Pediatric Emergency Radiology

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Library of Congress Cataloging-in-Publication Data
Names: Dietrich, Ann M., editor. | Sreedher, Gayathri, editor.
Title: Pediatric emergency radiology / editor, Ann Dietrich; associate editor, Gayathri Sreedher.
Description: New York, NY : Oxford University Press, [2023] |
Includes bibliographical references and index.
Identifiers: LCCN 2022040656 (print) | LCCN 2022040657 (ebook) |
ISBN 9780197628553 (paperback) | ISBN 9780197628577 (epub) |
ISBN 9780197628584 (online)
Subjects: MESH: Emergencies | Child | Infant | Radiology |
Pediatric Emergency Medicine | Case Reports
Classification: LCC RJ370 (print) | LCC RJ370 (ebook) | NLM WS 205 |
DDC 618.92/0025—dc23/eng/20230103
LC record available at https://lccn.loc.gov/2022040656
LC ebook record available at https://lccn.loc.gov/2022040657
DOI: 10.1093/​med/​9780197628553.001.0001
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v

Contents

Contributors vii

1. Walking and Wheezing 1

Rajesh Krishnamurthy and Beth Bubolz

2. Fast-​Breathing Baby 9
Ajay K. Puri, Mantosh S. Rattan, and Melissa A. McGuire

3. Green Vomit . . . Ewwww!!! 25

Esther Ro, Yamini Jadcherla, and Maegan S. Reynolds

4. What’s That in the Diaper? 37

Maegan S. Reynolds, Yamini Jadcherla, and Esben Vogelius

5. My Baby Won’t Poop! 49

Yamini Jadcherla, Narendra Shet, and Maegan S. Reynolds

6. Breathing through a Straw 59

Gina Pizzitola, David Teng, and Peter Assaad

7. Drooling, Drooling, Drooling All the Way Home 67

Brooke Lampl, Nkeiruka Orajiaka, and Meika Eby

8. Burn, Baby, Burn 75

Cory Gotowka, Ailish Coblentz, and Michael Stoner

9. To Wheeze or Not to Wheeze 89

Linda Vachon and Emily Rose

10. I Thought They Fixed Me? 101

Gina Pizzitola, William Mak, and Rachelle Goldfisher

11. Weebly, Wobbly 109

Meika Eby, Nkeiruka Orajiaka, and Lauren May

12. Extreme Extremity 117

Waroot S. Nimjareansuk and Jane S. Kim

13. FOOSHING through the Snow . . . 127

David Fernandez, Bindu N. Setty, and Isabel A. Barata

14. Sentinel Injuries: It’s What’s Inside That Counts 137

Madeline Zito, Summit Shah, Isabel A. Barata,
and Dana Kaplan
vi

15. What a Pain in the Neck 151

Michael Sperandeo and Gayathri Sreedher

16. Torticollis in a Child with Down Syndrome 165

Kristy Williamson and Rachelle Goldfisher

17. Shouldn’t This Be Connected? 175

Joshua Rocker and Anna Thomas

18. Head First into the Pool 185

Aaron McAllister and Kristol Das

19. Pain in the Back 195

Deanna Margius, Sophia Gorgens, David Foster,
and Shankar Srinivas Ganapathy

20. Why Is This Infant So Fussy? 205

Michelle Greene, Anna Thomas, and Berkeley Bennett

21. Ripping Apart My Heart 221

Thomas P. Conway, George C. Koberlein, and
Francesca M. Bullaro

22. The Unlucky Hit! 231

McKenzie Montana, Robert L. Gates, and Zachary Burroughs

Index 247

vi Contents
vi

Contributors

