This document discusses an adult chest x-ray presentation from the Carolinas Medical Center and Levine Children's Hospital. It provides disclosures about the goal of promoting chest x-ray interpretation skills. Cases are submitted by various departments and international colleagues. The presentation reviews multiple chest x-ray cases and corresponding diagnoses, including pneumomediastinum, spontaneous pneumothorax, deep sulcus sign, pericardial effusion, pulmonary hypertension, mitral stenosis, pulmonary bullae, situs inversus, dextrocardia, and cavitary lesions. A website is provided for an archive of past chest x-ray presentations.

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
January 2020

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. Healthy 13-Year-Old With Throat And Upper Chest Pain

8. Healthy 13-Year-Old With Throat And Upper Chest Pain
Pneumomediastinum & Pneumopericardium

9. Healthy 13-Year-Old With Throat And Upper Chest Pain
Pneumomediastinum & Pneumopericardium

10. Young Male With
Intractable
Vomiting

11. Young Male With
Intractable
Vomiting
Pneumomediastinum & Pneumopericardium
Subcutaneous
Emphysema
Subcutaneous
Emphysema

12. Young Male With Intractable Vomiting
Pneumomediastinum + Pneumopericardium + Subcutaneous Emphysema

13. 25-Year-Old Presents With Sharp Chest Pain After Smoking
Marijuana

14. Pneumomediastinum
25-Year-Old Presents With Sharp Chest Pain After Smoking
Marijuana

15. Pneumomediastinum
25-Year-Old Presents With Sharp Chest Pain After Smoking
Marijuana

16. Pneumomediastinum
2° Iatrogenic 2° Medical & Traumatic Spontaneous
 Endoscopic procedures
 Intubation
 Pleural instrumentation
 Central vascular procedure
 Chest/abdominal surgery
 Blunt chest injury
 Penetrating chest injury
 Asthma/COPD
 Bronchiectasis
 Interstitial lung disease
 Thoracic malignancy
 Tobacco use
 Recreational drugs
 Breath holding
 Weight lifting
Vasileios K. Journal of Thoracic Disease 2015; 7:S44-S49.
Management Essentials
 Manage the underlying cause
 Pain management & cough suppression as indicated
 Oxygen may increase gas absorption in severe cases
 Brief period of observation vs. close outpatient follow-up

17. Traumatic Pneumomediastinum
Single-Center Trauma Registry Review 2007-2012:
9,946 admitted trauma patients studied: 258 had pneumomediastinum
Chouliaras K. Journal of Trauma & Acute Care Surgery 2015; 79:188-193.
CXR diagnosis in 25% CT diagnosis in 75%
21 patients (8.1%) had an aerodigestive work-up with bronchoscopy, esophagram or
esophagoscopy: 4 injuries (1.6%) were identified.
 3 tracheobronchial injuries [2 (0.7%) managed surgically]
 1 esophageal injury managed non-operatively
Isolated pneumomediastinum poorly predict of injury: selective work-up recommended.

18. Gunshot Wound
To The Neck…

19. Gunshot Wound
To The Neck…

20. Gunshot Wound
To The Neck…
Injury To The Trachea & Esophagus

21. Pneumomediastinum
Injury To The Trachea & Esophagus

22. Pneumomediastinum
Pneumomediastinum
Pneumomediastinum
Injury To The Trachea & Esophagus

23. Healthy Young
Female With
Sudden Onset
Right-Sided
Pleuritic Chest
Pain

24. Spontaneous Pneumothorax
Healthy Young
Female With
Sudden Onset
Right-Sided
Pleuritic Chest
Pain

25. Healthy Male
Presents With
Sharp Chest Pain

26. Left Spontaneous Pneumothorax
Healthy Male
Presents With
Sharp Chest Pain

27. After Drainage
Healthy Male
Presents With
Sharp Chest Pain

28. Healthy Male
Presents With
Sharp Chest Pain

29. Healthy Male
Presents With
Sharp Chest Pain
Right Spontaneous Pneumothorax

30. Healthy Male
Presents With
Sharp Chest Pain
After Drainage

31. Sahn SA. NEJM 2000; 342:868-874.
Classification Of Pneumothorax According To Cause
Spontaneous
1°: No clinical lung disease
2°: A complication of clinically apparent lung disease
Traumatic
• Penetrating trauma
• Blunt trauma
Iatrogenic
• Transthoracic needle aspiration
• Central line placement
• Thoracentesis
• Lung biopsy

32. NEJM 2000; 342:868-874.

33. 33-Year-Old In A Roll
Over Motor Vehicle
Crash.

