Drs. Kaley El-Arab and Neha Ray are interested in education and Pediatric Emergency Medicine. Follow along with the EMGuideWire.com team and Drs. Nikki Richardson, Mary Grady, and Michael Gibbs as they post these educational, self-guided radiology slides on Pediatric Emergency Medicine Radiology. This month’s topics include: • Acute chest syndrome (review) • Traumatic diaphragmatic hernia • Cervical distraction injury • Traumatic pneumothorax • Pelvic fractures from GSW • Lung whiteout from mucous plug • Scapula fracture and subclavian artery injury from GSW • Pulmonary contusions • Pneumomediastinum • Post-op pneumothorax • Pulmonary contusions, femur fracture, and pelvic fractures • Lines and tubes practice

1. Pediatric X-Rays of the Month
Neha Ray, MD & Kaley El-Arab, MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Nicholena Richardson, MD & Mary Grady, MD, Faculty Editors
Michael Gibbs, MD Lead Editor, CMC Imaging Mastery Project
February 2022

2. Process and Disclosures
This ongoing pediatric chest x-ray
interpretation series is proudly sponsored
by the Emergency Medicine Residency
Program and Pediatric Emergency Medicine
Fellowship at Carolinas Medical Center.
The goal is to promote widespread mastery
of CXR interpretation.
Cases are submitted by contributors from
many CMC departments.
Ages have been changed to protect patient
confidentiality. No protected health
information (PHI) will be shared.
For more educational content, visit
EMGuidewire.com

3. Reading systematically…
A for airway
B for bones
C for cardiac silhouette
D for diaphragm
E for everything else
For more educational content, visit
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4. Normal CXR
for your
reference

5. CASE 1 (REVIEW): 3-year-old male
with HbSS disease who presents for
two days of cough, congestion,
and increased work of
breathing. Room air saturations are
in the 80s and he is tachypneic,
grunting, and having intercostal
retractions.
Interpret this chest x-ray.

6. CASE 1 (REVIEW): 3-year-old male
with HbSS disease who presents for
two days of cough, congestion, and
increased work of breathing. Room
air saturations are in the 80s and he
is tachypneic, grunting, and having
intercostal retractions.
Bilateral opacities, right > left with air
bronchograms. Moderate right sided
pleural effusion. Overlying high flow nasal
cannula.
DDx: pulmonary edema, multifocal
pneumonia

7. CASE 1 (REVIEW): 3-year-old male
with HbSS disease who presents for
two days of cough, congestion, and
increased work of breathing. Room
air saturations are in the 80s and he
is tachypneic, grunting, and having
intercostal retractions.
Placed on high flow nasal cannula, given
antibiotics, and admitted to the
pediatric ICU.
Final Dx: Acute chest syndrome

8. CASE 2: A 7-year-old female
presents following a motor vehicle
accident with hypoxia and labored
breathing.
How do you review a CXR in trauma?

9. Interpreting CXR in Trauma
Airway: Look for tracheal deviation
Bones: Are there rib fractures?
Check the scapula, clavicle, sternum,
and spine for fractures. Examine the
acromioclavicular, sternoclavicular,
and glenohumeral joints. Is there a
visible humerus fracture?
Cardiac: Is the cardiac silhouette
enlarged. Is there mediastinal air or
a widened mediastinum? Is there a
continuous diaphragm sign?

10. Interpreting CXR in Trauma (cont)
Diaphragm: Are the costophrenic
angles blunted? Is the diaphragm
elevated or irregular? Are there
abdominal organs or an NG tube in
the chest? Is there free air under
the diaphragm?
Everything Else/Lung Fields:
Evaluate lung markings for
pneumothorax. Is there
subcutaneous air? Is there a
hemothorax? Is there a deep sulcus
sign? Is there a pulmonary
contusion. Are their foreign bodies?
Are tubes properly positioned?

11. CASE 2: A 7-year-old female
presents following a motor vehicle
accident with hypoxia and labored
breathing.
Back to our case. What do you see?

12. CASE 2: A 7-year-old female
presents following a motor vehicle
accident with hypoxia and labored
breathing.
-Trachea midline
-No apparent rib fractures or other
bony injuries
-Difficult to assess cardiac silhouette
-Blunting of costophrenic angle on
right
-Low lung volumes bilaterally
What’s happening on the left?

