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: - Line Identification - Thoracic Trauma - Neutropenic Fever - ARDS - ECMO - Pneumomediastinum

1. Pediatric Chest X-Rays of the Month
Elizabeth Olson, MD & Kendra Jackson, MD
Department of Emergency Medicine &
Department of Pediatrics
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
November 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.
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3. Reading systematically…
A for airway
B for bones
C for cardiac silhouette
D for diaphragm
E for everything else
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4. Normal CXR
for your
reference

5. Review:
This 10-year-old with
cerebral palsy is seen at
an outside ED with
hypoxia requiring
intubation. EMS
transports the patient to
your ED.
Name those lines
B
A

6. Review:
A: Central line
B: Endotracheal tube
C: Ventilator tubing
The central line and ETT
are in appropriate
position.
B
A

7. 15-year-old with history of
spina bifida presents with
vomiting and cough for 24
hours
What type of line is seen in
this CXR?
What did the radiologist have
to say about the line?

8. The patient has a VP shunt
(ventriculoperitoneal shunt).
The radiologist commented,
"There are two areas of relatively
acute curvature in the
supraclavicular aspect of the
tubing.
These curvatures may be due to
positioning resulting in
superimposition, but cannot
entirely exclude two areas of
kinking/stenosis."

9. 4-year-old male brought to the ED
after high-speed ATV accident.
During EMS transport, he arrested
and EMS initiated CPR.
From the lines seen in this image,
what interventions have been
performed?
• First, try to find all the lines.
• The next slide will label them A,
B, C, etc.
• The final slide will identify them
by name.

10. 4-year-old male brought to the ED
after high-speed ATV accident.
During EMS transport, he arrested
and EMS initiated CPR.
Did you find all these lines?
The next slide will identify them by
name.
A
BC
D
E
Bonus: What
is this device?

11. 4-year-old male brought to the ED
after high-speed ATV accident.
During EMS transport, he arrested
and EMS initiated CPR.
ET tube
OG tube
Large-bore
chest tube
Medium-bore
chest tube
EKG lead
Phased array
ultrasound
probe for
EFAST exam

12. Same patient, repeat CXR.
A new finding is visible on this CXR
that was not previously seen. Can
you find it?
Read the CXR systematically. The
next slide has a hint.

13. Same patient, repeat CXR.
Can you find the bony injury?

14. Same patient, repeat CXR.
Can you find the bony injury?

15. Same patient, repeat CXR.
The patient has a cervical
distraction injury.
Always remember to read the
entire CXR.
What cervical level is this at?
How can you tell?

16. Same patient, repeat CXR.
The patient has a cervical
distraction injury at C5-C6.
Find the vertebrae to which the
first ribs connect. That's the T1
vertebrae. Count upwards.
In this case,
T1 → C7 → C6 → Injury → C5.
T1
C7
C6
C5

17. 2-year-old male undergoing treatment
for recently diagnosed pre-B cell ALL
presents to the ED for fever. His ANC is 20.
CXR interpretation?

18. 2-year-old male undergoing treatment
for recently diagnosed pre-B cell ALL
presents to the ED for fever. His ANC is 20.
Interpretation: Normal chest.
(They can’t all be abnormal!)

19. 16-year-old male, intubated in the
ICU with hypoxic respiratory
failure.
Interpret this CXR:
• How would you describe the
pulmonary findings?
• How is the central line
positioned?

20. 16-year-old male, intubated in the
ICU with hypoxic respiratory
failure.
Radiologist interpretation:
“Hazy diffuse pulmonary opacities
may be pneumonia, ARDS, or
edema.
The right IJ central line projects
over the inferior right atrium and
should be retracted approximately
8 centimeters.”

21. 16-year-old male, intubated in the
ICU with hypoxic respiratory
failure.
His mother arrives and gives the
following history: “I don’t know
what happened. He was vomiting
earlier today but I gave him some
Zofran and he seemed better and
went to bed. I went to work and
then his dad calls me and says he’s
at the hospital on life support!””
What is the most likely diagnosis?

22. 16-year-old male, intubated in the
ICU with hypoxic respiratory
failure.
His mother arrives and gives the
following history: “I don’t know
what happened. He was vomiting
earlier today but I gave him some
Zofran and he seemed better and
went to bed. I went to work and
then his dad calls me and says he’s
at the hospital on life support!”
Diagnosis: ARDS from aspiration
pneumonitis.

23. 16-year-old male, intubated in the
ICU with hypoxic respiratory
failure. This CXR is taken two days
later.
Interpret this CXR:
• How would you describe the
pulmonary findings?
• What new lines have been
inserted?

24. 16-year-old male, intubated in the
ICU with hypoxic respiratory
failure. This CXR is taken two days
later.
Radiologist interpretation:
"Interval worsening of right upper
lobe airspace opacification, most
compatible with complete right
upper lobar atelectasis.
ECMO cannulas have been
inserted and are well-positioned.”

