Drs. Olson and Jackson are interested in education and Pediatric Emergency Medicine. Follow along with the EMGuideWire.com team and Drs. Nikki Richardson, Mary Grady, and Michael Gibbs as they post these educational, self-guided radiology slides on Pediatric Emergency Medicine Radiology. This month’s topics include: - Pneumatocele - Croup - Pulmonary Contusion - Blast Injury - Bowel Obstruction - Lobar Pneumonia - Cavitary Lung Lesions - Ileus - Malposition of Central Line

1. Pediatric X-Rays of the Month
Charles Harris III, MD & Neha Ray, MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD, Faculty Editor
Nicholena Richardson, MD & Mary Grady, MD, Junior Faculty Editors
Chest X-Ray Mastery Project
August 2021

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. CASE 1 (REVIEW):
11-year-old female who
presented with dyspnea
after jumping on a
trampoline.
HR 127, RR 24, SpO2 96%
Spot the abnormality

6. Dx: Pneumatocele
CASE 1 (REVIEW):
Thin-walled, air-containing
cyst of the lung. Can be of
infectious (tuberculosis,
staph aureus, etc) or
noninfectious (trauma,
mechanical ventilation, etc)
etiology.

7. What is the diagnosis?
CASE 2:
Patient is a 22-
month M with
intermittent
dyspnea and
“abnormal
breathing” x2 days
Parents “pretty
sure” the patient
didn’t swallow
anything

8. CASE 2:
Patient is a 22-
month M with
intermittent
dyspnea and
“abnormal
breathing” x2 days
Parents “pretty
sure” the patient
didn’t swallow
anything
Subglottic
narrowing
Steeple Sign – Indicative of croup
No foreign bodies appreciated
Dx: Croup

9. CASE 3:
13 y/o M presents after playing
with fireworks which explode near
his chest. He comes complaining of
chest pain and has had multiple
episodes of hemoptysis. He is
hypoxic to the low 80% on RA
improved to 100% on 4L NC but
otherwise hemodynamically stable.
Multiple abrasions to the chest
without obvious burns.
Interpret this CXR.

10. CASE 3:
13 y/o M presents after playing
with fireworks which explodes near
his chest. He comes complaining of
chest pain and has had multiple
episodes of hemoptysis. Hypoxic to
the low 80% on RA improved to
100% on 4L NC but otherwise
hemodynamically stable. Multiple
abrasions to the chest without
obvious burns.
What does the circled abnormality
indicate?

11. CASE 3:
13 y/o M presents after playing
with fireworks which explodes
near his chest. He comes
complaining of chest pain and has
had multiple episodes of
hemoptysis. Hypoxic to the low
80% on RA improved to 100% on
4L NC but otherwise
hemodynamically stable. Multiple
abrasions to the chest without
obvious burns.
Interpretation: Pulmonary
contusion due to blast injury. This
is sometimes referred to as blast
lung.

12. CASE 3:
13 y/o M presents after playing
with fireworks which explodes near
his chest. He comes complaining of
chest pain and has had multiple
episodes of hemoptysis. Hypoxic to
the low 80% on RA improved to
100% on 4L NC but otherwise
hemodynamically stable. Multiple
abrasions to the chest without
obvious burns.
There was concern about a
widened mediastinum per radiology
and decision was to obtain a CT
chest to rule out aortic injury.

13. CASE 3:
13 y/o M presents after playing with
fireworks which explodes near his
chest. He comes complaining of chest
pain and has had multiple episodes of
hemoptysis. Hypoxic to the low 80%
on RA improved to 100% on 4L NC but
otherwise hemodynamically stable.
Multiple abrasions to the chest
without obvious burns.
CT of the chest confirmed bilateral
pulmonary contusions; no aortic
injury. Patient was observed in the
PICU, titrated off oxygen, and
discharged home the next day.

