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Dr. Michael Gibbs's CMC X-Ray Mastery Project - Week #5 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: Acute aortic dissection, cardiomegaly, right mainstem intubation, right middle lobe pnuemonia, lung ass, pulmonary necrosis

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Dr. Michael Gibbs's CMC X-Ray Mastery Project - Week #5 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 CMC X-Ray Mastery Series March 11th 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 be distributed next week.  The 1st image will show a chest X-ray without identifiers and the 2nd image will reveal the diagnoses.
  4. 4. It’s All About The Anatomy!
  5. 5. Airway Bones Cardiac Diaphragm Effusion Foreign body Gastric Hilum
  6. 6. 69 Year Old With Acute Chest And Neck Pain
  7. 7. Wide Mediastinum 69 Year Old With Acute Chest And Neck Pain Type A Aortic Dissection.
  8. 8. 69 Year Old With Acute Chest & Neck Pain Emergency Department Bedside Ultrasound
  9. 9. 69 Year Old With Acute Chest & Neck Pain Dilated Aortic Root Emergency Department Bedside Ultrasound
  10. 10. 69 Year Old With Acute Chest & Neck Pain Dilated Aortic Root Emergency Department Bedside Ultrasound Aortic Free Wall
  11. 11. Type A Aortic Dissection. 69 Year Old With Acute Chest & Neck Pain
  12. 12. 69 Year Old With A History Of Thoracic Aortic Aneurysm
  13. 13. 69 Year Old With A History Of Thoracic Aortic Aneurysm Wide Mediastinum Aneurysmal Thoracic Aorta With A Type A Dissection.
  14. 14. 69 Year Old With A History Of Thoracic Aortic Aneurysm Aneurysmal Thoracic Aorta With A Type A Dissection.
  15. 15. 73 Year Old With A History Of HPTN Develops Acute Chest Radiating To His Back Type A Aortic Dissection.
  16. 16. 73 Year Old With A History Of HPTN Develops Acute Chest Radiating To His Back Wide Mediastinum Type A Aortic Dissection.
  17. 17. 73 Year Old With Chest Pain Radiation To His Back Type A Aortic Dissection.
  18. 18. 73 Year Old With Chest Pain Radiation To His Back Emergency Department Bedside Ultrasound
  19. 19. 73 Year Old With Chest Pain Radiation To His Back Emergency Department Bedside Ultrasound Dissection Flap Thoracic Aorta
  20. 20. 63 Year Old With Several Days Of Worsening Flank Pain
  21. 21. 63 Year Old With Several Days Of Worsening Flank Pain Type B Aortic Dissection. Dissection Flap Ascending Aorta Not Involved
  22. 22. 63 Year Old With Several Days Of Worsening Flank Pain Just Below The Diaphragm At The Level Of The Celiac Axis
  23. 23. 63 Year Old With Several Days Of Worsening Flank Pain Our Patient: 9 Months Ago. Normal Aortic Arch On CT 9 Months Ago
  24. 24. Lot’s Of Aortic Dissections This Week! Here’s Some More Information On The Topic.
  25. 25. Aortic Dissection “A man was seized with pain of the right arm and soon after the left. He was ordered to think seriously and piously of his departure from this mortal life, which was very near at hand and inevitable.” J.B. Morgagni, 1761. “There is no diagnosis more conducive to clinical humility than dissection of the aorta.” Sir William Osler, 1900.
  26. 26. Here’s The Problem… We Are Not Very Good At Making The Diagnosis Initial diagnosis correct 15-50% Diagnosis >24 hours in 40% Klompas M. JAMA 2002.
  27. 27. Here’s The Problem… We Are Not Very Good At Making The Diagnosis When We Miss The Diagnosis Patients Die We Can’t CT Every Patient With Chest Pain Initial diagnosis correct 15-50% Diagnosis >24 hours in 40% Klompas M. JAMA 2002.
  28. 28. Aortic Dissection: Risk Factors • Hypertension • Cocaine • Trauma • Pregnancy Iatrogenic • Heart surgery • AVR • Catheterization Congenital • Aortic coarctation • Bicuspid valve • Marfan • Ehlers-Danlos • Turner
  29. 29. Branch Vessel Compromise Myocardial infarction Stroke Spinal cord infarction Mesenteric and renal ischemia Limb ischemia
  30. 30. Aortic Dissection?
  31. 31. Chest Pain Back Pain Stroke Symptoms Paraplegia Acute Abdomen Renal Failure Aortic Dissection? Paretic Extremity
  32. 32. Aortic Valve Dysfunction Aortic insufficiency Acute pulmonary edema Pericardial tamponade
  33. 33. Chest Pain Back Pain Acute CHF New AI Murmur Syncope Aortic Dissection?
