Drs. Potter and Richardson are interested in education and Pediatric Emergency Medicine. Follow along with the EMGuideWire.com team as they post these weekly educational, self-guided radiology slides on Pediatric Emergency Medicine Radiology Topics!

1. Pediatric Chest X-Ray Case Studies
Dr. Nikki Richardson and Dr. Jennifer Potter
CMC Emergency Medicine
Carolinas Medical Center and Levine Children’s Hospital

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 soon… Tanzania and Brazil.
 Cases submitted this week will be distributed next week.
 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. 3yo male with PMHx Down
Syndrome and AV canal
defect s/p repair presents
with cough and fever

6. RML infiltrates

7. 3yo from urgent care with fever and vomiting

8. 3yo from urgent care with fever and vomiting
LLL PNA

9. 2yo ex 33wk premie with
fever x 7d, lethargy and
decreased PO intake
HR 190
Temp 105

10. 2yo ex 33wk premie with
fever x 7d, lethargy and
decreased PO intake
HR 190
Temp 105
RUL PNA

11. 12mo seen out OSH 3d prior with CXR
reported to show mild PNA and started on
azithromycin, presents today with labored
breathing, decreased responsiveness
RR 55
SpO2 94%
Complete opacification of the L hemithorax with
rightward shift of mediastinal structures.
DDX Consolidation with fluid collection versus soft
tissue mass

12. 12mo seen out OSH 3d prior with CXR
reported to show mild PNA and started on
azithromycin, presents today with labored
breathing, decreased responsiveness
RR 55
SpO2 94%
Complete opacification of the L hemithorax with
rightward shift of mediastinal structures.
DDX Consolidation with fluid collection versus soft
tissue mass
DX: Parapneumonic effusion with shift

13. 500 cc Of
Purulent
Chest Tube
Output
DX: Parapneumonic effusion with shift
s/p pigtail thorocostomy
with significant
improvement in aeration

14. Healthy 5 Year Old
Treated With
Tamiflu For Flu
Symptoms,
Admitted With
Pneumonia

15. Healthy 5 Year Old
Treated With
Tamiflu For Flu
Symptoms,
Admitted With
Pneumonia
HD #1: LLL Pneumonia

16. Healthy 5 Year Old
Admitted With
Pneumonia

17. Healthy 5 Year Old
Admitted With
Pneumonia
HD #4: Chest Tube With Purulent Drainage

18. Healthy 5 Year Old
Admitted With
Pneumonia

19. Healthy 5 Year Old
Admitted With
Pneumonia
HD #14: After Video Assisted Thoracoscopic Surgery [VATS]
One Liter Of Pus Removed
Pneumohydrothorax
With Mediastinal Shift

20. Air-Fluid Level: If It’s Flat There’s Air In There!

21. Healthy 5 Year Old Admitted With Pneumonia
HD #14: Pneumohydrothorax And Severe Pulmonary Necrosis/Trapped Lung (*)
Discharged The Following Day On IV Antibiotics With Planned Follow-Up
*

22. Pediatric Chest Tube Recommendations
• Consider what is it you have to drain
• Acute blood or air can easily be drained with a pigtail
catheter
• If it is expected to be viscous, you may need a small
caliber thoracostomy tube, however Chien-Heng found no
difference between drainage and hospitalization days
when using a pigtail catheter versus thoracostomy tube
for drainage of parapneumonic effusion1
• Be nice – anesthetize and sedate if needed
• Be safe – Use a flexible tipped guidewire and US for
guidance
• Aim high – above 6th intercostal space
1. Lin, Chien-Heng, et al. “Comparison of Pigtail Catheter with Chest Tube for
Drainage of Parapneumonic Effusion in Children.” Pediatrics and
Neonatology, U.S. National Library of Medicine, Dec. 2011,
www.ncbi.nlm.nih.gov/pubmed/22192262.
Pediatric EM Morsles – PigTail Catheter

23. Cardiomegaly?
17mo previously healthy male presenting
with 2wks URI symptoms. Clinically well
appearing with stable VS
17yo female with PMHx T1DM
presents with 2wks of LE edema
+ 17lbs weight gain

24. Cardiomegaly?
CXR = Enlarged cardiothymic silhouette,
normal pulmonary vascularity
CXR = prominent cardiac silhouette with
prominent vascular markings and patchy
airspace opacities
NO! Prominent
thymus,
appropriate for age
YES!

25. 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/.

