![Blood cultures were [+]
for Candida
Diagnosis: fungemia
Don’t forget your fungal
coverage for kiddos on
TPN!](https://image.slidesharecdn.com/pediatricchestx-raysofthemonth-april2021-gibbsolsonedits-210505190322/85/Drs-Olson-s-and-Jackson-s-CMC-Pediatric-X-Ray-Mastery-April-Cases-16-320.jpg)
![Hospital course:
• Ileitis seen incidentally
on hip MRI
• Blood cultures [-]
• Ferritin of 2000
• ESR 50, CRP 10
• Torso rash develops
Ultimate Diagnosis?](https://image.slidesharecdn.com/pediatricchestx-raysofthemonth-april2021-gibbsolsonedits-210505190322/85/Drs-Olson-s-and-Jackson-s-CMC-Pediatric-X-Ray-Mastery-April-Cases-22-320.jpg)
![Hospital course:
• Ileitis seen incidentally
on hip MRI
• Blood cultures [-]
• Ferritin of 2000
• ESR 50, CRP 10
• Torso rash develops
Systemic JIA](https://image.slidesharecdn.com/pediatricchestx-raysofthemonth-april2021-gibbsolsonedits-210505190322/85/Drs-Olson-s-and-Jackson-s-CMC-Pediatric-X-Ray-Mastery-April-Cases-23-320.jpg)
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Drs. Olson’s and Jackson’s CMC Pediatric X-Ray Mastery: April Cases
- 1. Pediatric Chest X-Rays of the Month Kendra Jackson, MD & Elizabeth Olson, MD Departments of Pediatrics & Emergency Medicine Carolinas Medical Center & Levine Children’s Hospital Nicholena Richardson, MD & Mary Grady, MD, Faculty Editors Michael Gibbs, MD, Senior Editor Chest X-Ray Mastery Project April 2021
- 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 For more educational content, visit EMGuidewire.com
- 5. 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 Diagnosis? Review
- 6. 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 R. Tension Pneumothorax Review
- 7. • Tracheal deviation • Left pleural effusion • Right pneumothorax • “Deep Sulcus Sign” A tension pneumothorax is life-threatening and if clinically suspected, it should be treated with needle decompression before a chest X-ray is obtained.
- 8. 10-year-old previously healthy male presents with fever, diarrhea, tachycardia and hypotension What’s the X-ray finding?
- 9. Remember Your ABCs Airway: Bone: Cardiac: Diaphragm: Effusions: Fields/Foreign Bodies: Gastric bubble: Hila:
- 10. Remember Your ABCs Airway: Patent, midline Bone: No fractures Cardiac: Normal silhouette Diaphragm: Symmetric Effusions: None Fields/Foreign Bodies: Clear lung fields Gastric bubble: Normal Hila: No lymphadenopathy
- 11. ED Course: tachycardia and hypotension are unresponsive to fluids. POCUS1 reveals moderately depressed cardiac function. Leading Diagnosis? 1POCUS = Point-Of-Care-Ultrasound
- 12. Diagnosis: Multisystem Inflammatory Syndrome in Children (MIS-C) Clinical pearl: a negative chest X-ray does not rule out this diagnosis.
- 13. 15-year-old male with CF, nocturnal BiPaP, and TPN dependence presents with fatigue, malaise, and sore throat Interpret this CXR
- 14. Airway: Patent Bone: Normal Cardiac: Normal Diaphragm: L lower than R Effusions: None Fields/Foreign Bodies: RLL consolidation. Central line present in the R atrium Gastric bubble: Present Hila: Stable
- 15. Our 15-year-old was admitted, respiratory and blood cultures were obtained, and he was start on cefepime and fluconazole. He developed increased WOB on the floor Diagnosis?
- 16. Blood cultures were [+] for Candida Diagnosis: fungemia Don’t forget your fungal coverage for kiddos on TPN!
- 17. 5-year-old male presenting with respiratory distress in the setting of joint pain, fatigue, and fever for two weeks Spot the abnormality
- 18. 5-year-old male presenting with respiratory distress in the setting of joint pain, fatigue, and fever for two weeks CXR interpretation: Mild cardiomegaly
- 19. After 48 hours in the hospital our 5-year-old now develops hypotension and distant heart sounds Spot the abnormality
- 20. Our 5-year-old has been admitted for 48 hours and develops hypotension and distant heart sounds Holy moly guacamole… that’s cardiomegaly!
- 21. Diagnosis? Cardiac tamponade until proven otherwise
- 22. Hospital course: • Ileitis seen incidentally on hip MRI • Blood cultures [-] • Ferritin of 2000 • ESR 50, CRP 10 • Torso rash develops Ultimate Diagnosis?
