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
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Two Minutesto evaluate a CXR
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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
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3
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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
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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
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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”