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Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery October 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:
• Scoliosis
• Pneumothorax
• Parapneumonic Effusion
• Cardiomegaly
• Vaping associated lung injury

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Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery October 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 October 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 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. Visit Our Website www.EMGuidewire.com For A Complete Archive Of Chest X-Ray Presentations And Much More!
  5. 5. 10 year old female with history of severe scoliosis. What are the pulmonary complications associated with severe scoliosis?
  6. 6. After stage I of the repair
  7. 7. 13 year old female presented to the emergency department after a car accident with complaint of Chest Pain Dx: ?
  8. 8. 13 year old female presented to the emergency department after a car accident with complaint of Chest Pain Dx: L apical penumothorax
  9. 9. After placement of L sided pigtail catheter
  10. 10. 15 year old male with history of Pierre Robin Syndrome, skeletal dysplasia, and asthma presented to the emergency department for one day of chest tightness and shortness of breath. Initial ED vital signs Heart Rate: 133 Respiratory Rate: 26 SpO2: 93% Blood Pressure: 122/77 Dx: ?
  11. 11. 15 year old male with history of Pierre Robin Syndrome, skeletal dysplasia, and asthma presented to the emergency department for one day of chest tightness and shortness of breath. Initial ED vital signs Heart Rate: 133 Respiratory Rate: 26 SpO2: 93% Blood Pressure: 122/77 Dx: R penumothorax Notice the flattening of the R hemidiaphragm, which suggests a degree of tension physiology
  12. 12. After placement of R sided pigtail catheter
  13. 13. 15 year old male with presented to the Emergency Department after stab wound to the R posterior shoulder. Vital Signs: Stable Physical Exam: Decreased breath sounds on R EFAST: No lung sliding on R Dx: ?
  14. 14. 15 year old male with presented to the Emergency Department after stab wound to the R posterior shoulder. Vital Signs: Stable Physical Exam: Decreased breath sounds on R EFAST: No lung sliding on R Dx: R pneumothorax with subcutaneous emphysema
  15. 15. After placement of R sided pigtail catheter with residual 10 mm apical PTX
  16. 16. Pediatric Pneumothorax - Diagnosis • In the case of spontaneous pneumothorax: • Children are typically 10-17 year old males with a history of asthma or tobacco abuse • Most patients will present with acute onset of chest pain and shortness of breath, although the majority actually present in a delayed fashion • Diagnostic tools: • Supine CXR has only ~50% sensitivity, increases wot ~90% with use of erect CXR • Ultrasound has an ~90% sensitivity, which may increase to 99% when used by a trained and experienced operator Pediatric EM Morsels – Spontaneous pneumothorax When using M mode, the “barcode sign” indicates a PTX while the “seashore sign” or “waves on a beach” indicates normally aerated lung Click here for a demonstration of thorax ultrasound by Dr. Tony Weeks
  17. 17. Pediatric Pneumothorax - Treatment • When preforming open thoracostomy, remember that the small rib spaces may prevent you from inserting your finger into the intercostal space. The narrow intercostal space also exposes the neurovascular bundle, making complications more likely • The pediatric mediastinum is more mobile, and the intrathoracic pressures are more readily transmitted to the right atrium, making it more likely that these patient will have decreased cardiac output or tension physiology • Despite this, emergent thoracostomy is rarely required in children! • Does it need to be drained? • Small pneumothoraces (some have said up to 20%, but no good pediatric studies available) can be managed conservatively Pediatric EM Morsels – Traumatic pneumothorax
  18. 18. 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 Morsels – PigTail Catheter From April’s Presentation!
  19. 19. 14 year old female with history of scoliosis who presented to the emergency department with shortness of breath, cough and intermittent fever. Dx: ?
