Drs. Angela Pikus, Alex Blackwell, Mark Baumgarten, Rosa Malloy-Post 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: • Naloxone-Associated Aspiration Pneumonitis & Pulmonary Edema • Superior Vena Cava Syndrome • Pulmonary Aspergillosis And The “Air Crescent Sign” • Needle-Chest Decompression & Recent Pneumothorax Literature

1. Adult Chest X-Rays Of The Month
Angela Pikus, MD, Mark Baumgarten, MD,
Alex Blackwell, MD, Rosa Malloy-Post, MD
Departments of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD - Faculty Editor
CMC Imaging Mastery Project
Presentation #45

2. Disclosures
 This ongoing imaging interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote diagnostic imaging interpretation mastery.
 There is no personal health information [PHI] within, and all ages have
been changed to protect patient confidentiality.

3. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Imaging Presentations And Much More!

4. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

5. It’s All About The Anatomy!

6. 35-Year-Old-Male
Found Down At
Home, Obtunded
And Covered In
Vomit. Given 4mg
Of Narcan By EMS.
Hypoxemic And
Combative On ED
Arrival.
ED Vital Signs
T 97.1, HR 149, RR 31,
BP 128/79, SPO2 86%
Initial ED Chest X-Ray

7. 35-Year-Old-Male
Found Down At
Home.
Diffuse
Right Lung
Opacities
Initial ED Chest X-Ray

8. 35-Year-Old-Male
Found Down At
Home.
Repeat CXR 2 Hours Later
Developing
Left Lung
Opacification
Worsening
Right Lung
Opacities

9. 35-Year-Old-Male
Found Down At
Home.
Diagnosis: Aspiration Pneumonitis Due To Opioid Overdose

10. Image From Biology Forums.
The Obtuse Take-Off Angle Of The Right Mainstem
Bronchus Makes Right Lung Aspiration More Likely.

11. 27-Year-Old-Male
Found Down By
EMS Following A
Suspected
Overdose. 6 mg Of
IM Naloxone Given.
ED Vital Signs
T: 99.5, HR: 110, RR: 30,
SPO2: 78% On 10L
GCS = 8 In The ED.
Initial ED Chest X-Ray

12. 27-Year-Old-Male
Found Down By
EMS Following A
Suspected
Overdose.
Interstitial And Alveolar Opacities Right > Left

13. 1 Hour Later
Given Persistent
Hypoxia, The
Patient Was Placed
On A Naloxone
Drip.
ED Vital Signs
T 99.5, HR 103, RR 43,
SPO 72% On 10L
Diagnosis: Naloxone-Related Pulmonary Edema

14. Bilateral Perihilar Consolidation
“Bat Wing Pattern"

15. 4 Hours Later
The Patient Is
Intubated But
Remains
Persistently
Hypoxemic.
A Decision Is Made
To Initiate
V-V ECMO
Support.
Worsening Infiltrates With Near “White Out”

16. ECMO Cannulation
Day #1
Intake Cannula
Air Visible In
The Pericardium

17. ECMO Cannulation
Day #2
Worsening Vascular Congestion

18. ECMO Cannulation
Day #3
Radiographic And Clinical Improvement
Persistent
Pneumopericardium

19. Extracorporeal Membrane Oxygenation (ECMO)
Indications: Acute, severe reversible respiratory or cardiac failure with
a high risk of death that is refractory to conventional therapies.
V-V = veno-venous
V-A = veno-arterial

20. V-V ECMO
Support for severe pulmonary failure (w/o cardiac failure).
Clinical Condition Appropriate For V-V ECMO
• Pneumonia
• ARDS
• Acute GVHD
• Pulmonary contusion
• Smoke inhalation
• Status asthmaticus
• Airway obstruction
• Aspiration
• Bridge to lung transplant
• Submersion injury

21. Figure 1: V-V ECMO
Blood is drained from the femoral vein
and returned to the right heart.

22. Figure 2: V-V ECMO
Central venous blood is drained, and
oxygenation blood is returned to the
right atrium.

23. V-A ECMO
Support for cardiac failure (+/- pulmonary failure).
Clinical Condition Appropriate For V-A ECMO
• Graft failure post heart or heart
lung transplant
• Non-ischemic cardiogenic shock
• Failure to wean post
cardiopulmonary bypass
• Bridge to LVAD
• Drug overdose
• Sepsis
• Pulmonary embolus
• Cardiac or major vessel trauma
• Massive pulmonary hemorrhage
• Pulmonary trauma
• Acute anaphylaxis

