Drs. Potter and Richardson are interested in education and Pediatric Emergency Medicine. Follow along with the EMGuideWire.com team and Dr. Michael Gibbs as they post these educational, self-guided radiology slides on Pediatric Emergency Medicine Radiology Topics including: • Myocarditis • Pulmonary Contusions • Clavicle Fracture • Pneumonia • Acute Chest Syndrome • Pleural Effusion

1. Pediatric Chest X-Rays Of The Month
Nikki Richardson MD & Jennifer Potter MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs MD, Faculty Editor
Chest X-Ray Mastery Project
February 2020

2. Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of CXR interpretation.
 There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.

3. Process
 Many are providing cases and these slides are shared with all contributors.
 Contributors from many CMC departments, and now… Tanzania and Brazil.
 Cases submitted this week will be distributed monthly.
 When reviewing the presentation, the 1st image will show a chest X-ray
without identifiers and the 2nd image will reveal the diagnosis.

4. The majority of the cases this month show a step-wise approach to final
diagnosis using multiple imaging modalities.

5. Normal CXR
For Your Reference

6. HPI: 12-month-old female
who presented to the
Emergency Department
with increased work of
breathing and grunting.
Vital Signs:
Afebrile
HR: 143
RR: 56
BP: 103/52
Initial CXR
Physical Exam:
Lungs clear to auscultation
bilaterally, increased work
of breathing with grunting,
retractions and tachypnea.

7. Cardiomegaly
Interstitial opacities
Initial CXR = Cardiomegaly with Mild Pulmonary Edema
HPI: 12-month-old female
who presented to the
Emergency Department
with increased work of
breathing and grunting.

8. Cardiomegaly
Interstitial opacities
Initial CXR = Cardiomegaly with Mild Pulmonary Edema
HPI: 12-month-old female
who presented to the
Emergency Department
with increased work of
breathing and grunting.

9. Cardiomegaly
Four chamber
dilation
Bedside Echocardiogram = 4 chamber dilation
HPI: 12-month-old female
who presented to the
Emergency Department
with increased work of
breathing and grunting.

10. Cardiomegaly
Four chamber
dilation
Bedside Echocardiogram = 4 chamber dilation
HPI: 12-month-old female
who presented to the
Emergency Department
with increased work of
breathing and grunting.

11. Patient admitted, required
intubation for respiratory
support. Received IVIG for
presumed viral myocarditis.
Discharged 2 weeks after
admission with improving
cardiac function
HPI: 12-month-old female
who presented to the
Emergency Department
with increased work of
breathing and grunting.
Discharge CXR = improving cardiomegaly and
resolved pulmonary edema

12. • Myocarditis is classically associated with a viral prodrome with
fever, myalgias, and respiratory/GI symptoms.
• Children often present with a more fulminant presentation with
mean duration of illness <2 weeks.
• The most common initial complaints include shortness of
breath, vomiting and abdominal pain, poor feeding, and
hypoperfusion.
• The most common misdiagnoses include pneumonia, asthma,
URI and gastroenteritis.
Freedman SB. Pediatric Myocarditis: Emergency Department Clinical Findings and Diagnostic Evaluation. Pediatrics
2007;120:1278.
Durani Y. Pediatric Myocarditis: Presenting Clinical Characteristics. American Journal of Emergency Medicine. 2009;27:942.
Myocarditis: Pathophysiology

13. • Acute injury leads to cardiac damage,
exposure of intracellular antigens such as
cardiac myosin, and activation of the
innate immune system.
• Over weeks, specific immunity that is
mediated by T lymphocytes and
antibodies directed against pathogens and
similar endogenous heart epitopes cause
robust inflammation.
• In most patients, the pathogen is cleared
and the immune reaction is down-
regulated with few sequelae.
• The basis of myocarditis as an overactive
immune response is why IVIG is often
used to treat pediatric myocarditis.
Cooper LT. Myocarditis. N Engl J Med.
2009;360:1526-38
Myocarditis: Pathophysiology

14. • ECG has been shown to be abnormal in 100% of cases!
• But… the most common finding is Sinus Tachycardia
• Other common findings include:
• Abnormally large voltage
• Axis deviation
• ST/T wave abnormalities
• AV Block
• Ischemic patterns
• CXR is often abnormal including:
• Cardiomegaly
• Pulmonary edema
• Pleural effusions
Shu-Ling C et al. Diagnostic Evaluation of Pediatric Myocarditis in the Emergency Department: A 10-year Case Series in the
Asian Population. Pediatric Emergency Care 2013 Mar;29(3):346-51.
Myocarditis: Pathophysiology

15. HPI: 9-year-old male
presented after a high
speed MVC.
Vital Signs:
Afebrile
HR: 105
RR: 35
BP: 124/89
GCS: 13-14

16. Initial CXR = Bilateral interstitial opacities
concerning for pulmonary contusions
HPI: 9-year-old male
presented after a high
speed MVC.

