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

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. 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. Normal CXR
For Your
Reference

5. 2 Month Old With
Respiratory Distress

6. Bowel In
The Chest
Diaphragmatic Hernia
2 Month Old With
Respiratory Distress

7. 5 Year Old With Fever,
Cough, And Tachypnea
RUL Collapse & RLL Necrotizing Pneumonia

8. RUL Collapse & RLL Necrotizing Pneumonia
5 Year Old With Fever, Cough, And Tachypnea

9. 9 Year Old Presents To An
Urgent Care Center With
URI Symptoms

10. Pneumomediastinum
9 Year Old Presents To An
Urgent Care Center With
URI Symptoms

11. 9 yo presents to urgent care with URI symptoms
Pneumomediastinum

12. Healthy 13 year old with throat and upper chest pain

13. Healthy 13 Year Old With Throat & Upper Chest Pain
Pneumomediastinum & Pneumopericardium

14. Healthy 13 Year Old With Throat & Upper Chest Pain
Pneumomediastinum & Pneumopericardium

15. Healthy 13 Year Old With Throat & Upper Chest Pain
Pneumomediastinum & Pneumopericardium

16. 6 Month Old S/P Difficult
Intubation In The OR

17. Right Mainstem Intubation & Left Lung Collapse
6 Month Old S/P Difficult
Intubation In The OR

18. CASE #1
11 day old born at full term
with 2 days of progressive
respiratory distress, grunting
and decreased PO intake

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. CASE #2
5 day old full term
found to have a heart
murmur after delivery

21. CASE #2
5 day old full term
found to have a heart
murmur after delivery
Coarctation Of The Aorta

22. Coarctation Of The Aorta (CoA)
EARLY is detection is IMPORTANT!!
Late repair of CoA is associated with increased CAD
in early adulthood.

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. 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. 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. 3 Year Old With
Cough That Initially
Improved However
Worsened Again 4
Days Prior To ED Visit

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. 3 Year Old With
Cough That Initially
Improved However
Worsened Again 4
Days Prior To ED Visit

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. 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. 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. 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