14. Explosions and Blast Injuries. Centers for Disease Control,
www.cdc.gov/masstrauma/preparedness/primer.pdf.
• Blasts and explosions can cause unique patterns of
injury with “blast lung” (pulmonary barotrauma) being
the most common fatal injury afflicting survivors.
• Blast injuries can be categorized into 4 subtypes:
• Primary – Occurs with high impact explosions
causing over-pressurization impact; mostly affects
gas-filled organs
• Notable injuries: Blast lung, TM rupture,
concussion, globe rupture
• Secondary – Occurs from flying debris and
fragments acting as ballistic projectiles
• Notable injuries: penetrating or blunt injuries
• Tertiary – Occurs with blast powerful enough to
throw the patient
• Notable injuries: blunt trauma, fractures,
closed head injury
• Quaternary – Those injuries that do not fit other
categories (e.g. asthma exacerbation, burns,
inhalation injuries, crush injuries)
Blast Injury

15. CASE 4:
Patient is an otherwise healthy 12F
presenting with fever, vomiting, and
abdominal pain for the past 6 days.
Seen in multiple EDs with negative
workup and followed up with the
PCP who obtained the imaging to
the right.
Interpret this CXR.

16. CASE 4:
Patient is an otherwise healthy 12F
presenting with fever, vomiting, and
abdominal pain for the past 6 days.
Seen in multiple EDs with negative
workup and followed up with the
PCP who obtained the imaging to
the right.
Hint: CXR does not only give us
information about the patient's
pulmonary status. This lateral image
is also helpful for this diagnosis.

17. CASE 4:
Patient is an otherwise healthy 12F
presenting with fever, vomiting,
and abdominal pain for the past 6
days. Seen in multiple EDs with
negative workup and followed up
with the PCP who obtained the
imaging to the right.
Interpretation: Bowel obstruction.
You can see the lateral XR view has
multiple air-fluid levels (circle) and
the AP shows dilated bowel loops
(arrow)

18. CASE 4:
Patient is an otherwise healthy 12F
presenting with fever, vomiting, and
abdominal pain for the past 6 days.
Seen in multiple EDs with negative
workup and followed up with the PCP
who obtained the imaging to the
right.
Bonus: Dedicated KUB shows dilated
bowel loops consistent with high-
grade SBO (>3cm dilation)

19. CASE 4:
Patient ultimately was admitted
to the pediatric surgery service at
an outside hospital and once
transferred, found to have
perforated appendiceal abscess
which caused her SBO. Patient
had operative washout with
appendectomy and lysis of
adhesions caused by infection.
Patient had postop ileus which
resolved after a couple days and
was discharged home on
antibiotics.

20. CASE 5:
4-year-old female presents to
an urgent care with 1 week
of cough and fever (Tmax
100.4F). Vitals are otherwise
stable.
Interpret this CXR.

21. CASE 5:
4-year-old female presents to
an urgent care with 1 week
of cough and fever (Tmax
100.4F). Vitals are otherwise
stable.
Dx: RLL Consolidation.
Visualized well in the
retrocardiac view (circle).
Radiologist read as rounded
opacity roughly 4 to 5cm in
diameter. Patient sent home
with oral amoxicillin-
clavulanic acid for suspected
pneumonia.

22. CASE 5:
The same patient presents a
week later with continued cough
and fever. Mom states the
patient has completed 4 of 5
days of her Augmentin. Tested
COVID negative a few days ago.

23. CASE 5:
The same patient presents a
week later with continued cough
and fever. Mom states the
patient has completed 4 of 5
days of her Augmentin. Tested
COVID negative a few days ago
Interpretation: Previously noted
RLL opacity with newly
formed cavitary lesion noted by
the central lucency (blue circle).
Concern at this time for failure of
outpatient antibiotics. Patient
was admitted for IV antibiotics.

24. • Cavitary lesions can be associated with a
number of both infectious and noninfectious
pathologies. In this patient with fever and
previous diagnosis of pneumonia, the
etiology is very likely infectious.
• Cavitary pneumonia can be associated
with TB, COVID infection, forming
abscess, necrosis, and other processes. The
patient has no high risk factors for TB and
had tested COVID negative with no previous
infections thus the suspicion was for abscess
vs necrosis.
• This patient was admitted with
an infectious disease consultation with
recommendation for medical management
given absence of high risk factors, no
respiratory distress or failure, and no signs of
sepsis. Patient is still currently hospitalized
and tolerating nonsurgical management
well.
Gadkowski LB, Stout JE. Cavitary pulmonary disease. Clin Microbiol Rev.
2008;21(2):305-333. doi:10.1128/CMR.00060-07
Cavitary Lung Lesions

25. CASE 6:
15 year-old male with history of
failure to thrive with recent G-tube
placement presents with urinary
retention and noisy breathing.
Here is his CXR.

