Drs. Daniel Escobar, Angela Pikus, and Alex Blackwell are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover: - Traumatic Pneumothorax - Flail Chest And Surgical Rib Fixation - Traumatic Pulmonary Pseudocyst - Stab Wound To The Heart

1. Adult Chest X-Rays Of The Month
Daniel Escobar, MD1, Angela Pikus, MD1,
Alex Blackwell, MD1
Bradley Thomas, MD2 and Jason McCartt MD2
Departments of Emergency Medicine1 & Surgery2
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD - Faculty Editor
CMC Imaging Mastery Project
Presentation #43

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. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Imaging Presentations And Much More!

4. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

5. It’s All About The Anatomy!

6. A 45-Year-Old
Male Presents To
The ED After
Crashing His
Mountain Bike
T: 98.1, HR: 67, RR: 18,
BP: 152/80, SpO2 97%
What Do You See?

7. 45-Year-Old Male
In A Mountain
Bike Crash.
Notice Rightward
Deviation Of The
Tracheal And Cardiac
Silhouette. These
Findings May Indicate
Tension Physiology,
However In This Case
The Patient’s Vital
Signs Were Stable.
Tension
Pneumothorax Is A
Clinical Diagnosis!
Rib Fractures (→), Pneumothorax (→)
Deep Sulcus
Sign

8. 45-Year-Old Male
In A Mountain
Bike Crash.
A Left Chest Tube
Was Placed With
Improved Left Lung
Expansion.
The Trachea And
Cardiac Silhouette
Return The The
Midline.
Pigtail Catheter Placement & Lung Re-Expansion

9. IMAGES IN EMERGENCY MEDICINE
DIAGNOSIS:
Deep sulcus sign. First described by Gordon in 19801, the deep sulcus sign describes a deepening of the
costophrenic angle when air tracks anteriorly and caudally along the pleural space when the patient is lying
supine.2 The deep sulcus sign may be the only evidence of pneumothorax on a supine chest X-ray. False-positive
examples of deep sulcus sign have been described in patients with advanced chronic obstructive pulmonary
disease and in those receiving mechanical ventilation with high tidal volumes.2
REFERENCES
1Gordon R. The deep sulcus sign. Radiology. 1980. 136:25-27.
2Kong A. The deep sulcus sign. Radiology. 2003. 228:415-417.
Volume 49, Number 5, May 2007.
www.EMGuidewire.com 2020

10. Deep Sulcus
Sign
Deep Sulcus
Sign
Bilateral Pneumothorax
33-Year-Old In A
Roll Over Motor
Vehicle Crash.
www.EMGuidewire.com 2020

11. 35-Year-Old Male
In A High-Speed
Car Crash
Right Pneumothorax With Shift
Deep Sulcus
Sign
www.EMGuidewire.com 2020

12. Stab Wound To
The Left Chest.
Deep Sulcus
Sign
www.EMGuidewire.com 2020
Left Pneumothorax With Shift

13. What Is The Latest Literature On The Management Of
Traumatic Pneumothorax In Stable Patients?

14. J Trauma Acute Care Surg. 2022;92: 951-957.
Objective:
To assess a previously developed guideline to observe any pneumothorax (PNTX) <35 mm in stable patients.1,2
Methods:
Single-center, retrospective, before (2015-2016) and after (2018-2019) review of all patient with CT-guided PNTX.
Patients with concurrent hemothorax, on mechanical ventilation, and dying in <24 hours were excluded.
Results
266 patients (37% before 2017 and 63% after 2017) were included and there were no demographic differences
between groups. Tube thoracostomy decreased from 28.3% to 18%. There were no differences in hospitalization
outcomes, complications, or mortality.
Conclusion
The 35 mm Guideline is an effective tool to decrease unnecessary tube thoracostomy in stable patients without
evidence of hemothorax.
1Pneumothorax dimensions were determined using measurement of an axial chest CT.
2By protocol chest X-rays were repeated at 4 and 24 hours.