24. Figure 3: V-A ECMO
Central venous blood is drained, and
oxygenation blood is returned to the
arterial system.

25. Naloxone-Induced
Non-Cardiogenic
Pulmonary Edema
• Rare and thought to occur in 0.2-3.6% of patients
(based on data from elective post-operative
anesthetic reversal).
• Mostly reported in patients with co-existing cardiac
disease and/or in young adults with obstructive sleep
apnea.
• Thought to be caused by catecholamine release
which antagonizes the mu-opioid receptors in the
adrenal medulla; leading to increased pulmonary
blood volumes and pressures, and increased capillary
permeability.
Jiwa, Nasheena et al. “Naloxone-Induced Non-Cardiogenic
Pulmonary Edema: A Case Report.” Drug Safety - Case Reports
Vol. 5,1 20. 10 May. 2018, doi:10.1007/s40800-018-0088-x

26. Objective
To determine whether administration of higher doses of naloxone for the treatment of opioid
overdose is associated with increased pulmonary complications.
Methods
Retrospective, observation study of 1,831 patients treated with naloxone by the City of
Pittsburgh EMS. “High-dose” naloxone was defined as a total administration exceeding 4.4 mg.

27. Results
• Patients receiving high dose naloxone were 62% more likely to have a pulmonary complication
(42% versus 26% absolute risk; odds ratio 2.14; 95% CI 1.44 to 3.18).
• When the initial dose of naloxone exceeded 0.4 mg, there was an increased risk of pulmonary
complications (27% versus 13% absolute risk; odds ratio 2.57; 95% CI 1.45 to 4.54).
• Pulmonary edema occurred in 1.1% of patients.
Recommendations
• Naloxone-associated pulmonary complications are rare and dose-dependent.
• Titrate naloxone carefully to achieved the desired clinical effect.

28. Pulmonary Edema
Differential
Diagnosis
• Cardiogenic (high pulmonary capillary pressure):
• Left heart failure
• Mitral regurgitation
• Aortic stenosis
• Myocardial pathology (Cardiomyopathy, Myocarditis)
• Non-cardiogenic (increased capillary permeability):
• Neurogenic pulmonary edema
• High altitude pulmonary edema
• Reperfusion pulmonary edema
• Re-expansion pulmonary edema
• Overdose (heroin, methadone, fentanyl, naloxone)
• Salicylate toxicity
• Drugs (amiodarone, immunosuppressives)
• Pulmonary embolism
• Eclampsia
• Viral infections
• Pulmonary veno-occlusive disease
• Transfusion related acute lung injury (TRALI)

29. What Should You
Look For
On Chest X-Ray?
Pulmonary Interstitial Edema
• Kerley B lines
• Peri-bronchial cuffing
Pulmonary Alveolar Edema
• “Bat wing” pattern
• Air bronchograms
Cardiomegaly
Pulmonary Vascular Engorgement
• Vascular cephalization

30. 42-Year-Old With
5 Months Of
Progressive Chest
Discoloration,
Dyspnea,
Dysphagia And
Hoarseness.
Sent To The ED
After His PCP
Ordered A Chest
CT.
CT Scout Film

31. Large Irregular Mediastinal Mass
42-Year-Old With
5 Months Of
Progressive Chest
Discoloration,
Dyspnea,
Dysphagia And
Hoarseness.
Sent To The ED
After His PCP
Ordered A Chest
CT.

32. Here Is His Chest X-Ray Just 6 Months Prior!

33. Diagnosis: Superior Vena Cava Syndrome
42-Year-Old With A Large Mediastinal Mass

34. • A Core Biopsy Demonstrated Primary Mediastinal B-Cell Lymphoma (PMBCL).
• A Staging PET Scan Demonstrated A Large Hypermetabolic Mediastinal Mass With No
Other Disease Outside The Chest, Consistent With Stage 1.
• Treatment Was Initiated With Steroids, Chemo & Radiation Therapy.

