CHEST X-RAY INTERPRETATION
BASICS MANNY MORTELL FEBRUARY 2013
CHEST XRAYS MOST FREQUENT REQUESTED INVESTIGATION NURSES OFTEN MAKE INITIAL INTERPRETATIONS ON RECOGNITION OF ANOMALIES IMMEDIATE MEDICAL AWARENESS SHOULD BE INITIATED
THIS LECTURE WILL FOCUS ON THE A - P FILM SINCE IT WILL BE REVIEWED MORE COMMONLY IN THE CLINICAL AREA IN ADDITION A RADIOLOGIST MUST ALWAYS REVIEW EVERY CHEST X – RAY FURTHER USEFUL SELF DIRECTED EDUCATION CAN BE OBTAINED FROM
http://intensivecare.hsnet.nsw.gov.au
WILHELM CONRAD ROENTGEN “FATHER “ OF THE “X” RAY
(1845 - 1923) DEUTCHLAND
PRE-KNOWLDGE REVIEW
Q.1: DENSITY THAT CREATES THE BLACK IMAGE ON X-RAY IS: A) AIR B) FLUIDS C) BONE D) TISSUES
Q.1: DENSITY THAT CREATES THE BLACK IMAGE ON X-RAY IS: A) AIR B) FLUIDS C) BONE D) TISSUES
Q.2 IF BONE IS X-RAYED THE IMAGE WILL BE: A) GREY B) PINK C) WHITE D) BLACK
Q.2 IF BONE IS X-RAYED THE IMAGE WILL BE: A) GREY B) PINK C) WHITE D) BLACK
Q.3 IF THE HEART IS ON THE X-RAY, THE IMAGE WILL BE: A) GREEN B) PINK C) WHITE D) BLACK
Q.3 IF THE HEART IS ON THE X-RAY, THE IMAGE WILL BE: A) GREEN B) PINK C) WHITE D) BLACK
Q.4 THE DENSEST BODY STRUCTURE IS: A) BONE B) LUNG C) FAT D) MUSCLE
Q.4 THE DENSEST BODY STRUCTURE IS: A) BONE B) LUNG C) FAT D) MUSCLE
Q.5 WHEN INTERPRETING AN X-RAY FILM YOU SHOULD: A) CHECK THE PATIENT NAME AND MRN B) CHECK FOR TECHNICAL ERRORS C) CHECK THE X-RAY USING A SYSTEMATIC APPROACH D) ALL THE ABOVE
Q.5 WHEN INTERPRETING AN X-RAY FILM YOU SHOULD: A) CHECK THE PATIENT NAME AND MRN B) CHECK FOR TECHNICAL ERRORS C) CHECK THE X-RAY USING A SYSTEMATIC APPROACH D) ALL THE ABOVE
Q.6 WHEN REVIEWING THE CXR ALWAYS: A) RELATE THE FINDINGS TO YOUR CLINICAL FINDINGS B) HAVE PATIENT INPUT C) ONLY ALLOW THE RADIOLOGIST TO MAKE AN INTERPRETATION D) NEVER USE A VIEWING BOX THAT IS WORKING
Q.6 WHEN REVIEWING THE CXR ALWAYS: A) RELATE THE FINDINGS TO YOUR CLINICAL FINDINGS B) HAVE PATIENT INPUT C) ONLY ALLOW THE RADIOLOGIST TO MAKE AN INTERPRETATION D) NEVER USE A VIEWING BOX THAT IS WORKING
Q.7 REVIEWING TECHNICAL QUALITY OF THE FILM INCLUDES: A) PROJECTION, ORIENTATION, PENETRATION, ROTATION AND DEGREE OF INSPIRATION B) PROJECTION, ORIENTATION, PENETRATION, ROTATION AND DEGREE OF EXPIRATION C) PROJECTION, DISORIENTATION, PENETRATION, ROTATION AND DEGREE OF INSPIRATION D) PROJECTION, ORIENTATION, PENETRATION, ROTATION AND RADIOGRAPHER IDENTIFICATION
Q.7 REVIEWING TECHNICAL QUALITY OF THE FILM INCLUDES: A) PROJECTION, ORIENTATION, PENETRATION, ROTATION AND DEGREE OF INSPIRATION B) PROJECTION, ORIENTATION, PENETRATION, ROTATION AND DEGREE OF EXPIRATION C) PROJECTION, DISORIENTATION, PENETRATION, ROTATION AND DEGREE OF INSPIRATION D) PROJECTION, ORIENTATION, PENETRATION, ROTATION AND RADIOGRAPHER IDENTIFICATION
