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: Subcutaneous air Osteopenia Bronchiolitis Constipation Asthma exacerbation Alveolar Rhabdomyosarcoma Aspirated Foreign Bodies Small Bowel Obstruction Kyphoscoliosis Pneumatocele Cecal Volvulus

1. Pediatric Chest X-Rays of the Month
Taylor Anderson, MD & Kendra Jackson, MD
Departments of Pediatrics & Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Nicholena Richardson, MD & Mary Grady, MD, Faculty Editors
Michael Gibbs, MD, Senior Editor
Chest X-Ray Mastery Project
May 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
Program 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:
www.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
www.EMGuidewire.com

4. Normal CXR
for your
reference

5. 3-year-old girl presents
after falling on a hunting
knife at home.
Spot the abnormality
Review

6. 3-year-old girl presents
after falling on a hunting
knife at home.
Subcutaneous air present
Note: Lung herniation on
physical exam

7. Don’t forget to consult
Social Work and the Child
Protection Team to rule
out non-accidental trauma
(NAT).
Review

8. 2.5-year-old
female presents after
ROSC following a cardiac
arrest at home.
Spot the abnormality

9. Remember Your ABCs!
Airway: ET tube in R main stem
Bone: severe ostepenia
Cardiac: no cardiomegaly
Diaphragm: symmetric
Effusions: none
Fields/Foreign Bodies: NG tube
in place. Bilateral haziness
Gastric bubble: not visualized
Hila: no LAD

10. Additional history: She
lived on an all-vegan diet.
Her height and weight
were at the 50th percentile
for an 8-month-old.
Differential diagnosis?

11. • Child abuse
• Severe neglect
• Osteogenesis Imperfecta
• Rickets
• Osteitis fibrosa cystica
• Renal osteodystrophy
• Chronic kidney disease
Differential diagnosis

12. Additional imaging was
obtained because the
patient had disfigurement
of all extremities. Of note,
the child was never been
seen by a doctor before
this presentation.
Diagnosis?

13. Child's siblings were UTD on
vaccines and healthy.
SW and the Child Protection
team were consulted.
Concern for neglect and a
metabolic bone disorder

14. 10-month-old female with
a history of epilepsy,
microcephaly, G-tube
dependence, and
developmental delay who
presents with 1 week of a
worsening cough and 3
days of emesis.
What’s the X-ray finding?

15. 10-month-old female with
a history of epilepsy,
microcephaly, G-tube
dependence, and
developmental delay who
presents with 1 week of a
worsening cough and 3
days of emesis.
Mild cardiomegaly
No infiltrates

16. ED Course: Respiratory
status improved after
deep suctioning, chest
physiotherapy and Zofran.
She tolerated continuous
Pedialyte tube feeds in ED
and was discharged home.
Mild cardiomegaly
No infiltrates

17. She returns to the ED four
days later with lethargy,
cyanosis and tachypnea.
On exam bilateral course
breath sounds are noted
in both lower lung fields.
What’s the X-ray finding?

18. A
A
B
A. B/L pneumothoraces
B. Right pleural effusion
C. Mild cardiomegaly
She returns to the ED four
days later with lethargy,
cyanosis and tachypnea.
On exam bilateral course
breath sounds are noted
in both lower lung fields.
C

19. PICU course: Infant was
briefly of BiPAP and was
found to be Rhino and
RSV positive. COVID
negative
Diagnosis?

20. PICU course: Infant was
briefly of BiPAP and was
found to be Rhino and
RSV positive. COVID
negative
Bronchiolitis

21. 1.5-year-old male with
history of trisomy 18
presents with fever and
constipation.
What are the ABCDE.....

22. Airway: patent
Bone: no fractures
Cardiac: cardiomegaly
Diaphragm: symmetric
Effusions: none
Fields: diffuse opacities
GI: Significant stool present
Hila: difficult to assess

23. Hospital course:
Respiratory distress
resolved after manual
decompression.
Respiratory viral panel
and covid negative.
Diagnosis: Respiratory
distress due to severe
constipation

24. 5-year-old male with a
history of asthma presents
in respiratory distress.
T: 99.8 °F HR: 153 RR:
44 BP: 116/61 SpO2:
93%
Spot the abnormality

25. He was recently weaned off
of his Flovent and has had
itchy eyes with the weather
change. He was admitted to
the PICU.
Hyperexpanded with
peribronchial thickening
consistent with an acute
asthma exacerbation
1
2
3
4
6
5
7
8

26. 17-year-old boy with
history of alveolar
rhabdomyosarcoma
presents with dyspnea.
Interpret the CXR

27. Airway: Patent?
Bone: Good mineralization. No
fractures
Cardiac: Obscured
Diaphragm: L lower than R
Effusions: Difficult to assess
Fields/Foreign Bodies: Chest
tube at T7. Left upper lobe
mass-like lesion
Gastric bubble: Present
Hila: wide

28. Click to add text
Diagnosis: Recurrence of Alveolar Rhabdomyosarcoma

29. 1-year-old male presents
with drooling after playing
with his sister's jewelry.
Name that character!

30. 1-year-old male presents
with drooling after playing
with his sister's jewelry.
Oh boy, oh boy, oh boy...

31. 2-year-old female
presenting to ED with 5
days of cough, emesis with
meals, and recurrent fever
after failing oral antibiotics
provided by outpatient
pediatrician.
VS: T 98.3, HR 134, RR 28,
SpO2 95%
Spot the abnormality

32. What is your
management plan?
Screw in right bronchus.
Inflammation
and consolidation in the
right middle and right
lower lobes.

