Dr. Escobar’s CMC X-Ray Mastery Project: December Cases

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
December 2021

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.

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

Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

Case #1
63-Year-Old
Male Involved
In A High-
Speed MVC.
He Complains
Of Back Pain
And Right-
Sided Chest
Pain.

Case #1
63-Year-Old
Male Involved
In A High-
Speed MVC.
He Complains
Of Back Pain
And Right-
Sided Chest
Pain.
Haziness Of The Right Lower Lung Fields

In The Supine Patient A
Hemothorax May Appear Only
As “Haziness” On The CXR
Our Patient Had 500 cc Of Bloody
Chest Tube Output Following Tube
Insertion In The ED.

Case #2
25-Year-Old
Male Involved
In A High-
Speed MVC
With Roll-Over.

Case #2
25-Year-Old
Male Involved
In A High-
Speed MVC
With Roll-Over.
Haziness Of The Left Lower Lung Fields

Case #2: 25-Year-Old Male Involved In A High-Speed MVC With Roll-Over.
Severe Pulmonary Contusions

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.

A Recent Outpatient CT Scan Reveals A Compression Fracture Of L4
An MRI Obtained In The ED Reveals A Lytic Lesion of L4 With Soft Tissue Extension
Case #3
A 71-Year-Old
Female Is
Referred To
The ED With
Low Back Pain
And An
“Abnormal
Spine CT.”

Case #3: The ED Team Orders A Screening Chest X-Ray

*
*
Large Right Lower Lobe Density (*)
Case #3: The ED Team Orders A Screening Chest X-Ray

*
* *
Chest CT Imaging Reveals A Right
Lower Lobe Lung Mass
Dx: Squamous Cell Lung Cancer

Relative Incidence
Breast 65%-75%
Prostate 65%-75%
Thyroid 60%
Lung 30%-40%
Bladder 40%
Renal Cell 20%-25%
Melanoma 15%-45%
Bone metastases are a major cause of morbidity, characterized by pain, impaired mobility,
pathologic fractures, spinal cord compression, bone marrow aplasia, and hypercalcemia.
Based On These Incidences, Once You Have Identified A
Bone Metastases What Might Your Do In The ED1 To
Help Zero In On The Primary Malignancy?
Physical Exam
• Breast exam
• Prostate exam
• Neck exam
• Skin exam
Testing
• Chest X-ray
• CBC, metabolic package
• PSA in males (send)
1Additional laboratory & imaging studies should be done outpatient

Case #4a
A 25-Year-Old Male
With Diabetes
Presents With
Symptoms Of
Hyperglycemia And
Multiple Episodes
On Non-Bilious
Vomiting.

Case #4a
A 25-Year-Old Male
With Diabetes
Presents With
Symptoms Of
Hyperglycemia And
Multiple Episodes
On Non-Bilious
Vomiting.
Pneumomediastinum

What Do You See?
Case #4b
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.

The Image On The Right Is A Prior CXR
From The Same Patient For Comparison

Arrows Pointing To Tracking Free Air
Case #4b
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

Common Signs and Symptoms:
Shortness of breath, chest and/or, neck pain, sore throat, dysphagia, voice changes
Common Physical Exam Findings:
Palpable subcutaneous crepitus
Hamman’s Sign (an auscultatory crunch or clicking sound heard synchronously with each heartbeat)

First, let’s review
mediastinal anatomy!
The mediastinum is
structurally divided
into Superior &
Inferior
Compartments, along
the Sternal Angle
The Inferior
Compartment is
further divided into
Anterior, Middle, and
Posterior divisions

Subcutaneous Emphysema
Free air that tracks through the soft tissues
leading to physical exam findings of crepitus

Thymic (“Spinnaker”)Sail Sign
Both lobes of the thymus become displaced
from center by mediastinal free air
Normal Thymic Appearance Spinnaker Sail Of A Ship
Pneumomediastinum Thymic Appearance

Pneumopericardium
Mediastinal air fills the pericardial sac and surround
the heart (Arrow 1). Arrow 2 points to a chest tube.

