emergency x ray films dr ahmed esawy
TRANSCRIPT
Dr Ahmed Esawy
Emergency X
RAY films
Dr. Ahmed Esawy
MBBS M.Sc MD
Dr Ahmed Esawy
Plain x- ray
Dr Ahmed Esawy
Dr Ahmed Esawy
• The Elements of a chest x-ray
(CXR)
• The Broncho-vascular markings in
the lung
• The borders of the heart
• The contours of the mediastinum
and pleural space
• The ribs and spine
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• The Elements of a chest x-ray (CXR)
• The Broncho-vascular markings in the lung
• The borders of the heart
• The contours of the mediastinum and pleural space
• The ribs and spine
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• The normal
structures that
account for the
mediastinal contours
seen on chest X-ray
are diagramed below
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Dr Ahmed Esawy A- A resin corrosion cast of the adult human lower trachea and bronchial tree Dr Ahmed Esawy
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• This diagram shows
the appearance of a
bronchogram ( X-ray
dye in the bronchi)
and a schematic
identifying the
bronchial segments.
Note that on the frontal
view there is
considerable overlap
of segments.
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• The diagrams below
show the portion of
the mediastinum
associated with each
of the lobes.
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•ATELECTASIS,
LOBAR
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• COLLAPSE (ATELECTASIS)
• Collapse means partial or complete loss of
volume of a lung.
• Mechanisms of collapse (types):
• 1. Relaxation or passive collapse
• 2. Cicatrization collapse :
• 3. Adhesive collapse :
• 4. Resorption collapse (obstructive):
(causes : outside - inside - lumen)
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A. Direct signs (Lobar signs) of collapse
- Displacement of the interlobar fissures.
The most reliable sign.
• - Loss of aeration or increased density of
the collapsed area.
• - Vascular and bronchial signs
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B. Indirect signs (extra-labor):
• 1. Elevation of the hemidiaphragm:
especially in lower lobes collapse.
• 2. Mediastinal shift:
• 3. Hilar displacement:
• 4. Compensatory hyperinflation of
the normal parts of the lung:
• 5. Rib approximation.
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PATTERNS OF COLLAPSE
• A. Entire lung collapse “complete collapse”:
• B. Lobar collapse:
• C. Multilobar collapse :
• D. Atypical forms of collapse :
• 1. Rounded atalectasis or folded lung:
• 2. Fleischner’s plate atalectasis :
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• Lobar atelectasis.
Lingula collapses
medially.
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• Lobar atelectasis. Complete atelectasis of left lung.
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Lobar atelectasis. Left upper lobe collapses
superiorly and anteriorly.
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• Lobar atelectasis. Left upper lobe collapse. The radiograph shows opacity contiguous with the
aortic knob, a smaller left hemithorax, and a mediastinal shift. The luftsichel sign is
hyperextension of superior segment of the left lower lobe, which then occupies the left apex.
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• Lobar atelectasis. Left upper lobe collapse results in a veil-like opacity extending
upward and outward from the hilum. Additional signs of loss of volume in the left
hemithorax and crowding of the ribs are also evident on this radiograph.
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• Lobar atelectasis. Left upper lobe collapses anteriorly, as shown on
this lateral chest radiograph
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• Lobar atelectasis. Left lower lobe collapses
posteriorly and inferiorly.
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• Lobar atelectasis. Left lower lobe collapse. Radiograph shows volume loss
on left side, an elevated and silhouetted left diaphragm, and an opacity
behind the heart (sail sign).
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• Lobar atelectasis. Right upper lobe collapses posteriorly
and inferiorly.
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• Lobar atelectasis. Complete right lung atelectasis.
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• Lobar atelectasis. Right upper lobe collapse. Radiograph shows volume loss in the upper lobe, upward shifting of the horizontal fissure, and elevation of the right side of the diaphragm.
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• Lobar atelectasis. Left lower lobe collapse. The
opacity is in a posteroinferior location
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• Lobar atelectasis. As the right upper lobe collapses anteriorly and
superiorly, the opacity is seen in anterior and superior locations on this
lateral chest radiograph.
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• Lobar atelectasis. Right middle lobe collapses
medially
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• Lobar atelectasis. Right middle lobe collapse
obliterates the right heart border on a posteroanterior
(PA) image and projects as a wedge-shaped opacity
on a lateral chest radiograph
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• Lobar atelectasis. Right lower lobe collapses medially
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• Lobar atelectasis.
Right lower lobe
collapse results in
volume loss,
obliteration of the
right side of the
diaphragm, and a
posterior opacity on
this lateral chest
radiograph
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• Near drowning in a 46-year-old man. Anteroposterior chest
radiograph obtained in the intensive care unit shows diffuse,
bilateral pulmonary edema.
