Drs. Breeanna Lorenzen and Travis Barlock 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 aortic disruption - Giant Bullous Emphysema (Vanishing Lung Syndrome)

1. Adult Chest X-Rays Of The Month
Travis Barlock MD & Breeanna Lorenzen, MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs MD, Faculty Editor
Chest X-Ray Mastery Project
November 2020

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. 32-Year-Old Male Involved In A High-Speed Car Crash

8. 32-Year-Old Male Involved In A High-Speed Car Crash
Tracheal
Deviation
Wide
Mediastinum
Loss Of The
Aortopulmonary
Window

9. 32-Year-Old Male Involved In A High-Speed Car Crash

10. 32-Year-Old Male Involved In A High-Speed Car Crash
Aortic
Disruption

11. 32-Year-Old Male Involved In A High-Speed Car Crash

12. 32-Year-Old Male Involved In A High-Speed Car Crash

13. 22-Year-Old Male Involved In A Head-On Car Crash

14. 22-Year-Old Male Involved In A Head-On Car Crash
Tracheal
Deviation
Wide
Mediastinum

15. 22-Year-Old Male Involved In A Head-On Car Crash

16. 22-Year-Old Male Involved In A Head-On Car Crash
Aortic
Disruption

17. 22-Year-Old Male Involved In A Head-On Car Crash

18. 22-Year-Old Male Involved In A Head-On Car Crash
Aortic
Endograph

19. Proposed
Mechanisms
Of Blunt
Aortic Injury

20. From: Gibbs MA. EM Critical Care 2011.

21. From: Gibbs MA. EM Critical Care 2011.

22. From: Gibbs MA. EM Critical Care 2011.

23. From: Gibbs MA. EM Critical Care 2011.

24. TAD Chest X-Ray Findings
1. Wide mediastinum
2. Abnormal aortic contour
3. Lost of aortopulmonary window
4. Tracheal deviation
5. Depressed left mainstem
6. Apical cap
7. Deviated nasogastric tube
8. Widened paratracheal stripe

26. Wide
Mediastinum

27. Wide
Mediastinum
Tracheal
Deviation

28. Wide
Mediastinum
Tracheal
Deviation
Apical Cap

29. Wide
Mediastinum
Tracheal
Deviation
Apical Cap
Loss Of The
Aortopulmonary Window

30. Wide
Mediastinum Loss Of The
Aortopulmonary Window
Tracheal
Deviation
Apical Cap
Depressed Left
Mainstem Bronchus

33. Grade 1:
 Intimal tear
 No external change to aortic contour
 Small tear with <10 mm of thrombus
 Rarely, can be treated conservatively
Grade 2:
 Larger intimal flap
 No external change to aortic contour
 >10 mm of thrombus visible
Sagittal View
Sagittal View

34. Grade 3:
 Pseudoaneurysm
 Bulbar appearance with change in
the appearance of the aorta
 Contained rupture
Grade 4:
 Free rupture
 Extravasated contrast beyond the
contour of the aorta
Sagittal View
Axial View

46. 42 (0.17%) Patients
Had Aortic Injury

48. 54-Year-Old
Male With A
History Of
Emphysema.
Here Is His
Chest X-Ray
3 Years Ago.

49. 54-Year-Old
Male With A
History Of
Emphysema.
Here Is His
Chest X-Ray
3 Years Ago.
Bilateral Upper
Lobe Bullous
Lung
Disease

50. 54-Year-Old Male With A History Of Emphysema.
The Patient Now Presents With Acute Pleuritic Chest Pain
And A CT Is Ordered To Rule Out Pulmonary Embolus.

51. 54-Year-Old Male With A History Of Emphysema

52. Severe Apical Bullous Disease
Acute Right Pneumothorax
54-Year-Old Male With A History Of Emphysema

53. 54-Year-Old Male With A History Of Emphysema
Lung Re-expanded After Pigtail Catheter Placement

54. 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

60. Be Cautious With That Chest Tube!

61. Summary Of Diagnoses This Month
 Traumatic aortic disruption
 Giant bullous emphysema (vanishing lung syndrome)

62. See You Next Month!