  20. 20. 14 year old female with history of scoliosis who presented to the emergency department with shortness of breath, cough and intermittent fever. Dx: Paraneumonic Effusion
  21. 21. After left sided video assisted thoracoscopic surgery with persistent left sided chest tube Notice decreased size of left sided loculated pleural effusion
  22. 22. One month post-procedure patient seen in follow-up with small residual left sided pleural effusion with no residual airspace consolidation
  23. 23. 7 year old male with past medical history of SMA, tracheomalacia, trach/vent dependence presented to the emergency department with 3 days of shortness of breath, fever, and cough. Initial ED vital signs: HR: 150 RR: 18 BP: 105/80 SpO2: 93% AP CXR shows no significant consolidation
  24. 24. Lateral CXR shows no dense RLL retrocardiac opacity consistent with pneumonia Lesson: If no consolidation seen on AP and clinical picture fits, obtain lateral film to evaluate retrocardiac space!
  25. 25. Case 1: 2 week old male presented to the emergency department with tachypnea and increased work of breathing. ED Vital Signs: HR: 166 BP: 82/69 SpO2: 96% RR: 81 Afebrile AP CXR shows significantly enlarged cardiac silhouette
  26. 26. Case 2: 2 week old male presented to the emergency department with intermittent increased work of breathing. ED Vital Signs: HR: 163 BP: 63/39 SpO2: 96% RR: 42 Afebrile AP CXR shows mild cardiomegaly
  27. 27. What is the next step? Obtain an echocardiogram to better evaluate cardiac function
  28. 28. Echocardiograms Case 1 • Severe pulmonary hypertension with R heart dilation and flattened interventricular septum • Severe tricuspid regurgitation • Moderate mitral valve regurgitation • Patent foramen ovale with right-to- left shunting • Small patent ductus arteriosus with primary right to left shunting Case 2 • Normal echocardiogram
  29. 29. What’s the difference between these two CXRs?
  30. 30. What’s the difference between these two CXRs? It’s the thymus!
  31. 31. 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/. From April’s Presentation!
  32. 32. Notch Sign Wave sign Review the CXR from Case 2 with the thymic shadow indications in mind:
  33. 33. Follow-up from Case #1 • Congestive heart failure in the newborn period is rare, and most often related to congenital structural heart disease, however the differential diagnosis is broad and includes arrhythmias, congenital or acquired myopathies, sepsis, severe anemia, or conditions leading to high-output heart failure • Causes of high output heart failure in the pediatric population includes AVM (hemangiomas, venous malformations), cirrhosis, carcinoid syndrome hyperthyroidism, myeloproliferative disorders, Beriberi, sepsis, mitochondrial disease, and many others Merritt, Chris, et al. “A Neonate With High-Outflow Congestive Heart Failure and Pulmonary Hypertension Due to an Intracranial Arteriovenous Malformation.” Pediatric Emergency Care, vol. 27, no. 7, 2011, pp. 645–648., doi:10.1097/pec.0b013e3182225679.
  34. 34. Follow-up from Case #1 • Vein of Galen aneurysmal malformations are rare congenital anomalies that constitute 1% of all intracranial vascular malformations • Due to a persistent embryonic median vein of prosencephalon • In utero, the placental circulation provides a low-resistance path preventing cardiac damage from fluid overload • With loss of the placenta at birth, up to 70% of the cardiac output is directed to the low resistant Vein of Galen Malformation AV shunt which allows direct return of large flow volume to the right heart Gupta, AK, Varma, DR Vein of Galen malformations: Review.. Neurol India. (2004). 52 43–53 Li, AH, Armstrong, D, terBrugge, KG Endovascular treatment of vein of Galen aneurysmal malformation: Management strategy and 21-year experience in Toronto.. J Neurosurg Pediatr. (2011). 7 3–10 MRA from our case showing dilation of the median prosencephalic vein draining in to a persistent falcine sinus = Vein of Galen Malformation
  35. 35. Our Last Case Is An Adult Example Of New Disease State That Is Being Seen In Both Adults And Children!
  36. 36. 33 Year Old Previously Healthy Male With A History Of Nicotine/THC Vaping Presents With Severe Dyspnea & Hypoxia Bilateral Airspace Disease On CXR Diagnosis?