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• Anteroposterior chest radiograph shows interstitial and alveolar pulmonary edema
Pulmonary Edema, Noncardiogenic
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• Anteroposterior chest radiograph shows bilateral alveolar opacities in a patient with subarachnoid hemorrhage who developed neurogenic pulmonary edema
Pulmonary Edema, Noncardiogenic
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Pneumothorax
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• II. PNEUMOTHORAX
• Definition : Air within the pleural cavity due to defect in parietal or visceral pleura.
• Etiology :
• Spontaneous pneumothorax :
• 2. Traumatic pneumothorax
• Tension pneumothorax (valvular type):
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• A large right-sided pneumothorax has occurred
from a rupture of a subpleural bleb.
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• A true pneumothorax line. Note that the visceral
pleural line is observed clearly, with the absence of
vascular marking beyond the pleural line.
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• Note that although a skin fold can mimic subtle
pneumothorax, lung markings are visible
beyond the skin fold.
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• Deep sulcus sign in a supine patient in the ICU.
The pneumothorax is subpulmonic .
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• An older man admitted to ICU postoperatively. Note the right-sided pneumothorax induced by the incorrectly positioned small bowel feeding tube in the right-sided bronchial tree. Marked depression of the right hemidiaphragm is noted, and mediastinal shift is to the left side, suggestive of tension pneumothorax. The endotracheal tube is in a good position.
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• Right main stem intubation resulting in left-sided
tension pneumothorax, right mediastinal shift,
deep sulcus sign, and subpulmonic
pneumothorax
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• Pneumothorax Injury to the lung, either trauma or iatrogenic, frequently result in air leakage into the pleural space. Spontaneous cases (idiopathic) also occur. Severity and duration of pneumothorax is made worse by increased airway pressure, either by obstructive airway disease or positive pressure ventilation. If a "flap valve" mechanism is present, progressive enlargement of space may compromise cardiac filling and ventilation (tension pneumothorax).
• Below, a left pneumothorax with near complete collapse of the lung. Can you find the lung edge?
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• Below is a lateral view showing the middle lobe as a thin atelectatic band over the heart. Once air and blood volume are lost from atelectatic lung, the remaining structure is remarkably compact, and often hard to identify. In some cases, tracing the vessels to identify a missing segment is the only reliable way to detect complete atelectasis.
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•Pneumomediastinum
•pneumopericardium
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• Pneumomediastinum
from barotrauma
may result in tension
pneumothorax and
obstructive shock.
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• patient in ICU developed pneumopericardium as
a manifestation of barotrauma .
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• Posteroanterior chest
radiograph demonstrates
a pneumomediastinum
in bronchial asthma.
Mediastinal air is noted
adjacent to the
anteroposterior window
and airtrapping extends
to the neck, especially
on the right side.
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• Lateral chest radiograph
demonstrates a
pneumomediastinum in
bronchial asthma. Air is
noted anterior to the
trachea.
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Esophagus,
Foreign Body
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• Esophagus, foreing body. Chest radiograph depicts deviation of the trachea to the right in an 18-month-old female infant with upper respiratory congestion lasting 3 months
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• Esophagus, foreign
body. Anteroposterior
radiograph of the neck
demonstrates tracheal
deviation to the right.
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• Esophagus, foreign body.
Anteroposterior chest
radiograph depicts a
penny at the thoracic inlet
of a 13-month-old infant
who refused to eat.
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• Esophagus, foreign
body. Radiograph in a
13-year-old girl who was
playing with jacks
recently.
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• Thorax trauma.
Supine chest
radiograph shows a
misplaced Ryle tube
in the left main
bronchus.
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• Thorax trauma.
Chest radiograph in
a child shows an
inhaled metal screw.
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The viscera
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Retro-peritoneal Structures,
outlined by fat.
