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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
July 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 providing cases and these slides are shared with all contributors.
 Contributors from many Carolinas Medical Center departments, and now…
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.
It’s All About The Anatomy!
Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum
MVC – Struck Chest On The Steering Wheel
What is your interpretation?
Be sure to look at both views closely.
MVC – Struck Chest On The Steering Wheel
Sternal Fracture
 Direct impact to the anterior chest.
 Best seen on the lateral view.
MVC – Struck Chest On The Steering Wheel
MVC – Struck Chest On The Steering Wheel
Right Sided Effusion. Could It Be Blood?
Remember Not To Miss The 2nd (Or 3rd, Or 4th) Finding(s)!
What Do You See?
Stab Wound
To Left Chest
Stab Wound
To Left Chest
Left Hemothorax
Stab Wound
To Left Chest
Notice:
Early Tracheal Deviation
Left Hemothorax
After Chest Tube Placed
Side Note:
If chest tube output
>1000 ml, consider
autotransfusion
Stab Wound
To Left Chest
After Chest Tube Placed
Notice:
Midline Trachea
Side Note:
If chest tube output
>1000 ml, consider
autotransfusion
Stab Wound
To Left Chest
A 70 Year-Old
Male Is
Thrown From
A Horse And
Presents To
An Outside ED
with Right
Sided Chest
Pain
A Chest CT Is
Ordered
Right Pneumothorax Visible On The CT Scout Film
A 70 Year-Old
Male Is
Thrown From
A Horse And
Presents To
An Outside ED
with Right
Sided Chest
Pain
A Chest CT Is
Ordered
A 70 Year-Old
Male Is
Thrown From
A Horse And
Presents To
An Outside ED
with Right
Sided Chest
Pain
Right Pneumothorax Visible On The CT Scout Film
A 70 Year-Old
Male Is
Thrown From
A Horse And
Presents To
An Outside ED
with Right
Sided Chest
Pain
Oops!
A 70 Year-Old
Male Is
Thrown From
A Horse And
Presents To
An Outside ED
with Right
Sided Chest
Pain
Pigtail Placed – Pneumothorax Persists
A 70 Year-Old
Male Is
Thrown From
A Horse
Pigtail Replaced
A 70 Year-Old Male Is Thrown From A Horse
Multiple Posterior Rib Fractures
What Are You Concerned About?
78 Year-Old
Who Moved To
Charlotte From
El Salvador
This Month
Thoracic Aortic Aneurysm [TAA]
 Thoracic aorta >3.5 cm considered dilated.
 Thoracic aorta >4.5 cm considered aneurysmal.
78 Year-Old
Who Moved To
Charlotte From
El Salvador
This Month
TAA: Anatomy Defined By CT Angiography
Thoracic Aortic Aneurysm
Endovascular Repair
TAA: Endograft
Thoracic Aortic Aneurysm
25 Year Old With A
History Of Sickle Cell
Disease Presents
With Severe Pain of
Both Of His Legs and
His Lower Back.
Hospital Day 1
Afebrile, Vital Signs
Are Stable
What is your interpretation?
25 Year Old With A
History Of Sickle Cell
Disease Presents
With Severe Pain of
Both Of His Legs and
His Lower Back.
Hospital Day 3
Now Febrile,
Dyspneic,
Tachypneic And
Tachycardic
25 Year Old With A
History Of Sickle Cell
Disease Presents
With Severe Pain of
Both Of His Legs and
His Lower Back.
Hospital Day 3
Now Febrile,
Dyspneic,
Tachypneic And
Tachycardic
Acute Chest Syndrome
Acute Chest Syndrome
25 Year Old With A
History Of Sickle Cell
Disease Presents
With Severe Pain of
Both Of His Legs and
His Lower Back.
Hospital Day 3
Now Febrile,
Dyspneic,
Tachypneic And
Tachycardic
25 Year Old With A
History Of Sickle Cell
Disease Presents
With Severe Pain of
Both Of His Legs and
His Lower Back.
Hospital Day 5
Clinically Improved
After Exchange
Transfusion
Acute Chest Syndrome
Side Note:
Recall that the CXR
looked normal on
initial presentation.
This is the case for
≈50% of hospitalized
SCD patients who go
on to develop ACS.
