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:
Bullous Lung Disease
Influenza Myocarditis Requiring Circulatory Support
Free Air representing:
Pneumothorax
Tension Pneumothorax
Pneumoperitoneum
Subdiaphragmatic Abscess
Pneumobilia
Subcutaneous Free Air
Pneumomediastinum
Drs. Escobar, Pikus, and Blackwell’s CMC X-Ray Mastery Project: February Cases
1. Adult Chest X-Rays Of The Month
Daniel Escobar, MD, Angela Pikus, MD,
Alex Blackwell, MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD - Faculty Editor
CMC Imaging Mastery Project
February 2022
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.
14. 54-Year-Old
Male With A
History Of
Emphysema.
Here Is His
Chest X-Ray
3 Years Ago.
www.EMGuidewire.org – November 2020
Bilateral Upper
Lobe Bullous
Lung
Disease
16. Severe Apical Bullous Disease
Acute Right Pneumothorax
54-Year-Old Male With A History Of Emphysema
www.EMGuidewire.org – November 2020
17. 54-Year-Old Male With A History Of Emphysema
Lung Re-expanded After Pigtail Catheter Placement
www.EMGuidewire.org – November 2020
18. Definition:
Giant bullae on one or both upper lobes occupying at least 1/3 of the hemithorax,
compressing adjacent lung tissue
Demographics:
Young male smokers with a history of cannabis use
Chronic obstructive pulmonary disease
𝛼-1 antitrypsin disease, Marfan syndrome, Ehlers-Danlos syndrome
Complications:
Hypoxia, dyspnea, hemoptysis, spontaneous pneumothorax
Infection of bullae
www.EMGuidewire.org – November 2020
24. 40-Year-Old
Male With
Cough, Dyspnea
And Vomiting
For Past Few
Days. He
Presented To The
ED In Cardiac
Arrest!
Laboratory Results:
WBC- 30.9 (h)
Lactate- 12.1 (h)
Troponin- 6,312 (h)
Flu A- Positive
COVID- Negative
What Do You See?
25. 40-Year-Old
Male With
Cough, Dyspnea
And Vomiting
For Past Few
Days. He
Presented To The
ED In Cardiac
Arrest!
Chest X-Ray Results:
Diffuse Interstitial
Opacities
Representing Fluid
Or Pneumonia.
26. Our Same In The
ICU Patient With
A Lot More
Wires!
What Do You See?
27. Our Same In The
ICU Patient With
A Lot More
Wires!
Properly Placed
Swan Ganz
Catheter.
Swan Ganz
Measurements
Suggest Cardiac
Failure That Is
Felt To Be Due To
Viral
Myocarditis
28. Swan-Ganz
Catheter
Provides Continuous
Assessments Of
Flow, Pressure, O2
Delivery And
Consumption To
Assess Cardiac
Function.
Placed Via The
Internal Jugular
Vein, Right Atrium,
Right Ventricle, And
Into The Pulmonary
Artery. Results Are
Indirect
Measurement Of
Pressures In The Left
Atrium.
29. Our Same
Patient A Few
Days Later With
Less Wires But
One Big
Addition.
What Do You See?
32. ECMO
Indication: Acute, severe reversible respiratory or cardiac failure with a
high risk of death that is refractory to conventional therapies.
V-V = veno venous
V-A = veno-arterial
www.EMGuidewire.org
33. Figure 1: Graphical depiction of V-VECMO, where blood is drained from the femoral vein above the diaphragm and
Figure 1: V-V ECMO
Blood is drained from the femoral vein
and returned to the right heart.
www.EMGuidewire.org
34. Figure 2: V-V ECMO
Central venous blood is drained, and
oxygenation blood is returned to the
right atrium.
www.EMGuidewire.org
35. V-V ECMO
Support for severe pulmonary failure (w/o cardiac failure).
Clinical Condition Appropriate For V-V ECMO
• Pneumonia
• ARDS
• Acute GVHD
• Pulmonary contusion
• Smoke inhalation
• Status asthmaticus
• Airway obstruction
• Aspiration
• Bridge to lung transplant
• Drowning
www.EMGuidewire.org
36. Figure 3: V-A ECMO
Central venous blood is drained, and
oxygenation blood is returned to the
arterial system.
Figure 3: Graphical depiction of V-A ECMO, where central venous blood is drained and oxygenated blood is returned
www.EMGuidewire.org
37. V-A ECMO
Support for cardiac failure (+/- pulmonary failure).
Clinical Condition Appropriate For V-A ECMO
• Graft failure post heart or heart
lung transplant
• Non-ischemic cardiogenic shock
• Failure to wean post
cardiopulmonary bypass
• Bridge to LVAD
• Drug overdose
• Sepsis
• Pulmonary embolus
• Cardiac or major vessel trauma
• Massive pulmonary hemorrhage
• Pulmonary trauma
• Acute anaphylaxis
www.EMGuidewire.org
39. A 40-Year-Old
Male With COVID-
Related ARDS
Intubated in ED.
