Drs. Olson and Jackson are interested in education and Pediatric Emergency Medicine. Follow along with the EMGuideWire.com team and Drs. Nikki Richardson, Mary Grady, and Michael Gibbs as they post these educational, self-guided radiology slides on Pediatric Emergency Medicine Radiology. This month’s topics include: - Hemopneumothorax - COVID Pneumonia - Metastatic Testicular Cancer - Tension Pneumothorax - Acute Chest Syndrome - Status Asthmaticus - Severe Anemia - Pulmonary Infarct and Pulmonary Embolism

1. Pediatric Chest X-Rays of the Month
Kendra Jackson, MD & Elizabeth Olson, MD
Department of Emergency Medicine &
Department of Pediatrics
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD, Faculty Editor
Nicholena Richardson, MD & Mary Grady, MD, Junior Faculty Editors
Chest X-Ray Mastery Project
December 2020

2. Process and Disclosures
This ongoing pediatric chest x-ray
interpretation series is proudly sponsored
by the Emergency Medicine Residency
Program and Pediatric Emergency Medicine
Fellowship at Carolinas Medical Center.
The goal is to promote widespread mastery
of CXR interpretation.
Cases are submitted by contributors from
many CMC departments, and now…
Tanzania and Brazil.
Ages have been changed to protect patient
confidentiality. No protected health
information (PHI) will be shared.
For more educational content, visit
EMGuidewire.com

3. Reading systematically…
A for airway
B for bones
C for cardiac silhouette
D for diaphragm
E for everything else
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4. Normal CXR
for your
reference

5. Review
13-year-old male presents after
falling onto a sharp piece of metal
sticking out of a curb. He has a
laceration to his right armpit.
Interpret this CXR.

6. 13-year-old male presents after
falling onto a sharp piece of metal
sticking out of a curb. He has a
laceration to his right armpit.
Interpretation:
“There is a moderate right-sided
hemopneumothorax with air
dissecting through the right chest
wall soft tissue.”
Arrows indicate the pleural-air
interface.

7. 12-year-old male with
history of CP presents in
respiratory distress after 1
week of cough and nasal
congestion
What’s the xray finding?

8. 12-year-old male with
history of CP presents in
respiratory distress after 1
week of cough and nasal
congestion. COVID +
Bilateral ground-glass
opacities
*Don’t forget the VP
shunt

9. 19-year-old male
presenting with chest
pain, back pain worse at
night, with an enlarged
left testicle
What’s the xray finding?

10. 19-year-old male
presenting with chest
pain, back pain worse at
night, with an enlarged
left testicle
Large right sided pleural
effusion with possible
nodules

11. Additional history:
Testicular US was found to
have a 1cm mass
consistent with testicular
neoplasm. CT chest was
ordered.
Spot the abnormality

12. Additional history:
Testicular US was found to
have a 1cm mass
consistent with testicular
neoplasm. CT chest was
ordered.
Multiple lung nodules in
addition to the
hemothorax

13. Hospital Day 1:
He had an US guided
thoracentesis with 1.5L of
fluid drained. On the floor,
he developed hemoptysis
and tachypnea on a non-
rebreather.
Interpret this xray

14. Hospital Day 1:
He had an US guided
thoracentesis with 1.5L of
fluid drained. On the floor,
he developed hemoptysis
and tachypnea on a non-
rebreather.
Multifocal opacities of both
lungs as well as likely bilateral
pleural fluid(no diaphragmatic
angles)
Poor aeration

15. Hospital Day 1:
He had an US guided
thoracentesis with 1.5L of
fluid drained. On the floor,
he developed hemoptysis
and tachypnea on a non-
rebreather.
Clinical Pearl: Remember
rebound pulmonary edema

16. He had an US guided
thoracentesis with 1.5L of
fluid drained. On the floor,
he developed hemoptysis
and tachypnea on a non-
rebreather
Name those lines
A
B
C
D

17. He had an US guided
thoracentesis with 1.5L of
fluid drained. On the floor,
he developed hemoptysis
and tachypnea on a non-
rebreather
A: Port
B: Central line
C: ET tube in good
positioning
D: Feeding tube
A
B
C
D

18. 15-year-old male with CF,
interstitial lung disease,
and multiple central line
infections presents in
respiratory distress and is
emergently intubated
Vitals:
97.7 108 61/35 RR 24
Clinical Diagnosis?

19. 15-year-old male with CF,
interstitial lung disease,
and multiple central line
infections presents in
respiratory distress and is
emergently intubated
Vitals:
97.7 108 61/35 RR 24
Right tension
pneumothorax

20. 15-year-old male with CF,
interstitial lung disease,
and multiple central line
infections presents in
respiratory distress and is
emergently intubated
Vitals:
97.7 108 61/35 RR 24
Spot the abnormalities

21. • Tracheal deviation
• Left pleural effusion
• Right pneumothorax
• “Deep Sulcus Sign”
A tension pneumothorax
is life-threatening and
should be diagnosed
clinically and treated with
needle decompression
prior to obtaining
imaging.