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Intra-peritoneal Structures, that
may be outlined by fat
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Normal Gas 'lucency'
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Complete Abdomen Erect
Looking for
Free air
Air-fluid levels
Substitute – left
lateral decubitus
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Complete Abdomen Erect Chest
Looking for
Free air
Pneumonia at bases
Pleural effusions
Substitute – supine
chest
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Normal Fluid Levels
Stomach
Always (except supine film)
Small Bowel
Two or three levels
possible
Large Bowel
None normally
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Plain Radiographs
1. Bowel obstruction
Small & Large
2. Free intra-
peritoneal air
3. Intra-mural gas
Gas in Rectum &
sigmoid
Gas in few
bowel loops
Gas in
stomach
Normal supine Abdomen
Abnormal gas patterns
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•Extra-luminal air
•Free intraperitoneal
air
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Free intra-peritoneal air
Perforated diverticulitis
Perforated carcinoma
Trauma
Intussusception
Post operative 5-7 days
Not perforated appendix
Plain Radiographs
Crescent sign:
air beneath
the diaphragm
Erect AP abdomen
Dr Ahmed Esawy
• a.Crescent sign :air beneath the diaphragm
• b.Falciform ligament sign: air delineating the falciform ligament
• c. Football sign: A large air collection beneath that does not conform to any bowel loop
• d.Rigler's sign: If both the serosal and the related mucosal walls of the bowel are delineated it means free air is at that serosal surface
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Falciform
Ligament
Sign
Football sign
Free intra-peritoneal air
Air on both sides of bowel wall –
Rigler’s Sign
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Algorithmic approach: Imaging of bowel wall lesions
Plain Radiographs
1. Bowel obstruction
Small & Large
2. Free intra-
peritoneal air
3. Intra-mural gas
Gas in Rectum &
sigmoid
Gas in few
bowel loops
Gas in
stomach
Normal supine Abdomen
Abnormal gas patterns
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Dilated
Air-fluid levels
Plain Radiographs
Mechanical obstruction
Collapsed
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Bowel gas pattern
Large bowel
obstruction
Small bowel
obstruction
Peripheral Central
Few Multiple
Haustra incomplete Valvulae: complete lines
Diameter }5cm Diameter <5 cm
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Large vs. Small Bowel
Large Bowel
Peripheral
Haustral markings don't
extend from wall to wall
Small Bowel
Central
Valvulae extend across lumen
Maximum diameter of 2"
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Air in L.
bowel
NO
Distended
loops
Localized
ileus
few
Generalized
ileus
multiple
Air in S.
bowel
LBO SBO
Decompressed
LBO
Air in the
rectum Yes
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LBO decompressed into SB
• in incompetent ileo-caecal valve, gas
in the large bowel may decompress
in the small bowel giving a small
bowel obstruction appearance
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Bowel obstruction
SBO LBO LBO decompressed
into SB
Supine AP
Plain Radiographs
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Intra-mural gas
• pneumatosis coli: Air in the wall of
the bowel with linear areas. It can be
due to obstruction, infection,
ischemia, necrosis, or following
colonoscopy
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Diagnostic Value of plain
radiographs in bowel wall
lesions: • 1. Differentiation between
mechanical obstruction and paralytic
ileus.
2- . Differentiation between small
and large bowel obstruction
3-Diagnosis of perforated viscus
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Esophagus
, Tear
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• Posteroanterior chest
radiograph shows a right-
sided
hydropneumothorax after
an esophageal rupture.
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Sternum,
Fractures
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• Sternum, fractures.
Lateral radiograph of
the normal sternum
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• Sternum, fractures.
Posterior surface of
the sternum
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• Sternum, fractures.
Lateral border of the
sternum
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• Sternum, fractures.
Complete dislocation
at the sternal angle
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• Sternum, fractures.
Lateral radiograph in
the same patient as
in Image before
shows a complete
displaced fracture of
the sternum (arrow).
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Thorax
Trauma
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• Thorax trauma. Bilateral pneumothoraces in an infant with a deep costophrenic sulcus
sign, sharp demarcation of the cardiac border, double-diaphragm contour and
depression of left hemidiaphragm and hyperlucency in lower thorax and upper abdomen.
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• Thorax trauma. Left-sided
tension pneumothorax in
an infant.
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• Thorax trauma. 32-year-
old man with gunshot
wounds. Multiple lead
pellets are noted in the
pleura, adjacent to the
thoracic aorta, spleen,
and left kidney. Note the
hemothorax and splenic
laceration.
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• Thorax trauma. 32-year-
old man with gunshot
wounds. Multiple lead
pellets are noted in the
pleura, adjacent to the
thoracic aorta, spleen,
and left kidney. Note the
hemothorax and splenic
laceration.
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• Thorax trauma. Supine
chest radiograph in a
man who was stabbed.
The knife has been left in
the thorax. Note the
associated left
hemothorax and
pulmonary laceration.
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Rupture
daiphragm
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• Chest radiograph in a
patient with a recent
history of thoracic
trauma after a road-
traffic accident. No left
hemidiaphragmatic
dome can be identified.
An air-fluid level is
present at the left lung
base. At surgery, a left
diaphragmatic rupture
was repaired.
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• Scanogram obtained
before CT in a
patient involved in a
road-traffic accident
shows abdominal
visceral herniation
into the left
hemithorax
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• Chest radiograph in a patient
with a previous left phrenic
nerve injury shows an
elevated atrophic left
hemidiaphragm. Note the air-
filled stomach and bowel
loops under the diaphragm.
On fluoroscopy, paradoxical
movement was recorded.