This Chest X-Ray
Was Obtained
Following A
Bronchoalveolar
Lavage Was
Performed.
40. A 40-Year-Old
Male With COVID-
Related ARDS
Intubated in ED.
This Chest X-Ray
Was Obtained
Following A
Bronchoalveolar
Lavage Was
Performed.
Bilateral Pneumothorax
53. 80-Year-Old Male
With history of
GIST Tumor
Resection
Presented With
Severe Abdominal
Pain.
Red Arrows The
Diaphragms And
There Is Free Air
Beneath Them.
Pneumoperitoneum
59. 25-Year-Old Male
Presenting After
Being Found
Down By Family In
Living Room
Unresponsive.
At Laparotomy A
Perforated Gastric
Ulcer Was Found.
Due To Abdominal
Compartment And A
Large Amount Of
Bowel Ischemia The
Patient Did Not
Survive.
Free Air
Below The
Diaphragm
Tension Pneumoperitoneum
Free Air
Below The
Diaphragm
62. 28-Year-Old
Female Presenting
With A Stab
Wound To Neck.
Yellow Arrow:
Subcutaneous Air
Red Arrows:
Lung Edge
Right Pneumothorax & Subcutaneous Emphysema
64. 59-Year-Old
Female Presenting
After A High
Velocity Motor
Vehicle Crash.
Radiology Read As
“Normal” Other Than
Tubes And Lines.
Right Pneumothorax & Deep Sulcus Sign
67. 52-Year-Old male
With Cough,
Shortness Of
Breath, and Chest
Pain.
Sometimes The Most
Exaggerated
Pathology Can The
Most Difficult To Spot!
Shifting
Mediastinum
Shifting
Mediastinum
Right Tension Pneumothorax
68. 24-Year-Old Male
With Fever, Chills,
And Right Sided
Chest And
Abdominal Pain.
He Suffered A
Liver Injury 5
Weeks Ago
T-102.7, BP- 125/77,
HR- 114, SpO2- 96%
Air Under The
Right
Hemidiaphragm
69. 24-Year-Old Male
With Fever, Chills,
And Right Sided
Chest And
Abdominal Pain.
Adding A Lateral
View Often
Provides Very
Valuable
Information
Air Fluid
Level
70. 24-Year-Old Male With Fever, Chills, And Right Sided Chest And Abdominal Pain.
Hepatic Abscess (*) Under The Right Hemidiaphragm
*
*
*
79. 36-Year-Old Male
With Worsening
Chest Pain After
Getting Into A
Fight 2 Days Prior.
Yellow Arrow:
Subcutaneous Air
Red Arrows:
Lung Edge
Right Pneumothorax & Subcutaneous Emphysema
84. Left Apical Pneumothorax
22-Year-Old Male
With Chest Pain
After A Coughing
Fit While Vaping.
ED Management
He Was Managed
Conservatively With
Supplemental Oxygen
85. 22-Year-Old Male
With Chest Pain
After A Coughing
Fit While Vaping.
He Returns 2 Days
Later With Worsening
Chest Pain.
86. 22-Year-Old Male
With Chest Pain
After A Coughing
Fit While Vaping.
He Returns 2 Days
Later With Worsening
Chest Pain.
Enlarging Left Pneumothorax
87. A 25-Year-Old Male
With Diabetes
Presents With
Symptoms Of
Hyperglycemia And
Multiple Episodes
On Non-Bilious
Vomiting.
www.EMguidewire.com December 2021
88. A 25-Year-Old Male
With Diabetes
Presents With
Symptoms Of
Hyperglycemia And
Multiple Episodes
On Non-Bilious
Vomiting.
www.EMguidewire.com December 2021
Pneumomediastinum
90. What Do You See?
A 91-year-old-
female presents to
the Emergency
Department with
sudden onset of
hoarseness.
T-98, BP- 110/84, HR-
82, SpO2- 96%
The Physical Exam
Reveals Crepitus
Throughout The
Anterior Chest And
neck.
www.EMguidewire.com December 2021
91. The Image On The Right Is A Prior CXR
From The Same Patient For Comparison
www.EMguidewire.com December 2021
92. The diffuse tracking of free
air leads to four of several
classic findings of
pneumomediastinum:
Extrapleural Air (Red)
Extending up into the neck
Emphysema (Yellow)
Crepitus on exam
Tubular Artery Sign
Blue arrow
Pneumopericardium
Purple arrow
www.EMguidewire.com December 2021 Arrows Pointing To Tracking Free Air
93. Check Out The www.EMguidewire.com
December 2021 Adult Chest X-Ray
Presentation For A Deep Dive On Classic
Pneumomediastinum Findings!
94. Summary Of Diagnoses This Month
Bullous Lung Disease
Influenza Myocarditis Requiring Circulatory Support
“Spot The Free Air” Case Studies:
(Pneumothorax, Tension Pneumothorax, Pneumoperitoneum,
Subdiaphragmatic Abscess, Pneumobilia, Subcutaneous Free Air,
Pneumomediastinum)
![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.](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)