Bedside ultrasound in pediatric emergency medicine

Utilization of emergency ultrasound in pediatric emergency departments

OBJECTIVES

This study aimed to determine the utilization of emergency ultrasound (EUS) in pediatric emergency departments (EDs) and in pediatric emergency medicine (PEM) fellowship training programs and to assess if PEM fellowship programs provided formal training in EUS.

METHODS

A Web-based survey was administered to pediatric emergency medical directors, fellowship directors, and graduating fellows.

RESULTS

A response was received from 60% of individuals and 68% of institutions. Of the responders, 27% reported that their institution had a EUS program. Also, 96% of the responders reported having a dedicated US machine in the ED, but only 61% reported using EUS for managing ED patients. Responders reported using EUS for the focused assessment by sonography for trauma examination (93%), abscess management (82%), vascular access (78%), bladder scanning (70%), cardiac activity confirmation (59%), and pericardial effusion detection (59%). For pediatric emergency staff physicians, 63% of the responders reported obtaining EUS training from general emergency physicians and 59% from a commercial ultrasound course and from pediatric emergency physicians. For PEM fellows, 34% reported having a standardized EUS training program. Of the responders, 69% reported receiving training from general emergency physicians during adult ED rotations and 38% reported receiving training from pediatric emergency physicians. Only 28% of programs reported using criteria established by the American College of Emergency Physicians for the number of scans performed to attain competence.

CONCLUSIONS

In our study sample, there is wide variation in the uses of EUS and the training pediatric emergency physicians receive in its use.

Ultrasound equipment for the pediatric emergency department: a review

Ultrasound is gaining momentum for use in the pediatric emergency department. It is important to understand the fundamentals of ultrasound equipment as it relates to pediatric emergency medicine.

Accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults

INTRODUCTION

Injury is a major cause of death and disability in children and young adults worldwide. X-rays are routinely performed to evaluate injuries with suspected fractures. However, the World Health Organisation estimates that up to 75% of the world population has no access to any diagnostic imaging services. Use of clinician-performed point-of-care ultrasound to diagnose fractures is not only feasible in traditional healthcare settings, but also in underserved or remote settings. Our objective was to determine the accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults presenting to an acute care setting.

METHODS

We conducted a prospective cohort study of patients aged <25 years that presented to emergency departments with injuries requiring X-rays or CT for suspected fracture. Paediatric emergency physicians with a 1h training session diagnosed fractures by point-of-care ultrasound. X-rays or CT were used as the reference standard to determine test performance characteristics.

RESULTS

Point-of-care ultrasound was performed on 212 children and young adults with 348 suspected fractures. Forty-two percent of all bones imaged were non-long bones. The prevalence rate of fracture was 24%. Overall: sensitivity-73% (95% CI: 62-82%), specificity-92% (95% CI: 88-95%); long bones: sensitivity-73% (58-84%), specificity-92% (86-95%); non-long bones: sensitivity-77% (58-90%); specificity-93% (87-97%); age> or =18 years: sensitivity-60% (39-78%), specificity-92% (87-96%); age<18: sensitivity-78 (65-87%), specificity-93% (87-95)%. Majority of errors in diagnosis (>85%) occurred at the ends-of-bones.

CONCLUSIONS

Clinicians with focused ultrasound training were able to diagnose fractures using point-of-care ultrasound with a high specificity rate. Specificity rates to rule-in fracture were similar for non-long bone and long bone fractures, as well as in skeletally mature young adults and children with open growth plates. Clinician-performed point-of-care ultrasound accuracy was highest at the diaphyses of long bones, while most diagnostic errors were committed at the ends-of-bones or near joints. Point-of-care ultrasound may serve as a rapid alternative means to diagnose midshaft fractures in settings with limited or no access to X-ray.

Bedside emergency cardiac ultrasound in children

Bedside emergency ultrasound has rapidly developed over the past several years and has now become part of the standard of care for several applications. While it has only recently been applied to critically ill pediatric patients, several of the well-established adult indications may be applied to pediatric patients. One of the most important and life-saving applications is bedside echocardiography. While bedside emergency ultrasonography does not serve to replace formal comprehensive studies, it serves as an extension of the physical examination. It is especially useful as a rapid and effective tool in the diagnosis of pericardial effusions, tamponade and in distinguishing potentially reversible causes of pulseless electrical activity from asystole. Most recently, left ventricular function and inferior vena cava measurements have proven helpful in the assessment of undifferentiated hypotension and shock in adults and children. Future research remains to be carried out in determining the efficacy of bedside ultrasonography in pediatric-specific pathology such as congenital heart disease. This article serves as a comprehensive review of the adult literature and a review of the recent applications in the pediatric emergency department. It also highlights the techniques of bedside ultrasonography with examples of normal and pathologic images.