  34. 34. “The International Registry of Acute Aortic Dissection [IRAD]: New Insight Into An Old Disease.” Hagan PG. JAMA 2000, 283:897. N = 464 12 Centers
  35. 35. IRAD: Demographics Hagan PG. JAMA 2000. Male 65.3% Mean age* 63 years Type A 62.3% Hypertension 72.1% *Type B older, Marfans mean age 36 years
  36. 36. IRAD: Clinical Manifestations Pain reported in 95.5%: Chest pain 72.7% Anterior chest pain 60.9% Back pain 53.2% Abdominal pain 29.6% Hagan PG. JAMA 2000.
  37. 37. IRAD: Clinical Manifestations Quality of pain: Abrupt onset 84.4% ‘Worst pain ever’ 90.6% Sharp 64.4% Tearing or ripping 50.6% Radiating 28.3% Migratory 16.6% Hagan PG. JAMA 2000.
  38. 38. IRAD: Syncope • Syncope in 9.4% • More common with Type A dissection • Higher risk of tamponade & stroke Mortality History of Syncope 34% Overall 28% Hagan PG. JAMA 2000.
  39. 39. IRAD: Chest X-Ray Findings: Wide mediastinum 66.1% Abnormal aortic contour 49.6% Pleural effusion 19.2% Wall Ca++ displacement 14.1% Normal CXR 12.4% Hagan PG. JAMA 2000.
  40. 40. Egg Shell Sign Egg Shell Sign: The Dissection “Push” The Calcified Aortic Wall Inward.
  41. 41. Egg Shell Sign Egg Shell Sign: The Dissection “Push” The Calcified Aortic Wall Inward.
  42. 42. 69 year-old male with 5 days of vague chest & abdominal pain.
  43. 43. Old CXR New CXR
  44. 44. Be On The Look Out!
  45. 45. 35 Year Old With Alcoholic Cardiomyopathy
  46. 46. 35 Year Old With Alcoholic Cardiomyopathy Cardiomegaly
  47. 47. 6 Month Old Difficult Intubation In The O.R.
  48. 48. 6 Month Old Difficult Intubation In The O.R. Right Mainstem Intubation + Left Lung Collapse
  49. 49. 73 Year-Old With Fever, Cough And Confusion
  50. 50. 73 Year-Old With Fever, Cough And Confusion Right Middle Lobe Pneumonia
  51. 51. 52 Year-Old With With Advanced Lung Cancer Presents With Dyspnea & Hypoxia
  52. 52. 52 Year-Old With With Advanced Lung Cancer Presents With Dyspnea & Hypoxia Right Lung Mass With Severe Pulmonary Necrosis
  53. 53. 52 Year-Old With With Advanced Lung Cancer Presents With Dyspnea & Hypoxia Right Lung Mass With Severe Pulmonary Necrosis
  54. 54. 68 Year-Old Diabetic With Cough And Fever
  55. 55. 68 Year-Old Diabetic With Cough And Fever Right-Sided Infiltrates – Primarily RUL
  56. 56. 68 Year-Old Diabetic With Cough And Fever Right-Sided Infiltrates – Primarily RUL
  57. 57. Healthy 5 Year Old Treated With Tamiflu For Flu Symptoms, Admitted With Pneumonia
  58. 58. Healthy 5 Year Old Treated With Tamiflu For Flu Symptoms, Admitted With Pneumonia HD #1: LLL Pneumonia
  59. 59. Healthy 5 Year Old Admitted With Pneumonia
  60. 60. Healthy 5 Year Old Admitted With Pneumonia HD #4: LLL Pneumonia + Effusion Chest Tube
  61. 61. Healthy 5 Year Old Admitted With Pneumonia
  62. 62. Healthy 5 Year Old Admitted With Pneumonia HD #14: After Video Assisted Thoracoscopic Surgery [VATS] One Liter Of Pus Removed Pneumohydrothorax With Mediastinal Shift
  63. 63. Air-Fluid Level: If It’s Flat There’s Air In There!
  64. 64. Healthy 5 Year Old Admitted With Pneumonia HD #14: Pneumohydrothorax And Severe Pulmonary Necrosis/Trapped Lung (*) Discharged The Following Day On IV Antibiotics With Planned Follow-Up *
  65. 65. 25 Year Old With Worsening Epigastric Pain Self-Medicating With Narcotics
  66. 66. 25 Year Old With Worsening Epigastric Pain Self-Medicating With Narcotics Free Air Under The Diaphragm: Gastric Perforation
  67. 67. Summary Of Diagnoses This Week • Acute aortic dissection • Cardiomegaly • Right mainstem intubation • Right middle lobe pneumonia • Lung mass with severe pulmonary necrosis • Right upper lobe pneumonia • Pneumohydrothorax & severe pulmonary necrosis
  68. 68. See You Next Week!

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