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: Tetralogy of Fallot, Pneumonia, Bronchiolitis, Esophageal Foreign Body, Pneumothorax, ECMO

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
August 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 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. It’s All About The Anatomy!

6. 5 year old female transferred from Mission
Hospital presented to our hospital for evaluation
of septic shock in the setting of Methicillin-
Susceptible Staphylococcus aureus bacteremia.
Per outside hospital report, the patient had been
seen in various outside hospital emergency
departments 3-4 times in the week leading up to
her hospitalization with complaints of abdominal
pain and rash

7. 5 year old female transferred from Mission
Hospital presented to our hospital for evaluation
of septic shock in the setting of Methicillin-
Susceptible Staphylococcus aureus bacteremia.
Per outside hospital report, the patient had been
seen in various outside hospital emergency
departments 3-4 times in the week leading up to
her hospitalization with complaints of abdominal
pain and rash
On arrival to our hospital, a chest x-ray was
obtained which shows diffuse patchy infiltrates,
small right pleural effusion, and L pigtail chest
tube with resolution of prior left sided
pneumothorax

8. Initial Chest
X-Ray

9. Right pleural effusion
Pigtail
Diffuse patchy infiltrates
bilaterally
Dx: ARDS
Initial Chest
X-Ray

10. Upon arrival, the patient was noted
to be persistently hypoxic despite
maximum ventilator settings and
persistently hypotensive despite
multiple vasopressors
(norepinephrine, epinephrine,
vasopressin, angiotensin) thus
decision was made to place the
patient on ECMO
Dx: Successful ECMO cannulation,
worsening airspace disease

11. Day 1 of Extracorporeal Membrane
Oxygenation (ECMO) with very poor
lung aeration

12. Day 2 of Extracorporeal Membrane
Oxygenation (ECMO) with improved
lung aeration bilaterally

13. Patient was noted to have decreasing
oxygen saturations after she was
lifted to change her bedding. STAT
chest x-ray obtained

14. Patient was noted to have decreasing
oxygen saturations after she was
lifted to change her bedding. STAT
chest x-ray obtained
Dx: Spontaneous R pneumothorax

15. Post procedural chest x-ray shows
adequate lung re-expansion after
pigtail chest tube placement.

16. 2-year-old female presented to the emergency
department with fever, non-productive cough,
and upper respiratory tract symptoms
CXR shows prominent perihilar
streaky opacities
Dx: Viral Process

17. 2-year-old female presented to the
emergency department for
evaluation of shortness of breath
RR 36, SpO2 94% on RA
Physical Exam: Corse rhonchi
bilaterally, +tachypnea, nasal flaring

18. 2-year-old female presented to the
emergency department for
evaluation of shortness of breath
RR 36, SpO2 94% on RA
CXR shows perihilar bronchial wall
thickening
Dx: Bronchiolitis
Work of breathing improved with
high flow nasal canula
Physical Exam: Corse rhonchi
bilaterally, +tachypnea, nasal flaring

19. 6 year old boy presented with throat
pain, drooling and raspy voice.
Respiratory Rate: 18
SpO2: 100%

20. 6 year old boy presented with throat
pain, drooling and raspy voice.
Respiratory Rate: 18
SpO2: 100%
Later reported he was throwing a
quarter up in the air and catching it
in his mouth…
Dx: Esophageal Foreign Body

21. 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-
Remember
from April….

22. 1 year old hospitalized patient
presented with tachypnea and
increased work of breathing

23. 1 year old hospitalized patient
presented with tachypnea and
increased work of breathing
Dx: Spontaneous left upper lobe
collapse

24. History: 4 year old female presented with 3 days of generalized abdominal pain,
fever, nausea and vomiting.
Physical Exam:
Vital signs: Temperature 101.8, HR 169 bpm, RR 26, SpO2 100%, BP 129/86
Lungs: Clear to auscultation bilaterally. Non-labored respirations
Abdomen: Firm, tender to palpation diffusely with severe tenderness in the right
lower quadrant. Voluntary and involuntary guarding noted. Pain worse with any
movement of the bed or patient
Laboratory Evaluation:
WBC: 21.3, neutrophil count 16.68
CRP: 11.9
Imaging obtained:
RLQ ultrasound: A noncompressible, tubular structure measuring up to 7mm in
diameter seen in the right lower quadrant with increased flow within the wall.
Suggestive of acute appendicitis.

