Drs. Breeanna Lorenzen and Travis Barlock 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 educational, self-guided radiology slides. This set will cover: Pneumonia Lung Masses Pulmonary Nodules Hilar Lymphadenopathy Aorto-enteric Fistula Diaphragmatic Hernia Intra-aortic Balloon Pump Pacemaker Impella

1. Adult Chest X-Rays Of The Month
Travis Barlock, MD & Breeanna Lorenzen, MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD - Faculty Editor
Chest X-Ray Mastery Project
May 2021

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. 65-year-old male
with a history of
right-sided lung
cancer presents
with dyspnea.

8. Diagnosis: Right lower lobe pneumonia
65-year-old male
with a history of
right-sided lung
cancer presents
with dyspnea.
Consolidation
Infusion
Port

9. 71-Year-Old
Female With
Several Weeks Of
Back Pain And
Fatigue Presents
To The ED For An
MRI After An
Outpatient
Lumbar CT Reveals
An Abnormality.
Diagnosis: Pathologic Fracture Of L4 With Involvement Of Adjacent Soft Tissue & The Spinal Canal.

10. 71-Year-Old Female Presents With Back Pain And Fatigue.
After Reviewing The MRI, The ED Team Orders A CXR As Part Of The Carcer Work-Up.

11. 71-Year-Old Female Presents With Back Pain And Fatigue.
After Reviewing The MRI, The ED Team Orders A CXR As Part Of The Carcer Work-Up.
Diagnosis: Right lung mass
Rounded
Opacity
Rounded
Opacity

12. 71-Year-Old Female Presents With Back Pain And Fatigue.
Histopathology:
Squamous Cell Lung Cancer
*
* *

13. 70-year-old
female
presents with
fatigue and
diarrhea.

14. 70-year-old
female
presents with
fatigue and
diarrhea.
Official Read: “Mild Bilateral Interstitial Changes.”

15. 70-year-old
female
presents with
fatigue and
diarrhea.
Fluid In The
Fissure
Interstitial
Edema
What Else To You Notice?

16. 70-year-old
female
presents with
fatigue and
diarrhea.
What Else To You Notice?
Widened Mediastinum
Markedly Enlarged
Right Hilum

17. Diagnosis: Malignant Mediastinal & Hilar Adenopathy
71-Year-Old Female Presents Fatigue & Diarrhea.

18. Our Patient’s Lesion Is In The Middle Mediastinum

19. Our Patient’s Lesion Is In The Middle Mediastinum

20. 20-year-old
male with
testicular
cancer
presents with
shortness of
breath.

21. 20-year-old
male with
testicular
cancer
presents with
shortness of
breath.
Diagnosis: Right Pleural Effusion (*) + Scattered Metastatic Pulmonary Nodules (Arrows).
* * *

22. 57-year-old
male with prior
repaired aortic
dissection
presents with
nausea and
hematemesis.

23. 57-year-old
male with prior
repaired aortic
dissection
presents with
nausea and
hematemesis.
Clinical Diagnosis: Aorto-Esophageal Fistula.
Properly Positioned
Aortic Endograph

