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: Pericardial Effusion, Vaping Lung Injury, Cavitary Pulmonary Abscess, Esophageal Foreign Body, Dilated Cardiomyopathy, Acute Aortic Dissection, Pneumomediastinum, Massive Pneumoperitoneum, Malignant Pleuarl Effusion, Right Sided Aortic Arch, RLL pneumonia

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
November 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. 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. 8 Months Ago Today
27 Year Old Male With ESRD On Hemodialysis Presents With Two Weeks Of Dyspnea

8. 27 Year Old Male
With ESRD On
Hemodialysis
Presents With
Two Weeks Of
Progressive
Dyspnea
Massive Pericardial Effusion

9. Massive Pericardial Effusion
27 Year Old Male With ESRD On Hemodialysis Presents With Two Weeks Of Dyspnea

10. Massive Pericardial Effusion
*
*
*
*
**
* *
*
*
27 Year Old Male With ESRD On Hemodialysis Presents With Two Weeks Of Dyspnea

11. 27 Year Old Male
With ESRD On
Hemodialysis
Presents With
Two Weeks Of
Progressive
Dyspnea
Pericardial
Drain In Place
2.7 Liters Of Fluid Removed!

12. 37 Year Old Being
Treated For
Pneumonia.
History Of
Vaping.

13. 37 Year Old Being Treated For Pneumonia. History Of Vaping.

14. Butt Y, Smith M, Tazelarr H, Vaszar L, Swanson K, Cecchini M, Boland J, Bois M, Boyum
J, Froemming A, Khror A, Mira-Avdndanno I, Patel A, Larsen B.

17. What We Know
About the Outbreak:
As of October 22, 2019, 1,604* cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have
been reported to CDC from 49 states (all except Alaska), the District of Columbia, and 1 U.S. territory.
Thirty-four deaths have been confirmed in 24 states

18. Georgia (2), Illinois (2), Indiana (3), Kansas (2), Massachusetts, Michigan, Minnesota (3), Mississippi, Missouri,
Montana, Nebraska, New Jersey, New York, Oregon (2), Pennsylvania, Tennessee, Texas, Utah, and Virginia.
More deaths are under investigation.
The median age of deceased patients was 49 years and ranged from 17 to 75 years.
Among 1,358 patients with data on age and sex (as of October 15, 2019)(as of October 15, 2019):
70% of patients are male.
The median age of patients is 23 years and ages range from 13 to 75 years.
79% of patients are under 35 years old.
By age group category:
15% of patients are under 18 years old;
21% of patients are 18 to 20 years old;
18% of patients are 21 to 24 years old;
25% of patients are 25 to 34 years old; and
21% of patients are 35 years or older.
Among 849 patients with information on substances used in e-cigarette, or vaping, products in the 3 months prior
to symptom onset* * (as of October 15, 2019)(as of October 15, 2019):
About 78% reported using THC-containing products; 31% reported exclusive use of THC-containing
products.
Latest Outbreak Information
Updated every Thursday
This complex investigation spans almost all states, involves over a thousand patients, and a wide variety of
brands and substances and e-cigarette, or vaping, products. Case counts continue to increase and new cases are
being reported, which makes it more difficult to determine the cause or causes of this outbreak.
As of October 22, 2019, 1,604* cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have
been reported to CDC from 49 states (all except Alaska), the District of Columbia, and 1 U.S. territory.
Thirty-four deaths have been confirmed in 24 states: Alabama, California (3), Connecticut, Delaware, Florida,
Georgia (2), Illinois (2), Indiana (3), Kansas (2), Massachusetts, Michigan, Minnesota (3), Mississippi, Missouri,
Montana, Nebraska, New Jersey, New York, Oregon (2), Pennsylvania, Tennessee, Texas, Utah, and Virginia.
More deaths are under investigation.
The median age of deceased patients was 49 years and ranged from 17 to 75 years.
Among 1,358 patients with data on age and sex (as of October 15, 2019)(as of October 15, 2019):
70% of patients are male.
The median age of patients is 23 years and ages range from 13 to 75 years.
79% of patients are under 35 years old.
By age group category:

21. 65 Year Old With
COPD Presents
With Cough And
Fever

22. 65 Year Old With
COPD Presents
With Cough And
Fever
What Is This?

23. 65 Year Old With COPD Presents With Cough And Fever
Pulmonary Abscess

24. Adults Swallow
Things To!

25. 30 Year Old With
A History Of
HPTN Presents
With Dyspnea

26. 30 Year Old With
A History Of
HPTN Presents
With Dyspnea
Cardiomegaly

27. 44 Year Old With A History Of HPTN And Presents With Acute Chest Back And Abdominal Pain
Today One Year Ago

28. 44 Year Old With A History Of HPTN And Presents With Acute Chest Back And Abdominal Pain
Type A Dissection

29. 44 Year Old With A History Of HPTN And Presents With Acute Chest Back And Abdominal Pain
Type A Dissection

30. 44 Year Old With A History Of HPTN And Presents With Acute Chest Back And Abdominal Pain
Type A Dissection: Hemopericardium

31. 44 Year Old With A History Of HPTN And Presents With Acute Chest Back And Abdominal Pain
Type A Dissection: Hemopericardium
*
*
*
*
*

