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Drs. Milam and Thomas's CMC X-Ray Mastery Project: August 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: Aortic Dissection, Hiatal Hernia, Pleural Effusion, Metastatic Cancer, Cystic Fibrosis, Pulmonary Contusions, Esophageal-pleural Fistula, Diaphragmatic Hernia, Pulmonary Artery Hypertension, Hemorrhagic Pericardial Effusion, Pulmonary Infarct

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Drs. Milam and Thomas's CMC X-Ray Mastery Project: August 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 August 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 providing cases and these slides are shared with all contributors.  Contributors from many Carolinas Medical Center departments, and now… 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. It’s All About The Anatomy!
  5. 5. Airway Bones Cardiac Diaphragm Effusion Foreign body Gastric Hilum
  6. 6. 36 Year-Old With Acute Onset Chest Pain, Back Pain And Leg Numbness Case #1 Look closely, what do you notice?
  7. 7. Wide Mediastinum On CT Scout Film 36 Year-Old With Acute Onset Chest Pain, Back Pain And Leg Numbness
  8. 8. Type A Dissection From Aortic Root To Both Iliac Arteries Case #1 CT Images
  9. 9. Type A Dissection Post-Operative CXR
  10. 10. TYPE A TYPE B Recall the differences between Type A and Type B dissections
  11. 11. Branch Vessel Compromise Myocardial infarction Stroke Spinal cord infarction Mesenteric and renal ischemia Limb ischemia As a dissection progresses, any branches off the aorta may suffer from ischemia
  12. 12. Chest Pain Back Pain Stroke Symptoms Paraplegia Acute Abdomen Renal Failure Aortic Dissection? Paretic Extremity Whenever you have chest/back pain + other major organ symptom, then consider aortic dissection…
  13. 13. Type A Dissections Acute aortic insufficiency Acute pulmonary edema Pericardial tamponade Acute myocardial infarction Let’s take a second to focus on Type A Dissections…
  14. 14. Type A Dissections
  15. 15. Aortic Dissection? ACS + widened mediastinum on CXR should clue you in to consider aortic dissection
  16. 16. Chest Pain Back Pain Acute CHF New AI Murmur Syncope Aortic Dissection?
  17. 17. Acute Aortic Dissections are challenging to diagnose and treat Lit Review for Case #1
  18. 18. IRAD: Demographics And Risks Type A 67% Type B 33% Risk Factors Hypertension 77% Atherosclerosis 27% Known aneurysm 16% Cardiac surgery 16% Marfan syndrome 5% Iatrogenic 4% Cocaine use1 2% 1Cocaine use 12% in black patients 66% of patients were male The mean age was 63 years Lit Review for Case #1
  19. 19. IRAD: Demographics And Risks Type A 67% Type B 33% Risk Factors Hypertension 77% Atherosclerosis 27% Known aneurysm 16% Cardiac surgery 16% Marfan syndrome 5% Iatrogenic 4% Cocaine use1 2% 1Cocaine use 12% in black patients 66% of patients were male The mean age was 63 years Lit Review for Case #1
  20. 20. IRAD: Clinical Manifestations Pain1 reported in 93.7%: A B Chest pain 79% 63% Back pain 43% 64% HPTN on presentation 36% 70% Pulse deficit 30% 20% Syncope2 19% 1,2Painless AAD and patients presenting with syncope had a higher risk of heart failure, tamponade and death. A = Type A Dissection B = Type B Dissection Lit Review for Case #1
  21. 21. IRAD: Clinical Manifestations Quality of pain [from the original IRAD data set published in 2000]: Hagan PG. JAMA 2000. Abrupt onset 84% Worst pain ever 91% Sharp 64% Tearing or ripping 51% Radiating 28% Migratory 17% History is key! - Most patients will know the exact time the pain started Lit Review for Case #1
  22. 22. Elderly Male With Progressive Dyspnea Case #2 What Do You See?
  23. 23. Elderly Male With Progressive Dyspnea What Is This?
  24. 24. Elderly Male With Progressive Dyspnea Hiatal Hernia
  25. 25. Diaphragm Hiatal Hernia Hiatal Hernia
  26. 26. Hiatal Hernia Sxs • Heartburn • Regurgitation • Dysphagia
  27. 27. Right Pleural Effusion
  28. 28. After Pleural Drainage
  29. 29. Light’s Criteria Transudate Versus Exudate1,2 Pleural Fluid Protein/Plasma Protein >0.5 Pleural Fluid LDH/Plasma LDH >0.6 Pleural Fluid LDH >200 IU 1In patients with heart failure on diuretics, Light’s Criteria may misclassify a transudate as an exudate up to 25% of the time. 2In heart failure patients, a serum protein 3.1 g/dl higher than the pleural fluid, or a serum albumen 1.2 g/dl higher than the pleural fluid will help correctly identify a transudate.
