Test 1: Xray Flashcards
Overexposure:
-too dark, could see bones well
-thoracic spine, mediastinal structures, and retrocardiac areas seen well, but fine structures in lung not seen
Underexposure:
-too white/light
-can think infiltrates are present when they are not
What’s the main difference in AP vs PA x-rays?
-anterior-posterior (AP) x-rays will make the heart appear LARGER.
System for interpreting x-rays:
ATMIB
-Abdomen
-Thorax
-Mediastinum
-Individual Lungs
-Bilateral lungs
Most important things to look at with abdomen on x-ray:
-location of gastric bubble
-hemidiaphragms
What is the deep sulcus sign?
-air/pneumo can push down on lung and this depresses the diaphragm
What does this image show?
-Pneumothorax in the lower left lobe (dark space that contours to the normal costophrenic angle)
Counting ribs: start on anterior or posterior side?
Anterior!!
When are we worried about the size of the cardiac silhouette?
-If greater than 1/2 to 2/3 the thoracic distance, this would indicate cardiomegaly
What does 3 indicate in this image?
The aortic knob
What can we do to the x-ray image to see air-filled structures easier?
invert it!
So no matter what system we use, what all do we need to assess on x-rays?
-bony framework
-soft tissues
-lung fields and Hila
-diaphragm and pleural spaces
-mediastinum and heart
-abdomen and neck
Which ribs should the diaphragm overlie?
-posterior aspect of the 10th or 11th ribs
What parts of spine can we make out on x-ray from an anterior view?
-Down to T3 to T4
What can be blocked by mediastinum and underexposed?
Sternum
True or false: hemothoraxes are usually one-sided
True!
What is the hilum or the “lung root”?
-the shadow of pulmonary artery and vein adjacent the heart shadow
What’s a picture of a normal air bubble?
:)
Examples of Different Densities:
Pitfalls to poor chest x-ray interpretation:
-poor inspiration
-over or under-penetration
-rotation of patient
-forgetting the path of x-ray beam
Where do we want ETT to be?
2-3 cm above the carina
Where are aspirated substances more likely to settle?
-in the bases of the lungs
Image of Segments of right lung:
-extensive overlap in the anterior view!
-RUL occupies upper 1/3 of right lung
-anteriorly, RUL extends inferiorly as far as 4th rib
Which ribs do the right upper lobe of the right lung sit adjacent to?
-first 3-5 ribs
Which of the 3 right segments are the smallest?
-the right middle lobe, triangular in shape, narrowest near the hilum
Info about the RLL:
-largest of all 3 lobes, extends superiorly to the 6th vertebral body, and inferiorly to the diaphragm
-occupies 2/3 space of lung
Minor vs Major Fissure:
-both on right side
-minor fissure separates RUL and RML, whereas the major fissure separates the two from the RLL (more oblique)
True or false: there is a defined left minor fissure
false. No defines left minor fissure, only two lobes: left upper and left lower lobe
-only a left major fissure! (slightly inferior in location)
Left vs. Right lung: (referring to number of fissures)
one fissure on left, two on right
What portion of the left lung best corresponds to the right middle lobe?
left upper lobe
What do these numbers correspond with on a normal chest x-ray?
- Aortic Arch
- Pulmonary Trunk
- Left atrial appendage
- Left ventricle
- Right ventricle
- Superior Vena Cava
- Right hemidiaphragm
- Left hemidiaphragm
- Horizontal Fissure
Numbers corresponding with normal chest x-ray, lateral view:
- Oblique Fissure
- Horizontal Fissure
- Thoracic spine and retrocardiac space
- Retrosternal Space
What is the silhouette sign?
-anatomic contact with a border will obscure that border.
-an intrathoracic lesion NOT anatomically contiguous with a border or a normal structure will NOT obliterate that border.
-SO, black line on the chest is normal and NOT a pneumo, it’s just the silhouette of the mediastinum!
What is the air bronchogram sign?
-when you can see the intrapulmonary bronchi on a chest x-ray.
-It means there is abnormal lung consolidation
-with consolidated lung, you can’t see the blood vessels b/c of being surrounded by other soft tissue.
What part of the body can make it hard to visualize lung markings?
-the scapula
What do most disease states do to the lungs?
-replace air with a pathological process
-ex: losing air space to fluid or tumor
Generalized liquid density:
-diffuse alveolar
-diffuse interstitial
-mixed
-vascular
Localized liquid density:
-infiltrate
-consolidation
-cavitation
-mass
-congestion
-atelectasis
Increased Air Density:
-localized airway obstruction
-diffuse airway obstruction
-emphysema
-Bulla
Lobar Consolidation:
-alveolar space filled with inflammatory exudate
-interstitium and architecture intact
-airway is patent
-density to segment or lobe
-airbonchogram
-no significant loss of volume (unless mucus plug)
Atelectasis:
-loss of air
-when obstructive, no ventilation to the lobe beyond obstruction
-density to segment or lobe
-significant loss of volume
-hyperinflation of normal lung as comp.
