Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Dr. Michael Gibbs's CMC X-Ray Mastery Project - Week #6 Cases

661 views

Published on

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: Colonic perforation, free air, coarctation, multifocal pneumonia, several pneumothoraces, Oral Gastric Tube in right mainstem bronchus, Traumatic aortic disruption, Scoliosis, lung metastases, pneumomediastinum

Published in: Education
  • Be the first to comment

  • Be the first to like this

Dr. Michael Gibbs's CMC X-Ray Mastery Project - Week #6 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 February 18th 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. Patient With Abdominal Pain And Sepsis Free Air Under The Diaphragm: Colonic Perforation
  7. 7. Patient With Abdominal Pain And Sepsis Free Air Under The Diaphragm: Colonic Perforation
  8. 8. Patient With Chest Pain Why Would A Patient Have Cardiomegaly And Inferior “Notching” Of Ribs? Coarctation Of The Thoracic Aorta
  9. 9. Patient With Chest Pain Coarctation Of The Thoracic Aorta
  10. 10. Patient With Chest Pain Coarctation Of The Thoracic Aorta
  11. 11. Coarctation – Stent Graft Placed Thoracic Endovascular Aortic Repair [TEVAR]
  12. 12. Why Does Coarctation Cause Rib Notching? • The descending aorta is stenotic and therefore collateral flow is needed. • The collateral pathway is via the subclavian artery to the internal thoracic artery to the anterior intercostal artery to the posterior intercostal artery and then to the descending thoracic aorta. • The dilated, tortuous vessels erode the lower rib margins, seen most commonly in ribs 4 – 8. • Notching seen in 70% of cases presenting in older children or adults.
  13. 13. Coarctation Of The Thoracic Aorta
  14. 14. “ACC/AHA 2008 Guidelines For The Management Of Adults With Congenital Heart Disease.” A Report of the ACC/AHA Task Force On Practice Guidelines. Warnes CA. Circulation 2008; 23:e714-e833..
  15. 15. Warnes CA. Circulation 2008; 23:e714-e833. Coarctation Of The Thoracic Aorta In Adults Clinical Features  Hypertension in right arm relative to the lower extremities  Hyperdynamic carotid pulses  A murmur may be heard over the left intrascapular position  A continuous murmurs may be hear over parasternal areas Presenting Symptoms  May remain asymptomatic if collateral flow is adequate  Hypertension – discrepant between the upper and lower extremities  Increased proximal pressure [chest pain, headache, epistaxis]  Decreased distal pressure [lower extremity claudication]
  16. 16. Warnes CA. Circulation 2008; 23:e714-e833. Coarctation Of The Thoracic Aorta In Adults Chest X-Ray Findings  Cardiomegaly  An indentation at the coarctation may produce a “3-sign” beneath the aortic arch  Notching under ribs 3-9 ECG Findings  Left ventricular hypertrophy  Secondary ST-T changes due to strain
  17. 17. Coarctation Of The Thoracic Aorta
  18. 18. Coarctation Of The Thoracic Aorta
  19. 19. Coarctation Of The Thoracic Aorta
  20. 20. Patient With A History of ESRD Presents With Fever And Cough Patchy Multifocal Pneumonia
  21. 21. Young Adult With Stab Wounds To The Chest & Neck * * Bilateral Pneumothoraces & Subcutaneous Emphysema (*)
  22. 22. Carina Dobhoff Tube Placed In The Right Mainstem Brochus Young Adult With Aspiration Pneumonia
  23. 23. Young Adult In A Motor Vehicle Crash:  Femur fracture  Splenic injury Wide Mediastinum Traumatic Aortic Disruption
  24. 24. Traumatic Aortic Disruption Young Adult In A Motor Vehicle Crash:  Femur fracture  Splenic injury
  25. 25. Young Adult In A Motor Vehicle Crash Thoracic Endovascular Aortic Repair [TEVAR] Coarctation Of The Thoracic Aorta
  26. 26. Pediatric Patient With A Viral Prodrome, Now Cough, Fever, Confusion. Multilobar Pneumonia: RML + RLL RML RLLRLL RML
  27. 27. Untreated Scoliosis Asymptomatic Young Adult
  28. 28. Traumatic Pneumothorax Chest Pain After Motor Vehicle Crash
  29. 29. Uterine Cancer Metastases – Entire Left Hemithorax + Right Lung Lesion History Of Uterine Cancer – Now More Short Of Breath
  30. 30. Uterine Cancer Metastases – Entire Left Hemithorax + Right Lung Lesion
  31. 31. Young Male With Intractable Vomiting Pneumomediastinum & Pneumopericardium
  32. 32. Young Male With Intractable Vomiting Pneumomediastinum & Pneumopericardium
  33. 33. Pneumomediastinum 2° Iatrogenic 2° Medical & Traumatic Spontaneous  Endoscopic procedures  Intubation  Pleural instrumentation  Central vascular procedure  Chest/abdominal surgery  Blunt chest injury  Penetrating chest injury  Asthma/COPD  Bronchiectasis  Interstitial lung disease  Thoracic malignancy  Tobacco use  Recreational drugs  Breath holding  Weight lifting Vasileios K. Journal of Thoracic Disease 2015; 7:S44-S49. Management Essentials  Manage the underlying cause  Pain management & cough suppression as indicated  Oxygen may increase gas absorption in severe cases  Brief period of observation vs. close outpatient follow-up
  34. 34. Summary Of Diagnoses This Week • Free air: colonic perforation • Coarctation of the aorta • Multifocal pneumonia • Several pneumothoraces • Dobhoff tube place in the right mainstem bronchus • Traumatic aortic disruption • Untreated scoliosis • Lung metastases • Pneumomediastinum due to intractable vomiting

×