Q.8 WHICH OF THE FOLLOWING STATEMENTS IS TRUE? A) THE STANDARD CXR FILM IS A P-A B) THE STANDARD CXR FILM IS AN A-P C) THE STANDARD CXR FILM IS A LATERAL D) THE STANDARD
Q.8 WHICH OF THE FOLLOWING STATEMENTS IS TRUE? A) THE STANDARD CXR FILM IS A P-A B) THE STANDARD CXR FILM IS AN A-P C) THE STANDARD CXR FILM IS A LATERAL D) THE STANDARD
Q.9 THE ERECT A – P FILM: A) ALLOWS FREE AIR TO MOVE TO THE APICES OF THE LUNG B) ALLOWS FREE FLUID TO GRAVITATE TO THE BASES OF THE LUNG C) MAKES THE TAKING OF AN INSPIRATION FILM EASIER D) ALL THE ABOVE ARE CORRECT
Q.9 THE ERECT A – P FILM: A) ALLOWS FREE AIR TO MOVE TO THE APICES OF THE LUNG B) ALLOWS FREE FLUID TO GRAVITATE TO THE BASES OF THE LUNG C) MAKES THE TAKING OF AN INSPIRATION FILM EASIER D) ALL THE ABOVE ARE CORRECT
Q.10 THE SUPINE A- P FILM: A) ALLOWS FREE AIR TO MOVE TO THE POSTERIOR ASPECTS OF THE LUNG B) WILL NORMALLY MAKE UPPER PULMONARY VESSELS APPEAR CONGESTED AND HEART LARGER C) MAKES THE TAKING OF AN INSPIRATION FILM EASIER D) ALLOWS FREE FLUID TO GRAVITATE TO THE ANTERIOR ASPECTS OF THE LUNG
Q.10 THE SUPINE A- P FILM: A) ALLOWS FREE AIR TO MOVE TO THE POSTERIOR ASPECTS OF THE LUNG B) WILL NORMALLY MAKE UPPER PULMONARY VESSELS APPEAR CONGESTED AND HEART LARGER C) MAKES THE TAKING OF AN INSPIRATION FILM EASIER D) ALLOWS FREE FLUID TO GRAVITATE TO THE ANTERIOR ASPECTS OF THE LUNG
Q.11 A UNDER PENETRATED FILM WILL MAKE THE X-RAY IMAGES MORE: A) WHITE OR RADIO-LUCENT B) BLACK OR RADIO-OPAQUE C) WHITE OR RADIO-OPAQUE D) BLACK OR RADIO-LUCENT
Q.11 A UNDER PENETRATED FILM WILL MAKE THE X-RAY IMAGES MORE: A) WHITE OR RADIO-LUCENT B) BLACK OR RADIO-OPAQUE C) WHITE OR RADIO-OPAQUE D) BLACK OR RADIO-LUCENT
Q.12 A OVER PENETRATED FILM WILL MAKE THE X-RAY IMAGES MORE: A) WHITE OR RADIO-LUCENT B) BLACK OR RADIO-OPAQUE C) WHITE OR RADIO-OPAQUE D) BLACK OR RADIO-LUCENT
Q.12 A OVER PENETRATED FILM WILL MAKE THE X-RAY IMAGES MORE: A) WHITE OR RADIO-LUCENT B) BLACK OR RADIO-OPAQUE C) WHITE OR RADIO-OPAQUE D) BLACK OR RADIO-LUCENT
Q.13 WHAT IS THE MAIN PROBLEM WITH THE CXR BELOW
Q.13 NOTHING – IT IS A NORMAL CXR
Q.14 WHAT IS THE MAIN ANOMALY IN THE CXR BELOW
Q.14 THE RIGHT UPPER LOBE IS WHITE
Q.15 WHAT IS THE MAIN ANOMALY IN THE CXR BELOW
Q.15 THE RIGHT LUNG IS WHITE
Q.16 WHAT IS THE MAIN ANOMALY IN THE CXR BELOW
Q.16 THE HEART IS BIG
WELL DONE
OBJECTIVES REVIEW HOW IMAGES ARE CREATED ANTERIOR POSTERIOR FILM THE 4 DENSITIES TECHNICAL ASPECTS EXPLAIN A SYSTEMATIC APPROACH TO INTERPRETATION LOCATE INTRA - THORACIC STRUCTURES REVIEW SOME CASE SCENARIOS
WHAT IS A CXR?