22. 2-year-old with history of sickle cell anemia
presents with fever, pain all over, and fussiness
CXR interpretation?

23. 2-year-old with history of sickle cell anemia
presents with fever, pain all over, and fussiness
Radiology read: Right Upper and
Lower lobe pneumonia

24. 2-year-old with history of sickle cell anemia
presents with fever, pain all over, and fussiness
What diagnosis can we not
exclude?

25. Acute Chest Syndrome:
Clinical Pearls
Ped EM Morsels - Acute Chest Syndrome, Dr. Sean Fox 2013
ACS is the most common cause of death
in children with sickle cell
Pain management is an ED PRIORITY
Severe pain increased stress  more
sickling repeat
Cover for encapsulated organisms and
atypical – CTX and azithromycin
Check, and double check the spleen!!

26. 3-year-old female with
history of asthma presents
with wheezing and
hypoxia
Spot the abnormality

27. 3-year-old female with
history of ezcema
presents with wheezing
and hypoxia
Hyperinflation with
peribronchial cuffing

28. ED Course:
She continued to have
respiratory distress
despite continuous
albuterol, magnesium,
and subcutaneous
terbutaline.
Diagnosis?

29. ED Course:
She continued to have
respiratory distress
despite continuous
albuterol, magnesium,
and subcutaneous
terbutaline.
Status Asthmaticus

30. 15-year-old male with
history of hemophilia
presents with severe chest
pain and a normal EKG
Differential for pediatric
chest pain in a child with
hemophilia?

31. 15-year-old male with
history of hemophilia
presents with severe chest
pain with a normal EKG.
Normal

32. Additional history: Chest
tightness, shortness of breath,
and dizziness while at school
today. Feeling fatigued in the
ER. D dimer and exam are
normal. Normal bedside echo.
Vitals:
99.7 130 103/70 RR 30
Admitted for persistent
tachycardia

33. Hospital Day 1:
Patient had a large bloody
emesis and became
hypotensive. Hemoglobin
dropped from baseline of
15 to 10. Patient
remembered he had
several dark stools last
week.
Diagnosis: Acute GI
Bleed
Clinical Pearl: Severe
Anemia can cause chest
pain!

34. 16-year-old year female with history of anemia
presents with left-sided rib pain, worse with
deep breaths. Previously on OCPs.
Spot the abnormality

35. In the ED, she was tachycardic to 120,
tachypneic to 30 and satting at 95% on RA.
Radiology reading: Segmental
atelectasis

36. 16-year-old year female with history of anemia
presents with left-sided rib pain, worse with
deep breaths. Previously on OCPs.
CTA showed saddle PE, ultimately diagnosed
with lupus. CXR likely pulmonary infarct.

37. Pediatric Chest Pain Pearls
Chest Pain in Children and Adolescents. Surendranath R. Veeram Reddy, Harinder R. Singh
Pediatrics in Review Jan 2010, 31 (1) e1-e9; DOI: 10.1542/pir.31-1-e1
An EKG and CXR CANNOT help rule out life threatening
etiologies
Only 2-5% of pediatric chest pain is cardiac in origin
Though PE are uncommon in kids, there are no evidence-
based tools to help identify them
- When PERC was applied RETROSPECTIVELY to pediatric PE,
it was found that 84% of PEs would have been missed
- For Wells Criteria, there was no statistical difference
between scores of children with or without PE even when
the HR was adjusted by age

38. Clinical Pearl: History is Key
Cohen, E, MacKenzie, R.G., Yates, G.L. (1991). HEADSS, a psychosocial risk assessment instrument: Implications for designing effective intervention programs
for runaway youth. Journal of Adolescent Health 12 (7): 539-544.
Although ED providers do not have time to perform a full adolescent psychosocial
interview, or H.E.A.D.S.S. exam, a one-on-one interview with adolescent patients is
critical in the evaluation for chest pain
Home – Patient is not safe at home, being abused by family member (Trauma)
Education – Not in school. Lives with a boyfriend who is over 18 (Trauma)
Activities – Patient used to love baseball, but can no longer keep up (Cardiac)
Drugs – Uses cocaine and takes friend’s Adderall before exams (Stimulants)
Sex – Recently started the pill and parents are not aware (Pulmonary Embolism)
Suicide – Has a long history of anxiety and attempted to end their life by taking lots of
pills (Anxiety, Intentional ingestion)

39. Summary of This
Month’s Diagnoses
• Hemopneumothorax (Review)
• COVID pneumonia
• Hemothorax in Metastatic Testicular
Cancer
• Tension Pneumothorax with Deep
Sulcus sign
• Acute Chest Syndrome
• Status Asthmaticus
• Severe Anemia in Hemophilia, normal
CXR
• Pulmonary infarct
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