  30. 30. Parapneumonic Effusions • The most common exudative effusions are those associated with underlying pneumonia • Mortality is higher among pneumonia patients who have a parapneumonic effusion, compared with those with pneumonia and no effusion • With the aging of the population, the incidence and mortality due to parapneumonic effusion and empyema continues to rise
  31. 31. Right Parapneumonic Effusion
  32. 32. Malignant Effusions • The second most common exudative effusions are those associated with underlying malignancy • The majority of malignant pleural effusions arise from lung cancer, breast cancer, and lymphoma • The presence of a malignant pleural effusion is associated with higher mortality and significantly shorter survival
  33. 33. Lung Mass With Malignant Effusion
  34. 34. Lung Mass After Effusion Drainage
  35. 35. Metastatic Round Cell Cancer * * * * *
  36. 36. 24 Year-Old With Cystic Fibrosis Presents With Cough And Hemoptysis
  37. 37. 24 Year-Old With Cystic Fibrosis Presents With Cough And Hemoptysis Severe Bronchiectasis And Bullous Lung Disease
  38. 38. 24 Year-Old With Cystic Fibrosis Presents With Cough And Hemoptysis Severe Bronchiectasis And Bullous Lung Disease
  39. 39. Cystic Fibrosis: • Characterized by chronic respiratory infections resulting in progressive loss of lung function • Acutely worsening symptoms (Pulmonary Exacerbations) manifest as: increased cough, sputum production, and shortness of breath. Varying degrees of hemoptysis may occur with severe cases.
  40. 40. Emergency Department Management Of Pulmonary Exacerbations: Atrium Health order set: ADULT MED Cystic Fibrosis Exacerbations • Aggressive bronchodilator therapy • Order ‘CF Bronchiectasis Sputum Culture’ [will capture rare bacteria species] • Broad spectrum antibiotics with double-coverage for Pseudomonas • No evidence that steroids are routinely beneficial, OK to administer if bronchospasm if felt to be a significant contributor to the exacerbation • Trial of non-invasive ventilation if intubation is felt to be necessary
  41. 41. 25 Year-Old With Cystic Fibrosis
  42. 42. 49 Year-Old With Cystic Fibrosis
  43. 43. 46 Year-Old Male Sustains Multiple GSWs To The Right Chest And Abdomen Severe Pulmonary Contusion
  44. 44. 46 Year-Old Male Sustains Multiple GSWs To The Right Chest And Abdomen Severe Pulmonary Contusion – After Chest Tube
  45. 45. 46 Year-Old Male Sustains Multiple GSWs To The Right Chest And Abdomen Severe Pulmonary Contusion – Post Injury Day #1
  46. 46. 46 Year-Old Male Sustains Multiple GSWs To The Right Chest And Abdomen Severe Pulmonary Contusion – Post Injury Day #2
  47. 47. 46 Year-Old Male Sustains Multiple GSWs To The Right Chest And Abdomen Severe Pulmonary Contusion – Post Injury Day #3
  48. 48. 46 Year-Old Male Sustains Multiple GSWs To The Right Chest And Abdomen Severe Pulmonary Contusion – Post Injury Day #10
  49. 49. 62 Year-Old Male Struck By A Car While Riding His Moped
  50. 50. 62 Year-Old Male Struck By A Car While Riding His Moped Pulmonary Contusion
  51. 51. 62 Year-Old Male Struck By A Car While Riding His Moped Pulmonary Contusion
  52. 52. 23 Year-Old Male With AIDS Presents With Fever Dyspnea A Case From Kenya
  53. 53. 23 Year-Old Male With AIDS Presents With Fever Dyspnea A Case From Kenya Tuberculous Effusion With Shift Did Well After Drainage & TB Therapy
  54. 54. 53 Year-Old Female With Two Years Of Upper Abdominal Pain + Two Months Of Dyspnea + Two Weeks Of Fever Cases Studies From Our Emergency Medicine Partners In Brazil
  55. 55. 53 Year-Old Female With Two Years Of Upper Abdominal Pain + Two Months Of Dyspnea + Two Weeks Of Fever Cases Studies From Our Emergency Medicine Partners In Brazil A Chronic Ulcer Of The Gastroesophageal Junction Erodes Into The Right Chest Creating A Fistula. Full Recovery After Surgical Repair.
  56. 56. Let’s Pause And Look At A Normal CXR
  57. 57. 45 Year-Old Male Involved In A Roll-Over Car Crash Intubated In The Field What Do You See?
  58. 58. 45 Year-Old Male Involved In A Roll-Over Car Crash Intubated In The Field Rib Fracture Elevated Hemidiaphragm
  59. 59. 45 Year-Old Male Involved In A Roll-Over Car Crash Intubated In The Field Why Is The Left Hemidiaphragm Elevated? Rib Fracture Elevated Hemidiaphragm
  60. 60. 45 Year-Old Male Involved In A Roll-Over Car Crash Intubated In The Field Ruptured Diaphragm
  61. 61. 45 Year-Old Male With Rupture Of The Left Diaphragm Chest X-Ray After Repair
  62. 62. Diaphragm Injury Demographics ACS National Trauma Data Bank [n=833,309]: • Diaphragm injuries are rare, incidence: 0.46% • Mechanism: 67% penetrating and 33% blunt Penetrating Blunt  Gunshot wounds 67%  Motor vehicle crash 63%  Stab wounds 33%  Bicycle/pedestrian stuck 10% Mortality 9% Mortality 20% Fair KA. J Trauma 2015; 209:864-868.
