Drs. Claire Milam, Alyssa Thomas, Breeanna Lorenzen, and Travis Barlock 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 educational, self-guided radiology slides. This set will cover: • Diaphragmatic Injury • Malignant Pleural Effusion • Subcutaneous Emphysema • Tension Pneumothorax • Pulmonary Contusion • Complete Lung Consolidation • Tuberculosis

1. Adult Chest X-Rays Of The Month
Alyssa Thomas, MD & Claire Milam, MD
Travis Barlock, MD & Breeanna Lorenzen, MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs MD, Faculty Editor
CMC Imaging Mastery Project™
August 2020

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. 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. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Chest X-Ray Presentations And Much More!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. It’s All About The Anatomy!

7. 45-Year-Old
Restrained
Driver In A
Vehicle That
Was T-Boned
At A High Rate
Of Speed.

8. 45-Year-Old
Restrained
Driver In A
Vehicle That
Was T-Boned
At A High Rate
Of Speed.
Diagnosis: Diaphragmatic Rupture
Elevated
Hemidiaphragm

9. 45-Year-Old
Restrained
Driver In A
Vehicle That
Was T-Boned
At A High Rate
Of Speed.
Herniating
Viscera Between
Ribs 7 & 8

10. 60-Year-Old In
A Motor
Vehicle Crash.

11. Elevated
Hemidiaphragm
Diagnosis: Diaphragmatic Rupture
60-Year-Old In
A Motor
Vehicle Crash.

12. 60-Year-Old In A Motor Vehicle Crash
Diagnosis: Diaphragmatic Rupture

13. 45-Year-Old
Male Involved
In A Roll-Over
Car Crash.
Intubated In
The Field.

14. 45-Year-Old
Male Involved
In A Roll-Over
Car Crash.
Intubated In
The Field.
Elevated
Hemidiaphragm
Rib Fracture
Diagnosis: Diaphragmatic Rupture

15. 45-Year-Old Male Involved In
A Roll-Over Car Crash
Intubated In The Field.
Diagnosis: Diaphragmatic Rupture

16. 45-Year-Old
Male With
Rupture Of The
Left
Diaphragm.
Chest X-Ray After Repair

17. 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.

19. 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.

20. 78-Year-Old
Female with
History of
Cancer
Presents with
Shortness of
Breath.

21. 78-Year-Old
Female with
History of
Cancer
Presents with
Shortness of
Breath.
Diagnosis: Malignant Pleural Effusion
Notice Blunting of
The Costophrenic
Angle Rather than
Elevation.

22. • MPE is a complication of a number of cancers, most commonly lung, followed
by breast, lymphoma, gynecological malignancies, and mesothelioma.
• It is estimated to affect 150,000 people each year in the US and over 100,000
people in Europe.
• Lung and breast cancer comprise between 50-65% of malignant effusions.
• Between 7-11% occur in unknown primary malignancy.
Penz E. Cancer Management and Research 2017; 9: 229-241

24. 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.

27. 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

28. Right Parapneumonic Effusion

30. 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

31. Lung Mass With Malignant Effusion

32. Lung Mass After Effusion Drainage

34. 54-Year-Old
Ventilated
Patient
Develops
Hypoxia
Acutely.

35. 54-Year-Old
Ventilated
Patient
Develops
Hypoxia
Acutely.
Free Air
Free Air
Free AirEndotracheal
Tube
Bilateral Infiltrates
Diagnosis: ARDS, Pneumomediastinum, Subcutaneous Emphysema

36. 25-Year-Old
Male with
Chest Pain
After Blunt
Trauma.

37. 25-Year-Old
Male with
Chest Pain
After Blunt
Trauma.
Tracheal
Deviation
Subcutaneous
Air
Lung
Markings
Diagnosis: Tension Pneumothorax

38. Immediately
After Chest
Tube
Placement
25-Year-Old
Male with
Chest Pain
After Blunt
Trauma.

39. 25-Year-Old
Male with Chest
Pain After Blunt
Trauma.
Chest Tube
Placed.
Day 2 of
Hospitalization.

40. 33-Year-Old In A
Roll Over Motor
Vehicle Crash.

41. 33-Year-Old In A
Roll Over Motor
Vehicle Crash.
Deep Sulcus
Sign
Deep Sulcus
Sign
Bilateral Tension Pneumothorax

42. 35-Year-Old Male
In A High-Speed
Car Crash.