26. CXR Formal Read: “Impression:
Pulmonary vascular congestion
without focal consolidation”

27. CXR Formal Read: “Impression:
Pulmonary vascular congestion
without focal consolidation”
Review of imaging reveals fracture
of pacer lead

28. 9 yo male with hx of ASD and ADHD
presenting today after inhaling vs.
swallowing a thumbtack

29. Plastic thumbtack noted in the right hilum region on CXR,
discovered in the R mainstem bronchus on bronchoscopy

30. 16mo female presents
with intermittent
inspiratory stridor x 3
days after an episode
of vomiting
Case 1

31. Initial CXR =
Hyperlucency and
increase in volume
of L lung when
compared to R lung
16mo female presents
with intermittent
inspiratory stridor x 3
days after an episode
of vomiting
Case 1

32. 16mo male presents
with 3 days of fever
and wheezing
Case 2

33. Initial CXR =
No acute disease in
the chest
16mo male presents
with 3 days of fever
and wheezing
Case 2

34. Repeat CXR =
Hyperinflation of R
lung
16mo male presents
with 3 days of fever
and wheezing
Case 2 – Repeat Imaging

35. Next Step?

36. Next Step?
Lateral Decubitus Films

37. Next Step?
• Bilateral decubitus lateral films allows assessment of air-trapping caused by
an inhaled foreign body. The expectation is that the dependent lung will
collapse partially in the normal patient. Where there is an obstructive
foreign body there will be air-trapping and hyperlucency of the dependent
lung so that the dependent lung is increased in volume or paradoxically
normal in volume
• BUT they are not perfect. A small retrospective study of 28 children who
underwent bronchoscopy for suspected foreign body aspiration found that
as a measure of detecting foreign body aspiration, positive decubitus
radiographs had a sensitivity of 27%, a specificity of 67%, a positive
predictive value of 75%, and a negative predictive value of 20% - this does
not mean that lateral decubitus films should not be used, but shows the
importance of use of imaging in conjunction with a good HISTORY and
PHYSICAL EXAM!!!!
Lateral Decubitus Films
Assefa, Dagnachew, et al. “Use of Decubitus Radiographs in the Diagnosis of Foreign Body Aspiration in Young Children.” Pediatric
Emergency Care, U.S. National Library of Medicine, Mar. 2007, www.ncbi.nlm.nih.gov/pubmed/17413429.

38. Case 1

39. R lateral decubitus film normalCase 1

40. R lateral decubitus film normalCase 1L lateral decubitus film = Relative Increase in
volume of L lung, raising concern for
obstructing foreign body in the L mainstem
bronchus

41. L lateral decubitus film normalCase 2R lateral decubitus film = Relative Increase in
volume of R lung, raising concern for
obstructing foreign body in the R mainstem
bronchus
Pt proceed to OR for rigid bronchoscopy.
Several peanut fragments found occluding the R
bronchus intermedius

42. Airway Foreign Body

43. Airway Foreign Body
Coin In The Esophagus

44. Airway Foreign Body

45. Coin In The Esophagus
Airway Foreign Body

46. Airway Foreign Body

47. Coin In The Esophagus
Airway Foreign Body

48. Airway Foreign Body

49. Button Battery In The Esophagus
Airway Foreign Body

51. Adults Aspirate Things To!

52. Coin Vs. Button Battery
• Why does it matter?
• An electric current is generated when the battery comes in contact with mucosa, leading to localized burn
injury.
• If the alkaline battery leaks, corrosive injury and liquefactive necrosis can occur. This is more common with
non-lithium batteries and is usually not the cause of tissue damage that is seen to occur within 2 hours.
• The negative terminal, which is on the narrower side of the battery, generates hydroxide ions and is where
necrosis occurs. This can be remembered as “narrow-negative-necrotic.”
• Batteries lodged in the esophagus may cause serious burns in as little as 30 minutes and the patient might
be asymptomatic initially.
• Certain button batteries carry greater risk than others. Patients with lithium battery ingestions have worse
outcomes, as these have the potential to generate a higher current than other batteries and cause greater
damage.
• A button battery in the esophagus is an emergency and should be removed within 2 hours
AP/PA view – look for “halo
sign” – a ring of
radiolucency inside the
outer edge of the object
“TOXCard: Button Battery Ingestions.” EmDOCs.net - Emergency Medicine Education, 25 Feb. 2019, www.emdocs.net/toxcard-button-battery-

53. CXR are not only for pulmonary pathology
8mo present with fever and
cough, CXR obtained to r/o
infectious etiology. Lungs clear
but… Healing R clavicle fx,
birth trauma vs. NAT
CXR obtained for trauma eval…
R scapular fx