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: • Mycoplasma pneumonia • Thoracic aortic aneurysm • Hydropneumothorax • Sternal fracture • Foreign body • Iatrogenic pneumothorax • Pulmonary contusion • Type A aortic dissection • Cardiomegaly • PCP pneumonia • Pneumothorax

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
February 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. Healthy 20-Year-
Old Male Seen At
His PCP’s Office
Where This Chest
X-Ray Was
Obtained.

8. Healthy 20-Year-
Old Male Seen At
His PCP’s Office
Where This Chest
X-Ray Was
Obtained:
Diagnosed With
RLL Pneumonia.
Rx: Ceftriaxone + A Prescription For Amoxicillin/Clavulanate

9. The Patient Presents To The ED 24 Hours Later With Cough + Persistent Tachycardia & Hypoxia.

10. The Patient Presents To The ED 24 Hours Later With Cough + Persistent Tachycardia & Hypoxia.
Worsening Pneumonia Despite Therapy.

11. ED Rx: Azithromycin + Ceftriaxone & Admitted.
The Patient Presents To The ED 24 Hours Later With Cough + Persistent Tachycardia & Hypoxia.

12. Serology [+] For Mycoplasma.

13. The Patient Was Initially Treated
With Ceftriaxone In The Office And
Prescribed Amoxicillin-Clavulanate.
Is This An Appropriate Strategy For
The Outpatient Management of
Community Acquired Pneumonia?

14. The Patient Was Initially Treated
With Ceftriaxone In The Office And
Prescribed Amoxicillin-Clavulanate.
Is This An Appropriate Strategy For
The Outpatient Management of
Community Acquired Pneumonia?
According To The Most Recent IDSA/ATS
Guidelines: The Answer is Yes.

16. This Represents A Change From The 2007 IDSA/ATS Guidelines.

18. “In a departure from the prior CAP guidelines, the panel did not give a strong
recommendation for routine use of a macrolide antibiotic as monotherapy for
outpatient community acquired pneumonia. This was based on studies of macrolide
failures in patients with macrolide-resistant S. pneumonia1,2, in combination with a
macrolide resistance rate of >30% among S. pneumonia isolates in the United States, of
which is high-level resistance3.”
1Lonks JR. Clin Infect Dis 2002;35:556-564.
2Daneman N. Clin Infect Dis 2006; 43:432-438.
3CDC. Active Bacteria Core Surveillance (ABCs) Report - 2015. Report Accessed 2019.
PUNCH LINE?
 Macrolide monotherapy is no longer recommended because of Pneumococcal
resistance.
 Know your local resistance patterns [Charlotte, NC = 30% resistance in 2019].
 Choose double therapy if atypical pneumonia is a possibility.

19. A Complete Summary Of The 2019
IDSA/ATS Guidelines For The
Management of Community Acquired
Pneumonia Are Included At The End
Of This Presentation As An Appendix.

20. 65-Year-Old Traveling Through Charlotte Presents From The Airport With Dyspnea.65-Year-Old Traveling Through Charlotte Presents From The Airport With Dyspnea.

21. 65-Year-Old Traveling Through Charlotte Presents From The Airport With Dyspnea.65-Year-Old Traveling Through Charlotte Presents From The Airport With Dyspnea.
Calcified Aneurysm Of The Thoracic Aorta

22. Thoracic Aortic Aneurysm: 58 x 54 mm Maximal Diameter
65-Year-Old Traveling Through Charlotte

23. 75-Year-Old Has A Routine Pre-Operative Chest X-Ray

24. Thoracic Endovascular Aortic Repair [TEVAR]
75-Year-Old Has A Routine Pre-Operative Chest X-Ray

30. 62-Year-Old Male With Prostate Cancer
Presents To The ED With Acute Dyspnea.

31. 62-Year-Old Male With Prostate Cancer
Presents To The ED With Acute Dyspnea.
Right Hydropneumothorax

32. If It Looks Like This… There’s Air In There!

33. MVC – Struck Chest On The Steering Wheel

34. MVC – Struck Chest On The Steering Wheel
Sternal Fracture
 Direct impact to the anterior chest.
 Overlying tenderness & swelling.
 Best seen on the lateral view.

35. What Do You See?

37. Sometimes The Foreign Body Is No So Easy To See!
Get A 2nd Views If You Suspect It And Your PA or AP Views Are “Negative.”
Swallowed
Coin

38. What Do You See?

40. Nail Gun
Injury
Sometimes The Foreign Body Is No So Easy To See!
Get A 2nd Views If You Suspect It And Your PA or AP Views Are “Negative.”

