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:
- Tension Pneumothorax
- Atelectasis
- Esophageal Obstruction / Achalasia
- Right Upper Lobe Mass
- Right Upper and Right Middle Lobectomies
- Esophageal Foreign Body
- Transposition of the Great Vessels
Unit 3 Emotional Intelligence and Spiritual Intelligence.pdf
Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery November Cases
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
November 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.
5. 5 month old full term
infant with history of
congenital pulmonary
airway malformation s/p
VATS 10 days prior presents
to his pediatrician for
decreased oral intake and
UOP noted to have mild
increased work of
breathing and a RR of 42.
6. 5 month old full term
infant with history of
congenital pulmonary
airway malformation s/p
VATS 10 days prior presents
to his pediatrician for
decreased oral intake and
UOP noted to have mild
increased work of
breathing and a RR of 42.
Absent lung markings
Leftward mediastinal shift
7. 5 month old full term
infant with history of
congenital pulmonary
airway malformation s/p
VATS 10 days prior presents
to his pediatrician for
decreased oral intake and
UOP noted to have mild
increased work of
breathing and a RR of 42.
Absent lung markings
Leftward mediastinal shift
Dx: Right-sided tension
pneumothorax
8. 14 month old male with a
history of dwarfism seen at
an outside ED for
tachypnea and fever.
Clinical deterioration with
desaturation to 60%. CPR
initiated (6 min prior to
ROSC) with multiple
attempts at endotracheal
intubation prior to
successful passage of a 3.5
uncuffed ETT. Transferred
to our PICU.
9. Crowded vasculature
Opacity of the right lower lobe
Elevation of right bronchus
14 month old male with a
history of dwarfism seen at
an outside ED for
tachypnea and fever.
10. Dx: Right Lower Lobe Atelectasis
Crowded vasculature
Opacity of the right lower lobe
Elevation of right bronchus
14 month old male with a
history of dwarfism seen at
an outside ED for
tachypnea and fever.
11. How do we know that
consolidation isn’t a
pneumonia?!
14. THE OPACITY MOVED!
Pneumonias don’t
move…atelectasis can!
Triangle shaped opacity in RUL
Elevation of R hemidiaphragm
Rightward shift of mediastinum
15. THE OPACITY MOVED!
Pneumonias don’t
move…atelectasis can!
Dx: Right Upper Lobe
Atelectasis
Triangle shaped opacity in RUL
Elevation of R hemidiaphragm
Rightward shift of mediastinum
16. THE OPACITY MOVED!
Pneumonias don’t
move…atelectasis can!
Dx: Right Upper Lobe
Atelectasis
Triangle shaped opacity in RUL
Elevation of R hemidiaphragm
Rightward shift of mediastinum
**For those practicing in the ED…if clinical
clues (like SICK kid with fever) point to
possible pneumonia…TREAT like a
pneumonia**
17. Atelectasis
• Defined: reduced lung inflation
• CXR features (that distinguish
atelectasis from consolidation):
• Elevation of the hemidiaphragm
• Displaced fissure
• Crowded vasculature
• Mediastinal shift toward the collapse
• Subsegmental, with a linear or band-
like appearance
• Types/Causes:
• Post obstructive
• Mucous plug
• Foreign body aspiration
• Mass
• Compressive
• Mass
• Round/Cicatricle
• Chronic TB or sarcoid
• Adhesive
• ARDS
• Passive
• Pneumothorax
• Pleural effusion
https://litfl.com/cxr-essentials-types-of-atelectasis/
18. Atelectasis: Patterns Based On Location
• Right Upper Lobe
• Triangular opacity
• Elevation of right hilum
• Rightward mediastinal shift
• Right Middle Lobe
• Loss of right heart border
• BEST seen on lateral film as a wedge pointing toward the hilum
• Right Lower Lobe
• Triangular opacity near the spine
• Silhouetting of right hemidiaphragm
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/
19. Atelectasis: Patterns Based On Location
• Left Upper Lobe
• Loss of left upper heart border
• Elevated left hilum
• Luftsichel Sign: crescent of air creating
sharp border along the aorta
• Left Lower Lobe
• Triangular opacity creating an oddly
linear left heart border
• Silhouetting of the left
hemidiaphragm
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/
. https://4.bp.blogspot.com/_fBQVVpFhTQs/SjlDlLXAlrI/AAAAAAAAAvU/7By_wSFvB4k/s1600-h/left-upper-lobe-collapse-1.jpg
20. Patient is a 12 year old
female with past medical
history of eosinophilic
esophagitis who presented
to the ED with feelings of
chest fullness and
difficulty swallowing solids
and liquids. On exam,
noted to have a hoarse
voice with clear lung
sounds.
