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: • Non-accidental Trauma (NAT) • Hyperinflated Lungs • Esophageal Foreign Body • Neonatal Pulmonary Abscess • Neonatal Pneumatocele • Tuberculosis • Interstitial Lung Disease of Prematurity • Disseminated Neonatal HSV • Aspirated Foreign Body

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
September 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. REVIEW
HPI: 1-year-old
presents after his
sister was found to be
a victim of NAT (non-
accidental trauma)
Spot the abnormality

6. What abnormality is indicated
by the circle?
What is the arrow pointing to?
REVIEW
HPI: 1-year-old
presents after his
sister was found to be
a victim of NAT (non-
accidental trauma)

7. Circle: Corner fracture of the
proximal humerus
Arrow: Normal thymus tissue
REVIEW
HPI: 1-year-old
presents after his
sister was found to be
a victim of NAT (non-
accidental trauma)

8. Dedicated humerus x-ray
demonstrating corner
fracture
High suspicion for NAT
REVIEW
HPI: 1-year-old
presents after his
sister was found to be
a victim of NAT (non-
accidental trauma)

9. NAT: Suspicious Findings
on CXR
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, American Academy of Pediatrics; Section on Endocrinology, American Academy of Pediatrics; Section on Orthopaedics, American
Academy of Pediatrics; Society for Pediatric Radiology
Pediatrics Feb 2014, 133 (2) e477-e489; DOI: 10.1542/peds.2013-3793; https://pubmed.ncbi.nlm.nih.gov/24470642/
If a child presents with injuries with a high suspicion
for NAT, a STAT evaluation and skeletal surveys
should be performed on all siblings 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

10. 12-year-old boy presents for
evaluation of syncope
Spot the abnormality

11. 12-year-old boy presents for
evaluation of syncope
Hyperinflated lungs
>6 ribs when counting ventrally (stars)
>10 ribs when counting dorsally (numbers)
In this case, this is physiologic. On exam, patient
doesn't have evidence of Marfanoid habitus, and has
no wheezing or history of asthma to suggest chronic
obstructive pulmonary disease as an explanation for
hyperinflation.
This kid was just really exuberant about holding his
breath for the xray!
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
The cardiac silhouette
may appear abnormally
narrow, but his heart is
normal on bedside point-of-
care echocardiogram.

12. HPI: 5-year-old female
presents to the ED
reporting she
swallowed a ring an
hour prior to arrival.
She panicked and
vomited once but has
now calmed down.
Where is the ring?

13. HPI: 5-year-old female
presents to the ED
reporting she
swallowed a ring an
hour prior to arrival.
She panicked and
vomited once but has
now calmed down.
No obvious ring in the
chest. Parents show you
this picture of the ring.
What do you do next?

14. Soft tissue neck
xrays show the
ring resting on
the epiglottis

15. Dad calls you into the
room because the kid had
a coughing fit and now
triumphantly declares "I
swallowed it!"
Repeat CXR seen here.
Is the ring now in the
esophagus or the
trachea?
How can you tell?

16. The ring is in the esophagus.
1. The carina can be seen in the hole
in the ring in the AP xray. If the ring
were in the trachea, the entire ring
would be sitting above the carina.
2. The ring is oriented so that
the widest diameter lies in the coronal
orientation. Tracheal foreign bodies
typically have the widest diameter in
the sagittal plane.
3. The lateral xray shows the trachea
is anterior to the ring.

17. Esophageal foreign
body – Now what?

18. Some esophageal foreign
bodies will pass
spontaneously, so the
patient was admitted for
observation.
This is her repeat xray 15
hours after the last set.
Not much movement.
Now what?

19. Op Note Excerpt
"Patient was taken to the operating
room and underwent general
endotracheal intubation and anesthesia
without difficulty.
A rigid esophagoscope was introduced
and a ring was visualized in the mid
esophagus.
The ring was grasped and removed.
The scope was reintroduced and there
was very mild mucosal irritation.
The remainder of the esophagus was
normal in appearance with no
additional foreign bodies.
The scope was removed and the
patient allowed to awaken from
anesthesia."
Image source: Naveen Kumar, A. G. (2018). Foreign bodies in
esophagus: our experiences. International Journal of
Otorhinolaryngology and Head and Neck Surgery, 5(1), 83.
https://doi.org/10.18203/issn.2454-5929.ijohns20184692

20. 7-week-old born at 28
weeks (currently 35
weeks gestational age)
develops worsening
respiratory distress and
requires intubation.
Prior to intubation, this
xray is obtained.
Spot the abnormality.

21. What's the differential
for this round structure?
7-week-old born at 28
weeks (currently 35
weeks gestational age)
develops worsening
respiratory distress and
requires intubation.
Prior to intubation, this
xray is obtained.