Drs. Milam and Thomas's CMC X-Ray Mastery Project: July cases
Acute Chest Syndrome
 Defined as a new pulmonary infiltrate consistent with consolidation
[not atelectasis] of at least one lung segment.
 Usually accompanied by chest pain, cough, fever and wheezing.
 The most common cause or IC U admission and premature death in
patients with sickle cell disease.
Gladwin M. New England Journal of Medicine 2008; 359:2254-65.
Acute Chest Syndrome
Three proposed mechanisms:
 Pulmonary infection1
 Embolization of bone marrow fat2
 Pulmonary intravascular sickling and infarction3
1Bronchoalveolar lavage demonstrates bacterial and/or viral pathogens in 54% of patients with ACS.
2Associated with pain crisis of multiple bones, particularly the lumbar spine, femurs and the pelvis.
3In a small percentage of patients with ACS, wedge-shaped pulmonary infarcts may develop.
Gladwin M. New England Journal of Medicine 2008; 359:2254-65.
Drs. Milam and Thomas's CMC X-Ray Mastery Project: July cases
National Acute Chest Syndrome Study Group
 538 patients from 20 centers - the largest case series to date
 Results provide insights into the clinical presentations and outcomes of
hospitalized patients with ACS
49% Of Patients Initially Presented In Pain Crisis Without Signs Of ACS!
Vichinsky EP. New England Journal of Medicine 2000; 342:1855-65.
National Acute Chest Syndrome Study Group
 Manifestations: worsening hypoxia, decreased hemoglobin levels, and
progressive, multi-lobar pulmonary infiltrates
 The mean hospital length of stay was 10.5 days [vs. 3 days w/o ACS]
 30% required mechanical ventilation and overall mortality was 3%
Vichinsky EP. New England Journal of Medicine 2000; 342:1855-65.
Infection1,2 33%
Pulmonary Infarction 33%
Pulmonary fat emboli 16%
1Pathogens identified using bronchoalveolar lavage
2Chlamydophilia, Mycoplasma pneumoniae & respiratory syncytial virus the most common pathogens
Acute Chest Syndrome
ED Treatment Essentials:
 Antibiotics to cover both typical & atypical pathogens
 Supportive respiratory care
 A transfusion strategy based on goals and severity
Gladwin M. New England Journal of Medicine 2008; 359:2254-65.
Goal Target
Increase oxygen carrying capacity Hgb ≥10 grams
Manage vaso-occlusive complications HbS <30%
Both As above
Drs. Milam and Thomas's CMC X-Ray Mastery Project: July cases
Drs. Milam and Thomas's CMC X-Ray Mastery Project: July cases
RCE = Red Cell Exchange
Cases Studies From
Our Emergency
Medicine Partners In
Brazil
43 Year Old
Presents To An
Outpatient Clinic
After A Syncopal
Episode
He Has Normal
Labs, A Normal
ECG And This
Chest X-Ray
He Is Sent Home
Cases Studies From
Our Emergency
Medicine Partners In
Brazil
Right Upper Lobe Pneumonia
43 Year Old Seen
In The
Outpatient Clinic
Four Days Later
He Now
Presents To The
ED With Cough,
Fever & Rigors
Cases Studies From
Our Emergency
Medicine Partners In
Brazil
43 Year Old Seen
Four Days Ago In
The Outpatient
Clinic
Let’s Take
Another Look At
The First CXR…
Cases Studies From
Our Emergency
Medicine Partners In
Brazil
Subtle pneumonias can be easy to
miss (especially with overlapping
structures near by), make sure you
are comparing each lung field with
the other side.
43 Year Old Seen
Four Days Ago In
The Outpatient
Clinic
Let’s Take
Another Look At
The First CXR…
27 Year Old
With One
Week Of
Chest Pain
and Dyspnea
Transferred
From An
Outlying
Hospital After
Chest CT
Case #3
27 Year Old With One Week Of Chest Pain and Dyspnea
27 Year Old With One Week Of Chest Pain and Dyspnea
Chest CT Obtained: Large Pericardial Effusion
27 Year Old
With One
Week Of
Chest Pain
and Dyspnea
ECHO
27 Year Old
With One
Week Of
Chest Pain
and Dyspnea
Cardiac
Apex
27 Year Old
With One
Week Of
Chest Pain
and Dyspnea
Pericardial Effusion: Pericardiocentesis = 250 cc Straw-Colored Fluid
Cardiac
Apex
**
*
*
 Rapidly accumulating pericardial effusions cause swift increases in intrapericardial
pressure and tamponade physiology.