Peter Assaad, MD, MPH, MBA Zachary Burroughs, MD

Lurie Children’s Hospital Clinical Assistant Professor
Chicago, IL, USA Emergency Medicine, Division of
Pediatric Emergency Medicine
Isabel A. Barata, MS, MD, MBA
Prisma Health Upstate
Professor of Pediatrics and
Greenville, SC, USA
Emergency Medicine
Department of Emergency Ailish Coblentz, MBBS, FRCPC
Medicine Assistant Professor and Paediatric
Donald and Barbara Zucker Radiologist
School of Medicine at Department of Diagnostic Imaging
Hofstra/​Northwell The Hospital for Sick Children,
Ozone Park, NY, USA University of Toronto
Toronto, ON, CA
Berkeley Bennett, MD, MS
Attending Physician Thomas P. Conway, DO
Department of Emergency Physician Fellow
Nationwide Children’s Hospital, Department of Pediatric
The Ohio State University Emergency Medicine
Columbus, OH, USA Cohen Children’s Medical Center
Astoria, NY, USA
Beth Bubolz, MD
Assistant Professor Kristol Das, MD
Department of Pediatrics Fellow
The Ohio State University College Department of Pediatric
of Medicine Emergency Medicine
Lewis Center, OH, USA Nationwide Children’s Hospital
Columbus, OH, USA
Francesca M. Bullaro, MD
Associate Trauma Medical Director, Ann Dietrich, MD
Assistant Professor Professor of Pediatrics and Emergency
Pediatric Emergency Medicine Medicine, University of South
Cohen Children’s Medical Center Carolina College of Medicine
Northwell Health Department of Emergency Medicine
Garden City, NY, USA Division Chief Pediatric
Emergency Medicine, PRISMA
Greenville, SC, USA
vi

Meika Eby, MD, FAAP Rachelle Goldfisher, MD

Department of Pediatrics Associate Chief
Nationwide Children’s Department of Pediatric
Hospital, The Ohio State Radiology
University Northwell Health
Columbus, OH, USA Queens, NY, USA
David Fernandez, MD Sophia Gorgens, MD
Chief Resident-​Education Resident
Department of Emergency Medicine Department of Emergency
Northwell: Northshore-​LIJ Medicine
Hospital Zucker-​Northwell North Shore/​
Astoria, NY, USA Long Island Jewish
Manhasset, NY, USA
David Foster, MD, MS
Assistant Professor Cory Gotowka, DO, MS
Departments of Emergency Pediatric Hospitalist
Medicine and Pediatrics UPMC Hamot
Associate Director EM Residency Erie, PA
Program, Northwell Health,
Michelle Greene, DO
Zucker School of Medicine
Assistant Professor
Manhasset, NY, USA
Division of Emergency Medicine,
Shankar Srinivas Ganapathy, Department of Pediatrics
MBBS, MD The Ohio State University
Pediatric Radiologist, Associate College of Medicine, and
Professor of Radiology Nationwide Children’s
at NEOMED Hospital, Columbus, OH
Department of Radiology Columbus, OH, USA
Akron Children’s Hospital
Yamini Jadcherla, MD
Akron, OH, USA
Pediatric Emergency
Robert L. Gates, MD Medicine Fellow
Professor Department of Pediatric
Department of Surgery Emergency Medicine
University of South Carolina Nationwide Children’s Hospital
School of Medicine—​Greenville Galena, OH, USA
Greenville, SC, USA