33. ED Course: IV ceftriaxone
and pediatric surgery
consult. Recommended
emergent surgical removal
via rigid bronchoscopy.
ED Course

34. Hospital Course
In the OR the screw was
removed, and large
amount of purulent
material suctioned distally.
Received dexamethasone
0.5mg/kg for 3 doses over
24 hours and discharged
to complete 7-day course
of Augmentin.

35. 13-year-old female presented
to ED with fever, abdominal
pain, and vomiting for 4-5
days.
VS: T 98.4, HR 104, RR 18, BP
130/99, SpO2 98%
Physical exam: hypoactive bowel
sounds, mild abdominal
distention, mild guarding, mild
tenderness to palpation on left
side.
But let's back up...

36. Additional history
This patient had presented to
ED three days prior with fever,
emesis x2, decreased oral
intake, and left lower quadrant
abdominal pain. Physical exam
notable for left lower quadrant
and suprapubic tenderness.
Urinalysis with 80 ketones but
no sign of infection. No other
work up completed.
Differential diagnosis?

37. Differential diagnosis at initial
presentation:
- Viral gastroenteritis
- Acute cystitis
- Pyelonephritis
- Appendicitis
- Obstruction
- Constipation
Fast forward again to the second
presentation... AP chest X-ray
read as normal. Interpret this
lateral film.

38. Lateral film reveals
multiple air fluid levels!
Now what are you worried
about? Diagnosis?

39. KUB demonstrates
numerous dilated loops of
small bowel, and the
lateral film shows multiple
air fluid levels.
Diagnosis? High grade
small bowel obstruction

40. The Radiologist felt that the
process was most likely
caused by a perforation such
as a perforated appendicitis.
A CT then obtained which
revealed ruptured
appendicitis complicated by
bowel obstruction and
abscess. Patient started on
zosyn and transferred for
surgical management.

41. 12-year-old male with
history of
myelomeningocele who
was admitted with hypoxia
Interpret the X-ray

42. Spot the abnormality
Airway: Patent
Bone: kyphoscoliosis
Cardiac: no cardiomegaly
Diaphragm: left obscured by
atelectasis/infiltrate
Effusions: none
Fields/Foreign Bodies: Poor lung
expansion, VP shunt
Gastric bubble: not visualized
Hila: central congestion
1
2
3
4
5
Remember Your ABCs

43. Spot the abnormality
Clinical pearl: Don't
forget the BONES.
Missing a rib fracture
could be the only sign of
child abuse. Early signs of
osteopenia could be sign
of neglect and prevent
life threatening
electrolyte imbalances.
1
2
3
4
5

44. 11-year-old female who
presented with dyspnea
after jumping on a
trampoline.
HR 127, RR 24, SpO2 96%
Spot the abnormality

45. Differential diagnosis?
11-year-old female
who presented with
dyspnea after jumping
on trampoline

46. Differential and
associated conditions
Lung abscess
Bronchial cyst
Pneumatocele
Tuberculosis
Mycosis
Marfan syndrome
Pneumonia
Empyema
Fungal infection
Lung cancer
Cystic fibrosis

47. Pneumatocele
Thin-walled, air-
containing cyst of the
lung. Can be of
infectious (tuberculosis,
staph aureus, etc) or
noninfectious (trauma,
mechanical ventilation,
etc) etiology.

48. Pneumatocele:
Risk factors
Young age, post-traumatic,
post-infectious, post
pneumonic, HIV, IV drug
use, Hyper IgE syndrome.

49. These resolve spontaneously in up to
90% of children. Needle decompression
is recommended if the lesion is:
occupying >50% of the hemithorax,
creating significant atelectasis, or causing
development of a bronchopleural fistula,
tension pneumothorax, or infection
within the cyst. Treat with antibiotics if
pneumonia is present.
Pneumatocele:
Management

50. Interpret the chest X-ray
10-year-old male with
complex medical history due
to bacterial meningitis in
infancy presented with
abdominal distention and
respiratory distress, found to
have cecal volvulus. Patient
required intubation in ICU.

51. Remember Your ABCs
Airway: ET tube in mid trachea
Bone: no fracture
Cardiac: no cardiomegaly
Diaphragm: symmetric
Effusions: none
Fields/Foreign Bodies: NG tube
in stomach. Right arm PICC
projects over right atrium. Lung
volumes low. Right basilar
opacity, likely atelectasis
Gastric bubble: present
Hila: no LAD
1
2
3
4
5
6
7

52. What has changed on
his chest X-ray?
2 days later the patient has
been extubated and
transferred to the floor. His
NG tube was dislodged and
not replaced.

53. - ET tube removed
- Right arm PICC over right
atrium (A)
- Left internal jugular CVC
terminates at level of left
innominate vein confluence
with SVC (B)
- Worsening interstitial edema
with less distinct pulmonary
vessels (circle)
- Lung volumes decreased
- Worsening right infrahilar
atelectasis (arrow)
- Worsening gaseous
distention of abdomen
A
B
1
2
3
4
5
6

54. Summary of This Month’s Diagnoses
• Subcutaneous air and lung herniation
• Severe osteopenia
• Bronchiolitis
• Severe Constipation
• Asthma exacerbation
• Alveolar Rhabdomyosarcoma
• Foreign body: Mickey mouse charm
• Foreign body: Screw
• Small bowel obstruction
• Kyphoscoliosis
• Pneumatocele
• Cecal volvulus
For more educational content, visit:
www.EMGuidewire.com