Is sonography reliable for the diagnosis of pediatric blunt abdominal trauma?

BACKGROUND

Computerized tomography (CT) is considered as the imaging study of choice for blunt abdominal trauma in children. Nevertheless, recent investigations clearly indicate an increased risk of cancer in children exposed to radiation during abdominal spiral CT. Therefore, alternative strategies should be used for the diagnosis and surgical decision making in blunt abdominal trauma in children.

METHODS

Retrospective analysis included all children with intraabdominal organ rupture after blunt abdominal trauma. Patients were diagnosed by a standardized emergency protocol that included primary clinical assessment and repeated ultrasound but not routine CT. Efficacy of abdominal ultrasound was evaluated in regard to safe diagnosis and appropriate surgical decision making.

RESULTS

The study included 35 children with intraabdominal organ rupture diagnosed by ultrasound. One fifth (7/35) of the patients were polytraumatized, whereas 28 of 35 had an isolated blunt abdominal trauma. All patients underwent immediate ultrasound scanning of the abdomen and retroperitoneal space. Two patients were immediately operated because of hemodynamically instability. Four of 7 polytraumatized patients and 7 of 28 patients with isolated blunt abdominal trauma were additionally diagnosed by spiral CT. Only 1 patient underwent subsequent surgery because of the findings in the CT. Ultrasound was effective in more than 97% (34/35) of the patients for diagnosis and appropriate surgical decision making.

CONCLUSION

Ultrasound combined with clinical assessment presents an effective method for safe diagnosis and appropriate surgical decision making in pediatric blunt abdominal trauma. Selected cases with polytrauma and/or unequivocal findings in the ultrasound should undergo abdominal CT. Patients requiring abdominal CT should have an anticipated benefit that exceeds the radiation risk. The importance of repeated clinical assessment cannot be overstated.

Rapid screening for the posterior fat pad sign in suspected pediatric elbow fractures using point-of-care ultrasound: a “FAST exam” for the traumatized elbow

Purpose

Children with elbow injuries frequently present to the emergency department for evaluation. Fractures of the elbow are sometimes not visualized on plain radiographs and the only sign of an occult fracture is an elevated posterior fat pad that normally sits within the olecranon fossa. The elevated posterior fat pad sign is highly sensitive and its absence likely rules out fractures of the elbow and can be readily visualized by ultrasound. Lipohemarthrosis within an elevated fat pad can also be visualized by ultrasound, but not by X-ray. This finding with an elevated posterior fat pat adds additional specificity to rule in elbow fractures.

Methods

We report the use of point-of-care ultrasound to rapidly screen for the presence of the posterior fat pad sign and lipohemarthrosis in a series of children presenting with elbow injuries to the emergency department.

Results

Point-of-care ultrasound identified elevated and normal posterior fat pads that correlated with X-ray. Lipohemarthrosis within an elevated fat pad was also detectable by ultrasonography.

Conclusions

Knowledge of whether a posterior fat pad is elevated or not and noting the presence of lipohemarthrosis by using point-of-care ultrasound may be helpful to expedite diagnosis and treatment of these patients, especially in settings with no access to plain radiography.

Crianças necessitam de jejum antes de ultrassonografia abdominal?

OBJETIVO: Comparar a qualidade de imagens ultrassonográficas do abdome de crianças, obtidas com e sem a instituição de jejum prévio. MATERIAIS E MÉTODOS: Trata-se de estudo prospectivo, incluindo crianças com até 12 anos de idade. Os pacientes foram examinados sequencialmente por dois utrassonografistas e as imagens foram classificadas em escores: 1 (não visualizado ou parcialmente visualizado, inadequada para diagnóstico); 2 (suficientes para diagnóstico); 3 (excelentes). As imagens foram ainda classificadas como "diagnósticas" ou "não diagnósticas". RESULTADOS: Foram examinados 77 pacientes, sendo 47 meninos e 30 meninas, com idades entre 0 e 12 anos (mediana de 1 ano). Jejum se mostrou vantajoso de forma estatisticamente significativa apenas na avaliação da vesícula biliar, por apenas um dos avaliadores (p = 0,032). Depois de agrupadas em "diagnóstica" ou "não diagnóstica", nenhuma diferença foi observada entre os grupos. CONCLUSÃO: A instituição de jejum não afetou de forma significativa a qualidade das imagens de ultrassonografias abdominais obtidas em crianças.