25. Patient seen by pediatric surgery
with concern for acute appendicitis.
Patient taken to the operating room
where a normal, non-inflamed
appendix was identified.
Dx: Left Lower Lobe Community
Acquired Pneumonia
Post-procedural chest X-ray was
obtained for further evaluation of
symptoms.

27. Pediatric Appendicitis
• Scoring systems for pediatric
appendicitis include the Alvarado
score and the Pediatric Appendicitis
Score
• When utilizing scoring systems, it is
important to take into account pre-
test probability.
• In a systemic review of the literature
comparing these scoring systems, the
determined pre-test probability from
the literature was noted to be 33% for
children
• At a pre-test probability of 33%,
likelihood ratios for the Alvarado score
were as follows: 0.02 (<4 points), 0.27
(4 to 6 points), and 4.2 (≥ 7 points);
and 0.04 (<5 points) and for the
Pediatric Appendicitis Score,
likelihood ratios were 0.13 (<4 points),
0.70 (4 to 7 points), and 8.1 (≥ 8
points).Ebell MH1, Shinholser J2. What Are the Most Clinically Useful Cutoffs for the Alvarado
and Pediatric Appendicitis Scores? A Systematic Review. Ann Emerg Med.
2014 Oct;64(4):365-372.

28. Remember, not all scoring systems are perfect…
• For our patient, his PAS score was 9 (likely appendicitis) and his Alvarado score
was 9 (indicative of appendicitis).
• Early involvement of pediatric surgeons prior to imaging is recommended
when appendicitis is highly suspected based on clinical decision scoring
system or clinical gestalt
• The best imaging modality continues to be debated. When unperforated
appendicitis is suspected, the American College of Radiology recommends
initial use of US imaging, with CT (versus MR) reserved for equivocal US
findings1.
• A large retrospective, single-center study of 1982 children revealed the
sensitivity of unequivocal US to be 98.7% with a positive predictive value of
89.8%, and specificity of 97.1%, with a negative predictive value of 99.7%2.
• As seen in this case, no imaging modality or clinical decision tool is perfect.
Don’t forget your differential diagnosis!
1. Smith MP, Katz DS, Lalani T et al. ACR appropriateness criteria right lower quadrant pain: suspected appendicitis. Ultrasound 2015;31(2):85–91.
2. Dibble EH, Swenson DW, Cartagena C, Baird GL, Herliczek TW. Effectiveness of a staged US and unenhanced MR imaging algorithm in the diagnosis of pediatric
appendicitis. Radiology 2018;286(3):1022–1029.

29. 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
colleagues in the pediatric cardiovascular surgery department. We thank
you for your continued support of this project!

30. 4 month old male who initially presented from outside
hospital due to murmur heard at birth. Birth history
notable for small for gestational age (SGA), weighing
2.1kg at 38 weeks gestation. No respiratory distress or
feeding difficulties noted.
Physical exam notable for a long 3/6 systolic ejection
murmur at the base which radiates to the back. 2+
femoral pulses bilaterally.

31. 5 month old female who initially presented from
immediately after birth due to abnormal prenatal
echocardiogram. Patient noted to be SGA (2.7 kg at term
birth) with no respiratory distress or feeding difficulties
noted.
Physical exam notable for a 3/6 low frequency systolic
ejection murmur at the left sternal boarder

32. 3 day old born at full term presented for hypoxia. Initial
O2 saturations noted to be 75-80% however these
decreased to 65-70%
No murmurs noted on physical exam. PGE-1 was initiated
which resulted in improvement in O2 saturations.

