Emergency Request Criteria
Based on SEUP protocols and international guidelines to reduce unnecessary radiation in pediatrics (ALARA Criteria).
YES it is indicated
- Clinical suspicion of pneumonia with torpid evolution, serious impairment of general condition or need for hospitalization.
- Auscultatory asymmetry persistent in the context of respiratory distress.
- Suspicion of foreign body aspiration (ask for inspiration and expiration, or lateral decubitus in infants).
- Prolonged fever without focus or with very high acute phase reactants (>20,000 leukocytes) in children under 3 years of age, according to local protocol.
- First episode of wheezing with atypical symptoms (sudden onset without cold, failure to thrive, etc.).
- Severe chest trauma or suspected pleural effusion/pneumothorax.
It is NOT routinely indicated
- Typical acute bronchiolitis mild or moderate. It does not change management and frequently shows false positives (atelectasis that look like consolidations).
- Known asthma attack without suspicion of complications, with good response to initial treatment in the emergency room.
- infection of upper respiratory tract (cold, mild laryngitis/croup).
- Radiological control of uncomplicated pneumonia in an asymptomatic patient (the image takes weeks to resolve).
Remember: A normal chest x-ray does not rule out incipient pathology, and the findings must always be correlated with the clinical symptoms.
Normal and Systematic Reading (ABCDEF)
In emergencies, stress can cause us to overlook details. Always follow this order.
A
Airway
- • Central trachea (slight deviation to the right in children is normal due to the aortic arch).
- • Uniform caliber, without subglottic narrowing.
- • Visualize carina and main bronchi.
B
Bones
- • Evaluate clavicles (common fractures in neonates/infants).
- • Ribs: count arcs. Adequate inspiration: 6th anterior arch crosses the diaphragm, or 9-10 posterior arches visible.
- • Spine and soft tissues (subcutaneous emphysema).
C
Cardio (Cardiac Silhouette)
- • Cardiothoracic index: Normal < 0.6 in neonates, < 0.5 in older children.
- • Watch out for the OWL! In < 2 years the thymus is large (candle sign), not to be confused with cardiomegaly or mediastinal mass.
- • Sharp edges (silhouette sign).
D
Diaphragm
- • Right hemicupula slightly higher than the left (because of the liver).
- • Smooth and rounded contours.
- • Flattening = hyperinflation (typical of asthma/bronchiolitis).
E
Effusion (Spills/Edges)
- • Acute and free costophrenic angles.
- • Free cardiophrenic angles.
- • Effacement = suspicion of incipient pleural effusion.
F
Fields (Lung Fields)
- • Symmetry in radiolucency.
- • Visible vascular pattern, decreasing towards the periphery.
- • Search for opacities (consolidations, atelectasis) or hyperclarities (pneumothorax).
Prior Quality Verification (RIP)
Before interpreting, ensure that the plate is valuable:
- Rotation: Clavicles equidistant from the spinous processes.
- Inspiration: 6 visible anterior arches.
- Penetration: Column barely visible through the heart.
Pathologies and Diagnostic Tips
Select a pathology to see its characteristics and typical radiography.