21. Patient is a 12 year old
female with past medical
history of eosinophilic
esophagitis who presented
to the ED with feelings of
chest fullness and
difficulty swallowing solids
and liquids. On exam,
noted to have a hoarse
voice with clear lung
sounds.
Dilated tubular structure
22. Patient is a 12 year old
female with past medical
history of eosinophilic
esophagitis who presented
to the ED with feelings of
chest fullness and
difficulty swallowing solids
and liquids. On exam,
noted to have a hoarse
voice with clear lung
sounds.
23. Dx: Esophageal obstruction
(achalasia by esophogram)
Abrupt tapering of the
esophagus
Patient is a 12 year old
female with past medical
history of eosinophilic
esophagitis who presented
to the ED with feelings of
chest fullness and
difficulty swallowing solids
and liquids. On exam,
noted to have a hoarse
voice with clear lung
sounds.
24. 7 year old female with no
past medical history
presents with intermittent
chest pain over the last 2
months with a normal
physical exam
25. Right Upper Lobe Mass
7 year old female with no
past medical history
presents with intermittent
chest pain over the last 2
months with a normal
physical exam
26. Right Upper Lobe Mass
Dx: further imaging needed
7 year old female with no
past medical history
presents with intermittent
chest pain over the last 2
months with a normal
physical exam
27. 7 year old female with no
past medical history
presents with intermittent
chest pain over the last 2
months with a normal
physical exam
28. Right Upper Lobe Mass
Dx: Inflammatory
Myofibroblastic Tumor
(biopsy diagnostic)
7 year old female with no
past medical history
presents with intermittent
chest pain over the last 2
months with normal
physical exam
29. Surgical clips at the right hilum
Same 7 year old female
with now known history of
RUL tumor s/p VATS guided
biopsy 2 weeks later…
Tiny pneumothorax
Decreased lung markings
30. Surgical clips at the right hilum
Dx: s/p RUL and RML resection
Same 7 year old female
with now known history of
RUL tumor s/p VATS guided
biopsy 2 weeks later…
Tiny pneumothorax
Decreased lung markings
31. 3 year old male reportedly
swallowed a coin who is
now experiencing vomiting
32. Foreign body
Dx: Esophageal foreign body
(quarter)
3 year old male reportedly
swallowed a coin who is
now experiencing vomiting
33. 5 year old female with
history of Down Syndrome
reportedly swallowed
something and is now
experiencing vomiting
34. 5 year old female with
history of Down Syndrome
reportedly swallowed
something and is now
experiencing vomiting
35. Foreign body
Dx: Esophageal foreign body
(quarter)
5 year old female with
history of Down Syndrome
reportedly swallowed
something and is now
experiencing vomiting
36. 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
collogues in the Pediatric Cardiovascular Surgery Department. We thank
this team for their continued support of this project!
37. 1 day old male with known
congenital abnormality
based on prenatal
screening admitted to NICU
Physical Exam: II/VI
holosystolic murmur best
heard at apex; up slanting
palpebral fissures,
trigonocephaly,
micrognathia
38. 1 day old female with
known congenital
abnormality based on
prenatal screening
admitted to NICU
Physical Exam: II/VI
systolic murmur best heard
at LUSB; 1+ peripheral
pulses; capillary refill 4 sec
file:///.file/id=6571367.20974
880
39. 2 day old female with
known congenital
abnormality based on
prenatal screening
admitted to NICU for
hypoxia requiring CPAP
Physical Exam: III/VI
continuous systolic
murmur; coarse lung
sounds
40. 1 day old male transferred
from outside hospital for
hypoxia requiring CPAP and
ultimately intubation with
an elevated lactate
Physical Exam: systolic
murmur; tachypnea with
subcostal retractions
41. 1 day old female with
known congenital
abnormality based on
prenatal screening labs
born with hypoxia to the
80’s
Physical Exam: II/VI
systolic murmur along LSB,
cyanotic
42. 1 day old male with known
congenital abnormality
