CHEST X RAY

CONTENTS1. Identifying lung zones2. Stepwise approach to describe/read a

CXR.3. Coming to a diagnosis4. Hardware/ Equipment

CONCEPT OF ZONES

Anterior ribs Zones

2 - 4 UPPER zone

4 - 6 MIDDLE zone

BELOW 6 LOWER zone

Loss of normal silhouettes of structures aid in identifying lobes involved. E.g. Right heart border= right middle lobe

STEPWISE APPROACH

NAME, AGE, SEX & IP NO. DATE AND TIME OF STUDY

Do this before putting it on screen..

Ramu or GopalSequential improvement or worsening

TECHNICAL QUALITY

P • Position

I • Inspiration

E •Exposure

R • Rotation

POSITION AP v/s PAERECT V/S SUPINE

PA AP

INSPIRATION5-6 ant ribs in

MCL/ 8-10 posterior ribs

above diaphragm

Lung bases appear denser Apparent cardiomegaly

EXPOSURE

Just visible Intervertebral

spaces, spinous process / T4 visible

through cardiac shadow

ROTATION Medial ends of

clavicle equidistant from spinous process

Distort Mediastinal image Lung lesions hidden behind mediastinum Lung on rotated side appear denser

CENTRE PERIPHERY

Trachea & Bronchi Heart & Mediastinum Hila Lungs Pleura & angles Chest wall - Diaphragm - Soft tissue - Bony

AT EACH STEP LOOK AT..• Grey scale• Too white/Too black?G

• Position• Normal/ shifted?P

• Size/Shape• Normal/ alteredS

GREY SCALEBones- Denser – opaque

Tissue – Air – Grey

Air – Lucent - Darker

GREY SCALE (LUNGS)TOO WHITE

• Consolidation• Collapse• Lung mass/Nodule• Pleural mass/fluid/

thickening• ARDS/ Pulmonary

edema (Ground glass appearance)

TOO BLACK• Emphysema • Pneumothorax

TOO WHITE/ TOO BLACK

Focal/ Diffuse

Multiple/ Solitary

Homogenous/ Non homogenous

Signs of any surgery

NORMAL

Cardio-phrenic

Costo-phrenic

CENTRAL LINES

TRACHEAL TUBE POSITION 2-3 cm above the carina

T4 vertebra

1

32

4

NASOGASTRIC TUBE • Remains close to

midline and not follow the path of any of the main bronchi.

• Crosses the diaphragm in midline

• Tip is well below the diaphragm

PACING WIRES

RIGHT UPPER LOBE COLLAPSE Opacity Focal – R UL Homogenous Horizontal fissure pulled up

INDIRECT SIGNS Trachea pulled

ipsilaterally Compensatory

hyperinflation of RML Elevation of

hemidiaphragm

CONSOLIDATION RML

OpacityNon homogenous(Air bronchograms)

Focal- RML

PNEUMOTHORAX

• Lung field - Too black

• Visceral pleura – white line

• No vascular marking beyond pleural line.

• Trachea pushed to opposite side

• Widening of the ribs

CARDIOMEGALY

A

B

C

A= 6 cmB= 10 cm 0.61C= 26 cm

CT Ratio: A+B/C

Normal < 0.5

BATWING APPEARANCE

CONGESTIVE HEART FAILIURE

PNEUMONECTOMYHemithorax opacified

Ipsilateral mediastinal shiftContralateral lung

hyper-inflated

Absent left main bronchus

ISA MEETJUNE 2016

DR CHARULATHA R MD Assistant professor MGMCRI

Cervical spine injury in x ray Level of foreign body in chest x ray Ct brain in trauma

PART 1 CERVICAL SPINE INJURY IN XRAY

Cervical spine injury Spinal cord injuries -permanent paralysis Missed c spine fracture can lead to death

or life long neurological deficit 3 standard views – lateral view, AP view,

odontoid peg view or open mouth view Lateral view is the most informative

image Normal c spine xrays do not exclude

significant injuries

Cervical spine xray assessmentStep 1Assess adequacy and

alignmentA. Identify the presence of

all seven cervical vertebrae

B .Identify the 1. Anterior vertebral line 2. posterior spinal line 3. Spinolaminar line 4. Posterior spinous line