13. CASE 2: A 7-year-old female
presents following a motor vehicle
accident with hypoxia and labored
breathing.
Formal radiology impression: “Low
lung volumes bilaterally, left sided
moderate pleural effusion”
In the setting of trauma, differential
includes hemothorax and
diaphragmatic injury. A CT was
ordered to further evaluate.

14. CASE 2: A 7-year-old female
presents following a motor vehicle
accident with hypoxia and labored
breathing.
CT demonstrates rupture of the left
hemidiaphragm with herniation of
the stomach, the spleen, tail of the
pancreas and the splenic flexure of
the colon into the left chest.
Final Dx: Traumatic diaphragmatic
rupture

15. Marzona F, Parri N, Nocerino A, Giacalone M, Valentini E, Masi S, Bussolin L. Traumatic
diaphragmatic rupture in pediatric age: review of the literature. Eur J Trauma Emerg Surg.
2019 Feb;45(1):49-58. doi: 10.1007/s00068-016-0737-7. Epub 2016 Oct 21. PMID: 27770153.
Traumatic Diaphragmatic Rupture in Pediatric Patients
-Rare (≈3), and most frequently with blunt trauma
-Left>>right (liver “protects” right diaphragm)
-Twice as frequent in male patients
-Associated with other injuries in about 70% of cases
-Usually presents with respiratory symptoms, abdominal
symptoms are delayed and less common than in adult
patients
-Delayed diagnosis in children more common than in adults
-CXR provides important clues, CT the definitive study
-Treatment is surgical repair (open > laparoscopic)

16. Case 3 (from Nov 2020 Case Series):
4-year-old male brought to the ED
after high-speed ATV accident.
During EMS transport, he arrested
and EMS initiated CPR.
What lines and tubes (and device)
do you see?

17. Case 3 (from Nov 2020 Case Series):
4-year-old male brought to the ED
after high-speed ATV accident.
During EMS transport, he arrested
and EMS initiated CPR.
What lines and tubes (and device)
do you see?
ET tube
OG tube
Large-bore
chest tube
Medium-bore
chest tube
EKG lead
Phased array
ultrasound
probe for
EFAST exam

18. Case 3 (from Nov 2020 Case Series):
4-year-old male brought to the ED
after high-speed ATV accident.
During EMS transport, he arrested
and EMS initiated CPR.
The patient has a repeat x-ray
performed. What new injury is
visible?

19. Case 3 (from Nov 2020 Case Series):
4-year-old male brought to the ED
after high-speed ATV accident.
During EMS transport, he arrested
and EMS initiated CPR.
The patient has a cervical
distraction injury. Can you tell what
level it is at?

20. Case 3 (from Nov 2020 Case Series):
4-year-old male brought to the ED
after high-speed ATV accident.
During EMS transport, he arrested
and EMS initiated CPR.
Find the vertebrae to which the first
ribs connect. That's the T1
vertebrae. Count upwards.
In this case,
T1 → C7 → C6 → Injury → C5.
T1
C7
C6
C5

21. CASE 4: A 16-year-old male presents
with chest wall pain and shortness
of breath after getting tackled
during a football game the evening
prior.
What do you see?

22. CASE 4: A 16-year-old male presents
with chest wall pain and shortness
of breath after getting tackled
during a football game the evening
prior.
- Trachea midline
- No visible fractures
- Normal cardiac silhouette,
narrow mediastinum
- Sharp costophrenic angles
- Lung markings do NOT extend all
the way out on right
Final Dx: Moderate to large Right
pneumothorax

23. CASE 4: A 16-year-old male presents
with chest wall pain and shortness
of breath after getting tackled
during a football game the evening
prior.
A right chest tube is placed. What do
you see?

24. CASE 4: A 16-year-old male presents
with chest wall pain and shortness
of breath after getting tackled
during a football game the evening
prior.
-Right side chest tube overlying the
right lateral mid-lung zone
-Small residual apical pneumothorax

25. CASE 5: A 17-year-old male
presents with multiple gunshot
wounds to the pelvis.
A pelvic x-ray is obtained. What do
you see?

