apls pediatric emergency radiology 2
Post on 02-Jun-2015
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Hb1
Pediatric Emergency Radiology II
Hb2
Objectives•Identify the following conditions based on x-ray findings:
• Lobar emphysema• Vertebral compression
fractures• Pneumomediastinum• S aureus pneumonia• Ingested disk battery• Pneumatosis
intestinalis - necrotizing enterocolitis
• Midgut volvulus• Abdominal abscess
• Bowing fracture• Toddler fracture• Retropharyngeal abscess
and phlegmon• Infant skull sutures• Infant skull fractures• Leptomeningeal cyst• Syphilis of the bone• Rickets• Vascular rings• Discitis
Hb3
X-ray diagnosis? 2-week-old boy with respiratory distress.Tension pneumothorax was the initial interpretation.
What features speak against a tension pneumothorax?No penetrating trauma, no positive pressure ventilation.
No bradycardia, no hypotension. Hypoxia is modest.
Congenital Lobar Emphysema
Congenital Lobar Emphysema
Hyperexpanded left upper lobe, resembling a tension pneumothorax. This will not benefit from a chest tube.
Hb4
8 year old with abdominal pain for 2
weeks, back ache since
yesterday’s ballet practice.
8 year old with abdominal pain for 2
weeks, back ache since
yesterday’s ballet practice.
X-rays repeated8 days later.
X-rays repeated8 days later.
Multiple vertebral
body compression
fractures. Leukemia.
Multiple vertebral
body compression
fractures. Leukemia.
Hb5
Vertical air densities
Vertical air densities
Air filled aorto-pulmonarywindow
Air filled aorto-pulmonarywindow
Air outlining the trachea (air dissection around the trachea).
Vertical air densities in the mediastinum.
19-year-old with chest pain and grating
sound on auscultation.
Pneumomediastinum Hamman Sign
Pneumomediastinum Hamman Sign
Hb6
An abdominal series is obtained.An abdominal CT scan is done: Normal appendix.
Lower lung shows pleural effusion and
infiltrate.
His respiratory status worsens. CXR is repeated.
Large right pleural
effusion.What clinical entity is this
most consistent
with?
Rapid progression of worsening.Rapid development of large pleural effusion.
X-ray diagnosis? 6-year-old boy with fever, abdominal pain, tachypnea, suspected pneumonia.
Staphylococcus Aureus Pneumonia
Expect empyema, pneumothorax, blebs, fistula.
Hb7
Close-up view of the “coin.” Is it a penny?
Close-up view of the “coin.” Is it a penny?
20-month-old girl swallowed a coin (witnessed by 5-year-old cousin). Brief coughing episode. No symptoms at this time.
20-month-old girl swallowed a coin (witnessed by 5-year-old cousin). Brief coughing episode. No symptoms at this time.
Coin and battery lineupCoin and battery lineup
Ingested Disk
Battery
Ingested Disk
Battery
Hb8
Enlarged view: White arrows point at air dissecting within the bowel wall. Double density (“railroad tracks”).
Enlarged view: White arrows point at air dissecting within the bowel wall. Double density (“railroad tracks”).
3 day old premie with hematemesis.3 day old premie with hematemesis.
Air dissecting in the bowel wall.
Double outlining (railroad tracks).
Bubbles in the bowel wall.
Air dissecting in the bowel wall.
Double outlining (railroad tracks).
Bubbles in the bowel wall.
Obvious air dissecting within
bowel wall in a term infant.
Obvious air dissecting within
bowel wall in a term infant.
Pneumatosis Intestinalis
Due to Necrotizing
Enterocolitis (NEC)
Pneumatosis Intestinalis
Due to Necrotizing
Enterocolitis (NEC)
Hb9
This is an upper GI series using thin
barium.
Standard barium would demonstrate a “beak
sign” in which the contrast stops at the
gastric outlet or proximal duodenum.
X-ray diagnosis? 3-month-old with bilious vomiting.
Midgut Volvulus Complicating a Malrotation
(“guts on a stalk” syndrome)
Midgut Volvulus Complicating a Malrotation
(“guts on a stalk” syndrome)
Hb10
X-ray diagnosis? 4-year-old girl w/ abdominal pain for 3 days.
Enlarged view(darken the room)
Enlarged view(darken the room)
Arrows point to the peritoneal fat margins which mark edge
of peritoneal cavity. The bowel should be adjacent to the
peritoneal fat margin as in the LLQ. Note that in the RUQ and RLQ, the bowel is separated
from the peritoneal fat margin.
Arrows point to the peritoneal fat margins which mark edge
of peritoneal cavity. The bowel should be adjacent to the
peritoneal fat margin as in the LLQ. Note that in the RUQ and RLQ, the bowel is separated
from the peritoneal fat margin.
