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: • Aortic Transection • Hemothorax • Innominate Artery Transection • Dextrocardia • Situs Inversus • Pneumonia • Complete Lung Consolidation • Septic Pulmonary Emboli • Pulmonary Metastases • Pneumothorax

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
September 2020

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 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. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Chest X-Ray Presentations And Much More!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. It’s All About The Anatomy!

7. 37-Year-Old
Male After
An MVC.

8. Diagnosis: Aortic Pseudoaneurysm & Left Hemothorax
The patient is
supine. Blood
pools behind the
lung making the
left chest appear
hazier than the
right.
Widened
Mediastinum
37-Year-Old
Male After
An MVC.

9. Hematoma
Hemothorax
37-Year-Old
Male After
An MVC.
Final Diagnosis: Aortic Transection with hematoma, Left Hemothorax

11. CT With IV Contrast Vs. Catheter-Based
Angiography

12. “In patients with suspected blunt
traumatic aortic injury, we strongly
recommend the use of CT scan of the
chest with intravenous contrast for
diagnosis of clinically significant blunt
traumatic aortic injury.”

13. “The success of anti-hypertensive regimens in preventing rupture has resulted in the
practice of delayed repair of blunt traumatic aortic injury in both high- and low-risk
patients. [Once the patient has been stabilized and all significant injuries have
been identified and staged]1 any patient with blunt traumatic aortic injury should be
immediately started and maintained on an antihypertensive regimen to prevent aortic
rupture. These regimens are used to maintain the systolic blood pressure within a
‘‘normal’’ range, generally less than 120 mmHg.”
“In patients diagnosed with blunt traumatic aortic injury,
we suggest delayed repair. It is critical that effective blood
pressure control with antihypertensive medication is used
in these patients.”
1Added by M. Gibbs, MD

14. 59-Year-Old
Male With A
Crush Injury To
The Chest.

15. Diagnosis: Mediastinal Hematoma
Widened
Mediastinum
59-Year-Old
Male With A
Crush Injury To
The Chest.

16. Final Diagnosis: Innominate Artery Transection
59-Year-Old
Male With A
Crush Injury To
The Chest.

17. Objective: Characterize location, associated injuries, and stability of patients with
traumatic innominate artery rupture
Methods: Retrospective Review of Patients with Traumatic Innominate Artery
Rupture
Results: 65 patients over 5-year study were included, and 8 patients had blunt
traumatic injury. Of those 8 patients, 6 involved the origin, 1 middle, and 1 distal
segment. Four of these patients had an expanding hematoma. Every patient had
additional injuries (closed head injury, splenic rupture). Every patient was stable on
presentation except one who presented in shock. This was the only patient to die.
Conclusions: Blunt traumatic injury of the innominate artery typically affects the
origin, associated injuries are common, and if the patient is stable on admission they
will likely survive.
Lovelock T, Cheng A, Negri J, Fitzgerald M. Transection of the origin of the innominate artery: A rare sequela of
blunt traumatic chest trauma. Trauma Case Rep. 2020;27:100307. Published 2020 May 11.
doi:10.1016/j.tcr.2020.100307

18. 61-Year-Old
At Cardiology
Appointment.

19. Diaphragm Higher
On The Left
61-Year-Old
At Cardiology
Appointment.

20. 61-Year-Old With Known Situs Inversus.
LiverSpleen
Abdominal Transposition
Dextrocardia

