![Kids are not just little
adults!!!
Mandt MJ et al. Appropriate needle length for emergent pediatric needle thoracostomy utilizing
computed tomography. Prehosp Emerg Care 2019 Jan 9; 1; [e-pub].
(https://doi.org/10.1080/10903127.2019.1566422)
A standard angiocatheter length of 3.8 cm
should be sufficient for most pediatric patients
for needle decompression](https://image.slidesharecdn.com/pediatricchestx-raysofthemonthaugust-200817195925/85/Drs-Olson-s-and-Jackson-s-CMC-Pediatric-X-Ray-Mastery-August-Cases-13-320.jpg)
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Drs. Olson’s and Jackson’s CMC Pediatric X-Ray Mastery: August Cases
- 1. Pediatric Chest X-Rays of the Month Kendra Jackson, MD & Elizabeth Olson, MD Department of Pediatrics & Department of Emergency Medicine Levine Children’s Hospital & Carolinas Medical Center Michael Gibbs, MD, Faculty Editor Nicholena Richardson, MD, Junior Faculty Editor Chest X-Ray Mastery Project August 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 For more educational content, visit EMGuidewire.com
- 5. HPI: 11 yo presenting with hypertension, a new murmur, and decreased femoral pulses What’s the xray finding? What’s the diagnosis?
- 6. REVIEW HPI: 11 yo presenting with hypertension, a new murmur, and decreased femoral pulses Xray finding: Rib notching. Diagnosis: Aortic coarctation
- 7. Coarctation Quick Tips If the obstruction caused by a coarc that is not severe, collateral arteries will enlarge and create INFERIOR rib notches Older children can be relatively asymptomatic Look for associated left-sided lesions (mitral stenosis, bicommissural aortic valve) http://www.pted.org/?id=coarctation4
- 8. Clinical Pearl: Pediatric Hypertension 1.Pediatric hypertension is not always pain. About 3.5% of kids have hypertension 2.Re-check manually with an appropriately sized cuff 3.Encourage follow with PCP for BP recheck for incidental HTN
- 10. HPI: 3 mo with history of CPAM s/p VATS presents with poor PO, now intermittently tachypneic Spot the abnormality.
- 11. HPI: 3 mo with history of CPAM s/p VATS presents with poor PO, now intermittently tachypneic Diagnosis: Tension Pneumothorax Pearl: Poor feeding can also be a sign of respiratory distress
- 12. HPI: 3 mo with history of CPAM s/p VATS presents with poor PO, now intermittently tachypneic. Still on room air! Since the patient was so clinically stable, he had a pigtail placed under conscious sedation instead of a needle decompression
- 13. Kids are not just little adults!!! Mandt MJ et al. Appropriate needle length for emergent pediatric needle thoracostomy utilizing computed tomography. Prehosp Emerg Care 2019 Jan 9; 1; [e-pub]. (https://doi.org/10.1080/10903127.2019.1566422) A standard angiocatheter length of 3.8 cm should be sufficient for most pediatric patients for needle decompression
- 14. REVIEW from July 2020
- 15. HPI: 17-year-old with a hx of lupus presents with fever and back pain She later endorsed chest pain and body aches Spot the abnormality
- 16. HPI: 17-year-old with a hx of lupus presents with fever and back pain She later endorsed chest pain and body aches What could this be? What’s next?
- 17. HPI: 17-year-old with a hx of lupus presents with fever and back pain She later endorsed chest pain and body aches Diagnosis: COVID with wedge pneumonia
- 18. HPI: 5-month-old with a history of congenital heart disease presents with apnea Spot the abnormality
- 19. HPI: 5-month-old with a history of congenital heart disease presents with apnea Findings: boot shaped heart, cardiomegaly, and sternotomy ties
- 20. HPI: 5-month-old with a history of congenital heart disease presents with apnea What could this be? What’s congenital heart problem do they have?
- 21. HPI: 5-month-old with a history of congenital heart disease presents with apnea Diagnosis: COVID in a child with a history of Tetralogy of Fallot
- 22. HPI: 4-year-old w/ a h/o transposition of the great arteries presents with worsening difficulty breathing, wheezing, and decreased activity Spot the abnormality
- 23. HPI: 4-year-old w/ a h/o transposition of the great arteries presents with worsening difficulty breathing, wheezing, and decreased activity Findings: Perihilar edema and moderate cardiomegaly
- 24. HPI: 4-year-old w/ a h/o transposition of the great arteries presents with worsening difficulty breathing, wheezing, and decreased activity Name that hardware!
- 25. HPI: 4-year-old w/ a h/o transposition of the great arteries presents with worsening difficulty breathing, wheezing, and decreased activity Sternotomy ties and a biventricular pacemaker Teaching point: Up to 45% of people with Corrected Transposition of the Great Arteries will have complete AV block
- 26. HPI: 4-year-old w/ a h/o transposition of the great arteries presents with worsening difficulty breathing, wheezing, and decreased activity What’s your diagnosis?
