# Chest X-Ray Randomness



## VFlutter (Oct 31, 2012)

So I am studying some chest X-rays for class and thought I would share. Although not really an EMS skill it still could be helpful in certain situations (CCT)


1. (A) Name that device (as specific as you can). (B) how do you differentiate between an ICD and a pacmaker (I am thinking of 3 ways) and (C) with a  BiV / CRT in what vessel does the left lead rest







2. Name that condition 






3. What's going on here 





4. This on may be tricky. What's wrong with this intubation 





5. Why is this pacemaker malfunctioning 





6. What kind of breath sounds do you expect in this patient?


----------



## STXmedic (Oct 31, 2012)

Just a shot in the dark (no experience or education in reading CXRs)

1) I'm guessing AV pacemaker, just because of probe placement. Not a clue on the other questions though.

2) Dextrocardia?

3) Pericardial effusion

4) Right main-stem (edit: clearly wrong, didn't even look at the left side! I like JPs answer on no left lung.)

5) Can't see the picture

6) Rhonchi

Time to read up on pacemakers an ICDs


----------



## JPINFV (Oct 31, 2012)

Highlight for my answers
1: Not sure
2: Situs inversus 
3: Pericardial effusion?
4: Tension pneumo vs no left lung (no lung markings on the left)
5: No picture
6: Would like a 2 view, but it looks like pulmonary edema... so rales


----------



## VFlutter (Oct 31, 2012)

PoeticInjustice said:


> Just a shot in the dark (no experience or education in reading CXRs)
> 
> Time to read up on pacemakers an ICDs



Ill let some other people respond before giving answers but you have some right and some wrong. For number 1 you are not wrong but only 1/2 right...

Here is another picture of #5.... It's not the best but I can't find any better ones


----------



## usalsfyre (Oct 31, 2012)

ChaseZ33 said:


> So I am studying some chest X-rays for class and thought I would share. Although not really an EMS skill it still could be helpful in certain situations (CCT)


It's not a skill particularly useful to most providers below midlevels but I digress. 



ChaseZ33 said:


> 1. (A) Name that device (as specific as you can). (B) how do you differentiate between an ICD and a pacmaker (I am thinking of 3 ways) and (C) with a  BiV / CRT in what vessel does the left lead rest


Dual chamber pacer with an ICD. I believe the ICDs have the "thick" lead, other than that I'm not familiar.  




ChaseZ33 said:


> 2. Name that condition


Dextrocardia.



ChaseZ33 said:


> 3. What's going on here


Widened mediastinum, usually indicative of a disection or pneumomediastimum 



ChaseZ33 said:


> 4. This on may be tricky. What's wrong with this intubation


Right mainstem



ChaseZ33 said:


> 5. Why is this pacemaker malfunctioning


Broken lead 



ChaseZ33 said:


> 6. What kind of breath sounds do you expect in this patient?


Rales/rhonchi in the bases.

I'll add, what would you suspect when given this film?


----------



## usalsfyre (Oct 31, 2012)

PoeticInjustice said:


> 4) Right main-stem (edit: clearly wrong, didn't even look at the left side! I like JPs answer on no left lung.)


There's no left lung because we've only been ventilating the right for a while. If you look there's pretty clear shadowing, looks to me like mass atelectisis.


----------



## VFlutter (Oct 31, 2012)

usalsfyre said:


> I'll add, what would you suspect when given this film?



COPD / hyperinflation?


----------



## STXmedic (Oct 31, 2012)

Oh... Well that doesn't look very effective! Lol so the ventricular probe apparently broke near the generator... I'm wondering if it would still work though. Assuming they don't have a 3rd degree block, and that the generator doesn't just stop after a wire breaks, I would venture to say they'd be alright until they could go in and fix it...


----------



## JPINFV (Oct 31, 2012)

usalsfyre said:


> There's no left lung because we've only been ventilating the right for a while. If you look there's pretty clear shadowing, looks to me like mass atelectisis.



Yea...and I just traced it back to the original site. My issue with that is that someone either didn't check lung sounds and/or didn't check their CXR. Heck, even in the trauma bay we can get a CXR relatively timely after intubation, but during the resuscitation. This is a process that, my understanding is, takes hours to develop. Plenty of time to recognize and fix.


