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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
March 11th 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!

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“A man was seized with pain of
the right arm and soon after
the left. He was ordered to
think seriously and piously of
his departure from this mortal
life, which was very near at
hand and inevitable.”
J.B. Morgagni, 1761.
“There is no diagnosis more
conducive to clinical humility
than dissection of the aorta.”
Sir William Osler, 1900.
Here’s The
Problem…
We Are Not Very
Good At Making The
Diagnosis
Initial diagnosis correct 15-50%
Diagnosis >24 hours in 40%
Klompas M. JAMA 2002.
Here’s The
Problem…
We Are Not Very
Good At Making The
Diagnosis
When We Miss
The Diagnosis
Patients Die
We Can’t CT Every
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“The International Registry of Acute Aortic
Dissection [IRAD]:
New Insight Into An Old Disease.”
Hagan PG. JAMA 2000, 283:897.
N = 464
12 Centers
IRAD: Demographics
Hagan PG. JAMA 2000.
Male 65.3%
Mean age* 63 years
Type A 62.3%
Hypertension 72.1%
*Type B older, Marfans mean age 36 years
IRAD: Clinical Manifestations
Pain reported in 95.5%:
Chest pain 72.7%
Anterior chest pain 60.9%
Back pain 53.2%
Abdominal pain 29.6%
Hagan PG. JAMA 2000.
IRAD: Clinical Manifestations
Quality of pain:
Abrupt onset 84.4%
‘Worst pain ever’ 90.6%
Sharp 64.4%
Tearing or ripping 50.6%
Radiating 28.3%
Migratory 16.6%
Hagan PG. JAMA 2000.

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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 Angela Pikus, MD, Mark Baumgarten, MD, Andres Gil Bustamante, and Ahmed Mashal, MD. As always, Michael Gibbs, MD serves as the projects editor.

sickle cell diseaseacute chest syndromefever
IRAD: Syncope
• Syncope in 9.4%
• More common with Type A dissection
• Higher risk of tamponade & stroke
Mortality
History of Syncope 34%
Overall 28%
Hagan PG. JAMA 2000.
IRAD: Chest X-Ray
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Wide mediastinum 66.1%
Abnormal aortic contour 49.6%
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Wall Ca++
displacement 14.1%
Normal CXR 12.4%
Hagan PG. JAMA 2000.
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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 Spontaneous Pericardial Effusion and is brought to you by Chelsea Wilson, MD, and Emily Lipsitz, PA-C.

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This document provides a summary of adult chest x-rays reviewed from the Emergency Medicine department. It discusses various cases seen over the past month, including a malignant pleural effusion with lung mass from uterine cancer, pericardial effusions, traumatic aortic disruption from motor vehicle accidents, a case of femoral guidewire migration in an ICU patient, a disconnected HeRO graft in a dialysis patient, and a case of right-sided flail chest and pulmonary contusion from a motor vehicle crash. The document aims to promote mastery of chest x-ray interpretation among emergency medicine residents.

