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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
CMC X-Ray Mastery Series
February 25th 2019
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.
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 be distributed next week.
 The 1st image will show a chest X-ray without identifiers and the 2nd image
will reveal the diagnoses.
It’s All About The Anatomy!
Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum
Before Now
33 With A Complex Malignancy Now Presents With Dyspnea
Before Now
33 With A Complex Malignancy Now Presents With Dyspnea
The Cardiac
Silhouette Now
Looks Bigger And
More Globular
33 With A Complex Malignancy Now Presents With Dyspnea
ED Bedside Ultrasound: Pericardial Effusion
*
*
*
*
78 Year-Old With
HPTN, Atrial
Fibrillation Presents
With Dyspnea.
Before Now
78 Year Old With HPTN & Afib Presents With Dyspnea
Before Now
78 Year Old With HPTN & Afib Presents With Dyspnea
The Cardiac
Silhouette Now
Looks Bigger And
More Globular
78 Year-Old With
HPTN, Atrial
Fibrillation Presents
With Dyspnea.
*
*
*
*
*
*
A Chest CT Obtained To Rule Out
Pulmonary Embolus Instead Reveals
A Large Pericardial Effusion.
On Presentation
78 Year Old With HPTN & Afib Presents With Dyspnea
Pericardiocentesis
 300 cc of fluid removed
 Cardiac silhouette smaller
Post-Procedure
Thoughts On Pericardial Effusions
• Think about the possibility of a pericardial effusion in patients with
chest pain, dyspnea, syncope or pre-syncope.
• Slowly accumulating pericardial effusions stretch the pericardium and
enlarge the cardiac silhouette on CXR. A careful comparison with old
CXRs is helpful.
• Rapidly accumulating pericardial effusions (e.g.: stab wounds, blunt
trauma) typically ARE NOT associated with cardiac silhouette
enlargement on CXR
• The liberal use of bedside point-of-care ultrasound is diagnostic
33 Year-Old In A Roll
Over Motor Vehicle
Crash.
33 Year-Old In A Roll
Over Motor Vehicle
Crash.
Deep Sulcus
Sign
Deep Sulcus
Sign
Bilateral Pneumothoraces
56 Year Old Ventilated ICU Patient Who Develops Acute Hypoxia
56 Year Old Ventilated ICU Patient Who Develops Acute Hypoxia
Pneumothorax: Subpulmonic & Along The Medial Pleural Reflection
Dr. Michael Gibbs's CMC X-Ray Mastery Project - Week #3 Cases
Spontaneous Pneumothorax
41 Year-Old With
Marfan Syndrome
Presents With Chest
Pain
41 Year-Old With
Marfan Syndrome
Presents With Chest
Pain
Thoracic Aneurysm & Chronic Type-B Aortic Dissection
41 Year-Old With
Marfan Syndrome.
Thoracic Aneurysm & Chronic Type-B Aortic Dissection
63 Year-Old With
Metastatic Breast
Cancer
63 Year-Old With
Metastatic Breast
Cancer
Malignant Left Pleural Effusion
60 Year-Old With
Metastatic Ovarian
Cancer
60 Year-Old With
Metastatic Ovarian
Cancer
Metastases To RUL + Bilateral Malignant Left Pleural Effusions
Dr. Michael Gibbs's CMC X-Ray Mastery Project - Week #3 Cases
Cardiomegaly From Longstanding HPTN
51 Year-Old With
HPTN And Severe
Heart Failure In The
Dickson Heart Unit
51 Year-Old With
HPTN And Severe
Heart Failure In The
Dickson Heart Unit
Swan Ganz
Catheter
Left
Subclavian
Central Line
Cardiomegaly From Longstanding HPTN
5 Year-Old With
Fever, Cough And
Tachypnea
5 Year-Old With
Fever, Cough And
Tachypnea
RUL Collapse + RLL Necrotizing Pneumonia
5 Year-Old With Fever, Cough And Tachypnea
RUL Collapse + RLL Necrotizing Pneumonia
81 Year-Old With
Cough And Fever
81 Year-Old With
Cough And Fever
RUL Density
81 Year-Old With
Cough And Fever
Chest CT Suggests Bronchogenic Carcinoma
Summary Of Diagnoses This Week
• Pericardial effusions
• Various spontaneous and traumatic pneumothoraces
• Marfan syndrome: thoracic aneurysm + chronic Type-B aortic dissection
• Malignant pleural effusion
• Pulmonary metastatic disease
• Cardiomegaly
• Necrotizing pneumonia
• Bronchogenic carcinoma
See You Next Week!