Stages of Evaluating an abnormality:
- ID abnormal shadows
- Localize lesion
- ID pathological process
- ID etiology
- Confirm clinical suspension
How can clavicles help us visualize ETT placement on chest x-ray?
-the clavicles should be 2-3 cm above ETT
Why is right main stem intubation common in peds?
-smaller space, smaller margin of error
-even neck extension can cause this
True or false: peds breath sounds can refer from side to side.
True! This is why it’s important to feel chest with hand and also pay attention to their airway pressures.
Where should a central line catheter tip lie on x-ray?
-between the most proximal venous valves of the subclavian or jugular veins and the right atrium
What does it mean if the spine and sternum are not lined up with one another on xray?
Pt is probably rotated
When placing a central line, what MUST you do before dilating?
Transduce BEFORE you dilate!
B/c an IJ and a carotid artery will look the same on xray, don’t wanna dilate a carotid!
ID this xray:
Right pleural effusion
ID this xray:
Right middle lobe pneumonia
stays higher than it would if it was lower lobe pneumonia
ID this xray:
Right upper lobe pneumonia
ID this xray:
Right lower lobe pneumonia
ID this xray:
-free air under the diaphragm
-worry about gastric ulcer or perforated ulcer
ID this xray:
-cavity infiltrate, someone has aspirated, walled off inside that chest
ID this xray:
TB
What is the name of this complex?
-Gohn Complex
-a lesion in the lungs caused by TB. Lesions consist of a calcified focus of infection and associated with a lymph node.
-MULTIPLE lesions, not one
ID this xray:
-wide medastinum (anterior mediastinal mass)
-could be aortic rupture b/c cannot visualize aortic knob well
ID this xray:
Left upper lobe mass
ID this xray:
metastatic testicular cancer
-yellow: metastasis
-purple: portocath
ID this xray:
pulmonary metastasis hematogenous
ID this xray:
-pneumomediastinum
-different from air silhouette b/c air is around heart on BOTH sides
ID this xray:
-pneumothorax
-pulmonary markings go out on right side but not all the way on left side, has dark area
ID this xray:
-sub-q air/emphysema
-concern about depressed diaphragm
What is the deep sulcus sign?
-left side has a gastric silhouette and the diaphragm is actually pushed down
ID this xray:
foreign body, in this case, nail in chest
-examples of others:
ID this xray:
-idiopathic pulmonary fibrosis
-ppl working in coal mines for years
ID this xray:
-widespread pulmonary edema, not localized
-large cardiac silhouette can indicate CHF
What does “bat wing” look like on xray and what does it mean?
-fulminant pulmonary edema, can develop into widespread pulmonary edema often
ID this xray:
-left-sided pneumonectomy
ID this xray:
-transverse aortic arch aneurysm
-large, either tumor or wide aorta
-lateral view along with pt hx will tell you if aneurysm or tumor
ID this xray:
cardiomegaly
ID this xray
aortic dissection
(think really wide medastinum)
What is Chilaiditi sign?
-rare, pain due to transposition of a loop of large intestine in between diaphragm and the liver
-can be asymptomatic
-air in bowel is visible instead of just random air under diaphragm
What is boerhaave’s syndrome?
-large scale aspiration, air around the heart
-extremely sick, require thoracotomy, difficult to manage, often septic, high mortality rate
ID this xray:
Bilateral hilar adenopathy
(hilum has fluid retention)
ID this xray:
squamous cell carcinoma, thin-walled cavitation
ID this xray:
LUL atelectasis, loss of heart borders or silhouetting
notice overinflation of unaffected lung
ID this xray:
-right, middle, and upper lobe pneumonia
-anterior atelectasis on the left upper lobe
ID this xray:
cavitation lesions, look gross and smell bad
ID this xray:
TB
ID this xray:
emphysema, pink circle shows air trapping, notice flattened out diaphragm on right side
What are anatomical indicators of COPD?
-increase in heart diameter, flattenign of the diaphragm, and increase in size of retrosternal air space
-upper lobes also become hyperflucent due to destruction of lung tissue
ID this xray:
-pseudotumor, fluid filled minor fissure that looks like a tumor but isn’t
-is actually pleural effusion in right pleura
ID this xray:
pneumonia
(right lower lobe)
ID this xray:
CHF
-notice how much diuretic therapy can help in this image taken 24 hours later:
ID this xray:
-chest wall lesion, not on lung itself
-will still cause compression and some irritation
ID this xray:
chylothorax-loss of costophrenic angle-pleural effusion
ID this xray:
lung mass
Id this xray:
LUL pneumothorax
small, lung has been “pushed down” by the air
ID this xray:
right middle lobe pneumothorax, notice how much it improves after chest tube insertion!
ID this xray:
metastatic lung cancer
ID this xray:
RUL pulmonary nodule
ID this xray:
TB
ID this xray:
Perihilar mass: hodgkin’s disease
ID this xray:
-widened mediastinum
-aortic dissection, pt also has tracheal deviation or rotation
ID this xray:
-pulmonary artery stenosis with cardiomegaly, likely secondary to the stenosis
What is the most common cause of consolidation?
What is the alveolar space filled with?
-Pneumococal Pneumonia
-Debris