24. Our patient
after
esophageal
stenting.
Properly Positioned
Aortic Endograph
Properly Positioned
Esophageal Stent

25. Ima g es In emer g enc y medIc Ine
Aortoesophageal Fistula
Ryan Roten, DO
Ryan Peterfy, DO
Section Editor: Rick A. McPheeters, DO
Submission history: Submitted; Submitted November 16, 2016; Revision received February 10, 2017; Accepted February 22, 2017
Electronically published July 6, 2017
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
DOI: 10.5811/cpcem.2017.2.33141
[Clin Pract Cases Emerg Med. 2017;1(3):260–261.]
Desert Regional Medical Center, Department of Emergency Medicine, Palm Springs, California
CASE PRESENTATION
A 90-year-old female presented after sudden collapse
with a Glasgow Coma Score of 3, and profound hypotension.
Shortly after endotracheal intubation, the patient developed
subsequently instituted. Computed tomography angiogram of
the chest revealed active bleeding from an aortoesophageal
blood were collected via oral gastric tube and manual suctioning
by nursing staff before the resuscitation was terminated at the
family’s request.
DISCUSSION
thoracic aortic aneurysm, foreign body ingestion, postoperative
complications, and esophageal malignancy. The classic
presentation of mid-thoracic chest pain and sentinel arterial
hemorrhage followed by exsanguination is known as Chiari’s
triad.1
asymptomatic period using endoscopy or computed tomography
angiogram of the chest, survival is possible with immediate
surgical intervention or endovascular stenting.2
Medical
providers must be familiar with the presentation, diagnostics,
rapid interruption of diagnostics and treatment of
typically fatal pathology possible.
Ima g es In emer g enc y medIc Ine
Aortoesophageal Fistula
Ryan Roten, DO
Ryan Peterfy, DO
Section Editor: Rick A. McPheeters, DO
Submission history: Submitted; Submitted November 16, 2016; Revision received February 10, 2017; Accepted February 22, 2017
Electronically published July 6, 2017
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
DOI: 10.5811/cpcem.2017.2.33141
[Clin Pract Cases Emerg Med. 2017;1(3):260–261.]
Desert Regional Medical Center, Department of Emergency Medicine, Palm Springs, Calif
CASE PRESENTATION
A 90-year-old female presented after sudden collapse
with a Glasgow Coma Score of 3, and profound hypotension.
Shortly after endotracheal intubation, the patient developed
subsequently instituted. Computed tomography angiogram of
the chest revealed active bleeding from an aortoesophageal
blood were collected via oral gastric tube and manual suctioning
by nursing staff before the resuscitation was terminated at the
family’s request.
DISCUSSION
thoracic aortic aneurysm, foreign body ingestion, postoper
complications, and esophageal malignancy. The classic
presentation of mid-thoracic chest pain and sentinel arteria
hemorrhage followed by exsanguination is known as Chia
triad.1
asymptomatic period using endoscopy or computed tomog
angiogram of the chest, survival is possible with immediat
surgical intervention or endovascular stenting.2
Medical
providers must be familiar with the presentation, diagnosti
rapid interruption of diagnostics and treatment of
typically fatal pathology possible.
Clinical Practice and Cases in Emergency Medicine 260 Volume I, no. 3: August 2017
CASE PRESENTATION
A 90-year-old female presented after sudden collapse
with a Glasgow Coma Score of 3, and profound hypotension.
Shortly after endotracheal intubation, the patient developed
subsequently instituted. Computed tomography angiogram of
the chest revealed active bleeding from an aortoesophageal
blood were collected via oral gastric tube and manual suctioning
by nursing staff before the resuscitation was terminated at the
family’s request.
DISCUSSION
thoracic aortic aneurysm, foreign body ingestion, postoperative
complications, and esophageal malignancy. The classic
presentation of mid-thoracic chest pain and sentinel arterial
hemorrhage followed by exsanguination is known as Chiari’s
triad.1
asymptomatic period using endoscopy or computed tomography
angiogram of the chest, survival is possible with immediate
surgical intervention or endovascular stenting.2
Medical
providers must be familiar with the presentation, diagnostics,
rapid interruption of diagnostics and treatment of
typically fatal pathology possible.
Image 1.
Clinical Practice and Cases in Emergency Medicine 260 Volume I, no. 3: August 2017
subsequently instituted. Computed tomography angiogram of
the chest revealed active bleeding from an aortoesophageal
blood were collected via oral gastric tube and manual suctioning
by nursing staff before the resuscitation was terminated at the
family’s request.
DISCUSSION
hemorrhage followed by exsanguination is known as Chiari’s
triad.1
asymptomatic period using endoscopy or computed tomography
angiogram of the chest, survival is possible with immediate
surgical intervention or endovascular stenting.2
Medical
providers must be familiar with the presentation, diagnostics,
rapid interruption of diagnostics and treatment of
typically fatal pathology possible.
Image 1.
Clinical Practice and Cases in Emergency Medicine 260 Volume I, no. 3: August 2017
blood were collected via oral gastric tube and manual suctioning
by nursing staff before the resuscitation was terminated at the
family’s request.
DISCUSSION
surgical intervention or endovascular stenting.2
Medical
providers must be familiar with the presentation, diagnostics,
rapid interruption of diagnostics and treatment of
typically fatal pathology possible.
Image 1.
1º Causes:
• Thoracic aortic aneurysms
• Foreign body ingestion
• Esophageal malignancy
• Mediastinal infections
2º Causes:
• Prior aortic surgery and/or
stenting
Chiari’s Triad:
• Mid-thoracic chest pain
• Sentinel bleed followed by…
• Brisk exsanguination
Outcomes:
• 77% mortality
• 100% mortality without
intervention (surgery or
stenting).

