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: • Scoliosis • Pneumothorax • Parapneumonic Effusion • Cardiomegaly • Vaping associated lung injury

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
October 2019

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. Process
 Many are providing cases and these slides are shared with all contributors.
 Contributors from many CMC departments, and soon… Tanzania and Brazil.
 Cases submitted this week will be distributed next week.
 When reviewing the presentation, the 1st image will show a chest X-ray
without identifiers and the 2nd image will reveal the diagnosis.

4. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Chest X-Ray Presentations And Much More!

5. 10 year old female with history
of severe scoliosis.
What are the pulmonary
complications associated with
severe scoliosis?

6. After stage I of the repair

7. 13 year old female
presented to the
emergency
department after
a car accident with
complaint of Chest
Pain
Dx: ?

8. 13 year old female
presented to the
emergency
department after
a car accident with
complaint of Chest
Pain
Dx: L apical
penumothorax

9. After placement of
L sided pigtail
catheter

10. 15 year old male with history of
Pierre Robin Syndrome, skeletal
dysplasia, and asthma
presented to the emergency
department for one day of
chest tightness and shortness
of breath. Initial ED vital signs
Heart Rate: 133
Respiratory Rate: 26
SpO2: 93%
Blood Pressure: 122/77
Dx: ?

11. 15 year old male with history of
Pierre Robin Syndrome, skeletal
dysplasia, and asthma
presented to the emergency
department for one day of
chest tightness and shortness
of breath. Initial ED vital signs
Heart Rate: 133
Respiratory Rate: 26
SpO2: 93%
Blood Pressure: 122/77
Dx: R penumothorax
Notice the flattening of the R
hemidiaphragm, which suggests
a degree of tension physiology

12. After placement of R
sided pigtail catheter

13. 15 year old male with
presented to the Emergency
Department after stab wound
to the R posterior shoulder.
Vital Signs: Stable
Physical Exam: Decreased
breath sounds on R
EFAST: No lung sliding on R
Dx: ?

14. 15 year old male with
presented to the Emergency
Department after stab wound
to the R posterior shoulder.
Vital Signs: Stable
Physical Exam: Decreased
breath sounds on R
EFAST: No lung sliding on R
Dx: R pneumothorax with
subcutaneous emphysema

15. After
placement of R
sided pigtail
catheter with
residual 10 mm
apical PTX

16. Pediatric Pneumothorax - Diagnosis
• In the case of spontaneous pneumothorax:
• Children are typically 10-17 year old males with a history of asthma or tobacco abuse
• Most patients will present with acute onset of chest pain and shortness of breath,
although the majority actually present in a delayed fashion
• Diagnostic tools:
• Supine CXR has only ~50% sensitivity, increases wot ~90% with use of erect CXR
• Ultrasound has an ~90% sensitivity, which may increase to 99% when used by a trained
and experienced operator
Pediatric EM Morsels – Spontaneous pneumothorax
When using M mode, the “barcode sign” indicates a
PTX while the “seashore sign” or “waves on a beach”
indicates normally aerated lung
Click here for a
demonstration of
thorax ultrasound by
Dr. Tony Weeks

17. Pediatric Pneumothorax - Treatment
• When preforming open thoracostomy, remember that the small rib
spaces may prevent you from inserting your finger into the intercostal
space. The narrow intercostal space also exposes the neurovascular
bundle, making complications more likely
• The pediatric mediastinum is more mobile, and the intrathoracic
pressures are more readily transmitted to the right atrium, making it
more likely that these patient will have decreased cardiac output or
tension physiology
• Despite this, emergent thoracostomy is rarely required in children!
• Does it need to be drained?
• Small pneumothoraces (some have said up to 20%, but no good pediatric studies
available) can be managed conservatively
Pediatric EM Morsels – Traumatic pneumothorax

18. Pediatric Chest Tube Recommendations
• Consider what is it you have to drain
• Acute blood or air can easily be drained with a pigtail
catheter
• If it is expected to be viscous, you may need a small
caliber thoracostomy tube, however 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
1. 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
From April’s
Presentation!

19. 14 year old female with history
of scoliosis who presented to
the emergency department
with shortness of breath, cough
and intermittent fever.
Dx: ?

