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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 4 Two Minutes to evaluate a CXR 5 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?) 7 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 10 “ABCs” • A=Air (Gastric/Free/Lungs) ▫Gastric Air? ▫Free Air? ▫Lung Spaces Too White or Too Black? 11 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! 13 14 “ABCs” • C = Cardiovascular/mediastinal ▫ Heart size: enlarged cardiac silhouette Check the cardiothorasic ratio Greater than 50%? ▫ Mediastinal : Enlarged? Pager Sign?/8cm 15 16 “ABCs” • S = Soft tissue ▫ Neck: shifting of structures SQ air? ▫ Breast tissue/chest tissue 17 18 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) 1 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 47 Bronchial Pneumonia 48 Bronchial Pneumonia (Bad Bugs: “PEAS”) •P =Pseudomonas •E = E. Coli •A = Anaerobes (aspiration) ▫ Klebsiella classic w/ ETOH’ers •S = Staph 49 Alveolar Pneumonia (aka: CAP) 50 Typical CAP Bugs: “SHzAM” •S = Strep Pnuemo •H = H. Flu •A = Atypicals •M = M. Cat • Macrolide/FQ /Combo therapy 51 Alveolar Pneumonia 52 Interstitial Pneumonia (Small Bugs: Viruses/ PCP ) Question: When can you have a pneumonia and NOT see an infiltrate on CXR? 55 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 56 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 58 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” [email protected]