Ami pro - icu_xray.pdf

Normal CXR
- measured inside ribs- PA, inspiratory, erect film ~ 1.5 cm change in diameter between inspiration / expiration "Apparantly" Normal CXR
- clavicles & hyperparathyroidism- spine - small pneumothorax- apical lung disease Respiratory Distress & "Normal" CXR
- FB, secretions, ETT cuff, epiglottis, croup, etc.
Single - Common
Multiple - Common
Single - Uncommon
Multiple - Uncommon
Features suggestive of malignancy,
CXR appearances
Lobar pneumonia
2. no "air" bronchogram
Common causes
Butterfly Appearance
Reversed Butterfly Appearance
Bilateral Hilar Enlargement
- renal cell- melanoma- nead/neck carcinoma vascular
pulmonary hypertension- chronic lung disease - multiple pulmonary emboli- primary pulmonary hypertension post-pulmonary stenosiscongenital large pulmonary arteryaneurysm Cavitating Lesion on CXR
Lung Infections
- Staph., gram negatives, Klebsiella, anaerobes - Staph., gram negatives, Klebsiella, anaerobes, fungi - viral, TB, atypical, fungal, pneumocystis Apical Disease on CXR
Peribronchial Thickening
Diffuse Pulmonary Infiltrates
NB: divide into
acute or chronic,
upper or lower distribution
- sepsis, trauma, transfusion reaction, fat emboli, etc.
- contusions, trauma- infarction, Goodpasture's, coagulopathy- idiopathic haemosiderosis in severe COAD the distribution of oedema is patchy
upper zones
ankylosing spondylitis, ulcerative colitis chronic:
lower zones
amiodarone, bleomycin, busulphan, methysergide, hydrallazine, procainamide,sulphonamides Upper Lobe

