1. Emergency Medicine Radiology Tips
Andrew Coggins

2. Learning Objectives Fracture Description Find your Lines
Calling a registrar
Find your Lines
Tubes, NGT and ETT
Introduction to C spine XR
Chest X-rays in Detail
The most common x-ray you see
“Pictures from LITFL.com, Radiopaedia.com and FOAMed”
Disclaimer – opinions my own, use your brain

3. What will be expected of you…
That you
Can read a CXR
Can find a line on a film
Can describe a fracture over the phone
Your Internship goals:
You learn lots about XR film interpretation
You are enthusiastic
You are systematic
What you won’t be expected to do without help:
C spine Imaging
That you can read a CT…

4. Description & Calling for Help

5. Can you confidently describe a Fracture?

6. Orthopaedic Phone Call
‘ISBAR’
Patient Stable or Unstable
Closed v Open
Type (e.g. Simple, Comminuted, Transverse etc.)
Of the…
Location
The fragments are… (displaced, angulated, rotated)…
Neurological and / or Vascular signs

7. A Fracture Example ISBAR Haemodynamics Closed v Open Type Location
The fragments are…
Neurological Status
Vascular Status

8. 10 year old fell off Skateboard Write Down your description…
Monteggia Fracture

9. Surgical/Medical Staff Radiographer Radiologist Books Apps
Where can you get help?
ED Staff
Surgical/Medical Staff
Radiographer
Radiologist
Books
Apps

10. Summary

11. Find your Line!

12. Central Lines Endotracheal Tubes Other Devices ‘Apparatus’ on the CXR
Position Varies but Ideally Should be in the Proximal SVC
Endotracheal Tubes
Should be around 4cm above the Carina
Other Devices
NGT, Chest Tubes

14. PICC Line - check position

16. Nasogastric Tube Look for the “tip” Ideally below LOS (10cm)

17. Nasogastric Tubes

20. ‘ETT’ Just Below the Clavicles Or Measured 4cm above the Carina
Intubated Patients
‘ETT’ Just Below the Clavicles Or
Measured 4cm above the Carina

23. Chest Tube X-ray

29. Summary

31. A Note On AXRs (In general don’t do them…
Obstruction main indication

33. The C Spine XR

34. Scenario – A Major Car Crash
Context
Scenario – A Major Car Crash
How common are C-spine Injuries?
What are the signs that an Injury to the neck is likely?
What are the Pros and Cons of immobilising the Cervical Spine with a collar +/- Spine Board?

35. Assessment - NEXUS Study
Neurological Deficit
Spinal Tenderness (Midline)
Altered Mental Status/Level of Consciousness
Intoxication
Distracting Injury**
>34000 patients studied - 8 of 818 patients who had cervical-spine injury were not detected
Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med Oct;32(4):461-9.

36. What is a Distracting Injury?

37. The Canadian C-spine Rule
Stiell IG et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med Dec 25;349(26):

38. Cervical Spine Imaging
Need to see top of T1
for an adequate film

39. Lateral C spine Look for 4 Lines

41. Anterior Verterbral Line
Posterior Verterbral Line
(Spino)laminar Line
Spinous Process Line

44. The Most Common Test you do: The Chest X ray

46. Do you have a Systematic Approach? Should you use a Checklist?

48. Suggested Approach = DRABCDE
Demographics (Name, Time Taken)
‘Rotation’
(Quality = Rotation/Adequacy/Penetration)
Apparatus
Airway (Trachea)
Breathing
Mediastinum (>7cm)
Hilum (Left Should be Higher than Right)
Lungs (Lung Fields, Fissures)
Angles (Costoprenic, Cardioprenic)

49. CXR Routine - DRABCDE Circulation Diaphragm Everything Else
Step Back – Consider ‘Overall Appearance’
Your ‘gestalt’ comes in here
Everything Else
Bones
Soft Tissues
Subtle Findings (especially Pneunothorax)

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

51. AP v PA

52. Film Quality: Rotation and Penetration
Angulation / Rotation of the Film
Penetration of the film
Angulation / Rotation
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

53. Adequacy of Inspiration
Films are generally taken on inspiration
Why is this important?
How can you tell it is adequate?
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

54. Lateral Films How useful are they? When would you use one?
What would you look for?
May be useful in Right Sided Lesion
Hemidiaphram is Seen Well
Stomach Bubble aids with orientation
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)

55. Boring (but important) Terminology
Lung Zones
Silhouettes
Density
Opacity (white)
Lucency (black)
Zones – not west zones refers to Radiographic zones - (Upper (top 2 ribs) Middle (3rd and 4th Ribs) and Lower (Below 4th Rib))
Silhouette – border of two densities, significant findings may be suggested by obliteration of a distinct border - ‘silhouette sign’

57. Density
5 Densities
Air
Fat
Soft Tissue
Bone
Metal

58. You decide the film quality is ok What now?

59. Apparatus and Airway First Steps Describe any ‘Lines’
Look at this Position of the Trachea

62. Breathing Look at the Mediastinum Enlargement Projection Masses (?)
Aortic Dissection
Unfolded Aorta
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)

