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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 18th 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
Patient With
Abdominal Pain
And Sepsis
Free Air Under The Diaphragm: Colonic Perforation
Patient With
Abdominal Pain
And Sepsis
Free Air Under The Diaphragm: Colonic Perforation
Patient With
Chest Pain
Why Would A
Patient Have
Cardiomegaly
And Inferior
“Notching” Of
Ribs?
Coarctation Of The Thoracic Aorta
Patient With
Chest Pain
Coarctation Of The Thoracic Aorta
Patient With
Chest Pain
Coarctation Of The Thoracic Aorta
Coarctation – Stent Graft Placed
Thoracic Endovascular Aortic Repair [TEVAR]
Why Does Coarctation Cause Rib Notching?
• The descending aorta is stenotic and therefore collateral flow is needed.
• The collateral pathway is via the subclavian artery to the internal
thoracic artery to the anterior intercostal artery to the posterior
intercostal artery and then to the descending thoracic aorta.
• The dilated, tortuous vessels erode the lower rib margins, seen most
commonly in ribs 4 – 8.
• Notching seen in 70% of cases presenting in older children or adults.
Coarctation Of The Thoracic Aorta
“ACC/AHA 2008 Guidelines For The Management Of Adults
With Congenital Heart Disease.”
A Report of the ACC/AHA Task Force On Practice Guidelines.
Warnes CA. Circulation 2008; 23:e714-e833..
Warnes CA. Circulation 2008; 23:e714-e833.
Coarctation Of The Thoracic Aorta In Adults
Clinical Features
 Hypertension in right arm relative to the lower extremities
 Hyperdynamic carotid pulses
 A murmur may be heard over the left intrascapular position
 A continuous murmurs may be hear over parasternal areas
Presenting Symptoms
 May remain asymptomatic if collateral flow is adequate
 Hypertension – discrepant between the upper and lower extremities
 Increased proximal pressure [chest pain, headache, epistaxis]
 Decreased distal pressure [lower extremity claudication]
Warnes CA. Circulation 2008; 23:e714-e833.
Coarctation Of The Thoracic Aorta In Adults
Chest X-Ray Findings
 Cardiomegaly
 An indentation at the coarctation may produce a “3-sign” beneath the
aortic arch
 Notching under ribs 3-9
ECG Findings
 Left ventricular hypertrophy
 Secondary ST-T changes due to strain
Coarctation Of The Thoracic Aorta
Coarctation Of The Thoracic Aorta
Coarctation Of The Thoracic Aorta
Patient With A
History of ESRD
Presents With
Fever And Cough
Patchy Multifocal Pneumonia
Young Adult With Stab Wounds To The Chest & Neck
* *
Bilateral Pneumothoraces & Subcutaneous Emphysema (*)
Carina
Dobhoff Tube Placed In The Right Mainstem Brochus
Young Adult With
Aspiration
Pneumonia
Young Adult In A
Motor Vehicle
Crash:
 Femur fracture
 Splenic injury
Wide
Mediastinum
Traumatic Aortic Disruption
Traumatic Aortic Disruption
Young Adult In A
Motor Vehicle
Crash:
 Femur fracture
 Splenic injury
Young Adult In A Motor Vehicle Crash
Thoracic Endovascular Aortic Repair [TEVAR]
Coarctation Of The Thoracic Aorta
Pediatric Patient With A Viral Prodrome, Now Cough, Fever, Confusion.
Multilobar Pneumonia: RML + RLL
RML
RLLRLL
RML
Untreated Scoliosis
Asymptomatic
Young Adult
Traumatic Pneumothorax
Chest Pain After
Motor Vehicle
Crash
Uterine Cancer Metastases – Entire Left
Hemithorax + Right Lung Lesion
History Of
Uterine Cancer –
Now More Short
Of Breath
Uterine Cancer Metastases – Entire Left
Hemithorax + Right Lung Lesion
Young Male With
Intractable
Vomiting
Pneumomediastinum & Pneumopericardium
Young Male With Intractable Vomiting
Pneumomediastinum & Pneumopericardium
Pneumomediastinum
2° Iatrogenic 2° Medical & Traumatic Spontaneous
 Endoscopic procedures
 Intubation
 Pleural instrumentation
 Central vascular procedure
 Chest/abdominal surgery
 Blunt chest injury
 Penetrating chest injury
 Asthma/COPD
 Bronchiectasis
 Interstitial lung disease
 Thoracic malignancy
 Tobacco use
 Recreational drugs
 Breath holding
 Weight lifting
Vasileios K. Journal of Thoracic Disease 2015; 7:S44-S49.
Management Essentials
 Manage the underlying cause
 Pain management & cough suppression as indicated
 Oxygen may increase gas absorption in severe cases
 Brief period of observation vs. close outpatient follow-up
Summary Of Diagnoses This Week
• Free air: colonic perforation
• Coarctation of the aorta
• Multifocal pneumonia
• Several pneumothoraces
• Dobhoff tube place in the right mainstem bronchus
• Traumatic aortic disruption
• Untreated scoliosis
• Lung metastases
• Pneumomediastinum due to intractable vomiting