  63. 63. SUMMARY Of 2018 EAST Practice Management Guidelines #1 In stable patients with left thoracoabdominal stab wounds, laparoscopy is recommended rather than CT imaging to decrease the incidence of missed diaphragm injuries. #2 In stable patients with confirmed or suspected penetrating injuries of the right diaphragm, non-operative management is recommended over operative management. #3 In stable patients with acute diaphragm injuries, the abdominal rather than the thoracic approach is preferred for injury repair. #4 In patients with acute penetrating diaphragm injuries without concerns for other intraabdominal injuries, laparoscopic repair is recommended over open repair.
  64. 64. 33 Year-Old With Dyspnea. What Do You See?
  65. 65. 33 Year-Old With Dyspnea. Enlarged Right Pulmonary Artery Enlarged Left Pulmonary Artery
  66. 66. 33 Year-Old With Dyspnea. Pulmonary Arterial Hypertension Enlarged Right Pulmonary Artery Enlarged Left Pulmonary Artery
  67. 67. 68 Year-Old On Warfarin Presents With Dyspnea. Her INR is 7.5.
  68. 68. 68 Year-Old Presents With Dyspnea. Large Pericardial Effusion * * * * * * * *
  69. 69. 68 Year-Old Presents With Dyspnea. ED ECHO: Large Pericardial Effusion ** * * * Diastolic Collapse
  70. 70. 68 Year-Old On Warfarin Presents With Dyspnea. Her INR is 7.5. Our Patient  Full reversal with Vitamin K, PCC  Pericardiocentesis and removal of >800 cc bloody fluid
  71. 71. “Spontaneous Hemopericardium In A Patient Receiving Apixaban Therapy.” Sigawy C. Pharmacotherapy 2015. Epub, June 10. “Dabigatran-Induced Spontaneous Hemopericardium And Cardiac Tamponade.” Qurat-ul ain, J. Tex Heart Inst. 2017; 44(5):370-372. “Bleeding Heart: A Case Of Spontaneous Hemopericardium And Tamponade In A Patient On Warfarin.” Sajawal A. BMJ Case Reports. 2016; 1136/bcr-2016-215731.
  72. 72. “2017 ACC Expert Consensus Decision Pathway on Management Of Bleeding In Patients On Oral Anticoagulants. A Report of the ACC Task Force On Decision Pathways. Tomaselli GF. JACC 2017; 70:3042-63. Question #1: Is There Major Bleeding? Question #2: Is There Bleeding At A Critical Site?
  73. 73. Tomaselli GF. JACC 2017. 70:3046-63 Does ≥1 Of The Following Apply?  Hemodynamic instability  Hemoglobin drop ≥2 grams  Transfusion ≥2 units of PRBCs  Bleeding at a critical site Major Bleeding Y Yes No Y Non-Major Bleeding Is There Major Bleeding?
  74. 74. Critical Bleeding Sites Intracranial Intraparenchymal, subdural, epidural, SAH Other CNS Intraocular, intra- or para- spinal Pericardium Airway Epistaxis, upper/lower airway Intracavitary Thoracic, abdominal, retroperitoneum Extremity Muscle compartment, joint Is Bleeding At A Critical Site Or Life-Threatening? Immediate Reversal Y Yes No Y Case Specific Reversal
  75. 75. Critical Bleeding Sites Intracranial Intraparenchymal, subdural, epidural, SAH Other CNS Intraocular, intra- or para- spinal Pericardium Airway Epistaxis, upper/lower airway Intracavitary Thoracic, abdominal, retroperitoneum Extremity Muscle compartment, joint Is Bleeding At A Critical Site Or Life-Threatening? Immediate Reversal Y Yes No Y Case Specific Reversal
  76. 76. 60 Year-Old With Right Sided Pleuritic Chest Pain What Do You See?
  77. 77. 60 Year-Old With Right Sided Pleuritic Chest Pain Is This Pneumonia?
  78. 78. 60 Year-Old With Right Sided Pleuritic Chest Pain Chest CT [+] For PE: RLL Pulmonary Infarct
  79. 79. Summary Of Diagnoses This Month  Type A aortic dissection  Hiatal hernia  Pleural effusion  Metastatic round cell carcinoma  Cystic fibrosis and severe bronchiectasis  Pulmonary contusions  Esophageal-pleural fistula  Ruptured left hemidiaphragm • Pulmonary artery hypertension • Hemorrhagic pericardial effusion • Pulmonary infarct
  80. 80. See You Next Month!

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