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Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery week 1

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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!

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Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery week 1

  1. 1. Pediatric Chest X-Ray Case Studies Dr. Nikki Richardson and Dr. Jennifer Potter CMC Emergency Medicine Carolinas Medical Center and Levine Children’s Hospital
  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. It’s All About The Anatomy!
  5. 5. 3yo male with PMHx Down Syndrome and AV canal defect s/p repair presents with cough and fever
  6. 6. RML infiltrates
  7. 7. 3yo from urgent care with fever and vomiting
  8. 8. 3yo from urgent care with fever and vomiting LLL PNA
  9. 9. 2yo ex 33wk premie with fever x 7d, lethargy and decreased PO intake HR 190 Temp 105
  10. 10. 2yo ex 33wk premie with fever x 7d, lethargy and decreased PO intake HR 190 Temp 105 RUL PNA
  11. 11. 12mo seen out OSH 3d prior with CXR reported to show mild PNA and started on azithromycin, presents today with labored breathing, decreased responsiveness RR 55 SpO2 94% Complete opacification of the L hemithorax with rightward shift of mediastinal structures. DDX Consolidation with fluid collection versus soft tissue mass
  12. 12. 12mo seen out OSH 3d prior with CXR reported to show mild PNA and started on azithromycin, presents today with labored breathing, decreased responsiveness RR 55 SpO2 94% Complete opacification of the L hemithorax with rightward shift of mediastinal structures. DDX Consolidation with fluid collection versus soft tissue mass DX: Parapneumonic effusion with shift
  13. 13. 500 cc Of Purulent Chest Tube Output DX: Parapneumonic effusion with shift s/p pigtail thorocostomy with significant improvement in aeration
  14. 14. Healthy 5 Year Old Treated With Tamiflu For Flu Symptoms, Admitted With Pneumonia
  15. 15. Healthy 5 Year Old Treated With Tamiflu For Flu Symptoms, Admitted With Pneumonia HD #1: LLL Pneumonia
  16. 16. Healthy 5 Year Old Admitted With Pneumonia
  17. 17. Healthy 5 Year Old Admitted With Pneumonia HD #4: Chest Tube With Purulent Drainage
  18. 18. Healthy 5 Year Old Admitted With Pneumonia
  19. 19. Healthy 5 Year Old Admitted With Pneumonia HD #14: After Video Assisted Thoracoscopic Surgery [VATS] One Liter Of Pus Removed Pneumohydrothorax With Mediastinal Shift
  20. 20. Air-Fluid Level: If It’s Flat There’s Air In There!
  21. 21. Healthy 5 Year Old Admitted With Pneumonia HD #14: Pneumohydrothorax And Severe Pulmonary Necrosis/Trapped Lung (*) Discharged The Following Day On IV Antibiotics With Planned Follow-Up *
  22. 22. Pediatric Chest Tube Recommendations • Consider what is it you have to drain • Acute blood or air can easily be drained with a pigtail catheter • If it is expected to be viscous, you may need a small caliber thoracostomy tube, however Chien-Heng found no difference between drainage and hospitalization days when using a pigtail catheter versus thoracostomy tube for drainage of parapneumonic effusion1 • Be nice – anesthetize and sedate if needed • Be safe – Use a flexible tipped guidewire and US for guidance • Aim high – above 6th intercostal space 1. Lin, Chien-Heng, et al. “Comparison of Pigtail Catheter with Chest Tube for Drainage of Parapneumonic Effusion in Children.” Pediatrics and Neonatology, U.S. National Library of Medicine, Dec. 2011, www.ncbi.nlm.nih.gov/pubmed/22192262. Pediatric EM Morsles – PigTail Catheter
  23. 23. Cardiomegaly? 17mo previously healthy male presenting with 2wks URI symptoms. Clinically well appearing with stable VS 17yo female with PMHx T1DM presents with 2wks of LE edema + 17lbs weight gain
  24. 24. Cardiomegaly? CXR = Enlarged cardiothymic silhouette, normal pulmonary vascularity CXR = prominent cardiac silhouette with prominent vascular markings and patchy airspace opacities NO! Prominent thymus, appropriate for age YES!
  25. 25. Differentiating the Thymic Shadow “thymic sail sign” is a triangular extension of the normal thymus laterally The anterior reflections of the ribs produce a wavy contour of the thymus known as the “thymus wave sign” The inferior margin of the thymus merges with the margin of the cardiac silhouette, producing the “notch sign” Manchanda, Smita, et al. “Imaging of the Pediatric Thymus: Clinicoradiologic Approach.” World Journal of Clinical Pediatrics, Baishideng Publishing Group Inc, 8 Feb. 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5296624/.
  26. 26. CXR Formal Read: “Impression: Pulmonary vascular congestion without focal consolidation”
