Drs. Claire Milam and Alyssa Thomas 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 monthly educational, self-guided radiology slides on: Cryptococcal Pneumonia, Coarctation of the Thoracic Aorta, Pulmonary Contusion, Ruptured Left Hemidiaphragm, Septic Pulmonary Emboli

1. Adult Chest X-Rays Of The Month
Alyssa Thomas MD & Claire Milam MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs MD, Faculty Editor
Chest X-Ray Mastery Project
December 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 providing cases and these slides are shared with all contributors.
 Contributors from many CMC/LCH departments, and now from EM
colleagues in Brazil, Chile and Tanzania.
 Cases submitted this month will be distributed next month.
 When reviewing the presentation, the 1st image will show a chest X-ray
without identifiers and the 2nd image will reveal the diagnosis.

4. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Chest X-Ray Presentations And Much More!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. It’s All About The Anatomy!

7. 57 Year Old Renal Transplant Patient Presents With Two Weeks Of Cough.
What do you notice?

8. 57 Year Old Renal Transplant Patient Presents With Two Weeks Of Cough.
Multifocal Infiltrates

9. 57 Year Old Renal Transplant Patient Presents With Two Weeks Of Cough.
Multifocal Infiltrates: What
opportunistic infection should
you consider?

10. 57 Year Old Renal Transplant Patient Presents With Two Weeks Of Cough.
Diagnosis: Cryptococcal Pneumonia

12. Cryptococcosis
• Cryptococcosis is a major opportunistic pathogen worldwide.
• In developed countries the widespread use of HAART for patients
with HIV has lowered the incidence of cryptococcosis dramatically.
• In developing countries with persistently uncontrolled HIV and limited
access to HAART therapy, the incidence of cryptococcosis, and its
associated mortality remain extremely high.

13. Cryptococcosis
In developed countries cryptococcosis in largely seen in patients:
• With newly diagnosed HIV
• Receiving immunosuppressants following organ transplantation
• Taking high-dose corticosteroids
• On certain monoclonal antibody therapies, e.g.:
• Infliximab (Remicade®) for rheumatologic conditions
• Alemtuzumab (Lemtrada®) for chronic lymphocytic leukemia

14. Cryptococcosis
Punch Line For The Acute Care Clinician?

15. Cryptococcosis
Punch Line For The Acute Care Clinician?
THINK ABOUT IT In The At-Risk Patient!

16. Treatment for
Cryptococcosis

22. 35 Year Old
Healthy Male
Evaluated After A
Fall
What do you
notice?

23. 35 Year Old
Healthy Male
Evaluated After A
Fall
Cardiomegaly
And Inferior
“Notching” Of
Ribs

24. 35 Year Old
Healthy Male
Evaluated After A
Fall
Why Would A
Patient Have
Cardiomegaly
And Inferior
“Notching” Of
Ribs?

25. 35 Year Old
Healthy Male
Evaluated After A
Fall
Why Would A
Patient Have
Cardiomegaly
And Inferior
“Notching” Of
Ribs?
Coarctation Of The Thoracic Aorta

26. 35 Year Old
Healthy Male
Evaluated After A
Fall
Coarctation Of The Thoracic Aorta

27. Another Young
Healthy Patient
With Chest Pain
Coarctation Of The Thoracic Aorta
Notice the
Inferior
“Notching” Of
Ribs

28. Another Young
Healthy Patient
With Chest Pain
Coarctation Of The Thoracic Aorta

29. Patient With
Chest Pain
Coarctation Of The Thoracic Aorta

30. Coarctation – Stent Graft Placed
Thoracic Endovascular Aortic Repair [TEVAR]

31. 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.

32. Coarctation Of The Thoracic Aorta

33. “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..

34. 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]

35. 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

36. Coarctation Of The Thoracic Aorta

37. Coarctation Of The Thoracic Aorta

38. Coarctation Of The Thoracic Aorta

39. 19 Year Old Male Presents After MVC
What do you notice?

40. Pulmonary Contusion
and Hemothorax
19 Year Old Male Presents After MVC

41. 19 Year Old Male Presents After MVC
Pulmonary Contusion
and Hemothorax
Remember to
Look at Your
Images
Systematically!
Broken Clavicle

42. Worsening Pulmonary Contusions
Requiring Intubation
19 Year Old Male Presents After MVC

43. CT Chest Showing Pulmonary
Contusion and Hemothorax
19 Year Old Male Presents After MVC

45. EAST Guidelines For The Management Of Pulmonary Contusion & Flail Chest
 The use of optimal analgesia and aggressive chest physiotherapy should be used to
minimize the risk of respiratory failure.
 A trial of mask CPAP in combination with optimal regional anesthesia, should be
considered in alert, compliant patients with marginal respiratory status.
 Epidural catheter is the preferred method of analgesia delivery.
 Patients should be adequately resuscitated, and hypovolemia should be avoided. When
there are clear signs of hydrostatic fluid overload, diuretics may be used.
 Steroids should not be used in patients with pulmonary contusion.
 For patients requiring mechanical ventilation, PEEP and CPAP should be part in the
ventilatory strategy.

46. 60 Year Old
In A Motor
Vehicle Crash

47. 60 Year Old
In A Motor
Vehicle Crash
Why Is The Left
Hemidiaphragm
Indistinct?

