This document provides a summary of adult chest x-rays reviewed from the Emergency Medicine department. It discusses various cases seen over the past month, including a malignant pleural effusion with lung mass from uterine cancer, pericardial effusions, traumatic aortic disruption from motor vehicle accidents, a case of femoral guidewire migration in an ICU patient, a disconnected HeRO graft in a dialysis patient, and a case of right-sided flail chest and pulmonary contusion from a motor vehicle crash. The document aims to promote mastery of chest x-ray interpretation among emergency medicine residents.

1. Adult Chest X-Rays Of The Month
Daniel Escobar, MD & Breeanna Lorenzen, MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD - Faculty Editor
CMC Imaging Mastery Project
August 2021

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. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Imaging Presentations And Much More!

4. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

5. It’s All About The Anatomy!

6. 55-Year-Old With A History Of Uterine Cancer Presents With Dyspnea.

7. 55-Year-Old With A History Of Uterine Cancer Presents With Dyspnea.
Lung Mass With Malignant Pleural Effusion

8. ED Point-Of-Care Ultrasound

9. ED Point-Of-Care Ultrasound
Pleural
Effusion
Pericardium
The relationship of a fluid
collection with the aorta
(“A”) helps distinguish a
pleural effusion from a
pericardial effusion.
Pericardial Effusion
Spine
A

10. Lung Mass After Effusion Drainage

11. 68-Year-Old With A History Of Breast Cancer Presents With Dyspnea.
Today 1 Year Ago

12. 68-Year-Old With
A History Of
Breast Cancer
Presents With
Dyspnea.
Malignant Pleural Effusion

14. Light’s Criteria
Transudate Versus Exudate1,2
Pleural Fluid Protein/Plasma Protein >0.5
Pleural Fluid LDH/Plasma LDH >0.6
Pleural Fluid LDH >200 IU
1In patients with heart failure on diuretics, Light’s Criteria may misclassify a
transudate as an exudate up to 25% of the time.
2In heart failure patients, a serum protein 3.1 g/dl higher than the pleural fluid,
or a serum albumin 1.2 g/dl higher than the pleural fluid will help correctly
identify a transudate.

17. Parapneumonic Effusions
• The most common exudative effusions are those associated with
underlying pneumonia.
• Mortality is higher among pneumonia patients who have a
parapneumonic effusion, compared with those with pneumonia and
no effusion.
• With the aging of the population, the incidence and mortality due to
parapneumonic effusion and empyema continues to rise.

19. Malignant Effusions
• The second most common exudative effusions are those associated
with underlying malignancy.
• Most malignant pleural effusions arise from lung cancer, breast
cancer, and lymphoma.
• The presence of a malignant pleural effusion is associated with higher
mortality and significantly shorter survival.

21. 77-Year-Old
Male With A
History Of CML
And Anemia
Presents To
The ED After A
Syncopal Event.
HR 66, BP 87/53

22. 77-Year-Old Presents To The ED Following A Syncopal Event.
Day Of Presentation 3 Months Prior

23. Pericardial Effusion (*)
*
*
*
*
* * *
*
*
*
77-Year-Old Presents To The ED Following A Syncopal Event.

24. ED Point-Of-Care Ultrasound (POCUS).
77-Year-Old Presents To The ED Following A Syncopal Event.

25. Pericardium
Pericardial Effusion (*)
* * * *
There Are No
Sonographic Signs Of
Pericardial
Tamponade In The ED.
77-Year-Old Presents To The ED Following A Syncopal Event.
ED Point-Of-Care Ultrasound (POCUS).

26. Day #2: A Pericardiocentesis Is Performed And 1.2 Liters Of Fluid Is Removed.
Pericardium
Pericardial Effusion (*)
* * * *
77-Year-Old Presents To The ED Following A Syncopal Event.

27. CXR One Month After Pericardial Drainage
77-Year-Old
Male With A
History Of CML
And Anemia
Presents To
The ED After A
Syncopal Event.

