Drs. Claire Milam and Alyssa Thomas 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 monthly educational, self-guided radiology slides on: Aortic Dissection, Hiatal Hernia, Pleural Effusion, Metastatic Cancer, Cystic Fibrosis, Pulmonary Contusions, Esophageal-pleural Fistula, Diaphragmatic Hernia, Pulmonary Artery Hypertension, Hemorrhagic Pericardial Effusion, Pulmonary Infarct

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
August 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 Carolinas Medical Center departments, and now…
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. It’s All About The Anatomy!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. 36 Year-Old
With Acute
Onset Chest
Pain, Back Pain
And Leg
Numbness
Case #1
Look closely, what do you notice?

7. Wide Mediastinum
On CT Scout Film
36 Year-Old
With Acute
Onset Chest
Pain, Back Pain
And Leg
Numbness

8. Type A Dissection
From Aortic Root To Both Iliac Arteries
Case #1 CT Images

9. Type A Dissection
Post-Operative CXR

10. TYPE A TYPE B
Recall the
differences
between Type A
and Type B
dissections

11. Branch Vessel Compromise
Myocardial infarction
Stroke
Spinal cord infarction
Mesenteric and renal ischemia
Limb ischemia
As a dissection
progresses, any
branches off the aorta
may suffer from
ischemia

12. Chest Pain
Back Pain
Stroke Symptoms
Paraplegia
Acute Abdomen
Renal Failure
Aortic
Dissection?
Paretic Extremity
Whenever you have
chest/back pain + other
major organ symptom, then
consider aortic dissection…

13. Type A Dissections
Acute aortic insufficiency
Acute pulmonary edema
Pericardial tamponade
Acute myocardial infarction
Let’s take a
second to focus
on Type A
Dissections…

14. Type A Dissections

15. Aortic
Dissection?
ACS + widened
mediastinum on CXR
should clue you in to
consider aortic
dissection

16. Chest Pain
Back Pain
Acute CHF
New AI Murmur
Syncope
Aortic
Dissection?

17. Acute Aortic Dissections
are challenging to
diagnose and treat
Lit Review
for Case #1

18. IRAD: Demographics And Risks
Type A 67%
Type B 33%
Risk Factors
Hypertension 77%
Atherosclerosis 27%
Known aneurysm 16%
Cardiac surgery 16%
Marfan syndrome 5%
Iatrogenic 4%
Cocaine use1 2%
1Cocaine use 12% in black patients
66% of patients were male
The mean age was 63 years
Lit Review for Case #1

19. IRAD: Demographics And Risks
Type A 67%
Type B 33%
Risk Factors
Hypertension 77%
Atherosclerosis 27%
Known aneurysm 16%
Cardiac surgery 16%
Marfan syndrome 5%
Iatrogenic 4%
Cocaine use1 2%
1Cocaine use 12% in black patients
66% of patients were male
The mean age was 63 years
Lit Review for Case #1

20. IRAD: Clinical Manifestations
Pain1 reported in 93.7%:
A B
Chest pain 79% 63%
Back pain 43% 64%
HPTN on presentation 36% 70%
Pulse deficit 30% 20%
Syncope2 19%
1,2Painless AAD and patients presenting with syncope had a
higher risk of heart failure, tamponade and death.
A = Type A Dissection
B = Type B Dissection
Lit Review for Case #1

21. IRAD: Clinical Manifestations
Quality of pain [from the original IRAD data set published in 2000]:
Hagan PG. JAMA 2000.
Abrupt onset 84%
Worst pain ever 91%
Sharp 64%
Tearing or ripping 51%
Radiating 28%
Migratory 17%
History is key!
- Most patients will
know the exact time
the pain started
Lit Review for Case #1

22. Elderly Male
With
Progressive
Dyspnea
Case #2
What Do You See?

23. Elderly Male
With
Progressive
Dyspnea
What Is This?

24. Elderly Male
With
Progressive
Dyspnea
Hiatal Hernia

25. Diaphragm
Hiatal
Hernia
Hiatal
Hernia

26. Hiatal Hernia Sxs
• Heartburn
• Regurgitation
• Dysphagia

28. Right Pleural Effusion

29. After Pleural Drainage

31. 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 albumen 1.2 g/dl higher than the pleural fluid will help correctly
identify a transudate.

