Data Interpretation + Radiology Flashcards
2 major groups of IV fluids? Which are used less frequently due to a risk of anaphylaxis?
Crystalloids: solutions of small molecules in water e.g. NaCl, Hartmann’s, dextrose
Colloids: solutions of larger organic molecules e.g. albumin, Gelofusine
Colloids
5 Rs for prescribing IV fluids?
Resus, routine maintenance, replacement, redistribution, reassessment
Findings of hypervolaemia?
Increased RR>20 breaths/ minute, decreased oxygen SATs, bilateral crackles on auscultation
Hypertension, elevated JVP
Increased urine output, abdominal distension, peripheral oedema, fluid chart= positive fluid balance, weight gain
Findings of hypovolaemia?
High HR>90 BPM, hypotension, prolonged CRT, non-visible JVP
Decreased GCS if volume depleted
Increased output from wounds and drains, decreased urine output, fluid chart= negative fluid balance, weight loss, other sources of fluid loss
If hypovolaemic next step? Administer what bolus initially?
Initiate fluid resus- DON’T IF HYPERVOLAEMIC
500ml of a crystalloid solution e.g. NaCl 0.9%/ Hartmann’s solution over less than 15 minutes
After administering an initial 500ml bolus for resus, do what? If clinical evidence of ongoing hypovolaemia? Repeat process up until what total?
Reassess using ABCDE approach
Further 250-500ml bolus of crystalloid solution, reassess using ABCDE approach
2000ml–> expert help if still
If complex comorbidities e.g. HF, renal failure and/ or elderly what bolus should be given? If normovolaemic, but signs of shock do what?
250ml
Seek expert help immediately
If patient able to meet their fluid and/ or electrolyte needs orally/ enterally no further what required? Unable? Will likely need what? Don’t have above issues, but unable to meet fluid requirement? When should be administered?
No further IV fluids
Consider if complex fluid issues, electrolyte replacement issues, abnormal fluid redistribution issues
Fluid replacement and/ or redistribution
Routine maintenance IV fluids- during daytime hours to prevent sleep disturbance
What is the daily maintenance fluid requirements as per NICE guidelines? What should weight-based potassium prescriptions be rounded to? What should NOT be manually added to fluids?
25-30ml/ kg/ water + approx 1 mmol/kg/day of K+, Na+ and Cl- and approx 50-100g/ day of glucose to limit starvation ketosis
The nearest common fluids
Potassium
Who should you use the lower range for volume per kg? Other patient groups who you should take a more cautious approach to fluid prescribing?
Obese patients
Elderly patients
Patients with renal impairment/ cardiac failure
Malnourished patients at risk of refeeding syndrome
NG fluids/ enteral feeding is preferable when maintenance needs are more than how many days? Patients requiring a slightly different approach than the routine fluid maintenance regimen?
3 days
Those with existing fluid or electrolyte deficits or excesses, ongoing abnormal fluid or electrolyte losses, redistribution and other complex issues
Where to put the 6 chest ECG electrodes?
V1: 4th IC space at right sternal edge
V2: 4th IC space at left sternal edge
V3: midway between V2 and V4 electrodes
V4: 5th IC space in MC line
V5: left anterior axillary line at same horizontal level as V4
V6: left mid-axillary line at same horizontal level as V4 & V5
Leads for inferior view of the heart? Lateral view? Anterior view? Septal view?
II, III & aVF
I, aVL, aVR, V5 & V6
V3 & V4
V1 & V2
DRSABCDE for chest X-rays? Mnemonic for assessing image quality?
Details: patient name, age/ DOB, sex, type of film- PA/ AP(assume PA if no label,) erect/ supine, correct L/R marker, inspiratory/ expiratory series
RIPE: rotation- medial clavicle ends equidistant from spinous processes/ inspiration- at least 6 anterior ribs, poor inspiration/ hyperexpanded?/ projection- straight vs oblique, entire lung fields, scapulae outside lung fields, visualise vertebral bodies behind heart border/ exposure- left hemidiaphragm should be visible to the spine and the vertebrae should be visible behind the heart
Soft tissues and bones- ribs, sternum, spine, clavicles- symmetry, fractures, dislocations, lytic lesions, density, swelling, loss of tissue planes, SC air, masses, breast shadows, calcification- great vessels, carotids
Airway and mediastinum- trachea deviated?
