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Dr. Michael Gibbs's CMC X Ray Mastery Project - Week #9 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: Spontaneous Pneumothorax, Pneumoperitoneum, Esophageal Perforation, Hemothorax, Traumatic Aortic Disruption, PCP pneumonia, HIV, Large Pneumatocele, Pericardial Effusion, Cardiomegaly, Pulmonary Hypertension, Flail Chest

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Dr. Michael Gibbs's CMC X Ray Mastery Project - Week #9 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 8th 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, Surgery, Internal Medicine, 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. Healthy Young Female With Sudden Onset Right-Sided Pleuritic Chest Pain
  7. 7. Spontaneous Pneumothorax Healthy Young Female With Sudden Onset Right-Sided Pleuritic Chest Pain
  8. 8. Sahn SA. NEJM 2000; 342:868-874. Classification Of Pneumothorax According To Cause Spontaneous 1°: No clinical lung disease 2°: A complication of clinically apparent lung disease Traumatic • Penetrating trauma • Blunt trauma Iatrogenic • Transthoracic needle aspiration • Central line placement • Thoracentesis • Lung biopsy
  9. 9. NEJM 2000; 342:868-874.
  10. 10. Esophageal Food Impaction – Then Severe Upper Abdominal Pain
  11. 11. Esophageal Food Impaction – Then Severe Upper Abdominal Pain Pneumoperitoneum: Esophageal Perforation
  12. 12. Esophageal Food Impaction – Then Severe Upper Abdominal Pain Pneumoperitoneum: Esophageal Perforation
  13. 13. Gunshot Wound To The Right Upper Quadrant
  14. 14. Gunshot Wound To The Right Upper Quadrant Large Right Hemothorax & Two Foreign Bodies
  15. 15. Bilateral Pleural Effusions Loss Of The Normal Costophrenic Angles Flattened Effusion Well Seen On Lateral
  16. 16. Normal Sharp Costophrenic Angles
  17. 17. Pedestrian Struck By A Car
  18. 18. Pedestrian Struck By A Car Irregular Aortic Knob Traumatic Aortic Disruption Right Humerus Fracture
  19. 19. Pedestrian Struck By A Car
  20. 20. Pedestrian Struck By A Car Traumatic Aortic Disruption
  21. 21. Pedestrian Struck By A Car Traumatic Aortic Disruption
  22. 22. Pedestrian Struck By A Car Traumatic Aortic Disruption Successfully Deployed Endograft
  23. 23. TAD Chest X-Ray Findings 1. Wide mediastinum 2. Abnormal aortic contour 3. Lost of aortopulmonary window 4. Tracheal deviation 5. Depressed left mainstem 6. Apical cap 7. Deviated nasogastric tube 8. Widened paratracheal stripe
  24. 24. Tracheal Deviation
  25. 25. Apical CapTracheal Deviation
  26. 26. Apical CapTracheal Deviation Loss Of The Aortopulmonary Window
  27. 27. Apical CapTracheal Deviation Loss Of The Aortopulmonary Window
  28. 28. 25 Year Old With Recently Diagnosed HIV and PCP Pneumonia
  29. 29. 25 Year Old With Recently Diagnosed HIV and PCP Pneumonia Diffuse Infiltrates Consistent With PCP Pneumonia
  30. 30. 25 Year Old With Recently Diagnosed HIV and PCP Pneumonia Diffuse Infiltrates Consistent With PCP Pneumonia But What Is This?
  31. 31. 25 Year Old With Recently Diagnosed HIV and PCP Pneumonia Diffuse Infiltrates Consistent With PCP Pneumonia Large Pneumatocele
  32. 32. 25 Year Old With Recently Diagnosed HIV and PCP Pneumonia Large Pneumatocele Next Day: Pneumatocele Rupture And Pneumothorax
  33. 33. 25 Year Old With Recently Diagnosed HIV and PCP Pneumonia Large Pneumatocele Percutaneous Chest Tube
  34. 34. 2003; 126:859-861. • Thin walled parenchymal cysts • More common in children than in adults Causes: • Blunt chest trauma • COPD and other bullous/cystic lung diseases • Severe pneumonia [aspiration, anaerobic, TB, Pneumocystis…] • Mechanical ventilator barotrauma Complications: • Infection • Rupture and pneumothorax • Rapid expansion and tension pneumatocele
  35. 35. 60 Year Old With Dyspnea
  36. 36. 60 Year Old With Dyspnea Pericardial Effusion
  37. 37. 60 Year Old With Dyspnea. ED Bedside ECHO: Pericardial Effusion
  38. 38. 36 Year Old With Dyspnea History Of HPTN And ESRD
  39. 39. 36 Year Old With Dyspnea History Of HPTN And ESRD Cardiomegaly With Interstitial Edema
  40. 40. 56 Year Old With Dyspnea History Of Pulmonary HPTN
  41. 41. 56 Year Old With Dyspnea History Of Pulmonary HPTN Enlarged Pulmonary Artery Enlarged Pulmonary Artery
  42. 42. 59 Year Old Falls One Story From The Attic Severe Left Sided Chest Pain
  43. 43. 59 Year Old Falls One Story From The Attic Severe Left Sided Chest Pain Multiple Rib Fractures And Subcutaneous Emphysema
  44. 44. 59 Year Old Falls One Story From The Attic
  45. 45. 59 Year Old Falls One Story From The Attic Multiple Rib Fractures FLAIL CHEST
  46. 46. Flail Chest  Inspiration increases [-] thoracic pressure.  Leads to paradoxical motion of the flail segment.
  47. 47. 59 Year Old Falls One Story From The Attic Flail Chest  Mechanical ventilation frequently required.  Rib plating stabilizes the flail segment.
  48. 48. Summary Of Diagnoses This Week • Spontaneous pneumothorax • Pneumoperitoneum caused by esophageal perforation • Hemothorax secondary to penetrating chest trauma • Bilateral pleural effusion • Traumatic aortic disruption • PCP pneumonia with a large pneumatocele • Pericardial effusion • Cardiomegaly and interstitial edema • Pulmonary hypertension • Flail chest
  49. 49. See You Next Week!

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