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Dr. Michael Gibbs's CMC X-Ray Mastery Project: June cases

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Dr. Michael Gibbs is a Professor of Emergency Medicine and interested in educating others. Radiology is a passion of his. Follow along with the EMGuideWire.com team as they post Dr. Gibbs's weekly educational, self-guided radiology slides on: Alveolar Hemorrhage, Rib Fractures, Tension, Flail Chest, Traumatic Aortic Disruption, Active Tuberculosis, Transfusion Related Acute Lung Injury

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Dr. Michael Gibbs's CMC X-Ray Mastery Project: June cases

  1. 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 June 2019
  2. 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. 3. Process  Many are providing cases and these slides are shared with all contributors.  Contributors from many CMC departments, and now… Tanzania and Brazil.  Cases submitted this week will be distributed monthly.  When reviewing the presentation, the 1st image will show a chest X-ray without identifiers and the 2nd image will reveal the diagnosis.
  4. 4. It’s All About The Anatomy!
  5. 5. Airway Bones Cardiac Diaphragm Effusion Foreign body Gastric Hilum
  6. 6. Cases Studies From Our Emergency Medicine Partners In Brazil History of Goodpasture syndrome presenting with SOB
  7. 7. Cases Studies From Our Emergency Medicine Partners In Brazil What is the diagnosis? History of Goodpasture syndrome presenting with SOB
  8. 8. Cases Studies From Our Emergency Medicine Partners In Brazil Alveolar Hemorrhage From Goodpasture Syndrome History of Goodpasture syndrome presenting with SOB
  9. 9. Goodpasture syndrome = anti- glomerular basement membrane antibody (ABMA) - Hemoptysis (up to 33% of patients do not present with this) - Alveolar opacities - Falling hemoglobin - Nonspecific lung examination - Symptoms are usually of short duration before presentation - 60-80% cases of ABMA lung and renal disease occur simultaneously Treatment Systemic glucocorticoids with additional immunosuppressive therapy. Plasmapheresis has also shown to be beneficial Alveolar Hemorrhage From Goodpasture Syndrome Quick Tidbits! A review of 34 cases of alveolar hemorrhage found that 12% were secondary to Goodpasture syndrome - More common in men - More common in smokers thought to be 2/2 to increase alveolar permeability in smokers Harold R. Collard MD, Talmadge E. King MD and Marvin I. Schwarz MDMurray and Nadel's Textbook of Respirator: Alveolar Hemorrhage and Rare Infiltrative Diseases Medicine, 67, 1207-1220.e11
  10. 10. High Speed MVC Against A Truck
  11. 11. High Speed MVC Against A Truck What’s the diagnosis?
  12. 12. High Speed MVC Against A Truck Tension Hemothorax + Left-Sided Rib Fractures
  13. 13. Fall Off Of A Roof
  14. 14. What do you see? Given this finding, what associated diagnosis are you concerned about? Fall Off Of A Roof
  15. 15. Flail Chest  The result of severe blunt chest trauma.  Multiple ribs fractured in ≥2 places. Fall Off Of A Roof
  16. 16. Flail Chest  Inspiration increases [-] thoracic pressure.  Leads to paradoxical motion of the flail segment.
  17. 17. Flail Chest  Frequently requires mechanical ventilation.  Rib plating stabilizes the fail segment. Side Note: Temporizing measures in the ED? Place an occlusive dressing!
  18. 18. Pedestrian Struck By An SUV
  19. 19. Pedestrian Struck By An SUV What is your interpretation?
  20. 20. Pedestrian Struck By An SUV Traumatic Aortic Disruption [TAD]  Typically a high mechanism of injury.  MVC, pedestrian struck, fall from a height. Wide Mediastinum
  21. 21. Our Patient Aortic Laceration
  22. 22. 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
  23. 23. 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 Practice identifying the above findings in blue on this TAD CXR
  24. 24. Tracheal Deviation
  25. 25. Apical CapTracheal Deviation
  26. 26. Apical CapTracheal Deviation Loss Of The Aortopulmonary Window
  27. 27. Apical CapTracheal Deviation Loss Of The Aortopulmonary Window
  28. 28. Cases Studies From Our Emergency Medicine Partners In Brazil
  29. 29. Cases Studies From Our Emergency Medicine Partners In Brazil Patient With Active Tuberculosis Shot In The Chest
  30. 30. High Speed MVC Against A Truck HD#3 4 Hours After A 3-Unit PRBC Transfusion Interesting Case for the Month!
  31. 31. High Speed MVC Against A Truck HD#3 4 Hours After A 3-Unit PRBC Transfusion Transfusion-Related Acute Lung Injury [TRALI] Interesting Case for the Month!
  32. 32. High Speed MVC Against A Truck HD#3 4 Hours After A 3-Unit PRBC Transfusion Transfusion-Related Acute Lung Injury [TRALI] Side Note: What else do you notice in the left chest? Don’t forget to look for tubes and lines! Interesting Case for the Month!
  33. 33. Summary Of Diagnoses This Month • Alveolar hemorrhage • Rib fractures with tension hemothorax • Rib fractures with flail chest • Traumatic Aortic Disruption • Active Tuberculosis • Transfusion related acute lung injury (TRALI)
  34. 34. See You Next Month!

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