Breathing- lung fields, costophrenic & cardiophrenic angles
Circulation- heart & aortic knuckle(ONLY ON PA CXRs,) cardiomegaly- valvular heart disease, cardiomyopathy, pulmonary HTN & pericardial effusion/ widened mediastinum, mediastinal shift?
Diaphragm- elevation, pneumoperitoneum?
Extras- ECG tabs/ oxygen tubing, no broken bones, no pacemaker, no sternal wires/ valves visible
Reasons for requesting a chest X-ray?
NG tube placement, change in oxygen requirement or SOB, pleuritic chest pain, septic screen- fever of unclear cause
In community= non-resolving cough>3 weeks, weight loss in a smoker
Causes of true and apparent tracheal deviation?
True= pushing of trachea: large pleural effusion or tension pneumothorax
Pulling of trachea: consolidation with associated lobar collapse
Apparent: rotation of patient can given appearance of apparent tracheal deviation- inspect clavicles to rule out presence of rotation
Causes of unilateral/ asymmetrical and bilateral hilar enlargement? Pushed or pulled by what? Cause of visible pleura? Absence of lung markings due to what?
Unilateral= underlying malignancy/ bilateral= sarcoidosis
Pushed by enlarging soft tissue mass/ pulled by lobar collapse
Mesothelioma
Pneumothorax
What makes up most of the right heart border? The left heart border? Reduced definition of the right border is typically associated with what? Left heart border? Syndrome resulting in the abnormal position of the colon between the liver and diaphragm–> appearance of free gas under the diaphragm?
Right atrium
Left ventricle
Right middle lobe consolidation
Lingular consolidation
Chilaiditi syndrome
What can costophrenic blunting indicate? Reduced definition of the aortic knuckle can occur in what? Space of the aortopulmonary window can be lost as a result of what?
Fluid or consolidation in the area, secondary to lung hyperinflation as a result of diaphragmatic flattening e.g. COPD
Aneurysm
Mediastinal lymphadenopathy e.g. malignancy
Normal view of small bowel on AXR? Large bowel? 3/6/9 approach?
Central position in the abdomen, valvulae conniventes(mucosal folds that cross the full width of the bowel)
Peripheral position in the abdomen- transverse and sigmoid colon occupy variable positions, haustra, contains faeces
Small bowel= 3cm, colon= 6cm, caecum= 9cm
Soft tissue organs visible on abdominal X-rays? Bones visible? Added densities are due to what?
What approach?
Liver, spleen, kidneys, psoas muscles, bladder & lung bases
Lower ribs, lumbar spine, sacrum, coccyx, pelvis and proximal femora
Artefact or calcified soft tissue
BBC approach- bowel & other organs, bones, calcification & artefact
Other organs & structures on abdominal X-ray?
Lung bases, liver, gallbadder- cholecystectomy clips/ calcified gallstones, stomach, psoas muscles, kidneys, spleen, bladder
Views used to look at hip X-rays? Approach?
AP either standing or supine- usually both legs internally rotated to obscure femoral neck length
Lateral- lying supine, knees flexed, hip abducted and externally rotated (frog-leg position)
ABCS: adequacy/ alignment, bones, cartilage & joint spaces, soft tissue
3 rings on pelvic X-rays? Joint spaces? Acetabulum? Proximal femur?
Pelvic inlet & 2 obturator foramina
Sacroiliac joints(2-4mm) & pubic symphysis(space<5mm)
Iliopectineal line- anterior column/ ilioischial line- posterior column
Proximal femur- Shenton line(interruption–> NOF fracture)
Sacral foramina- arcuate lines should be smooth & symmetrical, angulated–> sacral fracture
What is the adequate anatomy to be visible within the borders of the image? Ensure what are in the midline?
Most common intracapsular (NOF) hip fractures? Also what types? Extracapsular fractures occur where?