21. Healthy 45-
Year-Old
Undergoes
Preoperative
Screening.

22. Healthy 45-
Year-Old
Undergoes
Preoperative
Screening.
Dextrocardia
Heart On The Right, Gastric Bubble On The Left

23. Definitions:
Situs Solitus is dextrocardia associated with a normal position of other structures. This is often asymptomatic. Situs
Inversus Totalis is accompanied by a reversal in other organs. In Situs Ambiguous (Heterotaxy) positioning may be hard to
determine.
Dextrocardia is mostly secondary to abnormal positioning during embryonic development, Kartagener syndrome being an
example.
To think about:
EKG: Inversion of all complexes in lead I, upright p wave in AVL, and an absent R wave progression in the anterior leads.
Limb reversal might produce similar EKG findings; however, with a normal EKG pattern in the precordial leads.
Spurious dextrocardia happens when the image is flipped (look at the markers.)
Complications:
Depends on the other congenital anomalies a patient may have/had. Situs Inversus Totalis has been seen to have
congenital heart disease in 3%–5% of cases. This can include TGA, Tetralogy of Fallot, septal defects, defects of the wall of
the heart and valvular abnormalities. Chronic sinusitis and bronchiectasis is seen in Kartagener syndrome. In Heterotaxy,
complications depend on what malformations the patient has and if patient has asplenia (right isomerism) vs polysplenia
(left isomerism.) Most all people with Heterotaxy also have some congenital heart disease.
Maldjian PD, Saric M. Approach to dextrocardia in adults: review. AJR Am J Roentgenol. 2007 Jun;188(6 Suppl):S39-49; quiz S35-8. doi: 10.2214/AJR.06.1179.
PMID: 17515336.
Dextrocardia

24. 56-Year-Old Male
With Fever,
Shortness Of
Breath, And
Intractable
Hiccups.

25. Diagnosis: Complete Lung Consolidation
56-Year-Old Male
With Fever,
Shortness Of
Breath, And
Intractable
Hiccups.

26. Final Diagnosis: Lung Neoplasia
56-Year-Old Male
With Fever,
Shortness Of
Breath, And
Intractable
Hiccups.

27. 48-Year-Old
Female
With
Cough.

28. Diagnosis: RLL Pneumonia
Spine Sign
Obscured Right
Heart Border
48-Year-Old
Female
With
Cough.

29. 25-Year-Old
Person Who
Injects Drugs
Presenting
With Fevers,
Chills, and
Shortness Of
Breath.

30. Diagnosis: Septic Pulmonary Emboli
Notice The
Diffuse Patchy
Infiltrates And
The Numerous
Circumscribed
Lesions.
25-Year-Old
Person Who
Injects Drugs
Presenting
With Fevers,
Chills, and
Shortness Of
Breath.

31. Diagnosis: Septic Pulmonary Emboli
Air-Fluid Levels
Suggestive Of
Intrapulmonary
Abscesses.
25-Year-Old
Person Who
Injects Drugs
Presenting
With Fevers,
Chills, and
Shortness Of
Breath.

32. Slide on septic pulmonary embli
Objective: To understand the clinical and radiographic associations of septic pulmonary
embolism in patients presenting to an acute care safety net hospital.
Methods: Retrospective analysis of all cases seen at HCMC from 2000-2013.
Results: 40 patients with SPE over 13-year study were included. Presenting symptoms included:
febrile illness (85%); pulmonary complaints (66%) including pleuritic chest pain (22%), cough
(19%) and dyspnea (15%); and those related to the peripheral foci of infection (24%) and shock
(19%). Sources of infection included: skin and soft tissue (44%); infective endocarditis (27%);
and infected peripheral deep venous thrombosis (17%). 35/41 (85%) were bacteremic with
staphylococcus aureus. All patients had peripheral nodular lesions on chest CT scan. Treatment
included intravenous antibiotics in all patients.
Conclusions: The epidemiology of septic pulmonary embolism has broadened over the past
decade with an increase in identified extrapulmonary, non-cardiac sources. In the context of an
extrapulmonary infection, clinical features of persistent fever, bacteremia and pulmonary
complaints should raise suspicion for this syndrome, and typical findings on the chest CT scans
confirm the diagnosis.
Goswami U, Brenes JA, Punjabi GV, LeClaire MM, Williams DN. Associations and outcomes of septic pulmonary
embolism. Open Respir Med J. 2014;8:28-33. Published 2014 Jul 24. doi:10.2174/1874306401408010028
Associations and Outcomes of Septic Pulmonary Embolism

33.  12-fold increase in the incidence of hospitalization between 2010 and 2015
 Incidence increasing most rapidly amongst drug users who are younger,
white (87%), non-Hispanic (92%), and from rural areas
 18-fold increase in the total cost of hospitalization
 Median hospital charges $54,281
 In 2015 42% of patients were either uninsured or receiving Medicaid

35. Infective Endocarditis [IE] represents an infection of the cardiac
endothelium that can present as either acute or subacute disease.
Acute Advances rapidly, presenting with a sudden onset of high fever,
rigors, and systemic complications.
Subacute Symptoms develop over a period of weeks to months, can be
non-specific and therefore difficult to diagnose. Fever may or
may not be present.