viii Contributors
ix

Dana Kaplan, MD Deanna Margius, MD

Director of Child Abuse and Neglect Resident
Department of Pediatrics Department of Emergency Medicine
Staten Island University Hospital Hofstra Northwell NS-​LIJ
Marlboro, NJ, USA Manhasset, NY, USA
Jane S. Kim, MD Lauren May, MD
Assistant Professor of Pediatrics and Nemours Children’s Hospital,
Radiology Delaware, Wilmington, DE
Division of Diagnostic Imaging Clinical Assistant Professor
and Radiology Department of Radiology and
Children’s National Hospital Pediatrics
Kensington, MD, USA Sidney Kimmel School of Medicine
Thomas Jefferson University
George C. Koberlein, MD
Philadelphia, PA
Associate Professor
Department of Radiology Aaron McAllister, MS, MD
Atrium Health at Wake Forest Baptist Assistant Professor
Winston-​Salem, NC, USA Department of Radiology
Nationwide Children’s Hospital
Rajesh Krishnamurthy, MD
Columbus, OH, USA
Director, Cardiothoracic Imaging
Department of Radiology Melissa A. McGuire, MD
Nationwide Children’s Hospital Assistant Professor and Associate
Dublin, OH, USA Program Director of Northwell
Health CCMC Pediatric
Brooke Lampl, DO, FAOCR
Emergency Medicine Fellowship
Staff Radiologist/​Clinical Assistant
Department of Emergency Medicine
Professor of Radiology
Northwell Health, Cohen
Department of Diagnostic Radiology
Children’s Medical Center and
Cleveland Clinic
North Shore University Hospital
Pepper Pike, OH, USA
Massapequa Park, NY, USA
William Mak, DO
McKenzie Montana, DO
Attending Physician
Resident Physician
Department of Pediatrics
Department of Pediatrics
Cohen Children’s Medical Center
Prisma Health-​Upstate
Flushing, NY, USA
Greenville, SC, USA

Contributors ix
x

Waroot S. Nimjareansuk, DO Maegan S. Reynolds, MD

Assistant Professor Assistant Professor of Emergency
Department of Orthopaedics and Medicine and Pediatrics
Sports Medicine Department of Emergency
University of Florida Medicine The Ohio State
Minneola, FL, USA University and Division of
Pediatric Emergency
Nkeiruka Orajiaka, MBBS, MPH
Medicine Nationwide Children’s
Pediatrician, Assistant Professor
Fracture
Department of Emergency
Columbus, OH, USA
Medicine
Nationwide Children’s Hospital, Esther Ro, MD
The Ohio State University Instructor of Radiology
Columbus, OH, USA Department of Radiology
Northwestern University Feinberg
Gina Pizzitola, MD, MS
School of Medicine
Pediatric Emergency
Wilmette, IL, USA
Medicine Fellow
Department of Pediatric Joshua Rocker, MD
Emergency Medicine Associate Professor and
Cohen Children’s Medical Center, Division Chief
Northwell Health Department of Pediatric
Glen Oaks, NY, USA Emergency Medicine
Cohen Children’s Medical Center
Ajay K. Puri, MD
New Hyde Park, NY, USA
Fellow, Montefiore Medical
Center Emily Rose, MD
Critical Care Medicine Associate Professor of Clinical
North Shore University Emergency Medicine
Hospital (Educational Scholar)
Forest Hills, NY, USA Department of Emergency
Medicine
Mantosh S. Rattan, MD
Keck School of Medicine of
Staff Radiologist
the University of Southern
Department of Radiology
California
Cleveland Clinic Foundation
Arcadia, CA, USA
Cincinnati, OH, USA

x Contributors
xi

Bindu N. Setty, MD Michael Stoner, MD

Clinical Associate Professor Associate Professor and
Department of Radiology Section Chief
Boston University Department of Pediatrics/​Division
Lexington, MA, USA of Emergency Medicine
The Ohio State University College
Summit Shah, MD, MPH
of Medicine and Nationwide
Pediatric Radiologist
Children’s Hospital
Department of Radiology
Canal Winchester, OH, USA
Nationwide Children’s
Hospital David Teng, MD
Columbus, OH, USA Assistant Professor
Department of Pediatrics, Division
Narendra Shet, MD
of Emergency Medicine
Associate Professor and Director
Cohen Children’s Medical
of Body MR
Center—​Northwell Health
Division of Diagnostic Imaging
Dix Hills, NY, USA
and Radiology
Children’s National Hospital Anna Thomas, MD
Ellicott City, MD, USA Clinical Associate Professor
Department of Radiology
Michael Sperandeo, MD
Children’s Hospital of Los
Attending Physician
Angeles, USC Keck School of
Department of Emergency
Medicine
Medicine
Redlands, CA, USA
Long Island Jewish Medical
Center Linda Vachon, MD
Long Beach, NY, USA Associate Professor of Clinical
Radiology
Gayathri Sreedher, MBBS, MD
Department of Radiology
Staff Pediatric Radiologist
University of Southern California,
Department of Radiology
Keck School of Medicine
Akron Children’s Hospital
Manhattan Beach, CA, USA
Akron, OH, USA