26. CASE 6:
15 year-old male with history of
failure to thrive with recent G-tube
placement presents with urinary
retention and noisy breathing.
Airway: patent​
Bone: downsloping ribs, possible
skeletal dysplasia
Cardiac: no cardiomegaly
Diaphragm​: right slightly higher
Effusions: limited evaluation of L
costophrenic angle
Fields: no consolidations​
GI: limited evaluation

27. CASE 6:
15 year-old male with history of
failure to thrive with recent G-tube
placement presents with urinary
retention and noisier breathing.
The CXR is moved down for more
complete visualization.
Right costophrenic angle is clear.
But, there does appear be dilated
bowel that is partially visualized.

28. CASE 6:
15 year-old male with history of
failure to thrive with recent G-tube
placement presents with urinary
retention and noisier breathing.
A follow-up KUB is obtained. What is
the diagnosis?

29. CASE 6:
15 year-old male with history of
failure to thrive with recent G-tube
placement presents with urinary
retention and noisier breathing.
Dx: Ileus
Diffuse gaseous distention of small
and large bowel with no focal point of
obstruction

30. CASE 7:
14-year-old female presents
following as a restrained
passenger after a rollover MVC
with absent motor and sensation
below her nipple line.
Here is her initial CXR.

31. CASE 7:
14-year-old female presents
following as a restrained passenger
after a rollover MVC with absent
motor and sensation below her
nipple line.
Impression: Normal (objects on top
of patient)

32. CASE 7:
14-year-old female presents
following as a restrained passenger
after a rollover MVC with absent
motor and sensation below her
nipple line.
She is found to have C5 burst
fracture with retropulsion and likely
cord encroachment.

33. CASE 7:
14-year-old female presents
following as a restrained passenger
after a rollover MVC with absent
motor and sensation below her
nipple line.
She was intubated and taken to the
OR. Here a repeat CXR 2 days later.
What do you see?

34. CASE 7:
Airway: ETT at T2​ (*)
Bone: unremarkable
Cardiac: no cardiomegaly
Diaphragm​: elevated right
hemidiaphragm
Effusions: none
Fields: Diffuse hazy opacification on
R, atelectasis vs mucous plugging,
L subclavian CVC (#)
GI: NG/OG in stomach (^)
New Dx: Elevated right
hemidiaphragm likely due to R
phrenic nerve injury
*
#
^

35. CASE 8:
2-month-old admitted with fever
and decreased PO intake with
hematochezia. Noted to have
hypoxia and increased WOB on the
floor for which the patient was
emergently intubated and
transferred to the ICU.
What do you see?

36. CASE 8:
2-month-old admitted with fever
and decreased PO intake with
hematochezia. Noted to have
hypoxia and increased WOB on the
floor for which the patient was
emergently intubated and
transferred to the ICU.
* ETT 0.5 cm above carina
# R IJ line- what’s going on?
^ NG/OG into stomach

37. CASE 8:
2-month-old admitted with fever and
decreased PO intake with
hematochezia. Noted to have hypoxia
and increased WOB on the floor for
which the patient was emergently
intubated and transferred to the ICU.
Let’s take a closer look.
CVC is coiled in neck and coursing
superiorly.

38. CASE 8:
2-month-old admitted with fever
and decreased PO intake with
hematochezia. Noted to have
hypoxia and increased WOB on the
floor for which the patient was
emergently intubated and
transferred to the ICU.
The line was replaced and now
appropriately terminates in the SVC.

39. Summary of This
Month’s Diagnoses
• Pneumatocele (Review)
• Croup
• Pulmonary Contusions & Blast Injuries
• Bowel Obstruction
• Lobar Pneumonia
• Cavitary Lung Lesions
• Ileus after G-Tube placement
• Elevated right hemidiaphragm after
trauma
• Malpositioned central line
For more educational content, visit
EMGuidewire.com