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: Tetralogy of Fallot, Congenital Diaphragmatic Hernia, Clavicle Fracture, Lung Agenesis, Ingested Foreign Body, Truncus Arteriosus.

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
September 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 CMC/LCH departments, and now from EM
colleagues in 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. Normal CXR
for your reference

5. 3 month old female with history
of congenital heart defect s/p
repair who presented to the ED
with hypoxia and increased
work of breathing .
Her CXR is consistent with
which congenital heart defect?

6. Heart with wooden shoe shape
Oligohemia (reduction of blood flow
in the peripheral circulation
Pulmonary artery
segment concavityEnlarged aorta
Tetralogy of Fallot
for more information see
last month’s feature on
TOF

7. 3 year old female with past
medical history of congenital
diaphragmatic hernia s/p
repair who presents to the ED
with increased work of
breathing

8. Elevation of the right hemidiaphragm
and left basilar opacity.

9. When compared to multiple previous CXRs, this is
stable and consistent with a repaired congenital
diaphragmatic hernia.
2017 2019

10. 2017 2019
Always compare
with previous CXR!
When compared to multiple previous CXRs, this is
stable and consistent with a repaired congenital
diaphragmatic hernia.

11. Congenital Diaphragmatic Hernia
• 1 in every 3000 live births
• Predominantly male infants
• Can be isolated or associated with a
number of genetic syndromes
• Abdominal contents herniate through the
diaphragmatic defect and cause pulmonary
hypoplasia
• Most often presents with respiratory
distress at or soon after birth
• CXR findings
• Air filled and fluid filled loops of bowel in the
thorax
• Cardiac silhouette shifted to the opposite
hemithorax
https://pedemmorsels.com/congenital-diaphragmatic-hernia/
https://eapsa.org/parents/learn-about-a-condition/a-e/congenital-
diaphragmatic-hernia/

12. 12 year old female with no
past medical history presents
with back and left shoulder
pain after a rollover motor
vehicle crash.

13. Fracture of distal left clavicle
Have a routine approach to
evaluating CXRs so as not to
miss subtle findings!
A: Airway
B: Bones (as in this case)
C: Cardiac
D: Diaphragm
E: Extra-thoracic soft tissue
F: Foreign bodies/Fissures
G: Great vessels/Gastric bubble
H: Hila and mediastinum
https://radiopaedia.org/articles/chest-radiograph-assessment-using-abcdefghi?lang=us

14. 2 month old male with
a complex medical
history including lung
agenesis presents in
respiratory distress. The
family suctions a mucus
plug from the child’s
tracheostomy tube just
prior to arrival.

15. Dx: Right lung agenesis
(complete opacification of
the lung field)
Diagnosis: Left
middle and lower
lobe atelectasis

16. 4 year old male
presents to the ED
for evaluation after
swallowing a marble
3 days earlier. He
now complains of
abdominal pain.

17. No foreign body…
need more imaging!

18. Diagnosis: Foreign body;
most likely in the cecum

19. 7 year old male presents to
the ED for evaluation after
swallowing a metal ring 2
days earlier. He now
complains of abdominal
pain and vomiting.

20. No foreign body…
need more imaging!

21. Diagnosis: Foreign
body overlying the
stomach.
Delayed presentation
of ingested foreign
body. Get both chest
and abdominal X-
rays to evaluate!

22. What’s with these kids?
For the next section, we will review a series of cases & images with a
unifying diagnosis. Try to identify the similarities and come up with the
diagnosis! After each series of cases, we will discuss the
pathophysiology and imaging characteristics of the diagnosis.
These images and cases have been graciously shared with us from our
colleagues in the Pediatric Cardiovascular Surgery Division. We thank
everyone for your continued support of this project!

23. Female neonate with known
congenital abnormality based
on antenatal screening and
IUGR born at 39 weeks and
transferred to the NICU for
close monitoring
Physical exam notable for low
pitched 2/6 systolic murmur at
the left sternal border.