WAVELENGTHS OF ELECTROMAGNETIC RADIATION
X - RAY BEAM PENETRATES MATTER IMAGES ON A BLACK & WHITE FILM A PHOTO OF INTRA - THORACIC IMAGES A 2 DIMENTIONAL IMAGE
THE FILM CASSETTE “JUST THAT A PHOTOGRAPHIC FILM”
4 DENSITIES “COLOURS” CREATED BY INTRA-THORACIC IMAGES OVERLAPPING
AIR
LEAST DENSE RADIOLUCENT BLACK
FAT
SUBCUTANEOUS TISSUES - GRAY
FLUID/TISSUE OFF WHITE
BONE
MOST DENSE RADIO-OPAQUE WHITE
BONE - 1. MOST DENSE
FAT / SKIN - 3. NEXT DENSE AIR / LUNGS - 4. LEAST DENSE
FLUID / TISSUES - 2. NEXT DENSE
LOOKING AT CXR WHAT YOU SEE IS WHAT YOU KNOW
SCAN THE X - RAY ALWAYS USE A SYSTEM
WHAT DO YOU SEE … IS IT TO WHITE TO BLACK
TO BIG TO SMALL
IN THE WRONG PLACE
USE A SYSTEMATIC APPROACH
NAME DATE & TIME TECHNICAL QUALITY
SCAN THE FILM CHEST WALL PLEURA LUNG MEDIASTINUM DIAPHRAGM & BELOW
IF YOU DETECT ANY ANOMALIES DECIDE WHICH CATEGORY
TOO WHITE TOO BLACK TOO BIG TOO SMALL WRONG PLACE
ALWAYS EVALUATE THE CXR WITH
INFORMATION FROM
PATIENT HISTORY
INFORMATION FROM
PHYSICAL ASSESSMENT
INFORMATION FROM THE PATIENT’S
CLINICAL CONDITION
SERIAL CXRS IF AVAILABLE
ALWAYS REVIEW
TECHNICAL QUALITY BEFORE INTERPRETATION “5 COMPONENTS”
PROJECTION ORIENTATION ROTATION PENETRATION DEGREE OF INSPIRATION
PROJECTION
DIRECTION OF THE “CAMERA”
P-A A-P SUPINE ERECT LATERAL DECUBITUS
P-A POSTERIOR - ANTERIOR FILM IN FRONT OF PATIENT CHEST
STANDARD THE BEST / MOST ACCURATE
P-A DISTANCE 72 INCHES
P-A FILMS ALL INTRA-THORACIC STRUCTURES ARE CORRECTLY POSITIONED & PROPORTIONED
A-P ANTERIOR - POSTERIOR FILM UNDER PATIENT’S BACK
MANNY MORTELL - 2012
A-P DISTANCE
40 INCHES
A-P FILMS ALL INTRA-THORACIC STRUCTURES ARE NOT CORRECTLY PROPORTIONED ENLARGEMENT MAY OCCUR
TYPICALLY A-P FILMS ARE PORTABLE & CONVENIENT
PATIENTS ARE TOO SICK TO GO TO THE RADIOLOGY DEPATRTMENT FOR A P-A FILM
PROJECTION - A P
AP
ERECT
“BETTER” THAN SUPINE
PLEURAL AIR “RISES” TO APEX
PLEURAL FLUID “MOVES” TO BASES GASTRIC AIR - FLUID LEVEL
ERECT NORMAL PULMONARY BLOOD DISTRIBUTION