26. CASE 5: A 17-year-old male
presents with multiple gunshot
wounds to the pelvis.
-No foreign bodies
-Fractures of the right posterior
ilium and right sacral ala
A CT abdomen and pelvis is
ordered.

27. CASE 5: A 17-year-old male
presents with multiple gunshot
wounds to the pelvis.
Fractures of the right iliac wing and
right sacral ala are seen on CT.

28. CASE 5: A 17-year-old male
presents with multiple gunshot
wounds to the pelvis.
What else do you see on this CT?

29. CASE 5: A 17-year-old male
presents with multiple gunshot
wounds to the pelvis.
-Moderate to large volume
hemoperitoneum with free air
The patient was taken to the OR
where he was found to have a rectal
injury with hemoperitoneum and a
Zone 3 retroperitoneal hematoma.
He remained intubated post-
operatively and was taken to the
PICU.

30. CASE 5: A 17-year-old male
presents with multiple gunshot
wounds to the pelvis.
The next day, the following CXR was
obtained. What do you see?

31. CASE 5: A 17-year-old male
presents with multiple gunshot
wounds to the pelvis.
-ETT in mid-trachea
-OG tube terminates in stomach
-Whiteout of right lung (atelectasis)
with rightward mediastinal shift
-No appreciable pneumothorax

32. CASE 5: A 17-year-old male
presents with multiple gunshot
wounds to the pelvis.
After failed conservative
management, a flexible
bronchoscopy was performed with
thick mucus with plugs at the right
mainstem bronchus and segmental
bronchi. Mucus was suction and
repeat x-ray is shown. What do you
see?

33. CASE 5: A 17-year-old male
presents with multiple gunshot
wounds to the pelvis.
-Stable ETT and OG tube placement
-Improved aeration of the right lung
-Persistent dependent pleural
effusion and basilar atelectasis
-Small left pleural effusion
The patient’s oxygenation improved
and he was subsequently extubated.

34. CASE 6: 3-year-old male with a
gunshot wound to the chest.
What do you see?

35. CASE 6: 3-year-old male with a
gunshot wound to the chest.
- Trachea midline
- Abnormality over left scapula
- Normal cardiac silhouette,
narrow mediastinum
- Sharp costophrenic angles
- Lung markings extend to
periphery
Final dx: Left scapula fracture

36. CASE 6: 3-year-old male with a
gunshot wound to the chest.
What additional information do you
see on this CT?

37. CASE 6: 3-year-old male with a
gunshot wound to the chest.
-Redemonstrated comminuted left
scapula fracture
-Subcutaneous air

38. CASE 6: 3-year-old male with a
gunshot wound to the chest.
What do you see on this CT view of
the same patient?

39. CASE 6: 3-year-old male with a
gunshot wound to the chest.
-Left grade I subclavian artery injury
-Left axillary hematoma
The patient was managed non-
operatively with aspirin.

40. CASE 7: 14-year-old female
presenting after motor vehicle
collision.
What do you see?

41. CASE 7: 14-year-old female
presenting after motor vehicle
collision.
- Trachea midline
- No visible fractures
- Normal cardiac silhouette,
narrow mediastinum
- Sharp costophrenic angles
- Lung markings extend to
periphery, but with hazy opacities
bilaterally
Final dx: Bilateral pulmonary
contusions

42. CASE 8: 6-year-old male pedestrian
struck by a vehicle with traumatic
arrest now with return of
spontaneous circulation.
What tubes and lines do you see?

43. CASE 8: 6-year-old male pedestrian
struck by a vehicle with traumatic
arrest now with return of
spontaneous circulation.
-Endotracheal tube
-Bilateral chest tubes
-Enteric tube

44. CASE 8: 6-year-old male pedestrian
struck by a vehicle with traumatic
arrest now with return of
spontaneous circulation.
Where are the chest tubes and what
else do you see on this CT?

45. CASE 8: 6-year-old male pedestrian
struck by a vehicle with traumatic
arrest now with return of
spontaneous circulation.
-Pulmonary contusions
-Right chest tube in posterior chest
wall soft tissue
-Left chest tube is intrapulmonary

46. CASE 8: 6-year-old male pedestrian
struck by a vehicle with traumatic
arrest now with return of
spontaneous circulation.
What do you see on this pelvis x-
ray?

