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Drs. Lorenzen and Barlock’s CMC X-Ray Mastery Project: November Cases

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Drs. Breeanna Lorenzen and Travis Barlock are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
- Traumatic aortic disruption
- Giant Bullous Emphysema (Vanishing Lung Syndrome)

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Drs. Lorenzen and Barlock’s CMC X-Ray Mastery Project: November Cases

  1. 1. Adult Chest X-Rays Of The Month Travis Barlock MD & Breeanna Lorenzen, MD Department of Emergency Medicine Carolinas Medical Center & Levine Children’s Hospital Michael Gibbs MD, Faculty Editor Chest X-Ray Mastery Project November 2020
  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 providing cases and these slides are shared with all contributors.  Contributors from many CMC/LCH departments, and now from EM colleagues in Brazil, Chile and Tanzania.  Cases submitted this month will be distributed next month.  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. Visit Our Website www.EMGuidewire.com For A Complete Archive Of Chest X-Ray Presentations And Much More!
  5. 5. Airway Bones Cardiac Diaphragm Effusion Foreign body Gastric Hilum
  6. 6. It’s All About The Anatomy!
  7. 7. 32-Year-Old Male Involved In A High-Speed Car Crash
  8. 8. 32-Year-Old Male Involved In A High-Speed Car Crash Tracheal Deviation Wide Mediastinum Loss Of The Aortopulmonary Window
  9. 9. 32-Year-Old Male Involved In A High-Speed Car Crash
  10. 10. 32-Year-Old Male Involved In A High-Speed Car Crash Aortic Disruption
  11. 11. 32-Year-Old Male Involved In A High-Speed Car Crash
  12. 12. 32-Year-Old Male Involved In A High-Speed Car Crash
  13. 13. 22-Year-Old Male Involved In A Head-On Car Crash
  14. 14. 22-Year-Old Male Involved In A Head-On Car Crash Tracheal Deviation Wide Mediastinum
  15. 15. 22-Year-Old Male Involved In A Head-On Car Crash
  16. 16. 22-Year-Old Male Involved In A Head-On Car Crash Aortic Disruption
  17. 17. 22-Year-Old Male Involved In A Head-On Car Crash
  18. 18. 22-Year-Old Male Involved In A Head-On Car Crash Aortic Endograph
  19. 19. Proposed Mechanisms Of Blunt Aortic Injury
  20. 20. From: Gibbs MA. EM Critical Care 2011.
  21. 21. From: Gibbs MA. EM Critical Care 2011.
  22. 22. From: Gibbs MA. EM Critical Care 2011.
  23. 23. From: Gibbs MA. EM Critical Care 2011.
  24. 24. 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
  25. 25. Wide Mediastinum
  26. 26. Wide Mediastinum Tracheal Deviation
  27. 27. Wide Mediastinum Tracheal Deviation Apical Cap
  28. 28. Wide Mediastinum Tracheal Deviation Apical Cap Loss Of The Aortopulmonary Window
  29. 29. Wide Mediastinum Loss Of The Aortopulmonary Window Tracheal Deviation Apical Cap Depressed Left Mainstem Bronchus
  30. 30. Grade 1:  Intimal tear  No external change to aortic contour  Small tear with <10 mm of thrombus  Rarely, can be treated conservatively Grade 2:  Larger intimal flap  No external change to aortic contour  >10 mm of thrombus visible Sagittal View Sagittal View
  31. 31. Grade 3:  Pseudoaneurysm  Bulbar appearance with change in the appearance of the aorta  Contained rupture Grade 4:  Free rupture  Extravasated contrast beyond the contour of the aorta Sagittal View Axial View
  32. 32. 42 (0.17%) Patients Had Aortic Injury
  33. 33. 54-Year-Old Male With A History Of Emphysema. Here Is His Chest X-Ray 3 Years Ago.
  34. 34. 54-Year-Old Male With A History Of Emphysema. Here Is His Chest X-Ray 3 Years Ago. Bilateral Upper Lobe Bullous Lung Disease
  35. 35. 54-Year-Old Male With A History Of Emphysema. The Patient Now Presents With Acute Pleuritic Chest Pain And A CT Is Ordered To Rule Out Pulmonary Embolus.
  36. 36. 54-Year-Old Male With A History Of Emphysema
  37. 37. Severe Apical Bullous Disease Acute Right Pneumothorax 54-Year-Old Male With A History Of Emphysema
  38. 38. 54-Year-Old Male With A History Of Emphysema Lung Re-expanded After Pigtail Catheter Placement
  39. 39. Definition: Giant bullae on one or both upper lobes occupying at least 1/3 of the hemithorax, compressing adjacent lung tissue Demographics:  Young male smokers with a history of cannabis use  Chronic obstructive pulmonary disease  𝛼-1 antitrypsin disease, Marfan syndrome, Ehlers-Danlos syndrome Complications:  Hypoxia, dyspnea, hemoptysis, spontaneous pneumothorax  Infection of bullae
  40. 40. Be Cautious With That Chest Tube!
  41. 41. Summary Of Diagnoses This Month  Traumatic aortic disruption  Giant bullous emphysema (vanishing lung syndrome)
  42. 42. See You Next Month!

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