- 27. Additional history: This child’s father works in construction and he takes Lasix daily. Diagnosis: COVID and heart failure in the setting of worsening tricuspid regurgitation
- 28. Sometimes there is more than one diagnosis…
- 29. HPI: 10 year old presents in respiratory distress What additional history is needed?
- 30. Additional History: Their entire family was sick 1 month ago with URI symptoms What radiographic findings are present? What is the diagnosis?
- 31. Additional History: Their entire family was sick 1 month ago with URI symptoms Xray finding: bilateral white-out Diagnosis: ARDS secondary to Multisystem Inflammatory Syndrome in Children (MIS-C)
- 32. HPI: 10 yo F previously presenting in respiratory distress. Her entire family was sick 1 month ago with URI symptoms Name those lines A C B
- 33. HPI: 10yo F previously presenting in respiratory distress. Her entire family was sick 1 month ago with URI symptoms A: VA ECMO Cannula B: ET Tube C: Nasogastric Tube A C B
- 34. HPI: 23-month-old presents with coughing after aspirating a peanut 5 days ago Spot the abnormalities
- 35. HPI: 23-month-old presents with coughing after aspirating a peanut 5 days ago A. Normal thymus B. Aspiration pneumonia A B
- 36. Post Op: After bronchoscpy and removal of peanut and was unable to be extubated. Exam: Pink froth from ET tube What is the diagnosis now?
- 37. Post Op: After bronchoscpy, the patient was unable to be extubated Exam: Pink froth from ET tube Diagnosis: Mild PARDS after foreign body aspiration
- 38. New Pediatric ARDS Definition Cheifetz, IM. Pediatric ARDS. Respiratory Care Jun 2017, 62 (6) 718-731; DOI: 10.4187/respcare.05591 Age: Outside of the perinatal period Timing: 7 days from known clinical insult Origin of Edema: Respiratory failure not secondary to cardiac failure or fluid overload Radiographic Findings: New infiltrates consistent with parenchymal disease
- 39. Orloff KE, Turner DA, Rehder KJ. The Current State of Pediatric Acute Respiratory Distress Syndrome. Pediatr Allergy Immunol Pulmonol. 2019;32(2):35-44. doi:10.1089/ped.2019.0999 Bacterial or viral pneumonia COVID Sepsis Foreign body aspiration Acute chest syndrome Pancreatitis Trauma Lots of things can cause PARDS... Drowning Burns Inhalation Injury Vaping Drug Overdose Fat Emboli Massive blood transfusions
- 40. HPI: 14-month-old presents with Fever, Cough, And Emesis
- 41. HPI: 14-month-old presents with Fever, Cough, And Emesis Diagnosis: Aspiration pneumonia with foreign body in the right main stem
- 42. HPI: 1-year-old presents after his sister was found to be a victim of NAT What is the diagnosis? Differential?
- 43. HPI: 1-year-old presents for NAT evaluation Findings: Corner Fracture of the proximal humerus and normal thymus tissue
- 44. HPI: 1-year-old presents for NAT evaluation Dedicated humerus x- ray demonstrating corner fracture - High suspicion for NAT
- 45. High Suspicion Findings on CXR Advice Evaluating Children With Fractures for Child Physical Abuse Emalee G. Flaherty, Jeannette M. Perez-Rossello, Michael A. Levine, William L. Hennrikus, and the AMERICAN ACADEMY OF PEDIATRICS COMMITTEE ON CHILD ABUSE AND NEGLECT, SECTION ON RADIOLOGY, SECTION ON ENDOCRINOLOGY, SECTION ON ORTHOPAEDICS, the SOCIETY FOR PEDIATRIC RADIOLOGY Pediatrics Feb 2014, 133 (2) e477-e489; DOI: 10.1542/peds.2013-3793 If a child presents with injuries with a high suspicion for NAT, a STAT evaluation and skeletal surveys should be performed on all sibling who are: 1. Non-verbal 2. Developmentally delayed 3. 2 years old or younger • Posterior or lateral rib fractures • Corner, also known as Bucket Handle fractures that are caused by shaking or twisting • Fractures in differing stages of healing • Fractures of the scapula • Fractures of the sternum • Humeral shaft fractures in a child younger than 18 months
- 46. Summary of This Month’s Diagnoses • Aortic coarctation (review) • Tension pneumothorax • Pneumonia, COVID+ • Tetralogy of Fallot, COVID+ • L- Transposition of the Great Arteries, COVID+ • Pediatric ARDS in MIS-C • Mild Pediatric ARDS after foreign body aspiration • Aspiration pneumonia • Corner fracture in non-accidental trauma For more educational content, visit EMGuidewire.com