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Dr. Michael Gibbs's CMC X-Ray Mastery Project - Week #6 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 18th 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. Patient With Abdominal Pain And Sepsis Free Air Under The Diaphragm: Colonic Perforation
  • 7. Patient With Abdominal Pain And Sepsis Free Air Under The Diaphragm: Colonic Perforation
  • 8. Patient With Chest Pain Why Would A Patient Have Cardiomegaly And Inferior “Notching” Of Ribs? Coarctation Of The Thoracic Aorta
  • 9. Patient With Chest Pain Coarctation Of The Thoracic Aorta
  • 10. Patient With Chest Pain Coarctation Of The Thoracic Aorta
  • 11. Coarctation – Stent Graft Placed Thoracic Endovascular Aortic Repair [TEVAR]
  • 12. Why Does Coarctation Cause Rib Notching? • The descending aorta is stenotic and therefore collateral flow is needed. • The collateral pathway is via the subclavian artery to the internal thoracic artery to the anterior intercostal artery to the posterior intercostal artery and then to the descending thoracic aorta. • The dilated, tortuous vessels erode the lower rib margins, seen most commonly in ribs 4 – 8. • Notching seen in 70% of cases presenting in older children or adults.
  • 13. Coarctation Of The Thoracic Aorta
  • 14. “ACC/AHA 2008 Guidelines For The Management Of Adults With Congenital Heart Disease.” A Report of the ACC/AHA Task Force On Practice Guidelines. Warnes CA. Circulation 2008; 23:e714-e833..
  • 15. Warnes CA. Circulation 2008; 23:e714-e833. Coarctation Of The Thoracic Aorta In Adults Clinical Features  Hypertension in right arm relative to the lower extremities  Hyperdynamic carotid pulses  A murmur may be heard over the left intrascapular position  A continuous murmurs may be hear over parasternal areas Presenting Symptoms  May remain asymptomatic if collateral flow is adequate  Hypertension – discrepant between the upper and lower extremities  Increased proximal pressure [chest pain, headache, epistaxis]  Decreased distal pressure [lower extremity claudication]
  • 16. Warnes CA. Circulation 2008; 23:e714-e833. Coarctation Of The Thoracic Aorta In Adults Chest X-Ray Findings  Cardiomegaly  An indentation at the coarctation may produce a “3-sign” beneath the aortic arch  Notching under ribs 3-9 ECG Findings  Left ventricular hypertrophy  Secondary ST-T changes due to strain
  • 17. Coarctation Of The Thoracic Aorta
  • 18. Coarctation Of The Thoracic Aorta
  • 19. Coarctation Of The Thoracic Aorta
  • 20. Patient With A History of ESRD Presents With Fever And Cough Patchy Multifocal Pneumonia
  • 21. Young Adult With Stab Wounds To The Chest & Neck * * Bilateral Pneumothoraces & Subcutaneous Emphysema (*)
  • 22. Carina Dobhoff Tube Placed In The Right Mainstem Brochus Young Adult With Aspiration Pneumonia
  • 23. Young Adult In A Motor Vehicle Crash:  Femur fracture  Splenic injury Wide Mediastinum Traumatic Aortic Disruption
  • 24. Traumatic Aortic Disruption Young Adult In A Motor Vehicle Crash:  Femur fracture  Splenic injury
  • 25. Young Adult In A Motor Vehicle Crash Thoracic Endovascular Aortic Repair [TEVAR] Coarctation Of The Thoracic Aorta
  • 26. Pediatric Patient With A Viral Prodrome, Now Cough, Fever, Confusion. Multilobar Pneumonia: RML + RLL RML RLLRLL RML
  • 28. Traumatic Pneumothorax Chest Pain After Motor Vehicle Crash
  • 29. Uterine Cancer Metastases – Entire Left Hemithorax + Right Lung Lesion History Of Uterine Cancer – Now More Short Of Breath
  • 30. Uterine Cancer Metastases – Entire Left Hemithorax + Right Lung Lesion
  • 32. Young Male With Intractable Vomiting Pneumomediastinum & Pneumopericardium
  • 33. Pneumomediastinum 2° Iatrogenic 2° Medical & Traumatic Spontaneous  Endoscopic procedures  Intubation  Pleural instrumentation  Central vascular procedure  Chest/abdominal surgery  Blunt chest injury  Penetrating chest injury  Asthma/COPD  Bronchiectasis  Interstitial lung disease  Thoracic malignancy  Tobacco use  Recreational drugs  Breath holding  Weight lifting Vasileios K. Journal of Thoracic Disease 2015; 7:S44-S49. Management Essentials  Manage the underlying cause  Pain management & cough suppression as indicated  Oxygen may increase gas absorption in severe cases  Brief period of observation vs. close outpatient follow-up
  • 34. Summary Of Diagnoses This Week • Free air: colonic perforation • Coarctation of the aorta • Multifocal pneumonia • Several pneumothoraces • Dobhoff tube place in the right mainstem bronchus • Traumatic aortic disruption • Untreated scoliosis • Lung metastases • Pneumomediastinum due to intractable vomiting

Editor's Notes

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