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Kula R, Popela S, Klučka J, Charwátová D, Djakow J, Štourač P. Modern Paediatric Emergency Department: Potential Improvements in Light of New Evidence. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10040741. [PMID: 37189990 DOI: 10.3390/children10040741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023]
Abstract
The increasing attendance of paediatric emergency departments has become a serious health issue. To reduce an elevated burden of medical errors, inevitably caused by a high level of stress exerted on emergency physicians, we propose potential areas for improvement in regular paediatric emergency departments. In an effort to guarantee the demanded quality of care to all incoming patients, the workflow in paediatric emergency departments should be sufficiently optimised. The key component remains to implement one of the validated paediatric triage systems upon the patient's arrival at the emergency department and fast-tracking patients with a low level of risk according to the triage system. To ensure the patient's safety, emergency physicians should follow issued guidelines. Cognitive aids, such as well-designed checklists, posters or flow charts, generally improve physicians' adherence to guidelines and should be available in every paediatric emergency department. To sharpen diagnostic accuracy, the use of ultrasound in a paediatric emergency department, according to ultrasound protocols, should be targeted to answer specific clinical questions. Combining all mentioned improvements might reduce the number of errors linked to overcrowding. The review serves not only as a blueprint for modernising paediatric emergency departments but also as a bin of useful literature which can be suitable in the paediatric emergency field.
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Affiliation(s)
- Roman Kula
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Physiology, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Stanislav Popela
- Emergency Department, University Hospital Olomouc and Faculty of Medicine, Palacký University, I.P. Pavlova 185/6, 779 00 Olomouc, Czech Republic
- Emergency Medical Service of the South Moravian Region, Kamenice 798, 625 00 Brno, Czech Republic
| | - Jozef Klučka
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Daniela Charwátová
- Department of Surgery, Vyškov Hospital, Purkyňova 235/36, 682 01 Vyškov, Czech Republic
| | - Jana Djakow
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Paediatric Intensive Care Unit, NH Hospital Inc., 268 01 Hořovice, Czech Republic
| | - Petr Štourač
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
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Huang JS, Huang SY, Liao HZ, Cai RZ, Zeng Q, Xiang XT, Chen SX, Liu D, Yang ZK. Point-of-care ultrasound diagnosis of skull fracture in Chinese children 0–6 years old with scalp hematoma from minor head trauma: A preliminary prospective observational study. Heliyon 2023; 9:e15255. [PMID: 37096000 PMCID: PMC10121451 DOI: 10.1016/j.heliyon.2023.e15255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/27/2023] [Accepted: 03/31/2023] [Indexed: 04/09/2023] Open
Abstract
Background Previous studies have suggested that point-of-care ultrasound could help to evaluate and diagnose pediatric skull fracture for the closed scalp hematoma from blunt trauma. However, relevant data in Chinese children are missing, especially in children 0-6 years old. Objectives Our study aimed to evaluate the efficacy of point-of-care ultrasound to diagnose skull fracture in children 0-6 years old with scalp hematoma in China. Methods We performed a prospective observational study and screened children 0-6 years old with closed scalp hematoma and a Glasgow coma scale of 14-15 at Hospital in China. Enrolled children (N = 152) were first evaluated for skull fracture with point-of-care ultrasound by the emergency physician and then received a head computed tomography scan. Results The point-of-care ultrasound examination and computed tomography scan revealed skull fracture in 13 (8.6%) and 12 (7.9%) children, respectively. The kappa test showed a satisfactory agreement between two examinations (P < 0.0001), with kappa = 0.87 (95% confidence interval, i.e., 95% CI, [0.69, 1.00]) and area under the curve = 0.95 (95% CI [0.86, 1], P < 0.0001). The point-of-care ultrasound examination had the sensitivity of 91.7% (95% CI [62.5%, 100%]), specificity of 98.6% (95% CI [94.6%, 100%]), positive predictive value of 84.6% (95% CI [56.5%, 96.9%]), negative predictive value of 99.2% (95% CI [95.6%, 100%]), and accuracy of 98.0% (95% CI [94.1%, 99.6%]). Conclusions While our study is preliminary in nature, our findings may guide future larger studies in assessing the utility of point-of-care ultrasound examination in diagnosing skull fractures in children with scalp hematoma from minor head trauma.
