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: - Tuberculosis - Button Battery Ingestion - Constipation - Hirschprung's Disease - Aspiration Pneumonia - Generalized Lymphatic Anomaly - Pediatric Acute Respiratory Distress

1. Pediatric Chest X-Rays of the Month
Kendra Jackson, MD & Elizabeth Olson
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
October 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
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4. Normal CXR
for your
reference

5. 5-year-old boy from
Cambodia presents
with chronic cough,
fevers, night sweats
Diagnosis?
REVIEW

6. 5-year-old boy from
Cambodia presents
with chronic cough,
fevers, night sweats
Miliary Tuberculosis
REVIEW

7. v
What’s the xray
finding?
What’s the diagnosis?
HPI:
2-year-old presents
after playing with a
kitchen timer. Mom
can’t find the battery

8. v
Xray finding: A foreign
body with a “halo rim”
Diagnosis: Button
Battery Ingestion
HPI:
2-year-old presents
after playing with a
kitchen timer. Mom
can’t find the battery

9. Think about button battery ingestion when…
• Acute onset cough or gagging
• Acute onset drooling & dysphagia
• Acute onset vomiting
• First time wheezing
• Refusing to eat or speak
• Stridor with no other URI symptoms
• Acute GI bleed
Especially in teenagers with SI, children with
developmental delay, infant who crawl
https://pedemmorsels.com/button-battery-ingestion/

10. v
Where is the battery?
In the ED, the patient
is playful and in no
respiratory distress

11. Post-pyloric, distal small intestine

12. Button Battery Tips
• Remember your ABCs
• Give honey if ≥1years old and
no airway compromise,
otherwise NPO
• Immediately obtain an XR of
the neck, chest, and abdomen
• Look in the nose, mouth, and
ears
• Follow the guidelines
• Follow up is key!
https://www.poison.org/battery/guideline

13. Time is mucosa!
Visible tissue injury caused by the CR2032, alkaline, silver oxide, and zinc–air button batteries after 6 hours in
thawed sections of cadaveric piglet esophagus
The Laryngoscope, Volume: 127, Issue: 6, Pages: 1276-1282, First published: 09 November 2016, DOI: (10.1002/lary.26362)
Half of the mortalities related to button battery ingestion were associated with
misdiagnosis!

14. Honey is the gold standard!
The mucosal surface of cadaveric porcine esophageal tissue exposed to the anode side of a 3V‐CR2032 button
battery underwent serial 10‐mL irrigations at 10‐ to 15‐minute intervals with a solution of interest starting at t = 10
minutes. Shown are representative images of the esophageal mucosa att = 2 hours
The Laryngoscope, Volume: 129, Issue: 1, Pages: 49-57, First published: 11 June 2018, DOI: (10.1002/lary.27312)
Honey was proven to slow the discharge of the button batter
and neutralize the tissue’s pH

15. HPI:
2-month-old presents
after rolling off the
bed with swelling of
the right scalp. A CXR
was obtained on
trauma evaluation.
Spot the abnormality

16. HPI:
2-month-old presents
after rolling off the bed
with swelling of the
right scalp
Rib fracture
concerning for NAT

17. HPI
15 –year-old with history
of autism and
constipation presents
with belly pain and no
stool for 6 weeks
Spot the abnormality

18. HPI
15 –year-old with history
of developmental delay
presents with belly pain
and no stool for 6 weeks
Fecal impaction

19. Hospital day 1-2:
An NG was placed and he
given 4 liters of Golytley
without stool and has
worsening of his
abdominal distension. He
was start of enemas with
no success.
Spot the abnormality

20. Hospital day 1-2:
An NG was placed and he
given 4 liters of Golytley
without stool and has
worsening of his
abdominal distension. He
was start of enemas with
no success.
Worsening distention
with giant stool ball

21. Hospital day 3:
Transferred to the
children’s hospital where
he was manually
disimpacted under
anesthesia that took 2.5
hours
What is your
impression of the post-
disimpaction film?

22. Hospital day 5:
He had a rectal biopsy
with absent ganglia.
Persistent large
amounts of stool on XR
Diagnosis?

23. Returned one month later
for sigmoid colectomy
and colostomy
Hirschprungs!

24. HPI
Unvaccinated 1.5 year old
with a history of
Hirschsprungs presents
with bilious vomiting,
refusing solids, and
diarrhea.
Spot the abnormality

25. HPI
Unvaccinated 1.5 year old
with a history of
Hirschsprungs presents
with bilious vomiting,
refusing solids, and
diarrhea.
Findings:
Significant colonic
distension with air-fluid
levels

26. HPI
Unvaccinated 1.5 year old
with a history of
Hirschsprungs presents
with bilious vomiting,
refusing solids, and
diarrhea.
Differential diagnosis?

