Drs. Breeanna Lorenzen and Travis Barlock are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover: - Acute Chest Syndrome - Multifocal Pneumonia - Hiatal Hernia - Hemopneumothorax - Aortic Transection - Pneumomediastinum - Pulmonary Infarction

1. Adult Chest X-Rays Of The Month
Travis Barlock MD & Breeanna Lorenzen, MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs MD, Faculty Editor
Chest X-Ray Mastery Project
December 2020

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/LCH departments, and now from EM
colleagues in Brazil, Chile and Tanzania.
 Cases submitted this month will be distributed next month.
 When reviewing the presentation, the 1st image will show a chest X-ray
without identifiers and the 2nd image will reveal the diagnosis.

4. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Chest X-Ray Presentations And Much More!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. It’s All About The Anatomy!

7. 35-Year-Old Female With Sickle Cell Disease Presents
With Shortness Of Breath, Chest Pain, & Hypoxia.

8. Diagnosis: Acute Chest Syndrome (ACS).
35-Year-Old Female With Sickle Cell Disease Presents
With Shortness Of Breath, Chest Pain, & Hypoxia.

9. Diagnosis: Acute Chest Syndrome (ACS).
ACS Can Be
Difficult To
Differentiate
From
Pneumonia On
CXR!
When In
Doubt Involve
Hematology
Early For
Input.
35-Year-Old Female With Sickle Cell Disease Presents
With Shortness Of Breath, Chest Pain, & Hypoxia.

10. Diagnosis: Acute Chest Syndrome
35-Year-Old Female With Sickle Cell Disease Presents
With Shortness Of Breath, Chest Pain, & Hypoxia.

12. Acute Chest Syndrome
 Defined as a new pulmonary infiltrate consistent with consolidation
[not atelectasis] of at least one lung segment.
 Usually accompanied by chest pain, cough, fever and wheezing.
 The most common cause or ICU admission and premature death in
patients with sickle cell disease.
Gladwin M. New England Journal of Medicine 2008; 359:2254-65.

13. Acute Chest Syndrome
Three proposed mechanisms:
 Pulmonary infection1
 Embolization of bone marrow fat2
 Pulmonary intravascular sickling and infarction3
1Bronchoalveolar lavage demonstrates bacterial and/or viral pathogens in 54% of patients with ACS.
2Associated with pain crisis of multiple bones, particularly the lumbar spine, femurs and the pelvis.
3In a small percentage of patients with ACS, wedge-shaped pulmonary infarcts may develop.
Gladwin M. New England Journal of Medicine 2008; 359:2254-65.

15. National Acute Chest Syndrome Study Group
 538 patients from 20 centers - the largest case series to date
 Results provide insights into the clinical presentations and outcomes of
hospitalized patients with ACS
49% Of Patients Initially Presented In Pain Crisis Without Signs Of ACS!
Vichinsky EP. New England Journal of Medicine 2000; 342:1855-65.

16. National Acute Chest Syndrome Study Group
 Manifestations: worsening hypoxia, decreased hemoglobin levels, and
progressive, multi-lobar pulmonary infiltrates
 The mean hospital length of stay was 10.5 days [vs. 3 days w/o ACS]
 30% required mechanical ventilation and overall mortality was 3%
Vichinsky EP. New England Journal of Medicine 2000; 342:1855-65.
Infection1,2 33%
Pulmonary Infarction 33%
Pulmonary fat emboli 16%
1Pathogens identified using bronchoalveolar lavage
2Chlamydophilia, Mycoplasma pneumoniae & respiratory syncytial virus the most common pathogens

17. Acute Chest Syndrome
ED Treatment Essentials:
 Antibiotics to cover both typical & atypical pathogens
 Supportive respiratory care
 A transfusion strategy based on goals and severity
Gladwin M. New England Journal of Medicine 2008; 359:2254-65.
Goal Target
Increase oxygen carrying capacity Hgb ≥10 grams
Manage vaso-occlusive complications HbS <30%
Both As above

20. RCE = Red Cell Exchange

21. 57-Year-Old Male With Shortness Of Breath

22. Diagnosis: Multifocal Pneumonia/ARDS
Notice The Air
Bronchograms.
57-Year-Old Male With Shortness Of Breath

23. 73-Year-Old Male Intubated For Hypoxemia.