  27. 27. CXR Formal Read: “Impression: Pulmonary vascular congestion without focal consolidation” Review of imaging reveals fracture of pacer lead
  28. 28. 9 yo male with hx of ASD and ADHD presenting today after inhaling vs. swallowing a thumbtack
  29. 29. Plastic thumbtack noted in the right hilum region on CXR, discovered in the R mainstem bronchus on bronchoscopy
  30. 30. 16mo female presents with intermittent inspiratory stridor x 3 days after an episode of vomiting Case 1
  31. 31. Initial CXR = Hyperlucency and increase in volume of L lung when compared to R lung 16mo female presents with intermittent inspiratory stridor x 3 days after an episode of vomiting Case 1
  32. 32. 16mo male presents with 3 days of fever and wheezing Case 2
  33. 33. Initial CXR = No acute disease in the chest 16mo male presents with 3 days of fever and wheezing Case 2
  34. 34. Repeat CXR = Hyperinflation of R lung 16mo male presents with 3 days of fever and wheezing Case 2 – Repeat Imaging
  35. 35. Next Step?
  36. 36. Next Step? Lateral Decubitus Films
  37. 37. Next Step? • Bilateral decubitus lateral films allows assessment of air-trapping caused by an inhaled foreign body. The expectation is that the dependent lung will collapse partially in the normal patient. Where there is an obstructive foreign body there will be air-trapping and hyperlucency of the dependent lung so that the dependent lung is increased in volume or paradoxically normal in volume • BUT they are not perfect. A small retrospective study of 28 children who underwent bronchoscopy for suspected foreign body aspiration found that as a measure of detecting foreign body aspiration, positive decubitus radiographs had a sensitivity of 27%, a specificity of 67%, a positive predictive value of 75%, and a negative predictive value of 20% - this does not mean that lateral decubitus films should not be used, but shows the importance of use of imaging in conjunction with a good HISTORY and PHYSICAL EXAM!!!! Lateral Decubitus Films Assefa, Dagnachew, et al. “Use of Decubitus Radiographs in the Diagnosis of Foreign Body Aspiration in Young Children.” Pediatric Emergency Care, U.S. National Library of Medicine, Mar. 2007, www.ncbi.nlm.nih.gov/pubmed/17413429.
  38. 38. Case 1
  39. 39. R lateral decubitus film normalCase 1
  40. 40. R lateral decubitus film normalCase 1L lateral decubitus film = Relative Increase in volume of L lung, raising concern for obstructing foreign body in the L mainstem bronchus
  41. 41. L lateral decubitus film normalCase 2R lateral decubitus film = Relative Increase in volume of R lung, raising concern for obstructing foreign body in the R mainstem bronchus Pt proceed to OR for rigid bronchoscopy. Several peanut fragments found occluding the R bronchus intermedius
  42. 42. Airway Foreign Body
  43. 43. Airway Foreign Body Coin In The Esophagus
  44. 44. Airway Foreign Body
  45. 45. Coin In The Esophagus Airway Foreign Body
  46. 46. Airway Foreign Body
  47. 47. Coin In The Esophagus Airway Foreign Body
  48. 48. Airway Foreign Body
  49. 49. Button Battery In The Esophagus Airway Foreign Body
  50. 50. Adults Aspirate Things To!
  51. 51. Coin Vs. Button Battery • Why does it matter? • An electric current is generated when the battery comes in contact with mucosa, leading to localized burn injury. • If the alkaline battery leaks, corrosive injury and liquefactive necrosis can occur. This is more common with non-lithium batteries and is usually not the cause of tissue damage that is seen to occur within 2 hours. • The negative terminal, which is on the narrower side of the battery, generates hydroxide ions and is where necrosis occurs. This can be remembered as “narrow-negative-necrotic.” • Batteries lodged in the esophagus may cause serious burns in as little as 30 minutes and the patient might be asymptomatic initially. • Certain button batteries carry greater risk than others. Patients with lithium battery ingestions have worse outcomes, as these have the potential to generate a higher current than other batteries and cause greater damage. • A button battery in the esophagus is an emergency and should be removed within 2 hours AP/PA view – look for “halo sign” – a ring of radiolucency inside the outer edge of the object “TOXCard: Button Battery Ingestions.” EmDOCs.net - Emergency Medicine Education, 25 Feb. 2019, www.emdocs.net/toxcard-button-battery-
  52. 52. CXR are not only for pulmonary pathology 8mo present with fever and cough, CXR obtained to r/o infectious etiology. Lungs clear but… Healing R clavicle fx, birth trauma vs. NAT CXR obtained for trauma eval… R scapular fx

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