Lower Lobe

- other- busulphan, bleomycin, amiodarone, methotrexate Diffuse Interstitial Disease + Mediastinal Lymphadenopathy
Diffuse Interstitial Disease + Skeletal Abnormality
- RA, scleroderma, sarcoidosis- hypertrophic pulmonary osteoarthropathy Miliary Opacities
Cardiophrenic Angle Mass
Hyperinflated Lungs
bilateral hyperinflation
unilateral hyperinflation
apparent unilateral hyperinflation
Pulmonary Oligaemia
Pulmonary Plethora
- polycythaemia- thyrotoxicosis- fluid overload - ASD, VSD, PDA- partial anomalous pulmonary venous drainage - transposition, truncus arteriosus- partial anomalous pulmonary venous drainage Massive Lesion On CXR
> 6 cm
Mediastinal Masses
Calcification on CXR
NB: not carcinoma, not hydatid
localised calcification
diffuse calcification
hilar calcification
tuberculosissilicosissarcoidosishistoplasmosis "eggshell" calcification
pleural calcification
Extrapleural Mass on CXR
Pleural Effusion
NB: > 300 ml
homogenous opacity obscures heart border and diaphragm increase distance between lung and stomach gas on left.
lateral decubitus reveals change in meniscus and useful for small or unusual effusion
Massive Pleural Effusion
Rib Notching
Aspiration Pneumonitis
opacities spreading from hilum into parenchyma Tuberculosis
primary lesion in middle lobe or apex of lower lobe Carcinoma
lung metastases
central mass
peripheral mass
Pulmonary Embolus
transient unilateral increase in lung lucency pleurally-based, wedge-shaped or 'D'-shaped opacity on lateral CXR NB: lower lobe more common than upper lobe;
right lung more common than left lung
Pulmonary Arterial Hypertension
enlarged, well-defined hilar vessels - arise from hilum CXR changes are late
Pulmonary Venous Hypertension
NB: ↑ magnification on portable AP films, ∴ may exceed these limits Fat Embolus
Lung Infiltrates In Renal Failure
Mesothelioma / Asbestosis
Def'n: asbestosis
Heart Size
small heart
massive enlargement
moderate enlargement
- supine or AP film- raised hemidiaphrams ↑ pulmonary blood flow & LA volume overload Cardiac Failure
"cotton-wool" opacities around bronchi pleural effusion, fluid in lobar fissures NB: severe CAL
interstitial & vascular changes may not occur lung fields reflect cardiac function better than heart size does Pulmonary Oedema
chronic / cardiogenic
acute and/or non cardiogenic
no lymphatics nor venous congestion visible NB: Kerley's lines: A & B →
large, 4-6 cm, irregular, radiate from hilum to upper lobes short 1-2 cm, horizontal, basal, touch pleural margin permanent - MS, tumour, lymphangitis, pneumoconioses fine curvillinear, often generalised, giving reticular pattern Pulmonary Oedema:
NB: signs usually present in acute pulmonary oedema,
NB: all but #3 may be present in acute cardiogenic pulmonary oedema
Pulmonary Oedema:
re-expansion of collapsed lung or pneumothorax Mitral Stenosis
straight left heart border & ↑ LA appendage normal heart size in uncomplicated cases
Left Atrial Dilatation
Fallot's Tetralogy
apex of the heart raised above level of hemidiaphragm Atrial Septal Defect ASD
septal defect with mongolism can → isolated RUL congestion (mechanism unknown) NB: ↑↑ pulmonary blood flow & RV output with volume overload
Eisenmenger's Syndrome
Def'n: reversal of right → left shunt as a result of pulmonary hypertension
Coarctation of the Aorta
"wasting" or "3-sign" on descending aorta Pericardial Effusion
NB: XRay changes late
"water-bag" cardiomegaly, large globular cardiac shadow acute angle between cardiac shadow and hemidiaphragms.
- no movement of heart seen to blurr film Constrictive Pericarditis
chronic idiopathicchronic renal failurerheumatoid arthritisneoplastictuberculosisirradiation Patent Ductus Arteriosus
Right Heart Failure
no alveolar oedema
focal loss of bone density lining pituitary fossa > 2 mm shift of calcified pineal on lateral film CT Scan
loss of grey-white matter differentiation Hydrocephalus
CT Scan Criteria
± enlargement of basal cisterns and 4th ventricle ± periventricular deceased density → communicating hydrocephalus may have associated intracerebral blood or oedema convex (biconvex) bulging opaque swelling
classical shape does not occur post-surgically associated oedema and midline shift common often associated intracerebral haemorrhages area of decreased density within brain substanceusually within the territory of a major vesselreduced density & mild mass effect may be seen as early as 6 hrs, usually > 24 hrs may be focal or generalized, with loss of grey/white matter differentiation
may be normal in the presence of marked oedema & raised ICP
low density lesion which has peripheral enhancement on contrast the majority have no CT abnormalitiesHSV characteristically results in bilateral (initially unilateral) reduction in densityand surrounding compression of the temporal poles basal ganglia may appear more distinct due to ↑ contrast the majority have no CT abnormalitiesmeningeal enhancement may be seen with contrast AXR Review
liver edge, spleen edge, psoas margins, renal outlines - peritoneal cavity- biliary tree- renal system- uterus- subcutaneous - bodies, disc spaces, transverse processes Paralytic Ileus
increased air fluid levels predonimantly in small bowel no signs of mechanical obstruction (hernia, volvulus) Small Bowel Obstruction
many plica semilunares visible
gas below inguinal ligament
NB: gas in biliary tree + SBO at Mekel's
Large Bowel Obstruction
Plain AXR
- peripheral with haustra
> 5 cm
SBO usually absent if ileocaecal valve competent NB: if in doubt, barium enema will exclude pseudo-obstruction
Ischaemic Bowel
Plain AXR
small bowel, ascending and transverse colon Portal Venous Gas
NB: distribution
- peripheral to within 2 cm of liver edge Pneumothorax
translucent area superiorly without lung markings Pneumothorax
Pulmonary Barotrauma
linear air streaks radiating towards hilum Pulmonary Contusion
immediate (< 6 hrs) ill-defined density or consolidation Lung Infiltrates
does not extend beyond pericardial reflectionsgas beneath heart Thoracic Aortic Rupture
highly suggestive
left bronchus displaced inferiorly
low association
Diaphragmatic Rupture
CXR often normal,
with signs of major chest injury → high suspicion
gastric dilatationhigh hemidiaphragmloculated pbeumothoraxsubpulmonic haematoma Oesophageal Rupture
Raised Hemidiaphragm
- abscess, ascites, pancreatitis, hepatomegaly, tumour- obesity, pregnancy Rheumatoid Arthritis
- but not DIP


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