15. J Trauma Acute Care Surg. 2019;86: 557-564.
The Original 2019 Study
• Retrospective review 2011-2016
• 832 total pneumothorax patients
• Hemothorax and ventilated excluded
• Patients divided into <35 or >35 mm
• 257 patients had a PNTX <35 mm
Observation was successful in 91%

16. A 52-Year-Old
Male Presents
After A Vehicle
Slid Off Of A Car
Jack Onto His
Chest.
T: 97.4, HR: 81, RR: 20,
BP: 140/90, SpO2 95%

17. A 52-Year-Old
Male Presents
After A Vehicle
Slid Off Of A Car
Jack Onto His
Chest.
T: 97.4, HR: 81, RR: 20,
BP: 140/90, SpO2 95%
The Physical Exam
Reveals Paradoxical
Left-Sided Chest Wall
Motion Within The
Area Outlined By The
Blue Marker.
Clinical Flail
Segment
Of The Left
Chest

18. 52-Year-Old Male
With A Crush
Injury Of His Left
Chest Wall.
What Do You See?

19. 52-Year-Old Male
With A Crush
Injury Of His Left
Chest Wall.
The Patient Has A
Clinical Flail Chest.
A Pneumothorax
Should Be Suspected
Even If It Is Not Seen!
Multiple Left-Sided Rib Fractures

20. Severe Chest Wall Crush Injury

21. 52-Year-Old Male
With A Crush
Injury Of His Left
Chest Wall.
Because Of Extensive
Chest Wall Injury And
A Large Flail Segment,
Surgical Rib
Stabilization Was
Performed.
Post-Op Day #3

22. FLAIL CHEST
• ≥ 3 Contiguous Ribs Fractured At ≥ 2 Site On Each Rib
• Unstable Fractured Segment Mechanically Independence Of The Adjacent Chest Wall
• Causes Paradoxical Movement And Impaired Ventilation And Oxygenation

23. More Cases Of Flail Chest Injury From CMC

24. Case #1
A 55-Year-Old
Male Fell Crushed
By A Concrete
Mixer.
He Complains Of
Right-Sided Chest
Pain.

25. Case #1
A 55-Year-Old
Male Fell Crushed
By A Concrete
Mixer.
He Complains Of
Right-Sided Chest
Pain.
Multiple Right-Sided Rib Fractures

26. A 55-Year-Old Male Crushed By A Concrete Mixer.

27. Case #1
A 55-Year-Old
Male Fell Crushed
By A Concrete
Mixer.
Immediately Post-Op

28. Case #1
A 55-Year-Old
Male Fell Crushed
By A Concrete
Mixer.
Post-Op Day #3

29. Case #2
A 38-Year-Old
Male Is Involved In
A High-Speed
Motorcycle Crash.

30. Case #2
A 38-Year-Old
Male Is Involved In
A High-Speed
Motorcycle Crash.
Multiple Left-Sided Rib Fractures

31. A 38-Year-Old Male In A High-Speed Motorcycle
Crash.

32. Images Courtesy Of Bradley Thomas, MD

33. Images Courtesy Of Bradley Thomas, MD

34. Case #2
A 38-Year-Old
Male Is Involved In
A High-Speed
Motorcycle Crash.
Post-Op Day #2

35. Surgical Rib Fixation: What Does The Literature Tell Us?*
1. The literature supports early surgical rib fixation in patients with: (a) flail chest injuries, (b) ≥3
significantly displaced rib fractures (non-flail).
2. There is insufficient evidence to recommend routine surgical rib fixation in patient with multiple
non-displaced rib fractures.
3. There is evidence that surgical rib fixation improves outcomes in the elderly.
*See Key References on the next slide

36. Flail Chest Injuries
Randomized Controlled Trials
Marasco SF. Journal of the American College of Surgeons. 2013. 216(5): 924-932.
Gerakopoulos E. Journal of Orthopedic Trauma. 2019. 33(1):9-14.
Tanaka H. Journal of Trauma. 2002. 52(4):727-732.
Liu T. Journal of Surgical Research. 2019. 242:223-230.
Systematic Reviews
Cataneo AJ. Cochrane Database of Systematic Reviews. 2015. 7:CD009019.
Kasotakis G. Journal of Trauma and Acute Care Surgery. 2021. 82(3):618-626.
Coughlin TA. Bone and Joint Journal. 2016. 98-b(8):1119-1125.
Slobogean GP. Journal of the American College of Surgeons. 2013. 216(2):302-311.
Leinicke JA. Annals of Surgery. 2013. 258(6):214-221.
Tignanelli CJ. JAMA Network Open. 2020. 3(3):e201316.
Non-Flail Injuries (1 randomized trial)
Pieracci F. Journal of Trauma and Acute Care Surgery. 2020. 88(2):249-257.
Geriatric Patients
Ali-Osman. American Journal of Surgery. 2018. 216(1):46-51.
Chen Z. Journal of Trauma and Acute Care Surgery. 2020. 89(1):103-110
Fitzgerald MT. Journal of Trauma and Acute Care Surgery. 2017. 82(3):524-527.
Pieracci F. Journal of Trauma and Acute Care Surgery. 2021. 90:1014-1021.
Key References: Indications For Surgical Rib Stabilization