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Gordon I, Sinert R, Chao J. The Utility of Ultrasound in Detecting Skull Fractures After Pediatric Blunt Head Trauma: Systematic Review and Meta-Analysis. Pediatr Emerg Care 2021; 37:e1701-e1707. [PMID: 32118837 DOI: 10.1097/pec.0000000000001958] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Head trauma is a common reason for evaluation in the emergency department. The evaluation for traumatic brain injury involves computed tomography, exposing children to ionizing radiation. Skull fractures are associated with intracranial bleed. Point-of-care ultrasound (POCUS) can diagnose skull fractures. OBJECTIVES We performed a systematic review/meta-analysis to determine operating characteristics of POCUS skull studies in the diagnosis of fractures in pediatric head trauma patients. METHODS We searched PubMed, EMBASE, and Web of Science for studies of emergency department pediatric head trauma patients. Quality Assessment Tool for Diagnostic Accuracy Studies 2 was used to evaluate risk of bias. Point-of-care ultrasound skull study operating characteristics were calculated and pooled using Meta-DiSc. RESULTS Six studies of 393 patients were selected with a weighted prevalence of 30.84%. Most studies were at low risk of bias. The pooled sensitivity (91%) and specificity (96%) resulted in pooled positive likelihood ratio (14.4) and negative likelihood ratio (0.14). Using the weighted prevalence of skull fractures across the studies as a pretest probability (31%), a positive skull ultrasound would increase the probability to 87%, whereas a negative test would decrease the probability of a skull fracture to 6%. To achieve a posttest probability of a skull fracture of ~2% would require a negative skull ultrasound in a patient with only a pretest probability of ~15%. CONCLUSIONS A POCUS skull study significantly increases the probability of skull fracture, whereas a negative study markedly decreases the probability if the pretest probability is very low.
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Affiliation(s)
- Isaac Gordon
- From the Department of Emergency Medicine SUNY-Downstate Medical Center and Kings County Hospital Center, Brooklyn, NY
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Mastrangelo M, Baglioni V. Management of Neurological Emergencies in Children: An Updated Overview. Neuropediatrics 2021; 52:242-251. [PMID: 34192789 DOI: 10.1055/s-0041-1730936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Neurological emergencies account for about one-third of the highest severity codes attributed in emergency pediatric departments. About 75% of children with acute neurological symptoms presents with seizures, headache, or other paroxysmal events. Life-threatening conditions involve a minor proportion of patients (e.g., less than 15% of children with headache and less than 5% of children with febrile seizures). This review highlights updated insights about clinical features, diagnostic workup, and therapeutic management of pediatric neurological emergencies. Particularly, details will be provided about the most recent insights about headache, febrile seizures, status epilepticus, altered levels of consciousness, acute motor impairment, acute movement disorders, and functional disorders, as well as the role of diagnostic tools (e.g., neuroimaging, lumbar puncture, and electroencephalography), in the emergency setting. Moreover, the impact of the current novel coronavirus disease2019 (COVID-19) pandemic on the evaluation of pediatric neurologic emergencies will also be analyzed.