Usually above iliac crests to 1/3rd down the femoral shaft
Coccyx tip and pubic symphysis
Sub-capital- just distal to femoral head
Transcervical/ basicervical
Below the intertrochanteric line
What bones to assess on pelvic X-rays?
Cortical outline, bony texture and symmetry of: femur, pelvic bones, any bony mets
Cartilaginous joints to observe on pelvic X-rays? Soft tissues?
Acetabular joint- femoral head, joint space 3-5mm, pubic symphysis(>10mm in pubic diastasis- pain worse by weight-bearing/ walking & waddling gait,) sacroiliac joints- space, end-plates
Effusion, periosteal reaction, calcification of soft tissues, foreign bodies
Key features when describing fractures? Changes in alignment suggest what? ABCS approach?
Angle/ direction of the distal part compared to the anatomical position- forearms= supinated
Open vs closed= important, comminuted/ spiral/ transverse/ oblique
Fracture, subluxation- partial dislocation, or dislocation
Alignment & joint space- narrowing/ calcification/ osteophytes, bone texture, cortices- infection & tumours, soft tissues- swelling, foreign bodies or effusions
Describing fracture steps?
1) Where- proximal/ middle/ distal, whether the articular surface is involved
2) Complete fractures: transverse- fracture at right angles–> shaft, oblique- fracture at angle to shaft, spiral- twisting injury, comminuted- 2/ more bone fragments, impacted- bones forced together
Incomplete fractures(most common in children): torus/ buckle- bulge in cortex, bowing- bend in bone shaft, greenstick- bending of shaft with fracture on convex surface, salter-harris- involving growth plate
3) Open/ closed fractures
4) Displacement- in terms of the distal fragment to the body e.g. anterior/ posterior- can involve angulation- dorsal/ palmar or varus/ valgus or radial/ ulnar, translation- movement of bones away from each other, rotation- usually difficult to interpret
Adequacy needed in a cervical X-ray? Views needed?
From C1 down to the C7/T1 junction
Lateral: anterior & posterior longitudinal lines, spinolaminar line- along anterior edge of spinous processes
AP view
Odontoid/ open- mouth view- peg can be viewed as an increased area of density within the body of C1
Soft tissue is best assessed using what? Above C4 pre-vertebral soft tissue should be no longer than what? From C4 onwards?
Lateral views as a light grey opacity on cervical X-rays between vertebral bodies and darker-grey representing trachea- widening–> pre-vertebral haematoma
1/3 of the adjacent vertebral body in width, the width of one whole vertebral body
Canadian C-spine rules? High-risk? Low-risk? If low risk do what? At any point not satisfied do what?
Age>/=65 y/o, extremity paraesthesias/ dangerous mechanism, axial load injury, high speed MVC/ rollover/ ejection, bicycle collision, motorized recreational vehicle
Comfortable sitting ambulatory at any time, delayed neck pain, no midline tenderness, simple rear-end motor vehicle motor collision
Actively rotate neck 45 degrees left and right without issue
CT cervical spine
Views in wrist X-rays? How is adequacy checked?
Lateral & PA views- oblique may be assed for radial side of wrist
Includes distal radius and ulna with no overlap
How can alignment of wrist XR in PA view be checked?
Distal radial contour- smooth, distal radial articular surface’s position, radial inclination(>25 degrees= fracture,) radial length- loss= impacted radial fracture, Gilula’s/ carpal arcs
How is lateral view of wrist obtained? Normal volar tilt? Oblique view? Normal length of articular joint spaces?
Pronated wrist, thumb facing upwards
11 degrees
Pronating hand 45 degrees from position used for a lateral view–> radial side, radiocarpal joint, scaphoid, scaphotrapeziotrapezoidal joints
1-2mm
Monteggia fracture is what with what? Opposite called what? (MUGGER- MU/GR) Colles’ vs Smith fractures? Barton fractures?
Ulnar fracture with possible radial dislocation
Galleazzi
Colles- extra-articular bowing fracture by FOOSH in dorsiflexion/ palmarflexion
Intra-articular fractures of distal radius- can be dorsal(standard,) or volar(reverse)- usually ass w/ subluxation/ dislocation of radiocarpal joint