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:
It May Prove Quite Right (but) Stop And Be Certain How Lungs Appear

4. I = Identification (name, age, sex, indication for X-ray)
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)

5. Q = Quality - is the film penetrated properly
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
(but)

6. S = Soft tissue - look for subcutaneous emphysema (suggestive of trauma), soft tissue swelling
A = Abdomen - look for free abdominal air (suggests penetrating trauma, peritonitis, or recent surgery)
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

8. H = Hila (of the lungs) - can be affected in lung disease, malignant processes and infection (hilar lymphadenopathy).
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)

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

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

11. 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

13. Normal Anatomy and Variants

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.

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

17. Free gas under the diaphragm indicates bowel perforation
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 left lung has 2 lobes: Left upper lobe (the lingula anatomically corresponds to the middle lobe on the right) and lower lobe

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

23. Pneumonia
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)
Other radiographic features include:
interstitial infiltrates that may be the only manifestation or may coexist with consolidative changes.
± 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

29. Pneumothorax

31. Hemothorax

32. Contusion

33. Aortic Dissection

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

36. What`s wrong with this x ray?