Chest X-ray Interpretation for Critical Care Transports

Focusing on what matters…

Robert Donovan MD FACEPMedical Director PHI California

Chief of Staff Doctors Medical Center

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

How Are X-rays Made?

Metal : DenseNothing goes

through

Soft Tissues: L

east Dense

Grey color

Air: Not d

ense at

all

all x-ra

ys pass

through

Bone: Somewhat densewhiter than tissue,

darker than handcuffs

X-Ray Findings you

can’t afford to miss!!

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

Checklist A B C D SCheck 4 R’s

For all X-Rays, check the 4 R’s….

• Right Person?

• Right/Left?

• Rotated?

• Radiation?

25 yo Male with complaint of pleuritic chest pain on the right side.

If this is a 25 yo Male, then what are these?

Rightside

ChecklistAirway - Aorta

Breathing - BonesCirculation - Cardiac

Diaphragm - DeformitySoft tissues - Shoulder

Check 4 R’s

ChecklistAirway - Aorta

Check 4 R’s

A

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

A

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

ChecklistAirway - Aorta

Breathing - Bones

Check 4 R’s

B

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

What we are looking for with..

• Bones (Focus on Ribs)– Fractures• Points towards degree of injury/mechanism• Gives us clues of possible underlying injuries

ChecklistAirway - Aorta

Breathing - BonesCirculation - Cardiac

Check 4 R’s

C

What we are looking for with..

• Cardiac– “Big” or “Not Big”– Well defined Margins– Subtle bumps (RV enlargement)

ChecklistAirway - Aorta

Breathing - BonesCirculation - Cardiac

Diaphragm - Deformity

Check 4 R’s

D

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

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

Style Points

often lost h

ere

ChecklistAirway - Aorta

Breathing - BonesCirculation - Cardiac

Diaphragm - DeformitySoft tissues - Shoulder

Check 4 R’s

S

What we are looking for with..

• Soft Tissues– Air– Foreign Bodies (Including chest tube placement)

What we are looking for with..

• Shoulder– Fracture– Dislocation

Chest X-ray

• Pneumothorax• Effusions• Pneumonia

Spontaneous Pneumothorax

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!

Air

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

FINAL EXAM

ChecklistAirway - Aorta

Breathing - BonesCirculation - Cardiac

Diaphragm - DeformitySoft tissues - Shoulder

Check 4 R’s

65 yo male, c/o SOB