Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan...

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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

Transcript of Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan...

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

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

Page 2: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 3: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 4: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

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

Page 5: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 6: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

How Are X-rays Made?

Page 7: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 8: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 9: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

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

Page 10: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

X-Ray Findings you

can’t afford to miss!!

Page 11: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

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

Page 12: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

Checklist A B C D SCheck 4 R’s

Page 13: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

For all X-Rays, check the 4 R’s….

• Right Person?

• Right/Left?

• Rotated?

• Radiation?

Page 14: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

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

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

Page 15: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

Rightside

Page 16: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 17: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 18: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 19: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 20: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 21: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 22: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

ChecklistAirway - Aorta

Breathing - BonesCirculation - Cardiac

Diaphragm - DeformitySoft tissues - Shoulder

Check 4 R’s

Page 23: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

ChecklistAirway - Aorta

Check 4 R’s

A

Page 24: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

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

Page 25: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

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

Page 26: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 27: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 28: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 29: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

ChecklistAirway - Aorta

Breathing - Bones

Check 4 R’s

B

Page 30: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

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

Page 31: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 32: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

What we are looking for with..

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

Page 33: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 34: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

ChecklistAirway - Aorta

Breathing - BonesCirculation - Cardiac

Check 4 R’s

C

Page 35: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

What we are looking for with..

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

Page 36: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 37: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 38: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 39: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

ChecklistAirway - Aorta

Breathing - BonesCirculation - Cardiac

Diaphragm - Deformity

Check 4 R’s

D

Page 40: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

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

Page 41: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

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

Page 42: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 43: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 44: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

ChecklistAirway - Aorta

Breathing - BonesCirculation - Cardiac

Diaphragm - DeformitySoft tissues - Shoulder

Check 4 R’s

S

Page 45: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

What we are looking for with..

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

Page 46: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 47: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 48: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 49: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

What we are looking for with..

• Shoulder– Fracture– Dislocation

Page 50: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 51: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 52: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 53: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 54: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 55: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

Chest X-ray

• Pneumothorax• Effusions• Pneumonia

Page 56: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 57: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

Spontaneous Pneumothorax

Page 58: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 59: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 60: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 61: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 62: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

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

Page 63: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

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

Page 64: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 65: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 66: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 67: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 68: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

FINAL EXAM

Page 69: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

ChecklistAirway - Aorta

Breathing - BonesCirculation - Cardiac

Diaphragm - DeformitySoft tissues - Shoulder

Check 4 R’s

Page 70: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.

65 yo male, c/o SOB

Page 71: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.
Page 72: Chest X-ray Interpretation for Critical Care Transports Focusing on what matters… Robert Donovan MD FACEP Medical Director PHI California Chief of Staff.