Arrows now point to the right sided separation between the bowel and the peritoneal fat
margin. Also note the scalloping of the liver edge.
Arrows now point to the right sided separation between the bowel and the peritoneal fat
margin. Also note the scalloping of the liver edge.
This separation is most likely caused by fluid (pus) on the right (from the RLQ to the
liver). The black arrow points at air within this pus.
This separation is most likely caused by fluid (pus) on the right (from the RLQ to the
liver). The black arrow points at air within this pus.
Rupture appendix. Right abdominal
abscess formation.
Rupture appendix. Right abdominal
abscess formation.
Hb11
X-ray diagnosis? 4-year-old girl who fell at the playground. X-ray diagnosis? 4-year-old girl who fell at the playground.
Bowing Fracture of the UlnaBowing Fracture of the Ulna
Her forearm is swollen with a moderate deformity. Her forearm is swollen with a moderate deformity.
Hb12
Another view is obtained.
Another view is obtained.
X-ray diagnosis?20 month old female, refuses to stand on her right leg. No known trauma except for falling while running.
X-ray diagnosis?20 month old female, refuses to stand on her right leg. No known trauma except for falling while running.
Thin oblique fracture of the distal tibia.
Thin oblique fracture of the distal tibia.
White arrows point to the fracture. Black arrows point to a vascular groove.
White arrows point to the fracture. Black arrows point to a vascular groove.
Child abuse or due to a fall? Child abuse or due to a fall?
Toddler Fracture(probably accidental)
Toddler Fracture(probably accidental)
Hb13
X-ray diagnosis?7 year old male with fever, sore throat, headache and neck stiffness, sent to the ED for possible meningitis.
An LP is done: normal. Lateral neck x-ray demonstrates bulging of the prevertebral soft tissue, suspected abscess.
An LP is done: normal. Lateral neck x-ray demonstrates bulging of the prevertebral soft tissue, suspected abscess.
False positives sometimes occur:
Prevertebral soft tissue appears wide.
Neck extension results in a normal prevertebral soft tissue appearance.
Position the neck properly to avoid false positives
Prevertebral soft tissue appears wide.
Neck extension demonstrates persistence of the prevertebral soft tissue widening.
The Step-Off sign is sometimes helpful
The back of the pharynx should NOT be in line with the trachea.
The back of the pharynx should NOT be in line with the trachea.
Note that the back of the pharynx is in line with the trachea.
Note that the back of the pharynx is in line with the trachea.
Normal Step-OffNormal Step-Off Abnormal: Step-Off is absentAbnormal: Step-Off is absent
CT scanning helps to define the type of abscess
Large, rim enhancement with contrast, anterior bulging.
Large, rim enhancement with contrast, anterior bulging.
Small, no rim enhancement, no anterior bulging.
Small, no rim enhancement, no anterior bulging.
True abscessTrue abscessPhlegmonPhlegmon
Prevertebral (retropharyngeal)
abscess
Prevertebral (retropharyngeal)
abscess
Hb14
Normal Infant Skull Sutures:
S=Sagittal, C=Coronal,
L=lambdoidal
Normal Infant Skull Sutures:
S=Sagittal, C=Coronal,
L=lambdoidal
Normal Infant Skull Sutures:C=coronal, L=lambdoidal, P=parietomastoid,
O=Occipitomastoid
Normal Infant Skull Sutures:C=coronal, L=lambdoidal, P=parietomastoid,
O=Occipitomastoid
Hb15
Right Parietal Skull FractureRight Parietal Skull FractureFind the skull fracture - Case 1Find the skull fracture - Case 1
Hb16
Find the skull fracture - Case 2
Find the skull fracture - Case 2
Right Occipital Skull FractureRight Occipital Skull Fracture
Hb17
Find the skull fracture - Case 3Find the skull fracture - Case 3
AP viewsAP viewsLateral viewsLateral viewsRight Occipito-parietal Skull FractureRight Occipito-parietal Skull Fracture
Hb18
Find the skull fracture - Case 4Find the skull fracture - Case 4
AP viewsAP views
Lateral viewsLateral viewsDepressed Skull FractureDepressed Skull Fracture
Hb19
Find the skull fracture - Case 5Find the skull fracture - Case 5
Right Occipital Skull FractureRight Occipital Skull Fracture
Hb20
AP viewsAP viewsLateral viewsLateral views
Find the skull fracture - Case 6Find the skull fracture - Case 6
Right Parietal Skull FractureRight Parietal Skull Fracture
Hb21
AP viewsAP viewsLateral viewsLateral views
Find the skull fracture - Case 7Find the skull fracture - Case 7
Parietal Skull FractureParietal Skull Fracture
Hb22
AP viewsAP viewsLateral viewsLateral views
Find the skull fracture - Case 8Find the skull fracture - Case 8
Biparietal Skull FractureBiparietal Skull Fracture
Hb23
Case 9:10-month-old
boy fell and sustained a
parietal skull fracture
3 months ago. He is
neurologically normal but
has a persistent soft
area inregion of fracture.
