Chin FY2 Critical Care NGH 21 st October 2019 Learning Objectives Provide a structured approach to interpreting plain film radiographs Recognise and initiate management on common conditions diagnosed through XrayCT ID: 1047289
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1. Radiology TutorialKokWai ChinFY2 Critical Care, NGH21st October 2019
2. Learning Objectives Provide a structured approach to interpreting plain film radiographsRecognise and initiate management on common conditions diagnosed through X-ray/CTStructured approach in identifying and managing unwell patients
3. Chest X-Ray
4. CXR – The basics
5. Interpreting CXRPatient DemographicsAP/PA Film Quality Rotation – Spinous processes equidistant from heads of clavicles?Inspiration – Able to count at least 6 anterior ribs?Penetration – Able to visualise vertebral bodies behind heart border?
6. Interpreting CXRAirwayTrachea – deviated?BreathingLung fields CirculationHeart + aortic knuckleCardiomegaly? Widened mediastinum? Mediastinal shift?DiaphragmElevation? Pneumoperitoneum?Everything Else Ribs, clavicles, shoulder
7. Case 1 – Intro Mr Smith, 67MAttended A&E with shortness of breath and feverYou are the FY1 on A&EReview this patient
8. Case 1 - History3/7 hx of feeling generally unwellCough productive of green sputumSOB on trying to get out of bed todayPMH:HTNOtherwise F+WDH:Ramipril 5mg ODAmlodipine 5mg OD
9. Case 1 – Examination A – PatentB – Right sided creps, RR 26, SpO2 90% on RAC – BP 85/50, CRT 4s, HR 126 regular, HS I+II+0D – BM 5.2, PEARLE – Abdo/Calves SNT. T38.8, A V P U
10. Case 1 – Investigations FBCHb 121WCC 16.0Plt 300CRP 152INR 1.2 U&ECr 150 (107)Urea 16 (6.7)Na 137K+ 4.5LFTs stableABG (21% FiO2)pH 7.45 [7.35-7.45]pO2 6.0 [11.0-18.0]pCO2 5.0 [4.5-6.0]HCO3 26.0 [22.0-26.0]Lactate 3.2 [0-1.5]sO2 90%
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12. Case 1Diagnosis?1. CAP2. Septic shock3. Acute Kidney Injury
13. Case 1 - ManagementSEPSIS 6 AntibioticsBlood CulturesOxygenLactateIV FluidsUrinary Catheter Suspend antihypertensives
14. Case 1He is admitted to the ward for IV antibiotics and supplemental oxygen3 days later, nursing staff are concerned that his oxygen saturations are falling again
15. Case 1 – Examination A – PatentB – Reduced air entry right side, RR 18, SpO2 92% on 3L NC C – BP 126/50, CRT 2s, HR 95 regular, HS I+II+0D – BM 6, PEARLE – Abdo/Calves SNT. T37.7, A V P U
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17. Chest Drain Landmarks Image Reference: EBM consult https://www.ebmconsult.com/articles/chest-tube-placement-thoracostomy-procedure
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19. Picture Quiz – Image 11. Diagnosis?2. Immediate management?
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21. Picture Quiz – Image 11. Diagnosis?Pulmonary oedema/Acute heart failure/Fluid overload2. Immediate management?OxygenMorphineFurosemideGTNSit up
22. Picture Quiz – Image 21. Diagnosis?
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24. Picture Quiz – Image 21. Diagnosis?Pneumonectomy
25. Picture Quiz – Image 31. What is the most likely underlying condition?
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27. Picture Quiz – Image 31. What is the most likely underlying condition?Renal cell carcinoma
28. Picture Quiz – Image 41. Interpret the image2. Most at-risk population for CXR appearances?3. What is the most likely causative organism?
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30. Picture Quiz – Image 41. Interpret the imageCavitating pneumonia2. Most at-risk population for CXR appearances?IVDU3. What is the most likely causative organism?Staph. aureus
31. Picture Quiz – Image 532M, assaulted – penetrating chest injuryA – Patent, but visible SOBB – No breath sounds heard on R side of chest, No chest rise on R side, hyperresonant on R sideC – BP 70/40, HR 130 sinus tachy, CRT 3s, Distended neck veins D – A V P UE – 7cm laceration medial to border of R scapula
