Drs. Olson and Jackson are interested in education and Pediatric Emergency Medicine. Follow along with the EMGuideWire.com team and Drs. Nikki Richardson and Michael Gibbs as they post these educational, self-guided radiology slides on Pediatric Emergency Medicine Radiology. This month’s topics include: • Aortic Coarctation • Tension pneumothorax • Pneumonia • COVID-19 • Tetralogy of Fallot • L-Transposition of the Great Vessels • Pediatric ARDS • MIS-C • Foreign Body Aspiration • Aspiration Pneumonia • Corner fracture • Non-accidental Trauma

1. Pediatric Chest X-Rays of the Month
Kendra Jackson, MD & Elizabeth Olson, MD
Department of Pediatrics &
Department of Emergency Medicine
Levine Children’s Hospital & Carolinas Medical Center
Michael Gibbs, MD, Faculty Editor
Nicholena Richardson, MD, Junior Faculty Editor
Chest X-Ray Mastery Project
August 2020

2. Process and Disclosures
This ongoing pediatric chest x-ray
interpretation series is proudly sponsored
by the Emergency Medicine Residency
Program and Pediatric Emergency Medicine
Fellowship at Carolinas Medical Center.
The goal is to promote widespread mastery
of CXR interpretation.
Cases are submitted by contributors from
many CMC departments, and now…
Tanzania and Brazil.
Ages have been changed to protect patient
confidentiality. No protected health
information (PHI) will be shared.
For more educational content, visit
EMGuidewire.com

3. Reading systematically…
A for airway
B for bones
C for cardiac silhouette
D for diaphragm
E for everything else
For more educational content, visit
EMGuidewire.com

4. Normal CXR
for your
reference

5. HPI:
11 yo presenting with
hypertension, a new
murmur, and decreased
femoral pulses
What’s the xray finding?
What’s the diagnosis?

6. REVIEW
HPI:
11 yo presenting with
hypertension, a new
murmur, and decreased
femoral pulses
Xray finding: Rib notching.
Diagnosis: Aortic
coarctation

7. Coarctation Quick Tips
If the obstruction caused by a
coarc that is not severe, collateral
arteries will enlarge and create
INFERIOR rib notches
Older children can be relatively
asymptomatic
Look for associated left-sided
lesions (mitral
stenosis, bicommissural aortic
valve)
http://www.pted.org/?id=coarctation4

8. Clinical Pearl:
Pediatric
Hypertension
1.Pediatric hypertension is not
always pain. About 3.5% of
kids have hypertension
2.Re-check manually with an
appropriately sized cuff
3.Encourage follow with PCP for
BP recheck for incidental HTN

10. HPI:
3 mo with history of
CPAM s/p VATS
presents with poor
PO, now intermittently
tachypneic
Spot the abnormality.

11. HPI:
3 mo with history of
CPAM s/p VATS
presents with poor PO,
now intermittently
tachypneic
Diagnosis: Tension
Pneumothorax
Pearl: Poor feeding can also
be a sign of respiratory
distress

12. HPI:
3 mo with history of
CPAM s/p VATS
presents with poor PO,
now intermittently
tachypneic. Still on
room air!
Since the patient was so
clinically stable, he had a
pigtail placed under conscious
sedation instead of a needle
decompression

13. Kids are not just little
adults!!!
Mandt MJ et al. Appropriate needle length for emergent pediatric needle thoracostomy utilizing
computed tomography. Prehosp Emerg Care 2019 Jan 9; 1; [e-pub].
(https://doi.org/10.1080/10903127.2019.1566422)
A standard angiocatheter length of 3.8 cm
should be sufficient for most pediatric patients
for needle decompression

14. REVIEW from July 2020

15. HPI:
17-year-old with a hx of
lupus presents with
fever and back pain
She later endorsed
chest pain and body
aches
Spot the abnormality

16. HPI:
17-year-old with a hx of
lupus presents with
fever and back pain
She later endorsed chest
pain and body aches
What could this be?
What’s next?

17. HPI:
17-year-old with a hx of
lupus presents with
fever and back pain
She later endorsed chest
pain and body aches
Diagnosis: COVID with
wedge pneumonia

18. HPI:
5-month-old with a
history of congenital
heart disease presents
with apnea
Spot the abnormality

19. HPI:
5-month-old with a
history of congenital
heart disease presents
with apnea
Findings: boot shaped
heart, cardiomegaly, and
sternotomy ties

20. HPI:
5-month-old with a
history of congenital
heart disease presents
with apnea
What could this be?
What’s congenital heart
problem do they have?

21. HPI:
5-month-old with a
history of congenital
heart disease presents
with apnea
Diagnosis: COVID in a
child with a history of
Tetralogy of Fallot

22. HPI:
4-year-old w/ a h/o
transposition of the
great arteries presents
with worsening difficulty
breathing, wheezing,
and decreased activity
Spot the abnormality

23. HPI:
4-year-old w/ a h/o
transposition of the
great arteries presents
with worsening difficulty
breathing, wheezing,
and decreased activity
Findings: Perihilar
edema and moderate
cardiomegaly

24. HPI:
4-year-old w/ a h/o
transposition of the
great arteries presents
with worsening difficulty
breathing, wheezing,
and decreased activity
Name that hardware!

