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Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery Cases #2

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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 including: Diaphragmatic Hernia, Pneumomediastinum, Right Mainstem Intubation, Left Lung Collapse, Coarctation of the Aorta, Right Upper Lobe Pneumonia, Right Lower Lobe Pneumonia

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Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery Cases #2

  1. 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 June 2019
  2. 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. 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. 4. Normal CXR For Your Reference
  5. 5. 2 Month Old With Respiratory Distress
  6. 6. Bowel In The Chest Diaphragmatic Hernia 2 Month Old With Respiratory Distress
  7. 7. 5 Year Old With Fever, Cough, And Tachypnea RUL Collapse & RLL Necrotizing Pneumonia
  8. 8. RUL Collapse & RLL Necrotizing Pneumonia 5 Year Old With Fever, Cough, And Tachypnea
  9. 9. 9 Year Old Presents To An Urgent Care Center With URI Symptoms
  10. 10. Pneumomediastinum 9 Year Old Presents To An Urgent Care Center With URI Symptoms
  11. 11. 9 yo presents to urgent care with URI symptoms Pneumomediastinum
  12. 12. Healthy 13 year old with throat and upper chest pain
  13. 13. Healthy 13 Year Old With Throat & Upper Chest Pain Pneumomediastinum & Pneumopericardium
  14. 14. Healthy 13 Year Old With Throat & Upper Chest Pain Pneumomediastinum & Pneumopericardium
  15. 15. Healthy 13 Year Old With Throat & Upper Chest Pain Pneumomediastinum & Pneumopericardium
  16. 16. 6 Month Old S/P Difficult Intubation In The OR
  17. 17. Right Mainstem Intubation & Left Lung Collapse 6 Month Old S/P Difficult Intubation In The OR
  18. 18. CASE #1 11 day old born at full term with 2 days of progressive respiratory distress, grunting and decreased PO intake
  19. 19. Coarctation Of The Aorta CASE #1 11 day old born at full term with 2 days of progressive respiratory distress, grunting and decreased PO intake
  20. 20. CASE #2 5 day old full term found to have a heart murmur after delivery
  21. 21. CASE #2 5 day old full term found to have a heart murmur after delivery Coarctation Of The Aorta
  22. 22. Coarctation Of The Aorta (CoA) EARLY is detection is IMPORTANT!! Late repair of CoA is associated with increased CAD in early adulthood.
  23. 23. Clinical Presentation of CoA in Neonates/Infants Signs/Symptoms • Can present in shock during first 6-8 weeks • Decreased femoral arterial pulse compared to right brachial artery • Heart murmur • Cyanosis Associated conditions • Bicuspid aortic valve • VSD • PDA • Mitral valve stenosis • Hypoplastic aortic arch • Subaortic membrane or stenosis • Turner’s Syndrome • Intracranial berry aneurysm Joshi, Gitika, et al. “Presentation of Coarctation of the Aorta in the Neonates and the Infant with Short and Long Term Implications.”
  24. 24. Work up of CoA in Neonates/Infants In the ED • EKG • LVH • Flat ST segment or T waves • CXR • Enlarged heart • Pulmonary venous congestion • Its too early to see “classic” rib notching Beyond the ED • Formal Echocardiogram Joshi, Gitika, et al. “Presentation of Coarctation of the Aorta in the Neonates and the Infant with Short and Long Term Implications.”
  25. 25. Treatment of CoA in Neonates/Infants in the ED DOs • Prostaglandin E1 or E2 • Start at 5.0-15.0 ng/kg/min • Max 100 ng/kg/min –beware of increased risk of apnea at higher doses • Can be administered via peripheral access or IO • Inotropes • Dopamine, dobutamine, and epinephrine • Needs central access DON’Ts • Hyperventilation • High FiO2 • Vasodilators • Cautious use of fluids • Consider 5 ml/kg boluses • Re-evaluate for signs of heart failure with each bolus • Do not chase with diuretics as this can make things WORSE Joshi, Gitika, et al. “Presentation of Coarctation of the Aorta in the Neonates and the Infant with Short and Long Term Implications.”
  26. 26. 3 Year Old With Cough That Initially Improved However Worsened Again 4 Days Prior To ED Visit
  27. 27. No obvious findings on AP view 3 Year Old With Cough That Initially Improved However Worsened Again 4 Days Prior To ED Visit
  28. 28. 3 Year Old With Cough That Initially Improved However Worsened Again 4 Days Prior To ED Visit
  29. 29. Right Upper Lobe Pneumonia GET THE LATERAL VIEW!! 3 Year Old With Cough That Initially Improved However Worsened Again 4 Days Prior To ED Visit
  30. 30. 7 Year Old Girl Seen In The ED 1 Day Prior With Fever, Vomiting And Abdominal Pain S/P Appendicitis Work Up Returned To The ED With Persistent Fever And Pain
  31. 31. Right Lower Lobe Pneumonia In pediatric patients presenting with “abdominal pain,” always consider a lower lobe pneumonia as a cause. Start with a great chest exam, followed by chest radiography on a case-by-case basis. 7 Year Old Girl Seen In The ED 1 Day Prior With Fever, Vomiting And Abdominal Pain S/P Appendicitis Work Up Returned To The ED With Persistent Fever And Pain
  32. 32. Summary Of Diagnoses This Week • Diaphragmatic hernia • Pneumomediastinum & pneumopericardium • Right mainstem intubation with left lung collapse • Coarctation of the aorta • Right upper lobe pneumonia • Right lower lobe pneumonia

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