Interpretation of the Adult Chest X-Ray | The Advanced EM Boot Camp Imaging Workshop

we're here today to talk about something that's near and dear to my heart not just because I married a radiologist but because I do firmly believe that emergency imaging is a critical part of our job as emergency providers it's something I'm really passionate about and I've actually spent a good portion of my career studying and teaching it we actually I do a course a required course for our residents and emergency radiology because I feel that strongly in it and we're going to start today talking about chest x-rays which makes sense because that really is sort of the workhorse of the radiology world and something it seems like no matter what anyone comes to the emergency department and we figure out a way to get a chest x-ray on them for something so we'll start with that I'm very excited we have a brand new clicker today that lets me zoom in on things so for the radiology geek of me this is really awesome so bear with me so I get asked this all the time why do we care about x-rays it seems like everyone's getting a cat scan and yes undeniably cat scan is a better diagnostic test but when you look at the numbers plain radiography still holds the line share of imaging in the department it's roughly two-thirds of all imaging studies are playing radiographs and of those chest x-rays represent the most common and more critically there's a lot of valuable real estate in the chest if you think about it and when something goes wrong there a lot of the interventions that we have to do are fairly invasive and you may be the one that has to make that call depending on where you practice you may not have a radiologist right down the hall at your beck and call to interpret for you they may be in India or Australia and it may take two hours to get a read back and quite frankly they're not always right either so it's up to us to own this like Rick said we're ordering the studies we should be interpreting it so our goals for today are pretty simple we're going to talk about a systematic way of interpreting chest radiographs my residents hear this all the time you got to be systematic and you got to do it the same way every time and that way you don't make mistakes I'm going to talk about some of the common abnormal findings and disease processes that we see and along the way I want to touch on some of the pitfalls that I see people falling into not infrequently and by the way all these cases are from my own institution most of these were either my own mistakes or mistakes that my colleagues have made so I'm up here airing my dirty laundry for you guys to benefit from so show of hands who here still remembers actual plain films alright that makes me feel better than I'm about to to old but this is what my residents look like when somebody gets transferred in from an outside urgent care was like an actual plain film they have no idea what to do with it I don't even know if we have a hot like a viewing station in the IDI anymore I like to call chest x-rays the medical Rorschach drawing because it's even though it's a black-and-white study I like to say say it's all shades of grey it really is up to our interpretation and you know you hold it up in there me like yeah maybe they look a little bit wet or yeah maybe I see a hint of an ammonia you know really takes its whatever it takes to get grandma admitted to the hospital Asst you know what I mean we can sort of swing that any way that we want but the history and physical really do come down are very important how we interpret these images so again even though it's black and white there really are shades of gray in the advantage that we have as emergency providers is that we have the patient in front of us we know what they're presenting with we have their exam we have their history whereas the radiologists are really at a disadvantage they literally are in a black box reading these films and many different pathophysiology --zz have a very similar appearance on x-ray so we're going to spend some time talking about the different diseases that you will see and how the history and physical can really sort of play into it again you need to be systematic so first things first when we're looking at a chest x-ray and I know this sounds a little sort of silly but when you start looking at a radiograph the first thing you want to do is look at the marker so you want to see is it the right patient and is it the right study and the reason why I say that in particular for chest x-rays is because we tend to get serial chest x-rays in someone who's sick so somebody comes in they're short of breath we get an x-ray we intubate them we get an x-ray suddenly they decompensate we get another x-ray and so you can very quickly sort of rack up multiple x-rays on the same patient and it's very very easy and I've done it myself with electronic digital imaging to pull up the wrong study so before you make any sort of decisions just make sure that it's the right study that you're looking at the second thing is you want to look at the positioning markers and make sure that left is really left a few years ago our imaging software had a glitch in it where it started flipping images and somebody almost got a wrong sided chest tube