Contributors xi
xi

Esben Vogelius, MD Madeline Zito, DO, FAAP

Radiologist Department of Pediatrics
Department of Radiology Maimonides Children’s Hospital
Cleveland Clinic Brooklyn, NY, USA
Moreland Hills, OH, USA
Kristy Williamson, MD
Associate Chief
Department of Pediatric Emergency
Cohen Children’s Medical Center
Garden City, NY, USA

xii Contributors
1 Walking and Wheezing

Rajesh Krishnamurthy and Beth Bubolz

Case Study
A 16-​year-​old male with no past medical history and
a recent viral infection (not COVID) presents with 1
month of cough, shortness of breath, and wheezing
with walking. He must frequently stop and rest when
walking outside, has trouble going up the stairs,
and has stopped participating in sports. He also has
decreased appetite with associated nausea, vomiting,
and abdominal pain off and on for a few weeks.
He was seen by his pediatrician 2 weeks ago for
vague abdominal pain, nausea and diarrhea and was
diagnosed with gastroenteritis and was discharged with
ondansetron. Vital signs and physical examination at
that visit were normal.
His cough is currently dry. Vital signs are: blood
pressure 100/​67mmHg; pulse 106 beats per minute;
temperature 97.8°F (36.6°C); respiratory rate 20 breaths
per minute; weight 62.4 kg; oxygen saturation (SpO2)
93%. He is well-​appearing. Lungs are clear and his heart
sounds are normal, with no murmur. Abdominal exam
reveals no pain or masses, with a normal sized liver.
While completing the exam, he vomits, becomes
pale, diaphoretic, and tachypneic.

What do you do now?

1
2

DISCUSSION

An adolescent with cough, shortness of breath, and wheezing has a differ-

ential that includes asthma, pneumothorax, pneumonia, achalasia, myocar-
ditis, and congestive heart failure (HF).
Patients with asthma, a chronic inflammatory disease of the airways, typ-
ically have recurrent episodes of airflow obstruction resulting from edema,
bronchospasm, and increased mucus production in the airways. Children
frequently have associated seasonal allergies (allergic rhinitis) and eczema
(atopic dermatitis), with these three conditions forming what is known as
the atopic triad. This patient does not have a history of allergic diseases or
wheezing and on physical exam is not currently wheezing.
Children have an increased risk of pneumothorax with a previous history
of an emphysematous bleb, asthma (10%), and tobacco use (4%). An un-
derlying congenital anomaly might also serve as a predisposing factor, par-
ticularly in a younger child. Young males with Marfan syndrome, the most
common inherited disorder of connective tissue, are also more likely to
have a spontaneous pneumothorax. Clinically, children usually present with
the acute onset of pain at rest or during physical activity and, depending
on the size of the pneumothorax, might have dyspnea and cough. Physical
exam findings may reveal differences in air entry to the lungs; however,
with a small pneumothorax, unequal breath sounds, hyperresonance with
percussion, and asymmetric wall movements might be subtle or not yet
present. This child does not have risk factors or findings associated with a
pneumothorax.
Achalasia is a rare esophageal neurodegenerative disorder that may occur in
the pediatric population. Achalasia may be associated with other conditions
including Trisomy 21, congenital hypoventilation syndrome, glucocorticoid
insufficiency, eosinophilic esophagitis, familial dysautonomia, Chagas’
disease, and achalasia, alacrima, and adrenocorticotropic hormone (ACTH)
insensitivity (AAA) syndrome. Children afflicted with achalasia usually pre-
sent with progressive dysphagia, vomiting, and weight loss. Recurrent pneu-
monia, nocturnal cough, aspiration, hoarseness, and feeding difficulties may
occur in younger children. Although this patient has vomiting, he does not
have progressive dysphagia, making this diagnosis unlikely.