emergency medicineradiologyaortic injury
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acute epidural hematomasneurosurgical emergencyemergency medicine
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radiologyemergency medicineemergency imaging
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medical educationpediatric emergency medicine
Summary Of Diagnoses This Week
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Dr. Michael Gibbs's CMC X-Ray Mastery Project - Week #5 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 March 11th 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. 69 Year Old With Acute Chest And Neck Pain
  • 7. Wide Mediastinum 69 Year Old With Acute Chest And Neck Pain Type A Aortic Dissection.
  • 8. 69 Year Old With Acute Chest & Neck Pain Emergency Department Bedside Ultrasound
  • 9. 69 Year Old With Acute Chest & Neck Pain Dilated Aortic Root Emergency Department Bedside Ultrasound
  • 10. 69 Year Old With Acute Chest & Neck Pain Dilated Aortic Root Emergency Department Bedside Ultrasound Aortic Free Wall
  • 11. Type A Aortic Dissection. 69 Year Old With Acute Chest & Neck Pain
  • 12. 69 Year Old With A History Of Thoracic Aortic Aneurysm
  • 13. 69 Year Old With A History Of Thoracic Aortic Aneurysm Wide Mediastinum Aneurysmal Thoracic Aorta With A Type A Dissection.
  • 14. 69 Year Old With A History Of Thoracic Aortic Aneurysm Aneurysmal Thoracic Aorta With A Type A Dissection.
  • 15. 73 Year Old With A History Of HPTN Develops Acute Chest Radiating To His Back Type A Aortic Dissection.
  • 16. 73 Year Old With A History Of HPTN Develops Acute Chest Radiating To His Back Wide Mediastinum Type A Aortic Dissection.
  • 17. 73 Year Old With Chest Pain Radiation To His Back Type A Aortic Dissection.
  • 18. 73 Year Old With Chest Pain Radiation To His Back Emergency Department Bedside Ultrasound
  • 19. 73 Year Old With Chest Pain Radiation To His Back Emergency Department Bedside Ultrasound Dissection Flap Thoracic Aorta
  • 20. 63 Year Old With Several Days Of Worsening Flank Pain
  • 21. 63 Year Old With Several Days Of Worsening Flank Pain Type B Aortic Dissection. Dissection Flap Ascending Aorta Not Involved
  • 22. 63 Year Old With Several Days Of Worsening Flank Pain Just Below The Diaphragm At The Level Of The Celiac Axis
  • 23. 63 Year Old With Several Days Of Worsening Flank Pain Our Patient: 9 Months Ago. Normal Aortic Arch On CT 9 Months Ago
  • 24. Lot’s Of Aortic Dissections This Week! Here’s Some More Information On The Topic.
  • 25. Aortic Dissection “A man was seized with pain of the right arm and soon after the left. He was ordered to think seriously and piously of his departure from this mortal life, which was very near at hand and inevitable.” J.B. Morgagni, 1761. “There is no diagnosis more conducive to clinical humility than dissection of the aorta.” Sir William Osler, 1900.
  • 26. Here’s The Problem… We Are Not Very Good At Making The Diagnosis Initial diagnosis correct 15-50% Diagnosis >24 hours in 40% Klompas M. JAMA 2002.
  • 27. Here’s The Problem… We Are Not Very Good At Making The Diagnosis When We Miss The Diagnosis Patients Die We Can’t CT Every Patient With Chest Pain Initial diagnosis correct 15-50% Diagnosis >24 hours in 40% Klompas M. JAMA 2002.
  • 29. Aortic Dissection: Risk Factors • Hypertension • Cocaine • Trauma • Pregnancy Iatrogenic • Heart surgery • AVR • Catheterization Congenital • Aortic coarctation • Bicuspid valve • Marfan • Ehlers-Danlos • Turner
  • 30. Branch Vessel Compromise Myocardial infarction Stroke Spinal cord infarction Mesenteric and renal ischemia Limb ischemia
  • 32. Chest Pain Back Pain Stroke Symptoms Paraplegia Acute Abdomen Renal Failure Aortic Dissection? Paretic Extremity