24. Female neonate with known
congenital abnormality based on
antenatal screening and IUGR born
at 37 weeks and transferred to the
NICU for close monitoring.
Physical exam notable for a constant
systolic ejection click and 2/6, mildly
harsh systolic ejection murmur heard best
at the cardiac base.

25. So, what’s with these kids??

26. Truncus Arteriosus
https://www.cdc.gov/ncbddd/heartdefects/truncusarteriosus.html
• Single arterial trunk ascending from both
right and left ventricles
• Occurs due to a failure or incomplete
septation of the truncus arteriousus
during embryonic development
• Occurs in approximately 5-15 of 100,000
live births
• Slight male predominance
https://emedicine.medscape.com/article/892489-overview#a4
https://www.cdc.gov/ncbddd/heartdefects/truncusarteriosus.html
Yue, Esther L., and Garth D. Meckler.. "Congenital and Acquired Pediatric Heart
Disease." Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e

27. Truncus Arteriosus
Associated Cardiac Abnormalities:
• Ventricular septal defect
• Presence of truncal (semilunar) valve
• Significant regurgitation through truncal valve
• Abnormal coronary arteries
• Single coronary artery
• Intramural coronary artery
• Interruption of aortic arch
• Right sided aortic arch
• Left superior caval vein
• Aberrant subclavian artery
• Atrial septal defect
https://emedicine.medscape.com/article/892489-overview#a4
https://www.cdc.gov/ncbddd/heartdefects/truncusarteriosus.html
Yue, Esther L., and Garth D. Meckler.. "Congenital and Acquired Pediatric Heart
Disease." Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e

28. • During pregnancy:
• Rubella
• Poorly controlled diabetes
• Smoking
• Alcohol
• Some antiepileptics
• Ibuprofen
• Family history of congenital heart disease
• Chromosomal disorders:
• DiGeorge syndrome
• Velocardiofacial syndrome
https://emedicine.medscape.com/article/892489-overview#a4
https://www.cdc.gov/ncbddd/heartdefects/truncusarteriosus.html
Yue, Esther L., and Garth D. Meckler.. "Congenital and Acquired Pediatric Heart
Disease." Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e
Truncus Arteriosus
Risk Factors:

29. History:
• Poor feeding
• Breathing fast
• Sweating
• Turning blue
• Lethargy
Physical Exam:
• Lethargy, diaphoresis
• Tachypnea, cyanosis: can have normal SpO2
• Loud systolic murmur at left sternal border
• +/- High pitched diastolic decrescendo
murmur
• +/- diastolic rumble
• Prominent S2
Truncus Arteriosus
Clinical Presentation:
https://emedicine.medscape.com/article/892489-overview#a4
https://www.cdc.gov/ncbddd/heartdefects/truncusarteriosus.html
Yue, Esther L., and Garth D. Meckler.. "Congenital and Acquired Pediatric Heart
Disease." Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e

30. • Hyperoxia test:
• No improvement in
oxygenation after
administration of
supplemental O2
• EKG:
• Normal axis (right-axis
deviation is expected on
pediatric EKG)
• Biventricular hypertrophy
• Katz-Wachtel phenomenon
• V2-V5 with large biphasic
QRS
https://litfl.com/biventricular-hypertrophy-ecg-library/
https://emedicine.medscape.com/article/892489-overview#a4
Truncus Arteriosus
ED Evaluation

31. • Egg shaped heart; with significant
cardiac enlargement
• Flattened left upper heart border due
to absence of RV outflow tract
• Narrow mediastinum
• Increased pulmonary vascular
markings
• Thymus may be small or absent
(DiGeorge Syndrome)
https://radiologykey.com/heart-size-overall-configuration-and-specific-
chamber-enlargement/
Truncus Arteriosus
Chest X-Ray Findings:

32. Summary Of This Month’s Diagnoses
• Tetralogy of Fallot
• Congenital diaphragmatic hernia
• Clavicle fracture
• Lung agenesis and atelectasis
secondary to a mucous plug
• Ingested foreign bodies; delayed
presentation
• Truncus arteriosus