Download H = Heart (CHF/ACS)

Don’t make
a “HORID”
mistake
and miss
something
HORID
• H = Heart (CHF/ACS)
• O = Obstruction
• R = Reactive (COPD/Asthma)
• I = Infection
• D = Death! (From a PE/Pneumotx)
General Principles
of the CXR
• We are looking at shadows
▫ Five shades of Gray: black white
(Air  Fat  Muscle  Bone  Metal)
• “The Closer the Crisper”
• Silhouette sign
▫ Two substances of the same density will
lose the shadow between them
• Air is up/ fluid is down
▫ Think of patient position
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Two Minutes
to evaluate a CXR
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You Need a SYSTEM!
John’s
“RIP’T ROR’ing ABCs”
Technique
• RIP’T = Quality of the radiograph
• R = Rotation (Clavicles line up?)
• I = Inspiration (9-11 Ribs)
• P = Penetration (Vertebral bodies behind heart)
• T = Technique (PA versus AP?)
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Inspiration
Penetration
Technique?
AP = Blurred Image
PA = More Perfect Image
“ROAR”
•R=Right Patient
•O=Old films?
•A=Alignment Is it hung correctly?
•R=Right date
“ABCs”
• ABCs is the systematic approach
▫ A = Air Spaces
▫ B = Bones/Borders/Burned
▫ C = Cardiovascular/Mediastinal
▫ S = Soft Tissues
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“ABCs”
• A=Air (Gastric/Free/Lungs)
▫Gastric Air?
▫Free Air?
▫Lung Spaces
Too White or Too Black?
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Air Spaces
“ABCs”
• B = Bones/ Borders/ Burned
▫Look at all bones
▫ Right heart and right diaphragm
▫Left heart and left diaphragm
▫Don’t get BURNED!
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“ABCs”
• C = Cardiovascular/mediastinal
▫ Heart size: enlarged cardiac silhouette
 Check the cardiothorasic ratio
 Greater than 50%?
▫ Mediastinal : Enlarged?
 Pager Sign?/8cm
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“ABCs”
• S = Soft tissue
▫ Neck: shifting of structures
SQ air?
▫ Breast tissue/chest tissue
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Back to Pulmonary Symptoms
HORID
•H = Heart (CHF/ACS)
•
•
•
•
O = Obstruction
R = Reactive (COPD/Asthma)
I = Infection
D = Death! (From a PE/pneumotx)
It’s a “SAD” case of “CHF”
Cardiac (arterial) Risk Factors
• S = Smoking
• A = Age
• D = Diabetes
• C = Cholesterol
• H = Hypertension
• F = Family History
Heart: CHF
• Buzz words:
▫Chest Pain?
▫DOE?
▫Orthopnea? (Pillows?)
▫PND? (Cough?)
▫Leg Swelling?
How do we acutely treat CHF?
▫L=Lasix
▫M=Morphine
▫N=Nitrates
▫O=Oxygen…then you…
▫ P=Pee (as in to pee from the Lasix)
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2
3
2
1
3
Heart :
Radiographic Diagnosis of CHF
(…makes me “BELCH”)
B = Bat Wings (aka “perihilar cuffing”)
E = Effusions
L = Lines (Kerly A and B lines)
C = Cephalization
H = Heart enlargement
(Pearl: you must have a Big Heart to have CHF)
Cephalization
Enlarged Heart
Upon
Presentation
One
Day
Later:
CHF Review
Acute Treatment
The Money:
•Bi Pap
•Nitro Drip: Go Big!
▫Morphine?
“Kiss” them with Lasix, don’t pound them!
Nitro
• Contraindications to NTG
▫ Low Blood Pressure
▫ Erectile Dysfunction Medication
▫ Right Ventricular Infarction
 No NTG without …
_______________
CHF Points:
• An under penetrated CXR may appear as
CHF. Use pre-test probability to help in
the diagnosis. (BNP)
• Be careful of the diagnosis of Bilateral
pneumonia. Could this be urosepsis
putting the patient into failure?
