Diese Präsentation wurde erfolgreich gemeldet.
Wir verwenden Ihre LinkedIn Profilangaben und Informationen zu Ihren Aktivitäten, um Anzeigen zu personalisieren und Ihnen relevantere Inhalte anzuzeigen. Sie können Ihre Anzeigeneinstellungen jederzeit ändern.

Drs. Milam and Thomas's CMC X-Ray Mastery Project: October Cases

417 Aufrufe

Veröffentlicht am

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: E-Cigarette Associated Lung Injury, Pulmonary Tuberculosis, Lung Abscess, Left Spontaneous Pneumothorax, Right Lung Mass, Superior Vena Cava Syndrome, Goiter, Mediastinal Mass

Veröffentlicht in: Bildung
  • Als Erste(r) kommentieren

  • Gehören Sie zu den Ersten, denen das gefällt!

Drs. Milam and Thomas's CMC X-Ray Mastery Project: October 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 October 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/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. 4. Visit Our Website www.EMGuidewire.com For A Complete Archive Of Chest X-Ray Presentations And Much More!
  5. 5. Airway Bones Cardiac Diaphragm Effusion Foreign body Gastric Hilum
  6. 6. It’s All About The Anatomy!
  7. 7. 33 Year Old Previously Healthy Male With A History Of Nicotine/THC Vaping Presents With Severe Dyspnea & Hypoxia Bilateral Airspace Disease On CXR Diagnosis?
  8. 8. E-Cigarette Associated Pneumonitis 33 Year Old Previously Healthy Male With A History Of Nicotine/THC Vaping Presents With Severe Dyspnea & Hypoxia
  9. 9. 33 Year Old With A History Of Vaping Presents With Severe Dyspnea E-Cigarette Associated Pneumonitis
  10. 10. E-Cigarette Associated Pneumonitis 3 Days Later Symptoms Improved
  11. 11. Published On September 6, 2019, at NEJM.org
  12. 12. E-Cigarette Associated Lung Injury • Between 2017 and 2018, the prevalence of e-cigarette use increased from 11.7% to 20.8% amongst U.S. high school students. • Pulmonary illnesses related to e-cigarettes have been reported, but no larger series have been described previously. • In July 2019, the Wisconsin Department of Health Serves received reports of pulmonary disease associated with vaping. • The authors describe the demographic and outcome characteristics of 53 patients; representing the largest published case series to date.
  13. 13. Demographic Characteristics (n=53) Median age 19 (16-53) Male sex 83% White race 82% Reported nicotine use 61% Reported THC use 80% Reported nicotine & THC use 44%
  14. 14. Symptoms Reported On Presentation Median duration of symptoms 6 days (0-61) Any Respiratory Symptoms Shortness of breath Chest pain Cough Hemoptysis 98% 87% 55% 83% 11% Subjective fever 81% Chills 58% Nausea 70% Vomiting 66%
  15. 15. Vital Signs At Presentation Temperature >38° C 29% Heart rate >100 beats/min 64% Respiratory rate >20 breaths/min 82% Oxygen saturation: ≥95% 89-94% ≤88% 31% 38% 31%
  16. 16. Initial Laboratory Results WBC >11000/mm3 87% WBC >80% neutrophils 94% ESR >30 mm/hr 93% Initial Radiographic Finding Abnormal chest X-ray 91% Abnormal chest CT 100% Bilateral infiltrates on CT 100%
  17. 17. Treatment Antibiotics during hospitalization 90% Steroids during hospitalization 92% IV steroids during hospitalization 83% Clinical Course Hospitalization 94% Non-invasive ventilation 36% Endotracheal intubation 32% Death 1/53 (2%)
  18. 18. Published On September 6, 2019, at NEJM.org Identical To Our Patient!
  19. 19. The Vapors Are Viscous! E-cigarette liquids have been shown to contain a variety of chemicals that may have adverse health effects: • Propylene glycol • Glycerin • Polycyclic aromatic hydrocarbons • Volatile organic and inorganic chemicals • Toxic metals • Flavoring compounds that may cause adverse effects
  20. 20. Monitoring The Future Survey™ National survey of 8th, 10th and 12th graders assessing vaping trends: 2017 2018 2019 43,703 44,482 43,531 Prevalence of use more than doubled between 2017 and 2019!