Ring Around The Artery Sign
As visualized on LATERAL view, air surrounds
the pulmonary artery and/or its main branches

Tubular Artery Sign
Air surrounds the major branches of the
aorta, more clearly defining them

Double Bronchial Wall Sign
With air within the main bronchi and free air
surrounding the outside of the bronchi, you can
more crisply visualize both walls of each bronchi

Continuous Diaphragm Sign
Mediastinum air tracks behind the pericardium
giving the illusion of a continuous line crossing
the diaphragmatic surfaces

Extrapleural Sign
Air is entrapped within the mediastinum and
extends along the parietal pleura and diaphragm,
creating a line that parallels the descending aorta

Pneumomediastinum ED
Management Literature Review

References
Article Info
Related Articles
This paper is only available as a PDF. To read,
Please Download here.
Study objective:
To evaluate the clinical characteristics and natural history of
patients presenting with spontaneous pneumomediastinum.
Design:
A retrospective case series was conducted to identify patients
diagnosed with spontaneous pneumomediastinum. ICD-9
discharge codes were used for 1984 to 1990 at two institutions,
and emergency department records of a third hospital were
reviewed for 1981 to 1986. Clinical features, interventions,
complications, setting, etiology, symptoms, and length of
hospital stay were recorded.
Spontaneous pneumomediastinum: Clinical and natural
history
• • • •
DOI:
ORIGINAL CONTRIBUTION | VOLUME 21, ISSUE 10, P1222-1227, OCTOBER 01, 1992 !
Purchase
"
Subscribe
#
Save
$
Sha
MD Edward A Panacek + MD Andrew J Singer MD Bruce W Sherman PAC Amanda Prescott
MD William F Rutherford
https://doi.org/10.1016/S0196-0644(05)81750-0
'
Single-center retrospective cases series examining the cause and
outcomes of 17 ED patients presenting with pneumomediastinum.
Chest Pain 47%
Dyspnea 18%
Hamman’s Crunch 52%
Illicit Inhalation Drugs 76%
Valsalva Maneuver 70%
14 patients were admitted for a period of observation and none
suffered any complications or required any interventions.

www.EMGuidewire.com. February 2020

Conclusions
Spontaneous pneumomediastinum:
• A benign condition seen primarily in younger adults that is associated
with an uneventful recovery and unlikely recurrence
• In most cases the presentation involves chest pain, dyspnea, cough,
and/or subcutaneous emphysema
• The diagnosis requires a high index of suspicion because 30% of
patients present without any precipitating factors and 30% of patients
will have a normal initial chest X-ray

Conclusions
Secondary pneumomediastinum, that had a 39% mortality in this
study, is associated with:
• An older age at presentation
• A higher prevalence of associated pneumothorax
• A higher requirement for tube thoracostomy drainage
• The presence of a pleural effusion
• Longer hospital stays

Patient #1
52-year-old admitted with dyspnea, fever, cough. He was initially started on non-invasive
ventilation but worsened and required endotracheal intubation. Post-intubation reveal
consolidation and pneumomediastinum [Fig 1a]. He improved with supportive care.
Patient #2
68-year-old admitted with dyspnea requiring increasing CPAP support. Following intubation
imaging reveals pneumomediastinum with widespread extension. He did develop a
pneumothorax requiring drainage. He subsequently improved with complete resolution.
Patient #3
66-year-old requiring admission and early intubation. Chest X-ray revealed extensive
pneumomediastinum. Serial CXR confirmed gradual resolution.

Discussion
• In the patient with COVID-19, pneumomediastinum appears to be the
consequence of the high PEEP required to maintain oxygenation.
• In this case series all patient had gradual resolution of their
pneumomediastinum.
• While the patient is intubated, serial chest X-rays are recommended
to monitor for the possibility of iatrogenic pneumothorax.

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
Management Essentials
 Manage the underlying cause
 Pain management & cough suppression as indicated
 Oxygen may increase gas absorption in severe cases
 Advanced imaging (e.g.: esophagram) not routinely required
 Brief period of observation vs. close outpatient follow-up

Carolinas Medical Center
Pneumomediastinum Case Studies

Gunshot
Wound To
The Neck
With
Tracheal And
Esophageal
Injury
Pneumomediastinum & Pneumopericardium

Healthy 13-Year-Old With Throat And Upper Chest Pain

Pneumomediastinum
25-Year-Old With Intractable Vomiting

25-Year-Old With Intractable Vomiting
Pneumomediastinum

Summary Of Diagnoses This Week
• Blunt Hemothorax
• Pulmonary Contusion
• Lung Cancer With Bone Metastases
• Pneumomediastinum & Pneumopericardium

Dr. Escobar’s CMC X-Ray Mastery Project: December Cases

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Editor's Notes