34. 33-Year-Old In A Roll
Over Motor Vehicle
Crash.
Deep Sulcus
Sign
Deep Sulcus
Sign
Bilateral Tension Pneumothorax

35. 35-Year-Old Male
In A High-Speed
Car Crash

36. 35-Year-Old Male
In A High-Speed
Car Crash
Deep Sulcus
Sign
Tension Pneumothorax With Shift

39. 88-Year-Old Falls On
His Right Side.

40. 88-Year-Old Falls On
His Right Side.
Right Apical Pneumothorax + Multiple Rib
Fractures[*]
*
*
*
*
*
*

41. 88-Year-Old Falls On
His Right Side.

42. 73-Year-Old
Female With
Progressive
Dyspnea

43. 73-Year-Old
Female With
Progressive
Dyspnea
Massive Pericardial Effusion

44. 73-Year-Old
Female With
Progressive
Dyspnea
73-Year-Old
Female With
Progressive
Dyspnea
*
*
*
*
*
Massive Pericardial Effusion

45.  Rapidly accumulating pericardial effusions cause swift increases in intrapericardial
pressure and tamponade physiology.
 Slowly accumulating pericardial effusions gradually distend the pericardium and
symptoms can be delayed.

46. What Do You See?

47. What Do You See?
Enlarged Right
Pulmonary Artery
Enlarged Left
Pulmonary Artery

48. What Do You See?
Pulmonary Arterial Hypertension
Enlarged Right
Pulmonary Artery
Enlarged Left
Pulmonary Artery

49. To Learn More About ECG Findings In Pulmonary Hypertension, Visit:
www.EMGuidewire.com
Click On “EM Cardiology,” Then Click On “Monthly ECG Blogs.”
November ECG Lesson
Created skillfully by
Dr. Neha Ray, CMC E.M.
PGY-1 resident and…
Dr. Laszlo Littmann, the
master of ECG
interpretation and
education.

50. Valvular Heart Disease
Which cardiac chamber is enlarged in patients with significant chronic
mitral stenosis?
• Right atrium
• Right ventricle
• Left atrium
• Left ventricle

51. Valvular Heart Disease
Which cardiac chamber is enlarged in patients with significant chronic
mitral stenosis?
• Right atrium
• Right ventricle
• Left atrium
• Left ventricle

52. Mitral Stenosis

53. Mitral Stenosis

54. Mitral Stenosis

55. Mitral Stenosis

57. Pulmonary Bullae

58. Healthy 33-Year-
Old With Chest
Pain

59. Healthy 33-Year-
Old With Chest
Pain
Situs Inversus
Heart & Stomach Both On The Wrong Side

61. Dextrocardia
Heart On The Wrong Side, Stomach On The Correct Side

62. 45-Year-Old
Renal Transplant
Patient With
Cough And
Dyspnea.

63. 45-Year-Old
Renal Transplant
Patient With
Cough And
Dyspnea.
Cavitary Lesions

64. 45-Year-Old
Renal Transplant
Patient With
Cough And
Dyspnea.
Cavitary Lesions

65. Summary Of Diagnoses This Month
 Pneumomediastinum
 Spontaneous pneumothorax
 Deep Sulcus Sign
 Massive pericardial effusion
 Pulmonary hypertension
 Mitral stenosis
 Pulmonary bullae
 Situs inversus
 Dextrocardia
 Cavitary lesions

66. See You Next Month!