Exam IV: Thorax Imaging

Frequently the first step in patient imaging
Provides information about multiple organs and body cavities
Minimally invasive and well tolerated
Commonly available
Relatively inexpensive

Check patient data (Name, age, gender)
Look for old films
Arrange films on view boxes
Be certain of the positioning: (upright vs. supine, PA vs. AP)
Check the method: (Portable vs. in department)

Then make sure images are complete, good exposure, and look for gross abnormalities

Provide a wealth of information
Should be viewed whenever they are available
When using comparison films they should be arranged in order

Body part farthest from film is most magnified, shows the least detail
AP shows magnification of the heart and widening of the mediastinum
PA works best, AP reserved for very ill patients

Left side is against cassette holder or image intensifier
Places heart closest to film, then we turn it around to look at the image

Labeled as right because patient is lying with right side down
Air fluid level shows right pleural effusion
Most useful when patient is unable to stand up
Can also do decubitus films of the abdomen
To lie reclining= cubitous
Right lateral decubitous: right side down/against the table

Thoracic spine disc spaces should be barely visible through the heart
Bony details of the spine are not usually seen
Penetration is sufficient that bronchovascular structures can be seen through the heart

The sternum should be seen edge on
Posteriorly you should see two sets of ribs
The spine is lighter on top and darker at the bottom/ caudally because the amount of muscle and tissues surrounding the structures decrease inferiorly

See sternum and two ribs, one larger than the other because of magnification due to difference in distances
More magnification when farther away
In this photo the right rib is farthest

Spinous processes should be centered
Clavicular heads should be symmetrical
Sometimes patients that are in too much pain, very young or old, have mental disabilities that prevent them from being compliant and being still for the image

The size of the heart should be ½ the width of the entire chest
Works better when image is not magnified

So, on a large scale check:
Alignment of the visible structures
Borders of the organs and cavities
Cardiothoracic ratio

Finally, carefully look at:
The entire cardiac silhouette
Each lung field in detail including hila and trachea
Everything else including bones and any “Extra” structures

You will see smaller details if you move your eyes and even your head to cover the entire film
Remember the human eye only focuses well on one small area at a time
Blind spot in the eye and brain fixes it so you never notice it, therefore you need to move around the x ray to see it from different angles to make sure you don’t miss any information

Lung tissue naturally want to contract to shrink, so if exposed to atmospheric air, it contracts
If air gets in the pleural space, the lung will shrink and border of lung is more medially than laterally

Collapsed lung with build up of pressure from injury creating a hole like flap that moves over the wound
Causes deviation of the mediastinum and trachea to the opposite side of the injury
Impairs breathing and blood return
Surgical Emergency!
Chest tube or decompress with large bore needle in second intercostal space at the midclavicular line

If something goes into the lungs, usually through the right mainstem bronchus because straighter than left side and wants to take path of least resistance

Right subclavian venous catheter
Tip is in the superior vena cava (SVC) where it joins the right atrium
Chest x ray can show where catheter is and make sure no pneumothorax after catheter put in

If something goes into the lungs, usually through the right mainstem bronchus because straighter than left side and wants to take path of least resistance

Multiple wires from cardiac telemetry

Right internal jugular catheter with kink at tip (black Arrow)

Endotracheal tube

Sternal wires

Valve replacement

Very sick patient!

Figure out wires and tubes first, then look for pathology

If air outside of tube outside of GI tract= indicates leak in GI tract

Area underneath of the diaphragm- bad and needs to go to OR

Pt’s right side is on your left, their left on your right (Correct Anatomical Position)

Look at easy to recognize structures to calibrate your eye

The layer just deep to the thin skin shows how bright fat is

Vertebral column to see how bright bone is

Muscles behind the vertebral column to see how bright it is

The aorta to see how bright blood is (it will be bright if contrast dye was used)

Air is always black.

Different “windows” allow viewing of different tissues

Image is looking up shirt

Clot from a deep vein thrombosis (DVT) breaks free and goes to the lungs

Variable size and severity

Initially treated with anti-coagulants

If severe may require surgery to remove clot

Were awarded the Nobel Prize in Physiology or Medicine for the development of cardiac catheterization

1929 credited with the first human cardiac catheterization – on himself

While still a surgical resident, he incised his arm and fed a urinary catheter into the right atrium of his heart

Walked down a flight of stairs to the radiology department to x-ray it – he was later fired

Won the Nobel Prize in Physiology or Medicine in 1956 – 37 years later

Ultrasound study

Performed through anterior chest wall

US probe on chest, avoid bones of chest by going between the ribs

Can show: wall thickness and movement, ejection fraction, valvular function, vegetations

Minimal complications associated with ECG

Similar information as ECG but probe is closer to heart, allows more detail

Patient must be sedated

Get a probe down the throat to see behind the heart (heart is closer to esophagus) and see individual structures and get better calculations of function of the heart

Myriad potential complications: risk of aspiration, may react to sedation, never wake up…

Becomes technical in interpretation

Place all images in the same order every time to be able to know what and where you are looking

Craniocaudal images (CC): head to tail (look down shirt)

Medial Lateral Oblique (MLO): "short person dancing with lady and look side to side"

White dense material: pectoralis major

Smooth margins

No internal echoes (anechoic)

Enhanced through transmission of sound

Ultrasound is the test of choice for a suspected cyst

Gives excellent detail

At present quite expensive

May be too sensitive for screening test- many false positives

Is currently an “emerging technology”

It is named after Dr. Sven-Ivar Seldinger (1921-1998), a Swedish radiologist who introduced the procedure in 1953

A vessel or cavity is punctured with a sharp hollow needle

A round-tipped guide wire is then advanced through the lumen of the needle which is then withdrawn

A "sheath" or blunt cannula can now be passed over the guide wire into the cavity or vessel

Drainage tubes or indwelling catheters can also be passed over the guide wire and left in place while removing the wire

Steps:

Insert guide wire through needle in vein

Remove needle

Pass catheter over wire

Remove wire

Example: this is how stent is placed in ureters

J tip guide wire

| Have many sizes, textures, and shapes of guide wires

Guide wire is inserted into vessel, maneuvered to a specific location in the circulatory system

Catheter is passed over the guide wire to deliver contrast media to desired site for imaging

Also allows for angioplasty, chemoembolization or thrombolysis

Guide wire is passed beyond narrowing, inflate balloon when in place to increase blood flow of that vessel

Special balloon catheter is placed for maximum effectiveness

Diagram makes the lumen look perfectly smooth afterward – not really true

Opens up the lumen and increases blood flow

Metallic stent is wrapped around balloon

Locks into open position after balloon is expanded, provides structural support to newly re-opened vessel

Treated as a foreign body by the surrounding tissues

Wire cage and expand it and open the artery

Stenting of an artery, works but will not last indefinitely

Graft tube is attached to the stent

Performed through a femoral arteriotomy by an interventional radiologist

Less pain, quicker recovery

Unless the vessel ruptures