HORID
• H = Heart (CHF/ACS)
•O = Obstruction
• R = Reactive (COPD/Asthma)
• I = Infection
• D = Death! (From a PE/pneumotx)
Obstructive
• This could be a simple as an ingested
foreign body, tumor, allergic, traumatic.
• Stridor?
•
•
•
•
FBAO?
Allergic? (ACE Inhibitor?)
Lesion?
Infection? (Croup/Epiglottitis?)
Croup/Epiglottitis
Decadron
0.15mg/kg IM
Racemic Epi?
Obstruction in the Airway?
Handle with “TLC!”
•T=Timing
▫ How rapidly progressive is the lesion?
•L=Location
•C=Compression
HORID
• H = Heart (CHF/ACS)
• O = Obstruction
•R = Reactive (COPD/Asthma)
• I = Infection
• D = Death! (From a PE/pneumotx)
Reactive
COPD/Asthma
COPD
Emphysema
Air Space Destruction
Reactive
Airway Chronic
Disease Bronchitis
Enlarged Goblet Cells
Wheezing
Asthma
Treat them while they’re making “NOISE”
• N = Nebulizers
▫ Albuterol (B2 Agonists)
▫ Atrovent (Anticholenergic)
• O = Oxygen
• I = IVF
• S = Steroids
• E = Epinephrine
Mag? Aminophylline? Terbutaline?
HORID
• H = Heart (CHF/ACS)
• O = Obstruction
• R = Reactive (COPD/Asthma)
•I = Infection
• D = Death! (From a PE/pneumotx)
Infection
• Clinical Features?
▫Leukocytosis
▫Hypoxia
▫CXR infiltrate
Fever? Think “wind” (pneumonia) or “water” (UTI)
Pneumonia:
3 different radiographic presentations
Bronchial pneumonia
May be prone to atelectasis
Alveolar pneumonia
May be prone to air bronchograms
Interstitial pneumonia
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Bronchial Pneumonia
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Bronchial Pneumonia
(Bad Bugs: “PEAS”)
•P =Pseudomonas
•E = E. Coli
•A = Anaerobes
(aspiration)
▫ Klebsiella classic w/ ETOH’ers
•S = Staph
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Alveolar Pneumonia
(aka: CAP)
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Typical CAP Bugs: “SHzAM”
•S = Strep Pnuemo
•H = H. Flu
•A = Atypicals
•M = M. Cat
• Macrolide/FQ /Combo therapy
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Alveolar Pneumonia
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Interstitial Pneumonia
(Small Bugs: Viruses/ PCP )
Question:
When can you have a
pneumonia and NOT
see an infiltrate on
CXR?
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No infiltrate seen on CXR?
• Dehydration: the body is not going
to waste water to hydrate an infected
lung
• COPD’ers: they have excessive air in the chest,
making a pneumonia more subtle
• Retro Cardiac (Lingula) Pneumonia: on
AP film, you need a lateral
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HORID
•
•
•
•
H = Heart (CHF/ACS)
O = Obstruction
R = Reactive (COPD/Asthma)
I = Infection
•D = Death!
Pulmonary Embolism:
PE is the
Name
That
Tune
of
Chest
Symptoms
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Who is Your PAPPA?
• P = Pericarditis
• A = Acute Coronary Syndrome
• P = Pnemothorax
• P = Pulmonary Embolism
• A = Aortic Aneurysm (Thoracic)
Who is the
most accurate
medical provider to
diagnosis
pulmonary
embolism?
What’s the Key to Diagnosis?
High Degree of Clinical Suspicion!
That was a “WHALE” of a PE
•W= Westermark Sign
•H = Hampton's Hump
•A = Atelectasis
•L = Lovely
▫ Meaning perfectly normal
•E = Effusions
“No one can say
4 times in 4 seconds”
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