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: Sternal fracture, Left hemothorax, Traumatic aortic aneurysm, Acute chest syndrome, Right upper lobe pneumonia, Pericardial effusion, Pulmonary contusion, Pulmonary bleb, Non-small-cell lung cancer

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
July 2019

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 Carolinas Medical Center departments, and now…
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. It’s All About The Anatomy!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. MVC – Struck Chest On The Steering Wheel

7. What is your interpretation?
Be sure to look at both views closely.
MVC – Struck Chest On The Steering Wheel

8. Sternal Fracture
 Direct impact to the anterior chest.
 Best seen on the lateral view.
MVC – Struck Chest On The Steering Wheel

9. MVC – Struck Chest On The Steering Wheel
Right Sided Effusion. Could It Be Blood?
Remember Not To Miss The 2nd (Or 3rd, Or 4th) Finding(s)!

10. What Do You See?
Stab Wound
To Left Chest

11. Stab Wound
To Left Chest
Left Hemothorax

12. Stab Wound
To Left Chest
Notice:
Early Tracheal Deviation
Left Hemothorax

13. After Chest Tube Placed
Side Note:
If chest tube output
>1000 ml, consider
autotransfusion
Stab Wound
To Left Chest

14. After Chest Tube Placed
Notice:
Midline Trachea
Side Note:
If chest tube output
>1000 ml, consider
autotransfusion
Stab Wound
To Left Chest

15. A 70 Year-Old
Male Is
Thrown From
A Horse And
Presents To
An Outside ED
with Right
Sided Chest
Pain
A Chest CT Is
Ordered
Right Pneumothorax Visible On The CT Scout Film

16. A 70 Year-Old
Male Is
Thrown From
A Horse And
Presents To
An Outside ED
with Right
Sided Chest
Pain
A Chest CT Is
Ordered

17. A 70 Year-Old
Male Is
Thrown From
A Horse And
Presents To
An Outside ED
with Right
Sided Chest
Pain
Right Pneumothorax Visible On The CT Scout Film

18. A 70 Year-Old
Male Is
Thrown From
A Horse And
Presents To
An Outside ED
with Right
Sided Chest
Pain
Oops!

19. A 70 Year-Old
Male Is
Thrown From
A Horse And
Presents To
An Outside ED
with Right
Sided Chest
Pain
Pigtail Placed – Pneumothorax Persists

20. A 70 Year-Old
Male Is
Thrown From
A Horse
Pigtail Replaced

21. A 70 Year-Old Male Is Thrown From A Horse
Multiple Posterior Rib Fractures

22. What Are You Concerned About?
78 Year-Old
Who Moved To
Charlotte From
El Salvador
This Month

23. Thoracic Aortic Aneurysm [TAA]
 Thoracic aorta >3.5 cm considered dilated.
 Thoracic aorta >4.5 cm considered aneurysmal.
78 Year-Old
Who Moved To
Charlotte From
El Salvador
This Month

24. TAA: Anatomy Defined By CT Angiography

25. Thoracic Aortic Aneurysm
Endovascular Repair

26. TAA: Endograft

27. Thoracic Aortic Aneurysm

28. 25 Year Old With A
History Of Sickle Cell
Disease Presents
With Severe Pain of
Both Of His Legs and
His Lower Back.
Hospital Day 1
Afebrile, Vital Signs
Are Stable

29. What is your interpretation?
25 Year Old With A
History Of Sickle Cell
Disease Presents
With Severe Pain of
Both Of His Legs and
His Lower Back.
Hospital Day 3
Now Febrile,
Dyspneic,
Tachypneic And
Tachycardic

30. 25 Year Old With A
History Of Sickle Cell
Disease Presents
With Severe Pain of
Both Of His Legs and
His Lower Back.
Hospital Day 3
Now Febrile,
Dyspneic,
Tachypneic And
Tachycardic
Acute Chest Syndrome

31. Acute Chest Syndrome
25 Year Old With A
History Of Sickle Cell
Disease Presents
With Severe Pain of
Both Of His Legs and
His Lower Back.
Hospital Day 3
Now Febrile,
Dyspneic,
Tachypneic And
Tachycardic

32. 25 Year Old With A
History Of Sickle Cell
Disease Presents
With Severe Pain of
Both Of His Legs and
His Lower Back.
Hospital Day 5
Clinically Improved
After Exchange
Transfusion
Acute Chest Syndrome
Side Note:
Recall that the CXR
looked normal on
initial presentation.
This is the case for
≈50% of hospitalized
SCD patients who go
on to develop ACS.

34. Acute Chest Syndrome
 Defined as a new pulmonary infiltrate consistent with consolidation
[not atelectasis] of at least one lung segment.
 Usually accompanied by chest pain, cough, fever and wheezing.
 The most common cause or IC U admission and premature death in
patients with sickle cell disease.
Gladwin M. New England Journal of Medicine 2008; 359:2254-65.

35. Acute Chest Syndrome
Three proposed mechanisms:
 Pulmonary infection1
 Embolization of bone marrow fat2
 Pulmonary intravascular sickling and infarction3
1Bronchoalveolar lavage demonstrates bacterial and/or viral pathogens in 54% of patients with ACS.
2Associated with pain crisis of multiple bones, particularly the lumbar spine, femurs and the pelvis.
3In a small percentage of patients with ACS, wedge-shaped pulmonary infarcts may develop.
Gladwin M. New England Journal of Medicine 2008; 359:2254-65.