22. 7 week old F born at 28
weeks (currently 35
week gestational age)
develops worsening
respiratory distress and
requires intubation.
Prior to intubation, this
xray is obtained.
Ddx: Pneumonia, round
atelectasis, loculated
pleural fluid collection,
abscess

23. Repeat supine xray
demonstrates a
central clearing.
What does a central
clearing suggest this
opacity is?

24. Central clearing
suggests this is a
pulmonary parenchymal
abscess
Hazy opacities (arrows)
suggest infiltrates
consistent with
worsening pneumonia

25. What procedure has been
done?
Which of the patient's
lines is poorly positioned?

26. A pigtail chest tube has been
placed, and 15 cc of purulent
fluid was drained from the
parenchymal abscess.
The endotracheal tube is
positioned a bit high and can
be advanced.

27. ETT advancement
Carina is indistinct,
but compare
position of the ET
tube relative to the
clavicular heads

28. After 6 days, the
chest tube is
removed. Cultures
from the aspirated
fluid grew MRSA.
The residual lucency is
termed a pneumatocele

29. CT imaging of persistent pneumatocele

30. After 20 days, the pneumatocele has resolved

31. Pneumatoceles in preterm
infants
Risk factors:
• Degree of prematurity (younger
gestational age at birth associated
with higher risk)
• Staphylococcal infections
(pneumonia, lung abscess)
• Positive pressure ventilation leading
to high mean airway pressures
These have also been termed
"pseudocysts" - The "pseudo" refers to
the fact that pneumatoceles lack a true
epithelialized wall that one would see
with a cyst.
These are typically self-limited. If the
patient is on positive-pressure
ventilation, reducing the mean airway
pressure will hasten resolution. Rarely is
invasive intervention required.
Hussain, N. et al. "Pneumatoceles in preterm infants: Incidence and outcome in the
post-surfactant era." Nature, 2009. https://www.nature.com/articles/jp2009162

32. 5-year-old boy from
Cambodia presents
with chronic cough,
fevers, night sweats
Diagnosis?

33. Diagnosis:
Miliary Tuberculosis
5-year-old boy from
Cambodia presents
with chronic cough,
fevers, night sweats

34. 1-year-old ex-25-weeker with
Trisomy 21 and chronic wheezing
Diagnosis?

35. 1-year-old ex-25-weeker with
Trisomy 21 and chronic wheezing
Dx: Interstitial lung disease (ILD)

36. 8-day-old male
with poor
feeding
Differential for these
hazy opacities?

37. 8-day-old male with poor feeding
and diffuse bilateral pulmonary
opacities
Ddx: Multifocal pneumonia
(including COVID-19), pulmonary
edema from congenital heart
disease, pulmonary hemorrhage
Exam reveals vesicles to scalp and lips.
Labs demonstrate hypoglycemia,
thrombocytopenia, and transaminitis.
Viral panel sent to look for COVID-19,
hepatitis A/B/C, HSV, VZV, enterovirus.
HSV returns positive.

38. Disseminated neonatal HSV
Pearls:
• Can present as sepsis, respiratory
distress, hemorrhagic pneumonitis, GI
bleed, seizures, hypothermia.
• Approximately 10% of neonatal
HSV infection occurs postnatally,
typically through exposure to a
caregiver with an active herpes labialis
outbreak.
• If you see seizures, respiratory distress,
fulminant hepatic failure,
thrombocytopenia or evidence of DIC,
don't wait for confirmatory HSV PCR or
viral culture testing. Initiate treatment
with IV acyclovir, 20 mg/kg q8h.
The patient was born by c-section
and his mother had no evidence of
an outbreak at time of delivery. She
had even previously tested negative
for HSV. Vertical transmission still
occurred, possibly through use of a
fetal scalp electrode during delivery.
Shetty, A. et al. "Disseminated neonatal herpes simplex virus infection presenting with
pneumonia and progressive respiratory failure." J. Clin. Neonatology, 2014.
"Never trust a neonate."
- Maya Angelou

39. Where's the aspirated Lego?
ExpirationInspiration

40. Expiration
Obstructed lung will not deflate as well as
the unobstructed lung
Inspiration
Obstructed lung will not inflate as well as
the unobstructed lung
Where's the aspirated Lego?

41. Op Note Excerpt
"Patient uneventfully anesthetized and positioned
supine with a transverse shoulder roll.
Rigid bronchoscope inserted and ventilation
maintained through scope without hemodynamic
perturbation.
Both mainstem bronchi and secondary bronchi
thoroughly examined.
Foreign body identified in left mainstem
bronchus removed using a grasper.
Repeat examination showed normal airways without
evidence of injury or inflammation."

42. Summary of This
Month’s Diagnoses
• Non-accidental trauma (review from
August cases)
• Hyperinflated lungs and rib counting
• Esophageal foreign body
• Neonatal pulmonary abscess
• Neonatal pneumatocele
• Tuberculosis
• Interstitial lung disease of prematurity
• Disseminated neonatal HSV
• Aspirated lego
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