  21. 21. n integrated view of the ydiseaseoutbreak since ted online information ncluding news aggrega- and validated official assified the data by dis- me.3 Figure1 shows the ed and suspected cases ease from vaping over States. The first 8 sus- ed byour onlinemining g) on July 25, 2019, in 8, a total of 119 con- eshad been detected in more than doubled by ing a total of 288 cases ptember 11, cases had nning 39 states and the compoundsof e-cigaretteliquids, adulteration of devices with tetrahydrocannabinol (THC)–based oilsor vitamin E, and useof black market vaping products.1,4 Findingsfrom thisreport suggest that vaping-associated pulmonary disease cases have reached epidemic proportions. Incident cases con- tinueto rise. Further surveillanceis necessary to monitor the development and spread of this vap- ing-related outbreak. Yulin Hswen, M.P.H., Sc.D. John S. Brownstein, Ph.D. Innovation Program, Boston Children’sHospital Boston, MA yuh958@mail.harvard.edu Disclosure forms provided by the authors are available with thefull text of thisletter at NEJM.org. This letter was published on September 20, 2019, at NEJM.org.
  22. 22. n integrated view of the ydiseaseoutbreak since ted online information ncluding news aggrega- and validated official assified the data by dis- me.3 Figure1 shows the ed and suspected cases ease from vaping over States. The first 8 sus- ed byour onlinemining g) on July 25, 2019, in 8, a total of 119 con- eshad been detected in more than doubled by ing a total of 288 cases ptember 11, cases had nning 39 states and the compoundsof e-cigaretteliquids, adulteration of devices with tetrahydrocannabinol (THC)–based oilsor vitamin E, and useof black market vaping products.1,4 Findingsfrom thisreport suggest that vaping-associated pulmonary disease cases have reached epidemic proportions. Incident cases con- tinueto rise. Further surveillanceis necessary to monitor the development and spread of this vap- ing-related outbreak. Yulin Hswen, M.P.H., Sc.D. John S. Brownstein, Ph.D. Innovation Program, Boston Children’sHospital Boston, MA yuh958@mail.harvard.edu Disclosure forms provided by the authors are available with thefull text of thisletter at NEJM.org. This letter was published on September 20, 2019, at NEJM.org.
  23. 23. Sm oking & Tobacco Use Outbreak of Lung Injury Associated with E- Cigarette Use, or Vaping Posted Septem ber 19, 2019 at 12:00pm ETPosted Septem ber 19, 2019 at 12:00pm ET Electronic cigarettes – or e-cigarettes — are also called vapes, e-hookahs, vape pens, and electronic nicotine deliver systems (ENDS). CDC, the U.S. Food and Drug Adm inistration (FDA), state and local health departm ents, and otherCDC, the U.S. Food and Drug Adm inistration (FDA), state and local health departm ents, and other clinical and public health partners are investigating a m ultistate outbreak of lung injury associated withclinical and public health partners are investigating a m ultistate outbreak of lung injury associated with e-cigarette product (devices, liquids, re fill pods, and/or cartridges) use.e-cigarette product (devices, liquids, re fill pods, and/or cartridges) use. Key Facts about E-Cigarette Use, or Vaping Sm oking & Tobacco Use Outbreak of Lung Injury Associated with E- Cigarette Use, or Vaping Posted Septem ber 19, 2019 at 12:00pm ETPosted Septem ber 19, 2019 at 12:00pm ET CDC, the U.S. Food and Drug Adm inistration (FDA), state and local health departm ents, and otherCDC, the U.S. Food and Drug Adm inistration (FDA), state and local health departm ents, and other clinical and public health partners are investigating a m ultistate outbreak of lung injury associated withclinical and public health partners are investigating a m ultistate outbreak of lung injury associated with e-cigarette product (devices, liquids, re fill pods, and/or cartridges) use.e-cigarette product (devices, liquids, re fill pods, and/or cartridges) use. Key Facts about E-Cigarette Use, or Vaping