 Slowly accumulating pericardial effusions gradually distend the pericardium and
symptoms can be delayed.
23 Year Old Car Crash In To A Tree
A Chest CT Is Obtained
23 Year Old Car Crash In To A Tree
A Chest CT Is Obtained
Severe Pulmonary Contusion
23 Year Old Car
Crash In To A Tree.
He Is Transferred To
Our ED And Is
Intubated Upon
Arrival For Severe
Agitation And
Persistent Hypoxia
Severe Pulmonary Contusion
69 Year Old With
Emphysema
Does He Have A
Pneumothorax On
The Right?
No! He Has A Large Right Lung Bleb
69 Year Old With
Emphysema
Does He Have A
Pneumothorax On
The Right?
69 Year Old With
Emphysema
Pulmonary Bleb Drainage Catheters
79 Year Old Male
Smoker Presents
With Cough And
Two Weeks Of Right
Sided Chest Pain
Chest X-Ray From 3 Years Ago
79 Year Old Male
Smoker Presents
With Cough And
Two Weeks Of Right
Sided Chest Pain
Chest X-Ray From Today: What Do You See?
79 Year Old Male Smoker Presents With Cough And Two Weeks Of Right Sided Chest
The Lateral View Is Helpful
79 Year Old Male Smoker Presents With Cough And Two Weeks Of Right Sided Chest
The Lateral View Is Helpful
This Looks Like A Round Mass
79 Year Old Male Smoker Presents With Cough And Two Weeks Of Right Sided Chest
The Lateral View Is Helpful
This Looks Like A Round Mass
Is This Fluid, A Mass, Or Both?
Right Lung Mass + Effusion + Metastasis To The Chest Wall [*]
*
*
Pathology
Non-Small Cell Lung Cancer
Summary Of Diagnoses This Month
 Sternal fracture
 Left hemothorax
 Traumatic aortic aneurysm
 Acute chest syndrome
 Right upper lobe pneumonia
 Pericardial effusion
 Pulmonary contusion
 Pulmonary bleb
 Non-small-cell lung cancer
See You Next Month!

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Drs. Milam and Thomas's CMC X-Ray Mastery Project: July cases

  • 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 July 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 Carolinas Medical Center departments, and now… 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. It’s All About The Anatomy!
  • 6. MVC – Struck Chest On The Steering Wheel
  • 7. What is your interpretation? Be sure to look at both views closely. MVC – Struck Chest On The Steering Wheel
  • 8. Sternal Fracture  Direct impact to the anterior chest.  Best seen on the lateral view. MVC – Struck Chest On The Steering Wheel
  • 9. MVC – Struck Chest On The Steering Wheel Right Sided Effusion. Could It Be Blood? Remember Not To Miss The 2nd (Or 3rd, Or 4th) Finding(s)!
  • 10. What Do You See? Stab Wound To Left Chest
  • 11. Stab Wound To Left Chest Left Hemothorax
  • 12. Stab Wound To Left Chest Notice: Early Tracheal Deviation Left Hemothorax
  • 13. After Chest Tube Placed Side Note: If chest tube output >1000 ml, consider autotransfusion Stab Wound To Left Chest
  • 14. After Chest Tube Placed Notice: Midline Trachea Side Note: If chest tube output >1000 ml, consider autotransfusion Stab Wound To Left Chest
  • 15. A 70 Year-Old Male Is Thrown From A Horse And Presents To An Outside ED with Right Sided Chest Pain A Chest CT Is Ordered Right Pneumothorax Visible On The CT Scout Film
  • 16. A 70 Year-Old Male Is Thrown From A Horse And Presents To An Outside ED with Right Sided Chest Pain A Chest CT Is Ordered
  • 17. A 70 Year-Old Male Is Thrown From A Horse And Presents To An Outside ED with Right Sided Chest Pain Right Pneumothorax Visible On The CT Scout Film
  • 18. A 70 Year-Old Male Is Thrown From A Horse And Presents To An Outside ED with Right Sided Chest Pain Oops!
  • 19. A 70 Year-Old Male Is Thrown From A Horse And Presents To An Outside ED with Right Sided Chest Pain Pigtail Placed – Pneumothorax Persists
  • 20. A 70 Year-Old Male Is Thrown From A Horse Pigtail Replaced
  • 21. A 70 Year-Old Male Is Thrown From A Horse Multiple Posterior Rib Fractures
  • 22. What Are You Concerned About? 78 Year-Old Who Moved To Charlotte From El Salvador This Month
  • 23. Thoracic Aortic Aneurysm [TAA]  Thoracic aorta >3.5 cm considered dilated.  Thoracic aorta >4.5 cm considered aneurysmal. 78 Year-Old Who Moved To Charlotte From El Salvador This Month
  • 24. TAA: Anatomy Defined By CT Angiography
  • 28. 25 Year Old With A History Of Sickle Cell Disease Presents With Severe Pain of Both Of His Legs and His Lower Back. Hospital Day 1 Afebrile, Vital Signs Are Stable
  • 29. What is your interpretation? 25 Year Old With A History Of Sickle Cell Disease Presents With Severe Pain of Both Of His Legs and His Lower Back. Hospital Day 3 Now Febrile, Dyspneic, Tachypneic And Tachycardic
  • 30. 25 Year Old With A History Of Sickle Cell Disease Presents With Severe Pain of Both Of His Legs and His Lower Back. Hospital Day 3 Now Febrile, Dyspneic, Tachypneic And Tachycardic Acute Chest Syndrome
  • 31. Acute Chest Syndrome 25 Year Old With A History Of Sickle Cell Disease Presents With Severe Pain of Both Of His Legs and His Lower Back. Hospital Day 3 Now Febrile, Dyspneic, Tachypneic And Tachycardic
  • 32. 25 Year Old With A History Of Sickle Cell Disease Presents With Severe Pain of Both Of His Legs and His Lower Back. Hospital Day 5 Clinically Improved After Exchange Transfusion Acute Chest Syndrome Side Note: Recall that the CXR looked normal on initial presentation. This is the case for ≈50% of hospitalized SCD patients who go on to develop ACS.
  • 34. Acute Chest Syndrome  Defined as a new pulmonary infiltrate consistent with consolidation [not atelectasis] of at least one lung segment.  Usually accompanied by chest pain, cough, fever and wheezing.  The most common cause or IC U admission and premature death in patients with sickle cell disease. Gladwin M. New England Journal of Medicine 2008; 359:2254-65.
  • 35. Acute Chest Syndrome Three proposed mechanisms:  Pulmonary infection1  Embolization of bone marrow fat2  Pulmonary intravascular sickling and infarction3 1Bronchoalveolar lavage demonstrates bacterial and/or viral pathogens in 54% of patients with ACS. 2Associated with pain crisis of multiple bones, particularly the lumbar spine, femurs and the pelvis. 3In a small percentage of patients with ACS, wedge-shaped pulmonary infarcts may develop. Gladwin M. New England Journal of Medicine 2008; 359:2254-65.
  • 37. National Acute Chest Syndrome Study Group  538 patients from 20 centers - the largest case series to date  Results provide insights into the clinical presentations and outcomes of hospitalized patients with ACS 49% Of Patients Initially Presented In Pain Crisis Without Signs Of ACS! Vichinsky EP. New England Journal of Medicine 2000; 342:1855-65.
