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Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery September 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, Congenital Diaphragmatic Hernia, Clavicle Fracture, Lung Agenesis, Ingested Foreign Body, Truncus Arteriosus.

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Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery September 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 September 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/LCH departments, and now from EM colleagues in 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. Normal CXR for your reference
  5. 5. 3 month old female with history of congenital heart defect s/p repair who presented to the ED with hypoxia and increased work of breathing . Her CXR is consistent with which congenital heart defect?
  6. 6. Heart with wooden shoe shape Oligohemia (reduction of blood flow in the peripheral circulation Pulmonary artery segment concavityEnlarged aorta Tetralogy of Fallot for more information see last month’s feature on TOF
  7. 7. 3 year old female with past medical history of congenital diaphragmatic hernia s/p repair who presents to the ED with increased work of breathing
  8. 8. Elevation of the right hemidiaphragm and left basilar opacity.
  9. 9. When compared to multiple previous CXRs, this is stable and consistent with a repaired congenital diaphragmatic hernia. 2017 2019
  10. 10. 2017 2019 Always compare with previous CXR! When compared to multiple previous CXRs, this is stable and consistent with a repaired congenital diaphragmatic hernia.
  11. 11. Congenital Diaphragmatic Hernia • 1 in every 3000 live births • Predominantly male infants • Can be isolated or associated with a number of genetic syndromes • Abdominal contents herniate through the diaphragmatic defect and cause pulmonary hypoplasia • Most often presents with respiratory distress at or soon after birth • CXR findings • Air filled and fluid filled loops of bowel in the thorax • Cardiac silhouette shifted to the opposite hemithorax https://pedemmorsels.com/congenital-diaphragmatic-hernia/ https://eapsa.org/parents/learn-about-a-condition/a-e/congenital- diaphragmatic-hernia/
  12. 12. 12 year old female with no past medical history presents with back and left shoulder pain after a rollover motor vehicle crash.
  13. 13. Fracture of distal left clavicle Have a routine approach to evaluating CXRs so as not to miss subtle findings! A: Airway B: Bones (as in this case) C: Cardiac D: Diaphragm E: Extra-thoracic soft tissue F: Foreign bodies/Fissures G: Great vessels/Gastric bubble H: Hila and mediastinum https://radiopaedia.org/articles/chest-radiograph-assessment-using-abcdefghi?lang=us
  14. 14. 2 month old male with a complex medical history including lung agenesis presents in respiratory distress. The family suctions a mucus plug from the child’s tracheostomy tube just prior to arrival.
  15. 15. Dx: Right lung agenesis (complete opacification of the lung field) Diagnosis: Left middle and lower lobe atelectasis
  16. 16. 4 year old male presents to the ED for evaluation after swallowing a marble 3 days earlier. He now complains of abdominal pain.
  17. 17. No foreign body… need more imaging!
  18. 18. Diagnosis: Foreign body; most likely in the cecum
  19. 19. 7 year old male presents to the ED for evaluation after swallowing a metal ring 2 days earlier. He now complains of abdominal pain and vomiting.
  20. 20. No foreign body… need more imaging!
  21. 21. Diagnosis: Foreign body overlying the stomach. Delayed presentation of ingested foreign body. Get both chest and abdominal X- rays to evaluate!
  22. 22. 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 Division. We thank everyone for your continued support of this project!
  23. 23. Female neonate with known congenital abnormality based on antenatal screening and IUGR born at 39 weeks and transferred to the NICU for close monitoring Physical exam notable for low pitched 2/6 systolic murmur at the left sternal border.
  24. 24. Female neonate with known congenital abnormality based on antenatal screening and IUGR born at 37 weeks and transferred to the NICU for close monitoring. Physical exam notable for a constant systolic ejection click and 2/6, mildly harsh systolic ejection murmur heard best at the cardiac base.
  25. 25. So, what’s with these kids??
  26. 26. Truncus Arteriosus https://www.cdc.gov/ncbddd/heartdefects/truncusarteriosus.html • Single arterial trunk ascending from both right and left ventricles • Occurs due to a failure or incomplete septation of the truncus arteriousus during embryonic development • Occurs in approximately 5-15 of 100,000 live births • Slight male predominance https://emedicine.medscape.com/article/892489-overview#a4 https://www.cdc.gov/ncbddd/heartdefects/truncusarteriosus.html Yue, Esther L., and Garth D. Meckler.. "Congenital and Acquired Pediatric Heart Disease." Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e
  27. 27. Truncus Arteriosus Associated Cardiac Abnormalities: • Ventricular septal defect • Presence of truncal (semilunar) valve • Significant regurgitation through truncal valve • Abnormal coronary arteries • Single coronary artery • Intramural coronary artery • Interruption of aortic arch • Right sided aortic arch • Left superior caval vein • Aberrant subclavian artery • Atrial septal defect https://emedicine.medscape.com/article/892489-overview#a4 https://www.cdc.gov/ncbddd/heartdefects/truncusarteriosus.html Yue, Esther L., and Garth D. Meckler.. "Congenital and Acquired Pediatric Heart Disease." Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e
  28. 28. • During pregnancy: • Rubella • Poorly controlled diabetes • Smoking • Alcohol • Some antiepileptics • Ibuprofen • Family history of congenital heart disease • Chromosomal disorders: • DiGeorge syndrome • Velocardiofacial syndrome https://emedicine.medscape.com/article/892489-overview#a4 https://www.cdc.gov/ncbddd/heartdefects/truncusarteriosus.html Yue, Esther L., and Garth D. Meckler.. "Congenital and Acquired Pediatric Heart Disease." Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e Truncus Arteriosus Risk Factors:
  29. 29. History: • Poor feeding • Breathing fast • Sweating • Turning blue • Lethargy Physical Exam: • Lethargy, diaphoresis • Tachypnea, cyanosis: can have normal SpO2 • Loud systolic murmur at left sternal border • +/- High pitched diastolic decrescendo murmur • +/- diastolic rumble • Prominent S2 Truncus Arteriosus Clinical Presentation: https://emedicine.medscape.com/article/892489-overview#a4 https://www.cdc.gov/ncbddd/heartdefects/truncusarteriosus.html Yue, Esther L., and Garth D. Meckler.. "Congenital and Acquired Pediatric Heart Disease." Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e
  30. 30. • Hyperoxia test: • No improvement in oxygenation after administration of supplemental O2 • EKG: • Normal axis (right-axis deviation is expected on pediatric EKG) • Biventricular hypertrophy • Katz-Wachtel phenomenon • V2-V5 with large biphasic QRS https://litfl.com/biventricular-hypertrophy-ecg-library/ https://emedicine.medscape.com/article/892489-overview#a4 Truncus Arteriosus ED Evaluation
  31. 31. • Egg shaped heart; with significant cardiac enlargement • Flattened left upper heart border due to absence of RV outflow tract • Narrow mediastinum • Increased pulmonary vascular markings • Thymus may be small or absent (DiGeorge Syndrome) https://radiologykey.com/heart-size-overall-configuration-and-specific- chamber-enlargement/ Truncus Arteriosus Chest X-Ray Findings:
  32. 32. Summary Of This Month’s Diagnoses • Tetralogy of Fallot • Congenital diaphragmatic hernia • Clavicle fracture • Lung agenesis and atelectasis secondary to a mucous plug • Ingested foreign bodies; delayed presentation • Truncus arteriosus

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