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: • Esophageal Perforation • Perforated Viscous • Pneumothorax • Traumatic Diaphragmatic Hernia • Pulmonary Contusion • COVID-19 associated Pneumonia • COVID-19 • Influenza Like Illness

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
April 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. 54-Year-Old Male
With A History of
Alcoholism
Presents with
Chest Pain and
Back Pain.

8. CXR Read as
Normal
54-Year-Old Male
With A History of
Alcoholism
Presents with
Chest Pain and
Back Pain.

9. CT Scan Performed
Diagnosis: Ruptured Esophagus

10. Let’s Look Back At The
Original CXR For Clues…
Notice the Subcutaneous Air

11. Citation: He X, He Z and Li H. "Boerhaave syndrome: Challenges in diagnosis and treatment of the early
presentation and its complication." The Journal of Trauma and Acute Care Surgery 84.6 (2018): 1030-1032.
Ovid MEDLINE(R). Web. 17 April. 2020.
Esophageal Perforation
• Spontaneous esophageal perforation = Boerhaave syndrome
• Classic acute presentation includes:
 Vomiting,
 Chest Pain
 Subcutaneous Emphysema
• “Plain chest X-ray is the most useful in early diagnosis”
• CT scan will not show the location of the tear, but does have secondary findings
• Contrast esophogram will show leaking into the mediastinum

12. Citation: E. (Ilias) K. Sdralis, S. Petousis, F. Rashid, B. Lorenzi, A. Charalabopoulos, Epidemiology, diagnosis, and
management of esophageal perforations: systematic review, Diseases of the Esophagus, Volume 30, Issue 8, August
2017, Pages 1–6, https://doi.org/10.1093/dote/dox013
• Esophageal perforation has a high mortality rate (13.3%)
• Sepsis was a complication of 1 in 4 esophageal perforations
• Only 58.1% of people were admitted to the hospital within 24 hrs of symptom onset
• 72.6% were thoracic in location
• CXR was the initial imaging study for diagnosis in 36.6% of cases
Epidemiology, diagnosis, and management of esophageal perforations: systematic review

13. Citation: E. (Ilias) K. Sdralis, S. Petousis, F. Rashid, B. Lorenzi, A. Charalabopoulos, Epidemiology, diagnosis, and
management of esophageal perforations: systematic review, Diseases of the Esophagus, Volume 30, Issue 8, August
2017, Pages 1–6, https://doi.org/10.1093/dote/dox013
• Esophageal perforation is a high-risk clinical presentation
• There is currently no good consensus on the best way to diagnose and manage
esophageal perforation.
Epidemiology, diagnosis, and management of esophageal perforations: systematic review

14. Esophageal Perforation
• High risk of morbidity and mortality
• There is often a delay in diagnosis
• Prompt diagnosis and management are key to improve survival rates
• CXR is a good initial study. Consider contrast esophagram as the next step instead of CT:
 Have a high level of suspicion and look for secondary findings, like widened mediastinum,
subcutaneous emphysema, and mediastinal air
 Always compare to a prior study when able!

15. 26-Year-Old Male
Presents With Abdominal
Pain.

16. Diagnosis: Perforated Viscus From
Swallowing A Plastic Fork
26-Year-Old Male
Presents With Abdominal
Pain.

17. 60-Year-Old Male With A
History Of ESRD, COPD Presents
With Left-Sided Chest Pain And
Dyspnea.

18. Diagnosis: Spontaneous Left-Sided Pneumothorax
60-Year-Old Male With A
History Of ESRD, COPD Presents
With Left-Sided Chest Pain And
Dyspnea.

19. Resolution Of The Pneumothorax After
Pigtail Catheter Placement

20. Day 1 Day4

21. Day 6: After Left Video-Assisted
Thorascopy With Talc Pleurodesis.

22. Day 9: Shows Complete
Resolution Of The Left-Sided
Pneumothorax.

23. 19-Year-Old Female With
Substernal Chest Pain And Left
Upper Abdominal Pain After A
Car Crash.

24. Diagnosis: Left Traumatic Diaphragmatic Hernia
Notice the nasogastric tube
above the diaphragm
19-Year-Old Female With
Substernal Chest Pain And Left
Upper Abdominal Pain After A
Car Crash.

25. Post Diaphragmatic RepairPresenting CXR

26. 39-Year-Old Female Presents
With Dyspnea And Hypoxia
Following A Car Crash.

27. Diagnosis: Pulmonary Contusion
39-Year-Old Female Presents
With Dyspnea And Hypoxia
Following A Car Crash.

28. CT Chest With Severe Pulmonary Contusion

29. The Importance Of The Lung Window

30. 56-Year-Old Male With A History
Of Hypertension And Vascular
Disease Presenting With 1 Week
Of Progressive Myalgias And
Shortness Of Breath.

31. 56-Year-Old Male With A History
Of Hypertension And Vascular
Disease Presenting With 1 Week
Of Progressive Myalgias And
Shortness Of Breath.
Diagnosis: COVID-19 [+] Pneumonia

32. Bilateral Ground Glass Opacities
Bilateral Pleural Effusions
A CT Scan Of The
Chest Is Performed.
Diagnosis: COVID-19 [+] Pneumonia

33. 61-Year-Old Male With
Fever, Myalgias, And
Diarrhea.

34. Tested For COVID And Discharged to Self-Quarantine
61-Year-Old Male With
Fever, Myalgias, And
Diarrhea.

35. Prior CXR 3 Days later
61-Year-Old Male: COVID [+] And Returns With SPO2 Of 70% On Room Air!

36. Intubated
The NEXT Day
61-Year-Old Male: COVID [+].

37. 61-Year-Old Male: COVID [+].
After Failing Extubation Twice, A Tracheostomy Was Required.

38. 60-Year-Old Male With A
History COPD On Home
O2 Presents With Fever
And Symptoms Of An
Influenza-Like Illness
[ILI+].

39. Diffuse Interstitial Opacities
60-Year-Old Male With A
History COPD On Home
O2 Presents With Fever
And Symptoms Of An
Influenza-Like Illness
[ILI+].

40. Diagnosis: COVID-19 [+] Pneumonia

41. Admission CXR for comparison Present CXR

42. 70-Year-Old Male With A
History Of Diabetes And
Recent COVID [+] Testing
Presents With ILI Symptoms.

43. New Patchy Bilateral Opacities
70-Year-Old Male With A
History Of Diabetes And
Recent COVID [+] Testing
Presents With ILI Symptoms.

44. Prior CXR for comparison Present CXR

45. Summary Of Diagnoses This Month
 Ruptured Esophagus
 Perforated Viscus
 Persistent Spontaneous PTX
 Traumatic Diaphragmatic Hernia
 Pulmonary Contusion
 COVID -19 Pneumonia
PLEASE STAY TUNED FOR A COVID-19 SPECIFIC PRESENTATION
COMING SOON!

46. See You Next Month!