24. Notice The Air
Bronchograms.
Diagnosis: Multifocal Pneumonia/ARDS
73-Year-Old Male Intubated For Hypoxemia.

25. 60-Year-Old Female With Chest Pain & “Heartburn.”

26. Diagnosis: Hiatal Hernia
Notice The Air
Fluid Level Behind
The Cardiac
Silhouette.
60-Year-Old Female With Chest Pain & “Heartburn.”

27. Middle Aged Patient Presenting With Chest Pain.

28. Air-Fluid Level
Diagnosis: Hiatal Hernia
Middle Aged Patient Presenting With Chest Pain.

29. When Fluid Layers As A Flat Line In The Chest: “There Is Air In There!”

30. Young, Healthy Patient
Presents After Trauma
To The Chest.

31. Air Fluid Level
Diagnosis: Left Hemopneumothorax
Lung Markings
Young, Healthy Patient
Presents After Trauma
To The Chest.

32. Patient
Presents
After
Trauma To
The Chest.

33. Lung
Markings
Diagnosis: Left Hemopneumothorax
Patient
Presents
After
Trauma To
The Chest.

34. 33-Year-Old Male After Motor Vehicle Crash.

35. Widened Mediastinum
33-Year-Old Male After Motor Vehicle Crash.

36. Tear At The
Aortic
Isthmus
33-Year-Old Male After Motor Vehicle Crash.
Diagnosis: Aortic Transection

37. 18-Year-Old Male With Chest & Neck Pain After A Motor Vehicle Crash.

38. 18-Year-Old Male With Chest & Neck Pain After A Motor Vehicle Crash.
Diagnosis: Pneumomediastinum & Pneumopericardium

39. Diagnosis: Pneumomediastinum & Pneumopericardium
18-Year-Old Male With Chest & Neck Pain After A Motor Vehicle Crash.

40. Visit The “Condition Specific” Tab On Our Website
www.EMGuidewire.com
To View An Excellent Presentation On Pneumomediastinum Authored
By Drs. Wilson & Leederkerken.
Dr. Wilson Dr. Leederkerken

41. 23-year-old one week after an MVC With Multiple Orthopedic Injuries
Now With Left-Sided Pleuritic Chest Pain And Hypoxia.

42. 23-year-old one week after an MVC With Multiple Orthopedic Injuries
Now With Left-Sided Pleuritic Chest Pain And Hypoxia.

43. 23-year-old one week after an MVC With Multiple Orthopedic Injuries
Now With Left-Sided Pleuritic Chest Pain And Hypoxia.

44. 23-year-old one week after an MVC With Multiple Orthopedic Injuries
Now With Left-Sided Pleuritic Chest Pain And Hypoxia.
Diagnosis: Pulmonary Infarction

45. Pulmonary Infarction
Pulmonary infarction is rare because the lung parenchyma receives
three O2 sources:
• Pulmonary vascular system
• Bronchial vascular system – the primary O2 supply
• Diffusion of inspired oxygen
Following an occlusive pulmonary embolism the bronchial arteries are
recruited to increase pulmonary parenchymal blood flow by up to
300%.

46. Pulmonary Infarction
Pulmonary infarction becomes more likely when:
• Bronchial artery flow is reduced during shock states
• Pulmonary venous pressure is increased, e.g.: in patients with acute
pulmonary edema
In these scenarios pulmonary parenchymal blood flow is sufficiently
reduced to cause pulmonary infarction.

48. Chest X-Ray
• Wedged-shaped juxtapleural opacity (Hampton’s hump)1
• Pleural effusion (small, unilateral)
• Elevated hemidiaphragm (volume loss)
Computed Tomography
• Hampton’s hump1
• Consolidation with internal air (“bubbly consolidation”)2
• Vascular filling defects
• Pleural effusion
• Cavitation (<10%) in septic emboli or following infection of infarcted lung tissue
1Seen more often in the lower lobes.
2Represents non-infarcted lung parenchyma side-by-side with infarcted lung in the same lobule.

50. Hampton’s Hump

52. Hampton’s Hump

54. Hampton’s Hump

59. Summary Of Diagnoses This Month
 Acute Chest Syndrome
 Multifocal Pneumonia/ARDS
 Hiatal Hernia
 Hemopneumothorax
 Aortic Transection
 Pneumomediastinum
 Pulmonary Infarction

60. See You Next Month!