25. Extracorporeal Membranous
Oxygenation (ECMO)
• Cannulas draw blood flow out of the body,
route it through a circuit that oxygenates
the blood, then direct the blood back into
either the venous or arterial system.
• Veno-venous (VV) ECMO draws blood from
the venous system and directs it back into
the venous system. This bypasses the lungs
but requires a functional heart to circulate
the blood.
• Veno-arterial (VA) ECMO draws blood from
the venous system and directs it back into
the arterial system. This bypasses the lungs
as well as the heart.
Patroniti N, Grasselli G, Pesenti A. Extracorporeal support of gas exchange. In: Broaddus VC, Mason RJ, Ernst JD, et al, eds. Murray and Nadel's Textbook of
Respiratory Medicine. 6th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 103.
As the blood is drawn out of the body and through
the ECMO system, there is a high risk of clot
formation, which can result in thromboembolism.
Conversely, the required systemic anti-coagulation
carries a significant risk of bleeding, including
intracranial hemorrhage. Line infection is another
serious consideration.

26. 16-year-old male, intubated in the
ICU with hypoxic respiratory
failure. This CXR is taken one day
after the previous CXR.
Interpret this CXR:
• Given the improvement in the
RUL findings compared to the
last CXR, what procedure had
likely been performed?

27. 16-year-old male, intubated in the
ICU with hypoxic respiratory
failure. This CXR is taken one day
after the previous CXR.
The patient had undergone
bronchoscopy with removal of a
large mucus plug, allowing for re-
expansion of the right upper lobe.

28. 13-year-old male presents after
falling onto a sharp piece of metal
sticking out of a curb. He has a
laceration to his right armpit.
Interpret this CXR.

29. 13-year-old male presents after
falling onto a sharp piece of metal
sticking out of a curb. He has a
laceration to his right armpit.
Interpretation:
“There is a moderate right-sided
hemopneumothorax with air
dissecting through the right chest
wall soft tissue.”
Arrows indicate the pleural-air
interface.

30. 13-year-old male presents after
falling onto a sharp piece of metal
sticking out of a curb. He has a
laceration to his right armpit.
Repeat CXR after placement of
pigtail chest tube.

31. 3-year-old female presents with
fever and increased work of
breathing requiring high flow nasal
cannula.
Interpret this CXR.

32. 3-year-old female presents with
fever and increased work of
breathing requiring high flow nasal
cannula.
What are those arrows pointing
at?

33. 3-year-old female presents with
fever and increased work of
breathing requiring high flow nasal
cannula.
Interpretation:
Subcutaneous emphysema in the
neck. Faintly visible
pneumomediastinum.

34. Pneumomediastinum
• Spontaneous pneumomediastinum
typically results from small alveolar
ruptures that leak air into the
surrounding tissues.
• Esophageal perforation is a more
serious cause of pneumomediastinum.
• Fortunately, the subcutaneous tissues
are "forgiving" and will accept air, which
usually prevents pressure build-up.
Therefore, tension pneumomediastinum
is so rare that fewer than 20 cases have
been reported.
• Air may communicate to the spinal
canal, resulting in pneumorrhachis –
Though this sounds alarming, the
associated neurological symptoms are
typically mild and resolve with time.
Wong KS, Wu HM, Lai SH, Chiu CY. Spontaneous pneumomediastinum: analysis of 87 pediatric patients. Pediatr Emerg Care. 2013 Sep;29(9):988-91. doi:
10.1097/PEC.0b013e3182a26a08. PMID: 23974718.
Treatment:
• In uncomplicated patients who are asymptomatic
or minimally symptomatic, supportive care with
pain medication and rest is typically sufficient.
Avoid Valsalva, coughing, or forced expiration.
This includes incentive spirometry!
• In patients with moderate symptoms, high-
concentration oxygen can enhance nitrogen
washout.
• Complicated patients include those with
Boerhaave syndrome (esophageal rupture) or
tension pneumomediastinum (which may require
mediastinotomy).
• Monitor for pneumoPERICARDIUM, which rarely
can result in cardiac tamponade.

35. 3-year-old female presents with
fever and increased work of
breathing requiring high flow nasal
cannula. She was diagnosed with
pneumomediastinum and
subcutaneous emphysema in the
neck secondary to increased work
of breathing from bronchiolitis.
She improved with supportive care
and was discharged after 2 days
without any invasive intervention.

36. Summary of This Month’s
Diagnoses
• Line identification (review from
October cases)
• VP shunt identification
• Traumatic line identification
• Cervical distraction injury
• Neutropenic fever with normal CXR
• Malpositioned central line
• ARDS due to aspiration pneumonitis
• Right upper lobe atelectasis and ECMO
cannulation
• Atelectasis improvement after
bronchoscopy
• Spontaneous pneumomediastinum
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