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Drs. Milam and Thomas's CMC X-Ray Mastery Project: November 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: Pericardial Effusion, Vaping Lung Injury, Cavitary Pulmonary Abscess, Esophageal Foreign Body, Dilated Cardiomyopathy, Acute Aortic Dissection, Pneumomediastinum, Massive Pneumoperitoneum, Malignant Pleuarl Effusion, Right Sided Aortic Arch, RLL pneumonia

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Drs. Milam and Thomas's CMC X-Ray Mastery Project: November 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 November 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 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. 8 Months Ago Today 27 Year Old Male With ESRD On Hemodialysis Presents With Two Weeks Of Dyspnea
  8. 8. 27 Year Old Male With ESRD On Hemodialysis Presents With Two Weeks Of Progressive Dyspnea Massive Pericardial Effusion
  9. 9. Massive Pericardial Effusion 27 Year Old Male With ESRD On Hemodialysis Presents With Two Weeks Of Dyspnea
  10. 10. Massive Pericardial Effusion * * * * ** * * * * 27 Year Old Male With ESRD On Hemodialysis Presents With Two Weeks Of Dyspnea
  11. 11. 27 Year Old Male With ESRD On Hemodialysis Presents With Two Weeks Of Progressive Dyspnea Pericardial Drain In Place 2.7 Liters Of Fluid Removed!
  12. 12. 37 Year Old Being Treated For Pneumonia. History Of Vaping.
  13. 13. 37 Year Old Being Treated For Pneumonia. History Of Vaping.
  14. 14. Butt Y, Smith M, Tazelarr H, Vaszar L, Swanson K, Cecchini M, Boland J, Bois M, Boyum J, Froemming A, Khror A, Mira-Avdndanno I, Patel A, Larsen B.
  15. 15. What We Know About the Outbreak: As of October 22, 2019, 1,604* cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have been reported to CDC from 49 states (all except Alaska), the District of Columbia, and 1 U.S. territory. Thirty-four deaths have been confirmed in 24 states
  16. 16. Georgia (2), Illinois (2), Indiana (3), Kansas (2), Massachusetts, Michigan, Minnesota (3), Mississippi, Missouri, Montana, Nebraska, New Jersey, New York, Oregon (2), Pennsylvania, Tennessee, Texas, Utah, and Virginia. More deaths are under investigation. The median age of deceased patients was 49 years and ranged from 17 to 75 years. Among 1,358 patients with data on age and sex (as of October 15, 2019)(as of October 15, 2019): 70% of patients are male. The median age of patients is 23 years and ages range from 13 to 75 years. 79% of patients are under 35 years old. By age group category: 15% of patients are under 18 years old; 21% of patients are 18 to 20 years old; 18% of patients are 21 to 24 years old; 25% of patients are 25 to 34 years old; and 21% of patients are 35 years or older. Among 849 patients with information on substances used in e-cigarette, or vaping, products in the 3 months prior to symptom onset* * (as of October 15, 2019)(as of October 15, 2019): About 78% reported using THC-containing products; 31% reported exclusive use of THC-containing products. Latest Outbreak Information Updated every Thursday This complex investigation spans almost all states, involves over a thousand patients, and a wide variety of brands and substances and e-cigarette, or vaping, products. Case counts continue to increase and new cases are being reported, which makes it more difficult to determine the cause or causes of this outbreak. As of October 22, 2019, 1,604* cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have been reported to CDC from 49 states (all except Alaska), the District of Columbia, and 1 U.S. territory. Thirty-four deaths have been confirmed in 24 states: Alabama, California (3), Connecticut, Delaware, Florida, Georgia (2), Illinois (2), Indiana (3), Kansas (2), Massachusetts, Michigan, Minnesota (3), Mississippi, Missouri, Montana, Nebraska, New Jersey, New York, Oregon (2), Pennsylvania, Tennessee, Texas, Utah, and Virginia. More deaths are under investigation. The median age of deceased patients was 49 years and ranged from 17 to 75 years. Among 1,358 patients with data on age and sex (as of October 15, 2019)(as of October 15, 2019): 70% of patients are male. The median age of patients is 23 years and ages range from 13 to 75 years. 79% of patients are under 35 years old. By age group category:
  17. 17. 65 Year Old With COPD Presents With Cough And Fever
  18. 18. 65 Year Old With COPD Presents With Cough And Fever What Is This?