25. HPI:
4-year-old w/ a h/o
transposition of the
great arteries presents
with worsening difficulty
breathing, wheezing,
and decreased activity
Sternotomy ties and a biventricular
pacemaker
Teaching point: Up to 45% of people
with Corrected Transposition of the
Great Arteries will have complete AV
block

26. HPI:
4-year-old w/ a
h/o transposition of
the great arteries
presents with worsening
difficulty breathing,
wheezing, and
decreased activity
What’s your diagnosis?

27. Additional history:
This child’s father
works in construction
and he takes Lasix
daily.
Diagnosis: COVID and heart
failure in the setting of
worsening tricuspid
regurgitation

28. Sometimes there is more than one diagnosis…

29. HPI:
10 year old presents
in respiratory distress
What additional history is
needed?

30. Additional History:
Their entire family
was sick 1 month ago
with URI symptoms
What radiographic findings
are present?
What is the diagnosis?

31. Additional History:
Their entire family
was sick 1 month ago
with URI symptoms
Xray finding: bilateral white-out
Diagnosis: ARDS secondary to
Multisystem Inflammatory
Syndrome in Children (MIS-C)

32. HPI: 10 yo F
previously presenting
in respiratory distress.
Her entire family was
sick 1 month ago with
URI symptoms
Name those lines
A
C
B

33. HPI: 10yo F previously
presenting in
respiratory distress.
Her entire family was
sick 1 month ago with
URI symptoms
A: VA ECMO Cannula
B: ET Tube
C: Nasogastric Tube
A
C
B

34. HPI:
23-month-old presents
with coughing after
aspirating a peanut 5
days ago
Spot the abnormalities

35. HPI:
23-month-old presents
with coughing after
aspirating a peanut 5
days ago
A. Normal thymus
B. Aspiration pneumonia
A
B

36. Post Op:
After bronchoscpy and
removal of peanut and
was unable to be
extubated.
Exam: Pink froth from
ET tube
What is the diagnosis
now?

37. Post Op: After
bronchoscpy, the
patient was unable to
be extubated
Exam: Pink froth from
ET tube
Diagnosis: Mild
PARDS after foreign
body aspiration

38. New Pediatric ARDS Definition
Cheifetz, IM. Pediatric ARDS. Respiratory Care Jun 2017, 62 (6) 718-731; DOI: 10.4187/respcare.05591
Age: Outside of the perinatal period
Timing: 7 days from known clinical insult
Origin of Edema: Respiratory failure not secondary to cardiac failure or fluid overload
Radiographic Findings: New infiltrates consistent with parenchymal disease

39. Orloff KE, Turner DA, Rehder KJ. The Current State of Pediatric Acute Respiratory Distress Syndrome. Pediatr Allergy Immunol Pulmonol. 2019;32(2):35-44.
doi:10.1089/ped.2019.0999
Bacterial or viral
pneumonia
COVID
Sepsis
Foreign body aspiration
Acute chest syndrome
Pancreatitis
Trauma
Lots of things can cause PARDS...
Drowning
Burns
Inhalation Injury
Vaping
Drug Overdose
Fat Emboli
Massive blood transfusions

40. HPI:
14-month-old presents
with Fever, Cough, And
Emesis

41. HPI:
14-month-old presents
with Fever, Cough, And
Emesis
Diagnosis: Aspiration
pneumonia with
foreign body in the
right main stem

42. HPI: 1-year-old
presents after his
sister was found to be
a victim of NAT
What is the diagnosis?
Differential?

43. HPI: 1-year-old
presents for NAT
evaluation
Findings: Corner Fracture
of the proximal humerus
and normal thymus tissue

44. HPI: 1-year-old
presents for NAT
evaluation
Dedicated humerus x-
ray demonstrating
corner fracture - High
suspicion for NAT

45. High Suspicion Findings
on CXR
Advice
Evaluating Children With Fractures for Child Physical Abuse
Emalee G. Flaherty, Jeannette M. Perez-Rossello, Michael A. Levine, William L. Hennrikus, and the AMERICAN ACADEMY OF PEDIATRICS COMMITTEE ON CHILD
ABUSE AND NEGLECT, SECTION ON RADIOLOGY, SECTION ON ENDOCRINOLOGY, SECTION ON ORTHOPAEDICS, the SOCIETY FOR PEDIATRIC RADIOLOGY
Pediatrics Feb 2014, 133 (2) e477-e489; DOI: 10.1542/peds.2013-3793
If a child presents with injuries with a high suspicion
for NAT, a STAT evaluation and skeletal surveys
should be performed on all sibling who are:
1. Non-verbal
2. Developmentally delayed
3. 2 years old or younger
• Posterior or lateral rib fractures
• Corner, also known as Bucket Handle fractures
that are caused by shaking or twisting
• Fractures in differing stages of healing
• Fractures of the scapula
• Fractures of the sternum
• Humeral shaft fractures in a child younger
than 18 months

46. Summary of This Month’s
Diagnoses
• Aortic coarctation (review)
• Tension pneumothorax
• Pneumonia, COVID+
• Tetralogy of Fallot, COVID+
• L- Transposition of the Great Arteries,
COVID+
• Pediatric ARDS in MIS-C
• Mild Pediatric ARDS after foreign body
aspiration
• Aspiration pneumonia
• Corner fracture in non-accidental trauma
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