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EMGuideWire's Radiology Reading Room: COVID 19 Chest X-rays Update

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EMGuideWire's Radiology Reading Room: COVID 19 Chest X-rays Update

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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 COVID-19 infections as represented on Chest Radiography. It is brought to you by Nikki Richardson, MD, Claire Milam, MD, Alyssa Thomas, MD, and Shelby Hixson, PA. It has special guest editor, Infectious Disease Specialist, Catherine Passeretti, MD. In addition, this update also includes another special guest editor, Radiologist, Dr. Johnathan Clemente, 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 COVID-19 infections as represented on Chest Radiography. It is brought to you by Nikki Richardson, MD, Claire Milam, MD, Alyssa Thomas, MD, and Shelby Hixson, PA. It has special guest editor, Infectious Disease Specialist, Catherine Passeretti, MD. In addition, this update also includes another special guest editor, Radiologist, Dr. Johnathan Clemente, MD.

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EMGuideWire's Radiology Reading Room: COVID 19 Chest X-rays Update

  1. 1. COVID-19 Chest X-Ray Cases Shelby Hixson, PA; Claire Milam, MD; Nikki Richardson, MD; Alyssa Thomas, MD Department of Emergency Medicine Carolinas Medical Center & Levine Children’s Hospital Michael Gibbs, MD: Lead Editor Chest X-Ray Mastery Project™ Johnathan Clemente, MD Charlotte Radiology Guest Editor Catherine Passaretti, MD CMC Infectious Disease Guest Editor
  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 are providing 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: COVID-19 Case Studies.
  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. COVID-19 Case Studies From Carolinas Medical Center & Levine Children’s Hospital
  8. 8. Healthy 35- Year Old One Week Of Dyspnea, Subjective Fever And Loose Stools. He Is Treated For Pneumonia And Swabbed For COVID.
  9. 9. He Presents To The ED Three Days Later In Severe Respiratory Distress. COVID [+].
  10. 10. Healthy 42- Year Presents In Severe Respiratory Distress And Severe Hypoxemia. COVID [+] Two Days Ago. Intubated Upon Arrival To The ED.
  11. 11. Healthy 42- Year Presents In Severe Respiratory Distress And Severe Hypoxemia. COVID [+] 72 Hours Ago.
  12. 12. Healthy 55- Year-Old Is Evaluated For A Cough. His Chest X- Ray Is Normal. COVID Testing [+].
  13. 13. Our Patients Presents To The ED Three Days Later In Respiratory Distress.
  14. 14. 78-Year-Old With Cough, Dyspnea, And Fever. Day Of Admission.
  15. 15. 78-Year-Old With Cough, Dyspnea, And Fever. Hospital Day 3.
  16. 16. 78-Year-Old With Cough, Dyspnea, And Fever. Hospital Day 5.
  17. 17. 78-Year-Old With Cough, Dyspnea, And Fever. Hospital Day 7.
  18. 18. 75-Year-Old With Cough, Dyspnea, And Fever PCP’s Office. Swabbed For COVID-19
  19. 19. 75-Year-Old Now Presents To The ED Two Days Later. Worsening Dyspnea And Hypoxia.
  20. 20. 75-Year-Old Now Presents To The ED Two Days Later. Worsening Dyspnea And Hypoxia.
  21. 21. 75-Year-Old With Progressive Respiratory Failure. Hospital Day 3.
  22. 22. 75-Year-Old With Progressive Respiratory Failure. Hospital Day 5.
  23. 23. 23-Year-Old With A History Of Sickle Cell Disease Presents With Cough, Dyspnea And Fever. Day Of Admission.
  24. 24. 23-Year-Old With A History Of Sickle Cell Disease Presents With Cough, Dyspnea And Fever. Hospital Day 2.
  25. 25. 23-Year-Old With A History Of Sickle Cell Disease Presents With Cough, Dyspnea And Fever. Hospital Day 5.
  26. 26. 23-Year-Old With A History Of Sickle Cell Disease Presents With Cough, Dyspnea And Fever. Hospital Day 10.
  27. 27. 35-Year-Old With Cough And Fever. Day Of Admission.
  28. 28. 35-Year-Old With Cough And Fever. Hospital Day 2.