  37. 37. E-Cigarette Associated Pneumonitis 33 Year Old Previously Healthy Male With A History Of Nicotine/THC Vaping Presents With Severe Dyspnea & Hypoxia
  38. 38. 33 Year Old With A History Of Vaping Presents With Severe Dyspnea E-Cigarette Associated Pneumonitis
  39. 39. E-Cigarette Associated Pneumonitis 3 Days Later Symptoms Improved
  40. 40. Published On September 6, 2019, at NEJM.org
  41. 41. E-Cigarette Associated Lung Injury • Between 2017 and 2018, the prevalence of e-cigarette use increased from 11.7% to 20.8% amongst U.S. high school students. • Pulmonary illnesses related to e-cigarettes have been reported, but no larger series have been described previously. • In July 2019, the Wisconsin Department of Health Serves received reports of pulmonary disease associated with vaping. • The authors describe the demographic and outcome characteristics of 53 patients; representing the largest published case series to date.
  42. 42. Demographic Characteristics (n=53) Median age 19 (16-53) Male sex 83% White race 82% Reported nicotine use 61% Reported THC use 80% Reported nicotine & THC use 44%
  43. 43. Symptoms Reported On Presentation Median duration of symptoms 6 days (0-61) Any Respiratory Symptoms Shortness of breath Chest pain Cough Hemoptysis 98% 87% 55% 83% 11% Subjective fever 81% Chills 58% Nausea 70% Vomiting 66%
  44. 44. Vital Signs At Presentation Temperature >38° C 29% Heart rate >100 beats/min 64% Respiratory rate >20 breaths/min 82% Oxygen saturation: ≥95% 89-94% ≤88% 31% 38% 31%
  45. 45. Initial Laboratory Results WBC >11000/mm3 87% WBC >80% neutrophils 94% ESR >30 mm/hr 93% Initial Radiographic Finding Abnormal chest X-ray 91% Abnormal chest CT 100% Bilateral infiltrates on CT 100%
  46. 46. Treatment Antibiotics during hospitalization 90% Steroids during hospitalization 92% IV steroids during hospitalization 83% Clinical Course Hospitalization 94% Non-invasive ventilation 36% Endotracheal intubation 32% Death 1/53 (2%)
  47. 47. Published On September 6, 2019, at NEJM.org Identical To Our Patient!
  48. 48. The Vapors Are Viscous! E-cigarette liquids have been shown to contain a variety of chemicals that may have adverse health effects: • Propylene glycol • Glycerin • Polycyclic aromatic hydrocarbons • Volatile organic and inorganic chemicals • Toxic metals • Flavoring compounds that may cause adverse effects
  49. 49. Monitoring The Future Survey™ National survey of 8th, 10th and 12th graders assessing vaping trends: 2017 2018 2019 43,703 44,482 43,531 Prevalence of use more than doubled between 2017 and 2019!
  50. 50. n integrated view of the ydiseaseoutbreak since ted online information ncluding news aggrega- and validated official assified the data by dis- me.3 Figure1 shows the ed and suspected cases ease from vaping over States. The first 8 sus- ed byour onlinemining g) on July 25, 2019, in 8, a total of 119 con- eshad been detected in more than doubled by ing a total of 288 cases ptember 11, cases had nning 39 states and the compoundsof e-cigaretteliquids, adulteration of devices with tetrahydrocannabinol (THC)–based oilsor vitamin E, and useof black market vaping products.1,4 Findingsfrom thisreport suggest that vaping-associated pulmonary disease cases have reached epidemic proportions. Incident cases con- tinueto rise. Further surveillanceis necessary to monitor the development and spread of this vap- ing-related outbreak. Yulin Hswen, M.P.H., Sc.D. John S. Brownstein, Ph.D. Innovation Program, Boston Children’sHospital Boston, MA yuh958@mail.harvard.edu Disclosure forms provided by the authors are available with thefull text of thisletter at NEJM.org. This letter was published on September 20, 2019, at NEJM.org.
  51. 51. Summary of this month’s diagnoses • Scoliosis • Pneumothorax • Parapneumonic Effusion • Cardiomegaly • Vaping associated lung injury

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