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Drs. Milam and Thomas's CMC X-Ray Mastery Project: April Cases

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Drs. Claire Milam and Alyssa Thomas 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 monthly educational, self-guided radiology slides on:
• Esophageal Perforation
• Perforated Viscous
• Pneumothorax
• Traumatic Diaphragmatic Hernia
• Pulmonary Contusion
• COVID-19 associated Pneumonia
• COVID-19
• Influenza Like Illness

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Drs. Milam and Thomas's CMC X-Ray Mastery Project: April Cases

  1. 1. Adult Chest X-Rays Of The Month Alyssa Thomas MD & Claire Milam MD Department of Emergency Medicine Carolinas Medical Center & Levine Children’s Hospital Michael Gibbs MD, Faculty Editor Chest X-Ray Mastery Project April 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. 54-Year-Old Male With A History of Alcoholism Presents with Chest Pain and Back Pain.
  8. 8. CXR Read as Normal 54-Year-Old Male With A History of Alcoholism Presents with Chest Pain and Back Pain.
  9. 9. CT Scan Performed Diagnosis: Ruptured Esophagus
  10. 10. Let’s Look Back At The Original CXR For Clues… Notice the Subcutaneous Air
  11. 11. Citation: He X, He Z and Li H. "Boerhaave syndrome: Challenges in diagnosis and treatment of the early presentation and its complication." The Journal of Trauma and Acute Care Surgery 84.6 (2018): 1030-1032. Ovid MEDLINE(R). Web. 17 April. 2020. Esophageal Perforation • Spontaneous esophageal perforation = Boerhaave syndrome • Classic acute presentation includes:  Vomiting,  Chest Pain  Subcutaneous Emphysema • “Plain chest X-ray is the most useful in early diagnosis” • CT scan will not show the location of the tear, but does have secondary findings • Contrast esophogram will show leaking into the mediastinum
  12. 12. Citation: E. (Ilias) K. Sdralis, S. Petousis, F. Rashid, B. Lorenzi, A. Charalabopoulos, Epidemiology, diagnosis, and management of esophageal perforations: systematic review, Diseases of the Esophagus, Volume 30, Issue 8, August 2017, Pages 1–6, https://doi.org/10.1093/dote/dox013 • Esophageal perforation has a high mortality rate (13.3%) • Sepsis was a complication of 1 in 4 esophageal perforations • Only 58.1% of people were admitted to the hospital within 24 hrs of symptom onset • 72.6% were thoracic in location • CXR was the initial imaging study for diagnosis in 36.6% of cases Epidemiology, diagnosis, and management of esophageal perforations: systematic review
  13. 13. Citation: E. (Ilias) K. Sdralis, S. Petousis, F. Rashid, B. Lorenzi, A. Charalabopoulos, Epidemiology, diagnosis, and management of esophageal perforations: systematic review, Diseases of the Esophagus, Volume 30, Issue 8, August 2017, Pages 1–6, https://doi.org/10.1093/dote/dox013 • Esophageal perforation is a high-risk clinical presentation • There is currently no good consensus on the best way to diagnose and manage esophageal perforation. Epidemiology, diagnosis, and management of esophageal perforations: systematic review
  14. 14. Esophageal Perforation • High risk of morbidity and mortality • There is often a delay in diagnosis • Prompt diagnosis and management are key to improve survival rates • CXR is a good initial study. Consider contrast esophagram as the next step instead of CT:  Have a high level of suspicion and look for secondary findings, like widened mediastinum, subcutaneous emphysema, and mediastinal air  Always compare to a prior study when able!
  15. 15. 26-Year-Old Male Presents With Abdominal Pain.
  16. 16. Diagnosis: Perforated Viscus From Swallowing A Plastic Fork 26-Year-Old Male Presents With Abdominal Pain.
  17. 17. 60-Year-Old Male With A History Of ESRD, COPD Presents With Left-Sided Chest Pain And Dyspnea.
  18. 18. Diagnosis: Spontaneous Left-Sided Pneumothorax 60-Year-Old Male With A History Of ESRD, COPD Presents With Left-Sided Chest Pain And Dyspnea.
  19. 19. Resolution Of The Pneumothorax After Pigtail Catheter Placement
  20. 20. Day 1 Day4
  21. 21. Day 6: After Left Video-Assisted Thorascopy With Talc Pleurodesis.
  22. 22. Day 9: Shows Complete Resolution Of The Left-Sided Pneumothorax.
  23. 23. 19-Year-Old Female With Substernal Chest Pain And Left Upper Abdominal Pain After A Car Crash.
  24. 24. Diagnosis: Left Traumatic Diaphragmatic Hernia Notice the nasogastric tube above the diaphragm 19-Year-Old Female With Substernal Chest Pain And Left Upper Abdominal Pain After A Car Crash.
  25. 25. Post Diaphragmatic RepairPresenting CXR
  26. 26. 39-Year-Old Female Presents With Dyspnea And Hypoxia Following A Car Crash.
  27. 27. Diagnosis: Pulmonary Contusion 39-Year-Old Female Presents With Dyspnea And Hypoxia Following A Car Crash.
  28. 28. CT Chest With Severe Pulmonary Contusion
  29. 29. The Importance Of The Lung Window
  30. 30. 56-Year-Old Male With A History Of Hypertension And Vascular Disease Presenting With 1 Week Of Progressive Myalgias And Shortness Of Breath.
  31. 31. 56-Year-Old Male With A History Of Hypertension And Vascular Disease Presenting With 1 Week Of Progressive Myalgias And Shortness Of Breath. Diagnosis: COVID-19 [+] Pneumonia
  32. 32. Bilateral Ground Glass Opacities Bilateral Pleural Effusions A CT Scan Of The Chest Is Performed. Diagnosis: COVID-19 [+] Pneumonia
  33. 33. 61-Year-Old Male With Fever, Myalgias, And Diarrhea.
  34. 34. Tested For COVID And Discharged to Self-Quarantine 61-Year-Old Male With Fever, Myalgias, And Diarrhea.
  35. 35. Prior CXR 3 Days later 61-Year-Old Male: COVID [+] And Returns With SPO2 Of 70% On Room Air!
  36. 36. Intubated The NEXT Day 61-Year-Old Male: COVID [+].
  37. 37. 61-Year-Old Male: COVID [+]. After Failing Extubation Twice, A Tracheostomy Was Required.
  38. 38. 60-Year-Old Male With A History COPD On Home O2 Presents With Fever And Symptoms Of An Influenza-Like Illness [ILI+].
  39. 39. Diffuse Interstitial Opacities 60-Year-Old Male With A History COPD On Home O2 Presents With Fever And Symptoms Of An Influenza-Like Illness [ILI+].
  40. 40. Diagnosis: COVID-19 [+] Pneumonia
  41. 41. Admission CXR for comparison Present CXR
  42. 42. 70-Year-Old Male With A History Of Diabetes And Recent COVID [+] Testing Presents With ILI Symptoms.
  43. 43. New Patchy Bilateral Opacities 70-Year-Old Male With A History Of Diabetes And Recent COVID [+] Testing Presents With ILI Symptoms.
  44. 44. Prior CXR for comparison Present CXR
  45. 45. Summary Of Diagnoses This Month  Ruptured Esophagus  Perforated Viscus  Persistent Spontaneous PTX  Traumatic Diaphragmatic Hernia  Pulmonary Contusion  COVID -19 Pneumonia PLEASE STAY TUNED FOR A COVID-19 SPECIFIC PRESENTATION COMING SOON!
  46. 46. See You Next Month!

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