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: Acute aortic dissection, cardiomegaly, right mainstem intubation, right middle lobe pnuemonia, lung ass, pulmonary necrosis
Dr. Michael Gibbs's CMC X-Ray Mastery Project - Week #5 Cases
1. Chest X-Rays Of The Week
Michael Gibbs, MD, FACEP, FAAEM
Professor And Chair
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Vice President of Research
Atrium Health
CMC X-Ray Mastery Series
March 11th 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 contributing: Emergency Medicine, Fellows from the Center For
Advanced Practice, Trauma & Acute Care Surgery, SHVI, and Medical
Critical Care. Slides are shared with all contributors.
Cases submitted this week be distributed next week.
The 1st image will show a chest X-ray without identifiers and the 2nd image
will reveal the diagnoses.
8. 69 Year Old With
Acute Chest &
Neck Pain
Emergency Department Bedside Ultrasound
9. 69 Year Old With
Acute Chest &
Neck Pain
Dilated Aortic
Root
Emergency Department Bedside Ultrasound
10. 69 Year Old With
Acute Chest &
Neck Pain
Dilated Aortic
Root
Emergency Department Bedside Ultrasound
Aortic
Free Wall
11. Type A Aortic Dissection.
69 Year Old With
Acute Chest &
Neck Pain
12. 69 Year Old With
A History Of
Thoracic Aortic
Aneurysm
13. 69 Year Old With
A History Of
Thoracic Aortic
Aneurysm
Wide
Mediastinum
Aneurysmal Thoracic Aorta With A Type A Dissection.
14. 69 Year Old With
A History Of
Thoracic Aortic
Aneurysm
Aneurysmal Thoracic Aorta With A Type A Dissection.
15. 73 Year Old With
A History Of
HPTN Develops
Acute Chest
Radiating To His
Back
Type A Aortic Dissection.
16. 73 Year Old With
A History Of
HPTN Develops
Acute Chest
Radiating To His
Back
Wide
Mediastinum
Type A Aortic Dissection.
17. 73 Year Old With Chest Pain Radiation To His Back
Type A Aortic Dissection.
18. 73 Year Old With Chest Pain Radiation To His Back
Emergency Department Bedside Ultrasound
19. 73 Year Old With Chest Pain Radiation To His Back
Emergency Department Bedside Ultrasound
Dissection Flap
Thoracic
Aorta
20. 63 Year Old With
Several Days Of
Worsening Flank
Pain
21. 63 Year Old With
Several Days Of
Worsening Flank
Pain
Type B Aortic Dissection.
Dissection Flap
Ascending Aorta Not
Involved
22. 63 Year Old With Several Days Of Worsening Flank Pain
Just Below The Diaphragm At The Level Of The Celiac Axis
23. 63 Year Old With
Several Days Of
Worsening Flank
Pain
Our Patient: 9 Months Ago.
Normal Aortic Arch
On CT 9 Months Ago
24. Lot’s Of Aortic Dissections
This Week!
Here’s Some More Information On The Topic.
25. Aortic
Dissection
“A man was seized with pain of
the right arm and soon after
the left. He was ordered to
think seriously and piously of
his departure from this mortal
life, which was very near at
hand and inevitable.”
J.B. Morgagni, 1761.
“There is no diagnosis more
conducive to clinical humility
than dissection of the aorta.”
Sir William Osler, 1900.
26. Here’s The
Problem…
We Are Not Very
Good At Making The
Diagnosis
Initial diagnosis correct 15-50%
Diagnosis >24 hours in 40%
Klompas M. JAMA 2002.
27. Here’s The
Problem…
We Are Not Very
Good At Making The
Diagnosis
When We Miss
The Diagnosis
Patients Die
We Can’t CT Every
Patient With
Chest Pain
Initial diagnosis correct 15-50%
Diagnosis >24 hours in 40%
Klompas M. JAMA 2002.
41. IRAD: Syncope
• Syncope in 9.4%
• More common with Type A dissection
• Higher risk of tamponade & stroke
Mortality
History of Syncope 34%
Overall 28%
Hagan PG. JAMA 2000.
68. Healthy 5 Year Old
Admitted With
Pneumonia
HD #14: After Video Assisted Thoracoscopic Surgery [VATS]
One Liter Of Pus Removed
Pneumohydrothorax
With Mediastinal Shift
70. Healthy 5 Year Old Admitted With Pneumonia
HD #14: Pneumohydrothorax And Severe Pulmonary Necrosis/Trapped Lung (*)
Discharged The Following Day On IV Antibiotics With Planned Follow-Up
*
71. 25 Year Old With
Worsening
Epigastric Pain
Self-Medicating
With Narcotics
72. 25 Year Old With
Worsening
Epigastric Pain
Self-Medicating
With Narcotics
Free Air Under The Diaphragm: Gastric Perforation
73. Summary Of Diagnoses This Week
• Acute aortic dissection
• Cardiomegaly
• Right mainstem intubation
• Right middle lobe pneumonia
• Lung mass with severe pulmonary necrosis
• Right upper lobe pneumonia
• Pneumohydrothorax & severe pulmonary necrosis
![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.](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)