1. Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff Doctors Medical Center

4. We went from surface anatomy to being able to look under the skin

6. How Are X-rays Made?

9. Metal : Dense Nothing goes through Soft Tissues: Least Dense Grey color Air: Not dense at all all x-rays pass through Bone: Somewhat dense whiter than tissue, darker than handcuffs

10. X-Ray Findings you can’t afford to miss!!

11. 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

12. A B C D S

13. For all X-Rays, check the 4 R’s…. R ight Person? R ight/Left? R otated? R adiation?

14. 25 yo Male with complaint of pleuritic chest pain on the right side. If this is a 25 yo Male, then what are these?

22. Airway - Aorta Breathing - Bones Circulation - Cardiac Diaphragm - Deformity Soft tissues - Shoulder

23. Airway - Aorta A

24. 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

25. 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

29. Airway - Aorta Breathing - Bones B

30. 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

32. What we are looking for with.. Bones (Focus on Ribs) – Fractures Points towards degree of injury/mechanism Gives us clues of possible underlying injuries

34. Airway - Aorta Breathing - Bones Circulation - Cardiac C

35. What we are looking for with.. Cardiac – “Big” or “Not Big” – Well defined Margins – Subtle bumps (RV enlargement)

39. Airway - Aorta Breathing - Bones Circulation - Cardiac Diaphragm - Deformity D

40. 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

41. 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

44. Airway - Aorta Breathing - Bones Circulation - Cardiac Diaphragm - Deformity Soft tissues - Shoulder S

45. What we are looking for with.. Soft Tissues – Air – Foreign Bodies (Including chest tube placement)

49. What we are looking for with.. Shoulder – Fracture – Dislocation

55. Chest X-ray Pneumothorax Effusions Pneumonia

57. Spontaneous Pneumothorax

62. 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!

63. 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

68. FINAL EXAM

69. Airway - Aorta Breathing - Bones Circulation - Cardiac Diaphragm - Deformity Soft tissues - Shoulder

70. 65 yo male, c/o SOB