Don’t make a

“HORID” mistake and miss something

HORID•H = Heart (CHF/ACS)•O = Obstruction •R = Reactive (COPD/Asthma)•I = Infection•D = Death! (From a PE/Pneumotx)

General Principles of the CXR

•We are looking at shadows▫Five shades of Gray: black white

(Air Fat Muscle Bone Metal)

•“The Closer the Crisper”

•Silhouette sign ▫Two substances of the same density will lose the shadow between them

•Air is up/ fluid is down ▫Think of patient position

4

Two Minutesto evaluate a CXR

5

You Need a SYSTEM!

John’s

“RIP’T ROR’ing ABCs”

Technique

•RIP’T = Quality of the radiograph

•R = Rotation (Clavicles line up?) •I = Inspiration (9-11 Ribs)•P = Penetration (Vertebral bodies behind heart)

•T = Technique (PA versus AP?)

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Rotation

Technique?AP = Blurred Image

PA = More Perfect Image

Penetration

Inspiration

“ROAR”•R=Right Patient•O=Old films? •A=Alignment Is it hung

correctly?

•R=Right date

“ABCs”• ABCs is the systematic approach

▫A = Air Spaces▫B = Bones/Borders/Burned ▫C = Cardiovascular/Mediastinal

▫S = Soft Tissues10

“ABCs”•A=Air (Gastric/Free/Lungs)

▫Gastric Air?▫Free Air?▫Lung Spaces Too White or Too Black? 11

GastricFree Air?

Air Spaces

Hilum

“ABCs”• B = Bones/ Borders/ Burned

▫Look at all bones▫Right heart and right diaphragm

▫Left heart and left diaphragm ▫Don’t get BURNED! 13

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“ABCs”•C = Cardiovascular/mediastinal

▫Heart size: enlarged cardiac silhouetteCheck the cardiothorasic ratio Greater than 50%?

▫Mediastinal : Enlarged? Pager Sign?/8cm 15

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“ABCs”•S = Soft tissue

▫Neck: shifting of structuresSQ air?

▫Breast tissue/chest tissue

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Back to Pulmonary Symptoms

HORID•H = Heart (CHF/ACS)

•O = Obstruction •R = Reactive (COPD/Asthma)•I = Infection•D = Death! (From a PE/pneumotx)

It’s a “SAD” case of “CHF”

Cardiac (arterial) Risk Factors•S = Smoking•A = Age •D = Diabetes

•C = Cholesterol •H = Hypertension•F = Family History

Heart: CHF•Buzz words:

▫Chest Pain?▫DOE?▫Orthopnea? (Pillows?)▫PND? (Cough?)▫Leg Swelling?

How do we acutely treat CHF?

▫L=Lasix▫M=Morphine▫N=Nitrates▫O=Oxygen…then you…

▫P=Pee (as in to pee from the Lasix)

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3

2

1

3

2

Heart :Radiographic Diagnosis of CHF

(…makes me “BELCH”)

B = Bat Wings (aka “perihilar cuffing”)E = EffusionsL = Lines (Kerly A and B lines)C = Cephalization H = Heart enlargement

(Pearl: you must have a Big Heart to have CHF)

Kerley B Line

Kerley A Line

Cephalization

Enlarged Heart

UponPresentation

OneDay

Later:CHF Review

Acute TreatmentThe Money:

•Bi Pap•Nitro Drip: Go Big!▫Morphine?

“Kiss” them with Lasix, don’t pound them!

Nitro•Contraindications to NTG

▫Low Blood Pressure▫Erectile Dysfunction Medication▫Right Ventricular Infarction No NTG without …_______________

CHF Points:•An under penetrated CXR may appear

as CHF. Use pre-test probability to help in the diagnosis. (BNP)

•Be careful of the diagnosis of Bilateral pneumonia. Could this be urosepsis putting the patient into failure?

HORID•H = Heart (CHF/ACS)

•O = Obstruction •R = Reactive (COPD/Asthma)•I = Infection•D = Death! (From a PE/pneumotx)

Obstructive•This could be a simple as an ingested

foreign body, tumor, allergic, traumatic.

•Stridor?

•FBAO? •Allergic? (ACE Inhibitor?)

•Lesion?•Infection? (Croup/Epiglottitis?)

Croup/Epiglottitis

Decadron0.15mg/kg

IMRacemic

Epi?

Decadron0.15mg/kg

IMRacemic

Epi?

Obstruction in the Airway?

Handle with “TLC!”

•T=Timing▫How rapidly progressive is the lesion?

•L=Location

•C=Compression

HORID•H = Heart (CHF/ACS)•O = Obstruction

•R = Reactive (COPD/Asthma)

•I = Infection•D = Death! (From a PE/pneumotx)

Reactive COPD/Asthma

EmphysemaAir Space Destruction

Reactive Airway Disease

Wheezing

Chronic BronchitisEnlarged Goblet Cells

COPD

AsthmaTreat them while they’re making “NOISE”

•N = Nebulizers▫ Albuterol (B2 Agonists)

▫ Atrovent (Anticholenergic)

•O = Oxygen•I = IVF•S = Steroids •E = EpinephrineMag? Aminophylline? Terbutaline?

HORID•H = Heart (CHF/ACS)

•O = Obstruction •R = Reactive (COPD/Asthma)

•I = Infection•D = Death! (From a PE/pneumotx)

Infection•Clinical Features?

▫Leukocytosis▫Hypoxia▫CXR infiltrate

Fever? Think “wind” (pneumonia) or “water” (UTI)

Pneumonia: 3 different radiographic presentations

Bronchial pneumoniaMay be prone to atelectasis

Alveolar pneumoniaMay be prone to air bronchograms

Interstitial pneumonia 47

Bronchial Pneumonia

48

Bronchial Pneumonia

(Bad Bugs: “PEAS”)•P =Pseudomonas•E = E. Coli•A = Anaerobes (aspiration) ▫Klebsiella classic w/ ETOH’ers

•S = Staph49

Alveolar Pneumonia (aka: CAP)

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Typical CAP Bugs: “SHzAM”

•S = Strep Pnuemo •H = H. Flu•A = Atypicals•M = M. Cat

•Macrolide/FQ /Combo therapy 51

Alveolar Pneumonia

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Interstitial Pneumonia

(Small Bugs: Viruses/ PCP )

Question: When can you have a pneumonia and NOT see an infiltrate on

CXR?

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No infiltrate seen on CXR?

•Dehydration: the body is not going to waste water to hydrate an infected lung

•COPD’ers: they have excessive air in the chest, making a pneumonia more subtle

•Retro Cardiac (Lingula) Pneumonia:

on AP film, you need a lateral

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HORID•H = Heart (CHF/ACS)•O = Obstruction •R = Reactive (COPD/Asthma)•I = Infection

•D = Death!

Pulmonary Embolism:PE is the

of Chest

Symptoms

58

Name That Tune

Who is Your PAPPA?

•P = Pericarditis•A = Acute Coronary Syndrome

•P = Pnemothorax•P = Pulmonary Embolism•A = Aortic Aneurysm (Thoracic)

Who is the most accurate

medical provider to diagnosispulmonary embolism?

What’s the Key to Diagnosis?

High Degree of Clinical Suspicion!

That was a “WHALE” of a PE

•W= Westermark Sign•H = Hampton's Hump •A = Atelectasis•L = Lovely

▫Meaning perfectly normal•E = Effusions

“No one can say

4 times in 4 seconds”

John@CME4Life.com