----------



## STXmedic (Oct 31, 2012)

usalsfyre said:


> There's no left lung because we've only been ventilating the right for a while. If you look there's pretty clear shadowing, looks to me like mass atelectisis.



Ahh, that does make sense then. I initially thought mainstem because it look like there's a guide-wire tracing where the tube would be, then leading into the right bronchi. Still wasn't seeing the whole picture, but at least I was on the right track (hopefully)


----------



## VFlutter (Oct 31, 2012)

Solid black arrow is the atrial lead, dotted black is the thickened portion of an ICD wire and the red arrow is the left lead in the coronary sinus 

#1 was a cardiac resynchronization therapy - defibrillator (CRT-D) it's basically a Atrial Bi-Ventricular pacemaker with a ICD. They are becoming more common for CHF patients and are very effective from what I understand. 

The 3 ways I can think of to tell an AICD are 1) the size of the device 2) thickening of the ventricle wire (the defibrillator coil) or reading the device model (I can never see it clear enough) 

When would you want a pacmaker in DOO/VOO? What (deadly) risk do you run if the patients intrinsic HR is faster than the programmed pacing rate while in VOO?


----------



## usalsfyre (Oct 31, 2012)

JPINFV said:


> Yea...and I just traced it back to the original site. My issue with that is that someone either didn't check lung sounds and/or didn't check their CXR. Heck, even in the trauma bay we can get a CXR relatively timely after intubation, but during the resuscitation. This is a process that, my understanding is, takes hours to develop. Plenty of time to recognize and fix.



Cool, nice to know i can read simple stuff alright, I was actually able to pick it up without going back to the original site...


Probably happened in ICU with a nurse who was stretched to thin and/or wasn't paying attention. What surprises me is the vent wasn't screaming about high pressure.


----------



## VFlutter (Oct 31, 2012)

PoeticInjustice said:


> Oh... Well that doesn't look very effective! Lol so the ventricular probe apparently broke near the generator... I'm wondering if it would still work though. Assuming they don't have a 3rd degree block, and that the generator doesn't just stop after a wire breaks, I would venture to say they'd be alright until they could go in and fix it...



It looks like the atrial wire is the one that broke so they would lose atrial sensing/pacing ability which is not ideal but not really life threatening


----------



## usalsfyre (Oct 31, 2012)

ChaseZ33 said:


> Solid black arrow is the atrial lead, dotted black is the thickened portion of an ICD wire and the red arrow is the left lead in the coronary sinus
> 
> #1 was a cardiac resynchronization therapy - defibrillator (CRT-D) it's basically a Atrial Bi-Ventricular pacemaker with a ICD. They are becoming more common for CHF patients and are very effective from what I understand.
> 
> ...



Complete heart block and R on T.


----------



## VFlutter (Oct 31, 2012)

usalsfyre said:


> Complete heart block and R on T.



They usually put pacers into VOO during surgeries using electrocautery. Correct on the R-on-T. 


I agree on the limited usefulness but I think a very basic understanding of common problems is helpful. Especially recognizing a pacemaker/ICD if the patient does not have their card or can not provide information. It is a frustrating situation when a PM patient is crashing and you don't want what kind of device it is or if the wires are intact.

Also not all PM have the same magnet mode so you should know what it is set for before you throw a magnet on them


----------



## JPINFV (Oct 31, 2012)

usalsfyre said:


> Cool, nice to know i can read simple stuff alright, I was actually able to pick it up without going back to the original site...




I originally put right mainstem because I was only looking at the ET tube, then I looked at the other side and had a "that don't look right... somethin's missin here" moment. We had a radiology come in at one of the hospitals I rotated through and do a series like this and one of them was the patient missing clavicles (like this one) that no one picked up on because everyone focuses on the heart and lungs.


----------



## VFlutter (Oct 31, 2012)

A cool image of a standard dual chamber pacemaker. Notice a difference in the wires compared to the previous images?


----------



## VFlutter (Oct 31, 2012)

Edit: my IPad is not liking image codes


----------