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Affiliation(s)
- Mario Mastrangelo
- Child Neurology and Infantile Psychiatry Unit, Department of Human Neuroscience, Sapienza Università di Roma, Rome, Italy
| | - Valentina Baglioni
- Child Neurology and Infantile Psychiatry Unit, Department of Human Neuroscience, Sapienza Università di Roma, Rome, Italy
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Lawson M, Tully J, Ditchfield M, Metcalfe P, Qi Y, Kuganesan A, Badawy MK. A review of current imaging techniques used for the detection of occult bony fractures in young children suspected of sustaining non-accidental injury. J Med Imaging Radiat Oncol 2021; 66:68-78. [PMID: 34176229 DOI: 10.1111/1754-9485.13270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 06/01/2021] [Indexed: 11/30/2022]
Abstract
Non-accidental injuries remain a leading cause of preventable morbidity and mortality in young children. The accurate identification of the full spectrum of injuries in children presenting with suspected abuse is essential to ensure the appropriate protective intervention is taken. The identification of occult bone fractures in this cohort is important as it raises the level of concern about the mechanism of injury and maintaining the child's safety. Radiographic imaging remains the modality of choice for skeletal assessment; however, current studies report concerns regarding the ability of radiographs to detect certain fractures in the acute stage. As such, alternative modalities for the detection of fractures have been proposed. This article reviews the current literature regarding fracture detectability and radiation dose burden of imaging modalities currently used for the assessment of occult bony injury in young children in whom non-accidental injury is suspected.
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Affiliation(s)
- Michael Lawson
- Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,Centre for Medical and Radiation Physics, School of Physics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | - Joanna Tully
- Victorian Forensic Paediatric Medical Service, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Michael Ditchfield
- Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter Metcalfe
- Centre for Medical and Radiation Physics, School of Physics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | - Yujin Qi
- Centre for Medical and Radiation Physics, School of Physics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | | | - Mohamed K Badawy
- Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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Alexandridis G, Verschuuren EW, Rosendaal AV, Kanhai DA. Evidence base for point-of-care ultrasound (POCUS) for diagnosis of skull fractures in children: a systematic review and meta-analysis. Emerg Med J 2020; 39:30-36. [PMID: 33273039 PMCID: PMC8717482 DOI: 10.1136/emermed-2020-209887] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Blunt head trauma is a common presentation to emergency departments (EDs). Identifying skull fractures in children is important as they are known factor of risk for traumatic brain injury (TBI). Currently, CT is the reference standard for diagnosing skull fractures and TBIs in children. Identifying skull fractures with point-of-care ultrasound (POCUS) may help risk-stratify children for TBI following blunt trauma. The purpose of this study is to evaluate the sensitivity, specificity, positive predictive value and negative predictive value of POCUS in identifying skull fractures in children. METHODS A systematic search was performed on 17 July 2020 in Ovid Medline, Cochrane Library, Google Scholar, Web of Science and Embase. Prospective studies reporting skull fractures diagnosed with ultrasound in children younger than 18 years due to blunt head injury were included. Studies that did not confirm the fracture with CT were excluded. The quality of studies was evaluated using the QUADAS-2 tool. Data were extracted from the eligible studies to calculate outcomes such as sensitivity and specificity; when possible overall outcomes were calculated. RESULTS Seven studies were included. All eligible studies included patients for whom the decision to perform a CT scan was made in advance. Overall, the included studies demonstrated low risk of bias or had minor concerns regarding risk of bias. The pooled data (n=925) demonstrated a sensitivity of 91%, specificity of 96%, positive predictive value of 88% and negative predictive value of 97%. CONCLUSION The included studies demonstrate minor methodological limitations. Overall, the evidence suggests that POCUS is a valid option for diagnosing skull fractures in children visiting the ED after blunt head injury.
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Affiliation(s)
- Georgios Alexandridis
- Emergency Medicine, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands .,Emergency Medicine, Franciscus Gasthuis en Vlietland, Rotterdam, Zuid-Holland, The Netherlands
| | - Eva W Verschuuren
- Emergency Medicine, Franciscus Gasthuis en Vlietland, Rotterdam, Zuid-Holland, The Netherlands
| | - Arthur V Rosendaal
- Emergency Medicine, Franciscus Gasthuis en Vlietland, Rotterdam, Zuid-Holland, The Netherlands
| | - Danny A Kanhai
- