104-C

Stabilization in Action: Emergency Pediatric Case Scenarios

Sharon Stapleton, RN, BSN, CCRN
stapleto@ohsu.edu

Upon completion of this course the participant will be able to:

1) Describe a systematic approach to interpreting pediatric x-rays;
2) Describe measures used to promote oxygenation, ventilation, and comfort for the child in respiratory
distress and/or shock; and
3) State three symptoms a child may show when progressing from respiratory distress to failure.

I. Review of Pediatric X-ray Interpretation

A. Common radiographic terms
1. Radiodensities of the body: Gas, fat, bone, fluid, etc.
2. Underexposed (too light) vs. overexposed (too dark)
3. Anteroposterior view: Beam is directed from front of child to film
4. Decubitus view: Lying on side. Left lateral decubitus is left side down, the film against the
patient’s back and with a horizontal beam
5. Lateral: Lying on back with patient’s side against film
6. Inspiratory vs. expiratory films
7. Air bronchograms:Air outlining the bronchial tree
8. Cardiothoracic ratio: Ratio used to determine the heart size (normal heart size is < 60% of
the entire thoracic width)
9. Perihilar:The radiographic area bordering mediastinal structures
10. Skinfold: Results from folding over of redundant skin; can mimic pneumothorax or an effu-
sion
11. Sail sign: Elevation or outlining of the thymus, usually by air
12. Lordotic positioning (as though leaning backwards) and its significance
B. Important concepts
1. Always check patient name and date before interpreting the x-ray.
2. Identify proper orientation. Use common sense.
3. Determine what type of x-ray you are looking at (A-P).
4. Avoid tendency to stop looking for abnormalities once an area of concern is identified.
5. Always know when to ask for expert advice and review.
6. Free air rises into superior portions of the body. Free fluid shifts into dependent portions of
the body.
7. Treat the patient and not the x-ray.
8. Neck flexion will move the tip of the oral ET tube further into the trachea. Remember that
the oral ET tube will “follow” the position of the chin.
C. How can an x-ray assist you?
1. Can support a potential diagnosis.
2. Assists in guiding treatment.
3. Suggests need for further treatment.
D. How can an x-ray hinder you?
1. Suggests an incorrect disease process.
2. A “normal” reading can falsely reassure.
3. Adds confusion to what was a straightforward process. Obvious abnormalities may over-
shadow other significant, but more subtle findings.
4. All caretakers are not equal when it comes to reading x-rays.
5. Can be time consuming to obtain.
E. Systematic approach
1. Head-to-toe approach vs. systems approach
2. Global view, then a focused view
F. Interpretation
1. Determine patient history and indications for the film.
2. Patient name, date, patient orientation and quality of film
3. Extraneous objects (lead wires, rings on assistant’s fingers, pen/fingerprint signs)
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 4. Soft tissues (skin folds, neck, fat, edema, subcutaneous emphysema)
5. Bones
a. Clavicles, ribs, spine, extremities, skull.Any fractures present?
b. Number of rib pairs (normal = 12)
c. General skeletal appearance
6. Respiratory system
a. Rib expansion (normal on inspiration is a 9-10 rib expansion)
b. Lung volume
c. Lung fields.Any pathology? Is it homogenous or not?
d. Presence of free air or air bronchograms
e. Location of tubes (endotracheal tube, chest tube)
f. Position of the carina
g. Trachea (location, shape)
h. Pulmonary vascular markings
i. Costophrenic angle should be sharp
7. Heart and mediastinum
a. Heart size and shape. Measure cardiothoracic ratio.
b. Position of apex (normally points to the left)
c. Orientation of heart in relation to abdominal organs
d. Heart and mediastinal borders should be distinct
e. Thymus…presence of and size. Presence of a sail sign?
8. Diaphragm
a. General appearance and position
9. Abdomen/gastrointestinal tract
a. Passage of air through GI system
b. Location of stomach and appearance
c. Bowel gas pattern or lack of
d. Fluid, masses, calcifications, ascites
e. Location of gastric tube, urinary tube, and/or umbilical catheters
f. Pathology?
g. Liver (size and position)
h. Bladder
10. Tubes and catheters
a. Endotracheal tube: Should be 1 to 1.5 cm above the carina and below the level of the
clavicles (usually between T-2 and T-3)
b. Umbilical arterial catheters: Makes a downward loop, then proceeds toward the infant’s
head.
i. High placement: Between T-6 and T-9
ii. Low placement: Between L-3 and L-4
c. Umbilical venous catheters: Proceeds directly toward the head without making the
downward loop. Placement should be above the diaphragm and below the right atrium,
usually between T-6 and T-9.
d. Chest tubes: Correct placement is confirmed by x-ray and proper evacuation of the
pneumothorax
e. Gastric tubes
f. Urinary catheters
g. Other
G. Examples of pediatric radiographs

II. Interactive Case

A. Respiratory failure
B. Shock
C. Traumatic brain injury/nonaccidental trauma (NAT)
D. Seizures/toxins and poisons
E. Other

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