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Drs. Milam and Thomas's CMC X-Ray Mastery Project: July 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: Sternal fracture, Left hemothorax, Traumatic aortic aneurysm, Acute chest syndrome, Right upper lobe pneumonia, Pericardial effusion, Pulmonary contusion, Pulmonary bleb, Non-small-cell lung cancer

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Drs. Milam and Thomas's CMC X-Ray Mastery Project: July 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 July 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. MVC – Struck Chest On The Steering Wheel
  7. 7. What is your interpretation? Be sure to look at both views closely. MVC – Struck Chest On The Steering Wheel
  8. 8. Sternal Fracture  Direct impact to the anterior chest.  Best seen on the lateral view. MVC – Struck Chest On The Steering Wheel
  9. 9. MVC – Struck Chest On The Steering Wheel Right Sided Effusion. Could It Be Blood? Remember Not To Miss The 2nd (Or 3rd, Or 4th) Finding(s)!
  10. 10. What Do You See? Stab Wound To Left Chest
  11. 11. Stab Wound To Left Chest Left Hemothorax
  12. 12. Stab Wound To Left Chest Notice: Early Tracheal Deviation Left Hemothorax
  13. 13. After Chest Tube Placed Side Note: If chest tube output >1000 ml, consider autotransfusion Stab Wound To Left Chest
  14. 14. After Chest Tube Placed Notice: Midline Trachea Side Note: If chest tube output >1000 ml, consider autotransfusion Stab Wound To Left Chest
  15. 15. A 70 Year-Old Male Is Thrown From A Horse And Presents To An Outside ED with Right Sided Chest Pain A Chest CT Is Ordered Right Pneumothorax Visible On The CT Scout Film
  16. 16. A 70 Year-Old Male Is Thrown From A Horse And Presents To An Outside ED with Right Sided Chest Pain A Chest CT Is Ordered
  17. 17. A 70 Year-Old Male Is Thrown From A Horse And Presents To An Outside ED with Right Sided Chest Pain Right Pneumothorax Visible On The CT Scout Film
  18. 18. A 70 Year-Old Male Is Thrown From A Horse And Presents To An Outside ED with Right Sided Chest Pain Oops!
  19. 19. A 70 Year-Old Male Is Thrown From A Horse And Presents To An Outside ED with Right Sided Chest Pain Pigtail Placed – Pneumothorax Persists
  20. 20. A 70 Year-Old Male Is Thrown From A Horse Pigtail Replaced
  21. 21. A 70 Year-Old Male Is Thrown From A Horse Multiple Posterior Rib Fractures
  22. 22. What Are You Concerned About? 78 Year-Old Who Moved To Charlotte From El Salvador This Month
  23. 23. Thoracic Aortic Aneurysm [TAA]  Thoracic aorta >3.5 cm considered dilated.  Thoracic aorta >4.5 cm considered aneurysmal. 78 Year-Old Who Moved To Charlotte From El Salvador This Month
  24. 24. TAA: Anatomy Defined By CT Angiography
  25. 25. Thoracic Aortic Aneurysm Endovascular Repair
  26. 26. TAA: Endograft
  27. 27. Thoracic Aortic Aneurysm
  28. 28. 25 Year Old With A History Of Sickle Cell Disease Presents With Severe Pain of Both Of His Legs and His Lower Back. Hospital Day 1 Afebrile, Vital Signs Are Stable
  29. 29. What is your interpretation? 25 Year Old With A History Of Sickle Cell Disease Presents With Severe Pain of Both Of His Legs and His Lower Back. Hospital Day 3 Now Febrile, Dyspneic, Tachypneic And Tachycardic
  30. 30. 25 Year Old With A History Of Sickle Cell Disease Presents With Severe Pain of Both Of His Legs and His Lower Back. Hospital Day 3 Now Febrile, Dyspneic, Tachypneic And Tachycardic Acute Chest Syndrome
  31. 31. Acute Chest Syndrome 25 Year Old With A History Of Sickle Cell Disease Presents With Severe Pain of Both Of His Legs and His Lower Back. Hospital Day 3 Now Febrile, Dyspneic, Tachypneic And Tachycardic
  32. 32. 25 Year Old With A History Of Sickle Cell Disease Presents With Severe Pain of Both Of His Legs and His Lower Back. Hospital Day 5 Clinically Improved After Exchange Transfusion Acute Chest Syndrome Side Note: Recall that the CXR looked normal on initial presentation. This is the case for ≈50% of hospitalized SCD patients who go on to develop ACS.
  33. 33. Acute Chest Syndrome  Defined as a new pulmonary infiltrate consistent with consolidation [not atelectasis] of at least one lung segment.  Usually accompanied by chest pain, cough, fever and wheezing.  The most common cause or IC U admission and premature death in patients with sickle cell disease. Gladwin M. New England Journal of Medicine 2008; 359:2254-65.
  34. 34. Acute Chest Syndrome Three proposed mechanisms:  Pulmonary infection1  Embolization of bone marrow fat2  Pulmonary intravascular sickling and infarction3 1Bronchoalveolar lavage demonstrates bacterial and/or viral pathogens in 54% of patients with ACS. 2Associated with pain crisis of multiple bones, particularly the lumbar spine, femurs and the pelvis. 3In a small percentage of patients with ACS, wedge-shaped pulmonary infarcts may develop. Gladwin M. New England Journal of Medicine 2008; 359:2254-65.