36. Epidemiology
• In the U.S. there are 40,000 – 50,000 new case each year.
• The one-year mortality of IE has not improved in two decades.
• Risk factors: IV drug use, prosthetic valve replacement, implantable
cardiac devices, hemodialysis, venous catheters, and immunosuppression.
• There has been an increase in incidence, reflecting a growing number of
healthcare-acquired case, that now make up 25% of total cases.

37. Diagnosis
[+] Blood cultures + diagnostic imaging.
Imaging Strategies
• TTE generally recommended as the initial modality of imaging.
• TEE when TTE is positive with high risk features, or negative but high suspicion.
• Cardiac CT scanning is the key adjunctive modality when the anatomy is not
clearly delineated by echocardiography.

38. Cardiac CT Scan Of A Patient With Aortic Valve Endocarditis.
Vegetations See
As Filling Defects
Contrast-Filled
Perivalvular Abscess
Image Courtesy Of Dr. Markus Scherer, MD. March 2020.

39. The Microbiology Of Infective Endocarditis
S. aureus 30-40%
Viridans group streptococcus (VGS):
• Oral pathogens
• S. mutans, S. sanguinis, S. oralis, S. salivarius
20%
Enterococci 10%
HACEK organisms:
• Haemophilus species, Aggregati bacter actinomycetemcomitans,
Cardiobacterium hominis, Eikenella corrodens, Kingella species
<5%
Culture negative 10-20%

40. Management
• AHA and IDSA recommends Infectious Disease consultation.
• Mainstay of therapy is antimicrobial therapy, and surgery in selected
cases.
• Choice of antimicrobial therapy based on several factors:
• Patient presentation
• Native vs. prosthetic valve
• For prosthetic valves, length of time since valve replacement

41. Empiric Therapy: Native Valve Endocarditis
Acute Clinical Presentation:
• Recommend coverage for S. aureus, beta-hemolytic streptococci, and
aerobic gram-negative bacilli.
• Vancomycin and Cefepime (Aztreonam if penicillin allergic).
Subacute Clinical Presentation:
• Recommend coverage for S. aureus, VGS, HACEK, and enterococci
• Vancomycin and Ampicillin-Sulbactam.

42. Empiric Therapy: Prosthetic Valve Endocarditis
Onset Of Symptoms Within 1 Year Of Prosthetic Valve Placement:
• Recommend coverage for staphylococci, enterococci, and aerobic gram-
negative bacilli.
• Regimen could include Vancomycin, Gentamicin, Cefepime, Rifampin.
Onset Of Symptoms >1 Year After Prosthetic Valve Placement:
• Recommend coverage for staphylococci, VGS, and enterococci.
• Vancomycin and Ceftriaxone.

43. Surgery
The IDSA recommends early surgery for patients with:
• Endocarditis caused by fungi or highly resistant organisms
• Valve dysfunction resulting in symptoms of heart failure
• Endocarditis causing complete heart block
• Annular or aortic abscesses or destructive penetrating lesions
• Recurrent emboli or persistent/enlarging vegetations
• Mobile vegetations >10 mm
• Relapsing prosthetic valve endocarditis

44. 30-Year-Old
Female
With
Weakness.

45. Diagnosis: Pulmonary Nodules
30-Year-Old
Female
With
Weakness.

46. Final Diagnosis: Metastatic Cervical Cancer
30-Year-Old
Female
With
Weakness.

47. 58-Year-Old
Female With
Interstitial Lung
Disease Presents
With Shortness
Of Breath.

48. Diagnosis: Pneumothorax
58-Year-Old
Female With
Interstitial Lung
Disease Presents
With Shortness
Of Breath.

49. Summary Of Diagnoses This Month
 Aortic Transection
 Hemothorax
 Innominate Artery Transection
 Dextrocardia/Situs Inversus
 Pneumonia
 Complete Lung Consolidation
 Septic Pulmonary Emboli
 Pulmonary Metastases
 Pneumothorax

50. See You Next Month!