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Dr. Michael Gibbs's CMC X-Ray Mastery Project - Week #3 Cases

  • 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 CMC X-Ray Mastery Series February 25th 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 be distributed next week.  The 1st image will show a chest X-ray without identifiers and the 2nd image will reveal the diagnoses.
  • 4. It’s All About The Anatomy!
  • 6. Before Now 33 With A Complex Malignancy Now Presents With Dyspnea
  • 7. Before Now 33 With A Complex Malignancy Now Presents With Dyspnea The Cardiac Silhouette Now Looks Bigger And More Globular
  • 8. 33 With A Complex Malignancy Now Presents With Dyspnea ED Bedside Ultrasound: Pericardial Effusion * * * *
  • 9. 78 Year-Old With HPTN, Atrial Fibrillation Presents With Dyspnea.
  • 10. Before Now 78 Year Old With HPTN & Afib Presents With Dyspnea
  • 11. Before Now 78 Year Old With HPTN & Afib Presents With Dyspnea The Cardiac Silhouette Now Looks Bigger And More Globular
  • 12. 78 Year-Old With HPTN, Atrial Fibrillation Presents With Dyspnea. * * * * * * A Chest CT Obtained To Rule Out Pulmonary Embolus Instead Reveals A Large Pericardial Effusion.
  • 13. On Presentation 78 Year Old With HPTN & Afib Presents With Dyspnea Pericardiocentesis  300 cc of fluid removed  Cardiac silhouette smaller Post-Procedure
  • 14. Thoughts On Pericardial Effusions • Think about the possibility of a pericardial effusion in patients with chest pain, dyspnea, syncope or pre-syncope. • Slowly accumulating pericardial effusions stretch the pericardium and enlarge the cardiac silhouette on CXR. A careful comparison with old CXRs is helpful. • Rapidly accumulating pericardial effusions (e.g.: stab wounds, blunt trauma) typically ARE NOT associated with cardiac silhouette enlargement on CXR • The liberal use of bedside point-of-care ultrasound is diagnostic
  • 15. 33 Year-Old In A Roll Over Motor Vehicle Crash.
  • 16. 33 Year-Old In A Roll Over Motor Vehicle Crash. Deep Sulcus Sign Deep Sulcus Sign Bilateral Pneumothoraces
  • 17. 56 Year Old Ventilated ICU Patient Who Develops Acute Hypoxia
  • 18. 56 Year Old Ventilated ICU Patient Who Develops Acute Hypoxia Pneumothorax: Subpulmonic & Along The Medial Pleural Reflection
  • 21. 41 Year-Old With Marfan Syndrome Presents With Chest Pain
  • 22. 41 Year-Old With Marfan Syndrome Presents With Chest Pain Thoracic Aneurysm & Chronic Type-B Aortic Dissection
  • 23. 41 Year-Old With Marfan Syndrome. Thoracic Aneurysm & Chronic Type-B Aortic Dissection
  • 25. 63 Year-Old With Metastatic Breast Cancer Malignant Left Pleural Effusion
  • 26. 60 Year-Old With Metastatic Ovarian Cancer
  • 27. 60 Year-Old With Metastatic Ovarian Cancer Metastases To RUL + Bilateral Malignant Left Pleural Effusions
  • 30. 51 Year-Old With HPTN And Severe Heart Failure In The Dickson Heart Unit
  • 31. 51 Year-Old With HPTN And Severe Heart Failure In The Dickson Heart Unit Swan Ganz Catheter Left Subclavian Central Line Cardiomegaly From Longstanding HPTN
  • 32. 5 Year-Old With Fever, Cough And Tachypnea
  • 33. 5 Year-Old With Fever, Cough And Tachypnea RUL Collapse + RLL Necrotizing Pneumonia
  • 34. 5 Year-Old With Fever, Cough And Tachypnea RUL Collapse + RLL Necrotizing Pneumonia
  • 36. 81 Year-Old With Cough And Fever RUL Density
  • 37. 81 Year-Old With Cough And Fever Chest CT Suggests Bronchogenic Carcinoma
  • 38. Summary Of Diagnoses This Week • Pericardial effusions • Various spontaneous and traumatic pneumothoraces • Marfan syndrome: thoracic aneurysm + chronic Type-B aortic dissection • Malignant pleural effusion • Pulmonary metastatic disease • Cardiomegaly • Necrotizing pneumonia • Bronchogenic carcinoma
  • 39. See You Next Week!