Must Know Radiology

Must Know Radiology

MUST KNOW CHEST RADIOGRAPH RADIOLOGY Joanna R. Fair, M.D., Ph.D. Vice Chair of Education Department of Radiology Many slides courtesy of UNM Radiology faculty and Petra Lewis, M.D. Associate Professor of Radiology Dartmouth Medical School

Objectives Review normal chest radiograph anatomy Describe findings of common emergent diagnoses on chest radiographs

Identify proper and improper positioning of tubes and lines on chest radiographs Normal Anatomy Chest radiograph scan pattern ABCDE A. Airway

Trachea R/L main bronchi B. B E Bones D.

Cardiac Diaphragm E A Shoulders Spine Ribs C.

A B B and all below E. Everything else = Lungs

B A D C B

Chest radiograph scan pattern ABCDE A. Airway Trachea B. A

Bones Spine Sternum Cardiac D. Diaphragm C. B B

C E and all below E. Everything else = Lungs D

Common ER Diagnoses on Chest Radiographs Where is the abnormality? No abnormality B. Left lung C. Right lung A.

Where is the abnormality? No abnormality B. Left lung C. Right lung A. Lingular pneumonia Silhouette sign Well defined right

lung opacity Surrounded by air Silhouette sign with diaphragm Silhouette sign with heart Middle lobe pneumonia The BEST interpretation of

this CXR is: A. B. C. D. Normal Emphysema Left lower lobe pneumonia Pulmonary edema

The BEST interpretation of this CXR is: A. B. C. D. Normal Emphysema Left lower lobe pneumonia

Pulmonary edema Kerley B lines Interstitial pulmonary edema

Distension/blurring of upper lobe pulmonary veins Peribronchial cuffing/indistinct hilar fuzziness Kerley B lines Pleural effusions +/- Enlarged cardiac silhouette Baseline - Enlarged cardiac silhouette - Superior redistribution of vessels

- Early interstitial edema (See next image for close-up) Fuzzy vessels Sharp Sharp vessels vessels Baseline

Early CHF Vascular redistribution to upper lobes. Vessels less distinct, larger caliber. CHF with lymphatic engorgement: Kerley B lines Another patient with CHF Mag of RLL

Interstitial & alveolar pulmonary edema. The MOST likely dx is: A. B. C. D. E.

Pneumonia Pulmonary hemorrhage Pulmonary edema Aspiration ARDS The MOST likely dx is: A.

B. C. D. E. Pneumonia Pulmonary hemorrhage Pulmonary edema Aspiration ARDS

Could be any of these! Bilateral Airspace Opacification Edema Pneumonia/aspiration

Hemorrhage ARDS Unusual conditions such as alveolar proteinosis Asymmetric pulmonary edema Pulmonary hemorrhage ARDS

Pneumonia (aspiration) Best diagnosis for the LEFT thorax is: A. B. C. D. Pleural effusion

Hydropneumothorax Pneumonia Atelectasis Best diagnosis for the LEFT thorax is: A. B. C. D.

Pleural effusion Hydropneumothorax Pneumonia Atelectasis Pleural Effusions

Best seen on CT or ultrasound CXR: Lat > PA upright > AP supine Confirm presence/mobility with ipsilateral decubitus film/US Horizontal line = air/fluid level = hydropneumothorax Supine Diffuse ground glass opacity lower zones Diaphragm obscured

Very large effusions mass effect Pleural Effusions Pleural Effusions PA Left effusion

Left lateral decubitis What is the MOST likely diagnosis? A. B. C. D. Left pneumothorax Right pneumothorax

Left lower lobe pneumonia Right lower lobe pneumonia What is the MOST likely diagnosis? A. B. C. D.

Left pneumothorax Right pneumothorax Left lower lobe pneumonia Right lower lobe pneumonia Pneumothorax

Expiratory or upright or lateral decubitus film more sensitive White line with absent lung markings distally Apex on upright film Play with contrast/brightness Skin folds may confuse

Look for signs of tension Pneumothorax inspiratory/expiratory films Inspiratory Expiratory Easier to see BEST diagnosis

for the RIGHT is: A. B. C. D. Middle lobe pneumonia Tension

pneumothorax Upper lobe atelectasis Aortic rupture BEST diagnosis for the RIGHT is: A. B.

C. D. Middle lobe pneumonia Tension pneumothorax Upper lobe atelectasis Aortic rupture

Tension pneumothorax Medical emergency Often total lung collapse Pneumothorax plus Mediastinal shift Diaphragmatic depression Hypotension, pulsus paradoxus, hypoxia

Tension pneumothorax Trauma film. Your most IMMEDIATE concern would be for: A. B. C. D.

Left lower lobe pneumonia Fractured clavicle Left pleural effusion Aortic injury Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 31553 Trauma film. Your most IMMEDIATE concern would be for:

A. B. C. D. Left lower lobe pneumonia Fractured clavicle Left pleural effusion Aortic injury

Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 31553 Mediastinal Hematoma Wide mediastinum Left apical pleural cap Abnormal aortic contour Deviation of trachea or NGT to right

Where is all that air? pneumomediastinum subQ emphysema possible pneumothorax Lines and tubes

Which of these lines is NOT inserted correctly? A. B. C. D. Dobhoff (feeding)

tube ET tube PICC line Subclavian line Which of these lines is NOT inserted correctly? A.

B. C. D. Dobhoff (feeding) tube ET tube PICC line Subclavian line NG tube

Correct Tip and side port below GE junction Incorrect Coiled in esophagus Dobhoff (feeding) tube Correct

Tip in duodenum Tip in stomach (may be OK) Must be below GE junction; prefer duodenum Dobhoff (feeding) tube Incorrect In both main bronchi

Incorrect Tip in distal esophagus Central line Correct Right IJ tip mid-distal SVC Incorrect Left IJ in aorta

Central line Incorrect IJ into right subclavian Incorrect PICC coiled What happened here?

Right subclavian line placement with PTX Chest tube Chest tube OK Side port inside thorax Side port outside thorax ET tube

ETT position OK Best at level of aortic arch Incorrect In right main bronchus Line placements: Summary

NG Both ports in stomach Dobhoff tube Tip must be below GE junction, pref. in duodenum ET

Few cm above carina in adult At level of aortic arch Line placements: Summary (2) PICC/IJ/SCV Tip in distal SVC

Chest tubes Both ports in chest Basal and posterior for effusions Anterior and apical for ptx Radiology Ordering Tips More history = better interpretation

Radiologists available 24/7 (check AMION) Call with ?s about protocols or interpretations Some studies (nuc med, fluoroscopy, IR) require a phone call if after hours or on weekends

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