Drs. Olson and Jackson are interested in education and Pediatric Emergency Medicine. Follow along with the EMGuideWire.com team and Drs. Nikki Richardson and Michael Gibbs as they post these educational, self-guided radiology slides on Pediatric Emergency Medicine Radiology. This month’s topics include: • Aortic Aneursym • Aortic Coarctation • Aspirated Foreign Body • Ingested Foreign Body • VP Shunt Malfunction • Hemopneumothorax • COVID-19 pneumonia and pneumothorax

1. Pediatric Chest X-Rays of the Month
Elizabeth Olson, MD & Kendra Jackson, MD
Department of Emergency Medicine &
Department of Pediatrics
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD, Faculty Editor
Nicholena Richardson, MD, Junior Faculty Editor
Chest X-Ray Mastery Project
July 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. Normal CXR
for your
reference

4. HPI: 12-year-old female, hx
asthma, presents with
worsening exertional
dyspnea and increasing
dependence on albuterol
inhaler.
Additionally complains of
poor energy and night
sweats.
Spot the abnormality

5. HPI: 12-year-old female, hx
asthma, presents with
worsening exertional
dyspnea and increasing
dependence on albuterol
inhaler.
Additionally complains of
poor energy and night
sweats.
What could this be?
What’s next?

6. HPI: 12-year-old female, hx
asthma, presents with
worsening exertional
dyspnea and increasing
dependence on albuterol
inhaler.
Additionally complains of
poor energy and night
sweats.
CT obtained to evaluate
for lymphoma
Mediastinal mass

7. Diagnosis?

8. 8 cm ascending aortic aneurysm

9. Underwent valve-sparing
aortic root replacement
with ascending aortic
aneurysm repair
Original CXR
One week post-op

10. Underwent valve-sparing
aortic root replacement
with ascending aortic
aneurysm repair
Original CXR
One week post-op

11. Median age at operation: 13.6 years
Mean preoperative aortic diameter: 4.4 cm
Marfan syndrome in 51%
Loeys-Dietz syndrome in 39%
2% Perioperative valve-sparing root replacement mortality
Six patients developed pseudoaneurysms requiring
reintervention
Eight patients underwent additional aortic surgery

12. HPI: 11-year-old boy
presented to ENT clinic
for a consultation prior
to scheduling
tonsillectomy. Found to
be markedly
hypertensive, so sent to
the ED for evaluation.
Spot the abnormality.

13. HPI: 11-year-old boy
presented to ENT clinic
for a consultation prior
to scheduling
tonsillectomy. Found to
be markedly
hypertensive, so sent to
the ED for evaluation.
What’s the xray finding?
What’s the diagnosis?

14. HPI: 11-year-old boy
presented to ENT clinic
for a consultation prior
to scheduling
tonsillectomy. Found to
be markedly
hypertensive, so sent to
the ED for evaluation.
Xray finding: Rib notching.
Diagnosis: Aortic
coarctation

15. Rib notching

16. Aortic coarctation
Red arrows: Aortic narrowing
Orange arrows: Blood is
shunted through the
subclavian arteries to the
internal thoracic arteries to
the anterior intercostal
arteries to the posterior
intercostal arteries before
rejoining the descending
thoracic aorta. The dilated
intercostal arteries erode the
ribs.

17. HPI: 9-year-old boy
referred to cardiology
for hypertension.
Found to have
decreased femoral
pulses.
Spot the abnormality.

18. HPI: 9-year-old boy
referred to cardiology
for hypertension.
Found to have
decreased femoral
pulses.
Xray finding: Rib
notching.
Diagnosis: Aortic
coarctation

19. Aortic coarctation
Red arrows: Aortic narrowing
Orange arrows: Blood is
shunted through the
subclavian arteries to the
internal thoracic arteries to
the anterior intercostal
arteries to the posterior
intercostal arteries before
rejoining the descending
thoracic aorta. The dilated
intercostal arteries erode the
ribs.

20. Clinical Presentation of
CoA in Neonates/Infants
Signs/Symptoms
• Can present in shock during first 6-8
weeks… or may be completely
asymptomatic until adulthood
• Decreased femoral arterial pulse
compared to right brachial artery
• Heart murmur
• Cyanosis
Associated conditions
• Valvular: MV stenosis, bicuspid AV
• Congenital heart defects: PDA, VSD,
Hypoplastic aortic arch
• Subaortic membrane or stenosis
• Turner’s Syndrome
• Intracranial berry aneurysm
Joshi, Gitika, et al. “Presentation of Coarctation of the Aorta in the
Neonates and the Infant with Short- and Long-Term Implications.”

