Drs. Olson and Jackson 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: • Tension pneumothorax • MIS-C • Fungal Pneumonia • Systemic JIA • Large Pericardial Effusion • Post-obstructive Pulmonary Edema • Normal Thymus • Pneumonia

1. Pediatric Chest X-Rays of the Month
Kendra Jackson, MD & Elizabeth Olson, MD
Departments of Pediatrics & Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Nicholena Richardson, MD & Mary Grady, MD, Faculty Editors
Michael Gibbs, MD, Senior Editor
Chest X-Ray Mastery Project
April 2021

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, and now…
Tanzania and Brazil.
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
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4. Normal CXR
for your
reference

5. 15-year-old male with CF,
interstitial lung disease,
and multiple central line
infections presents in
respiratory distress and is
emergently intubated
Vitals:
97.7 108 61/35 RR 24
Diagnosis?
Review

6. 15-year-old male with CF,
interstitial lung disease,
and multiple central line
infections presents in
respiratory distress and is
emergently intubated
Vitals:
97.7 108 61/35 RR 24
R. Tension Pneumothorax
Review

7. • Tracheal deviation
• Left pleural effusion
• Right pneumothorax
• “Deep Sulcus Sign”
A tension pneumothorax
is life-threatening and if
clinically suspected, it
should be treated with
needle decompression
before a chest X-ray is
obtained.

8. 10-year-old previously
healthy male presents with
fever, diarrhea, tachycardia
and hypotension
What’s the X-ray finding?

9. Remember Your ABCs
Airway:
Bone:
Cardiac:
Diaphragm:
Effusions:
Fields/Foreign Bodies:
Gastric bubble:
Hila:

10. Remember Your ABCs
Airway: Patent, midline
Bone: No fractures
Cardiac: Normal silhouette
Diaphragm: Symmetric
Effusions: None
Fields/Foreign Bodies:
Clear lung fields
Gastric bubble: Normal
Hila: No lymphadenopathy

11. ED Course: tachycardia and
hypotension are
unresponsive to fluids.
POCUS1 reveals moderately
depressed cardiac function.
Leading Diagnosis?
1POCUS = Point-Of-Care-Ultrasound

12. Diagnosis: Multisystem
Inflammatory Syndrome in
Children (MIS-C)
Clinical pearl: a negative
chest X-ray does not rule
out this diagnosis.

13. 15-year-old male with CF,
nocturnal BiPaP, and TPN
dependence presents with
fatigue, malaise, and sore
throat
Interpret this CXR

14. Airway: Patent
Bone: Normal
Cardiac: Normal
Diaphragm: L lower than R
Effusions: None
Fields/Foreign Bodies: RLL
consolidation. Central line
present in the R atrium
Gastric bubble: Present
Hila: Stable

15. Our 15-year-old was
admitted, respiratory and
blood cultures were
obtained, and he was start
on cefepime and
fluconazole. He developed
increased WOB on the floor
Diagnosis?

16. Blood cultures were [+]
for Candida
Diagnosis: fungemia
Don’t forget your fungal
coverage for kiddos on
TPN!

17. 5-year-old male
presenting with
respiratory distress in the
setting of joint pain,
fatigue, and fever for two
weeks
Spot the abnormality

18. 5-year-old male
presenting with
respiratory distress in the
setting of joint pain,
fatigue, and fever for two
weeks
CXR interpretation:
Mild cardiomegaly

19. After 48 hours in the
hospital our 5-year-old
now develops hypotension
and distant heart sounds
Spot the abnormality

20. Our 5-year-old has been
admitted for 48 hours and
develops hypotension and
distant heart sounds
Holy moly guacamole…
that’s cardiomegaly!

21. Diagnosis?
Cardiac tamponade until
proven otherwise

22. Hospital course:
• Ileitis seen incidentally
on hip MRI
• Blood cultures [-]
• Ferritin of 2000
• ESR 50, CRP 10
• Torso rash develops
Ultimate Diagnosis?