  35. 35. National Acute Chest Syndrome Study Group  538 patients from 20 centers - the largest case series to date  Results provide insights into the clinical presentations and outcomes of hospitalized patients with ACS 49% Of Patients Initially Presented In Pain Crisis Without Signs Of ACS! Vichinsky EP. New England Journal of Medicine 2000; 342:1855-65.
  36. 36. National Acute Chest Syndrome Study Group  Manifestations: worsening hypoxia, decreased hemoglobin levels, and progressive, multi-lobar pulmonary infiltrates  The mean hospital length of stay was 10.5 days [vs. 3 days w/o ACS]  30% required mechanical ventilation and overall mortality was 3% Vichinsky EP. New England Journal of Medicine 2000; 342:1855-65. Infection1,2 33% Pulmonary Infarction 33% Pulmonary fat emboli 16% 1Pathogens identified using bronchoalveolar lavage 2Chlamydophilia, Mycoplasma pneumoniae & respiratory syncytial virus the most common pathogens
  37. 37. Acute Chest Syndrome ED Treatment Essentials:  Antibiotics to cover both typical & atypical pathogens  Supportive respiratory care  A transfusion strategy based on goals and severity Gladwin M. New England Journal of Medicine 2008; 359:2254-65. Goal Target Increase oxygen carrying capacity Hgb ≥10 grams Manage vaso-occlusive complications HbS <30% Both As above
  38. 38. RCE = Red Cell Exchange
  39. 39. Cases Studies From Our Emergency Medicine Partners In Brazil 43 Year Old Presents To An Outpatient Clinic After A Syncopal Episode He Has Normal Labs, A Normal ECG And This Chest X-Ray He Is Sent Home
  40. 40. Cases Studies From Our Emergency Medicine Partners In Brazil Right Upper Lobe Pneumonia 43 Year Old Seen In The Outpatient Clinic Four Days Later He Now Presents To The ED With Cough, Fever & Rigors
  41. 41. Cases Studies From Our Emergency Medicine Partners In Brazil 43 Year Old Seen Four Days Ago In The Outpatient Clinic Let’s Take Another Look At The First CXR…
  42. 42. Cases Studies From Our Emergency Medicine Partners In Brazil Subtle pneumonias can be easy to miss (especially with overlapping structures near by), make sure you are comparing each lung field with the other side. 43 Year Old Seen Four Days Ago In The Outpatient Clinic Let’s Take Another Look At The First CXR…
  43. 43. 27 Year Old With One Week Of Chest Pain and Dyspnea Transferred From An Outlying Hospital After Chest CT Case #3
  44. 44. 27 Year Old With One Week Of Chest Pain and Dyspnea
  45. 45. 27 Year Old With One Week Of Chest Pain and Dyspnea Chest CT Obtained: Large Pericardial Effusion
  46. 46. 27 Year Old With One Week Of Chest Pain and Dyspnea ECHO
  47. 47. 27 Year Old With One Week Of Chest Pain and Dyspnea Cardiac Apex
  48. 48. 27 Year Old With One Week Of Chest Pain and Dyspnea Pericardial Effusion: Pericardiocentesis = 250 cc Straw-Colored Fluid Cardiac Apex ** * *
  49. 49.  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.
  50. 50. 23 Year Old Car Crash In To A Tree A Chest CT Is Obtained
  51. 51. 23 Year Old Car Crash In To A Tree A Chest CT Is Obtained Severe Pulmonary Contusion
  52. 52. 23 Year Old Car Crash In To A Tree. He Is Transferred To Our ED And Is Intubated Upon Arrival For Severe Agitation And Persistent Hypoxia Severe Pulmonary Contusion
  53. 53. 69 Year Old With Emphysema Does He Have A Pneumothorax On The Right?
  54. 54. No! He Has A Large Right Lung Bleb 69 Year Old With Emphysema Does He Have A Pneumothorax On The Right?
  55. 55. 69 Year Old With Emphysema Pulmonary Bleb Drainage Catheters
  56. 56. 79 Year Old Male Smoker Presents With Cough And Two Weeks Of Right Sided Chest Pain Chest X-Ray From 3 Years Ago
  57. 57. 79 Year Old Male Smoker Presents With Cough And Two Weeks Of Right Sided Chest Pain Chest X-Ray From Today: What Do You See?
  58. 58. 79 Year Old Male Smoker Presents With Cough And Two Weeks Of Right Sided Chest The Lateral View Is Helpful
  59. 59. 79 Year Old Male Smoker Presents With Cough And Two Weeks Of Right Sided Chest The Lateral View Is Helpful This Looks Like A Round Mass
  60. 60. 79 Year Old Male Smoker Presents With Cough And Two Weeks Of Right Sided Chest The Lateral View Is Helpful This Looks Like A Round Mass Is This Fluid, A Mass, Or Both?
  61. 61. Right Lung Mass + Effusion + Metastasis To The Chest Wall [*] * * Pathology Non-Small Cell Lung Cancer
  62. 62. Summary Of Diagnoses This Month  Sternal fracture  Left hemothorax  Traumatic aortic aneurysm  Acute chest syndrome  Right upper lobe pneumonia  Pericardial effusion  Pulmonary contusion  Pulmonary bleb  Non-small-cell lung cancer
  63. 63. See You Next Month!

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