because of it so as part of your initial assessment just make sure that left is really left and then the third thing and something if you take nothing else out of my talks I think this is probably one of the most critical things and that is evaluating the film technique and what I mean by that is what position was the patient and when they took the film where they upright or supine is it an AP or a PA film because those sort of things have can have a drastic impact on how we interpret the films I'm going to show you some examples as we go along where that really really matters the next thing you want to do as you're starting to assess the film is look for adequacy and there are four big things that go into adequacy basically penetration inspiration rotation and completeness and by completeness everything you need to see needs to be on the film so when we're assessing for penetration what you want to do is you should be able to see the lower thoracic vertebrae through the heart and if you look down here you're able to make out those vertebrae not in great detail like you would with a t spine film because that would mean the film is probably overexposed for the chest but you should be able to make out the outlines of it I don't think a lot of people realize that when the x-ray techs take the film it's not just a single button that they push it's not a one-size-fits-all solution they actually have to look at the patient look at their body habitus and they dial up or down the juice to match it and so there are times when the penetration may be off the next thing is we usually take chest x-rays in full inspiration and we do that so the lungs are fully inflated and were able to really adequately visualize everything and the way that we assess for that is we count the ribs and on the right where the heart meets the diaphragm we call it the cardio phrenic sulcus should be the 10th or 11th rib if you're not fully inspired what it does is it the lungs get squished down it makes the heart and mediastinum look bigger than they are and it makes the lungs look very congested when actually they're not so full inspiration the next thing we look at is rotation we want to make sure that the patient is centered on the film and the way that we do that is we don't look at soft tissue structures like the trachea because they're mobile and things can shift them around we look at the bony landmarks and in particular we look at the clavicular heads which are there and then we look at the tip of the spinous process and it should be right in between that space it's really important that you look for this particularly on a supine film where it's more likely to be rotated because if it's a rotated film it's gonna have two effects the first is that it's gonna splay out the mediastinum and make it look wider than it is the second effect if you think about it is that the second one of the lungs is going to be in closer contact to the cassette than the other and therefore it's going to expose differently one lung is going to be hazy er than the other in a supine patient a hemothorax or a plural effusion layers this way and what it can look like radiographically is just a hazy er long so in a trauma situation like this patient if the film is rotated if I were to look at this I'd be worried that that left side might have a hemothorax on because it's hazy er than the other when in reality it's all technique it's because the patient's rotated alright so again positioning can have a big impact on how we interpret things and then completeness you need to be able to see everything on the film you need to be able to fully see the costophrenic angles you also need to keep in mind that when we order a chest x-ray series it really is a PA and a lateral to be complete and we hide a lot of things on the lateral there's a lot of space back there where things can hide out things like pleural effusions pneumonias masses sternal fractures only show up on the lateral so again keep in mind if you really want to complete x-ray series you really should be getting a PA and a lateral so how do we actually read these if you look in textbooks there's different approaches that people talk about so there's the geographic approach where you either start at the outside and work your way in or vice versa the problem with that is unless you're incredibly well trained and diligent people when they see something they tend to stop and they miss everything else that's on the film that's sort of human nature so I'm not a big fan of the geographic approach the second approach that people use and I think a lot of people in emergency medicine use is the targeted approach for instance somebody comes in with a fever and a cough you get an x-ray looking for the pneumonia and you move on again the problem with that is you're only looking at one specific part of the film and there's a lot of other things that could be going on there my favorite approach and the one that I teach the residents is the ABCs and I like the ABCs because I'm gonna show you in a minute it makes you look at the lungs last so this is a great what I call a happy eyes case this is my own case it was a 21 year old gentleman very unfortunate he had severe EMR through palsy he was a quadriplegic nonverbal he had a seizure disorder