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Drs. Milam and Thomas's CMC X-Ray Mastery Project: June 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:
• Pneumothorax
• Non-cardiogenic Pulmonary Edema
• COVID – 19
• Right Lower Lobe Pneumonia
• Diaphragmatic Hernia
• Lung Abscess
• Miliary Tuberculosis
• Asbestosis

Published in: Education
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Drs. Milam and Thomas's CMC X-Ray Mastery Project: June Cases

  1. 1. Adult Chest X-Rays Of The Month Alyssa Thomas MD & Claire Milam MD & Travis Barlock MD Department of Emergency Medicine Carolinas Medical Center & Levine Children’s Hospital Michael Gibbs MD, Faculty Editor Chest X-Ray Mastery Project™ June 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. 52-Year-Old Male Presents After A Motor Vehicle Collision (MVC)
  8. 8. Diagnosis: Pneumothorax Don’t forget to look at the costophrenic angles! Deep Sulcus Sign 52-Year-Old Male Presents After A MVC
  9. 9. Diagnosis: Pneumothorax
  10. 10. 52-Year-Old Male Presents After A MVC with Pneumothorax Re-expansion of right lung after pigtail catheter placement
  11. 11. 33-Year-Old Male Presents After Being Found Poorly Responsive. He Was Given 5mg Of Naloxone What Do You See?
  12. 12. Diagnosis: Non-cardiogenic Pulmonary Edema 33-Year-Old Male Presents After Being Found Poorly Responsive. He Was Given 5mg Of Naloxone
  13. 13. Non- Cardiogenic Pulmonary Edema with Use of Naloxone Citation: Farkas A, Lynch MJ, Westover R, et al. Pulmonary Complications of Opioid Overdose Treated With Naloxone. Ann Emerg Med. 2020;75(1):39-48. doi:10.1016/j.annemergmed.2019.04.006 Due to: Negative pressure resulting from inspiration against a closed glottis Increased capillary permeability Increased pulmonary arterial pressure caused by catecholamine surge from precipitated withdrawal or sudden cerebral recognition of hypoxia Noncardiogenic Pulmonary Edema has been Theorized to Occur via a Variety of Mechanisms:
  14. 14. This is a retrospective, observational, cross-sectional study • A total of 485 (26.5%) cases had pulmonary complications • Patients receiving more than 4.4mg of naloxone experienced pulmonary complications 42% of the time compared with 26% for those receiving smaller doses • Patients receiving an initial naloxone dose of greater than 0.4mg also had higher rate of pulmonary complications compared with those who received less Multivariable analysis of patient factors associated with pulmonary complications Methods: Patients administered naloxone in the out-of-hospital setting and subsequently transported to Emergency Departments were evaluated for pulmonary complications Results:
  15. 15. • 24 cases of pulmonary edema with 18 (1.2%) of them being related to opioid overdose • 8 (44%) treated with positive-pressure ventilation, intubation or both • 10 (56%) received supplemental oxygen • 1 (5%) had radiographic evidence of pulmonary edema, but no hypoxia requiring supplemental oxygen Specific Pulmonary Edema Results:
  16. 16. The risk of pulmonary edema appeared to be higher in groups receiving greater than 4.4mg of total naloxone (OR 2.23, 95% CI .65 to 7.60) Or when the initial dose was greater than 0.4mg (OR 1.51; 95% CI 0.20 to 11.30) but were not statistically significant Specific Pulmonary Edema Results: Citation: Farkas A, Lynch MJ, Westover R, et al. Pulmonary Complications of Opioid Overdose Treated With Naloxone. Ann Emerg Med. 2020;75(1):39-48. doi:10.1016/j.annemergmed.2019.04.006
  17. 17. 25-Year-Old Male Presents with Chest Pain
  18. 18. 25-Year-Old Male Presents with Chest Pain Diagnosis: Right Lower Lobe (RLL) Pneumonia
  19. 19. 78-Year-Old Male Presents for Evaluation of Abdominal Pain What do you notice?
  20. 20. 78-Year-Old Male Presents For The Evaluation Of Abdominal Pain Calcified Pleural Plaques Blunting Of The Costophrenic Angles
  21. 21. Calcified Pleural Plaques Diagnosis: History of Asbestosis Exposure 78-Year-Old Male Presents For The Evaluation Of Abdominal Pain Blunting Of The Costophrenic Angles
  22. 22. 51-Year-Old Male With A Prior COVID-19 Infection Presents With Chest Pain
  23. 23. Diagnosis: Lung Abscess 51-Year-Old Male With A Prior COVID-19 Infection Presents With Chest Pain
  24. 24. AP Lateral
  25. 25. Air-Fluid Level: If It’s Flat There’s Air In There!
  26. 26. CT Imaging
  27. 27. 38-Year-Old Female Presents With Shortness Of Breath
  28. 28. Diagnosis: RLL Pneumonia, COVID (+) 38-Year-Old Female Presents With Shortness Of Breath
  29. 29. The Patient Decompensates And Requires ECMO 38-Year-Old Female Presents With Shortness Of Breath
  30. 30. Decannulated And Extubated After 11 Days Of ECMO