  19. 19. 65 Year Old With COPD Presents With Cough And Fever Pulmonary Abscess
  20. 20. Adults Swallow Things To!
  21. 21. 30 Year Old With A History Of HPTN Presents With Dyspnea
  22. 22. 30 Year Old With A History Of HPTN Presents With Dyspnea Cardiomegaly
  23. 23. 44 Year Old With A History Of HPTN And Presents With Acute Chest Back And Abdominal Pain Today One Year Ago
  24. 24. 44 Year Old With A History Of HPTN And Presents With Acute Chest Back And Abdominal Pain Type A Dissection
  25. 25. 44 Year Old With A History Of HPTN And Presents With Acute Chest Back And Abdominal Pain Type A Dissection
  26. 26. 44 Year Old With A History Of HPTN And Presents With Acute Chest Back And Abdominal Pain Type A Dissection: Hemopericardium
  27. 27. 44 Year Old With A History Of HPTN And Presents With Acute Chest Back And Abdominal Pain Type A Dissection: Hemopericardium * * * * *
  28. 28. TYPE A TYPE B
  29. 29. Branch Vessel Compromise Myocardial infarction Stroke Spinal cord infarction Mesenteric and renal ischemia Limb ischemia
  30. 30. Chest Pain Back Pain Stroke Symptoms Paraplegia Acute Abdomen Renal Failure Aortic Dissection? Paretic Extremity
  31. 31. Type A Dissections Acute aortic insufficiency Acute pulmonary edema Pericardial tamponade Acute myocardial infarction
  32. 32. Type A Dissections
  33. 33. Aortic Dissection?
  34. 34. Chest Pain Back Pain Acute CHF New AI Murmur Syncope Aortic Dissection?
  35. 35. Acute Aortic Dissections are challenging to diagnose and treat
  36. 36. 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
  37. 37. 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
  38. 38. 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%
  39. 39. 25 Year Old With Repeated Episodes Of Vomiting
  40. 40. 25 Year Old With Repeated Episodes Of Vomiting Pneumomediastinum
  41. 41. 25 Year Old With Repeated Episodes Of Vomiting Pneumomediastinum
  42. 42. 69 Year Old Fever And Right Upper Quadrant Abdominal Pain & No Pulmonary Symptoms
  43. 43. RLL Pneumonia 69 Year Old Fever And Right Upper Quadrant Abdominal Pain & No Pulmonary Symptoms
  44. 44. 23 Year Old Male Being Evaluated After A Car Crash
  45. 45. 23 Year Old Male Being Evaluated After A Car Crash Wide Mediastinum
  46. 46. 23 Year Old Male Being Evaluated After A Car Crash Wide Mediastinum Is There An Aortic Injury?
  47. 47. Not Today! Our Patient Has A Right-Sided Aortic Arch.
  48. 48. Not Today! Our Patient Has A Right-Sided Aortic Arch.
  49. 49. Right Sided Aortic Arch • Rare congenital anomaly: 0.05% - 0.1% of radiology/autopsy series • Several proposed classification schemes based on the arrangement of arch vessels, relationship with the esophagus, and the presence or absence of congenital heart disorders • Asymptomatic in the majority of patients • Clinical manifestations are uncommon, and these are caused by: Tracheal Compression: Typically seen in children Esophageal Compression: Typically seen in older adults
  50. 50. 65 Year Old With Presenting In Shock With Severe Abdominal Pain
  51. 51. 65 Year Old With Presenting In Shock With Severe Abdominal Pain Colonic Perforation With Pneumoperitoneum
  52. 52. 68 Year Old With A History Of Breast Cancer Presents With Dyspnea Today One Year Ago
  53. 53. 68 Year Old With A History Of Breast Cancer Presents With Dyspnea Malignant Pleural Effusion
  54. 54. 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.
  55. 55. 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
  56. 56. Right Parapneumonic Effusion
  57. 57. 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
  58. 58. Lung Mass With Malignant Effusion
  59. 59. Lung Mass After Effusion Drainage
  60. 60. Summary Of Diagnoses This Month  Pericardial effusion  E-cigarette associated pneumonitis  Cavitary pulmonary abscess  Fork in the esophagus  Dilated cardiomyopathy  Acute aortic dissection  Pneumomediastinum  RLL pneumonia presenting as abdominal pain  Right-sided aortic arch • Massive pneumoperitoneum • Malignant pleural effusion
  61. 61. See You Next Month!

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