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Drs. Milam and Thomas's CMC X-Ray Mastery Project: January 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:
• Pneumomediastinum
• Spontaneous Pneumothorax
• Deep Sulcus Sign
• Massive Pericardial Effusion
• Pulmonary Hypertension
• Mitral Stenosis
• Pulmonary Bullae
• Situs Inversus
• Dextrocardia
• Cavitary Lesions

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Drs. Milam and Thomas's CMC X-Ray Mastery Project: January 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 January 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. Healthy 13-Year-Old With Throat And Upper Chest Pain
  8. 8. Healthy 13-Year-Old With Throat And Upper Chest Pain Pneumomediastinum & Pneumopericardium
  9. 9. Healthy 13-Year-Old With Throat And Upper Chest Pain Pneumomediastinum & Pneumopericardium
  10. 10. Young Male With Intractable Vomiting
  11. 11. Young Male With Intractable Vomiting Pneumomediastinum & Pneumopericardium Subcutaneous Emphysema Subcutaneous Emphysema
  12. 12. Young Male With Intractable Vomiting Pneumomediastinum + Pneumopericardium + Subcutaneous Emphysema
  13. 13. 25-Year-Old Presents With Sharp Chest Pain After Smoking Marijuana
  14. 14. Pneumomediastinum 25-Year-Old Presents With Sharp Chest Pain After Smoking Marijuana
  15. 15. Pneumomediastinum 25-Year-Old Presents With Sharp Chest Pain After Smoking Marijuana
  16. 16. Pneumomediastinum 2° Iatrogenic 2° Medical & Traumatic Spontaneous  Endoscopic procedures  Intubation  Pleural instrumentation  Central vascular procedure  Chest/abdominal surgery  Blunt chest injury  Penetrating chest injury  Asthma/COPD  Bronchiectasis  Interstitial lung disease  Thoracic malignancy  Tobacco use  Recreational drugs  Breath holding  Weight lifting Vasileios K. Journal of Thoracic Disease 2015; 7:S44-S49. Management Essentials  Manage the underlying cause  Pain management & cough suppression as indicated  Oxygen may increase gas absorption in severe cases  Brief period of observation vs. close outpatient follow-up
  17. 17. Traumatic Pneumomediastinum Single-Center Trauma Registry Review 2007-2012: 9,946 admitted trauma patients studied: 258 had pneumomediastinum Chouliaras K. Journal of Trauma & Acute Care Surgery 2015; 79:188-193. CXR diagnosis in 25% CT diagnosis in 75% 21 patients (8.1%) had an aerodigestive work-up with bronchoscopy, esophagram or esophagoscopy: 4 injuries (1.6%) were identified.  3 tracheobronchial injuries [2 (0.7%) managed surgically]  1 esophageal injury managed non-operatively Isolated pneumomediastinum poorly predict of injury: selective work-up recommended.
  18. 18. Gunshot Wound To The Neck…
  19. 19. Gunshot Wound To The Neck…
  20. 20. Gunshot Wound To The Neck… Injury To The Trachea & Esophagus
  21. 21. Pneumomediastinum Injury To The Trachea & Esophagus
  22. 22. Pneumomediastinum Pneumomediastinum Pneumomediastinum Injury To The Trachea & Esophagus
  23. 23. Healthy Young Female With Sudden Onset Right-Sided Pleuritic Chest Pain
  24. 24. Spontaneous Pneumothorax Healthy Young Female With Sudden Onset Right-Sided Pleuritic Chest Pain
  25. 25. Healthy Male Presents With Sharp Chest Pain
  26. 26. Left Spontaneous Pneumothorax Healthy Male Presents With Sharp Chest Pain
  27. 27. After Drainage Healthy Male Presents With Sharp Chest Pain
  28. 28. Healthy Male Presents With Sharp Chest Pain
  29. 29. Healthy Male Presents With Sharp Chest Pain Right Spontaneous Pneumothorax
  30. 30. Healthy Male Presents With Sharp Chest Pain After Drainage
  31. 31. Sahn SA. NEJM 2000; 342:868-874. Classification Of Pneumothorax According To Cause Spontaneous 1°: No clinical lung disease 2°: A complication of clinically apparent lung disease Traumatic • Penetrating trauma • Blunt trauma Iatrogenic • Transthoracic needle aspiration • Central line placement • Thoracentesis • Lung biopsy
  32. 32. NEJM 2000; 342:868-874.
  33. 33. 33-Year-Old In A Roll Over Motor Vehicle Crash.
  34. 34. 33-Year-Old In A Roll Over Motor Vehicle Crash. Deep Sulcus Sign Deep Sulcus Sign Bilateral Tension Pneumothorax
  35. 35. 35-Year-Old Male In A High-Speed Car Crash
  36. 36. 35-Year-Old Male In A High-Speed Car Crash Deep Sulcus Sign Tension Pneumothorax With Shift
  37. 37. 88-Year-Old Falls On His Right Side.
  38. 38. 88-Year-Old Falls On His Right Side. Right Apical Pneumothorax + Multiple Rib Fractures[*] * * * * * *
  39. 39. 88-Year-Old Falls On His Right Side.
  40. 40. 73-Year-Old Female With Progressive Dyspnea
  41. 41. 73-Year-Old Female With Progressive Dyspnea Massive Pericardial Effusion
  42. 42. 73-Year-Old Female With Progressive Dyspnea 73-Year-Old Female With Progressive Dyspnea * * * * * Massive Pericardial Effusion
  43. 43.  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.
  44. 44. What Do You See?
  45. 45. What Do You See? Enlarged Right Pulmonary Artery Enlarged Left Pulmonary Artery
  46. 46. What Do You See? Pulmonary Arterial Hypertension Enlarged Right Pulmonary Artery Enlarged Left Pulmonary Artery
  47. 47. To Learn More About ECG Findings In Pulmonary Hypertension, Visit: www.EMGuidewire.com Click On “EM Cardiology,” Then Click On “Monthly ECG Blogs.” November ECG Lesson Created skillfully by Dr. Neha Ray, CMC E.M. PGY-1 resident and… Dr. Laszlo Littmann, the master of ECG interpretation and education.
  48. 48. Valvular Heart Disease Which cardiac chamber is enlarged in patients with significant chronic mitral stenosis? • Right atrium • Right ventricle • Left atrium • Left ventricle
  49. 49. Valvular Heart Disease Which cardiac chamber is enlarged in patients with significant chronic mitral stenosis? • Right atrium • Right ventricle • Left atrium • Left ventricle
  50. 50. Mitral Stenosis
  51. 51. Mitral Stenosis
  52. 52. Mitral Stenosis
  53. 53. Mitral Stenosis
  54. 54. Pulmonary Bullae
  55. 55. Healthy 33-Year- Old With Chest Pain
  56. 56. Healthy 33-Year- Old With Chest Pain Situs Inversus Heart & Stomach Both On The Wrong Side
  57. 57. Dextrocardia Heart On The Wrong Side, Stomach On The Correct Side
  58. 58. 45-Year-Old Renal Transplant Patient With Cough And Dyspnea.
  59. 59. 45-Year-Old Renal Transplant Patient With Cough And Dyspnea. Cavitary Lesions
  60. 60. 45-Year-Old Renal Transplant Patient With Cough And Dyspnea. Cavitary Lesions
  61. 61. Summary Of Diagnoses This Month  Pneumomediastinum  Spontaneous pneumothorax  Deep Sulcus Sign  Massive pericardial effusion  Pulmonary hypertension  Mitral stenosis  Pulmonary bullae  Situs inversus  Dextrocardia  Cavitary lesions
  62. 62. See You Next Month!

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