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

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. 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 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. It’s All About The Anatomy!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. Healthy Young
Female With
Sudden Onset
Right-Sided
Pleuritic Chest
Pain

7. Spontaneous Pneumothorax
Healthy Young
Female With
Sudden Onset
Right-Sided
Pleuritic Chest
Pain

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. NEJM 2000; 342:868-874.

10. Esophageal Food
Impaction – Then
Severe Upper
Abdominal Pain

11. Esophageal Food
Impaction – Then
Severe Upper
Abdominal Pain
Pneumoperitoneum: Esophageal Perforation

12. Esophageal Food
Impaction – Then
Severe Upper
Abdominal Pain
Pneumoperitoneum: Esophageal Perforation

13. Gunshot Wound
To The Right
Upper Quadrant

14. Gunshot Wound
To The Right
Upper Quadrant
Large Right Hemothorax & Two Foreign Bodies

16. Bilateral Pleural Effusions
Loss Of The Normal
Costophrenic Angles
Flattened Effusion
Well Seen On Lateral

18. Normal Sharp Costophrenic Angles

19. Pedestrian Struck
By A Car

20. Pedestrian Struck
By A Car
Irregular
Aortic Knob
Traumatic Aortic Disruption
Right Humerus
Fracture

21. Pedestrian Struck
By A Car

22. Pedestrian Struck
By A Car
Traumatic Aortic Disruption

23. Pedestrian Struck
By A Car
Traumatic Aortic Disruption

24. Pedestrian Struck
By A Car
Traumatic Aortic Disruption
Successfully
Deployed Endograft

25. 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

28. Tracheal
Deviation

29. Apical
CapTracheal
Deviation

30. Apical
CapTracheal
Deviation
Loss Of The
Aortopulmonary
Window

31. Apical
CapTracheal
Deviation
Loss Of The
Aortopulmonary
Window

32. 25 Year Old With
Recently
Diagnosed HIV and
PCP Pneumonia

33. 25 Year Old With
Recently
Diagnosed HIV and
PCP Pneumonia
Diffuse Infiltrates Consistent With PCP Pneumonia

34. 25 Year Old With
Recently
Diagnosed HIV and
PCP Pneumonia
Diffuse Infiltrates Consistent With PCP Pneumonia
But What
Is This?

35. 25 Year Old With
Recently
Diagnosed HIV and
PCP Pneumonia
Diffuse Infiltrates Consistent With PCP Pneumonia
Large
Pneumatocele

36. 25 Year Old With
Recently
Diagnosed HIV and
PCP Pneumonia
Large Pneumatocele
Next Day:
Pneumatocele
Rupture And
Pneumothorax

37. 25 Year Old With
Recently
Diagnosed HIV and
PCP Pneumonia
Large Pneumatocele
Percutaneous
Chest Tube

38. 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

39. 60 Year Old With
Dyspnea

40. 60 Year Old With
Dyspnea
Pericardial Effusion

41. 60 Year Old With Dyspnea. ED Bedside ECHO: Pericardial Effusion

42. 36 Year Old With
Dyspnea
History Of HPTN
And ESRD

43. 36 Year Old With
Dyspnea
History Of HPTN
And ESRD
Cardiomegaly With Interstitial Edema

44. 56 Year Old With
Dyspnea
History Of
Pulmonary HPTN

45. 56 Year Old With
Dyspnea
History Of
Pulmonary HPTN
Enlarged
Pulmonary Artery
Enlarged
Pulmonary Artery

46. 59 Year Old Falls
One Story From
The Attic
Severe Left Sided
Chest Pain

47. 59 Year Old Falls
One Story From
The Attic
Severe Left Sided
Chest Pain Multiple Rib
Fractures And
Subcutaneous
Emphysema

48. 59 Year Old Falls
One Story From
The Attic

49. 59 Year Old Falls
One Story From
The Attic
Multiple Rib Fractures
FLAIL CHEST

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

51. 59 Year Old Falls
One Story From
The Attic
Flail Chest
 Mechanical ventilation frequently required.
 Rib plating stabilizes the flail segment.

52. 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

53. See You Next Week!