20. 14 year old female with history
of scoliosis who presented to
the emergency department
with shortness of breath, cough
and intermittent fever.
Dx: Paraneumonic Effusion

21. After left sided video
assisted thoracoscopic
surgery with persistent
left sided chest tube
Notice decreased size of
left sided loculated
pleural effusion

22. One month post-procedure
patient seen in follow-up with
small residual left sided pleural
effusion with no residual
airspace consolidation

23. 7 year old male with past medical history of
SMA, tracheomalacia, trach/vent dependence
presented to the emergency department with 3
days of shortness of breath, fever, and cough.
Initial ED vital signs:
HR: 150
RR: 18
BP: 105/80
SpO2: 93%
AP CXR shows no significant
consolidation

24. Lateral CXR shows no dense RLL
retrocardiac opacity consistent
with pneumonia
Lesson: If no consolidation seen on AP
and clinical picture fits, obtain lateral
film to evaluate retrocardiac space!

25. Case 1: 2 week old male presented to the
emergency department with tachypnea
and increased work of breathing.
ED Vital Signs:
HR: 166
BP: 82/69
SpO2: 96%
RR: 81
Afebrile
AP CXR shows significantly
enlarged cardiac silhouette

26. Case 2: 2 week old male
presented to the emergency
department with intermittent
increased work of breathing.
ED Vital Signs:
HR: 163
BP: 63/39
SpO2: 96%
RR: 42
Afebrile
AP CXR shows mild
cardiomegaly

27. What is the next step?
Obtain an echocardiogram to better evaluate cardiac function

28. Echocardiograms
Case 1
• Severe pulmonary hypertension
with R heart dilation and flattened
interventricular septum
• Severe tricuspid regurgitation
• Moderate mitral valve
regurgitation
• Patent foramen ovale with right-to-
left shunting
• Small patent ductus arteriosus with
primary right to left shunting
Case 2
• Normal echocardiogram

29. What’s the difference
between these two CXRs?

30. What’s the difference
between these two CXRs?
It’s the thymus!

31. Differentiating the Thymic Shadow
“thymic sail sign” is a triangular extension of the
normal thymus laterally
The anterior reflections
of the ribs produce a wavy
contour of the thymus
known as the “thymus
wave sign”
The inferior margin of the
thymus merges with the
margin of the cardiac
silhouette, producing the
“notch sign”
Manchanda, Smita, et al. “Imaging of the Pediatric Thymus: Clinicoradiologic Approach.” World Journal of Clinical
Pediatrics, Baishideng Publishing Group Inc, 8 Feb. 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5296624/.
From April’s
Presentation!

32. Notch Sign
Wave sign
Review the CXR from Case 2 with the thymic
shadow indications in mind:

33. Follow-up from Case #1
• Congestive heart failure in the newborn period is rare, and most often
related to congenital structural heart disease, however the differential
diagnosis is broad and includes arrhythmias, congenital or acquired
myopathies, sepsis, severe anemia, or conditions leading to high-output
heart failure
• Causes of high output heart failure in the pediatric population includes
AVM (hemangiomas, venous malformations), cirrhosis, carcinoid
syndrome hyperthyroidism, myeloproliferative disorders, Beriberi, sepsis,
mitochondrial disease, and many others
Merritt, Chris, et al. “A Neonate With High-Outflow Congestive Heart Failure and Pulmonary
Hypertension Due to an Intracranial Arteriovenous Malformation.” Pediatric Emergency Care,
vol. 27, no. 7, 2011, pp. 645–648., doi:10.1097/pec.0b013e3182225679.

34. Follow-up from Case #1
• Vein of Galen aneurysmal malformations are rare congenital anomalies that constitute 1% of
all intracranial vascular malformations
• Due to a persistent embryonic median vein of prosencephalon
• In utero, the placental circulation provides a low-resistance path preventing cardiac damage from fluid
overload
• With loss of the placenta at birth, up to 70% of the cardiac output is directed to the low resistant Vein of
Galen Malformation AV shunt which allows direct return of large flow volume to the right heart
Gupta, AK, Varma, DR Vein of Galen malformations: Review.. Neurol India. (2004). 52 43–53
Li, AH, Armstrong, D, terBrugge, KG Endovascular treatment of vein of Galen aneurysmal malformation: Management strategy and 21-year
experience in Toronto.. J Neurosurg Pediatr. (2011). 7 3–10
MRA from our case
showing dilation of the
median prosencephalic
vein draining in to a
persistent falcine sinus =
Vein of Galen
Malformation

35. Our Last Case Is An Adult
Example Of New Disease State
That Is Being Seen In Both
Adults And Children!

36. 33 Year Old
Previously
Healthy Male
With A History Of
Nicotine/THC
Vaping Presents
With Severe
Dyspnea &
Hypoxia
Bilateral Airspace
Disease On CXR
Diagnosis?