37. Healthy 33-Year-
Old In A Motor
Vehicle Crash.

38. Absent Lung
Markings
Healthy 33-Year-
Old In A Motor
Vehicle Crash.

39. 33-Year-Old In A Motor Vehicle Crash.
Pneumothorax
There Is An Obvious Left Pneumothorax. What Are The Arrows Pointing At?

40. After Pigtail Catheter Insertion
Healthy 33-Year-
Old In A Motor
Vehicle Crash.

41. 33-Year-Old In A Motor Vehicle Crash.
Post-Injury Day 3

42. 33-Year-Old In A Motor Vehicle Crash.
Left Lower Lobe Cystic Structure With Air-Fluid Level

43. Definitions
Represents air trapped within a pulmonary laceration
Different terms: traumatic pulmonary pseudocyst*, traumatic pneumatocoele, traumatic lung cyst
Pathophysiology
Pulmonary contusion: concussive wave, parenchymal compression, bursting force of the airway
One-way communication between the airway and area of contusion leads to cavity formation
Clinical Presentation
Chest pain, dyspnea, hemoptysis in 50%. May have fever if late-presenting due to local inflammation
Diagnosis
Thin-walled, air-filled cavity, with or without an air-fluid level
Chest X-ray sensitivity is low. Chest CT imaging 100% sensitive
*Traumatic pulmonary pseudocyst in the preferred term since the cavity is not lined by epithelium.

44. 16-year-old pedestrian struck. Normal physical exam other than transient hypoxia (SAO2
85% RA). He was observed for three days and discharged without complication.

45. 14-year-old with right-sided chest pain after being involved in a fight two days prior. The
patient recovered completely with symptomatic treatment.

47. A 55-Year-Old
Male Sustains A
Stab Wound To
The Left Chest.
Upright CXR
What Do You See?

48. A 55-Year-Old
Male Sustains A
Stab Wound To
The Left Chest.
Upright CXR
Radiology Report: “Opacity Left Lung Base May Represent Pulmonary Contusion.”
Hazy
Appearance
Of The Left
Lower Lung
Field

49. A 55-Year-Old Male Sustains A Stab Wound To The Left Chest.
POCUS: Hemopericardium With Clotted Blood (*)
* * *

50. The Patient Was Taken Emergently To The OR
• A pericardial window was grossly [+] and this was
immediately converted to a median sternotomy
• The pericardium was excised and a large amount of
clotted blood was removed
• A right ventricular laceration was identified and
closed primarily with pledgeted sutures (→)
• An intraoperative TEE did not reveal any additional
cardiac injury
Images Courtesy Of Jason McCartt, MD
The surgical team also identified a laceration that
communicated between the pericardial and left
pleural spaces. This likely allowed the
hemopericardium to intermittently “decompress” into
the left chest… preventing fatal pericardial
tamponade!

51. A 55-Year-Old
Male Sustains A
Stab Wound To
The Left Chest.
Post-Op Day #1

52. Now… Let’s Take
Another Look At
The 1st CXR
Obtained In The
ED.
The “Opacity” Of The Lower Left Lung Field Represents A Subtle Left Hemothorax.
Hazy
Appearance
Of The Left
Lower Lung
Field

53. Repair Of A Cardiac Laceration Using Pledgeted Sutures

54. Summary Of Diagnoses This Month
 Traumatic Pneumothorax
 Flail Chest And Surgical Rib Fixation
 Traumatic Pulmonary Pseudocyst
 Stab Wound To The Heart

55. See You Next Month!