and he came in because he was having repeated seizures and he had one in front of us he vomited and aspirated and like you could hear the chunks going down it was just right in front of us nothing we could do and subsequently he was hypoxic and tachypnic and really working so we got the x-ray and sure enough it showed this big dense consolidation just like we thought it would and so I admitted him for his ongoing hypoxia and work of breathing and the mother kept coming out of the room and she's like something's not right with my son I know him while something is just not right and I sort of patted her on the head and I was like yeah well he's got this pneumonia you know he vomited and aspirated and blah blah blah go back in your room and it wasn't until about two hours later when the radiologist actually came out of the booth and you know that that is never a good sign when they come stumbling out into the bright light right like something bad is going on and he came up to me and he's like Bob what's what's going on with this guy and I said what do you mean broaden it he's governed ammonia he aspirated he's like yeah I haven't seen any post reductions come by my desk and I'm like what are you talking about and sure enough when you look his shoulders out from a seizure so I let this poor nonverbal kid sit there with his shoulder hanging out for hours because I got happy eyes I expected to see the pneumonia I saw the pneumonia and I moved on and I forgot to look at the whole picture so what I would encourage you guys is as you start to approach your chest x-rays is use the ABCs airway bones cardiac diaphragm everything used for everything else and that means things like lines tubes foreign bodies air under the diaphragm era elsewhere where it doesn't belong and then finally f is for fields or lung fields and if I really really encourage you guys to try and train yourself do it this way every time and look at the lungs last now sure if somebody comes in they're in respiratory distress they're you know super hypoxic looking like they're about to code fine look at the lungs make sure they don't have a huge pneumothorax or something like that but at least make sure you go back and do the system and you will save yourself in your patients a lot of grief all right so now that we know how to read them let's look at some cases I love cases and again these are all real-life cases from my institution so this guy comes in he's 40 year old gentleman and comes in with a fever in a cough and for the sake of time I want to run through a bunch of cases so we're not gonna go fully go through all the ABCs on all these but when we look at this guy as we get to our lung fields we see has this big dense consolidation down here at the base there we are and so you notice I say consolidation and not infiltrate I'm trying to be a real stickler here we use that term very sloppily when we say infiltrate what it really means is infiltration of inflammatory cells into that area so that's a hysto pathologic diagnosis we don't know that for sure and so the radiographic term is a consolidation or an opacity all right and we're describing what we're seeing so what I'm seeing is an opacity on the right and with his history fever and a cough pretty consistent with a pneumonia so then the next question is where is it and as we look as we do our ABCs we look at the cardia mediastinum and what I'm noticing is I'm not seeing the right heart border at all it's obscured by this consolidation now I like to say that x-rays are a study in contrast in order for you to see a border on x-ray you need something of one density against something of a different density so normally we have dense heart and aerated lung sitting next to each other and you see a nicely defined heart border now what we have is dense heart and pus filled out vo I like Ana pneumonia so dense and dense and we lose that contrast we lose border and in this case I'm losing that right heart border and I know anatomically that the right middle lobe sits up against the right heart border and so this tells me that this is a right middle lobe consolidation alright this is what we refer to as one of the silhouette signs and it's really a misnomer because it's the loss of silhouette but it helps us localize lesions on playing film so it can come in really handy some of the other silhouette signs if you lose the right hemidiaphragm we know the right lower lobe sits against the right hemidiaphragm so if you lose the right hemidiaphragm at the right lower lobe lesion if you lose the left upper heart border we know that that's where the left leg elicits so that's a left leg Euler lesion alright so these are all silhouette signs that we use here's another guy very similar story a couple days fever cough he's got some right-sided pleuritic pain and sure enough when we get the x-ray it looks a lot like the one that we just saw but when we take a closer look at it you can actually trace out that right heart border pretty well all the way down to the diaphragm but when I trace over the the right hemidiaphragm I lose it immediately near the heart so this tells me this is most likely a right lower lobe process going on he's tilted a little bit because he's splinting because pneumonia hurts it irritates the pleura if we