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: Retropharyngeal abscess, Metapneumovirus pneumonia requiring ECMO, Heart failure, Several cases of lobar pneumonia, Left mainstem placement of Dobhoff tube with pneumothorax, Mystery case from Tanzania!

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
July 2019

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 Carolinas Medical Center departments, and now…
Brazil, Chile and Tanzania.
 Cases submitted this month will be distributed next month.
 When reviewing the presentation, the 1st image will show a chest X-ray
without identifiers and the 2nd image will reveal the diagnosis.

4. It’s All About The Anatomy!

5. 9 month-old healthy female initially
presented to an outside hospital ED due
to fever and decreased oral intake in the
setting of a recent diagnosis otitis media.
Appeared well & was discharged
Initial ED Diagnosis: Viral infection.

6. 9 month-old healthy female initially
presented to an outside hospital ED due
to fever and decreased oral intake in the
setting of a recent diagnosis otitis media.
Appeared well & was discharged
Initial ED Diagnosis: Viral infection.
She represented 1 day later to the same
ED due to decreased oral intake and
increased fussiness. He was noted to be
febrile and tachypneic without hypoxia,
ill appearing with decreased peripheral
perfusion. Given 20cc/kg IVF bolus + high
flow oxygen. Transferred to Charlotte.
Working Diagnosis: Bronchiolitis.

7. At the Levine Children’s Hospital ED the patient was noted to be in respiratory distress with increased accessory muscle use,
and grunting. The neck was swollen with enlarged lymph nodes and the patient resisted neck movement. She would not
open her mouth, even to cry.
Initial Imaging: chest X-ray and soft-tissue lateral neck X-ray.

8. At the Levine Children’s Hospital ED the patient was noted to be in respiratory distress with increased accessory muscle use,
and grunting. The neck was swollen with enlarged lymph nodes and the patient resisted neck movement. She would not
open her mouth, even to cry.
Initial Imaging: chest X-ray and soft-tissue lateral neck X-ray.

10. Noted to have marked prevertebral
tissue swelling of 2.5cm which partially
narrows the subglottic airway putting
thw patient at significant risk for airway
compromise.

12. The patient was intubated prior to CT scan
due to concern for airway compromise. CT
shows a large retropharyngeal abscess
1.6cm x 7.3cm in AP diameter and 11.3cm
in craniocaudal dimension.

13. The patient was intubated prior to CT scan
due to concern for airway compromise. CT
shows a large retropharyngeal abscess
1.6cm x 7.3cm in AP diameter and 11.3cm
in craniocaudal dimension.
Pt taken to the OR 6/16 with ENT and 6/17
with pediatric surgery for abscess I&D.
Fluid cultures = MRSA. Pt extubated 6/26.
Remains in PICU for respiratory support.

14. Retropharyngeal Abscesses [RPA] In Children
• Typically occur in children <5yrs old, before retropharyngeal lymph tissue naturally atrophies.
• If there is a high clinical suspicion for RPA, lateral neck X-rays may be obtained, but these do
not completely rule out the disease. CT is the imaging modality of choice to evaluate the extent
of the abscess.
• It is recommended that AP and lateral CXRs are also obtained in children with suspected RPA to
evaluate for complications including mediastinitis and aspiration pneumonia.
• The differential diagnosis includes all conditions which cause upper airway obstruction, sore
throat, and neck stiffness: epiglottitis, coup, bacterial tracheitis, peritonsillar abscess, uvulitis,
diphtheria, trauma to the oropharynx (e.g.: burns, penetrating trauma, foreign body), and
tumors (e.g.: lymphangioma, hemangioma)
• Empiric antibiotics: ampicillin-sulbactam (50mg/kg q6hrs) OR clindamycin (15mg/kg q8hrs). In
patients who fail to respond to initial treatment or have moderate to severe disease, it is
recommended that vancomycin (40-60mg/kg/d divided TID-QID) or linezolid (30mg/kg/d
divided TID) be added to cover resistant gram (+) cocci.
UpToDate: Retropharyngeal Infections in Children

15. • In children < 5 years old, the
retropharyngeal (RP) space normally
measures ½ the width of the adjacent
vertebral body and is considered
widened if it is greater than a full
vertebral body at C2 or C3
• The RP space is pathologically
widened in children if it is greater than
7mm at C2 or 14mm at C6
C2/C3 > ½ width of
vertebral body
C2 > 7mm
C6 > 14mm

16. 12 year-old previously healthy male presented
to ED due to 2 days fever, nausea, vomiting.
He then developed acute onset chest pain and
dyspnea with ambulatory O2 saturations of
77% on room air. In the ED he was noted to
have increased work of breathing.
Initial CXR. Serum lactate >7.