17. Initial CXR = Bilateral interstitial opacities
concerning for pulmonary contusions
HPI: 9-year-old male
presented after a high
speed MVC.
Anything else on the CXR??

18. Left clavicle fracture
HPI: 9-year-old male
presented after a high
speed MVC.

19. Remember Your Systematic Approach
ABCDE
A Airway
B Bones (clavicles, ribs, humeri, etc.)
C Cardiomediastinal Silhoutte
D Diaphragms (costophrenic angles)
E Everything else!

20. HPI: 9-year-old male
presented after a high
speed MVC.

21. CT Chest Demonstrates Pulmonary Contusions.
HPI: 9-year-old male
presented after a high
speed MVC.

22. HPI: 11-month-old male
presented after a high
speed MVC.

23. Initial CXR = Bilateral upper lobe opacities
concerning for pulmonary contusions.
HPI: 11-month-old male
presented after a high
speed MVC.

24. Initial CXR: No obvious
traumatic injuries in the chest
HPI: 4-month-old male
presented after a high
speed MVC.

25. Initial CXR: No obvious
traumatic injuries in the chest
HPI: 4-month-old male
presented after a high
speed MVC.
But wait, is that a widened
mediastinum?

26. Differentiating the Thymic Shadow
“Thymic Sail Sign” is a triangular extension of the
normal thymus laterally.
The anterior reflections
of the ribs produce a wavy
contour of the thymus
known as the “thymus
wave sign.”
The inferior margin of the
thymus merges with the
margin of the cardiac
silhouette, producing the
“notch sign”.
Manchanda, Smita, et al. “Imaging of the Pediatric Thymus: Clinicoradiologic Approach.” World Journal of Clinical
Pediatrics, Baishideng Publishing Group Inc, 8 Feb. 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5296624/.

27. HPI: 4-month-old male
presented after a high
speed MVC.
Thymic Sail Sign
Normal appearance of the
mediastinum for age.

28. HPI: 4-month-old male
presented after a high
speed MVC.
But, CT chest shows
pulmonary contusion in
the right upper lobe.

30. EAST Guidelines For The Management Of Pulmonary Contusion & Flail Chest
 The use of optimal analgesia and aggressive chest physiotherapy should be used to
minimize the risk of respiratory failure.
 A trial of mask CPAP in combination with optimal regional anesthesia, should be
considered in alert, compliant patients with marginal respiratory status.
 Epidural catheter is the preferred method of analgesia delivery.
 Patients should be adequately resuscitated, and hypovolemia should be avoided. When
there are clear signs of hydrostatic fluid overload, diuretics may be used.
 Steroids should not be used in patients with pulmonary contusion.
 For patients requiring mechanical ventilation, PEEP and CPAP should be part in the
ventilatory strategy.

31. HPI: 6-month-old with
complex past medical
history including chronic
lung disease and
prematurity presented
with cough, tachypnea, and
increased work of
breathing.
Vital Signs:
Temp: 100.8
HR: 174
RR: 52
BP: 124/86
SpO2: 80s

32. CXR = RUL Infiltrate
HPI: 6-month-old with
complex past medical
history including chronic
lung disease and
prematurity presented
with cough, tachypnea, and
increased work of
breathing.

33. HPI: 3-year-old previously
healthy male presented with
5 days of fever, cough and
increased work of breathing.
Initial CXR
Vital Signs:
Temp: 99.0
HR: 133
RR: 41
BP: 99/69
SpO2: 88%

34. HPI: 3-year-old previously
healthy male presented with
5 days of fever, cough and
increased work of breathing.
Initial CXR = multiple
consolidations consistent
with multifocal
pneumonia.