take an even closer look at it hopefully you guys can appreciate there's this Y shaped inverted Y shaped structure here and what that is is a classic finding in pneumonia that's known as an air Branca Graham you guys have probably heard that term before and what an air Branca Graham is is normally you have air filled bronchus surrounded by air filled IV lie so you don't see the bronchi very well now what we have is an air-filled bronchus surrounded by pus filled alveoli and that's pretty consistent with a pneumonia alright so this is a classic air program with a right lower lobe pneumonia all right this woman comes in I distinctly remember this one was very impressive presentation she was a pretty morbidly obese 65 year old woman very sedentary who came in with pretty rapid onset of left-sided pleuritic chest pain she was 2 Kip Nick she was tachycardic she was hypoxic down to about 90% she didn't have any known lung pathology or CHF and she was really working I distinctly remember this woman so what does she have she's tachycardic to kipnuk hypoxic she's sedentary she has a PE right and so I got the x-ray and honestly I wasn't really expecting to see much because in my mind I had already decided you know at least number 1 2 & 3 or my differential was a PE and as I'm looking at it she looks a little hazy but it was it's more her body habitus that's giving that impression and if you look you're actually able to make out her lower thoracic vertebrae there so I know that it's adequately penetrated but I wasn't really seeing much else here's her lateral and again nothing super jumped out at me right away and so then I looked at her priors which I always encourage you guys to do if you have access to priors that can be really illuminating to go back and compare them and when I look at her prior from a year ago it looks different and in particular what's different is on her prior I'm able to trace her left hemidiaphragm all the way over behind the heart and today I can't I lose it and when I look at her lateral from a year ago it also looks different and again what looks different is in that posterior space as her spine goes down it's becoming more loosen it's getting darker whereas on today's film it gets brighter and what that tells me is that something is sitting behind the heart there in that retro cardiac space now to my mind initially that was pretty subtle and it didn't really seem to fit with her really impressive clinical presentation so I scanned her looking for a PE and sure enough she had a big socked in pneumonia all right and so you can see same patient I'm probably about a half an hour difference in between the film's just how subtle that plain film finding is and how real the pathology was and so this is what we call this so on the lateral as you go down it should get darker not brighter if it is getting brighter you need to appreciate it for what it really represents and that's typically a retro cardiac either pneumonia or an effusion all right so again very subtle plain film findings very real pathology all right this woman comes in 45 year old woman she was homeless she came in with about two weeks a low-grade fever cough increasing work of breathing and she looked pretty rough she was hypoxic she was working and here's her x-ray she had a temper like a hundred point four is pretty low grade and as I look at it I'm able to trace out our heart borders I don't see any big focal consolidation to suggest a like a lobar pneumonia but her interstitial just looks wet it looks too busy there's too much going on in her interstitial tissues and our helpful radiologist gives me this you know increased interstitial markings differential includes pulmonary edema versus a typical inflammatory process great you know it's super helpful I didn't think she had cardiogenic pulmonary edema she had no history of that but I was worried in this case with low-grade fever cough infectious symptoms could this be something like myocarditis with subsequent heart failure and increased interstitial markings from that could be this ended up being PCP Pneumocystis we did an HIV on her she her cd4 count was almost non-existent they brought her and that's what this ended up being and in retrospect this is pretty classic for what Pneumocystis pneumonia can look like originally was described as having this reticular or reticular nodular appearance so reticular means lace-like or net-like and that's that increased understa shil pattern and then nodular you can sometimes see sort of modular opacities and that's what this guy had I saw him about a month later almost the same exact clinical scenario a couple of weeks a low-grade fever and cough and on him he has less of that interstitial pattern and more of kind of a fluffy nodular appearance to it now the other big thing on my list on my differential with this guy with that appearance was something like infective endocarditis with septic emboli so we actually did end up scanning this guy looking for things like cavity reasons etc but at the end of the day this ended up also being PCP alright so can have a fairly variable appearance so when we're talking about pneumonia we look for things like consolidations for low bar type pneumonias we look for the silhouette science to help us localize them we