- 23. Hospital course: • Ileitis seen incidentally on hip MRI • Blood cultures [-] • Ferritin of 2000 • ESR 50, CRP 10 • Torso rash develops Systemic JIA
- 24. Pediatric Rheumatology Pearls A family history is key Check the joints! Know the pGALS exam? AKA Pediatric Gait, Arms, Legs, and Spine Stiff joints in kiddos = not normal Stiffness better with exercise? Fever timing – persistent despite infectious work up, morning or nighttime (when serum cortisol is naturally the lowest)
- 25. Foster, H.E., Jandial, S. pGALS – paediatric Gait Arms Legs and Spine
- 26. Pediatric Rheumatology Pearls Foster, H.E., Jandial, S. pGALS – paediatric Gait Arms Legs and Spine: a simple examination of the musculoskeletal system. Pediatr Rheumatol 11, 44 (2013). https://doi.org/10.1186/1546-0096-11-44
- 27. 12-year-old presents after a strangulation event Spot the abnormality
- 28. 12-year-old presents after a strangulation event CXR Interpretation: Clear lung fields. ET tube at T-3, half-way between carina and the thoracic outlet
- 29. The patient later developed high peak pressures and desaturates on the ventilator. Pink froth in the ET tube. What is this clinical phenomena?
- 30. The patient later developed high peak pressures and desaturates on the ventilator. Pink froth in the ET tube. Post-obstructive pulmonary edema Physiology?
- 31. Negative-Pressure Pulmonary Edema CHEST 2016 150927-933DOI: (10.1016/j.chest.2016.03.043) Attempts to inhale against an upper airway obstruction leads to extreme negative intrathoracic pressures This leads to ↑ RV preload and afterload, then higher pulmonary venous pressures This ↑ capillary hydrostatic pressures, causing leaking into the alveolar space
- 32. On hospital day 2 in the PICU, our 12-year-old developed low tidal volumes and hypoxia Spot the abnormality
- 33. On hospital day 2 in the PICU, our 12-year-old developed low tidal volumes and hypoxia Bilateral pneumothoraces
- 34. Bilateral chest tubes were placed Identify the radiographic findings
- 35. Remember your ABCs Airway: ETT @ T3 Bone: No fractures Cardiac: Normal Silhouette Diaphragm: R>L Effusions: Unclear, CXR does not visualize Fields/Foreign Bodies: Diffuse bilateral haziness, NG tube, 2 pigtails, central line in R atrium Gastric bubble: Difficult to assess Hila: Difficult to assess
- 36. 3-year-old girl presents after falling on a hunting knife at home Spot the abnormality
- 37. 3-year-old girl presents after falling on a hunting knife at home Subcutaneous air present Note: Lung herniation on exam
- 38. Radiology Interpretation: No focal consolidation, pleural effusion or pneumothorax. Cardiomediastinal morphology is normal. Osseous structures are unremarkable. “No acute cardiopulmonary abnormality.” Lesson: read your own films! Also.. don’t forget to consult Social Work and the Child Protection Team to rule out non-accidental trauma (NAT).
- 39. 7-month-old female seen three times for nasal congestion and wheezing presenting again one month later with respiratory distress. Interpret the CXR
- 40. Clear lung field with no hyperinflation. Normal thymus 7-month-old female seen three times for nasal congestion and wheezing presenting again one month later with respiratory distress.
- 41. 8-month-old girl who was recently admitted for viral bronchiolitis 2 weeks ago presents in respiratory distress Spot the abnormality
- 42. 8-month-old girl who was recently admitted for viral bronchiolitis presents in respiratory distress Right upper load consolidation with air bronchogram
- 43. Our 8-month-old girl was re-admitted to the PICU and received one dose of ampicillin Interpret the chest X-ray
- 44. Our 8-month-old girl was re-admitted to the PICU and and received one dose of ampicillin. Of note, Dad has a history of severe asthma. The infant is responsive to albuterol. Perihilar thickening with hyperinflation
- 45. Our 8-month-old girl was re-admitted to the PICU and got x1 dose of ampicillin. Of note, Dad has a history of severe asthma. The infant is responsive to albuterol What is the most likely diagnosis?
- 46. Our 8-month-old girl was re-admitted to the PICU and got x1 dose of ampicillin. Of note, Dad has a history of severe asthma. The infant is responsive to albuterol The clinical diagnosis is most consistent with asthma, triggered by a URI
- 47. Summary of This Month’s Diagnoses • Tension pneumothorax with deep sulcus sign (Review) • Normal CXR, MISC • Fungal pneumonia • Systemic JIA with large pericardial effusion • Post-obstructive pulmonary edema • Subcutaneous air and lung herniation • Thymus appropriate for age • RUL infiltrated with air bronchograms • Perihilar thickening and hyperinflation (in newly diagnosed asthma) For more educational content, visit: EMGuidewire.com