35. After 1 Month Of Treatment The Size Of The Mass Is Reduced

36. 43-Year-Old With
3 Weeks Of
Progressive Right
Arm & Neck
Swelling.
www.EMguidewire.com October 2019

37. 43-Year-Old With
3 Weeks Of
Progressive Right
Arm & Neck
Swelling.
What Is
This?
www.EMguidewire.com October 2019
Notice The Leftward
Deviation Of The
Trachea & Spine

38. 43-Year-Old With 3 Weeks Of Progressive Right Arm & Neck Swelling
Lung
Mass
Compressed
Superior
Vena Cava
Superior Vena Cava Syndrome
www.EMguidewire.com October 2019

40. 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.

42. Superior Vena Cava Syndrome
Causes:
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%

43. Superior Vena Cava Syndrome
Pathophysiology:
Edema Manifestations
Scalp/Face/Arms Physically striking but usually of little
consequence
Eyes Visual symptoms
Brain Headaches, confusion, encephalopathy
Larynx Stridor, hoarseness, airway obstruction

45. 48-Year-Old
Homeless Male With
No Past Medical
History Presents
With 3-5 Days Of
Body Aches, Cough,
Fever.
ED Vital Signs Are Stable

46. Circular Right Upper Lobe Density
48-Year-Old
Homeless Male With
No Past Medical
History Presents
With 3-5 Days Of
Body Aches, Cough,
Fever.
ED Vital Signs Are Stable

47. 48-Year-Old Homeless Male With 3-5 Days Of Body Aches, Cough, Fever.

48. Air Crescent Sign: Circular Lesion With A Central
Density Partially Surrounded By A Rim Of Air.
48-Year-Old Homeless Male With 3-5 Days Of Body Aches, Cough, Fever.

49. 48-Year-Old Homeless Male With 3-5 Days Of Body Aches, Cough, Fever.
Air Crescent Sign: Circular Lesion With A Central
Density Partially Surrounded By A Rim Of Air.

50. Air Crescent Sign
• Half-moon-shaped collection of air in the
periphery of an intracavitary nodule,
separating the nodule from the cavity wall.
• Aspergillosis is the most common cause.
• The differential also includes cavitary
bronchogenic carcinoma, intracavitary
clot, and Rasmussen’s aneurysm in the
setting of prior tuberculosis.
• Rarer causes include foreign bodies, thick
pus, teratoma, and hydatid cysts.
Repositioning the patient (supine and
prone) during CT can help identify the
etiology. A mobile central mass suggests a
fungus ball or clot. A fixed central mass
suggests carcinoma or aneurysm.

51. QJM: An International Journal of Medicine 2019:47-48.
Clinical Picture: Diabetes Mellitus and Air Crescent Sign
66-year-old with poorly controlled diabetes presents with cough, fever, and dyspnea. He was admitted and started on
levofloxacin. His condition worsened and on Day 3 a chest CT revealed bilateral consolidation with several areas rimmed by
air (air crescent sign →). Bronchoscopy confirmed Aspergillosis and the patient responded well to amphotericin B.

52. Diagnostic & Interventional Radiology 2015; 96:435-442.
Pulmonary Aspergillosis
Lobectomy pathologic specimen demonstrating an
aspergilloma (“fungus ball”) within a cavity.

53. Infectious and Non-Infectious Diseases Causing the Air Crescent Sign:
A State-of-the-Art Review
Lung 2018:1-10. //doi.org/10.1007/s00408-017-0069-3.
Ruptured Hydatid Cyst Metastatic Uterine Cancer

54. Supine
Prone
Rasmussen’s Aneurysm
• No mobility with positioning
• Nodule enhancement
40-Year-Old Presenting With One Month Of Cough, Fever,
Weight Loss And Recent Hemoptysis.
Nodule Enhancement
Lung 2018:1-10. //doi.org/10.1007/s00408-017-0069-3.

55. Back To Our Patient
• The patient was admitted and treated with IV antibiotics
• AFB x3 and QuantiFERON were both negative for tuberculosis
• The diagnosis of Aspergillosis was confirmed by the analysis of
bronchoscopy samples and cultures
• The patient responded well to treatment with amphotericin B

56. 17-Year-Old In An
ATV Crash
Complaining Of Right
Sided Chest Pain.