32. TYPE A TYPE B

33. Branch Vessel Compromise
Myocardial infarction
Stroke
Spinal cord infarction
Mesenteric and renal ischemia
Limb ischemia

34. Chest Pain
Back Pain
Stroke Symptoms
Paraplegia
Acute Abdomen
Renal Failure
Aortic
Dissection?
Paretic Extremity

35. Type A Dissections
Acute aortic insufficiency
Acute pulmonary edema
Pericardial tamponade
Acute myocardial infarction

36. Type A Dissections

37. Aortic
Dissection?

38. Chest Pain
Back Pain
Acute CHF
New AI Murmur
Syncope
Aortic
Dissection?

39. Acute Aortic Dissections
are challenging to
diagnose and treat

40. IRAD: Demographics And Risks
Type A 67%
Type B 33%
Risk Factors
Hypertension 77%
Atherosclerosis 27%
Known aneurysm 16%
Cardiac surgery 16%
Marfan syndrome 5%
Iatrogenic 4%
Cocaine use1 2%
1Cocaine use 12% in black patients
66% of patients were male
The mean age was 63 years

41. IRAD: Clinical Manifestations
Pain1 reported in 93.7%:
A B
Chest pain 79% 63%
Back pain 43% 64%
HPTN on presentation 36% 70%
Pulse deficit 30% 20%
Syncope2 19%
1,2Painless AAD and patients presenting with syncope had a
higher risk of heart failure, tamponade and death.
A = Type A Dissection
B = Type B Dissection

42. IRAD: Clinical Manifestations
Quality of pain [from the original IRAD data set published in 2000]:
Hagan PG. JAMA 2000.
Abrupt onset 84%
Worst pain ever 91%
Sharp 64%
Tearing or ripping 51%
Radiating 28%
Migratory 17%

43. 25 Year Old With Repeated Episodes Of Vomiting

44. 25 Year Old With Repeated Episodes Of Vomiting
Pneumomediastinum

45. 25 Year Old With Repeated Episodes Of Vomiting
Pneumomediastinum

46. 69 Year Old Fever And Right Upper Quadrant Abdominal Pain & No Pulmonary Symptoms

47. RLL Pneumonia
69 Year Old Fever And Right Upper Quadrant Abdominal Pain & No Pulmonary Symptoms

48. 23 Year Old Male
Being Evaluated
After A Car Crash

49. 23 Year Old Male
Being Evaluated
After A Car Crash
Wide
Mediastinum

50. 23 Year Old Male
Being Evaluated
After A Car Crash
Wide
Mediastinum
Is There An Aortic Injury?

51. Not Today! Our Patient Has A Right-Sided Aortic Arch.

52. Not Today! Our Patient Has A Right-Sided Aortic Arch.

54. Right Sided Aortic Arch
• Rare congenital anomaly: 0.05% - 0.1% of radiology/autopsy series
• Several proposed classification schemes based on the arrangement of
arch vessels, relationship with the esophagus, and the presence or
absence of congenital heart disorders
• Asymptomatic in the majority of patients
• Clinical manifestations are uncommon, and these are caused by:
Tracheal Compression: Typically seen in children
Esophageal Compression: Typically seen in older adults

56. 65 Year Old With
Presenting In
Shock With
Severe
Abdominal Pain

57. 65 Year Old With
Presenting In
Shock With
Severe
Abdominal Pain
Colonic Perforation With Pneumoperitoneum

58. 68 Year Old With A History Of Breast Cancer Presents With Dyspnea
Today One Year Ago

59. 68 Year Old With
A History Of
Breast Cancer
Presents With
Dyspnea
Malignant Pleural Effusion

61. Light’s Criteria
Transudate Versus Exudate1,2
Pleural Fluid Protein/Plasma Protein >0.5
Pleural Fluid LDH/Plasma LDH >0.6
Pleural Fluid LDH >200 IU
1In patients with heart failure on diuretics, Light’s Criteria may misclassify a
transudate as an exudate up to 25% of the time.
2In heart failure patients, a serum protein 3.1 g/dl higher than the pleural fluid,
or a serum albumen 1.2 g/dl higher than the pleural fluid will help correctly
identify a transudate.

64. Parapneumonic Effusions
• The most common exudative effusions are those associated with
underlying pneumonia
• Mortality is higher among pneumonia patients who have a
parapneumonic effusion, compared with those with pneumonia and
no effusion
• With the aging of the population, the incidence and mortality due to
parapneumonic effusion and empyema continues to rise

65. Right Parapneumonic Effusion

67. Malignant Effusions
• The second most common exudative effusions are those associated
with underlying malignancy
• The majority of malignant pleural effusions arise from lung cancer,
breast cancer, and lymphoma
• The presence of a malignant pleural effusion is associated with higher
mortality and significantly shorter survival

68. Lung Mass With Malignant Effusion

69. Lung Mass After Effusion Drainage

71. Summary Of Diagnoses This Month
 Pericardial effusion
 E-cigarette associated
pneumonitis
 Cavitary pulmonary abscess
 Fork in the esophagus
 Dilated cardiomyopathy
 Acute aortic dissection
 Pneumomediastinum
 RLL pneumonia presenting as
abdominal pain
 Right-sided aortic arch
• Massive pneumoperitoneum
• Malignant pleural effusion

72. See You Next Month!