based on prenatal
screening labs born who
became apneic and
bradycardic ultimately
requiring intubation
Physical Exam: 2+ upper
extremity pulses; 1+ lower
extremity pulses; no
murmur
43. 3 day old male with known
congenital abnormality
based on prenatal
screening labs born who
became apneic and
bradycardic ultimately
requiring intubation
Physical Exam: 2+ upper
extremity pulses; 1+ lower
extremity pulses; no
murmur
44. 1 day old female with
known congenital
abnormality based on
prenatal screening labs
born and taken to NICU for
monitoring
Physical Exam: narrow s2
splitting
46. Transposition Of The Great Arteries (TGA)
• The two main arteries that carry
blood away from the heart are
swapped:
• Body ⇨ Heart ⇨ Body
• Lungs ⇨ Heart ⇨ Lungs
• Occurs in 1250 US births/year
• Slight male predominance
https://www.heart.org/en/health-topics/congenital-heart-defects/about-
congenital-heart-defects/d-transposition-of-the-great-arteries
https://www.cdc.gov/ncbddd/heartdefects/d-tga.html
47. TGA: Associated Cardiac Abnormalities
• Isolated TGA is not compatible with life
• These defects allow for the mixing of
oxygenated blood:
• VSD
• ASD
• PDA
• PFO
• Extracardiac anomalies are less common
https://www.cdc.gov/ncbddd/heartdefects/d-tga.html
https://radiopaedia.org/articles/transposition-of-the-great-arteries?lang=us
Martins, Paula, and Eduardo Castela. “Transposition of the Great Arteries.” Orphanet Journal of Rare Diseases, vol. 3, no. 1, 2008, doi:10.1186/1750-1172-3-27.
Yue, Ester L. “Congenital and Acquired Pediatric Heart Disease.” Tintinallis Emergency Medicine, by J. Tintinalli, 8th ed., Mcgraw-Hill 2015, pp. 822–832.
48. TGA: Risk Factors
• Gestational diabetes
• Maternal exposures:
• Rodenticides
• Herbicides
• Maternal antiepileptic use
• Maternal age >40 years
• Rubella or other viral illnesses during pregnancy
https://www.mayoclinic.org/diseases-conditions/transposition-of-the-great-arteries/symptoms-causes/syc-20350589
Martins, Paula, and Eduardo Castela. “Transposition of the Great Arteries.” Orphanet Journal of Rare Diseases, vol. 3, no. 1, 2008,
doi:10.1186/1750-1172-3-27.
49. TGA: Clinical Presentation
• History:
• Blue skin
• Labored breathing
• Lack of appetite
• Poor weight gain
• Physical Exam:
• Hypoxia
• Cyanosis
• Single loud S2
• Murmur may be absent
(depending on other cardiac
abnormalities present)
https://www.mayoclinic.org/diseases-conditions/transposition-of-the-great-arteries/symptoms-causes/syc-20350589
Martins, Paula, and Eduardo Castela. “Transposition of the Great Arteries.” Orphanet Journal of Rare Diseases, vol. 3, no. 1, 2008,
doi:10.1186/1750-1172-3-27.
50. TGA: Evaluation
• Hyperoxia test:
• No improvement in SAO2 after
oxygen administration
• EKG:
• Right axis deviation
• Right ventricular hypertrophy:
• Dominant R wave in V1
• Dominant S wave in V5 or V6
• QRS <120 ms https://litfl.com/right-ventricular-hypertrophy-rvh-ecg-library/
Yue, Ester L, and Garth D Meckler. “Congenital and Acquired Pediatric Heart
Disease.” Tintinallis Emergency Medicine, by Judith Tintinalli, 8th ed.,
Mcgraw-Hill Education, 2015, pp. 822–832.
51. TGA: Chest X-Ray Findings
• Egg-shaped heart
• Narrow mediastinum
• Increased pulmonary vascular
markings
https://radiopaedia.org/articles/transposition-of-the-
great-arteries?lang=us
Yue, Ester L, and Garth D Meckler. “Congenital and
Acquired Pediatric Heart Disease.” Tintinallis Emergency
Medicine, by Judith Tintinalli, 8th ed., Mcgraw-Hill
Education, 2015, pp. 822–832.
Case courtesy of Dr Vincent Tatco,
<a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case
<a href="https://radiopaedia.org/cases/43062">rID: 43062</a>
52. Summary of This Month’s Diagnoses
• Tension pneumothorax
• Atelectasis
• Esophageal obstruction/achalasia
• Right upper lobe mass
• Right upper and right middle lobectomies
• Esophageal quarter
• Transposition of the great arteries
![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.](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)