1Diagnosis

Can you tell why this patient is short of breath?

Tension pneumothorax

Complete right-sided

pneumothorax

Lung is compressed

against mediastinum

Shift of heart and trachea to

left

Tension pneumothorax

Pneumothorax

Post

Ant

With person lying on their back, air in

pleural space rises to top and displaces

normal lung

2Diagnosis

This person developed chest pain after vomiting

Pneumomediastinum

Streaky, linear densities due

to air in the mediastinumStreaky, linear

densities due to air in the mediastinum

Pneumomediastinum – CT scan

Air surrounding esophagus in mediastinum

Extraluminal contrast from

perforation along left

lateral wall of distal

esophagus

3Diagnosis

Why does this patient have abdominal pain?

Pneumoperitoneum

Air outlines under surface of left hemidiaphragm

Air outlines under surface of

right hemidiaphragm

Pneumoperitoneum

Air outlines both sides of the wall of the stomach-a sign of free air in

the peritoneal cavity

Pneumoperitoneum - CT

CT scans on 2 different people show a small and large amount of free air in the peritoneal cavity which rises to the highest point (anterior abdomen with the

person lying on their back) and is not contained within bowel

Free airFree air

4Diagnosis

57 year-old female with shortness of breath

Pleural Effusions

Meniscus-shaped density at left base from a pleural effusion

Meniscus-shaped density

at right base from a pleural

effusion

Pleural Effusions

Meniscus-shaped density

at right base from a pleural

effusion Meniscus-shaped density at left base from a pleural effusion

Effect of Position - Layering

Supine Erect

In the supine position, the fluid layers out posteriorly and produces a haziness, especially near the bases (since the patient is actually semi-

recumbent). In the erect position, the fluid falls even more to the bases.

5Diagnosis

This patient has atrial fibrillation and a heart murmur

Pulmonary Venous Hypertension from Mitral Stenosis

Size (not number) of vessels at the apex exceeds size of vessels at the base in this upright person. This is called “cephalization.” Normally the vessels at the base exceed the size of the vessels at the apex

Pulmonary Interstitial Edema

Pulmonary interstitial edema produced by Kerly A and C lines

Pulmonary Alveolar Edema

Bilateral, diffuse airspace disease more marked centrally than at the periphery of the lung (“bat-wing appearance”)

6Diagnosis

63 year-old man with chest pain

Aortic Dissection

Linear lucency in the contrast-filled descending aorta is the intimal flap of an aortic dissection

Aortic Dissection

• Widened mediastinum

• Left pleural effusion

• Chest pain

Should make you think of an aortic dissection

Classification of Dissecting Aneurysms

Stanford classification

• Widened mediastinum

• Left pleural effusion

• Chest pain

7Diagnosis

Why did this 85 year-old have abrupt onset of abdominal pain?

Aortic rupture

Red arrows point to active extravasation of contrast from the aorta into the retroperitoneum

Thrombus inside the lumen of the aorta

Red arrows point to active extravasation of contrast from the aorta into the retroperitoneum

AortaAorta

Ruptured Aortic Aneurysm

Enlargement of abdominal aorta > 3cm Usually 2 to atherosclerosis Below renals, above iliacs

About 20-25% rupture <4cm~10%; >10 cm~60% Retroperitoneal, usually on left Into GI tract: massive hemorrhage Into IVC: rapid cardiac decompensation

8Diagnosis

Newborn with tachypnea

Diaphragmatic Rupture

Left hemithorax contains multiple lucencies--air in the lumen of bowel, now located in the chest

Heart and trachea are

displaced to right by bowel in

opposite hemithorax

Diaphragmatic RuptureGeneral

5% of all diaphragmatic hernias Most (90%) are left-sided

Central and posterior >10cm in length Contain stomach, colon, small bowel,

omentum, spleen

Half have no initial abnormal radiographic findings

Half are missed clinically

Diaphragmatic Rupture General

Associated with Fx ribs Pneumoperitoneum Ruptured spleen

Delayed diagnosis = higher mortality MRI most useful in showing site of tear

The End