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Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery August Cases

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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

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Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery August Cases

  1. 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. 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 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. 4. It’s All About The Anatomy!
  5. 5. 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
  6. 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 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
  7. 7. Initial Chest X-Ray
  8. 8. Right pleural effusion Pigtail Diffuse patchy infiltrates bilaterally Dx: ARDS Initial Chest X-Ray
  9. 9. 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
  10. 10. Day 1 of Extracorporeal Membrane Oxygenation (ECMO) with very poor lung aeration
  11. 11. Day 2 of Extracorporeal Membrane Oxygenation (ECMO) with improved lung aeration bilaterally
  12. 12. Patient was noted to have decreasing oxygen saturations after she was lifted to change her bedding. STAT chest x-ray obtained
  13. 13. 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
  14. 14. Post procedural chest x-ray shows adequate lung re-expansion after pigtail chest tube placement.
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 6 year old boy presented with throat pain, drooling and raspy voice. Respiratory Rate: 18 SpO2: 100%
  19. 19. 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
  20. 20. 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….
  21. 21. 1 year old hospitalized patient presented with tachypnea and increased work of breathing
  22. 22. 1 year old hospitalized patient presented with tachypnea and increased work of breathing Dx: Spontaneous left upper lobe collapse
  23. 23. 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.
  24. 24. 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.
  25. 25. 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.
  26. 26. 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.
  27. 27. 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!
  28. 28. 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.
  29. 29. 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
  30. 30. 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.
  31. 31. 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.
  32. 32. 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.
  33. 33. 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
  34. 34. So, What’s With These Kids??
  35. 35. 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
  36. 36. 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/
  37. 37. 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).
  38. 38. 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

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