63. Pneumomediastinum on the CXR
Look for a Pneumomediastinum
Why is this important?
Lucency Surrounding Heart
Tubular Artery Sign
Continuous Diaphragm Sign
Subcutaneous Emphysema

66. Breathing
Next look at:
Hilum
Lungs

67. Made up of Pulmonary Vessels and Bronchial Lymph Nodes
The Hilum
Hilum
Made up of Pulmonary Vessels and Bronchial Lymph Nodes
Position
Shape
Density
99% of the normal Hilar Shadow is Pulmonary Vessels 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 Symmetrical

69. Breathing Describe the Lung Zones Tips: Any White Stuff
= Opacity/Opacification/Shadowing
Specifically describe the ‘white’ stuff as”
Consolidation, Reticular or Nodular
Look for a Pneumothorax
Lung Zones
Describe as Lower, Middle or Upper Zone
White = Opacity/Opacification/Shadowing
Shadowing
Consolidation, Reticular or Nodular
Distinct Masses are often described as ‘Coin Shaped’ Lesions
Look Very Carefully for Pneumothorax (see next slide)

71. Circulation Heart Contours and Borders Heart Position (may shift)
Pericardial “Fat pads” can be normal
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

72. 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

73. Left Ventricular Failure
Cardiac Failure
Left Ventricular Failure
(Congestive Heart Failure)
Increased Heart Size (Cardiomegaly)
Calibre Changes – Upper Lobe Vessel Enlargement
Parenchymal Change – Reticular Linear Changes and Interstitial Changes. Airspace Opacification
Pleural Effusions (Right>Left)

75. Dissection Wide Mediastinum (>8cm)
Changes in the Smoothness of the Aortic Knuckle
Left Pleural Effusion, Pericardial Effusion
Normal CXR
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

77. Unfolded Aorta
An Unfolded Aorta may be Misinterpreted as a dissection – it tends to have a very smooth contour
This is common in elderly patients
While not ‘normal’ is a relatively benign finding

79. Other Stuff Don’t forget D and E Diaphragm
Everything else – bones, soft tissues

80. Summary

81. Quiz

82. 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.

83. - Describe and interpret his CXR
- Outline your treatment options

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

85. 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

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

88. 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.
What does the X ray show (Use DRABCDE approach)

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

91. 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:

92. Describe and interpret his Chest X-ray
Outline your management.

93. 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)

94. 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.
Her observations are:

95. Describe the CXR findings
Outline your Differential Diagnosis

96. Answer(s) X-ray showed Large left pleural effusion
Multiple discrete lung parenchymal lesions typical of metastatic lung disease
Porta-cath
OTHER:
?Mastectomy ?O2 Mask

97. 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)

98. 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

99. Case 6
A distressed 60 year old man from a nursing home is brought into the ED having ‘choked on his dentures’
His CXR is shown
- Describe the CXR findings
- What further investigations may be indicated in this man?

101. Answers A CXR showing dentures overlying the mediastinum
Probable air in the neck soft tissues.
Possible oesophageal perforation due to a foreign body.

102. Case 7
An 18 year old woman with a history of asthma since childhood presents with a one month history of weight loss, cough and malaise
She has been treated with two courses of antibiotics by her local GP. She now presents with increasing shortness of breath.
- Describe the X-ray
- List your differential diagnosis

104. Answers Patchy Opacification ?Fluid in Pleural Space
Broad Differential Diagnosis
?Pneumonia

105. Case 8
A 35 year old homeless man presents with two months of increasing cough. He has no other medical past history.

106. - Describe his Chest X-ray
What are the possible causes of this appearance?

107. Lung Cavity Infective cause including TB, Fungi, Aspiration Malignancy
Chest X-ray showing large cavitating lesion in right hemithorax with soft tissue density in lowerzone laterally.
Causes:
Infective cause including TB, Fungi, Aspiration
Malignancy
Abscess and other bacterial infection Staph/Kleb
Wegner’s and Massive Fibrosis PE

108. Case 9
A 4 year old boy presents to the emergency department following a choking episode at home 30 minutes previously.

109. - Describe and interpret his X-ray
- What factors would determine further management?

110. Answer CXR showing round radio-opaque midline foreign body.
Round metallic FB in lower oesophagus
Most likely coin but need to consider button battery
NB: The classic teaching is that on an AP/PA radiograph coins in the esophagus are oriented in the coronal plane whereas coins in the trachea are oriented sagittally

111. Button Battery Ingestion
Almost Exclusivly in the paediatric Population
Majority (<15mm) pass throught the GIT uneventfully
Larger Batteries (>20mm) may Lodge in the Oesophagus
This leads to Significant Complications
This is due to direct pressure and release of alkali
Mercury may also be ‘released’ from the battery

112. Button Batteries
A button battery in the Oesophagus requires removal ideally within 6 hours
This also allows examination of the mucosa
If beyond the oesophagus it may pass naturally
ENT batteries should be removed urgently
Confusion may arise between coins and batteries – the battery has a stepped appearance
Follow up with repeat X-rays at 48 hours

113. Case 10
You are called by the nurse on the ward to check position of NG tube
Where is the NGT?
Where should it be?

115. Thanks………….