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Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery July 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: Retropharyngeal abscess, Metapneumovirus pneumonia requiring ECMO, Heart failure, Several cases of lobar pneumonia, Left mainstem placement of Dobhoff tube with pneumothorax, Mystery case from Tanzania!

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Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery July 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 July 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 Carolinas Medical Center departments, and now… Brazil, Chile and Tanzania.  Cases submitted this month will be distributed next month.  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. 9 month-old healthy female initially presented to an outside hospital ED due to fever and decreased oral intake in the setting of a recent diagnosis otitis media. Appeared well & was discharged Initial ED Diagnosis: Viral infection.
  6. 6. 9 month-old healthy female initially presented to an outside hospital ED due to fever and decreased oral intake in the setting of a recent diagnosis otitis media. Appeared well & was discharged Initial ED Diagnosis: Viral infection. She represented 1 day later to the same ED due to decreased oral intake and increased fussiness. He was noted to be febrile and tachypneic without hypoxia, ill appearing with decreased peripheral perfusion. Given 20cc/kg IVF bolus + high flow oxygen. Transferred to Charlotte. Working Diagnosis: Bronchiolitis.
  7. 7. At the Levine Children’s Hospital ED the patient was noted to be in respiratory distress with increased accessory muscle use, and grunting. The neck was swollen with enlarged lymph nodes and the patient resisted neck movement. She would not open her mouth, even to cry. Initial Imaging: chest X-ray and soft-tissue lateral neck X-ray.
  8. 8. At the Levine Children’s Hospital ED the patient was noted to be in respiratory distress with increased accessory muscle use, and grunting. The neck was swollen with enlarged lymph nodes and the patient resisted neck movement. She would not open her mouth, even to cry. Initial Imaging: chest X-ray and soft-tissue lateral neck X-ray.
  9. 9. Noted to have marked prevertebral tissue swelling of 2.5cm which partially narrows the subglottic airway putting thw patient at significant risk for airway compromise.
  10. 10. The patient was intubated prior to CT scan due to concern for airway compromise. CT shows a large retropharyngeal abscess 1.6cm x 7.3cm in AP diameter and 11.3cm in craniocaudal dimension.
  11. 11. The patient was intubated prior to CT scan due to concern for airway compromise. CT shows a large retropharyngeal abscess 1.6cm x 7.3cm in AP diameter and 11.3cm in craniocaudal dimension. Pt taken to the OR 6/16 with ENT and 6/17 with pediatric surgery for abscess I&D. Fluid cultures = MRSA. Pt extubated 6/26. Remains in PICU for respiratory support.
  12. 12. Retropharyngeal Abscesses [RPA] In Children • Typically occur in children <5yrs old, before retropharyngeal lymph tissue naturally atrophies. • If there is a high clinical suspicion for RPA, lateral neck X-rays may be obtained, but these do not completely rule out the disease. CT is the imaging modality of choice to evaluate the extent of the abscess. • It is recommended that AP and lateral CXRs are also obtained in children with suspected RPA to evaluate for complications including mediastinitis and aspiration pneumonia. • The differential diagnosis includes all conditions which cause upper airway obstruction, sore throat, and neck stiffness: epiglottitis, coup, bacterial tracheitis, peritonsillar abscess, uvulitis, diphtheria, trauma to the oropharynx (e.g.: burns, penetrating trauma, foreign body), and tumors (e.g.: lymphangioma, hemangioma) • Empiric antibiotics: ampicillin-sulbactam (50mg/kg q6hrs) OR clindamycin (15mg/kg q8hrs). In patients who fail to respond to initial treatment or have moderate to severe disease, it is recommended that vancomycin (40-60mg/kg/d divided TID-QID) or linezolid (30mg/kg/d divided TID) be added to cover resistant gram (+) cocci. UpToDate: Retropharyngeal Infections in Children
  13. 13. • In children < 5 years old, the retropharyngeal (RP) space normally measures ½ the width of the adjacent vertebral body and is considered widened if it is greater than a full vertebral body at C2 or C3 • The RP space is pathologically widened in children if it is greater than 7mm at C2 or 14mm at C6 C2/C3 > ½ width of vertebral body C2 > 7mm C6 > 14mm
  14. 14. 12 year-old previously healthy male presented to ED due to 2 days fever, nausea, vomiting. He then developed acute onset chest pain and dyspnea with ambulatory O2 saturations of 77% on room air. In the ED he was noted to have increased work of breathing. Initial CXR. Serum lactate >7.