  • 33. Aortic Valve Dysfunction Aortic insufficiency Acute pulmonary edema Pericardial tamponade
  • 34. Chest Pain Back Pain Acute CHF New AI Murmur Syncope Aortic Dissection?
  • 37. “The International Registry of Acute Aortic Dissection [IRAD]: New Insight Into An Old Disease.” Hagan PG. JAMA 2000, 283:897. N = 464 12 Centers
  • 38. IRAD: Demographics Hagan PG. JAMA 2000. Male 65.3% Mean age* 63 years Type A 62.3% Hypertension 72.1% *Type B older, Marfans mean age 36 years
  • 39. IRAD: Clinical Manifestations Pain reported in 95.5%: Chest pain 72.7% Anterior chest pain 60.9% Back pain 53.2% Abdominal pain 29.6% Hagan PG. JAMA 2000.
  • 40. IRAD: Clinical Manifestations Quality of pain: Abrupt onset 84.4% ‘Worst pain ever’ 90.6% Sharp 64.4% Tearing or ripping 50.6% Radiating 28.3% Migratory 16.6% Hagan PG. JAMA 2000.
  • 41. IRAD: Syncope • Syncope in 9.4% • More common with Type A dissection • Higher risk of tamponade & stroke Mortality History of Syncope 34% Overall 28% Hagan PG. JAMA 2000.
  • 42. IRAD: Chest X-Ray Findings: Wide mediastinum 66.1% Abnormal aortic contour 49.6% Pleural effusion 19.2% Wall Ca++ displacement 14.1% Normal CXR 12.4% Hagan PG. JAMA 2000.
  • 44. Egg Shell Sign Egg Shell Sign: The Dissection “Push” The Calcified Aortic Wall Inward.
  • 45. Egg Shell Sign Egg Shell Sign: The Dissection “Push” The Calcified Aortic Wall Inward.
  • 46. 69 year-old male with 5 days of vague chest & abdominal pain.
  • 48. Old CXR New CXR
  • 50. Be On The Look Out!
  • 51. 35 Year Old With Alcoholic Cardiomyopathy
  • 52. 35 Year Old With Alcoholic Cardiomyopathy Cardiomegaly
  • 53. 6 Month Old Difficult Intubation In The O.R.
  • 54. 6 Month Old Difficult Intubation In The O.R. Right Mainstem Intubation + Left Lung Collapse
  • 55. 73 Year-Old With Fever, Cough And Confusion
  • 56. 73 Year-Old With Fever, Cough And Confusion Right Middle Lobe Pneumonia
  • 57. 52 Year-Old With With Advanced Lung Cancer Presents With Dyspnea & Hypoxia
  • 58. 52 Year-Old With With Advanced Lung Cancer Presents With Dyspnea & Hypoxia Right Lung Mass With Severe Pulmonary Necrosis
  • 59. 52 Year-Old With With Advanced Lung Cancer Presents With Dyspnea & Hypoxia Right Lung Mass With Severe Pulmonary Necrosis
  • 61. 68 Year-Old Diabetic With Cough And Fever Right-Sided Infiltrates – Primarily RUL
  • 62. 68 Year-Old Diabetic With Cough And Fever Right-Sided Infiltrates – Primarily RUL
  • 63. Healthy 5 Year Old Treated With Tamiflu For Flu Symptoms, Admitted With Pneumonia
  • 64. Healthy 5 Year Old Treated With Tamiflu For Flu Symptoms, Admitted With Pneumonia HD #1: LLL Pneumonia
  • 65. Healthy 5 Year Old Admitted With Pneumonia
  • 66. Healthy 5 Year Old Admitted With Pneumonia HD #4: LLL Pneumonia + Effusion Chest Tube
  • 67. Healthy 5 Year Old Admitted With Pneumonia
  • 68. Healthy 5 Year Old Admitted With Pneumonia HD #14: After Video Assisted Thoracoscopic Surgery [VATS] One Liter Of Pus Removed Pneumohydrothorax With Mediastinal Shift
  • 69. Air-Fluid Level: If It’s Flat There’s Air In There!
  • 70. Healthy 5 Year Old Admitted With Pneumonia HD #14: Pneumohydrothorax And Severe Pulmonary Necrosis/Trapped Lung (*) Discharged The Following Day On IV Antibiotics With Planned Follow-Up *
  • 71. 25 Year Old With Worsening Epigastric Pain Self-Medicating With Narcotics
  • 72. 25 Year Old With Worsening Epigastric Pain Self-Medicating With Narcotics Free Air Under The Diaphragm: Gastric Perforation
  • 73. Summary Of Diagnoses This Week • Acute aortic dissection • Cardiomegaly • Right mainstem intubation • Right middle lobe pneumonia • Lung mass with severe pulmonary necrosis • Right upper lobe pneumonia • Pneumohydrothorax & severe pulmonary necrosis
  • 74. See You Next Week!