Dr. Michael Gibbs is a Professor of Emergency Medicine and interested in educating others. Radiology is a passion of his. Follow along with the EMGuideWire.com team as they post Dr. Gibbs's weekly educational, self-guided radiology slides on: Colonic perforation, free air, coarctation, multifocal pneumonia, several pneumothoraces, Oral Gastric Tube in right mainstem bronchus, Traumatic aortic disruption, Scoliosis, lung metastases, pneumomediastinum

1. Chest X-Rays Of The Week
Michael Gibbs, MD, FACEP, FAAEM
Professor And Chair
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Vice President of Research
Atrium Health
CMC X-Ray Mastery Series
February 18th 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 contributing: Emergency Medicine, Fellows from the Center For
Advanced Practice, Trauma & Acute Care Surgery, SHVI, and Medical
Critical Care. Slides are shared with all contributors.
 Cases submitted this week be distributed next week.
 The 1st image will show a chest X-ray without identifiers and the 2nd image
will reveal the diagnoses.

4. It’s All About The Anatomy!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. Patient With
Abdominal Pain
And Sepsis
Free Air Under The Diaphragm: Colonic Perforation

7. Patient With
Abdominal Pain
And Sepsis
Free Air Under The Diaphragm: Colonic Perforation

8. Patient With
Chest Pain
Why Would A
Patient Have
Cardiomegaly
And Inferior
“Notching” Of
Ribs?
Coarctation Of The Thoracic Aorta

9. Patient With
Chest Pain
Coarctation Of The Thoracic Aorta

10. Patient With
Chest Pain
Coarctation Of The Thoracic Aorta

11. Coarctation – Stent Graft Placed
Thoracic Endovascular Aortic Repair [TEVAR]

12. Why Does Coarctation Cause Rib Notching?
• The descending aorta is stenotic and therefore collateral flow is needed.
• The collateral pathway is via the subclavian artery to the internal
thoracic artery to the anterior intercostal artery to the posterior
intercostal artery and then to the descending thoracic aorta.
• The dilated, tortuous vessels erode the lower rib margins, seen most
commonly in ribs 4 – 8.
• Notching seen in 70% of cases presenting in older children or adults.

13. Coarctation Of The Thoracic Aorta

14. “ACC/AHA 2008 Guidelines For The Management Of Adults
With Congenital Heart Disease.”
A Report of the ACC/AHA Task Force On Practice Guidelines.
Warnes CA. Circulation 2008; 23:e714-e833..

15. Warnes CA. Circulation 2008; 23:e714-e833.
Coarctation Of The Thoracic Aorta In Adults
Clinical Features
 Hypertension in right arm relative to the lower extremities
 Hyperdynamic carotid pulses
 A murmur may be heard over the left intrascapular position
 A continuous murmurs may be hear over parasternal areas
Presenting Symptoms
 May remain asymptomatic if collateral flow is adequate
 Hypertension – discrepant between the upper and lower extremities
 Increased proximal pressure [chest pain, headache, epistaxis]
 Decreased distal pressure [lower extremity claudication]

16. Warnes CA. Circulation 2008; 23:e714-e833.
Coarctation Of The Thoracic Aorta In Adults
Chest X-Ray Findings
 Cardiomegaly
 An indentation at the coarctation may produce a “3-sign” beneath the
aortic arch
 Notching under ribs 3-9
ECG Findings
 Left ventricular hypertrophy
 Secondary ST-T changes due to strain

17. Coarctation Of The Thoracic Aorta

18. Coarctation Of The Thoracic Aorta

19. Coarctation Of The Thoracic Aorta

20. Patient With A
History of ESRD
Presents With
Fever And Cough
Patchy Multifocal Pneumonia

21. Young Adult With Stab Wounds To The Chest & Neck
* *
Bilateral Pneumothoraces & Subcutaneous Emphysema (*)

22. Carina
Dobhoff Tube Placed In The Right Mainstem Brochus
Young Adult With
Aspiration
Pneumonia

23. Young Adult In A
Motor Vehicle
Crash:
 Femur fracture
 Splenic injury
Wide
Mediastinum
Traumatic Aortic Disruption

24. Traumatic Aortic Disruption
Young Adult In A
Motor Vehicle
Crash:
 Femur fracture
 Splenic injury

25. Young Adult In A Motor Vehicle Crash
Thoracic Endovascular Aortic Repair [TEVAR]
Coarctation Of The Thoracic Aorta

26. Pediatric Patient With A Viral Prodrome, Now Cough, Fever, Confusion.
Multilobar Pneumonia: RML + RLL
RML
RLLRLL
RML

27. Untreated Scoliosis
Asymptomatic
Young Adult

28. Traumatic Pneumothorax
Chest Pain After
Motor Vehicle
Crash

29. Uterine Cancer Metastases – Entire Left
Hemithorax + Right Lung Lesion
History Of
Uterine Cancer –
Now More Short
Of Breath

30. Uterine Cancer Metastases – Entire Left
Hemithorax + Right Lung Lesion

31. Young Male With
Intractable
Vomiting
Pneumomediastinum & Pneumopericardium

32. Young Male With Intractable Vomiting
Pneumomediastinum & Pneumopericardium

33. Pneumomediastinum
2° Iatrogenic 2° Medical & Traumatic Spontaneous
 Endoscopic procedures
 Intubation
 Pleural instrumentation
 Central vascular procedure
 Chest/abdominal surgery
 Blunt chest injury
 Penetrating chest injury
 Asthma/COPD
 Bronchiectasis
 Interstitial lung disease
 Thoracic malignancy
 Tobacco use
 Recreational drugs
 Breath holding
 Weight lifting
Vasileios K. Journal of Thoracic Disease 2015; 7:S44-S49.
Management Essentials
 Manage the underlying cause
 Pain management & cough suppression as indicated
 Oxygen may increase gas absorption in severe cases
 Brief period of observation vs. close outpatient follow-up

34. Summary Of Diagnoses This Week
• Free air: colonic perforation
• Coarctation of the aorta
• Multifocal pneumonia
• Several pneumothoraces
• Dobhoff tube place in the right mainstem bronchus
• Traumatic aortic disruption
• Untreated scoliosis
• Lung metastases
• Pneumomediastinum due to intractable vomiting