57. 17-Year-Old In An
ATV Crash.
EMS Angiocath
Right Pneumothorax

58. 17-Year-Old In An
ATV Crash.
Pigtail Catheter Drainage

59. Systematic review of 15 studies.
Thickness (mm)
MCL 42.79
MAL 39.85
AAL 34.33
MCL: Mid-Clavicular Line
MAL: Mid Axillary Line
AAL: Anterior Axillary Line Injury. 2016;47:797-804-564.

60. Emergency Needle
Thoracostomy Set
COLLAPSED EXPANDED
Cook products services program Portal
Order Number
Order Number Reference Part Number
Reference Part Number
Instructions
Instructions
for Use
for Use
MR
MR
Status
Status
Catheter
Catheter
Fr
Fr
Catheter
Catheter
Length
Length
cm
cm
Needle
Needle
gage
gage
More Info
More Info
Sets
Sets
G13722 C-TPTS-8.5-6.0-FSNS — 8.5 6 15 Expand »
G55524 C-TPTS-8.5-8.7-FSNS — 8.5 8.7 15 Expand »
Dry Sets
Dry Sets
G27292 C-TPTSJ-8.5-6.0-FSNS — 8.5 6 15 Expand »
Specifications
Specifications
Be Sure Your Catheter Is Long

61. Chest X-Ray Versus POCUS In
Pneumothorax?

62. Objective
To compare the diagnostic accuracy POCUS with chest X-ray for the diagnosis of
pneumothorax in Emergency Department (ED) trauma patients.
Methods
Comprehensive literature review from database inception to April 2020 – all prospective
paired accuracy studies were included. 13 studies were part of the analysis – capturing 410
traumatic pneumothorax patients out of 1271 patients).
Results
POCUS:
CXR:
Sensitivity 0.91 (95% CI 0.85 to 0.94); Specificity 0.99 (95% CI 0.97 to 1.00)
Sensitivity 0.47 (95% CI 0.31 to 0.63); Specificity 1.00 (95% CI 0.97 to 1.00)
Conclusions
The diagnostic performance of POCUS is superior to chest X-ray for the diagnosis of
pneumothorax in ED trauma patients.

63. Absence Of Lung Sliding Dynamic movement of the visceral on the parietal pleura during respirations.
Absence Of B-Lines Reverberation artifacts that disappear when air accumulates in the pleural space.
Lung Sliding B-Lines

64. Lung Point Sign Highly specific U/S finding that represents the point where the visceral pleura (lung) begins
to separate from the parietal pleura (chest wall) at the edge of the pneumothorax.

65. What Is The Latest Literature On The Management Of
Traumatic Pneumothorax In Stable Patients?

66. J Trauma Acute Care Surg. 2022;92: 951-957.
Objective
To assess a previously developed guideline to observe any pneumothorax (PNTX) <35 mm in stable patients.1,2
Methods
Single-center, retrospective, before (2015-2016) and after (2018-2019) review of all patient with CT-guided PNTX.
Patients with concurrent hemothorax, on mechanical ventilation, and dying in <24 hours were excluded.
Results
266 patients (37% before 2017 and 63% after 2017) were included and there were no demographic differences
between groups. Tube thoracostomy placement decreased from 28.3% to 18%. There were no differences in
hospitalization outcomes, complications, or mortality.
Conclusion
The 35 mm Guideline is an effective tool to decrease unnecessary tube thoracostomy in stable patients without
evidence of hemothorax.
1Pneumothorax dimensions were determined using measurement of an axial chest CT.
2By protocol chest X-rays were repeated at 4 and 24 hours.

67. J Trauma Acute Care Surg. 2019;86: 557-564.
The Original 2019 Study
• Retrospective review 2011-2016
• 832 total pneumothorax patients
• Hemothorax & ventilated patients excluded
• Patients divided into <35 or >35 mm
• 257 patients had a PNTX <35 mm
Observation was successful in 91%
Important Caveats:
• This approach is only for non-ventilated patients
• Longer hospitalizations may result
• Several factors will impact decision making

68. Diagnoses This Month
• Naloxone-Associated Aspiration Pneumonitis & Pulmonary Edema
• Superior Vena Cava Syndrome
• Pulmonary Aspergillosis And The “Air Crescent Sign”
• Needle-Chest Decompression & Recent Pneumothorax Literature

69. See You Next Month!