look for and respect that spine time when you see it it's real I'm looking for things like air Branca Graham's when we get into the a typical range things like mycoplasma viral pneumonias herpetic pneumonias pcp then we start to look at things like more like increased interstitial markings which can look for all the world sometimes like cardiogenic pulmonary edema and so again that's where the clinical scenario starts to come into play all right this woman comes in sudden onset shortness of breath respiratory distress and she's a mess she comes in she's hypoxic she's two kipnuk she's really working also fairly hypotensive and as we look at it a lot something start to jump out of me she has cardiomegaly she obviously has some vascular disease you see these intimal calcification xin re-order there as we zoom in and take a closer look as we look at her vessels in the upper lobes they're big they're really plump this is not a bright fill-in in an upright patient gravity should be pulling that blood down so the vessels in the upper lung fields should be smaller than the vessels in the lower lung fields and here they're about the same and what that's telling me is that there's increased back pressure the blood is not making it through the heart and everything is sort of backing up and this is what we refer to as cephalization of the vessels and this is a finding that's pretty consistent with cardiogenic pulmonary edema other things that we see we see a thickened a dimittis Fisher again reflective of back pressures there's fluid just backing up into the interstitial there's this Perry high Miller fluffiness or fullness has pulmonary edema progresses everything starts to weep and as it gets into the later stages your pulmonary vasculature your Perry higher vasculature starts to get indistinct and sort of fluffy like this if we take an even closer look at this if we at the periphery you see these linear lines based along the pleura there like there and there these are what I referred to as curly B lines and what curly B lines are are engorged inter lobular septa so again increased back pressure filling up those interstitial tissues and this is pretty specific again for cardiogenic pulmonary edema all right this guy comes in respiratory distress he was intubated pretty much on arrival we see his ET tube in place he's also got the band-aids of life on here the pads so somebody was worried about this guy right so he's pretty sick and as we look at his x-ray it's grossly abnormal he's got a huge heart he's supine so we can't really comment on cephalization at that point because the pressure gradients are fairly equal now but he does have very indistinct peri highly vasculature he has a thickened inter lobar fissure and if we look sort of closely down at the base he's got curly B lines walking their way up so this seat seems fairly consistent with cardiogenic pulmonary edema now the radiologist could look at this and say well he's got these really dense sort of Perry higher consolidations could this be multifocal pneumonia could be he's got a lot of other findings that sort of lean us more towards CHF but in the right clinical scenario fever cough whatever this could be pneumonia and again that's where the clinical scenario starts to play in a little bit so when we're looking for things like cardiogenic pulmonary edema we're looking at heart size looking for cardiomegaly keeping in mind that you can actually have acute heart failure with a normal heart size there are things that can do that look for increased interstitial markings look for fusions look for those curly B lines you will start to see them when you look for him look for cephalization on an upright thumb and then look for that Perry hilar crowding or fluffiness all right this guy comes in 45 year old male kind of tall thin guys smoker comes in with sudden onset sharp pleuritic chest and back pain we get his x-ray and as we sort of go through it one of the things that sort of jumps out at me right away is the guy's fairly hyper inflated he's got big long field which was the sort of goes along with his smoking history and then as we take a closer look up at his right apex he's having right-sided chest pain you'll see that it has a paucity of lung markings up in the apex it's really sort of loosen up there we're not seeing any interstitial markings at all and then when you take an even closer look you see this line there that doesn't really correspond to a rib or anything else and that's actually his plural reflection that's his long so this is a pretty classic apical pneumothorax sort of goes along with the clinical scenario this one as you look at it it is pretty obvious this one also not so subtle so I practiced in Rhode Island we have a very prominent art school there and some of the students sort of alternative lifestyles so but this young gentleman came in with again sudden onset sharply chest pain and shortness of breath and when you look on his left there were like no lung markings this is actually his entire left lung sitting right there so this is a huge spontaneous pneumothorax as you look as as you do your system and you look at the cardio mediastinum it sort of jumps out at me the things are starting to get shifted over so tension physiology is really a clinical