47. CASE 8: 6-year-old male pedestrian
struck by a vehicle with traumatic
arrest now with return of
spontaneous circulation.
-Left femur fracture
-Left pubic body fracture

48. CASE 9: 12-year-old male who
presented for feeling like something
was stuck in his throat after eating.
What do you see on this lateral film?

49. CASE 9: 12-year-old male who
presented for feeling like something
was stuck in his throat after eating.
-Linear gas along the prevertebral
soft tissues

50. CASE 9: 12-year-old male who
presented for feeling like something
was stuck in his throat after eating.
What do you see on this CT?

51. CASE 9: 12-year-old male who
presented for feeling like something
was stuck in his throat after eating.
-Pneumomediastinum
The patient was admitted for IV
antibiotics and did not require
surgical intervention.

52. CASE 10: 5-month-old male status
post left lower lobectomy four days
prior now presenting for fussiness
and swelling at prior chest tube site.
What do you see?

53. CASE 10: 5-month-old male status
post left lower lobectomy four days
prior now presenting for fussiness
and swelling at prior chest tube site.
-Subcutaneous emphysema
-Lucency at left lung base, which the
radiologist notes is possible due to
postoperative change, but cannot
exclude small pneumothorax.
The patient was admitted and
monitored with serial chest x-rays.

54. CASE 10: 5-month-old male status
post left lower lobectomy four days
prior now presenting for fussiness
and swelling at prior chest tube site.
This is his chest x-ray the following
morning. What do you see now?

55. CASE 10: 5-month-old male status
post left lower lobectomy four days
prior now presenting for fussiness
and swelling at prior chest tube site.
-Worsening subcutaneous
emphysema
-Deepening of the left costophrenic
angle and flattening of the left
hemidiaphragm

56. CASE 10: 5-month-old male status
post left lower lobectomy four days
prior now presenting for fussiness
and swelling at prior chest tube site.
This chest x-ray was performed later
the same day. Vital signs were
stable. What do you see now?

57. CASE 10: 5-month-old male status
post left lower lobectomy four days
prior now presenting for fussiness
and swelling at prior chest tube site.
-Left-sided pneumothorax
-Worsening subcutaneous
emphysema
-Tracheal deviation to the right
Final dx: Left-sided pneumothorax
with radiographic signs of tension
Note: Tension pneumothorax is a
clinical diagnosis and patient’s vitals
did not reflect tension physiology

58. CASE 10: 5-month-old male status
post left lower lobectomy four days
prior now presenting for fussiness
and swelling at prior chest tube site.
The patient was taken to the OR
for thoracoscopy which showed
leakage from the left mainstem
bronchus. The leak was fixed with
suture ligation and a chest tube
was placed.

59. CASE 10: 5-month-old male status
post left lower lobectomy four days
prior now presenting for fussiness
and swelling at prior chest tube site.
This chest x-ray was performed post-
operatively. What do you see?

60. CASE 10: 5-month-old male status
post left lower lobectomy four days
prior now presenting for fussiness
and swelling at prior chest tube site.
-Resolution of left pneumothorax
-Left chest tube
-Persistent subcutaneous
emphysema

61. CASE 10: 5-month-old male status
post left lower lobectomy four days
prior now presenting for fussiness
and swelling at prior chest tube site.
-Chest tube removed
-No pneumothorax
-Persistent subcutaneous
emphysema

62. CASE 11: 4-year-old female with pre
B-ALL complicated by respiratory
failure.
What tubes and lines do you see?

63. CASE 9: 4-year-old female with pre
B-ALL complicated by respiratory
failure.
-Right internal jugular central
venous catheter
-Left internal jugular central venous
catheter
-Right peripherally inserted central
catheter
-Tracheostomy cannula
-Enteric tube

64. Summary of This Month’s
Diagnoses
• Acute chest syndrome (review)
• Traumatic diaphragmatic hernia
• Cervical distraction injury
• Traumatic pneumothorax
• Pelvic fractures from GSW
• Lung whiteout from mucous plug
• Scapula fracture and subclavian artery
injury from GSW
• Pulmonary contusions
• Pneumomediastinum
• Post-op pneumothorax
• Pulmonary contusions, femur fracture,
and pelvic fractures
• Lines and tubes practice
For more educational content, visit
EMGuidewire.com