32. Picture Quiz – Image 51. Interpret the image2. Immediate management?
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34. Picture Quiz – Image 51. Interpret the image2. Immediate management?Needle decompression, followed by chest drain insertion
35. F1 Skills – Nasogastric tube reviewPatient A, 70MAdmitted with ischaemic stroke and is now NBMFeeding NGT passed for nutritionYou are the FY1 on-call for medicineNursing staff have bleeped you to ask if the NGT is safe to feed
36. F1 Skills – Nasogastric tube review1. AspirateIf able to aspirate and aspirate pH <5.5, then safe to feed2. CXRIf unable to aspirate or pH >5.5, then request CXR to check position
37. F1 Skills – Nasogastric tube reviewCXR image must include area below diaphragmNG tube should bisect the carinaTip of NGT should be visible below the level of the diaphragm
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42. Abdomen
43. Interpreting abdominal X-raysBowelSmall bowel – central, valvulae conniventesLarge bowel – peripheral, haustra3/6/9 ruleBone Calcification/ArtifactCalcified fibroids, renal calculi, foreign bodies
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45. Case 2 65M, brought into A&E with abdominal pain and vomitingPain intermittent in nature, comes in “waves”Last opened bowels 5 days ago, can’t remember passing flatus todayPMH – appendicectomy, cholecystectomy, previous inguinal hernia repair
46. Case 21. Most likely diagnosis?2. Immediate management?
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48. Case 21. Most likely diagnosis?Adhesional small bowel obstruction2. Immediate management?Bloods inc. VBG, clotting, G+SNG tube for drainageIV Fluids
49. Picture Quiz 61. Diagnosis?
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51. Picture Quiz 61. Diagnosis?Large bowel obstruction
52. Picture Quiz 71. Diagnosis?2. Further investigation?
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54. Picture Quiz 71. Diagnosis?Renal tract calculi2. Further investigation?Non-contast CT KUB
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56. Pelvis
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58. Interpreting Pelvic X-raysThree ringsPelvic inlet + 2 obturator foraminaJoint spacesSacroiliac joints + Pubic symphysisAcetabulumIliopectineal line – anterior acetabulumIlioischial line – posterior acetabulumProximal femurShenton line
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60. Case 3 70F, brought into A&E following RTC – pedestrian vs carAppears to be in significant amount of painPelvis is very tender to palpationPMH – Atrial fibrillation, CKD, OsteoporosisDHx – Warfarin, Calcichew
61. Case 3 – Examination BP 75/45CRT 4sHR 130 weak thready pulseHb 65INR 3.0
62. Case 31. Interpret the image2. Most likely diagnosis?3. Immediate management?
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64. Case 31. Interpret the image2. Most likely diagnosis?Open book fracture of pelvis3. Immediate management?Pelvic binderReversal of warfarinMassive transfusion protocol
65. Picture Quiz 81. Diagnosis?
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67. Picture Quiz 81. Diagnosis?Comminuted left neck of femur fractureLeft acetabular fractureLeft inferior pubic ramus fracture
68. Picture Quiz 91. Interpret the image2. Diagnosis?
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70. Picture Quiz 91. Interpret the image2. Diagnosis?Right neck of femur fracture
71. CT Head
72. Interpreting head CTsBloodHyperdense lesions Shapes of bleedsBoneSkull fractureSymmetryTissue ischaemiaSulcal effacementVentricular compressionMidline shift
73. Case 4 70F, brought in by family due to increasing confusion 1/52 ago fell while walking dog and hit head against pavementNo medical attention sought as felt well at time Fluctuating consciousness level, appears disorientedPMH – Atrial fibrillationDHx – Warfarin
74. Case 41. Interpret the image2. Most likely diagnosis?3. Immediate management?
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76. Case 41. Interpret the image2. Most likely diagnosis?Acute on chronic subdural haematoma3. Management?Surgical decompression
77. Picture Quiz 101. Diagnosis?2. Causes3. If CT –ve, other diagnostic test?
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79. Picture Quiz 101. Diagnosis?Subarachnoid haemorrhage2. CausesAneurysmAVMHead trauma3. If CT –ve, other diagnostic test?Lumbar puncture
80. Picture Quiz 111. Diagnosis?2. Acute management3. Further investigation/management
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82. Picture Quiz 111. Diagnosis?Left hemispheric posterior circulation stroke 2. Acute managementThrombolysis (if within window)Antiplatelet therapyNBM + SALT assessmentBP management3. Further investigation/managementTreat underlying cause (e.g AF)Physiotherapy/Occupational therapyLifestyle modification
83. Thank you!https://www.surveymonkey.com/r/PeerTeachingSockokwaichin@doctors.org.uk