diagnosis all right it depends on what the patient's hemodynamics are doing but radiographically this is sort of got my attention that he's showing radiographic signs of possible tension things are starting to get shifted over the reason why I say it's a clinical diagnosis is this kid was sitting there on a cell phone texting and looking pretty good all right young people can tolerate a lot before they sort of fall off the curve so even though radiographically it looked like tension this this young man did not show physiologic signs of it yet all right so again these are fairly obvious examples of pneumo fluoresces but sometimes they're not so obvious and so there are a few tips and tricks that you can use if you suspect it and you don't want to jump right to scan and trust me I am NOT saying that every pneumothorax needs to be diagnosed and certainly not every pneumothorax needs a chest tube there was actually a lot of debate out there as to when and how to put in it you know when we should be putting in chest tubes but when you really want to know there are a couple things you can do the first is you can send them over for an Vettori view remember I said we normally take chest x-rays and full inspiration you can send them over for an expert or review which will sort of smoosh his lungs down and it will widen out that space where the pneumothorax is and sometimes we'll make it more obvious and when we zoom in here you can sort of see there's a reflection coming across a plural reflection in there another trick that you can do is you can invert the image so in the old days a plane film every workstation have what they call a hot lamp and basically it was like a little spotlight and what you would do is you would take the film and backlight it with that hot lamp and look around the periphery and what the hot lamp would do would make lines appear black darker and so it would emphasize the lung markings so you could see are there lung markings up in the apex or not it would also emphasize the plural reflection and make it clear now with digital radiography most PAC stations have the ability to invert the image it usually looks like you know a circle half-black half-white click on that and it will flip your colors and it will sometimes make lung markings more obvious to see it's also a neat trick in orthopedic radiology when you have like an old osteoporotic person and you're questioning whether they have a subtle fracture try inverting the image and it will sometimes make the fracture line jump out at you a little easier how good is chest x-ray it's sort of our initial go-to at most places well it turns out it's not great so the best chest x-ray is actually a lateral decubitus with 88% sensitivity I was putting together a chest excel we talked for a SUP years ago and I went to our chest radiography radiologists and asked them if they had any lateral decubitus especially in like an unstable trauma patient the next-best in our upper a chest x-ray only about 59 percent sensitive which is really pretty terrible in terms of diagnostics and then for a supine x-ray which is sort of our initial screen in our trauma patients it's only 37 percent sensitive all right it's pretty terrible so negative chest x-ray it doesn't rule anything out now if you really need to know the answer the gold standard is really tea and bi really need to know the answer I mean if they're going to be transported out of your hospital for a long period of time or you know certainly if they're going by air you kind of want to know if there's a pneumothorax there if they're gonna be under anesthesia for hours and hours you kind of want to know but not every pneumothorax needs to be diagnosed necessarily this patient came in as a Level II activation to our trauma center pretty banged up here was this initial trauma screening x-ray and you can see it's a supine trauma patient and when we look at it it looks abnormal and as we run through our system when we get to diaphragm his left hemidiaphragm is really non-existent it's really deep and indistinct and plunging and hazy and this is classic for what we call a deep sulcus sign and the reason why we're seeing this this is a pneumothorax the reason why we're seeing this is again the technique this patient is supine so in an upright patient air rises up to the apex and that's why we look up in the apex for a pneumothorax and an upright patient but in a supine patient it raisin Rises anteriorly and the effect that that has is it tends to push down on the diaphragm and it makes it sort of hazy and plunging and indistinct so positioning really changes the appearance of some common pathology that we would see on playing film the other thing that concerns me on this patient is is I already checked and saw he's not really rotated but when I look at his lungs his left lung is definitely hazy er than the right so I am actually very worried that in this patient this is actually a hemopneumothorax with a layering Hema hemothorax coming up alright so again apical II in an upright patient anteriorly no tsukai patient this gentleman comes in he had sudden onset sharply or chest pain it's about 2:30 on a Friday night and here's his initial x-ray and as we go through our system we look at his airway and right away up in the neck I