  15. 15. 12 year-old previously healthy male presented to ED due to 2 days fever, nausea, vomiting. He then developed acute onset chest pain and dyspnea with ambulatory O2 saturations of 77% on room air. In the ED he was noted to have increased work of breathing. Initial CXR. Serum lactate >7. He remains hypoxic, requiring HFNC  BiPAP  intubation. Transferred to LCH Pediatric ICU.
  16. 16. On arrival to the PICU he is noted to be increasingly hypoxic and hypotension. Placed on 90% FiO2 and oscillator
  17. 17. On arrival to the PICU he is noted to be increasingly hypoxic and hypotension. Placed on 90% FiO2 and oscillator Second CXR on arrival demonstrates bilateral infiltrates
  18. 18. Emergently cannulated for ECMO Bronchoalveolar lavage reveals Human Metapneumovirus and Methacillin-Sensitive Staph Aureus [MSSA]
  19. 19. Repeat CXR prior to discharge shows significant improvement in consolidations Inpatient Course 4/17 Decannulated 4/22 Extubated 4/24 Transferred to floor 4/30 Discharged to rehab 5/8 Discharged home
  20. 20. 10 year old presented to ED with 3 days fever + cough after orthopedic foot surgery requiring intubation 5 days prior, Exam = right lung crackles VS: RR 24, Temp 99.9, O2 96%, HR 124
  21. 21. 10 year old presented to ED with 3 days fever + cough after orthopedic foot surgery requiring intubation 5 days prior, Exam = right lung crackles VS: RR 24, Temp 99.9, O2 96%, HR 124 Right Middle Lobe Pneumonia RML Infiltrate
  22. 22. DX: Severe constipation leading to respiratory distress 4 month old with PMHx significant for trisomy 13, ASD and VSD presented to the ED for evaluation of tachypnea and constipation. RR 67 Initial CXR: decreased lung volumes. No infiltrates identified. Abdominal XR: significant constipation with distension leading to decreased lung volumes
  23. 23. Readmitted days later for increased lethargy and apneic episodes CXR: Worsening cardiomegaly and air bronchograms consistent with pulmonary edema
  24. 24. 9 year old presented to Urgent Care Center with 2 days of cough and fever which developed approximately 1 week after a viral upper respiratory infection [URI] CXR: LLL PNA Discharged home with Rx Augmentin
  25. 25. Pt represented to ED 2 days later due to continued cough and increased WOB VS: HR 122, RR 48, SAO2 95% Rapid Desaturation With Ambulation
  26. 26. Pt represented to ED 2 days later due to continued cough and increased WOB VS: HR 122, RR 48, SAO2 95% Rapid Desaturation With Ambulation CXR: LLL pneumonia with new RML consolidation Multifocal Pneumonia
  27. 27. 16 year-old female underwent elective outpatient maxillofacial surgery. Post-procedurally she developed hypoxia
  28. 28. 16 year-old female underwent elective outpatient maxillofacial surgery. Post-procedurally she developed hypoxia Right Apical Pneumothorax
  29. 29. Pt transferred to the ED from PACU. Continued hypoxia requiring supplemental oxygen
  30. 30. Pt transferred to the ED from PACU. Continued hypoxia requiring supplemental oxygen 2nd CXR: pneumothorax + evolving bibasilar opacities concerning for developing aspiration pneumonia
  31. 31. Pigtail Drainage
  32. 32. 3rd CXR: improvement of the pneumothorax but evolving RLL consolidation concerning for aspiration pneumonia versus atelectasis Pigtail Drainage
  33. 33. Continued concerns for aspiration throughout hospitalization due to oromaxillofacial anomalies. A Dobhoff Tube [DHT] is recommended due to aspiration 4th CXR: Post DHT placement the patient complained of chest pain below L breast. Desaturation to 70% on RA.
  34. 34. Continued concerns for aspiration throughout hospitalization due to oromaxillofacial anomalies. A Dobhoff Tube [DHT] is recommended due to aspiration 4th CXR: Post DHT placement the patient complained of chest pain below L breast. Desaturation to 70% on RA. Iatrogenic L Pneumothorax due to DHT placed in left bronchus
  35. 35. 7 year old female presented with recurrent productive cough, night sweats, weight loss and fevers Air fluid level concerning for a cavitary lesion What Is Your Diagnosis? Tune in next month for more to come! Cases Studies From Our Emergency Medicine Partners In Tanzania
  36. 36. Air-Fluid Level: If It’s Flat There’s Air In There! Cases Studies From Our Emergency Medicine Partners In Tanzania
  37. 37. Summary Of Diagnoses This Month  Retropharyngeal abscess  Metapneumovirus pneumonia requiring ECMO  Heart failure  Several cases of lobar pneumonia  Left mainstem placement of Dobhoff tube with pneumothorax  Mystery case from Tanzania!
  38. 38. See You Next Month!

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