28. Notice Scattered Free Air Within
The Mediastinum.
Our Patient Subsequently
Develops Signs Of Sepsis.

29. Diagnosis: Aorto-Esophageal Fistula & Graft Infection

30. 57-year-old
male with
prior heart
transplant
presents with
nausea and
vomiting.

31. 57-year-old
male with
prior heart
transplant
presents with
nausea and
vomiting.
Diagnosis: Diaphragmatic Hernia.
Loops Of Bowel
In The Left Chest

32. 52-Year-Old With
With A History Of
Cardiac Sarcoid.
CXR Just Before
Heart Transplant.

33. 52-Year-Old With
With A History Of
Cardiac Sarcoid.
CXR Just Before
Heart Transplant.
Arrows Point To The Proximal (Red) And Distal (White) Radiopaque Markers Of The IABP

34. Intra Aortic Balloon Pump
Femoral Subclavian

35. Intra Aortic Balloon Pump

37. Marker Tip Seen On CXR

38. 38-Year-Old With
With Non-
Ischemic
Cardiomyopathy.
CXR Before Heart
Transplant.

39. 38-Year-Old With
With Non-
Ischemic
Cardiomyopathy.
CXR Before Heart
Transplant.
Arrows Points To The Radiopaque Markers Of The intra-aortic balloon pump

40. 62-Year-Old With
Ischemic
Cardiomyopathy.
CXR Just Prior To
Orthotopic Heart
Transplant.

41. 62-Year-Old With
Ischemic
Cardiomyopathy.
CXR Just Prior To
Orthotopic Heart
Transplant.
Defibrillator
Defibrillator coil
Impella™

42. Impella™
 Percutaneous femoral artery access – device advanced into the left ventricle (LV)
 LV blood drawn into the pump and released across the valve in the proximal aorta
 Aortic flow rates up to 5.0 liters/minute
 Increases cardiac output & coronary perfusion and decreases myocardial O2 consumption

43. Impella™

44. 62-Year-Old With
Ischemic
Cardiomyopathy.
CXR Just Prior To
Orthotopic Heart
Transplant.
Impella™
Inflow
Impella™
Outflow

45. 62-Year-Old With
Ischemic
Cardiomyopathy.
CXR Just Prior To
Orthotopic Heart
Transplant.
Impella™ Blood Flow
Directed Up The
Aorta

46. 62-Year-Old With
Ischemic
Cardiomyopathy.
CXR One Week
After Transplant!

47. Summary Of Diagnoses This Month
 Pneumonia
 Lung masses
 Pulmonary nodules
 Hilar lymphadenopathy
 Aorto-enteric fistula and graft infection
 Diaphragmatic hernia
 Intra-aortic balloon pumps
 Pacemaker and ICD
 Impella™ Assist Devices

48. See You Next Month!