start to see something a little funny I see these sort of dark loosen C's linear loosen C's up there those aren't normal and then as we go through and I look at his cardio mediastinum I start to see some other stuff I see a line here that catches my eye this is pneumomediastinum all right all these linear open dark opacities up in his neck that's all sub-q air and his heart is sort of outlined in a hair now and again a study in contrast this patient has a really specific finding for pneumomediastinum in addition to what we're seeing up in his neck if you look at his heart and where it meets the diaphragm you're actually able to trace that diaphragm all the way across and they call that the continuous diaphragm sign normally you shouldn't be able to do that because normally you have dense heart adhere to dense left hemidiaphragm anteriorly so you shouldn't be able to see a border there but now what we have is dense heart with air in between it and the diaphragm and so we're able to trace it all the way across and that's very specific for pneumomediastinum the only other thing that really causes this is pneumopericardium which is very rare thankfully so when you see this it's very specific for some Ferdinando mediastinum when we look at the lateral the corollary to it is there now we're able to trace that left hemidiaphragm all the way across whereas normally we would lose it where it joins the heart does everyone see that so again pneumomediastinum so when you see this the next question you want to ask is well what was the patient doing when this came on and it turns out that this gentleman was smoking crack you get pneumomediastinum when you have a forced exhalation against a closed glottis and very commonly associated with the inhalation on drug reduced about 40 percent of the time you also see it in athletes particularly weight lifters when they're straining to lift you'll see it in asthmatics you'll see it in cases of severe coughing there have been case reports of this with pertussis so you'll definitely see it there if however you see it with any hint in the history of vomiting and certainly if you see pneumomediastinum with a pleural effusion you have to assume it's bore Hobbs until proven otherwise or nowadays effort related esophageal rupture is the term but any whiff of vomiting in the history or any pleural effusion you need to rule this out because if you don't mean this tinnitus is pretty much fatal if it's untreated so any hint of vomiting you gotta go chase that down and it can be subtle so this guy came in he had some retching and then developed pretty severe chest pain after that here's his x-ray and as I look at it as I'm doing my system when I look at the cardio mediastinum I see these weird little bubbles down here at the base and as I look and try and trace out his diaphragm I'm not able to see his left hemidiaphragm behind the heart at all so that tells me that something is sitting back there and in this case it was a pleural effusion not super-impressive radiographically but then when you look at his cat scan you'll see air nicely outlining his esophagus there and a nice left pleural effusion all right so if we didn't treat this this guy would have died all right as it is the prognosis is still fairly you know serious this is a bad disease and so again pneumomediastinum with any hint of vomiting you got to chase this down if they can give you a pretty clear history that they were smoking dope and suddenly had this it's a sterile process that most of them do just fine so I don't necessarily think you need to chase down esophageal rupture in all of these patients but any vomiting it's sort of incumbent on you to do that all right so this was a whirlwind overview of chest x-rays we're going to touch on a few more at the end of the day in our mystery cases but in summary look for adequacy assess for penetration rotation inspiration and completeness remember to be systematic start practicing looking at the ABCs do it the same way every time and the more you do it the more intuitive it becomes and you don't even have to think about it remember that the film technique can have huge implications on how we interpret this was the patient upright or supine it's going to change where we look for the authorities it's going to change how hemothorax looks so really keep the positioning in mind when you look at these look for those silhouette signs and retro cardiac opacities the spine sign respect it know the pulmonary edema has a spectrum of findings look for those curly B lines the more you look the more you start to see them and remember that supine chest secretary in particular has a very poor sensitivity for pneumothorax so it doesn't rule anything out and it's gonna appear differently than it would on an operation and then any case of pneumomediastinum again with vomiting bore has until proven otherwise so with that I'm gonna turn it over tomorrow and I'm gonna hold questions I'll be in the back later in the day for questions if you guys have any thank you [Applause]

Channel: The Center for Medical Education

Views: 44,931

Keywords: emergency medicine, em boot camp, advanced em boot camp, physician assistant, nurse practitioner

Id: So50F42iqrA

Length: 35min 50sec (2150 seconds)

Published: Wed Oct 23 2019