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Dr. Michael Gibbs's CMC X Ray Mastery Project - Week #8 Cases

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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: Parapneumonic Effusion, Traumatic Aortic Disruption, Right Upper Lobe Pneumonia, Pulmonary Metastatic Disease, Type A Aortic Dissection, Left Mainstem Bronchus Obstruction due to Mucous Plugging

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Dr. Michael Gibbs's CMC X Ray Mastery Project - Week #8 Cases

  1. 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 Chest X-Ray Mastery Project April 1st 2019
  2. 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. 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 will be distributed next week.  When reviewing the presentation, the 1st image will show a chest X-ray without identifiers and the 2nd image will reveal the diagnosis.
  4. 4. It’s All About The Anatomy!
  5. 5. Airway Bones Cardiac Diaphragm Effusion Foreign body Gastric Hilum
  6. 6. 13 Month Old Being Treated For Pneumonia In The Setting Of Recent Influenza Now With More Dyspnea
  7. 7. 13 Month Old Being Treated For Pneumonia In The Setting Of Recent Influenza Now With More Dyspnea Parapneumonic Effusion With Shift
  8. 8. Parapneumonic Effusion With Shift 500 cc Of Purulent Chest Tube Output 13 Month Old Being Treated For Pneumonia In The Setting Of Recent Influenza Now With More Dyspnea
  9. 9. 21 Year Old On A Motorcycle That Collided Head-On With A Car
  10. 10. 21 Year Old On A Motorcycle That Collided Head-On With A Car Wide Mediastinum And Loss Of The Aortopulmonary Window Traumatic Aortic Disruption
  11. 11. 21 Year Old On A Motorcycle That Collided Head-On With A Car Prior CXR Now Traumatic Aortic Disruption
  12. 12. 21 Year Old On A Motorcycle That Collided Head-On With A Car Traumatic Aortic Disruption
  13. 13. 21 Year Old On A Motorcycle That Collided Head-On With A Car Traumatic Aortic Disruption
  14. 14. 21 Year Old On A Motorcycle That Collided Head-On With A Car Traumatic Aortic Disruption
  15. 15. 21 Year Old On A Motorcycle That Collided Head-On With A Car Traumatic Aortic Disruption
  16. 16. 55 Year Old Pedestrian Struck
  17. 17. 55 Year Old Pedestrian Struck Wide Mediastinum Tracheal Deviation And Loss Of The Aortopulmonary Window Traumatic Aortic Disruption & Multiple Rib Fractures
  18. 18. 55 Year Old Pedestrian Struck
  19. 19. 55 Year Old Pedestrian Struck Traumatic Aortic Disruption
  20. 20. 55 Year Old Pedestrian Struck
  21. 21. Traumatic Aortic Disruption Successfully Deployed TEVAR 55 Year Old Pedestrian Struck
  22. 22. 55 Year Old Pedestrian Struck Multiple Posterior Rib Fractures
  23. 23. 55 Year Old Pedestrian Struck Multiple Posterior Rib Fractures * * * * * * *
  24. 24. TAD Chest X-Ray Findings 1. Wide mediastinum 2. Abnormal aortic contour 3. Loss of the aortopulmonary window 4. Tracheal deviation 5. Depressed left mainstem 6. Apical cap 7. Deviated nasogastric tube 8. Widened paratracheal stripe
  25. 25. Right Upper Lobe Pneumonia Cough, Fever, Dyspnea
  26. 26. 2 Year Old With Cough And Fever Heart Rate 190 Temperature 105
  27. 27. 2 Year Old With Cough And Fever Heart Rate 190 Temperature 105 Right Upper Lobe Pneumonia
  28. 28. 70 Year Old With Ovarian Cancer Receiving Chemotherapy Presents With Fever
  29. 29. 70 Year Old With Ovarian Cancer Receiving Chemotherapy Presents With Fever Diffuse Pulmonary Metastatic Disease
  30. 30. 70 Year Old With Ovarian Cancer Receiving Chemotherapy Presents With Fever Diffuse Pulmonary Metastatic Disease
  31. 31. 65 Year Old With Hypertension Presents To The ED With Chest Pain
  32. 32. 65 Year Old With Hypertension Presents To The ED With Chest Pain Wide Mediastinum Type A Aortic Dissection
  33. 33. 65 Year Old With Hypertension Presents With Chest Pain Type A Aortic Dissection
  34. 34. Comprehensive English language MEDLINE literature review from 1966 to 2000. Thirteen studies permitted the analysis of 1337 chest X-rays.  90% of patient with aortic dissection had at least one CXR abnormal finding  The absence of a wide mediastinum had a [-] LR of 0.3 (95% CI: 0.2 – 0.4)
  35. 35. The absence of a wide mediastinum on chest X-Ray had a negative likelihood ratio ranging from 0.14 to 0.60, making this a finding decreases the risk of aortic dissection Evidence-based review of nine studies between 1986 and 2013, [n=2,400]. The prevalence or aortic dissection ranged form 21% to 76%. 2018
  36. 36. 2018
  37. 37. 80 Year Old Presenting With Weakness And Dyspnea
  38. 38. 80 Year Old Presenting With Weakness And Dyspnea Left Mainstem Obstruction: Neoplasm Vs. Mucous Plug
  39. 39. 80 Year Old Presenting With Weakness And Dyspnea Bronchoscopy Reveal A Mucous Plug
  40. 40. Summary Of Diagnoses This Week • Parapneumonic effusion • Traumatic aortic disruption • Right upper lobe pneumonia • Diffuse pulmonary metastatic disease • Type A aortic dissection • Left mainstem bronchus obstruction due to a mucous plug
  41. 41. See You Next Week!

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