34. 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

35. Right Parapneumonic Effusion

37. Malignant Effusions
• The second most common exudative effusions are those associated
with underlying malignancy
• The majority of 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

38. Lung Mass With Malignant Effusion

39. Lung Mass After Effusion Drainage

42. Metastatic Round Cell Cancer
*
*
*
*
*

43. 24 Year-Old
With Cystic
Fibrosis
Presents
With Cough
And
Hemoptysis

44. 24 Year-Old
With Cystic
Fibrosis
Presents
With Cough
And
Hemoptysis
Severe Bronchiectasis And Bullous Lung Disease

45. 24 Year-Old With Cystic Fibrosis Presents With Cough And Hemoptysis
Severe Bronchiectasis And Bullous Lung Disease

47. Cystic Fibrosis:
• Characterized by chronic respiratory infections resulting in
progressive loss of lung function
• Acutely worsening symptoms (Pulmonary Exacerbations) manifest as:
increased cough, sputum production, and shortness of breath.
Varying degrees of hemoptysis may occur with severe cases.

48. Emergency Department Management Of Pulmonary Exacerbations:
Atrium Health order set: ADULT MED Cystic Fibrosis Exacerbations
• Aggressive bronchodilator therapy
• Order ‘CF Bronchiectasis Sputum Culture’ [will capture rare bacteria species]
• Broad spectrum antibiotics with double-coverage for Pseudomonas
• No evidence that steroids are routinely beneficial, OK to administer if
bronchospasm if felt to be a significant contributor to the exacerbation
• Trial of non-invasive ventilation if intubation is felt to be necessary

49. 25 Year-Old With Cystic Fibrosis

50. 49 Year-Old With Cystic Fibrosis

51. 46 Year-Old
Male
Sustains
Multiple
GSWs To The
Right Chest
And
Abdomen
Severe Pulmonary Contusion

52. 46 Year-Old
Male
Sustains
Multiple
GSWs To The
Right Chest
And
Abdomen
Severe Pulmonary Contusion – After Chest Tube

53. 46 Year-Old
Male
Sustains
Multiple
GSWs To The
Right Chest
And
Abdomen
Severe Pulmonary Contusion – Post Injury Day #1

54. 46 Year-Old
Male
Sustains
Multiple
GSWs To The
Right Chest
And
Abdomen
Severe Pulmonary Contusion – Post Injury Day #2

55. 46 Year-Old
Male
Sustains
Multiple
GSWs To The
Right Chest
And
Abdomen
Severe Pulmonary Contusion – Post Injury Day #3

56. 46 Year-Old
Male
Sustains
Multiple
GSWs To The
Right Chest
And
Abdomen
Severe Pulmonary Contusion – Post Injury Day #10

57. 62 Year-Old
Male Struck
By A Car
While Riding
His Moped

58. 62 Year-Old
Male Struck
By A Car
While Riding
His Moped
Pulmonary Contusion

59. 62 Year-Old Male Struck By A Car While Riding His Moped
Pulmonary Contusion

60. 23 Year-Old
Male With
AIDS
Presents
With Fever
Dyspnea
A Case From Kenya

61. 23 Year-Old
Male With
AIDS
Presents
With Fever
Dyspnea
A Case From Kenya
Tuberculous Effusion With Shift
Did Well After Drainage & TB Therapy

62. 53 Year-Old
Female With
Two Years Of
Upper
Abdominal
Pain + Two
Months Of
Dyspnea +
Two Weeks
Of Fever
Cases Studies From
Our Emergency
Medicine Partners In
Brazil

63. 53 Year-Old
Female With
Two Years Of
Upper
Abdominal
Pain + Two
Months Of
Dyspnea +
Two Weeks
Of Fever
Cases Studies From
Our Emergency
Medicine Partners In
Brazil
A Chronic Ulcer Of The Gastroesophageal Junction Erodes Into The
Right Chest Creating A Fistula. Full Recovery After Surgical Repair.

64. Let’s Pause And Look At A Normal CXR

65. 45 Year-Old
Male
Involved In A
Roll-Over Car
Crash
Intubated In
The Field
What Do You See?

66. 45 Year-Old
Male
Involved In A
Roll-Over Car
Crash
Intubated In
The Field
Rib
Fracture
Elevated
Hemidiaphragm

67. 45 Year-Old
Male
Involved In A
Roll-Over Car
Crash
Intubated In
The Field
Why Is The Left Hemidiaphragm Elevated?
Rib
Fracture
Elevated
Hemidiaphragm

68. 45 Year-Old Male Involved In
A Roll-Over Car Crash
Intubated In The Field
Ruptured Diaphragm

69. 45 Year-Old
Male With
Rupture Of
The Left
Diaphragm
Chest X-Ray After Repair

70. Diaphragm Injury Demographics
ACS National Trauma Data Bank [n=833,309]:
• Diaphragm injuries are rare, incidence: 0.46%
• Mechanism: 67% penetrating and 33% blunt
Penetrating Blunt
 Gunshot wounds 67%  Motor vehicle crash 63%
 Stab wounds 33%  Bicycle/pedestrian stuck 10%
Mortality 9% Mortality 20%
Fair KA. J Trauma 2015; 209:864-868.

