Chest X-Ray and ECG

Interpretation
More Parts to the Puzzle
 X-Rays
• First, non-surgical look inside the human
body.
• Has been refined to include various
advanced imaging techniques
– CT
– MRI
– PET scans
 X-Rays
• Still a simple test that, when done and
interpreted properly, can yield a large
amount of data.
 How X-Rays Work
• Simply put:
– X-Rays passing through the body penetrate at
different rates depending upon the density of
the structure they pass through.
• High density structures (bone, metal) appear white
– This is known as being radio-opaque
• Low density structures appear black (lung tissue,
air)
– This is known as being radio-lucent
 X-Ray Indications
• Detecting pathological changes in the lung
• Determining the appropriateness of therapy
• Evaluating the effectiveness of treatment
• Determining the position of tubes and
catheters
• Observing the progression of lung disease
 X-Ray Views
• Different views are taken, they are named for the
direction that the X-rays take through the body
– PA
• Posterior-Anterior
– AP
• Anteroposterior
– Lateral
– Lateral Decubitus
– Etc.
Swan-Ganz and ETT Placement
 ETT Placement
• 3-5 cm above the carina
• Make sure that the ETT is not in the Right
main stem Bronchus
• Ensure that it is not in the esophagus
Right main
stem
Intubation
 CV Line Placement
• Any invasive line placed in the chest has
certain inherent risks associated with it
– Pneumothorax is one of the predominant ones
– Faulty placement of catheters can lead to
serious consequences
• Lines need to be placed in the proper
location in order for proper function
TPN via a
central line into
the pleural
space
CV Line in
the internal
jugular
If you start in the Subclavian there are many
places you could end up
Chest tubes, Swan Ganz, ETT, and
NG tubes all in good position
 Chest Tubes
• Need to be placed correctly in order to
ensure proper function
• Why do we place chest tubes?
 Tomography
• Non-computer aided tomography is not
done very much any more
• Consisted of a series of films taken via a
rotating camera
• Resulted in 1 cm cuts
• Used to see chest lesions
• Replaced by CT and MRI
Standard film showing a
density
Tomogram showing the
same density
 CT Scanning
• Frequently utilized, high resolution scan of the
chest
• Helpful in looking at a lot of different processes
– Lung tumors
– Chronic Interstitial Lung Disease
– AIDS related PNA
– Occupational Lung Disease
– Pneumonia
– Bronchiectasis
– COPD
– Chest Trauma
Chest CT of a patient with?
 MRI
• Role is limited in pulmonary disease
• Can evaluate hilar structures better than CT
• An enlarged hilum in the presence of
known CA is an indication of a poor
prognosis where surgery is not an option
X-Ray and MRI
of the same
patient with
Right chest
swelling
(lymphosarcoma)
 VQ Scans
• Evaluates the ventilation and perfusion of
the lung
• Separate studies done and then compared
– Ventilation
• Patient inhales a radioactive gas (xenon)
– Perfusion
• Patient is injected with a radioactive substance that
is carried by albumin into the capillaries
 VQ Scans
• Thought to be highly indicative of
Pulmonary Embolus
• Recent studies show this to not be true
• Another test is better at finding PE
– Any ideas?
Normal
Perfusion
Ventilation Perfusion