17. 12 year-old previously healthy male presented
to ED due to 2 days fever, nausea, vomiting.
He then developed acute onset chest pain and
dyspnea with ambulatory O2 saturations of
77% on room air. In the ED he was noted to
have increased work of breathing.
Initial CXR. Serum lactate >7.
He remains hypoxic, requiring HFNC 
BiPAP  intubation. Transferred to LCH
Pediatric ICU.

18. On arrival to the PICU he is noted to be
increasingly hypoxic and hypotension.
Placed on 90% FiO2 and oscillator

19. On arrival to the PICU he is noted to be
increasingly hypoxic and hypotension.
Placed on 90% FiO2 and oscillator
Second CXR on arrival demonstrates
bilateral infiltrates

20. Emergently cannulated
for ECMO
Bronchoalveolar lavage
reveals Human
Metapneumovirus and
Methacillin-Sensitive Staph
Aureus [MSSA]

22. Repeat CXR prior to discharge shows
significant improvement in consolidations
Inpatient Course
4/17 Decannulated
4/22 Extubated
4/24 Transferred to floor
4/30 Discharged to rehab
5/8 Discharged home

23. 10 year old presented to ED with 3 days
fever + cough after orthopedic foot surgery
requiring intubation 5 days prior,
Exam = right lung crackles
VS: RR 24, Temp 99.9, O2 96%, HR 124

24. 10 year old presented to ED with 3 days
fever + cough after orthopedic foot surgery
requiring intubation 5 days prior,
Exam = right lung crackles
VS: RR 24, Temp 99.9, O2 96%, HR 124
Right Middle Lobe Pneumonia
RML Infiltrate

25. DX: Severe constipation leading to
respiratory distress
4 month old with PMHx significant for trisomy 13, ASD
and VSD presented to the ED for evaluation of tachypnea
and constipation. RR 67
Initial CXR: decreased lung volumes. No
infiltrates identified.
Abdominal XR: significant constipation with
distension leading to decreased lung volumes

26. Readmitted days later for
increased lethargy and
apneic episodes
CXR: Worsening
cardiomegaly and air
bronchograms consistent
with pulmonary edema

27. 9 year old presented to Urgent Care Center
with 2 days of cough and fever which
developed approximately 1 week after a viral
upper respiratory infection [URI]
CXR: LLL PNA
Discharged home with Rx Augmentin

28. Pt represented to ED 2 days later due to
continued cough and increased WOB
VS: HR 122, RR 48, SAO2 95%
Rapid Desaturation With Ambulation

29. Pt represented to ED 2 days later due to
continued cough and increased WOB
VS: HR 122, RR 48, SAO2 95%
Rapid Desaturation With Ambulation
CXR: LLL pneumonia with
new RML consolidation
Multifocal Pneumonia

30. 16 year-old female underwent elective outpatient
maxillofacial surgery. Post-procedurally she developed
hypoxia

31. 16 year-old female underwent elective outpatient
maxillofacial surgery. Post-procedurally she developed
hypoxia
Right Apical
Pneumothorax

32. Pt transferred to the ED from PACU.
Continued hypoxia requiring
supplemental oxygen

33. Pt transferred to the ED from PACU.
Continued hypoxia requiring
supplemental oxygen
2nd CXR: pneumothorax + evolving
bibasilar opacities concerning for
developing aspiration pneumonia

34. Pigtail Drainage

35. 3rd CXR: improvement of the
pneumothorax but evolving RLL
consolidation concerning for
aspiration pneumonia versus
atelectasis
Pigtail Drainage

36. Continued concerns for aspiration
throughout hospitalization due to
oromaxillofacial anomalies. A
Dobhoff Tube [DHT] is
recommended due to aspiration
4th CXR: Post DHT placement the patient
complained of chest pain below L breast.
Desaturation to 70% on RA.

37. Continued concerns for aspiration
throughout hospitalization due to
oromaxillofacial anomalies. A
Dobhoff Tube [DHT] is
recommended due to aspiration
4th CXR: Post DHT placement the patient
complained of chest pain below L breast.
Desaturation to 70% on RA.
Iatrogenic L Pneumothorax due to DHT
placed in left bronchus

38. 7 year old female presented with recurrent
productive cough, night sweats, weight loss
and fevers
Air fluid level concerning
for a cavitary lesion
What Is Your Diagnosis?
Tune in next month for more to come!
Cases Studies From
Our Emergency
Medicine Partners In
Tanzania

39. Air-Fluid Level: If It’s Flat There’s Air In There!
Cases Studies From
Our Emergency
Medicine Partners In
Tanzania

40. Summary Of Diagnoses This Month
 Retropharyngeal abscess
 Metapneumovirus pneumonia requiring ECMO
 Heart failure
 Several cases of lobar pneumonia
 Left mainstem placement of Dobhoff tube with pneumothorax
 Mystery case from Tanzania!

41. See You Next Month!