ERECT NORMAL HEART SIZE
SUPINE
MAY DISPERSE FLUID (EFFUSIONS) / HIDE AIR (PNEUMOTHORAX)
PLEURAL AIR GRAVITATES SUPERIORLY
PLEURAL FLUID GRAVITATES INFERIORLY
SUPINE
PULMONARY VESSELS MAY FALSELY APPEAR CONGESTED
SUPINE
HEART MAY FALSELY APPEAR ENLARGED
LATERAL - SIDE VIEW
TO SEE SOMETHING MORE CLEARLY FOUND ON THE A-P FILM
PROJECTION - LATERAL
DECUBITUS
LYING ON SIDE TO IDENTIFY - FLUID
PROJECTION - DECUBITUS
FLUID LEVEL - PLEURAL EFFUSION
ORIENTATION
REFERS TO
RIGHT OR LEFT SIDE THE RADIOGRAPHER MARKS THE R OR L SIDE
ORIENTATION
ROTATION IS THE PATIENT
STRAIGHT or TWISTED MEDIAL CLAVICLE ENDS ARE EQUI-DISTANT FROM VERTEBRAE
NO ROTATION
CLAVICLES
CLAVICLE ENDS ARE EQUI-DISTANT FROM VERTEBRAE
ROTATED - TWISTED
DISTORTS THE IMAGES ON FILM
PENETRATION THE DOSE OF X - RAY BEAM USED 60 - 125 Kvolts > 0.2 mAmp seconds CORRECT - VERTEBRAE VISIBLE IN HEART SHADOW TOO MUCH - OVERPENETRATED - TO BLACK TOO LITTLE - UNDERPENETRATED - TO WHITE
CORRECT PENETRATION
SPINAL VERTEBRAE & PULMONARY BLOOD VESSELS VISIBLE THROUGH CARDIAC IMAGE
UNDER PENETRATED TOO WHITE
SPINAL VERTEBRAE & PULMONARY BLOOD VESSELS NOT VISIBLE THROUGH CARDIAC IMAGE
OVER PENETRATED TOO BLACK - LUNGS VERY DARK SPINAL VERTEBRAE & PULMONARY BLOOD VESSELS TOO VISIBLE THROUGH CARDIAC SHADOW
DEGREE OF INSPIRATION NORMALLY TAKEN ON INSPIRATION
5-7
ANTERIOR RIBS
MID HEMIDIAPHRAGM
9 - 10
POSTERIOR RIBS
MID HEMIDIAPHRAGM
INSPIRATORY FILM
ALL INTRA-THORACIC STRUCTURES ARE CLEAR CORRECT SIZE & IN THE CORRECT POSITION
EXPIRATORY FILM
INSPIRATORY
EXPIRATORY
REVIEW CXR FILM
L
ADULT
CHILD
INFANT
L
NEONATE
GENERAL PRINCIPLES FOR ALL AGES ARE SIMILAR BUT REMEMBER YOU ARE NOT RADIOLOGISTS
THE A - P FILM THORAX
AIRWAYS
PULMONARY BLOOD VESSELS
“VASCULAR MARKINGS”
NORMALLY EXTEND FROM THE HEART – HILA TO THE OUTER PERIPHERIES
BONY STRUCTURES
TRACHEA - BRONCHI
FISSURES
HORIZONTAL - LESSOR DIAGONAL
DIAGONAL - MAJOR
LOBES
RIGHT UPPER
LEFT UPPER
RIGHT MIDDLE
RIGHT LOWER
LEFT LOWER
DIAPHRAGM