  • 38. National Acute Chest Syndrome Study Group  Manifestations: worsening hypoxia, decreased hemoglobin levels, and progressive, multi-lobar pulmonary infiltrates  The mean hospital length of stay was 10.5 days [vs. 3 days w/o ACS]  30% required mechanical ventilation and overall mortality was 3% Vichinsky EP. New England Journal of Medicine 2000; 342:1855-65. Infection1,2 33% Pulmonary Infarction 33% Pulmonary fat emboli 16% 1Pathogens identified using bronchoalveolar lavage 2Chlamydophilia, Mycoplasma pneumoniae & respiratory syncytial virus the most common pathogens
  • 39. Acute Chest Syndrome ED Treatment Essentials:  Antibiotics to cover both typical & atypical pathogens  Supportive respiratory care  A transfusion strategy based on goals and severity Gladwin M. New England Journal of Medicine 2008; 359:2254-65. Goal Target Increase oxygen carrying capacity Hgb ≥10 grams Manage vaso-occlusive complications HbS <30% Both As above
  • 42. RCE = Red Cell Exchange
  • 43. Cases Studies From Our Emergency Medicine Partners In Brazil 43 Year Old Presents To An Outpatient Clinic After A Syncopal Episode He Has Normal Labs, A Normal ECG And This Chest X-Ray He Is Sent Home
  • 44. Cases Studies From Our Emergency Medicine Partners In Brazil Right Upper Lobe Pneumonia 43 Year Old Seen In The Outpatient Clinic Four Days Later He Now Presents To The ED With Cough, Fever & Rigors
  • 45. Cases Studies From Our Emergency Medicine Partners In Brazil 43 Year Old Seen Four Days Ago In The Outpatient Clinic Let’s Take Another Look At The First CXR…
  • 46. Cases Studies From Our Emergency Medicine Partners In Brazil Subtle pneumonias can be easy to miss (especially with overlapping structures near by), make sure you are comparing each lung field with the other side. 43 Year Old Seen Four Days Ago In The Outpatient Clinic Let’s Take Another Look At The First CXR…
  • 47. 27 Year Old With One Week Of Chest Pain and Dyspnea Transferred From An Outlying Hospital After Chest CT Case #3
  • 48. 27 Year Old With One Week Of Chest Pain and Dyspnea
  • 49. 27 Year Old With One Week Of Chest Pain and Dyspnea Chest CT Obtained: Large Pericardial Effusion
  • 50. 27 Year Old With One Week Of Chest Pain and Dyspnea ECHO
  • 51. 27 Year Old With One Week Of Chest Pain and Dyspnea Cardiac Apex
  • 52. 27 Year Old With One Week Of Chest Pain and Dyspnea Pericardial Effusion: Pericardiocentesis = 250 cc Straw-Colored Fluid Cardiac Apex ** * *
  • 53.  Rapidly accumulating pericardial effusions cause swift increases in intrapericardial pressure and tamponade physiology.  Slowly accumulating pericardial effusions gradually distend the pericardium and symptoms can be delayed.
  • 54. 23 Year Old Car Crash In To A Tree A Chest CT Is Obtained
  • 55. 23 Year Old Car Crash In To A Tree A Chest CT Is Obtained Severe Pulmonary Contusion
  • 56. 23 Year Old Car Crash In To A Tree. He Is Transferred To Our ED And Is Intubated Upon Arrival For Severe Agitation And Persistent Hypoxia Severe Pulmonary Contusion
  • 57. 69 Year Old With Emphysema Does He Have A Pneumothorax On The Right?
  • 58. No! He Has A Large Right Lung Bleb 69 Year Old With Emphysema Does He Have A Pneumothorax On The Right?
  • 59. 69 Year Old With Emphysema Pulmonary Bleb Drainage Catheters
  • 60. 79 Year Old Male Smoker Presents With Cough And Two Weeks Of Right Sided Chest Pain Chest X-Ray From 3 Years Ago
  • 61. 79 Year Old Male Smoker Presents With Cough And Two Weeks Of Right Sided Chest Pain Chest X-Ray From Today: What Do You See?
  • 62. 79 Year Old Male Smoker Presents With Cough And Two Weeks Of Right Sided Chest The Lateral View Is Helpful
  • 63. 79 Year Old Male Smoker Presents With Cough And Two Weeks Of Right Sided Chest The Lateral View Is Helpful This Looks Like A Round Mass
  • 64. 79 Year Old Male Smoker Presents With Cough And Two Weeks Of Right Sided Chest The Lateral View Is Helpful This Looks Like A Round Mass Is This Fluid, A Mass, Or Both?
  • 65. Right Lung Mass + Effusion + Metastasis To The Chest Wall [*] * * Pathology Non-Small Cell Lung Cancer
  • 66. Summary Of Diagnoses This Month  Sternal fracture  Left hemothorax  Traumatic aortic aneurysm  Acute chest syndrome  Right upper lobe pneumonia  Pericardial effusion  Pulmonary contusion  Pulmonary bleb  Non-small-cell lung cancer
  • 67. See You Next Month!