Case 9:10-month-old
boy fell and sustained a
parietal skull fracture
3 months ago. He is
neurologically normal but
has a persistent soft
area inregion of fracture.
Leptomeningeal Cyst(growing skull fracture)Leptomeningeal Cyst
(growing skull fracture)
Hb24
Destructive lytic lesions of the distal radius and ulna. Periosteal elevation of the radius and ulna.
Destructive lytic lesions of the distal radius and ulna. Periosteal elevation of the radius and ulna.
2-month-old girl who is not using her right arm today. No history of trauma. Wrist swelling noted 2 days ago.2-month-old girl who is not using her right arm today. No history of trauma. Wrist swelling noted 2 days ago.
A skeletal survey is obtained. Humerus and
elbows are normal.
Femurs are shown here.
A skeletal survey is obtained. Humerus and
elbows are normal.
Femurs are shown here.
Periosteal elevation along the length of
both femurs.
Periosteal elevation along the length of
both femurs.
Both tibiae and fibulae are shown here.
Both tibiae and fibulae are shown here.
Periosteal elevation along the length of both
tibiae. Destructive lesions of the proximal
tibiae and the left fibula.
Periosteal elevation along the length of both
tibiae. Destructive lesions of the proximal
tibiae and the left fibula.
Syphilis of the Bone
Syphilis of the Bone
Hb25
2-year-old boy with chronic liver disease with persistent forearm swelling 3 days after falling.
2-year-old boy with chronic liver disease with persistent forearm swelling 3 days after falling.
Rickets(vitamin D malabsorption)
Rickets(vitamin D malabsorption)
Severe demineralization:Mid-radius fracture
Ulnar bowing
Severe demineralization:Mid-radius fracture
Ulnar bowing
Hb26
6-month-old boy with difficulty breathing.Frequent noisy breathing episodes since birth.
6-month-old boy with difficulty breathing.Frequent noisy breathing episodes since birth.
Lateral neck
radiograph is obtained.
Tracheal size
appears to be normal or slightly
narrow.
Lateral neck
radiograph is obtained.
Tracheal size
appears to be normal or slightly
narrow.
Examine the
tracheal diameter
on the CXR.
Examine the
tracheal diameter
on the CXR.
Very narrow on the lateral view.
Very narrow on the lateral view.
A barium swallow
identifies a mass
posterior to the
esophagus
A barium swallow
identifies a mass
posterior to the
esophagus
Vascular “rings” encircle the trachea and esophagus. Two common types: double aortic arch and right sided aortic arch.
Vascular “rings” encircle the trachea and esophagus. Two common types: double aortic arch and right sided aortic arch.
Examine bend of trachea near
bifurcation. If it bends
toward the left, this suggests a
right-sided aortic arch.
Examine bend of trachea near
bifurcation. If it bends
toward the left, this suggests a
right-sided aortic arch.
Vascular Ring(tracheal and esophageal
compression)
Vascular Ring(tracheal and esophageal
compression)
Hb27
Following coin removal, persistent stridor is noted. PMH: frequent episodes of noisy breathing since birth.
Following coin removal, persistent stridor is noted. PMH: frequent episodes of noisy breathing since birth.
His trachea is narrow on the lateral CXR.This finding persists on a repeat CXR.
His trachea is narrow on the lateral CXR.This finding persists on a repeat CXR.
An esophagram identifies a mass posterior to the
esophagus.
An esophagram identifies a mass posterior to the
esophagus.
X-ray diagnosis? 10-month-old boy who swallowed a coin presents with noisy breathing.
X-ray diagnosis? 10-month-old boy who swallowed a coin presents with noisy breathing.
Esophageal Coin With a Vascular Ring
Esophageal Coin With a Vascular Ring
Hb28
Narrowed inter-vertebral space.
Narrowed inter-vertebral space.
Repeat views takenRepeat views taken
X-ray diagnosis?
8-year-old boy with chief
complaint of fever.
On exam, he is noted to have reproducible
tenderness over his upper
thoracic spine.
X-ray diagnosis?
8-year-old boy with chief
complaint of fever.
On exam, he is noted to have reproducible
tenderness over his upper
thoracic spine.
DiscitisDiscitis
Hb29
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