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

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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:
- Tension Pneumothorax
- Atelectasis
- Esophageal Obstruction / Achalasia
- Right Upper Lobe Mass
- Right Upper and Right Middle Lobectomies
- Esophageal Foreign Body
- Transposition of the Great Vessels

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

  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 November 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 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. 4. Normal CXR for your reference
  5. 5. 5 month old full term infant with history of congenital pulmonary airway malformation s/p VATS 10 days prior presents to his pediatrician for decreased oral intake and UOP noted to have mild increased work of breathing and a RR of 42.
  6. 6. 5 month old full term infant with history of congenital pulmonary airway malformation s/p VATS 10 days prior presents to his pediatrician for decreased oral intake and UOP noted to have mild increased work of breathing and a RR of 42. Absent lung markings Leftward mediastinal shift
  7. 7. 5 month old full term infant with history of congenital pulmonary airway malformation s/p VATS 10 days prior presents to his pediatrician for decreased oral intake and UOP noted to have mild increased work of breathing and a RR of 42. Absent lung markings Leftward mediastinal shift Dx: Right-sided tension pneumothorax
  8. 8. 14 month old male with a history of dwarfism seen at an outside ED for tachypnea and fever. Clinical deterioration with desaturation to 60%. CPR initiated (6 min prior to ROSC) with multiple attempts at endotracheal intubation prior to successful passage of a 3.5 uncuffed ETT. Transferred to our PICU.
  9. 9. Crowded vasculature Opacity of the right lower lobe Elevation of right bronchus 14 month old male with a history of dwarfism seen at an outside ED for tachypnea and fever.
  10. 10. Dx: Right Lower Lobe Atelectasis Crowded vasculature Opacity of the right lower lobe Elevation of right bronchus 14 month old male with a history of dwarfism seen at an outside ED for tachypnea and fever.
  11. 11. How do we know that consolidation isn’t a pneumonia?!
  12. 12. Here is the same patient’s CXR the next day…
  13. 13. THE OPACITY MOVED! Pneumonias don’t move…atelectasis can! Elevation of R hemidiaphragm
  14. 14. THE OPACITY MOVED! Pneumonias don’t move…atelectasis can! Triangle shaped opacity in RUL Elevation of R hemidiaphragm Rightward shift of mediastinum
  15. 15. THE OPACITY MOVED! Pneumonias don’t move…atelectasis can! Dx: Right Upper Lobe Atelectasis Triangle shaped opacity in RUL Elevation of R hemidiaphragm Rightward shift of mediastinum
  16. 16. THE OPACITY MOVED! Pneumonias don’t move…atelectasis can! Dx: Right Upper Lobe Atelectasis Triangle shaped opacity in RUL Elevation of R hemidiaphragm Rightward shift of mediastinum **For those practicing in the ED…if clinical clues (like SICK kid with fever) point to possible pneumonia…TREAT like a pneumonia**
  17. 17. Atelectasis • Defined: reduced lung inflation • CXR features (that distinguish atelectasis from consolidation): • Elevation of the hemidiaphragm • Displaced fissure • Crowded vasculature • Mediastinal shift toward the collapse • Subsegmental, with a linear or band- like appearance • Types/Causes: • Post obstructive • Mucous plug • Foreign body aspiration • Mass • Compressive • Mass • Round/Cicatricle • Chronic TB or sarcoid • Adhesive • ARDS • Passive • Pneumothorax • Pleural effusion https://litfl.com/cxr-essentials-types-of-atelectasis/
  18. 18. Atelectasis: Patterns Based On Location • Right Upper Lobe • Triangular opacity • Elevation of right hilum • Rightward mediastinal shift • Right Middle Lobe • Loss of right heart border • BEST seen on lateral film as a wedge pointing toward the hilum • Right Lower Lobe • Triangular opacity near the spine • Silhouetting of right hemidiaphragm https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/
  19. 19. Atelectasis: Patterns Based On Location • Left Upper Lobe • Loss of left upper heart border • Elevated left hilum • Luftsichel Sign: crescent of air creating sharp border along the aorta • Left Lower Lobe • Triangular opacity creating an oddly linear left heart border • Silhouetting of the left hemidiaphragm https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/ . https://4.bp.blogspot.com/_fBQVVpFhTQs/SjlDlLXAlrI/AAAAAAAAAvU/7By_wSFvB4k/s1600-h/left-upper-lobe-collapse-1.jpg
  20. 20. Patient is a 12 year old female with past medical history of eosinophilic esophagitis who presented to the ED with feelings of chest fullness and difficulty swallowing solids and liquids. On exam, noted to have a hoarse voice with clear lung sounds.