28. 3 Months Ago Day Of Presentation
33-Year-Old With A Complex Malignancy Now Presents With Dyspnea.

29. The Cardiac Silhouette
Now Appears To Be
Larger And More
Globular
3 Months Ago Day Of Presentation
33-Year-Old With A Complex Malignancy Now Presents With Dyspnea.

30. ED Point-Of-Care Ultrasound: Pericardial Effusion
*
*
*
*
33-Year-Old With A Complex Malignancy Now Presents With Dyspnea.

34. Objectives:
To investigate the presenting clinical features of patients presenting to the ED with pericardial effusion.
Methods:
Retrospective review of POCUS and EMR patients of ED patients found to have pericardial effusion.
Results: of 814 POCUS examinations 47 with pericardial effusion were included
• 16 patients (34%) had moderate/large effusions
• 5 patients (11%) required emergency pericardiocentesis
• Symptoms: dyspnea (65%), chest pain 35%, syncope 11%, AMS 11%
• Tachycardia or hypotension was present in 72% of patients
• None of the patients with pericardial tamponade were found to have Beck’s Triad
Conclusions:
This study illustrates the important limitations of the physical examination in diagnosing pericardial
effusion. The liberal use of POCUS in ED patients with dyspnea, chest pain and syncope is recommended.

37. All studies evaluated patients with pericardial tamponade and/or those
with a known pericardial effusion requiring a pericardiocentesis.
Finding Sensitivity
Dyspnea 87% - 89% sensitivity range
Tachycardia 77% (95% CI, 69% - 85%)
Pulsus paradoxus 76% (95% CI, 72% - 92%)
Elevated central venous pressure 76% (95% CI, 62% - 90%)
Cardiomegaly on chest X-Ray 89% (95% CI, 73% - 100%)
Based on 1 study, the presence of pulsus paradoxus >10 mm Hg in a patient
with a pericardial effusion increased the likelihood of tamponade
(LR, 3.3; 95% CI, 1.8 – 6.3), while a pulsus paradoxus of <10 mm Hg greatly
lowers the likelihood (LR, 0.03; 95% CI, 0.01 – 0.24).

44. 56-year-old with metastatic breast cancer and a larger pericardial effusion.

45. 44-Year-Old
Male In A Car
Crash
Complains Of
Chest Pain.

46. 44-Year-Old
Male In A Car
Crash
Complains Of
Chest Pain.
Mediastinal Widening

47. 44-Year-Old
Male In A Car
Crash
Complains Of
Chest Pain.
Traumatic Aortic Disruption

48. Chest X-Ray Findings In
Traumatic Aortic Disruption (TAD)
1. Wide mediastinum
2. Abnormal aortic contour
3. Loss of aortopulmonary window
4. Tracheal deviation to the right
5. Depressed left mainstem bronchus
6. Left apical cap
7. Deviated nasogastric tube
8. Widened left paratracheal stripe
9. Left Hemothorax

49. TAD Findings Defined
1. Wide mediastinum: > 6 cm on PA film, > 8 cm on AP or supine films
2. Abnormal aortic contour: Convexity caused by a hematoma
3. Loss of aortopulmonary window: Straight or convex window
4. Left apical cap: Density in the apex of the lung caused by
extrapleural hemorrhage
5. Widened left paratracheal stripe: A left paratracheal stripe is an
opacity between left upper lobe and left trachea. A left paratracheal
stripe is uncommonly seen on CXR.

51. Widened Mediastinum: > 6 cm on PA film, > 8 cm on AP or supine film.

52. The normal aortopulmonary window should angle inwards.

53. In patients with TAD the aortopulmonary window is often straightened or angles outwards.

54. 4 Cases of Traumatic Aortic Disruption
From CMC During The Past Year.

