The document highlights a series of chest x-ray interpretations aimed at improving mastery of radiographic analysis within emergency medicine. It discusses various cases of patients with conditions such as parapneumonic effusion, traumatic aortic disruption, and pneumonia, detailing specific diagnostic findings in their x-rays. A literature review is included, emphasizing the significance of wide mediastinum in diagnosing aortic dissection.

1. Chest X-Rays Of The Week
Michael Gibbs, MD, FACEP, FAAEM
Professor And Chair
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Vice President of Research
Atrium Health
Chest X-Ray Mastery Project
April 1st 2019

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 contributing: Emergency Medicine, Fellows from the Center For
Advanced Practice, Trauma & Acute Care Surgery, SHVI, and Medical
Critical Care. Slides are shared with all contributors.
 Cases submitted this week will be distributed next week.
 When reviewing the presentation, the 1st image will show a chest X-ray
without identifiers and the 2nd image will reveal the diagnosis.

4. It’s All About The Anatomy!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. 13 Month Old
Being Treated For
Pneumonia In
The Setting Of
Recent Influenza
Now With More
Dyspnea

7. 13 Month Old
Being Treated For
Pneumonia In
The Setting Of
Recent Influenza
Now With More
Dyspnea
Parapneumonic Effusion With Shift

8. Parapneumonic Effusion With Shift
500 cc Of
Purulent
Chest Tube
Output
13 Month Old
Being Treated For
Pneumonia In
The Setting Of
Recent Influenza
Now With More
Dyspnea

9. 21 Year Old On A
Motorcycle That
Collided Head-On
With A Car

10. 21 Year Old On A
Motorcycle That
Collided Head-On
With A Car
Wide Mediastinum
And Loss Of The
Aortopulmonary
Window
Traumatic Aortic Disruption

11. 21 Year Old On A Motorcycle That Collided Head-On With A Car
Prior CXR Now
Traumatic Aortic Disruption

12. 21 Year Old On A Motorcycle That Collided Head-On With A Car
Traumatic Aortic Disruption

13. 21 Year Old On A Motorcycle That Collided Head-On With A Car
Traumatic Aortic Disruption

14. 21 Year Old On A Motorcycle That Collided Head-On With A Car
Traumatic Aortic Disruption

15. 21 Year Old On A Motorcycle That Collided Head-On With A Car
Traumatic Aortic Disruption

16. 55 Year Old
Pedestrian Struck

17. 55 Year Old
Pedestrian Struck
Wide Mediastinum
Tracheal Deviation
And Loss Of The
Aortopulmonary
Window
Traumatic Aortic Disruption & Multiple Rib Fractures

18. 55 Year Old Pedestrian Struck

19. 55 Year Old Pedestrian Struck
Traumatic Aortic Disruption

20. 55 Year Old Pedestrian Struck

21. Traumatic Aortic Disruption
Successfully
Deployed TEVAR
55 Year Old Pedestrian Struck

22. 55 Year Old
Pedestrian Struck
Multiple Posterior Rib Fractures

23. 55 Year Old
Pedestrian Struck
Multiple Posterior Rib Fractures
*
*
*
*
*
*
*

24. TAD Chest X-Ray Findings
1. Wide mediastinum
2. Abnormal aortic contour
3. Loss of the aortopulmonary window
4. Tracheal deviation
5. Depressed left mainstem
6. Apical cap
7. Deviated nasogastric tube
8. Widened paratracheal stripe

25. Right Upper Lobe Pneumonia
Cough, Fever, Dyspnea

26. 2 Year Old With
Cough And Fever
Heart Rate 190
Temperature 105

27. 2 Year Old With
Cough And Fever
Heart Rate 190
Temperature 105
Right Upper Lobe Pneumonia

28. 70 Year Old With
Ovarian Cancer
Receiving
Chemotherapy
Presents With
Fever

29. 70 Year Old With
Ovarian Cancer
Receiving
Chemotherapy
Presents With
Fever
Diffuse Pulmonary Metastatic Disease

30. 70 Year Old With
Ovarian Cancer
Receiving
Chemotherapy
Presents With
Fever
Diffuse Pulmonary Metastatic Disease

31. 65 Year Old With
Hypertension
Presents To The
ED With Chest
Pain

32. 65 Year Old With
Hypertension
Presents To The
ED With Chest
Pain
Wide
Mediastinum
Type A Aortic Dissection

33. 65 Year Old With Hypertension Presents With Chest Pain
Type A Aortic Dissection

34. Comprehensive English language MEDLINE literature review from 1966 to 2000. Thirteen studies
permitted the analysis of 1337 chest X-rays.
 90% of patient with aortic dissection had at least one CXR abnormal finding
 The absence of a wide mediastinum had a [-] LR of 0.3 (95% CI: 0.2 – 0.4)

36. The absence of a wide mediastinum on chest X-Ray had a
negative likelihood ratio ranging from 0.14 to 0.60, making
this a finding decreases the risk of aortic dissection
Evidence-based review of nine studies between 1986 and 2013, [n=2,400]. The prevalence or aortic
dissection ranged form 21% to 76%.
2018

37. 2018

38. 80 Year Old
Presenting With
Weakness And
Dyspnea

39. 80 Year Old
Presenting With
Weakness And
Dyspnea
Left Mainstem Obstruction: Neoplasm Vs. Mucous Plug

40. 80 Year Old
Presenting With
Weakness And
Dyspnea
Bronchoscopy Reveal A Mucous Plug

41. Summary Of Diagnoses This Week
• Parapneumonic effusion
• Traumatic aortic disruption
• Right upper lobe pneumonia
• Diffuse pulmonary metastatic disease
• Type A aortic dissection
• Left mainstem bronchus obstruction due to a mucous plug

42. See You Next Week!