LIVER STOMACH
IMPORTANT LANDMARKS 1. TRACHEA
2. R MAIN BRONCHUS 3. L MAIN BRONCHUS 4. LPA 5. RUL - PA VEIN 6. RPA 7. RLL - RML VEINS 8. AORTIC ARCH 9. SVC 10. AZYGOS VEIN
THE A - P FILM HEART AND GREAT ARTERIES
RIGHT HEART LANDMARKS 1. RIGHT ATRIUM 2. RIGHT VENTRICLE 3. APEX (LV) 4. SVC 5. IVC 6. TRICUSPID VALVE 7. PULMONARY VALVE 8. PULMONARY TRUNK 9. R PULMONARY ARTERY 10.L PULMONARY ARTERY
RIGHT & LEFT HEART LANDMARKS 1. SUPERIOR VENA CAVA 2. INFERIOR VENA CAVA 3. RIGHT ATRIUM (BLUE) 4. RIGHT VENTRICLE (BLUE) 5. LEFT VENTRICLE (RED) 6. AORTA 7. PULMONARY TRUNK
MEASURING HEART
SIZE CARDIOTHORACIC RATIO
THE DIFFERENCE BETWEEN THE HEART WIDTH & CHEST WIDTH
NORMAL
ADULT < 0.5
THE TRANSVERSE THORACIC MEASUREMENT IS WIDEST ABOVE THE COSTO-PHRENIC ANGLES
ADULT > 0.5 MAY INDICATE CARDIOMEGALLY
ADULT > 0. 5
CARDIOMEGALLY
NORMAL
NEONATE < 0.65 THE TRANSVERSE THORACIC MEASUREMENT IS WIDEST ABOVE THE COSTO-PHRENIC ANGLES
NEONATE > 0.65 MAY INDICATE CARDIOMEGALLY
CARDIOTHORACIC RATIO
NEONATE > 0.65
CARDIOMEGALLY
MEASURING MEDIASTINUM WIDTH
TYPICAL
< 0.3 THE MEDIASTINUM WIDTH IS MEASURED ABOVE THE HEART SHADOW
> 0.3 MAY INDICATE WIDENING
30%
ADULT > 0. 3
LET US REVIEW THE
A-P FILM
1
ST
ENSURE RIGHT PATIENT
SCAN THE FILM FROM OUTER TO INNER COMPARE RIGHT & LEFT SUBCUTANEOUS TISSUES CHEST WALL - THORAX PLEURA LUNGS MEDIASTINUM - HEART DIAPHRAGMS BELOW THE DIAPHRAGMS
THORAX - PLEURA
SUBCUTANEOUS LUNGS
MEDIASTINUM - HEART
DIAPHRAGMS & BELOW
REMEMBER - THINK? ARE THE IMAGES TOO WHITE? ARE THE IMAGES TOO BLACK? ARE THE IMAGES TOO BIG? ARE THE IMAGES TOO SMALL? ARE IMAGES IN THE WRONG PLACE? WHAT YOU SEE IS WHAT YOU LEARN & KNOW
NORMALLY THE LUNGS ARE BLACK WITH VASCULAR MARKINGS ‘ LINES - BLOOD VESSELS’
LOOKING AT THE LUNGS
NORMALLY THE LUNGS ARE
EQUAL TRANSRADIANCY ‘BLACKNESS’
LOOKING AT THE LUNGS
SOMETIMES THE RIGHT LUNG’S
HORIZONTAL FISSURE MAY BE VISIBLE
LOOKING AT THE LUNGS
LOOK AT THE HILUM WHERE THE PULMONARY BLOOD VESSELS PULMONARY NERVES PULMONARY LYMPHATICS ARE LOCATED…
