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: Hemopericardium, Cardiomyopathy, Heart Failure, Myocarditis, Ruptured Hemidiaphragm, Hydropneumothorax, Pneumothorax, ECMO

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
CXR Mastery Project
March 25th 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. See You Next Week!Chest X-Ray Two Weeks Ago
History Of
Pacemaker
Placement At An
Outside Facility
Two Weeks Ago.

7. History Of
Pacemaker
Placement At An
Outside Facility
Two Weeks Ago.
Now Presents To
The CMC ED With
Weakness And
Dyspnea.

8. Large Pericardial Effusion Due To
Pacemaker Lead Perforation Of The Right Ventricle
History Of
Pacemaker
Placement At An
Outside Facility
Two Weeks Ago.
Now Presents To
The CMC ED With
Weakness And
Dyspnea.

9. History Of Pacemaker Placement At An Outside Facility Two Weeks Ago
ED Bedside ECHO: Large Pericardial Effusion (*)

10. History Of Pacemaker Placement At An Outside Facility Two Weeks Ago
ED Bedside ECHO: Large Pericardial Effusion (*)
Cardiac
Apex
***
*
**

11. Pericardiocentesis And 1300 cc Of Bloody Fluid Is Removed
History Of
Pacemaker
Placement At An
Outside Facility
Two Weeks Ago

12.  Rapidly accumulating pericardial effusions cause swift increases in intrapericardial
pressure and tamponade physiology.
 Slowly accumulating pericardial effusions gradually distend the pericardium and
symptoms can be delayed.

14. Cardiomegaly From Ischemic Cardiomyopathy
ICD
Leads

15. Acute Dyspnea In A 65 Year Old With Severe HPTN
Last Month Today

16. Acute Dyspnea In A 65 Year Old With Severe HPTN
Today: Acute Heart Failure With Cardiomegaly & Interstitial Edema
Last Month Today

17. 16 Year Old
Presents 2 Weeks
After A Viral
Illness With
Dyspnea and
Peripheral Edema

18. 16 Year Old
Presents 2 Weeks
After A Viral
Illness With
Dyspnea and
Peripheral Edema
Heart Failure Likely Due To Viral Myocarditis

19. 76 Year Old Who
Fell Backwards.
He Complains Of
Right Lower Back
Pain.

20. 76 Year Old Who
Fell Backwards.
He Complains Of
Right Lower Back
Pain.
Posterior
Rib
Fractures
Rib Fractures & A Small Apical Pneumothorax

21. 76 Year Old Who
Fell Backwards.
He Complains Of
Right Lower Back
Pain.

22. 17 Year Old In A
High Speed MVC
Complains Of
Abdominal Pain

23. 17 Year Old In A
High Speed MVC
Complains Of
Abdominal Pain
Ruptured Diaphragm

24. 17 Year Old In A
High Speed MVC
Complains Of
Abdominal Pain
Ruptured Diaphragm

25. 57 Year Old In High Speed MVC – At Outside Facility

26. 57 Year Old In High Speed MVC – At Outside Facility

27. Ruptured Diaphragm
Chest
Tube
57 Year Old In High Speed MVC – At Outside Facility

28. Ruptured Diaphragm With Chest Tube Next To The Stomach
57 Year Old In High Speed MVC – Now At CMC

29. Traumatic Diaphragmatic Injury [TDI]
The largest study to date is from the National Trauma Data Bank, that
reviewed 833,309 cases of blunt & penetrating trauma:
• In this population the incidence of TDI was low at 0.46%
• 67% were penetrating and 33% were blunt
• Left-side rupture more common than right (70% vs. 30%)
• Hepatic protection of the right side, increased strength of the right
hemidiaphragm, and weakness of the left hemidiaphragm at points of
embryonic fusion all contribute to the predominance of left-sided
diaphragmatic rupture
Fair KA. American Journal of Surgery 2015; 209:864-8.

32. 86 Year Old With COPD Presents With Shortness Of Breath

33. 86 Year Old With COPD Presents With Shortness Of Breath
Hydropneumothorax

34. Air-Fluid Level
If It Looks Like This… There’s Air In There!

35. 20 Year Old
Asthmatic
Intubated And
On ECMO

36. 20 Year Old
Asthmatic
Intubated And
On ECMO
Right Apical Pneumothorax

38. Summary Of Diagnoses This Week
• Hemopericardium
• Cardiomegaly from ischemic cardiomyopathy
• Heart Failure
• Heart failure due to viral myocarditis
• Ruptured left diaphragm
• Hydropneumothorax
• Rib fractures + pneumothorax
• ECMO cannulation

39. See You Next Week!