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: Septic Pulmonary Emboli, Severe Rib Fractures, Left Lower Lobe Resection, Pneumonia, Esophageal Stent, COPD, Hyperinflation, Pulmonary Contusion, Aortic Dissection, Tuberculosis

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
September 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 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. It’s All About The Anatomy!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. 26 Year Old
IV Drug User
Presents
With Back
Pain And
Fever

7. 26 Year Old
IV Drug User
Presents
With Back
Pain And
Fever
Bilateral Rounded Densities

8. 26 Year Old IV Drug User Presents With Back Pain And Fever
Septic Pulmonary Emboli

9. 30 Year Old With
A History Of
Intravenous Drug
Abuse Presents
With Weakness
and Shortness of
Breath

10. 30 Year Old With
A History Of
Intravenous Drug
Abuse Presents
With Weakness
and Shortness of
Breath
Bilateral Rounded Densities

11. 30 Year Old With A History Of Intravenous Drug Abuse
Presents With Weakness and Shortness of Breath
Septic Pulmonary Emboli

12. 22 Year Old With
A History Of
Intravenous Drug
Abuse Presents
With Fever, Chest
Pain & Cough

13. 22 Year Old With
A History Of
Intravenous Drug
Abuse Presents
With Fever, Chest
Pain & Cough
Bilateral Rounded Densities

14. 22 Year Old With A History Of Intravenous Drug Abuse
Presents With Fever, Chest Pain & Cough
Septic Pulmonary Emboli

15. 22 Year Old With
A History Of
Intravenous Drug
Abuse Presents
With Fever, Chest
Pain & Cough
Point Of Care
ED Echo:
Tricuspid Valve
Vegetation

16. Here Is The 3rd
Patient’s Chest X-Ray
One Month Ago!

17. In One Week We Received Three Cases Of Septic Pulmonary
Emboli In Young, IV Drug-Dependent Adults With Endocarditis.
This Seems Like A Lot!

18. In One Week We Received Three Cases Of Septic Pulmonary
Emboli In Young, IV Drug-Dependent Adults With Endocarditis.
This Seems Like A Lot!
Let’s Look At Some North Carolina-Specific CDC Data

19.  12-fold increase in the incidence of hospitalization
 Incidence increasing most rapidly amongst drug users who are younger,
white (87%), non-Hispanic (92%), and from rural areas
 18-fold increase in the total cost of hospitalization
 Median hospital charges $54,281
 In 2015 42% of patients were either uninsured or receiving Medicaid

29. Empiric Antibiotics In The ED
First Choice Vancomycin + Cefepime
Severe PCN Allergy Vancomycin + Aztreonam

30. Another More
Recent Case
39Year Old With
A History Of
Intravenous Drug
Abuse Presents
With Fever, Chest
Pain & Cough
Bilateral Rounded Densities

31. 39 Year Old With A History Of Intravenous Drug Abuse
Presents With Fever, Chest Pain & Cough
Septic Pulmonary Emboli

32. 37 Year-Old With A Remote History Of Severe Esophagitis & Perforation

33. Esophageal Stent
37 Year-Old With A Remote History Of Severe Esophagitis & Perforation

34.  Esophageal stents are used to palliate esophageal malignancies and a number of
non-malignant conditions, including: refracture strictures, tracheoesophageal
fistulas, and complex esophageal perforations.
 Self-expanding plastic stents (SEPS) and self-expanding metal stents (SEMS) exist.

35. Esophageal Stent Complications
Acute (<4 Weeks)1,2 Chronic (>4 Weeks)3
 Chest pain
 Fever
 Bleeding
 Globus sensation
 Perforation
 Migration
 Tumor ingrowth
 Stent migration
 Stent occlusion
 Esophageal fistula development
 Recurrence of strictures
1Complications in up to 30%
2Stent migration most common
3Complications in 50-60%

36. Old Surgical
Clips

37. Old Surgical
Clips
Prior Left Lower Lobectomy

38. 47 Year-Old With A Long History Of COPD

39. 47 Year-Old With A Long History Of COPD
ED CXR During Exacerbation
Demonstrated Hyperinflation
Follow-Up Office CXR:
Hyperinflation Resolves