  21. 21. Patient is a 12 year old female with past medical history of eosinophilic esophagitis who presented to the ED with feelings of chest fullness and difficulty swallowing solids and liquids. On exam, noted to have a hoarse voice with clear lung sounds. Dilated tubular structure
  22. 22. Patient is a 12 year old female with past medical history of eosinophilic esophagitis who presented to the ED with feelings of chest fullness and difficulty swallowing solids and liquids. On exam, noted to have a hoarse voice with clear lung sounds.
  23. 23. Dx: Esophageal obstruction (achalasia by esophogram) Abrupt tapering of the esophagus Patient is a 12 year old female with past medical history of eosinophilic esophagitis who presented to the ED with feelings of chest fullness and difficulty swallowing solids and liquids. On exam, noted to have a hoarse voice with clear lung sounds.
  24. 24. 7 year old female with no past medical history presents with intermittent chest pain over the last 2 months with a normal physical exam
  25. 25. Right Upper Lobe Mass 7 year old female with no past medical history presents with intermittent chest pain over the last 2 months with a normal physical exam
  26. 26. Right Upper Lobe Mass Dx: further imaging needed 7 year old female with no past medical history presents with intermittent chest pain over the last 2 months with a normal physical exam
  27. 27. 7 year old female with no past medical history presents with intermittent chest pain over the last 2 months with a normal physical exam
  28. 28. Right Upper Lobe Mass Dx: Inflammatory Myofibroblastic Tumor (biopsy diagnostic) 7 year old female with no past medical history presents with intermittent chest pain over the last 2 months with normal physical exam
  29. 29. Surgical clips at the right hilum Same 7 year old female with now known history of RUL tumor s/p VATS guided biopsy 2 weeks later… Tiny pneumothorax Decreased lung markings
  30. 30. Surgical clips at the right hilum Dx: s/p RUL and RML resection Same 7 year old female with now known history of RUL tumor s/p VATS guided biopsy 2 weeks later… Tiny pneumothorax Decreased lung markings
  31. 31. 3 year old male reportedly swallowed a coin who is now experiencing vomiting
  32. 32. Foreign body Dx: Esophageal foreign body (quarter) 3 year old male reportedly swallowed a coin who is now experiencing vomiting
  33. 33. 5 year old female with history of Down Syndrome reportedly swallowed something and is now experiencing vomiting
  34. 34. 5 year old female with history of Down Syndrome reportedly swallowed something and is now experiencing vomiting
  35. 35. Foreign body Dx: Esophageal foreign body (quarter) 5 year old female with history of Down Syndrome reportedly swallowed something and is now experiencing vomiting
  36. 36. 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 collogues in the Pediatric Cardiovascular Surgery Department. We thank this team for their continued support of this project!
  37. 37. 1 day old male with known congenital abnormality based on prenatal screening admitted to NICU Physical Exam: II/VI holosystolic murmur best heard at apex; up slanting palpebral fissures, trigonocephaly, micrognathia
  38. 38. 1 day old female with known congenital abnormality based on prenatal screening admitted to NICU Physical Exam: II/VI systolic murmur best heard at LUSB; 1+ peripheral pulses; capillary refill 4 sec file:///.file/id=6571367.20974 880
  39. 39. 2 day old female with known congenital abnormality based on prenatal screening admitted to NICU for hypoxia requiring CPAP Physical Exam: III/VI continuous systolic murmur; coarse lung sounds
  40. 40. 1 day old male transferred from outside hospital for hypoxia requiring CPAP and ultimately intubation with an elevated lactate Physical Exam: systolic murmur; tachypnea with subcostal retractions
  41. 41. 1 day old female with known congenital abnormality based on prenatal screening labs born with hypoxia to the 80’s Physical Exam: II/VI systolic murmur along LSB, cyanotic
  42. 42. 1 day old male with known congenital abnormality based on prenatal screening labs born who became apneic and bradycardic ultimately requiring intubation Physical Exam: 2+ upper extremity pulses; 1+ lower extremity pulses; no murmur
  43. 43. 3 day old male with known congenital abnormality based on prenatal screening labs born who became apneic and bradycardic ultimately requiring intubation Physical Exam: 2+ upper extremity pulses; 1+ lower extremity pulses; no murmur
  44. 44. 1 day old female with known congenital abnormality based on prenatal screening labs born and taken to NICU for monitoring Physical Exam: narrow s2 splitting
  45. 45. So, What’s With These Kids??