  24. 24. There are 530* cases of lung injury reported from 38 states and 1 U.S. territory. Seven deaths have been confirmed in 6 states. CDC has received complete sex and age data on 373 of 530 cases. Nearly three fourths (72%) of cases are male Two thirds (67%) of cases are 18 to 34 years old 16% of cases are under 18 years and 17% are 35 years or older All reported cases have a history of e-cigarette product use or vaping. Based on initial data from certain states we know: Most patients have reported a history of using e-cigarette products containing THC. Many patients have reported using THC and nicotine. Some have reported the use of e- cigarette products containing only nicotine. What we know We do not yet know the specific cause of these lung injuries. The investigation has not identified any specific e- cigarette or vaping product (devices, liquids, refill pods, and/or cartridges) or substance that is linked to all cases. What we don’t know What CDC recommends There are 530* cases of lung injury reported from 38 states and 1 U.S. territory. Seven deaths have been confirmed in 6 states. CDC has received complete sex and age data on 373 of 530 cases. Nearly three fourths (72%) of cases are male Two thirds (67%) of cases are 18 to 34 years old 16% of cases are under 18 years and 17% are 35 years or older All reported cases have a history of e-cigarette product use or vaping. Based on initial data from certain states we know: Most patients have reported a history of using e-cigarette products containing THC. Many patients have reported using THC and nicotine. Some have reported the use of e- cigarette products containing only nicotine. What we know We do not yet know the specific cause of these lung injuries. The investigation has not identified any specific e- cigarette or vaping product (devices, liquids, refill pods, and/or cartridges) or substance that is linked to all cases. What we don’t know What CDC recommends
  25. 25. 49 Year Old From Mexico Presents With One Month Of A Persistent Cough
  26. 26. 49 Year Old From Mexico Presents With One Month Of A Persistent Cough Circular Lesions Of The Left Upper Lobe
  27. 27. 49 Year Old From Mexico Presents With One Month Of A Persistent Cough Apical Cavitary Lesions What Is This?
  28. 28. 49 Year Old From Mexico Presents With One Month Of A Persistent Cough Tuberculosis Apical Cavitary Lesions
  29. 29. Tuberculosis Epidemiology In The U.S. 2017 • In 2017, the incidence of TB in the U.S. (2.8 cases per 100,000) was the lowest since national surveillance began in 1952. • The rate of TB among non-U.S.-born persons was 15 times the rate among U.S.-born persons. • The top five countries of birth of non-U.S.-born persons with TB were Mexico (19%), Philippines (12.3%), India (9.4%), Vietnam (8.3%), and China (6.3%). • Persons who received a diagnosis of TB ≥10 years after arriving in the U.S. accounted for 45% of all TB cases among non-U.S. born persons.
  30. 30. Tuberculosis Epidemiology In The U.S. 2017 • For those born in the United States, TB incidence was the highest among Native Hawaiian/Pacific Islanders (5.6 cases per 100 000 persons), followed closely by American Indian/Alaskan Natives (4.0 cases per 100 000 persons). • Individuals experiencing homelessness accounted for 4.1% of TB cases, while 3.3% occurred among individuals who were incarcerated, and 1.6% occurred among residents of long-term care facilities.
  31. 31. Background • Patients with TB risk factors are often cared for at busy urban hospitals with long wait times and crowded waiting rooms • The ED is a high-risk are for M. tuberculosis transmission • Most EDs do not have CDC-compliant TB isolation facilities • Admitted pneumonia patients with and without TB may have long ED wait times • It is desirable to accurately differentiate pneumonia patients at very low risk for TB from those for whom TB needs to be considered