55. 67-Year-Old In A Single Vehicle MVC Against A Tree.
Traumatic Aortic Disruption
Case #1

56. 67-Year-Old In A Single Vehicle MVC Against A Tree.
Endovascular Repair
Case #1

57. 33-Year-Old Male On A Moped Struck By A Car.
Traumatic Aortic Disruption
Case #2

58. 33-Year-Old Male On A Moped Struck By A Car.
Endovascular Repair
Case #2

59. 21-Year-Old On A Motorcycle That Collided Head-On With A Car.
Traumatic Aortic Disruption
Case #3

60. 21-Year-Old On A Motorcycle That Collided Head-On With A Car.
Endovascular Repair
Case #3

61. 55-Year-Old Pedestrian Struck.
Traumatic Aortic Disruption
Case #4

62. 55-Year-Old Pedestrian Struck.
Endovascular Repair
Case #4

63. What Do You See?
Morning Chest
X-Ray For An
ICU Patient.

64. Right Femoral Guidewire Migration Into The Right Heart & Internal Jugular Vein
Morning Chest
X-Ray For An
ICU Patient.

65. Morning Chest
X-Ray For An
ICU Patient.
What Do You See?

66. Right Femoral Guidewire Migration Into The Inferior Vena Cava And Right Heart
Morning Chest
X-Ray For An
ICU Patient.

67. What Do You See?
Dialysis
Patient
Admitted To
The ICU.

68. Disconnected HeRO® Graft
Dialysis
Patient
Admitted To
The ICU.

69. Dialysis
Patient
Admitted To
The ICU.
Last CXR In Our System: The HeRO® Graft Is Intact

70. What Is A HeRO® Graft?
• A HeRO graft (or HeRO catheter) is an arterial-to-
venous graft which allows high flow of blood for
dialysis. HeRO grafts are generally used in patients
who have few options for dialysis venous access.
• HeRO grafts have an arterial component that
attaches to an artery, usually on the upper arm. This
is then connected to the venous outflow component
which has a tip near the right atrium. The arterial
component and the venous outflow components are
connected using a titanium connector which is
responsible for attaching the arterial graft
component to the venous outflow component.

72. 50-Year-Old
Female In A Car
Crash.
Right-Sided
Flail Chest

73. 50-Year-Old
Female In A Car
Crash.
Right-Sided
Flail Chest
Multiple Right-Sided Rib Fractures

74. 50-Year-Old
Female In A Car
Crash.
Right-Sided
Flail Chest
Multiple Right-Sided Rib Fractures

75. 50-Year-Old
Female In A Car
Crash.
Right-Sided
Flail Chest
Pulmonary Contusion (→)

76. 50-Year-Old
Female In A Car
Crash.
12 Hours Post-Injury: Evolving Pulmonary Contusion

77. 24 Hours Post-Injury: Evolving Pulmonary Contusion
50-Year-Old
Female In A Car
Crash.

78. 72 Hours Post-Injury: Evolving Pulmonary Contusion
50-Year-Old
Female In A Car
Crash.
After Surgical
Rib Plating

79. 5 Days Post-Injury: Evolving Pulmonary Contusion
50-Year-Old
Female In A Car
Crash.
After Surgical
Rib Plating

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

82. EAST Guidelines For The Management Of Pulmonary Contusion & Flail Chest
 The use of optimal analgesia and aggressive chest physiotherapy should be used to
minimize the risk of respiratory failure.
 A trial of mask CPAP in combination with optimal regional anesthesia, should be
considered in alert, compliant patients with marginal respiratory status.
 Epidural catheter is the preferred method of analgesia delivery.
 Patients should be adequately resuscitated, and hypovolemia should be avoided. When
there are clear signs of hydrostatic fluid overload, diuretics may be used.
 Steroids should not be used in patients with pulmonary contusion.
 For patients requiring mechanical ventilation, PEEP and CPAP should be part in the
ventilatory strategy.

83. Summary Of Diagnoses This Month
 Malignant pleural effusion
 Pericardial effusion
 Traumatic aortic disruption
 Femoral guidewire migration
 Disconnected HeRO® graft
 Flail chest + pulmonary contusion

84. See You Next Month!