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NADEEN ISMAHEL FY1 CHESTX -RAYINTERPRET ATIONCONTENTS CHESTX -RA Y Indications Structured approach Common findings and management Tips and tricks QuestionsCHESTX -RAY Scenario:ou’re an FY1 starting nighou are handed over to chase Mr Smith’s chest X-ray. Background - NEWS = 2 for 2L NC - 70 y/o male - Admitted 3 days prior with a cough and lethargy - No PMH of note - Currently on IV amoxicillinCHESTX -RAY-INDICA TIONS reasons:e many indications for a CXR but these are some of the more common - Lung pathology - , pneumonia, pneumothorax, effusion - Septic screen - Post interventions - central line, chest drain, pacemaker CHESTX -RAY-STRUCTUREDAPPROACH Details Rotation Inspiration Projection Airway Exposure Breathing Cardiac Diaphragm Everything elseCHESTX -RAY-STRUCTUREDAPPROACH Details RIPE ABCDE - Rotation - The medial - Name should be equidistantle - hilar structures and - CHI number from the spinous - Breathing - Lung fields - Date and time the film processes - Cardiac - Heart size on - was taken - anterior ribs should be PA film visible - under the diaphragm, - AP or A?on - Is the film costophrenic angles  - Exposure -  check if the- bones, soft tissues, the heart, ensuring good foreign tubes & devices penetrationCHESTX -RAY-STRUCTUREDAPPROACH Details Rotation Inspiration Projection Airway Exposure Breathing Cardiac Diaphragm Everything elseCHESTX -RAY-COMMONFINDINGS Tension pneumothorax - Immediate decompression - Large bore cannula - 2nd intercostal space midclavicular lineCHESTX -RY-COMMONFINDINGSCHESTX -RAY-COMMONFINDINGS Pneumonia CURB 65 - Oral/ IV antibiotics - Oxygen if needed - Repeat CXR in 6 weeksCHESTX -RAY-COMMONFINDINGS Pulmonary oedema Can be secondary to heart failure - Upper lobe pulmonary venous diversion - Prominent line markings - Lung congestion - Kerley B linesCHESTX -RAY-COMMONFINDINGS Pulmonary oedema Oxygen if needed - IV diuretics - GTN spray - Position upright - Severe cases - positive pressure ventilationCHESTX -RA Y-COMMONFINDINGS Pleural effusion - Causes can be split into transudates and Transudates - heart failure, cirrhosis, - hypothyroidism - Exudates - pneumonia, malignancy, TBCHESTX -RAY-COMMONFINDINGS Pleural effusion - Identify underlying cause - Thoracentesis for light’s criteria - May need surgical interventionCHESTX -RAY-COMMONFINDINGS Pneumoperitoneum - Secondary to GI perforation - Treat underlying causeCHESTX -RA Y-COMMONFINDINGS NG tube - Used for feeding and administration of Also used for GI decompression and - aspiration - to administration of anything positioning priorCHESTX -RA Y-COMMONFINDINGS NG tube The NG tube should remain in the - midline down to the level of the diaphragm - The NG tube should bisect the carina - visible and below the left hemidiaphragm - approximately 10 cm beyond the GOJ CHESTX -RY-COMMONFINDINGSCHESTX -RAY-TIPSANDTRICKS Compare to previous CXR if available - - AP and portable chest X-rays usually indicate a very unwell patient Heart size cannot be assessed on an AP CXR - - resolutionith pneumonia typically have a repeat CXR in 6 weeks to assess forCHESTX -RAY-QUESTIONS Scenario:ou’re an FY1 starting nighou are handed over to chase Mr Smith’s chest X-ray. Background - NEWS = 2 for 2L NC - 70 y/o male - Admitted 3 days prior with a cough and lethargy - No PMH of note - Currently on IV amoxicillinCHESTX -RA Y-QUESTIONS Scenario:ou’re an FY1 starting nightou are handed over to chase Mr Smith’s chest X-ray. Is there adequate inspiration? A. es B. NoCHESTX -RA Y-QUESTIONS Scenario:ou’re an FY1 starting nightou are handed over to chase Mr Smith’s chest X-ray. Is there adequate inspiration? A. es B. NoCHESTX -RA Y-QUESTIONS Scenario:ou’re an FY1 starting night ou are handed over to chase Mr Smith’s chest X-ray. What does his CXR show? A. Right lower zone pneumonia B. Left lower zone pneumonia C. Pleural effusion D. PneumothoraxCHESTX -RA Y-QUESTIONS Scenario:ou’re an FY1 starting night ou are handed over to chase Mr Smith’s chest X-ray. What does his CXR show? A. Right lower zone pneumonia B. Left lower zone pneumonia C. Pleural effusion D. PneumothoraxCHESTX -RA Y-QUESTIONS Scenario:ou’re an FY1 starting night ou are handed over to chase Mr Smith’s chest X-ray. Given his diagnosis of pneumonia, when will Mr Smith require a repeat CXR? A. 1 week B. 2 weeks C. 4 weeks D. 6 weeksCHESTX -RA Y-QUESTIONS Scenario:ou’re an FY1 starting night ou are handed over to chase Mr Smith’s chest X-ray. Given his diagnosis of pneumonia, when will Mr Smith require a repeat CXR? A. 1 week B. 2 weeks C. 4 weeks D. 6 weeksCHESTX -RAY-QUESTIONS Scenario:ou’re an FY1 on night ou are bleeped to attend an emergency in resus in traffic accidentdepartment. Mr Jones has been brought in my ambulance following a road Background - 50 y/o man - GCS of 11 in resusedical history -CHESTX -RA Y-QUESTIONS Scenario:ou’re an FY1 on night shou are bleeped to attend an emergency in resus in the emergency department. Mr Jones has been brought in my ambulance following a road traffic accident You obtain a portable CXR. What does the CXR show? A. Right lower zone pneumonia B. Rided sided pleural effusion C. Right sided pneumothorax D. Right sided tension pneumothoraxCHESTX -RA Y-QUESTIONS Scenario:ou’re an FY1 on night shou are bleeped to attend an emergency in resus in the emergency department. Mr Jones has been brought in my ambulance following a road traffic accident You obtain a portable CXR. What does the CXR show? A. Right lower zone pneumonia B. Rided sided pleural effusion C. Right sided pneumothorax D. Right sided tension pneumothoraxCHESTX -RA Y-QUESTIONS Scenario:ou’re an FY1 on night shiou are bleeped to attend an emergency in resus in the emergency department. Mr Jones has been brought in my ambulance following a road traffic accident You obtain a portable CXR. What initial treatment will you carry out? A. IV antibiotics B. Positive pressure ventilation C. Urgent needle decompression D. IV diureticsCHESTX -RA Y-QUESTIONS Scenario:ou’re an FY1 on night shiou are bleeped to attend an emergency in resus in the emergency department. Mr Jones has been brought in my ambulance following a road traffic accident You obtain a portable CXR. What initial treatment will you carry out? A. IV antibiotics B. Positive pressure ventilation C. Urgent needle decompression D. IV diureticsCHESTX -RA Y-QUESTIONS Scenario:ou’re an FY1 on night shiou are bleeped to attend an emergency in resus in the emergency department. Mr Jones has been brought in my ambulance following a road traffic accident You obtain a portable CXR. decompression? insert the large bore cannula for A. 2nd intercostal space midclavicular line B. 3rd intercostal space midclavicular line C. 7th intercostal space midaxillary line D. 2nd intercostal space midaxillary lineCHESTX -RA Y-QUESTIONS Scenario:ou’re an FY1 on night shiou are bleeped to attend an emergency in resus in the emergency department. Mr Jones has been brought in my ambulance following a road traffic accident You obtain a portable CXR. decompression? insert the large bore cannula for A. 2nd intercostal space midclavicular line B. 3rd intercostal space midclavicular line C. 7th intercostal space midaxillary line D. 2nd intercostal space midaxillary lineCHESTX -RAY-QUESTIONS Scenario:ou’re an FY1 on night ou are bleeped to see a 20 y/o female Jennifer who is complaining of severe abdominal pain. Background - Admitted 1 day prior with left iliac fossa pain - Urinary pregnancy test negative - No relevant past medical history - On examination - pain in LIF and guardingCHESTX -RA Y-QUESTIONS Scenario:ou’re an FY1 on night sou are bleeped to see a 20 y/o female Jennifer who is complaining of severe abdominal pain. ou request an erect CXR Is there adequate exposure of the CXR? A. es B. NoCHESTX -RA Y-QUESTIONS Scenario:ou’re an FY1 on night sou are bleeped to see a 20 y/o female Jennifer who is complaining of severe abdominal pain. ou request an erect CXR Is there adequate exposure of the CXR? A. es B. NoCHESTX -RA Y-QUESTIONS Scenario:ou’re an FY1 on night sou are bleeped to see a 20 y/o female Jennifer who is complaining of severe abdominal pain. ou request an erect CXR What pathology is present on the CXR? A. No pathology, normal CXR B. Pneumonia C. Pneumoperitoneum D. PneumothoraxCHESTX -RA Y-QUESTIONS Scenario:ou’re an FY1 on night sou are bleeped to see a 20 y/o female Jennifer who is complaining of severe abdominal pain. ou request an erect CXR What pathology is present on the CXR? A. No pathology, normal CXR B. Pneumonia C. Pneumoperitoneum D. PneumothoraxCHESTX -RA Y-QUESTIONS Scenario:ou’re an FY1 on night shou are bleeped to see a 20 y/o female Jennifer who is complaining of severe abdominal pain. You request an erect CXR Given the history, what is the likely cause? A. Ruptured appendix B. Ectopic pregnancy C. Peptic ulcer D. Ruptured gallbladderCHESTX -RA Y-QUESTIONS Scenario:ou’re an FY1 on night shou are bleeped to see a 20 y/o female Jennifer who is complaining of severe abdominal pain. You request an erect CXR Given the history, what is the likely cause? A. Ruptured appendix B. Ectopic pregnancy C. Peptic ulcer D. Ruptured gallbladderQUESTIONS?QUESTIONS?