43. 35-Year-Old Male
In A High-Speed
Car Crash.
Deep Sulcus
Sign
Tension Pneumothorax With Shift

44. Middle Aged
Adult with
Chest Pain
And
Hypotension
After Motor
Vehicle
Collision.

45. Middle Aged
Adult with
Chest Pain
And
Hypotension
After Motor
Vehicle
Collision.
Diagnosis: Pulmonary Contusion

46. Chest CT
of Same
Patient.

47. Contrast
Extravasation
Consolidation
Chest CT
of Same
Patient.

48. Diagnosis: Periaortic Hematoma & Pulmonary Contusion

50. EAST Guidelines For The Management Of Pulmonary Contusion & Flail Chest
 The use of optimal analgesia and aggressive chest physiotherapy should be used to
minimize the risk of respiratory failure.
 A trial of mask CPAP in combination with optimal regional anesthesia, should be
considered in alert, compliant patients with marginal respiratory status.
 Epidural catheter is the preferred method of analgesia delivery.
 Patients should be adequately resuscitated, and hypovolemia should be avoided. When
there are clear signs of hydrostatic fluid overload, diuretics may be used.
 Steroids should not be used in patients with pulmonary contusion.
 For patients requiring mechanical ventilation, PEEP and CPAP should be part in the
ventilatory strategy.

51. 21-Year-Old
Vietnamese
Immigrant
Presents With
Worsening
Shortness of
Breath.

52. 21-Year-Old
Vietnamese
Immigrant
Presents With
Worsening
Shortness of
Breath.
Consolidation
Lung Markings
Shifted
Mediastinum
Diagnosis: Tuberculosis, Complete Lung Consolidation, Pneumothorax

54. Tuberculosis Epidemiology In The U.S. 2017
• In 2017, the incidence of TB in the U.S. (2.8 cases per 100,000) was
the lowest since national surveillance began in 1952.
• The rate of TB among non-U.S.-born persons was 15 times the rate
among U.S.-born persons.
• The top five countries of birth of non-U.S.-born persons with TB were
Mexico (19%), Philippines (12.3%), India (9.4%), Vietnam (8.3%), and
China (6.3%).
• Persons who received a diagnosis of TB ≥10 years after arriving in the
U.S. accounted for 45% of all TB cases among non-U.S. born persons.

55. Tuberculosis Epidemiology In The U.S. 2017
• For those born in the United States, TB incidence was the highest
among Native Hawaiian/Pacific Islanders (5.6 cases per 100 000
persons), followed closely by American Indian/Alaskan Natives (4.0
cases per 100 000 persons).
• Individuals experiencing homelessness accounted for 4.1% of TB
cases, while 3.3% occurred among individuals who were incarcerated,
and 1.6% occurred among residents of long-term care facilities.

58. Background
• Patients with TB risk factors are often cared for at busy urban
hospitals with long wait times and crowded waiting rooms
• The ED is a high-risk area for M. tuberculosis transmission
• Most EDs do not have CDC-compliant TB isolation facilities
• Admitted pneumonia patients with and without TB may have long ED
wait times
• It is desirable to accurately differentiate pneumonia patients at very
low risk for TB from those for whom TB needs to be considered

59. Design
• Prospective case series conducted at 11 (EMERGEncy ID NET) academic
urban EDs with a combined volume of 900,000
• Participants were ED patients admitted with a diagnosis of pneumonia
or suspected TB
• The main outcome measure was derivation and validation of a sensitive
clinical decision instrument to identify patients not having TB (and not
requiring isolation) according to clinical data and chest radiographs

60. Results
• Of 5,079 patients, 224 (4.4%) had pulmonary TB according to sputum
cultures or tissue staining.
• Instrument derived to predict which patient did not have TB:
No TB Or [+] PPD History Nonimmigrant Not Homeless
Not Recently Incarcerated No Recent Weight Loss No Cavitary Or Apical
Infiltrate On Chest X-Ray
NPV: 99.7[95% CI 99.1-99.9] Sensitivity: 96.4 [95% CI 91.9-99.9]

61. Conclusions
• The absence of all decision instrument criteria was highly predictive of
the absence of TB
• The decision instrument is not difficult to apply and it does not expend
additional resources in the ED
• Identifying low-risk patient may help preserve precious isolation beds
for higher risk patients

62. What About The CXR?
*Notice the high RR of TB associated with cavitation and apical infiltrate on CXR!
*
*

63. Punch Line?
• ALWAYS think about TB in your pneumonia patient who:
• Has a prior history of TB and/or a prior [+] PPD
• Is foreign born (see MMWR slides), homeless, and/or recently incarcerated
• Provides a history of non-volitional weight loss
• ALWAYS think about TB in your pneumonia patients with apical
and/or cavitary infiltrates on chest X-ray
When all of these historical and CXR finding are absent you can use a
validated clinical decision instrument to confidently conclude that
your pneumonia patient is not at significant risk for TB, and therefore
will not require respiratory isolation precautions.

64. Summary Of Diagnoses This Month
 Diaphragmatic Injury
 Malignant Pleural Effusion
 Subcutaneous Emphysema
 Tension Pneumothorax
 Periaortic Hematoma
 Pulmonary Contusion
 Complete Lung Consolidation & Tuberculosis

65. See You Next Month!