2 WHAT DO I DO NOW? PEDIATRIC EMERGENCY RADIOLOGY

3

Usually, acute myocarditis presents with preceding viral symptoms

(about two-​thirds of patients), HF symptoms, and a poorly functioning
ventricle with or without dilation. Fulminant myocarditis may present
with tachyarrhythmias and significant cardiac dysfunction. A history of
a preceding viral prodrome is commonly present (two-​thirds of patients);
ventricular and atrial arrhythmias are also common (about 45%). Sudden
cardiac death may also be a presentation of myocarditis. Complications of
myocarditis may include a dilated cardiomyopathy or a pericardial effusion.
The clinicians for this patient started with a chest radiograph. The in-
itial chest radiographic identified small pleural effusions and interlobular
septal thickening, which were suggestive of interstitial pulmonary edema
(see Figures 1.1a and 1.1b). Findings become more apparent when com-
pared with a normal 16-​year-​old’s chest radiographs (Figures 1.2a and
1.2b). Because of the patient’s vomiting, an abdominal film was also
obtained, which demonstrated significant cardiomegaly (see Figure 1.1c),
thus leading to the diagnosis of dilated cardiomyopathy and/​or pericardial
effusion. On the chest radiograph, the reduced lung volumes and elevated
hemidiaphragms masked the cardiomegaly, which was more apparent on
the better penetrated abdominal radiograph.
Careful attention to the heart, mediastinum, airway, lungs, pleura, bones,
and soft tissues is essential to accurately diagnose the cause of chest pain.
A screening chest film for patients with chest pain has low sensitivity for
structural cardiovascular lesions, such as myocarditis, dissection, or pulmo-
nary infarction, but is helpful in the acute setting to diagnose complications
of underlying cardiovascular conditions, such as HF, mediastinal hematoma,
or pulmonary infarction. It is also helpful to exclude noncardiac causes of
chest pain, including pneumonia, pneumothorax, rib fracture, or an aspi-
rated foreign body (see normal chest radiograph, Figures 1.2a and 1.2b).
In addition, the physician ordered an electrocardiogram (ECG). An
ECG with a chest radiograph is a great screening tool set for cardiomyop-
athy of any type. ECGs are particularly valuable in patients who present
with symptoms that may be suspicious for cardiac involvement and include
dyspnea, fatigue, shortness of breath, tachypnea, unexplained tachycardia,
murmur, gallop, rub, vague abdominal pain, etc.

1. Walking and Wheezing 3

4

ECG demonstrates sinus tachycardia, low voltage, borderline long QT interval, and mild
conduction delay in V1.

FIGURES 1.1a, 1.1b, 1.1c, AND 1.1d. (a, b) PA and lateral views of the chest demonstrating low
lung volumes, pulmonary vascular congestion, interstitial opacities in the lung bases, and bilateral
trace pleural fluid; (c) the abdominal radiograph is better penetrated than the chest radiograph,
and shows an enlarged cardiac silhouette; and (d) post-​procedure chest radiograph showing
decreased size of the cardiac silhouette after drainage of the pericardial effusion.
5

FIGURES 1.2a AND 1.2b. PA and lateral views of the chest in a normal 16-​year-​old for
comparison (different patient). Note the normal appearance of structures. Contour of descending
aorta (white arrowheads), superior mediastinal width between superior vena cava on the right
and aortic arch on the left (white thick arrows on right and left side), tracheal air column (black
arrow), carina (black arrowhead), and the orientation of the clavicles (thin white arrows). In a
properly positioned patient the spinous processes lie midway between the medial ends of the
clavicles. The cardiothoracic ratio is measured as the ratio of the cardiac transverse diameter
(black thin line) divided by the maximum chest transverse diameter (thick black line). The first and
second ribs on the left side are numbered (1, 2).