Step 21. Assess the bone2. Examine all

vertebrae for preservation of height and integrity of bony cortex

3. Examine facets4. Examine spinous

processes

Step3 1. Assess the

cartilage including examining cartilaginous disc spaces for narrowing or widening

Identify the fracture

Step 4 Assess the dens Examine the

outline of the dens Examine the

predental space Examine the

clivus;it should point to the dens

Assess the extraaxial soft tissue

Step 5 Examine the

extraaxial space and soft tissues

7 mm at C3 3 cm at C7 Widening of extra

axial space – possible fracture

PART 2 FOREIGN BODY ESOPHAGUS

Foreign body esophagus Nasopharynx is from base

of skull till soft palate. Oropharynx extends from

the plane of hard palate above till the plane of hyoid.

Hypopharynx is the lowest part of the pharynx and lies behind and partly on the sides of larynx.

Cervical esophagus starts at C6 level. Below this level F.B is in esophagus.

F.B in esophagus usually identified as it lies behind air column, and there will be prevertebral widening.

In this picture F.B is a the level of hypopharynx.

Esophagus or trachea? Foreign bodies in

esophagus appear face on in frontal projection

Foreign bodies in trachea appear end on

Foreign body esophagus

Coin or battery? Coin – single

shadow Button battery-

double density shadow

Foreign bodies in tracheobroncial tree usually lie in sagittal plane as they enter glottis in that plane.

PART 3 CT brain in trauma

What is a CT scan Is a diagnostic

imaging procedure Series of Xray

images taken from different angles

Processed to create cross sectional images of various tissues within our body

The internal structure of an object can be reconstructed from multiple images of the object

Reading the CT scan How to hold the film in

proper orientation ? Look at words on the

film Uppercase R and L on

the filmsIt is like looking at a

person from frontAnterior part of the body

on the top and posterior part on the bottom

NORMAL CT BRAIN ANATOMY

A. FALX CEREBRIB. FRONTAL LOBEC. BODY OF LAT.

VENTD. CORPUS

CALLOSUME. PARIETAL LOBEF. OCCIPITAL LOBEG. SUP.SAGITTAL

SINUS

Shades of Gray,White and black

Hounsefield units-represents the tissue density

Represented by assigned portion of gray scale Air ,Fat,

CSFBlack

White matter,gray matter

gray

Acute hemorrhage , bone

white

CT BRAIN –systematic approach

Check patient and image information Check date and time Check image quality Scalp and skull bones Brain volume Ischemia and Hemorrhage Mass effect

Look at old images and reports Check for movement artifacts and

medical artifacts Do not view only a single slice in isolation If you suspect brain stem

pathology ,consider MRI

Medical artifact -shunt

Movement artifact

Fracture or suture Sutures

found in typical anatomical locations

Jagged in appearance and corticated

Fracture passes across both inner and

outer table of the skull in a straight line

Edges of fractured skull bones are not corticated

Extra –axial hemorrhage Extradural hematoma Subdural hematoma Subarachnoid hemorrhage

Extradural hematoma Post traumatic event Injury to an intracranial

artery –middle meningeal artery

Leakage of injured artery –collection of blood which strips the dura mater away from inner table of skull

Lens shaped collection – dura is strongly adherent to the skull in the region of sutures

Extradural hematoma

Subdural hematoma Cerebral veins are

fragile Risk is increased in

elderly and anticoagulated patients

Not limited by attachment points of dura to bone

Crescent shaped collection

Arachnoid is intact-so blood does not pass into sulci

SDH- effaced sulci

Subarachnoid hemorrhage

Trauma or intracranial aneursym

Blood can pass into any part of CSF spaces-suci,fissures,basal cisterns and ventricles

Intracerebral hemorrhage Intra axial

hemorrhage -spontaneous or traumatic

Area of high density material (blood) surrounded by low density(oedema)

Intracerebral hemorrhage

Cerebral oedema Assess brain volume

by assessing volume of CSF spaces

Cerebral oedema- can cause the brain

to swell – generalised reduction of CSF volume and loss of differentiation between grey and white matter

Mass effect Can be caused by

intracranial masses,hemorrhage and oedema

Effacement of sulci, partial or complete effacement of adjacent ventricles

Displacement of midline structures

Effacement of contralateral ventricles and sulci

THANK YOU