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Dr. Michael Gibbs's CMC X-Ray Mastery Project - Week #7 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: Hemopericardium, Cardiomyopathy, Heart Failure, Myocarditis, Ruptured Hemidiaphragm, Hydropneumothorax, Pneumothorax, ECMO

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Dr. Michael Gibbs's CMC X-Ray Mastery Project - Week #7 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 CXR Mastery Project March 25th 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. See You Next Week!Chest X-Ray Two Weeks Ago History Of Pacemaker Placement At An Outside Facility Two Weeks Ago.
  7. 7. History Of Pacemaker Placement At An Outside Facility Two Weeks Ago. Now Presents To The CMC ED With Weakness And Dyspnea.
  8. 8. Large Pericardial Effusion Due To Pacemaker Lead Perforation Of The Right Ventricle History Of Pacemaker Placement At An Outside Facility Two Weeks Ago. Now Presents To The CMC ED With Weakness And Dyspnea.
  9. 9. History Of Pacemaker Placement At An Outside Facility Two Weeks Ago ED Bedside ECHO: Large Pericardial Effusion (*)
  10. 10. History Of Pacemaker Placement At An Outside Facility Two Weeks Ago ED Bedside ECHO: Large Pericardial Effusion (*) Cardiac Apex *** * **
  11. 11. Pericardiocentesis And 1300 cc Of Bloody Fluid Is Removed History Of Pacemaker Placement At An Outside Facility Two Weeks Ago
  12. 12.  Rapidly accumulating pericardial effusions cause swift increases in intrapericardial pressure and tamponade physiology.  Slowly accumulating pericardial effusions gradually distend the pericardium and symptoms can be delayed.
  13. 13. Cardiomegaly From Ischemic Cardiomyopathy ICD Leads
  14. 14. Acute Dyspnea In A 65 Year Old With Severe HPTN Last Month Today
  15. 15. Acute Dyspnea In A 65 Year Old With Severe HPTN Today: Acute Heart Failure With Cardiomegaly & Interstitial Edema Last Month Today
  16. 16. 16 Year Old Presents 2 Weeks After A Viral Illness With Dyspnea and Peripheral Edema
  17. 17. 16 Year Old Presents 2 Weeks After A Viral Illness With Dyspnea and Peripheral Edema Heart Failure Likely Due To Viral Myocarditis
  18. 18. 76 Year Old Who Fell Backwards. He Complains Of Right Lower Back Pain.
  19. 19. 76 Year Old Who Fell Backwards. He Complains Of Right Lower Back Pain. Posterior Rib Fractures Rib Fractures & A Small Apical Pneumothorax
  20. 20. 76 Year Old Who Fell Backwards. He Complains Of Right Lower Back Pain.
  21. 21. 17 Year Old In A High Speed MVC Complains Of Abdominal Pain
  22. 22. 17 Year Old In A High Speed MVC Complains Of Abdominal Pain Ruptured Diaphragm
  23. 23. 17 Year Old In A High Speed MVC Complains Of Abdominal Pain Ruptured Diaphragm
  24. 24. 57 Year Old In High Speed MVC – At Outside Facility
  25. 25. 57 Year Old In High Speed MVC – At Outside Facility
  26. 26. Ruptured Diaphragm Chest Tube 57 Year Old In High Speed MVC – At Outside Facility
  27. 27. Ruptured Diaphragm With Chest Tube Next To The Stomach 57 Year Old In High Speed MVC – Now At CMC
  28. 28. Traumatic Diaphragmatic Injury [TDI] The largest study to date is from the National Trauma Data Bank, that reviewed 833,309 cases of blunt & penetrating trauma: • In this population the incidence of TDI was low at 0.46% • 67% were penetrating and 33% were blunt • Left-side rupture more common than right (70% vs. 30%) • Hepatic protection of the right side, increased strength of the right hemidiaphragm, and weakness of the left hemidiaphragm at points of embryonic fusion all contribute to the predominance of left-sided diaphragmatic rupture Fair KA. American Journal of Surgery 2015; 209:864-8.
  29. 29. 86 Year Old With COPD Presents With Shortness Of Breath
  30. 30. 86 Year Old With COPD Presents With Shortness Of Breath Hydropneumothorax
  31. 31. Air-Fluid Level If It Looks Like This… There’s Air In There!
  32. 32. 20 Year Old Asthmatic Intubated And On ECMO
  33. 33. 20 Year Old Asthmatic Intubated And On ECMO Right Apical Pneumothorax
  34. 34. Summary Of Diagnoses This Week • Hemopericardium • Cardiomegaly from ischemic cardiomyopathy • Heart Failure • Heart failure due to viral myocarditis • Ruptured left diaphragm • Hydropneumothorax • Rib fractures + pneumothorax • ECMO cannulation
  35. 35. See You Next Week!

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