Hump Associated with PE with infarction Associated with PE with infarction Triangular or rounded density at periphery or pleural based Triangular or rounded density at periphery or pleural based Best seen hours after event Best seen hours after event

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36 What`s wrong with this x ray?


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