Chest X-ray Interpretation for
Critical Care Transports
Focusing on what matters…
Robert Donovan MD FACEP
Medical Director PHI California
Chief of Staff Doctors Medical Center
We went from surface anatomy to
being able to look under the skin
How Are X-rays Made?
Bone: Somewhat dense
whiter than tissue,
darker than handcuffs
Metal : Dense
Nothing goes
through
Systematic Approach to Chest X-rays
• Lots of methods
• Learn any one, then stick to it
• Most errors are made because of poor viewing
conditions, no method, and going too fast
A
B
C
D
S
For all X-Rays, check the 4 R’s….
• Right Person?
• Right/Left?
• Rotated?
• Radiation?
25 yo Male with
complaint of pleuritic
chest pain on the
right side.
Airway - Aorta
Breathing - Bones
Circulation - Cardiac
Diaphragm - Deformity
Soft tissues - Shoulder
Airway - Aorta
What we are looking for with..
• Airway
– Position
• Is it mid-line? If not: ?Rotation ? Pathology ? Tension?
– Corina
• Helps with placement of ET tube depth
– Caliber
• Steepling – hints towards croup as Dx
What we are looking for with..
• Aorta
– Location
• Helps Identify Left vs Right on x-ray
• Helps you find left mainstem bronchus
– Calcifications
• Nice but not particularly significant
– Size (Mediastinum)
• Despite current media: size matters
• Big -> possible aortic pathology
Airway - Aorta
Breathing - Bones
What we are looking for with..
• Breathing
– Look at the lung fields
– Hazy/White = pneumonia/infiltrate or mass
– Too Dark (or absence of markings)
• Possible Pneumothorax
• Possible Bulla
What we are looking for with..
• Bones (Focus on Ribs)
– Fractures
• Points towards degree of injury/mechanism
• Gives us clues of possible underlying injuries
Airway - Aorta
Breathing - Bones
Circulation - Cardiac
What we are looking for with..
• Cardiac
– “Big” or “Not Big”
– Well defined Margins
– Subtle bumps (RV enlargement)
Airway - Aorta
Breathing - Bones
Circulation - Cardiac
Diaphragm - Deformity
What we are looking for with..
• Diaphragm
– Configuration
• 2 rounded humps
– Sharp Margins
– Sharp Sulci
– Look underneath
• Gas where it should or shouldn’t be
• NG tube
What we are looking for with..
• Deformity (All the other Bones)
– Clavicle fractures/Dislocations
– Humeral fractures/Dislocations
– Scapula
• Follow the curve of the tip
• Look for Fracture
Airway - Aorta
Breathing - Bones
Circulation - Cardiac
Diaphragm - Deformity
Soft tissues - Shoulder
What we are looking for with..
• Soft Tissues
– Air
– Foreign Bodies (Including chest tube placement)
What we are looking for with..
• Shoulder
– Fracture
– Dislocation
Chest X-ray
• Pneumothorax
• Effusions
• Pneumonia
Spontaneous Pneumothorax
Looking for love in all the wrong places
• On all films, look for air where it shouldn’t be
• Air in the wrong place => pathology!
Beware of the “straight line”
• In nature (and with
x-rays), straight lines
are unusual
• In X-rays, if you see
a straight line, think
about an air-fluid
level
FINAL EXAM
Airway - Aorta
Breathing - Bones
Circulation - Cardiac
Diaphragm - Deformity
Soft tissues - Shoulder
65 yo male, c/o SOB