35. HPI: 5-year-old previously
healthy male presented with
cough, fever, abdominal
pain.
Initial CXR
Vital Signs:
Temp: 100.9
HR: 130
RR: 36
BP: 109/67
SpO2: 98%

36. HPI: 5-year-old previously
healthy male presented with
cough, fever, abdominal
pain.
Initial CXR = Large left
pleural effusion with left
lung consolidation
suggestive of complex
pneumonia

37. HPI: 5-year-old previously
healthy male presented with
cough, fever, abdominal
pain.
Patient underwent L VATS
with decortication and
chest tube placement.

38. HPI: 5-year-old previously
healthy male presented with
cough, fever, abdominal pain
CXR at Discharge =
Residual L layering pleural
effusion with improved
lung expansion.

39. HPI: 5-year-old male with
recent admission for
complex pneumonia
presented with increased
work of breathing.
Initial CXR
Vital Signs:
Temp: 98.2
HR: 102
RR: 30
BP: 112/63
SpO2: 97%
Back Again…

40. HPI: 5-year-old male with
recent admission for
complex pneumonia
presented with increased
work of breathing.
Initial CXR = Left lower
lobe infiltrate
Back Again…

41. HPI: 3-year-old previously
healthy male presents with
fever and cough for 5 days.
Initial CXR
Vital Signs:
Temp: 102.9
HR: 180
RR: 32
BP: 109/72
SpO2: 98%

42. HPI: 3-year-old previously
healthy male presents with
fever and cough for 5 days.
Initial CXR = multifocal
pneumonia

43. HPI: 2-year-old female with
past medical history of sickle
cell disease presents with
fever and cough for 3-4 days.
Initial CXR
Vital Signs:
Temp: 103.7
HR: 167
RR: 32
BP: 131/67
SpO2: 100%

44. HPI: 2-year-old female with
past medical history of sickle
cell disease presents with
fever and cough for 3-4 days.
Initial CXR = Left upper
lobe pneumonia
DX = Acute Chest
Syndrome

46. Acute Chest Syndrome
 Defined as a new pulmonary infiltrate consistent with consolidation
[not atelectasis] of at least one lung segment.
 Usually accompanied by chest pain, cough, fever and wheezing.
 The most common cause or ICU admission and premature death in
patients with sickle cell disease.
Gladwin M. New England Journal of Medicine 2008; 359:2254-65.

47. Acute Chest Syndrome
Three proposed mechanisms:
 Pulmonary infection1
 Embolization of bone marrow fat2
 Pulmonary intravascular sickling and infarction3
1Bronchoalveolar lavage demonstrates bacterial and/or viral pathogens in 54% of patients with ACS.
2Associated with pain crisis of multiple bones, particularly the lumbar spine, femurs and the pelvis.
3In a small percentage of patients with ACS, wedge-shaped pulmonary infarcts may develop.
Gladwin M. New England Journal of Medicine 2008; 359:2254-65.

49. National Acute Chest Syndrome Study Group
 538 patients from 20 centers - the largest case series to date
 Results provide insights into the clinical presentations and outcomes of
hospitalized patients with ACS
49% Of Patients Initially Presented In Pain Crisis Without Signs Of ACS!
Vichinsky EP. New England Journal of Medicine 2000; 342:1855-65.

50. National Acute Chest Syndrome Study Group
 Manifestations: worsening hypoxia, decreased hemoglobin levels, and
progressive, multi-lobar pulmonary infiltrates
 The mean hospital length of stay was 10.5 days [vs. 3 days w/o ACS]
 30% required mechanical ventilation and overall mortality was 3%
Vichinsky EP. New England Journal of Medicine 2000; 342:1855-65.
Infection1,2 33%
Pulmonary Infarction 33%
Pulmonary fat emboli 16%
1Pathogens identified using bronchoalveolar lavage
2Chlamydophilia, Mycoplasma pneumoniae & respiratory syncytial virus the most common pathogens

51. Acute Chest Syndrome
ED Treatment Essentials:
 Antibiotics to cover both typical & atypical pathogens
 Supportive respiratory care
 A transfusion strategy based on goals and severity
Gladwin M. New England Journal of Medicine 2008; 359:2254-65.
Goal Target
Increase oxygen carrying capacity Hgb ≥10 grams
Manage vaso-occlusive complications HbS <30%
Both As above

54. RCE = Red Cell Exchange

55. Summary of this month’s diagnoses
• Myocarditis
• Pulmonary Contusions
• Clavicle Fracture
• Right Upper Lobe Pneumonia
• Multifocal Pneumonia
• Complex L Lobe Pneumonia with
Pleural Effusion
• Left Lower Lobe Pneumonia
• Acute Chest Syndrome