23. Hospital course:
• Ileitis seen incidentally
on hip MRI
• Blood cultures [-]
• Ferritin of 2000
• ESR 50, CRP 10
• Torso rash develops
Systemic JIA

24. Pediatric Rheumatology Pearls
A family history is key
Check the joints! Know the pGALS exam? AKA Pediatric
Gait, Arms, Legs, and Spine
Stiff joints in kiddos = not normal
Stiffness better with exercise?
Fever timing – persistent despite infectious work up,
morning or nighttime (when serum cortisol is naturally
the lowest)

25. Foster, H.E., Jandial, S. pGALS – paediatric Gait Arms Legs and Spine

26. Pediatric Rheumatology Pearls
Foster, H.E., Jandial, S. pGALS – paediatric Gait Arms Legs and Spine: a simple examination of the musculoskeletal
system. Pediatr Rheumatol 11, 44 (2013). https://doi.org/10.1186/1546-0096-11-44

27. 12-year-old presents after
a strangulation event
Spot the abnormality

28. 12-year-old presents after
a strangulation event
CXR Interpretation:
Clear lung fields. ET tube
at T-3, half-way between
carina and the thoracic
outlet

29. The patient later
developed high peak
pressures and desaturates
on the ventilator. Pink
froth in the ET tube.
What is this clinical
phenomena?

30. The patient later
developed high peak
pressures and desaturates
on the ventilator. Pink
froth in the ET tube.
Post-obstructive
pulmonary edema
Physiology?

31. Negative-Pressure Pulmonary Edema
CHEST 2016 150927-933DOI: (10.1016/j.chest.2016.03.043)
Attempts to inhale against an
upper airway obstruction
leads to extreme negative
intrathoracic pressures
This leads to ↑ RV preload
and afterload, then higher
pulmonary venous pressures
This ↑ capillary hydrostatic
pressures, causing leaking
into the alveolar space

32. On hospital day 2 in the
PICU, our 12-year-old
developed low tidal
volumes and hypoxia
Spot the abnormality

33. On hospital day 2 in the
PICU, our 12-year-old
developed low tidal
volumes and hypoxia
Bilateral pneumothoraces

34. Bilateral chest tubes were
placed
Identify the radiographic
findings

35. Remember your ABCs
Airway: ETT @ T3
Bone: No fractures
Cardiac: Normal Silhouette
Diaphragm: R>L
Effusions: Unclear, CXR does not
visualize
Fields/Foreign Bodies: Diffuse
bilateral haziness, NG tube, 2
pigtails, central line in R atrium
Gastric bubble: Difficult to
assess
Hila: Difficult to assess

36. 3-year-old girl presents
after falling on a hunting
knife at home
Spot the abnormality

37. 3-year-old girl presents
after falling on a hunting
knife at home
Subcutaneous air present
Note: Lung herniation on
exam

38. Radiology Interpretation: No
focal consolidation, pleural
effusion or pneumothorax.
Cardiomediastinal morphology
is normal. Osseous structures
are unremarkable.
“No acute cardiopulmonary
abnormality.”
Lesson: read your own films!
Also.. don’t forget to consult
Social Work and the Child
Protection Team to rule out
non-accidental trauma (NAT).

39. 7-month-old female seen three times for nasal congestion and wheezing presenting again one month
later with respiratory distress.
Interpret the CXR

40. Clear lung field with no hyperinflation.
Normal thymus
7-month-old female seen three times for nasal congestion and wheezing presenting again one month
later with respiratory distress.

41. 8-month-old girl who was
recently admitted for viral
bronchiolitis 2 weeks ago
presents in respiratory
distress
Spot the abnormality

42. 8-month-old girl who was
recently admitted for viral
bronchiolitis presents in
respiratory distress
Right upper load
consolidation with air
bronchogram

43. Our 8-month-old girl was
re-admitted to the PICU
and received one dose of
ampicillin
Interpret the chest X-ray

44. Our 8-month-old girl was
re-admitted to the PICU
and and received one dose
of ampicillin. Of note, Dad
has a history of severe
asthma. The infant is
responsive to albuterol.
Perihilar thickening with
hyperinflation

45. Our 8-month-old girl was
re-admitted to the PICU
and got x1 dose of
ampicillin. Of note, Dad
has a history of severe
asthma. The infant is
responsive to albuterol
What is the most likely
diagnosis?

46. Our 8-month-old girl was
re-admitted to the PICU
and got x1 dose of
ampicillin. Of note, Dad
has a history of severe
asthma. The infant is
responsive to albuterol
The clinical diagnosis is
most consistent with
asthma, triggered by a URI

47. Summary of This Month’s
Diagnoses
• Tension pneumothorax with deep sulcus
sign (Review)
• Normal CXR, MISC
• Fungal pneumonia
• Systemic JIA with large pericardial effusion
• Post-obstructive pulmonary edema
• Subcutaneous air and lung herniation
• Thymus appropriate for age
• RUL infiltrated with air bronchograms
• Perihilar thickening and hyperinflation (in
newly diagnosed asthma)
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