40. Two Recent Cases With A
Common Theme

41. 55 Year Old
With Fever
And Dyspnea
Single AP View
Portable CXR
Obtained At
The Bedside

42. 55 Year Old
With Fever
And Dyspnea
Single AP View
Portable CXR
Obtained At
The Bedside
Sent For A Chest CT After This
CXR Was Taken

43. 55 Year Old
With Fever
And Dyspnea
Retrocardiac LLL Pneumonia

44. 55 Year Old
With Fever
And Dyspnea
Let’s Take
Another Look
At The CXR!

45. 55 Year Old
With Fever
And Dyspnea
Let’s Take
Another Look
At The CXR!
The Left
Hemidiaphragm Is
Indistinct

46. 40 Year Old
With Fever
And Dyspnea
Single AP View
Portable CXR
Obtained At
The Bedside

47. 40 Year Old
With Fever
And Dyspnea
Single AP View
Portable CXR
Obtained At
The Bedside
Sent For A Chest CT After This
CXR Was Taken

48. 40 Year Old
With Fever
And Dyspnea
Retrocardiac LLL Pneumonia

49. 40 Year Old
With Fever
And Dyspnea
Let’s Take
Another Look
At The CXR!

50. 40 Year Old
With Fever
And Dyspnea
Let’s Take
Another Look
At The CXR!
The Left
Hemidiaphragm Is
Indistinct

51.  In patients who are sick [i.e.: challenging from them to travel to Radiology] – we
may start with a single-view AP chest X-ray.
 In these two cases the “next step” was a CT scan of the chest.
 Another option would have been to obtain a higher quality two-view study that
would have provides the benefit of the lateral projection.

52. CMC/LCH Technical Charges – August 2019
1 view chest X-ray $296
2 view chest X-ray $369
CT chest with contrast $2,628
CT chest with contrast - angiogram $3,398

53. 25 Year Old In
High-Speed
MVC

54. 25 Year Old In
High-Speed
MVC
Bilateral Pulmonary Contusions

55. 25 Year Old In
High-Speed
MVC
Bilateral Pulmonary Contusions

56. 25 Year Old In
High-Speed
MVC
Bilateral Pulmonary Contusions

57. 35 Year Old With Poorly Controlled HPTN Presents With 2 Days Chest Pain
Today 1 Year Ago

58. 35 Year Old With Poorly Controlled HPTN Presents With 2 Days Chest Pain
False
Lumen
True
Lumen
Type A Acute Aortic Dissection

59. 55 Year Old
Female With
HPTN With
Chest And
Abdominal
Pain.

60. Type A Acute Aortic Dissection

61. Type A Acute Aortic Dissection

62. Type A Acute Aortic Dissection
Avascular
Right Kidney

63. 48 Year Old
From Mexico
With Fever
And
Hemoptysis

64. 48 Year Old From Mexico With Fever And Hemoptysis
Cavitary Tuberculosis

65. 27 Year Old
Involved In A
High-Speed
MVC With Roll
Over

66. 27 Year Old
Involved In A
High-Speed
MVC With Roll
Over
Multiple Left Upper Rib Fractures
Left Pulmonary Contusion

67. 27 Year Old
Involved In A
High-Speed
MVC With Roll
Over
Multiple Left Upper Rib Fractures

68. 27 Year Old
Involved In A
High-Speed
MVC With Roll
Over
Post-Injury
Day 2
Notice That The Fractures Are More Displaced
Because Of Ongoing Mechanical Ventilation

69. 27 Year Old
Involved In A
High-Speed
MVC With Roll
Over
Post-Injury
Day 3
A Perfect Case For Rib-Plating!

70. Summary Of Diagnoses This Month
 Septic pulmonary emboli
 Left lower lobe lung resection
 Esophageal stent after perforation
 COPD with hyperinflation
 The value of the lateral view
 Pulmonary contusion
 Aortic dissection
 Pulmonary tuberculosis
 Severe rib fractures with plating

71. See You Next Month!