NORMALLY THE HILA ARE WHITE WITH VASCULAR MARKINGS LEFT HIGHER THAN RIGHT < 3 CM CONCAVE IN APPEARANCE EQUAL IN SHAPE
LOOK AT THE HEART
THE NORMAL HEART
IS WHITE ADULT < 0.5 APEX MORE ON LEFT
NORMAL HEART
IS WHITE NEONATE < 0.65 APEX MAYBE EQUAL
LOOK AT THE MEDIASTINUM
NORMALLY IT IS WHITE
< 0.3 MEDIASTINAL THORACIC RATIO TRACHEA - MIDLINE CARDIAC BORDERS SHARP & CLEAR
30%
LOOK AT THE DIAPHRAGMS
NORMALLY THEY ARE
DOME SHAPED AND SHARP & CLEAR LINES RIGHT < 3 cm HIGHER THAN LEFT
ALSO ALWAYS LOOK UNDER THE DIAPHRAGM FOR A GAS BUBBLE
LOOK AT THE
COSTOCARDIAC COSTOPHRENIC ANGLES
NORMALLY THEY ARE GREY TO BLACK SHARP & CLEAR
LOOK AT THE TRACHEA
NORMALLY THE TRACHEA IS GREY TO BLACK IN COLOUR “AIR BRONCHOGRAM’
SHARP & CLEAR MIDLINE CARINA THE BIFURCATION
LOOK AT THE THORAX
NORMALLY THE BONES ARE WHITE & SYMMETRICAL SMOOTH CONTOURS EQUAL DENSITY NO FRACTURES ALSO COMPARE RIGHT TO LEFT
LOOK AT THE INTERCOSTAL SPACES
NORMALLY THEY ARE
SYMMETRICAL RIGHT TO LEFT
EQUAL WIDTH
LOOK AT THE SOFT TISSUES
NORMALLY THEY ARE
GREY - OFF WHITE RIGHT TO LEFT EQUAL DENSITY
ALSO DON’T FORGET TO LOOK FOR THE NIPPLES & BREAST TISSUE
USING LUNG
ZONES TO LOCATE ANOMALIES
APEX - 2ND ICS 2ND ICS - 4TH ICS 4TH ICS - BASE
LET US REVIEW
WHAT ARE THE 4 DENSITIES?
BONE
FAT AIR
FLUID - TISSUES
NAME SOME TYPES OF PROJECTION
P-A A-P SUPINE ERECT LATERAL DECUBITUS
HOW MANY RIBS SHOULD BE VISIBLE ON INSPIRATION?
5-7
ANTERIOR RIBS
MID HEMIDIAPHRAGM
9 - 10
POSTERIOR RIBS
MID HEMIDIAPHRAGM
NAME THE
LUNG LOBES ON THE A - P FILM
RUL
LUL
RML
RLL
LLL
NAME THE LUNG
FISSURES ON THE A - P FILM
LOOKING AT THE LUNGS
LOOKING AT THE HORIZONTAL – LESSOR FISSURE LUNGS
NAME THE FOLLOWING
CARDIOVASCULAR
STRUCTURES
1. SUPERIOR VENA CAVA
2. INFERIOR VENA CAVA
MANNY MORTELL - 2012
3. RIGHT ATRIUM (BLUE)
MANNY MORTELL - 2012
4. RIGHT VENTRICLE (BLUE)
5. LEFT VENTRICLE (RED)
MANNY MORTELL - 2012
6. ASCENDING AORTA
7. PULMONARY TRUNK
WELL DONE And …..