72. SUMMARY Of 2018 EAST Practice Management Guidelines
#1 In stable patients with left thoracoabdominal stab wounds, laparoscopy
is recommended rather than CT imaging to decrease the incidence of
missed diaphragm injuries.
#2 In stable patients with confirmed or suspected penetrating injuries of
the right diaphragm, non-operative management is recommended over
operative management.
#3 In stable patients with acute diaphragm injuries, the abdominal rather
than the thoracic approach is preferred for injury repair.
#4 In patients with acute penetrating diaphragm injuries without concerns
for other intraabdominal injuries, laparoscopic repair is recommended
over open repair.

73. 33 Year-Old
With Dyspnea.
What Do You
See?

74. 33 Year-Old
With Dyspnea.
Enlarged Right
Pulmonary Artery
Enlarged Left
Pulmonary Artery

75. 33 Year-Old
With Dyspnea.
Pulmonary Arterial Hypertension
Enlarged Right
Pulmonary Artery
Enlarged Left
Pulmonary Artery

76. 68 Year-Old
On Warfarin
Presents With
Dyspnea.
Her INR is 7.5.

77. 68 Year-Old Presents With Dyspnea.
Large Pericardial Effusion
*
*
*
*
*
*
*
*

78. 68 Year-Old Presents With Dyspnea.
ED ECHO: Large Pericardial Effusion
**
*
*
*
Diastolic Collapse

79. 68 Year-Old
On Warfarin
Presents With
Dyspnea.
Her INR is 7.5.
Our Patient
 Full reversal with Vitamin K, PCC
 Pericardiocentesis and removal of >800 cc bloody fluid

80. “Spontaneous Hemopericardium In A Patient Receiving
Apixaban Therapy.”
Sigawy C. Pharmacotherapy 2015. Epub, June 10.
“Dabigatran-Induced Spontaneous Hemopericardium And
Cardiac Tamponade.”
Qurat-ul ain, J. Tex Heart Inst. 2017; 44(5):370-372.
“Bleeding Heart: A Case Of Spontaneous Hemopericardium And
Tamponade In A Patient On Warfarin.”
Sajawal A. BMJ Case Reports. 2016; 1136/bcr-2016-215731.

81. “2017 ACC Expert Consensus Decision Pathway on Management
Of Bleeding In Patients On Oral Anticoagulants.
A Report of the ACC Task Force On Decision Pathways.
Tomaselli GF. JACC 2017; 70:3042-63.
Question #1: Is There Major Bleeding?
Question #2: Is There Bleeding At A Critical Site?

82. Tomaselli GF. JACC 2017. 70:3046-63
Does ≥1 Of The Following Apply?
 Hemodynamic instability
 Hemoglobin drop ≥2 grams
 Transfusion ≥2 units of PRBCs
 Bleeding at a critical site
Major
Bleeding
Y
Yes No
Y
Non-Major
Bleeding
Is There Major Bleeding?

83. Critical Bleeding Sites
Intracranial Intraparenchymal, subdural, epidural, SAH
Other CNS Intraocular, intra- or para- spinal
Pericardium
Airway Epistaxis, upper/lower airway
Intracavitary Thoracic, abdominal, retroperitoneum
Extremity Muscle compartment, joint
Is Bleeding At A Critical Site Or Life-Threatening?
Immediate
Reversal
Y
Yes No
Y
Case Specific
Reversal

84. Critical Bleeding Sites
Intracranial Intraparenchymal, subdural, epidural, SAH
Other CNS Intraocular, intra- or para- spinal
Pericardium
Airway Epistaxis, upper/lower airway
Intracavitary Thoracic, abdominal, retroperitoneum
Extremity Muscle compartment, joint
Is Bleeding At A Critical Site Or Life-Threatening?
Immediate
Reversal
Y
Yes No
Y
Case Specific
Reversal

85. 60 Year-Old
With Right
Sided Pleuritic
Chest Pain
What Do You
See?

86. 60 Year-Old
With Right
Sided Pleuritic
Chest Pain
Is This
Pneumonia?

87. 60 Year-Old With Right Sided Pleuritic Chest Pain
Chest CT [+] For PE: RLL Pulmonary Infarct

88. Summary Of Diagnoses This Month
 Type A aortic dissection
 Hiatal hernia
 Pleural effusion
 Metastatic round cell carcinoma
 Cystic fibrosis and severe
bronchiectasis
 Pulmonary contusions
 Esophageal-pleural fistula
 Ruptured left hemidiaphragm
• Pulmonary artery hypertension
• Hemorrhagic pericardial effusion
• Pulmonary infarct

89. See You Next Month!