21. Treatment of CoA in
Neonates/Infants in the ED
DOs:
• Prostaglandin E1 or E2
• Start at 5.0-15.0 ng/kg/min
• Max 100 ng/kg/min –beware of increased
risk of apnea at higher doses
• Can be administered via peripheral access
or IO
• Inotropes
• Dopamine, dobutamine, and epinephrine
• Needs central access
DON’Ts:
• Hyperventilation or High FiO2
• Vasodilators
• Over-exuberant use of fluids
• Consider 5 ml/kg boluses
• Re-evaluate for signs of heart failure with
each bolus
• Do not chase with diuretics as this can make
things WORSE
Joshi, Gitika, et al. “Presentation of Coarctation of the Aorta in the
Neonates and the Infant with Short- and Long-Term Implications.”
• EKG: LVH, Flat ST segments or T waves
• CXR: Cardiomegaly, pulmonary venous
congestion. Neonates won’t have rib
notching – This takes time to develop.
• Get a formal echocardiogram
Basic workup:

22. Parting wisdom on aortic coarctations
EARLY detection is important!!
Late repair of CoA is associated with an increased
risk of coronary artery disease in early adulthood.
For more on this topic, including adult presentations, check out
https://litfl.com/cxr-case-151/

23. HPI: 15-month-old girl
presents with
coughing, wheezing
that started suddenly
while her father’s back
was turned.

24. HPI: 15-month-old girl
presents with
coughing, wheezing
that started suddenly
while her father’s back
was turned.
Diagnosis: Foreign
body in the right
mainstem

25. HPI: 30-month-old girl
admits to swallowing a
foreign object but
cannot tell you what it
was. Child is well-
appearing and happily
drinking apple juice.
Spot the abnormality.

26. Object measures at
21.5 mm, the size of a
nickel. However, the
thin rim visualized on
xray is characteristic of
a button battery,
which has potentially
lethal consequences.

27. Esophageal batteries may be
asymptomatic but must be
removed within 2 hours to avoid
strictures, perforation, sepsis,
death.
Poison Control’s Rule of 12:
- Xrays for all patients < age 12
- Xrays for all batteries > 12 mm
Left: Endoscopic photo of button
battery actively burning the
esophagus
Center: Contrast esophagogram
performed 7 days later,
demonstrating stenosis
Right: Endoscopic photo of
resulting stricture at 7 days.
Image credit: Kim, S
et al. Drooling,
irritability, and
refusal to eat in a 22-
month-old child. J.
Gastro, 2015.
https://www.gastr
ojournal.org/articl
e/S0016-
5085(15)00629-
0/pdf

28. HPI: 10-year-old girl
presents with
confusion, headache,
vomiting. History of
VP shunt.
Spot the abnormality.

29. HPI: 10-year-old girl
presents with
confusion, headache,
vomiting. History of
VP shunt.
Diagnosis:
Mechanical VP
shunt disruption

30. Hydrocephalus

31. HPI: 16-year-old boy
transferred to the ED
from PCP’s office
where he was
incidentally found to
have decreased right
sided breath sounds.
No symptoms.
Reports an ATV
accident 3 weeks prior
to this.

32. Diagnosis:
Hemopneumothorax
Radiologist describes
findings consistent with
tension physiology.
But remember: Tension
pneumothorax is a
clinical diagnosis.
Without symptoms,
hypotension, or
tachycardia, this is just a
normal hemopneumo.

33. HPI: 14-year old girl
presents with
shortness of breath,
hypoxia, and known
COVID-19 exposure.
Day 1 Xray

34. HPI: 14-year old girl
presents with
shortness of breath,
hypoxia, and known
COVID-19 exposure.
Day 2 Xray –
Worsening infiltrates

35. HPI: 14-year old girl
presents with
shortness of breath,
hypoxia, and known
COVID-19 exposure.
Day 3 Xray – What
procedure has been
done?

36. HPI: 14-year old girl
presents with
shortness of breath,
hypoxia, and known
COVID-19 exposure.
Day 3 Xray – What
procedure has been
done? PICC insertion.

37. HPI: 14-year old girl
presents with
shortness of breath,
hypoxia, and known
COVID-19 exposure.
Day 4 Xray – Why is
she more tachypneic?

38. HPI: 14-year old girl
presents with
shortness of breath,
hypoxia, and known
COVID-19 exposure.
Day 4 Xray – Why is
she more tachypneic?
Right apical
pneumothorax.

39. HPI: 14-year old girl
presents with
shortness of breath,
hypoxia, and known
COVID-19 exposure.
Back to the day 3 xray:
Is the pneumo already
present?

40. HPI: 14-year old girl
presents with
shortness of breath,
hypoxia, and known
COVID-19 exposure.
Back to the day 3 xray:
On closer inspection,
very small pneumo
visible on day 3 xray.

41. PTX did not self-resolve.
Day 7: CT-guided chest
tube.
Red: Chest tube
entering through chest
wall (tip curves out of
plane)
Orange: Pneumothorax
Yellow: Air
bronchograms
Green: Densely
consolidated lung
Blue: Ground-glass
opacities

42. Pediatric Chest Tube
Recommendations
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
Acute blood or air can be drained with a pigtail catheter
For viscous pus or clotted blood, you may need a small
caliber thoracostomy tube. 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

43. Summary of This
Month’s Diagnoses
• Aortic aneurysm
• Aortic coarctation
• Aortic coarctation again
• Aspirated screw
• Ingested button battery
• VP shunt disruption with hydrocephalus
• Hemopneumothorax
• COVID-19 pneumonia with
pneumothorax
For more educational content, visit
EMGuidewire.com