… ALWAYS REMEMBER A CHEST X - RAY IS A JUST
BLACK & WHITE PHOTO LOOK AT IT SYSTEMATICALLY
NOW
SOME CASE SCENARIOS
CASE 1
68 YEAR OLD MALE POST MVA CHEST INJURIES DYSPNEA HEMOPTISIS ADMITTED TO THE INTENSIVE CARE UNIT
PHYSICAL ASSESSMENT & VITAL SIGNS VISIBLE BRUISING CHEST RIGHT SHOULDER EDEMA DECREASED LEFT SIDED AIR ENTRY LEFT SIDED FLAIL CHEST LEFT SIDED CHEST PAIN PULSE 125 BPM RESPIRATORY RATE 38 BPM BLOOD PRESSURE 130 / 70 mmHg SpO2 84% - NRM 15 LPM
PRE INTUBATION CXR & ABGS pH 7.32 PaCO2 65 mmHg PaO2 62 mmHg HCO3 29 mmols/L BE + 6 SaO2 88%
CASE 2
32 YEAR OLD MALE POST BIOSYNTHETIC AORTIC VALVE REPLACEMENT WITH COMPLICATIONS POST OPERATION DAY 5
PHYSICAL ASSESSMENT & VITAL SIGNS ACCESSORY MUSCLE USE MODERATE DYSPNEA DECREASED BILATERAL AIR ENTRY - ZONE 2 NO BREATH SOUNDS - ZONE 3 DULL PERCUSSION SOUNDS - ZONE 3 PULSE 110 BPM RESPIRATORY RATE 32 BPM BLOOD PRESSURE 110 / 70 mmHg SpO2 76% - NRM 15 LPM
PRE INTUBATION CXR & ABGS pH 7.30 PaCO2 65 mmHg PaO2 52 mmHg HCO3 18 mmols/L BE - 7 SaO2 78%
CASE 3
54 YEAR OLD MALE ADMITTED FOR CHOLECYSTECTOMY INTUBATED & VENTILATED IN THE GENERAL OR
PHYSICAL ASSESSMENT & VITAL SIGNS ALERT & ORIENTATED GCS - 15 / 15 COMFORTABLE & PAINFREE ORAL TEMPERATURE 36.8 DEGREES CELCIUS PULSE 85 BPM RESPIRATORY RATE 16 BPM BLOOD PRESSURE 120 / 70 mmHg SpO2 94% - ROOM AIR
PRE INTUBATION CXR & ABGS pH 7.40 PaCO2 42 mmHg PaO2 95 mmHg HCO3 25 mmols/L BE 0 SaO2 98%
CASE 4
NEWBORN FEMALE SEVERE RESPIRATORY DISTRESS INCREASED WOB HYPOXEMIA CYANOSIS ADMITTED TO PCICU
PHYSICAL ASSESSMENT & VITAL SIGNS AUDIBLE GRUNTING SEVERE DYSPNEA MARKED CYANOSIS NASAL FLARING STERNAL & RIB RECESSION PULSE 185 BPM RESPIRATORY RATE 89 BPM BLOOD PRESSURE 70 / 30 mmHg SpO2 64% - FACEMASK 15 LPM
PRE INTUBATION CXR & ABGS pH 7.28 PaCO2 72 mmHg PaO2 65 mmHg HCO3 15 mmols/L BE - 8 SaO2 68%
MANNY MORTELL - 2012
CASE 5
69 YEAR OLD MALE POST CARDIAC ARREST ANTERIOR STEMI CARDIOGENIC SHOCK ADMITTED TO THE MCICU
PHYSICAL ASSESSMENT & VITAL SIGNS GCS - 3 / 15 GLOBAL CRACKLES : ZONE 1 - 3 PULSE 125 BPM ECG - SINUS TACHYCARDIA VENTILATOR FREQUENCY / RATE 12 BPM BLOOD PRESSURE 80 / 60 mmHg RAP / CVP 22 mmHg PCWP 28 mmHg SpO2 78% - FiO2 .80
POST INTUBATION CXR & ABGS pH 7.31 PaCO2 62 mmHg PaO2 65 mmHg HCO3 12 mmols/L BE - 9 SaO2 72%
CASE 6