33. 3 month old female presented with
abnormal prenatal echocardiogram.
Oxygen saturations reported to be in
the high 80s-low 90s. No reported
issues with feeding difficulties or
increased work of breathing, however
parents did note that the child
occasionally turns blue when she cries.
Physical exam notable for high pitched
grade 2-3/6 crescendo-decrescendo
systolic murmur at the mid to upper
left sternal border.

34. 1 day old male born at 37 + 6 weeks
gestational age via stat c-section for
fetal bradycardia presented for
respiratory distress. Initial APGARs 4
and 8. Immediately after birth the
patient was noted to be in respiratory
distress initially requiring PPV and
later requiring intubation. An
echocardiogram was obtained and the
patient was started on PGE-1
Physical exam notable for grade 2/6
harsh systolic ejection murmur at the
left upper sternal boarder.

35. 6 week old female who presented for abnormal prenatal
echocardiogram. O2 sats noted to be in the mid 80s since
birth. She has been steadily gaining weight and has had
no difficulty breathing, cyanosis, or sweating with feeds.
Physical exam notable for a 2/6 systolic ejection murmur
at the left upper sternal boarder

36. So, What’s With These Kids??

37. Tetralogy of Fallot
Symptoms vary depending on the degree of
right ventricular outflow obstruction. The
degree of right ventricular outflow tract
obstruction is progressive over time and
worsens with exertion.
• P – Pulmonary stenosis
• R – Right ventricular hypertrophy
• O – Overriding Aorta
• V – Ventricular Septal Defect

38. Tet Spells
• AKA Hypercyanotic spells
• These “spells” do not only occur in patients
with Tetralogy of Fallot. They can occur in any
cyanotic heart lesions with a VSD and
decreased pulmonary blood flow
• Spells occur due to decreased pulmonary blood
flow, which may be caused by either decreased
systemic vascular resistance or increased
pulmonary vascular resistance
• Remember that decreased afterload/preload leads
to decreased systemic vascular resistance and thus
these factors also contribute to “spells”
• Hypoxia increases pulmonary vascular
resistance, which then further perpetuates the
problem
https://pedemmorsels.com/hypercyanotic-spells/

39. Tet Spells
• Spells are often precipitated by:
• Crying
• Defecation
• Feeding
• Treatment of Spells
• Calm the child
• Knees to chest position to increase preload and
systemic vascular resistance
• Medications
• Oxygen – decreases PVR
• Analgesic – morphine, ketamine to decrease PVR
• Fluid – Improves preload
• Beta Blockers – Propranolol and esmolol are thought to
decrease infundibular obstruction as well as decreasing
heart rate leading to greater diastolic filling
• Phenylephrine – increases SVR. Avoid epinephrine and
isoproterenol as these decrease SVR
• Fever
• Dehydration
• Tachycardia
Increasing SVR and decreasing PVR
decreases the right to left shunting
which limits the flow of de-oxygenated
blood into systemic circulation.
https://pedemmorsels.com/hypercyanotic-spells/
Drawing depicts the pattern of blood flow (arrows) with
the characteristic ventricular septal defect (1),
infundibular pulmonary stenosis (2), overriding aorta
(3), and right ventricular hypertrophy (4). The oxygen-
rich blood in the left side of the heart (5) mixes with
oxygen-poor blood in the right side of the heart (6)
before it proceeds to the aorta (7).

40. Chest X-Ray Characteristics
• The heart has the shape of a wooden shoe or boot, which is due to uplifting of the cardiac apex because of right
ventricular hypertrophy and concavity of the main pulmonary artery
• The shadow of the pulmonary arterial trunk is almost invariably absent, and blood flow to the lungs is usually
reduced
• The right ventricular infundibulum often forms a slight bulge in the upper left heart border, while the middle left
heart border is usually concave
• Approximately 25% of those affected by tetralogy of Fallot have a right-sided aortic arch
• The most common imaging finding is an upturned cardiac apex. This deformity becomes more pronounced as the
right ventricular outflow tract obstruction becomes more severe
Ferguson E, Krishnamurthy R, Oldham S. Classic Imaging Signs of Congenital Cardiovascular Abnormalities. Radiographics 2007; 27: 1323-1334