  31. 31. 22-Year-Old Male Presents With Influenza Like Illness (ILI) And Shortness Of Breath Important Social History: Our Patient Recently Immigrated From Vietnam 2 years Prior To Presentation
  32. 32. Important Social History: Our Patient Recently Immigrated From Vietnam 2 years Prior To Presentation Diagnosis: “Left Airspace Opacity” 22-Year-Old Male Presents With Influenza Like Illness (ILI) And Shortness Of Breath
  33. 33. Important Social History: Our Patient Recently Immigrated From Vietnam 2 years Prior To Presentation 22-Year-Old Male Presents With Influenza Like Illness (ILI) And Shortness Of Breath What Should You Consider?
  34. 34. Important Social History: Our Patient Recently Immigrated From Vietnam 2 years Prior To Presentation 22-Year-Old Male Presents With Influenza Like Illness (ILI) And Shortness Of Breath What Should You Consider? Notice The Tubular Lucencies
  35. 35. Important Social History: Our Patient Recently Immigrated From Vietnam 2 years Prior To Presentation 22-Year-Old Male Presents With Influenza Like Illness (ILI) And Shortness Of Breath Diagnosis: Miliary Tuberculosis
  36. 36. Diagnosis: Miliary Tuberculosis
  37. 37. Notice: 1. The “millet seed” appearance of the parenchyma in the right lung 2. The cavitary lesions in the left lung
  38. 38. Primary vs. Miliary Tuberculosis  Tuberculosis [TB] is infection by Mycobacterium tuberculosis bacilli.  Primary TB is the initial infection of the bacilli, often in the lungs.  Miliary TB is tuberculosis infection that has disseminated to other organs, often liver, spleen, bone, and brain. (i.e. bacteremia).  Miliary TB can be from hematogenous spread from primary focus, or from reactivation of latent TB. Citation: Sahn S, Neff miliary tuberculosis. The American Journal of Medcine. 1974;56(4):495- 505. doi: https://doi.org/10.1016/0002-9343(74)90482-3
  39. 39. History of Miliary TB  The term “miliary” historically comes from the radiographic finding of 1-2mm nodules scattered among both lung fields.  It was first described over 100 years ago and thought to look like “millet” seeds.  Each “seed” was where the blood had carried the infection and it settled in that area of the lungs.  Think of military TB as bacteremia, and though it often includes the classic CXR findings due to pulmonary involvement (as it was named for), you can have disseminated disease that does not involve the lungs. Citation: Manson, P., Farrar, J., Hotez, P. J., & Junghanss, T. (2014). Tuberculosis. In Manson's tropical diseases. Edinburgh: Saunders Elsevier.
  40. 40. Pulmonary Tuberculosis on CXR Miliary TB is not as easily diagnosed on CXR as findings can be subtle. One study had three chest radiologists review 71 CXRs of known miliary TB patients and identified 59-69% of them. Citation: Kwong JS, Carignan S, Kang EY, Müller NL, and FitzGerald JM: Miliary tuberculosis. Diagnostic accuracy of chest radiography. Chest 1996; 110: pp. 339-342 Findings on CXR • Consolidation • Cavitation • Pleural Effusion • Hilar and Mediastinal Lymphadenopathy • Pneumatocele • Atelectasis • Disseminated Miliary Disease • Empyema • Fibrosis • Upper lobe lesions • Spontaneous pneumothorax • Normal – no findings Citation: Woodring JH, Vandiviere HM, Fried AM, Dillon ML, Williams TD, and Melvin IG: Update: the radiographic features of pulmonary tuberculosis. AJR Am J Roentgenol 1986; 146: pp. 497-506
  41. 41. 42-Year-Old Male With COVID (+) Who Presents With Shortness of Breath
  42. 42. 42-Year-Old Male With COVID (+) Who Presents With Shortness of Breath Diagnosis: Left Spontaneous Pneumothorax With Bilateral Opacities
  43. 43. Diagnosis: Left Spontaneous Pneumothorax With Bilateral Opacities Also: Notice The Subcutaneous Emphysema On The Right And In The Neck Bilaterally (Despite This Being A Left Sided Pneumothorax) Notice The lack Of Lung Markings. 42-Year-Old Male With COVID (+) Who Presents With Shortness of Breath
  44. 44. Notice the Interval Change of the Lung Markings As The Pneumothorax Is Worsening
  45. 45. Now Intubated With Left-Sided Chest Tube 42-Year-Old Male With COVID (+) Who Presents With Shortness of Breath
  46. 46. 55-Year-Old Male Presents With Dyspnea And Chest Pain
  47. 47. 55-Year-Old Male Presents With Dyspnea And Chest Pain Diagnosis: Diaphragmatic Hernia
  48. 48. Notice the NG Tube Location Diagnosis: Diaphragmatic Hernia
  49. 49. Summary Of Diagnoses This Month  Traumatic Pneumothorax  Non-Cardiogenic Edema  COVID-19  Right Lower Lobe Pneumonia  Diaphragmatic Hernia  Asbestosis Exposure  Lung Abscess in COVID (+)  Miliary Tuberculosis  Spontaneous Pneumothorax in COVID (+)
  50. 50. See You Next Month!

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