6 MONTH OLD MALE POST JATENE PROCEDURE FOR UNCOMPLICATED D-TGA & VSD REPAIR PDA LIGATION RETURNED TO PCICU
PHYSICAL ASSESSMENT & VITAL SIGNS ALERT & ORIENTATED SKIN COLOUR DUSKY AT REST GCS - 15 / 15 PULSE 135 BPM RESPIRATORY RATE 38 BPM ZONE 3 CRACKLES BLOOD PRESSURE 80 / 40 mmHg SpO2 72% - ROOM AIR
PRE OPERATION CXR & ABGS pH 7.34 PaCO2 52 mmHg PaO2 65 mmHg HCO3 32 mmols/L BE + 9 SaO2 72%
POST OPERATION CXR & ABGS pH 7.36 PaCO2 42 mmHg PaO2 85 mmHg HCO3 28 mmols/L BE - 4 SaO2 94%
CASE 7
82 YEAR OLD MALE ADMITTED PRE-OPERATION FOR LUNG BIOPSY HISTORY HEAVY CIGAR SMOKER COPD HEMATEMESIS
PHYSICAL ASSESSMENT & VITAL SIGNS ALERT & ORIENTATED MODERATE DYSPNEA AUDIBLE WHEEZE AT REST IRRITABLE COUGH PRESENT SPUTUM - BLOOD STAINED PULSE 89 BPM RESPIRATORY RATE 28 BPM BLOOD PRESSURE 110 / 70 mmHg SpO2 84% - ROOM AIR
PRE OPERATION CXR & ABGS pH 7.35 PaCO2 62 mmHg PaO2 65 mmHg HCO3 32 mmols/L BE + 9 SaO2 82%
CASE 8
61 YEAR OLD FEMALE WITH SUDDEN STABBING CHEST PAIN & FACIAL & NECK SUBCUTANEOUS EMPHYSEMA AFTER COUGHING
PHYSICAL ASSESSMENT & VITAL SIGNS SUBCUTANEOUS EMPHYSEMA - FACIAL MODERATE DYSPNEA TACTILE CREPITUS STABBING LEFT SIDED CHEST PAIN NO LEFT SIDED AIR ENTRY PULSE 128 BPM RESPIRATORY RATE 32 BPM BLOOD PRESSURE 130 / 70 mmHg SpO2 84% - SIMPLE FACEMASK 15 LPM
ADMISSION ED CXR & ABGS pH 7.48 PaCO2 29 mmHg PaO2 67 mmHg HCO3 25 mmols/L BE + 2 SaO2 82%
CASE 9
22 YEAR OLD FEMALE NONCOMPLIANT HEMODIALYSIS PATIENT URGENT ADMISSION HEMODIALISIS UNIT HISTORY AWAITING RENAL TRANSPLANT
PHYSICAL ASSESSMENT & VITAL SIGNS ALERT - ORIENTATED - APPREHENSIVE MODERATE DYSPNEA ACCESORY MUSCLE USE GLOBAL COARSE CRACKLES DECREASED ZONE 3 AIR ENTRY PULSE 118 BPM RESPIRATORY RATE 28 BPM BLOOD PRESSURE 100 / 60 mmHg SpO2 76% - ROOM AIR
ADMISSION ED CXR & ABGS pH 7.52 PaCO2 27 mmHg PaO2 67 mmHg HCO3 25 mmols/L BE + 2 SaO2 78%
CASE 10
32 YEAR OLD FEMALE FOUND UNRESPONSIVE BY PARAMEDICS HISTORY DIABETES MELLITUS POSSIBLE ASPIRATION
PHYSICAL ASSESSMENT & VITAL SIGNS GCS 9 /15 VISIBLE ORAL VOMITUS SWEET SMELLING BREATH KUSSMALS RESPIRATIONS DECREASED RIGHT SIDED AIR ENTRY RIGHT SIDED CRACKLES PULSE 108 BPM RESPIRATORY RATE 48 BPM BLOOD PRESSURE 90 / 60 mmHg SpO2 74% - ROOM AIR
ADMISSION ED CXR & ABGS pH 7.13 PaCO2 57 mmHg PaO2 69 mmHg HCO3 14 mmols/L BE - 9 SaO2 78%
REMEMBER THIS LEARNSHOP WEBSITE
http://intensivecare. hsnet.nsw.gov.au