This document provides an overview of the monthly adult chest x-ray cases from the Emergency Medicine department. It discusses cases submitted from partners in Brazil and Tanzania. The cases this month included alveolar hemorrhage from Goodpasture's syndrome, rib fractures with tension hemothorax from a motor vehicle collision, rib fractures with flail chest from a fall, traumatic aortic disruption from a pedestrian being struck, active tuberculosis, and transfusion related acute lung injury. The goal is to promote widespread mastery of chest x-ray interpretation and share cases between various international contributors.

1. Adult Chest X-Rays Of The Month
Alyssa Thomas MD & Claire Milam MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs MD, Faculty Editor
Chest X-Ray Mastery Project
June 2019

2. Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of CXR interpretation.
 There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.

3. Process
 Many are providing cases and these slides are shared with all contributors.
 Contributors from many CMC departments, and now… Tanzania and Brazil.
 Cases submitted this week will be distributed monthly.
 When reviewing the presentation, the 1st image will show a chest X-ray
without identifiers and the 2nd image will reveal the diagnosis.

4. It’s All About The Anatomy!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. Cases Studies From
Our Emergency
Medicine Partners In
Brazil
History of
Goodpasture
syndrome
presenting
with SOB

7. Cases Studies From
Our Emergency
Medicine Partners In
Brazil
What is the diagnosis?
History of
Goodpasture
syndrome
presenting
with SOB

8. Cases Studies From
Our Emergency
Medicine Partners In
Brazil
Alveolar Hemorrhage From Goodpasture Syndrome
History of
Goodpasture
syndrome
presenting
with SOB

9. Goodpasture syndrome = anti- glomerular basement membrane antibody
(ABMA)
- Hemoptysis (up to 33% of patients do not present with this)
- Alveolar opacities
- Falling hemoglobin
- Nonspecific lung examination
- Symptoms are usually of short duration before presentation
- 60-80% cases of ABMA lung and renal disease occur simultaneously
Treatment
Systemic glucocorticoids with additional immunosuppressive therapy.
Plasmapheresis has also shown to be beneficial
Alveolar Hemorrhage From Goodpasture Syndrome Quick Tidbits!
A review of 34 cases of alveolar hemorrhage found that 12% were
secondary to Goodpasture syndrome
- More common in men
- More common in smokers thought to be 2/2 to increase alveolar
permeability in smokers
Harold R. Collard MD, Talmadge E. King MD and Marvin I. Schwarz MDMurray and Nadel's Textbook of Respirator: Alveolar Hemorrhage and
Rare Infiltrative Diseases Medicine, 67, 1207-1220.e11

10. High Speed
MVC Against
A Truck

11. High Speed
MVC Against
A Truck
What’s the diagnosis?

12. High Speed
MVC Against
A Truck
Tension Hemothorax + Left-Sided Rib Fractures

13. Fall Off Of A Roof

14. What do you see?
Given this finding, what associated
diagnosis are you concerned about?
Fall Off Of A Roof

15. Flail Chest
 The result of severe blunt chest trauma.
 Multiple ribs fractured in ≥2 places.
Fall Off Of A Roof

16. Flail Chest
 Inspiration increases [-] thoracic pressure.
 Leads to paradoxical motion of the flail segment.

17. Flail Chest
 Frequently requires mechanical ventilation.
 Rib plating stabilizes the fail segment.
Side Note:
Temporizing measures
in the ED?
Place an occlusive
dressing!

18. Pedestrian
Struck By An
SUV

19. Pedestrian
Struck By An
SUV
What is your interpretation?

20. Pedestrian
Struck By An
SUV
Traumatic Aortic Disruption [TAD]
 Typically a high mechanism of injury.
 MVC, pedestrian struck, fall from a height.
Wide
Mediastinum

21. Our Patient
Aortic
Laceration

22. TAD Chest X-Ray Findings
1. Wide mediastinum
2. Abnormal aortic contour
3. Lost of aortopulmonary window
4. Tracheal deviation
5. Depressed left mainstem
6. Apical cap
7. Deviated nasogastric tube
8. Widened paratracheal stripe

23. TAD Chest X-Ray Findings
1. Wide mediastinum
2. Abnormal aortic contour
3. Lost of aortopulmonary window
4. Tracheal deviation
5. Depressed left mainstem
6. Apical cap
7. Deviated nasogastric tube
8. Widened paratracheal stripe
Practice identifying the
above findings in blue on this
TAD CXR

27. Tracheal
Deviation

28. Apical
CapTracheal
Deviation

29. Apical
CapTracheal
Deviation
Loss Of The
Aortopulmonary
Window

30. Apical
CapTracheal
Deviation
Loss Of The
Aortopulmonary
Window

35. Cases Studies From
Our Emergency
Medicine Partners In
Brazil

36. Cases Studies From
Our Emergency
Medicine Partners In
Brazil
Patient With Active Tuberculosis Shot In The Chest

37. High Speed
MVC Against
A Truck
HD#3
4 Hours After
A 3-Unit
PRBC
Transfusion
Interesting Case for the Month!

38. High Speed
MVC Against
A Truck
HD#3
4 Hours After
A 3-Unit
PRBC
Transfusion
Transfusion-Related Acute Lung Injury [TRALI]
Interesting Case for the Month!

39. High Speed
MVC Against
A Truck
HD#3
4 Hours After
A 3-Unit
PRBC
Transfusion
Transfusion-Related Acute Lung Injury [TRALI]
Side Note:
What else do you
notice in the left
chest?
Don’t forget to
look for tubes and
lines!
Interesting Case for the Month!

46. Summary Of Diagnoses This Month
• Alveolar hemorrhage
• Rib fractures with tension hemothorax
• Rib fractures with flail chest
• Traumatic Aortic Disruption
• Active Tuberculosis
• Transfusion related acute lung injury (TRALI)

47. See You Next Month!