Is this normal?
Pulmonary
Angiography
 X-ray Versus CT Versus PET
• X-rays may show a defect but not be indicative of
what the defect is
• CT may show the defect in more detail
• In the case of Cancer, PET scans help to locate
tumors because of the nature of a tumor’s
metabolism
– High metabolism picks up the tracer (Fluorine-18
fluorodeoxyglucose) used in PET scan that makes it
visible to the camera
X-ray showing density in the right upper lobe
CT showing the density in more detail
PET scan showing the density being localized
 X-Rays
• It is helpful to understand the location of
structures in the chest as they appear on X-
ray
RML
Consolidation
 RLL
consolidation
 Atelectasis
• Compressive atelectasis
– Results from pneumothorax, hemothorax, and
any space-occupying disease of the parenchyma
• Obstructive atelectasis
– Results from a bronchial obstruction that cuts
off a region of lung from ventilating
• Tumor, foreign body, mucous plug
 Atelectasis
• Classic signs
– Shift of fissure lines toward the area of collapse
– Movement of the hilar structures toward the
area of collapse
– Overall loss of volume in one lung
– Hemidiaphragm elevation
RUL
atelectasis
resulting
from
bronchial
obstruction.
Inferior
border of
RUL is
pulled
upwards
towards area
of atelectasis
 Pneumothorax
• Air in the pleural space
– Enters through hole in chest or hole in lung
• Tension Pneumothorax
– Has a one way valve effect that pumps air into
the pleural space and does not let it out
– Life threatening
• Hilar structures pushed away form effected side, and
hemidiaphragm pushed down
 Hyperinflation
• COPD
• Increased FRC, TLC and RV
• Large lung volumes
• Depressed diaphragms
• Enlarged intercostal spaces
 Interstitial Lung Disease
• Multiple causes
– Occupational, for example?
• X-ray reveals ground glass like appearance
– Air bronchograms visualized
 CHF
• Congestive Heart Failure produces a
distinct chest x-ray
– Pulmonary vasculature appears more prominent
in upper lobes
– Heart width increases, exceeds normal ½ of
chest width
– Kerley’s B Lines appear
• Indicative of lymph vessels filling with fluid
 Pleural Effusion
• Blunting of the costophrenic angle
• Small meniscus sign (seen as fluid begin to
move up chest wall)
• Partially obstructed diaphragm
• Complete whiteout in sever cases
• Lateral decubitus film helpful in
determining if an effusion is present
– Change patient’s position and see if fluid shifts.
 The ECG
• Measures the electrical activity of the heart
– Useful for discerning arrhythmias both life-
threatening and non-life-threatening
– Useful in identifying an MI as it is occurring
Anatomy of the heart
 Heart Cells
• Pacemaker cells
– Specialized cells that have a high degree of
automaticity and provide the electrical power for the
heart
• Conducting cells
– Cells that conduct the electrical impulse throughout the
heart
• Myocardial Cells
– Cells that contract in response to electrical stimuli and
pump the blood
Electrical Conducting System
Inherent rates for different areas of the
heart
 Contraction
• Depolarization results in the movement of
potassium out of the cell and sodium in to
the cell causing an electrical shift
• Repolarization is the opposite of
depolarization when the cell “resets” itself
for another cycle
• This occurs throughout the heart with every
heartbeat
 ST segment changes
• ST segment is normally isoelectric
– Depression of the ST segment and inversion of
the T wave indicate myocardial ischemia
– Elevation of the ST segment indicates
myocardial injury
– Significant Q waves indicate infarction has
occurred
 Lead Placement
• Four limb leads and six chest leads yield 12 leads
of ECG data
– Leads I, II, III, aVR, aVL, aVF, V1, V2, V3, V4, V5,
V6
• Different views of the electrical activity of the
heart allow us to determine a number of things
– Direction of electrical activity in the heart (axis
determination)
– Location of injury during an MI
 Axis Determination
• Lead Axis
• I and II are Positive Normal
• I is Positive
• II is Negative Left axis
• I is negative
• II is positive Right axis
• I and II are negative Extreme right axis
 Axis Determination
• Normal Mean Axis is between 0 and 90
degrees.
• Right axis deviation indicates that the right
ventricle is enlarged
• Left axis deviation suggests that the left
ventricle is enlarged
 Rhythm Interpretation
VARIABLE NORMAL INTERPRETATION
RANGE
Rate 60 – 100 /minute Rates > 100 = tachycardia
Rates <60 = bradycardia

PR Interval 0.12 – 0.20 seconds > 0.20 = heart block

QRS Interval <0.12 seconds > 0.12 = ectopic foci

ST segment Isoelectric Elevated = Injury

Depressed = Ischemia
T wave Upright and round Inverted with ischemia, tall and
peaked with electrolyte
imbalances
 ECG Steps
• 1. Identify the Heart Rate
– Above 100 = ?
– Below 60 = ?
 ECG Steps
• 2. Evaluate the rhythm
– Is it regular, irregular, are there any funny
looking beats?
 ECG Steps
• 3. Note the presence of P waves
– One p Wave per QRS, anything else is
abnormal
• A Fib
• A Flutter, etc.
 ECG Steps
• 4. Measure the PR interval
– Longer than normal PR intervals are indicative
of heart block
 ECG Steps
• 5. Measure the QRS interval
– Complex is too wide in bundle branch clocks,
ectopic beats, etc.
 ECG Steps
• 6. Inspect the ST segment in all leads
– Anterior Wall
• V1, V2, V3, V4
• Left anterior descending coronary artery
– Lateral Wall
• I, aVL, V5, V6
• LAD, or circumflex
– Inferior Wall
• II, III, aVF
Right coronary artery
 ECG Steps
• 7. Identify the mean QRS axis
• I and II are Positive Normal
• I is Positive
• II is Negative Left axis deviation
• I is negative
• II is positive Right axis deviation
• I and II are negative Extreme right axis deviation
 ECG Steps
• 8. Assess the waveform morphology
 ECG Steps
• 9. Evaluate the Q wave
– Could indicate the presence of an old MI
 ECG Steps
• 10. Look for signs of chamber enlargement
– High voltage waves indicate hypertrophy
 ECG Steps Simplified
• 1. Determine the regularity (rhythm)
– Is it regular or irregular
• 2. Calculate the rate
• 3. Examine the P waves
– One for every QRS?
• 4. Measure the PR interval
• 5. Measure the QRS complex