27. • Toxic Megacolon
• Cdiff
• Salmonella
• E Coli
• Shigella
• Hirschsprung's
enterocolitis
• Viral Gastroenteritis
• Rotavirus
• Constipation
Additional history
She has been afebrile
with normal BP and
HR. Her perfusion in
normal on exam.

28. Day 2:
She was started IVFs,
scheduled rectal irrigations,
and an NG was placed to
decompress her stomach.
She continued to be afebrile
and had a LARGE stool after
ex-lax. Now eating!

29. Day 3:
She is now running around
the exam room. Her stool
culture, Cdiff, and stool
PCR panels are all
negative.
Discharge diagnosis:
Constipation

30. Spot the abnormality.
HPI:
16-year-old with history
of CP presents with
respiratory distress and
lethargy

31. Aspiration Pneumonia
HPI:
16-year-old with history
of CP presents with
respiratory distress and
lethargy

32. Spot the abnormality
HPI:
16-year-old presents as a
trauma alert after being
dragged under a boat

33. Widen mediastinum and
multiple lytic bone
lesions
HPI:
16-year-old presents as a
trauma alert after being
dragged under a boat

34. Spot the abnormalities

35. Multiple lytic lesions and a femur fracture

36. Clinical Pearl: Don’t forget
the B in ABCDE
All lytic lesions should be
referred to hematology &
oncology
ED course: The original
radiologist read only
commented on the
widened mediastinum.

37. ED course:
She was pan-scanned
and was found to have
numerous
Diagnosis?

38. Generalized Lymphatic Anomaly
• Must be confirmed by biopsy
• A systemic lymphatic
malformations disease
• Can present with acute or
persistent pericardial, pleural, or
peritoneal effusions
• Can contribute pathologic
fractures
• Worsens in puberty
• Most importantly, BENIGN
PHEW!
Jochen et al. Personalized Therapy for Generalized Lymphatic Anomaly/Gorham-Stout Disease With a Combination of
Sunitinib and Taxol, Journal of Pediatric Hematology/Oncology: November 2015.37.8 . p e481-e485

39. HPI:
7-year-old with a
history of CF arrives via
EMS somnolent on a
10 L non-rebreather
Spot the abnormalities

40. HPI:
7-year-old with a
history of CF arrives
via EMS somnolent
on a 10 L non-
rebreather
Ground glass opacities,
scoliosis, and a central line
Diagnosis?

41. HPI:
7-year-old with a
history of CF arrives
via EMS somnolent
on a 10 L non-
rebreather
Multi-organism pneumonia

42. HPI:
10-year-old with a history
of interstitial lung disease
and TPN dependence
presents with tachypnea
and agitation
What is the XR finding?

43. Additional history:
He desated to 70% on
room air while yelling and
kicking. He is placed BiPAP
and continued to be
tachypnea.
Bilateral diffuse diffuse
interstitial edema

44. Clinical Pearl:
Hypercarbia can present
as agitation,
combativeness, and
confusion!
Name those lines
B
A

45. Additional history:
He desats to 70% on room
air while yelling and
kicking. He is placed BiPAP
and continued to be
tachypnea.
A: Central line
B: ET tube
C: Vent tubing
B
A

46. Additional history:
He was intubated in the
ED and admitted to the
PICU
Diagnosis?

47. ARDS
PARDS due to a fungal
central line infection

48. 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
FUNGEMIA
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

49. Who needs fungal
coverage?
Children with a history of…
Immunosuppression
Long-term Central Line Use
TPN Dependence
Renal Dialysis
Prolonged IV Antibiotics
Prior Fungal Infection (urine, bronch, or
blood)
Severe pancreatitis
https://em.umaryland.edu/educational_pearls/3402/

50. Summary of This
Month’s Diagnoses
• Tuberculosis(review from September
cases)
• Button Battery Ingestion
• Constipation, late diagnosis of
Hirschsprung's
• Constipation
• Aspiration Pneumonia
• Generalized Lymphatic Anomaly
• Pneumonia in CF
• PARDS in fungemia
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