  29. 29. 35-Year-Old With Cough And Fever. Hospital Day 3.
  30. 30. 35-Year-Old With Cough And Fever. Hospital Day 5.
  31. 31. 17-Year-Old presented with fever, chest pain and body aches. Dx: COVID with wedge shaped pneumonia
  32. 32. 4-year-old with history of transposition of the great arteries presents with wheezing and respiratory distress. Dx: COVID with worsening heart failure
  33. 33. 10-year-old with history of recent URI illness in the entire family presents in acute respiratory failure. Dx: ARDS secondary to multisystem inflammatory syndrome in children (MIS-C)
  34. 34. 14-year-old with no medical history presents with shortness of breath and hypoxia in the setting of known COVID-19 exposure. Day of Admission
  35. 35. 14-year-old with no medical history presents with shortness of breath and hypoxia in the setting of known COVID-19 exposure. Hospital Day 2
  36. 36. 14-year-old with no medical history presents with shortness of breath and hypoxia in the setting of known COVID-19 exposure. Hospital Day 3
  37. 37. 14-year-old with no medical history presents with shortness of breath and hypoxia in the setting of known COVID-19 exposure. Hospital Day 4
  38. 38. 14-year-old with no medical history presents with shortness of breath and hypoxia in the setting of known COVID-19 exposure. Thoracostomy Pneumothorax Air Bronchograms Consolidation Ground Glass Hospital Day 7
  39. 39. What Are The Key Chest Imaging Findings In Patients With COVID-19?
  40. 40. Chest Imaging Findings In Patients With COVID-19 [n=1099] Findings Total Non-Severe (926) Severe (173) Ground Glass Opacity 56% 56% 60% Local Patchy Shadowing 42% 39% 55% Bilateral Patchy Shadowing 52% 45% 82% Interstitial Abnormality 15% 12% 26%
  41. 41. Chest Imaging Findings In 24 ICU Patients With COVID-19 Plain Film Chest X-Ray Clear 0/23 Bilateral Infiltrates 23/23 Pleural Effusion 0/23 Computed Tomography Clear 4/5 [80%] Bilateral Infiltrates 1/5 [20%] Pleural Effusion 0/5
  42. 42. What Are The Guidelines For Chest Imaging In Patients With Suspected And Proven COVID-19?
  43. 43. R1 For asymptomatic contacts of patients with COVID-19, WHO suggests not using chest imaging for the diagnosis of COVID-19. [Use RT-PCR to confirm diagnosis]. R2.1 For symptomatic patients with suspected COVID-19, WHO suggests not using chest imaging for the diagnostic workup of COVID-19 when RT-PCR testing is available with timely results. R2.2 For symptomatic patients with suspected COVID-19, WHO suggests that using chest imaging for the diagnostic work-up COVID-19 when: • RT-PCR testing is not available; • RT-PCR testing is available, but results will be delayed; • Initial RT-PCR testing is negative, but there is high clinical suspicion for COVID-19 R3 For patients with suspected or confirmed COVID-19, not currently hospitalized and with mild symptoms, WHO suggests using chest imaging in addition to clinical and laboratory assessment to decide on hospital admission versus home discharge.
  44. 44. R4 For patients with suspected or confirmed COVID-19, not currently hospitalized and with moderate to severe symptoms, WHO suggests using chest imaging in addition to clinical and laboratory assessment to decide on regular ward admission versus intensive care unit admission. R5 For patients with suspected or confirmed COVID-19, currently hospitalized and with moderate to severe symptoms, WHO suggests using chest imaging in addition clinical and laboratory assessment to inform the therapeutic management. R6 For hospitalized patient with COVID-19 whose symptoms are resolving, WHO suggests not using chest imaging in additional to clinical and/or laboratory assessment to inform the decision regarding discharge.
  45. 45. If you have interesting cases of COVID-19 pneumonia, 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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