48. 60 Year Old In A Motor Vehicle Crash
Ruptured Diaphragm

49. 45 Year-Old
Male
Involved In A
Roll-Over Car
Crash
Intubated In
The Field
What do you notice?

50. 45 Year-Old
Male
Involved In A
Roll-Over Car
Crash
Intubated In
The Field
Rib
Fracture
Elevated
Hemidiaphragm

51. 45 Year-Old
Male
Involved In A
Roll-Over Car
Crash
Intubated In
The Field
Why Is The Left Hemidiaphragm Elevated?
Rib
Fracture
Elevated
Hemidiaphragm

52. 45 Year-Old Male Involved In
A Roll-Over Car Crash
Intubated In The Field
Ruptured Diaphragm

53. 45 Year-Old
Male With
Rupture Of
The Left
Diaphragm
Chest X-Ray After Repair

54. Diaphragm Injury Demographics
ACS National Trauma Data Bank [n=833,309]:
• Diaphragm injuries are rare, incidence: 0.46%
• Mechanism: 67% penetrating and 33% blunt
Penetrating Blunt
 Gunshot wounds 67%  Motor vehicle crash 63%
 Stab wounds 33%  Bicycle/pedestrian stuck 10%
Mortality 9% Mortality 20%
Fair KA. J Trauma 2015; 209:864-868.

56. SUMMARY Of 2018 EAST Practice Management Guidelines
#1 In stable patients with left thoracoabdominal stab wounds, laparoscopy
is recommended rather than CT imaging to decrease the incidence of
missed diaphragm injuries.
#2 In stable patients with confirmed or suspected penetrating injuries of
the right diaphragm, non-operative management is recommended over
operative management.
#3 In stable patients with acute diaphragm injuries, the abdominal rather
than the thoracic approach is preferred for injury repair.
#4 In patients with acute penetrating diaphragm injuries without concerns
for other intraabdominal injuries, laparoscopic repair is recommended
over open repair.

57. 55 Year Old
Intravenous
Drug User
Had New
Satisfactory
Pacemaker
Placement

58. 55 Year Old Intravenous Drug User Presents Two
Weeks Later with AMS and Signs of Sepsis
What do you notice?

59. 55 Year Old Intravenous Drug User Presents Two
Weeks Later with AMS and Signs of Sepsis
Bilateral Nodular Opacities
Consistent with Septic
Emboli

60. 55 Year Old Intravenous Drug User With Septic
Pulmonary Emboli on CT Chest

61. Remember Our Septic Emboli Cases In IV Drug
Users With Endocarditis From Earlier This Year…

62. 26 Year Old
IV Drug User
Presents
With Back
Pain And
Fever

63. 26 Year Old
IV Drug User
Presents
With Back
Pain And
Fever
Bilateral Rounded Densities

64. 26 Year Old IV Drug User Presents With Back Pain And Fever
Septic Pulmonary Emboli

65. 30 Year Old With
A History Of
Intravenous Drug
Abuse Presents
With Weakness
and Shortness of
Breath

66. 30 Year Old With
A History Of
Intravenous Drug
Abuse Presents
With Weakness
and Shortness of
Breath
Bilateral Rounded Densities

67. 30 Year Old With A History Of Intravenous Drug Abuse
Presents With Weakness and Shortness of Breath
Septic Pulmonary Emboli

68. 22 Year Old With
A History Of
Intravenous Drug
Abuse Presents
With Fever, Chest
Pain & Cough

69. 22 Year Old With
A History Of
Intravenous Drug
Abuse Presents
With Fever, Chest
Pain & Cough
Bilateral Rounded Densities

70. 22 Year Old With A History Of Intravenous Drug Abuse
Presents With Fever, Chest Pain & Cough
Septic Pulmonary Emboli

71. 22 Year Old With
A History Of
Intravenous Drug
Abuse Presents
With Fever, Chest
Pain & Cough
Point Of Care
ED Echo:
Tricuspid Valve
Vegetation

72. Here Is The 3rd
Patient’s Chest X-
Ray One Month
Ago!

73. In One Week We Received Three Cases Of Septic Pulmonary
Emboli In Young, IV Drug-Dependent Adults With Endocarditis.
This Seems Like A Lot!

74. In One Week We Received Three Cases Of Septic Pulmonary
Emboli In Young, IV Drug-Dependent Adults With Endocarditis.
This Seems Like A Lot!
Let’s Look At Some North Carolina-Specific CDC Data

75.  12-fold increase in the incidence of hospitalizations
 Incidence increasing most rapidly amongst drug users who are younger,
white (87%), non-Hispanic (92%), and from rural areas
 18-fold increase in the total cost of hospitalization
 Median hospital charges $54,281
 In 2015 42% of patients were either uninsured or receiving Medicaid

85. Empiric Antibiotics In The ED
First Choice Vancomycin + Cefepime
Severe PCN Allergy Vancomycin + Aztreonam

86. Summary Of Diagnoses This Month
 Cryptococcal pneumonia
 Coarctation of the thoracic aorta
 Pulmonary contusion
 Ruptured left hemidiaphragm
 Septic pulmonary emboli

87. See You Next Month!