  32. 32. Design • Prospective case series conducted at 11 (EMERGEncy ID NET) academic urban EDs with a combined volume of 900,000 • Participants were ED patients admitted with a diagnosis of pneumonia or suspected TB • The main outcome measure was derivation and validation of a sensitive clinical decision instrument to identify patients not having TB (and not requiring isolation) according to clinical data an chest radiographs.
  33. 33. Results • Of 5,079 patients, 224 (4.4%) had pulmonary TB according to sputum cultures or tissue staining. • Instrument derived to predict which patient do not have TB: No TB Or [+] PPD History Nonimmigrant Not Homeless Not Recently Incarcerated No Recent Weight Loss No Cavitary Or Apical Infiltrate On Chest X-Ray NPV: 99.7[95% CI 99.1-99.9] Sensitivity: 96.4 [95% CI 91.9-99.9]
  34. 34. Conclusions • The absence of all decision instrument criteria was highly predictive of the absence of TB • The decision instrument is not difficult to apply and it does not expend additional resources in the ED • Identifying low-risk patient may help preserve precious isolation beds for higher risk patients
  35. 35. What About The CXR? *Notice the high RR of TB associated with cavitation and apical infiltrate on CXR! * *
  36. 36. Punch Line? • ALWAYS think about TB in your pneumonia patient who: • Has a prior history of TB and/or a prior [+] PPD • Is foreign born (see MMWR slides), homeless, and/or recently incarcerated • Provides a history of non-volitional weight loss • ALWAYS think about TB in your pneumonia patients with apical and/or cavitary infiltrates on chest X-ray When all of these historical and CXR finding are absent you can use a validated clinical decision instrument to confidently conclude that your pneumonia patient is not at significant risk for TB, and therefore will not require respiratory isolation precautions.
  37. 37. IV Drug User With Cough, Fever, Chills
  38. 38. IV Drug User With Cough, Fever, Chills RLL Abscess
  39. 39. After Drainage
  40. 40. Air-Fluid Level: If It’s Flat There’s Air In There!
  41. 41. Left Spontaneous Pneumothorax
  42. 42. After Drainage
  43. 43. 43 Year Old With 3 Weeks Of Progressive Right Arm & Neck Swelling
  44. 44. 43 Year Old With 3 Weeks Of Progressive Right Arm & Neck Swelling What Is This?
  45. 45. 43 Year Old With 3 Weeks Of Progressive Right Arm & Neck Swelling Lung Mass Compressed Superior Vena Cava
  46. 46. 43 Year Old With 3 Weeks Of Progressive Right Arm & Neck Swelling Lung Mass Compressed Superior Vena Cava Superior Vena Cava Syndrome
  47. 47. Superior Vena Cava Syndrome Anatomy And Physiology: • Obstruction by the superior vena cava caused by either extrinsic compression, i.e.: masses in the middle and anterior mediastinum (tumor, infectious process, adenopathy, aortic aneurysm…), or intrinsic obstruction, i.e.: thrombosis. • Collateral flow to the inferior vena cave or azygous vein is established. • Edema of the head, neck and upper extremities results. • The severity of symptoms depends on the degree of obstruction and the speed of onset.
  48. 48. Superior Vena Cava Syndrome Etiologic Factors: Overall Thrombosis And Non-Malignant Causes Increased use of catheters and pacemakers 35% Malignant Causes Non-small cell lung cancer Small-cell lung cancer Lymphoma Metastatic Cancer 50% 25% 10% 10% 65%
  49. 49. Superior Vena Cava Syndrome Anatomic Swelling: Edema Manifestations Scalp/Face/Arms Physically striking but usually of little consequence Eyes Visual symptoms Brain Headaches, confusion, encephalopathy Larynx Stridor, hoarseness, airway obstruction
  50. 50. 65 Year Old Presents With 3 Months Of Dysphagia
  51. 51. 65 Year Old Presents With 3 Months Of Dysphagia What Is This?
  52. 52. 65 Year Old Presents With 3 Months Dysphagia
  53. 53. 65 Year Old Presents With 3 Months Dysphagia Large Goiter Compressing The Trachea
  54. 54. Summary Of Diagnoses This Month  E-cigarette associated lung injury  Pulmonary tuberculosis  Lung abscess  Left spontaneous pneumothorax  Right lung mass and Superior Vena Cava Syndrome  Goiter
  55. 55. See You Next Month!

×