37. National Acute Chest Syndrome Study Group
 538 patients from 20 centers - the largest case series to date
 Results provide insights into the clinical presentations and outcomes of
hospitalized patients with ACS
49% Of Patients Initially Presented In Pain Crisis Without Signs Of ACS!
Vichinsky EP. New England Journal of Medicine 2000; 342:1855-65.

38. National Acute Chest Syndrome Study Group
 Manifestations: worsening hypoxia, decreased hemoglobin levels, and
progressive, multi-lobar pulmonary infiltrates
 The mean hospital length of stay was 10.5 days [vs. 3 days w/o ACS]
 30% required mechanical ventilation and overall mortality was 3%
Vichinsky EP. New England Journal of Medicine 2000; 342:1855-65.
Infection1,2 33%
Pulmonary Infarction 33%
Pulmonary fat emboli 16%
1Pathogens identified using bronchoalveolar lavage
2Chlamydophilia, Mycoplasma pneumoniae & respiratory syncytial virus the most common pathogens

39. Acute Chest Syndrome
ED Treatment Essentials:
 Antibiotics to cover both typical & atypical pathogens
 Supportive respiratory care
 A transfusion strategy based on goals and severity
Gladwin M. New England Journal of Medicine 2008; 359:2254-65.
Goal Target
Increase oxygen carrying capacity Hgb ≥10 grams
Manage vaso-occlusive complications HbS <30%
Both As above

42. RCE = Red Cell Exchange

43. Cases Studies From
Our Emergency
Medicine Partners In
Brazil
43 Year Old
Presents To An
Outpatient Clinic
After A Syncopal
Episode
He Has Normal
Labs, A Normal
ECG And This
Chest X-Ray
He Is Sent Home

44. Cases Studies From
Our Emergency
Medicine Partners In
Brazil
Right Upper Lobe Pneumonia
43 Year Old Seen
In The
Outpatient Clinic
Four Days Later
He Now
Presents To The
ED With Cough,
Fever & Rigors

45. Cases Studies From
Our Emergency
Medicine Partners In
Brazil
43 Year Old Seen
Four Days Ago In
The Outpatient
Clinic
Let’s Take
Another Look At
The First CXR…

46. Cases Studies From
Our Emergency
Medicine Partners In
Brazil
Subtle pneumonias can be easy to
miss (especially with overlapping
structures near by), make sure you
are comparing each lung field with
the other side.
43 Year Old Seen
Four Days Ago In
The Outpatient
Clinic
Let’s Take
Another Look At
The First CXR…

47. 27 Year Old
With One
Week Of
Chest Pain
and Dyspnea
Transferred
From An
Outlying
Hospital After
Chest CT
Case #3

48. 27 Year Old With One Week Of Chest Pain and Dyspnea

49. 27 Year Old With One Week Of Chest Pain and Dyspnea
Chest CT Obtained: Large Pericardial Effusion

50. 27 Year Old
With One
Week Of
Chest Pain
and Dyspnea
ECHO

51. 27 Year Old
With One
Week Of
Chest Pain
and Dyspnea
Cardiac
Apex

52. 27 Year Old
With One
Week Of
Chest Pain
and Dyspnea
Pericardial Effusion: Pericardiocentesis = 250 cc Straw-Colored Fluid
Cardiac
Apex
**
*
*

53.  Rapidly accumulating pericardial effusions cause swift increases in intrapericardial
pressure and tamponade physiology.
 Slowly accumulating pericardial effusions gradually distend the pericardium and
symptoms can be delayed.

54. 23 Year Old Car Crash In To A Tree
A Chest CT Is Obtained

55. 23 Year Old Car Crash In To A Tree
A Chest CT Is Obtained
Severe Pulmonary Contusion

56. 23 Year Old Car
Crash In To A Tree.
He Is Transferred To
Our ED And Is
Intubated Upon
Arrival For Severe
Agitation And
Persistent Hypoxia
Severe Pulmonary Contusion

57. 69 Year Old With
Emphysema
Does He Have A
Pneumothorax On
The Right?

58. No! He Has A Large Right Lung Bleb
69 Year Old With
Emphysema
Does He Have A
Pneumothorax On
The Right?

59. 69 Year Old With
Emphysema
Pulmonary Bleb Drainage Catheters

60. 79 Year Old Male
Smoker Presents
With Cough And
Two Weeks Of Right
Sided Chest Pain
Chest X-Ray From 3 Years Ago

61. 79 Year Old Male
Smoker Presents
With Cough And
Two Weeks Of Right
Sided Chest Pain
Chest X-Ray From Today: What Do You See?

62. 79 Year Old Male Smoker Presents With Cough And Two Weeks Of Right Sided Chest
The Lateral View Is Helpful

63. 79 Year Old Male Smoker Presents With Cough And Two Weeks Of Right Sided Chest
The Lateral View Is Helpful
This Looks Like A Round Mass

64. 79 Year Old Male Smoker Presents With Cough And Two Weeks Of Right Sided Chest
The Lateral View Is Helpful
This Looks Like A Round Mass
Is This Fluid, A Mass, Or Both?

65. Right Lung Mass + Effusion + Metastasis To The Chest Wall [*]
*
*
Pathology
Non-Small Cell Lung Cancer

66. Summary Of Diagnoses This Month
 Sternal fracture
 Left hemothorax
 Traumatic aortic aneurysm
 Acute chest syndrome
 Right upper lobe pneumonia
 Pericardial effusion
 Pulmonary contusion
 Pulmonary bleb
 Non-small-cell lung cancer

67. See You Next Month!