  46. 46. Transposition Of The Great Arteries (TGA) • The two main arteries that carry blood away from the heart are swapped: • Body ⇨ Heart ⇨ Body • Lungs ⇨ Heart ⇨ Lungs • Occurs in 1250 US births/year • Slight male predominance https://www.heart.org/en/health-topics/congenital-heart-defects/about- congenital-heart-defects/d-transposition-of-the-great-arteries https://www.cdc.gov/ncbddd/heartdefects/d-tga.html
  47. 47. TGA: Associated Cardiac Abnormalities • Isolated TGA is not compatible with life • These defects allow for the mixing of oxygenated blood: • VSD • ASD • PDA • PFO • Extracardiac anomalies are less common https://www.cdc.gov/ncbddd/heartdefects/d-tga.html https://radiopaedia.org/articles/transposition-of-the-great-arteries?lang=us Martins, Paula, and Eduardo Castela. “Transposition of the Great Arteries.” Orphanet Journal of Rare Diseases, vol. 3, no. 1, 2008, doi:10.1186/1750-1172-3-27. Yue, Ester L. “Congenital and Acquired Pediatric Heart Disease.” Tintinallis Emergency Medicine, by J. Tintinalli, 8th ed., Mcgraw-Hill 2015, pp. 822–832.
  48. 48. TGA: Risk Factors • Gestational diabetes • Maternal exposures: • Rodenticides • Herbicides • Maternal antiepileptic use • Maternal age >40 years • Rubella or other viral illnesses during pregnancy https://www.mayoclinic.org/diseases-conditions/transposition-of-the-great-arteries/symptoms-causes/syc-20350589 Martins, Paula, and Eduardo Castela. “Transposition of the Great Arteries.” Orphanet Journal of Rare Diseases, vol. 3, no. 1, 2008, doi:10.1186/1750-1172-3-27.
  49. 49. TGA: Clinical Presentation • History: • Blue skin • Labored breathing • Lack of appetite • Poor weight gain • Physical Exam: • Hypoxia • Cyanosis • Single loud S2 • Murmur may be absent (depending on other cardiac abnormalities present) https://www.mayoclinic.org/diseases-conditions/transposition-of-the-great-arteries/symptoms-causes/syc-20350589 Martins, Paula, and Eduardo Castela. “Transposition of the Great Arteries.” Orphanet Journal of Rare Diseases, vol. 3, no. 1, 2008, doi:10.1186/1750-1172-3-27.
  50. 50. TGA: Evaluation • Hyperoxia test: • No improvement in SAO2 after oxygen administration • EKG: • Right axis deviation • Right ventricular hypertrophy: • Dominant R wave in V1 • Dominant S wave in V5 or V6 • QRS <120 ms https://litfl.com/right-ventricular-hypertrophy-rvh-ecg-library/ Yue, Ester L, and Garth D Meckler. “Congenital and Acquired Pediatric Heart Disease.” Tintinallis Emergency Medicine, by Judith Tintinalli, 8th ed., Mcgraw-Hill Education, 2015, pp. 822–832.
  51. 51. TGA: Chest X-Ray Findings • Egg-shaped heart • Narrow mediastinum • Increased pulmonary vascular markings https://radiopaedia.org/articles/transposition-of-the- great-arteries?lang=us Yue, Ester L, and Garth D Meckler. “Congenital and Acquired Pediatric Heart Disease.” Tintinallis Emergency Medicine, by Judith Tintinalli, 8th ed., Mcgraw-Hill Education, 2015, pp. 822–832. Case courtesy of Dr Vincent Tatco, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/43062">rID: 43062</a>
  52. 52. Summary of This Month’s Diagnoses • Tension pneumothorax • Atelectasis • Esophageal obstruction/achalasia • Right upper lobe mass • Right upper and right middle lobectomies • Esophageal quarter • Transposition of the great arteries

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