41. Intubated Patient In The ICU Develops Hypoxia & Hypotension.

42. Left Tension Pneumothorax After Central Line Placement

43. Left Tension Pneumothorax – After Chest Tube

44. 70-Year-Old With
Presents With
Dyspnea.

45. Spontaneous Pneumothorax
70-Year-Old With
Presents With
Dyspnea.

46. 70-Year-Old With
Presents With
Dyspnea.
Spontaneous Pneumothorax

47. 69-Year-Old In A
Motor Vehicle
Crash. Complains
Of Left Shoulder
Pain.

48. 69-Year-Old In A
Motor Vehicle
Crash. Complains
Of Left Shoulder
Pain.
RUL Pulmonary Contusion

49. 69-Year-Old In A Motor Vehicle Crash. Complains Of Left Shoulder Pain.
RUL Pulmonary Contusion

51. 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.

52. 53-Year-Old With
Hypertension
Presents With
Severe Chest And
Abdominal Pain.

53. 53-Year-Old With
Hypertension
Presents With
Severe Chest And
Abdominal Pain.
Read As “Normal.”
The Team Remains
Concerned About
Aortic Dissection.

54. 53-Year-Old With Hypertension Presents With Severe Chest And Abdominal Pain.

55. Chest X-Rays With The ABSENCE Of:
A Mediastinal Widening 37%
A Mediastinal Widening And Abnormal Contour 21%
N = 464

56. Chest X-Rays With The ABSENCE Of:
A Mediastinal Widening 37%
A Mediastinal Widening And Abnormal Contour 21%
N = 464
Punch Line?
If You Are Worried About Aortic Dissection… Don’t
Stop With A ”Normal” Chest X-Ray!

57. 45-Year-Old
Presents With
One Week Of
Dyspnea and
Night Sweats.

58. Diffuse Airspace Opacities.
45-Year-Old
Presents With
One Week Of
Dyspnea and
Night Sweats.
The Patient Has
Recently Been
Diagnosed With
HIV.

59. 45-Year-Old
Presents With
One Week Of
Dyspnea and
Night Sweats.
The Patient Has
Recently Been
Diagnosed With
HIV.
Pneumocystis Jiroveci Pneumonia.

62. Treatment Of Pneumocystis Pneumonia
Trimethoprim-sulfamethoxazole First Choice
Primaquine + clindamycin Alternative
Atovaquone suspension Alternative
Pentamidine1 Alternative
Patients with suspected or documented PCP and moderate to severe
disease, defined by a room air PO2 <70 mmHg should receive
adjunctive corticosteroids as soon as possible and certainly within
72 hours after starting specific PCP therapy.
1IV route only; aerosolized pentamidine should not be used.

63. Summary Of Diagnoses This Month
 Mycoplasma pneumonia
 Thoracic aortic aneurysm
 Hydropneumothorax
 Sternal fracture
 Subtle foreign bodies
 Iatrogenic pneumothorax
 Pulmonary contusion
 Type A aortic dissection
 Cardiomegaly
 Spontaneous pneumothorax
 Pneumocystis pneumonia

64. APPENDIX

70. Question #1:
In adults with CAP, should gram stain and cultures of lower respiratory secretions be
obtained at the time of diagnosis?
 Recommend not obtaining sputum Gram stain and cultures routinely in adults with
CAP managed in the outpatient setting.
 Recommend obtaining Gram stain and cultures in adults with CAP who: (1) have
severe CAP* [especially if intubated], or (2) are being treated empirically for MRSA or
P. aeruginosa.
*See next slide for IDSA/ATS definition of “severe community-acquired pneumonia.”

71. Question #2:
In adults with CAP, should blood cultures be obtained at the time of diagnosis?
 Recommend not obtaining blood cultures in adults with CAP managed in the
outpatient setting.
 Recommend obtaining blood cultures in adults with CAP managed in the hospital who:
(1) are classified as severe CAP, (2) are being treated empirically for MRSA or P.
aeruginosa, (3) were previously infected with MRSA or P. aeruginosa, (4) were
hospitalized and received parenteral antibiotics in the last 90 days.

72. Question #3:
In adults with CAP, should Legionella and Pneumococcal urinary antigen testing be
performed at the time of diagnosis?
Recommend not routinely testing adults with CAP, except in: (1) patients with severe CAP,
and/or (2) in cases where this is indicated by epidemiological factors such as exposure to
a Legionella outbreak, or recent travel.