37. E-Cigarette Associated Pneumonitis
33 Year Old
Previously
Healthy Male
With A History Of
Nicotine/THC
Vaping Presents
With Severe
Dyspnea &
Hypoxia

38. 33 Year Old With A History Of Vaping Presents With Severe Dyspnea
E-Cigarette Associated Pneumonitis

39. E-Cigarette
Associated
Pneumonitis
3 Days Later
Symptoms
Improved

40. Published On September 6, 2019, at NEJM.org

41. E-Cigarette Associated Lung Injury
• Between 2017 and 2018, the prevalence of e-cigarette use increased
from 11.7% to 20.8% amongst U.S. high school students.
• Pulmonary illnesses related to e-cigarettes have been reported, but
no larger series have been described previously.
• In July 2019, the Wisconsin Department of Health Serves received
reports of pulmonary disease associated with vaping.
• The authors describe the demographic and outcome characteristics of
53 patients; representing the largest published case series to date.

43. Demographic Characteristics (n=53)
Median age 19 (16-53)
Male sex 83%
White race 82%
Reported nicotine use 61%
Reported THC use 80%
Reported nicotine & THC use 44%

44. Symptoms Reported On Presentation
Median duration of symptoms 6 days (0-61)
Any Respiratory Symptoms
Shortness of breath
Chest pain
Cough
Hemoptysis
98%
87%
55%
83%
11%
Subjective fever 81%
Chills 58%
Nausea 70%
Vomiting 66%

45. Vital Signs At Presentation
Temperature >38° C 29%
Heart rate >100 beats/min 64%
Respiratory rate >20 breaths/min 82%
Oxygen saturation:
≥95%
89-94%
≤88%
31%
38%
31%

46. Initial Laboratory Results
WBC >11000/mm3 87%
WBC >80% neutrophils 94%
ESR >30 mm/hr 93%
Initial Radiographic Finding
Abnormal chest X-ray 91%
Abnormal chest CT 100%
Bilateral infiltrates on CT 100%

47. Treatment
Antibiotics during hospitalization 90%
Steroids during hospitalization 92%
IV steroids during hospitalization 83%
Clinical Course
Hospitalization 94%
Non-invasive ventilation 36%
Endotracheal intubation 32%
Death 1/53 (2%)

48. Published On September 6, 2019, at NEJM.org
Identical To Our Patient!

49. The Vapors Are Viscous!
E-cigarette liquids have been shown to contain a variety of chemicals
that may have adverse health effects:
• Propylene glycol
• Glycerin
• Polycyclic aromatic hydrocarbons
• Volatile organic and inorganic chemicals
• Toxic metals
• Flavoring compounds that may cause adverse effects

50. Monitoring The Future Survey™
National survey of 8th, 10th and 12th graders assessing vaping trends:
2017
2018
2019
43,703
44,482
43,531
Prevalence of use more than doubled between 2017 and 2019!

52. n integrated view of the
ydiseaseoutbreak since
ted online information
ncluding news aggrega-
and validated official
assified the data by dis-
me.3
Figure1 shows the
ed and suspected cases
ease from vaping over
States. The first 8 sus-
ed byour onlinemining
g) on July 25, 2019, in
8, a total of 119 con-
eshad been detected in
more than doubled by
ing a total of 288 cases
ptember 11, cases had
nning 39 states and the
compoundsof e-cigaretteliquids, adulteration of
devices with tetrahydrocannabinol (THC)–based
oilsor vitamin E, and useof black market vaping
products.1,4
Findingsfrom thisreport suggest that
vaping-associated pulmonary disease cases have
reached epidemic proportions. Incident cases con-
tinueto rise. Further surveillanceis necessary to
monitor the development and spread of this vap-
ing-related outbreak.
Yulin Hswen, M.P.H., Sc.D.
John S. Brownstein, Ph.D.
Innovation Program, Boston Children’sHospital
Boston, MA
yuh958@mail.harvard.edu
Disclosure forms provided by the authors are available with
thefull text of thisletter at NEJM.org.
This letter was published on September 20, 2019, at NEJM.org.

57. Summary of this month’s diagnoses
• Scoliosis
• Pneumothorax
• Parapneumonic Effusion
• Cardiomegaly
• Vaping associated lung injury