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EMGuideWire's Radiology Reading Room: Acute Chest Syndrome

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EMGuideWire's Radiology Reading Room: Acute Chest Syndrome

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The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Acute Chest Syndrome and is brought to you by Gabriela Rivera Camacho, MD and Mark Kastner, MD. It is has special guest editors: Ifeyinwa Osunkwo, MD and Padmaja Veeramreddy, MD

The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Acute Chest Syndrome and is brought to you by Gabriela Rivera Camacho, MD and Mark Kastner, MD. It is has special guest editors: Ifeyinwa Osunkwo, MD and Padmaja Veeramreddy, MD

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EMGuideWire's Radiology Reading Room: Acute Chest Syndrome

  1. 1. Acute Chest Syndrome Gabriela Rivera Camacho, MD & Mark Kastner, MD Departments of Emergency Medicine & Hematology Carolinas Medical Center & Levine Cancer Institute Charlotte, North Carolina Michael Gibbs, MD Chest X-Ray Mastery Project™ Lead Editor Ify Osunkwo, MD Padmaja Veeramreddy, MD Guest Editors
  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 all ages have been changed to protect patient confidentiality.
  3. 3. Process • Many of the provided clinical cases and presentations are then shared with all contributors on our departmental educational website. • Contributors from many Carolinas Medical Center departments, and now… Brazil, Chile, and Tanzania. • We will review a series of CXR case studies and discuss an approach to the diagnoses at hand: ACUTE CHEST SYNDROME.
  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. 25-Year-Old With A History Of Sickle Cell Disease Presents With Severe Back And Bilateral Leg Pain. Hospital Day 1 Afebrile And Vital Signs Are Normal.
  8. 8. What Is Your Interpretation? 25-Year-Old With A History Of Sickle Cell Disease Presents With Severe Back And Bilateral Leg Pain. Hospital Day 3 Now Febrile, Dyspneic, Tachypneic And Tachycardic.
  9. 9. 25-Year-Old With A History Of Sickle Cell Disease Presents With Severe Back And Bilateral Leg Pain. Hospital Day 3 Now Febrile, Dyspneic, Tachypneic And Tachycardic. Acute Chest Syndrome
  10. 10. 25-Year-Old With A History Of Sickle Cell Disease Presents With Severe Back And Bilateral Leg Pain. Hospital Day 3 Now Febrile, Dyspneic, Tachypneic And Tachycardic. Acute Chest Syndrome
  11. 11. 25-Year-Old With A History Of Sickle Cell Disease Presents With Severe Back And Bilateral Leg Pain. Hospital Day 3 Now Febrile, Dyspneic, Tachypneic And Tachycardic. Acute Chest Syndrome
  12. 12. Side Notes: 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. Also, recall that resolution of CXR findings may lag behind clinical improvement. 25-Year-Old With A History Of Sickle Cell Disease Presents With Severe Back And Bilateral Leg Pain. Hospital Day 5 Clinically Improved After Exchange Transfusion. Acute Chest Syndrome
  13. 13. 25-Year-Old With A History Of Sickle Cell Disease Develops Acute Chest Syndrome. Follow-Up CXR One Month Later.
  14. 14. 35-Year-Old With A History Of Sickle Cell Disease presents Admitted For Refractory Bilateral Leg Pain. CXR On Admission.
  15. 15. 35-Year-Old With A History Of Sickle Cell Disease presents Admitted For Refractory Bilateral Leg Pain. Worsening Dyspnea Three Days Later. What Is Your Interpretation?
  16. 16. 35-Year-Old With A History Of Sickle Cell Disease presents Admitted For Refractory Bilateral Leg Pain. Worsening Dyspnea Three Days Later. Acute Chest Syndrome
  17. 17. 35-year-old with a history of Sickle Cell Disease Develops Acute Chest Syndrome.
  18. 18. 35-Year-Old With A History Of Sickle Cell Disease Hospitalized For Acute Chest Syndrome. Follow-Up CXR Three Months Later.
  19. 19. 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 of ICU admission and premature death in patients with sickle cell disease. Gladwin M. New England Journal of Medicine 2008; 359:2254-65.
  20. 20. Acute Chest Syndrome Three proposed mechanisms:  Pulmonary infection  Bronchoalveolar lavage demonstrates bacterial and/or viral pathogens in 54% of patients with ACS.  Embolization of bone marrow fat  Associated with pain crisis of multiple bones, particularly the lumbar spine, femurs and the pelvis.  Pulmonary intravascular sickling and infarction  In a small percentage of patients with ACS, wedge-shaped pulmonary infarcts may develop. Gladwin M. New England Journal of Medicine 2008; 359:2254-65.
  21. 21. 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.
  22. 22. 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
  23. 23. 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
  24. 24. Acute Chest Syndrome ED Transfusion Caveats:  If the patient worsens, start simple transfusion early  2-4 units of PRBC on the way to the ICU  Ramping up exchange transfusion takes time… don’t delay simple transfusion waiting for this
  25. 25. American Society of Hematology Hematology 2016
  26. 26. American Society of Hematology Hematology 2016
  27. 27. RCE = Red Cell Exchange American Society of Hematology Hematology 2016
  28. 28. If you have interesting cases of Acute Chest Syndrome, we invite you to send a set of digital PDF images and a brief descriptive clinical history to: michael.gibbs@atriumhealth.org Your de-identified case(s) will be posted on our education website and you and your institution will be recognized!

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