73. Questions #4, #5, #6:
In adults with CAP:
 Should a respiratory sample be tested for Influenza virus at the time of diagnosis?
 Should influenza treatment be initiated for adults with a [+] test?
 Should influenza [+] adults being treated with an antiviral also be treated with an
antibacterial regimen?
 When influenza is circulating in the community, a rapid influenza molecular assay is
recommended.
 For [+] tests, treatment with oseltamivir is recommended.
 For [+] tests, standard antibacterial treatment is recommended.

74. Question #7:
In adults with CAP, should serum procalcitonin plus clinical judgment versus clinical
judgment alone be used to withhold initiation of antibiotic treatment?
Recommend that empiric antibiotic therapy should be initiated in adults with clinically
suspected and radiographically confirmed CAP regardless of initial serum procalcitonin
level.

75. Question #8, 9:
Should a clinical prediction rule for prognosis plus clinical judgment versus clinical
judgment alone be used to determine: (1) inpatient versus outpatient treatment location
for adults with CAP, and (2) the best site of treatment [floor vs. Step-Down vs. ICU]?
 In addition to clinical judgement clinicians should use a validated clinical prediction
rule for prognosis, preferentially the Pneumonia Severity Index (PSI).
 When compared with CURB-65, PSI identifies larger proportions of patients as low
risk, and has a higher discriminative power in predicting mortality.
 Compared with PSI, there is less evidence that CURB-65 is effective as a decision aid in
guiding the initial site of treatment.

76. Question #10:
In the outpatient setting, which antibiotics are recommended for empiric treatment of
CAP in adults?
For healthy outpatient adults: (1) amoxicillin 1 g TID, or (2) doxycycline 100 mg BID, or (3)
azithromycin 500 mg on first day then 250 mg daily, or (4) clarithromycin 500 BID.
For outpatient adults with comorbidities (heart failure, liver or renal disease, diabetes,
alcoholism, malignancy or asplenia):
 Amoxicillin/clavulanate 500mg/125 mg TID, or a cephalosporin, AND a macrolide
(azithromycin, clarithromycin, or
 Monotherapy with a respiratory fluoroquinolone: levofloxacin 750 mg QD, or
moxifloxacin 400 mg QD, or gemifloxacin 320 mg QD.

77. Question #11:
In the inpatient setting, which antibiotics are recommended for empiric treatment of CAP
in adults without risk factors for MRSA and P. aeruginosa?
In inpatients with non-severe CAP:
 A 𝛽-lactam + a macrolide, or
 Monotherapy with a respiratory fluoroquinolone, or
 A 𝛽-lactam + doxycycline [if macrolides & fluoroquinolones are not tolerated]
In patients with severe CAP:
 A 𝛽-lactam + a macrolide, or
 A 𝛽-lactam + a respiratory fluoroquinolone

78. Question #12:
In the inpatient setting, should patients with suspected aspiration pneumonia receive
additional anaerobic coverage beyond standard empiric treatment?
Recommend not routinely adding anaerobic coverage for suspected aspiration
pneumonia unless lung abscess or empyema is suspected.

79. Question #13:
In the inpatient setting, should adults with CAP and risk factors for MRSA or P. aeruginosa
be treated with extended-spectrum antibiotic therapy instead of standard CAP regimens?
Recommend that clinicians only cover empirically for MRSA or P. aeruginosa in adults
with CAP if locally validated risk factors for either pathogen are present.
MRSA Vancomycin (15 mg/kg), or linezolid (600 mg BID)
P. aeruginosa Piperacillin-tazobactam (4.5 grams Qº6), or cefepime (2 grams Qº8), or
aztreonam (2 grams Qº8), or imipenem 500 mg Qº6)

80. Question #14:
In outpatient and inpatient adults with CAP who are improving, what is the appropriate
duration of antibiotic therapy?
Recommend that the duration of antibiotic therapy should be guided by a validated
measure of clinical stability (resolution of vital sign abnormalities, ability to eat, and
normal mentation), and antibiotic therapy should be continued until the patient achieves
stability for no less than 5 days.

81. Question #15:
In the inpatient setting, should adults with CAP be treated with corticosteroids?
 Recommend not routinely using corticosteroids in adults with non-severe CAP.
 Recommend not routinely using corticosteroids in adults with severe CAP.
 Recommend not routinely using corticosteroids in adults with severe influenza CAP.
 Endorse the Surviving Sepsis Campaign recommendations on the use of corticosteroids
in patients with CAP and refractory septic shock.

87. See You Next Month!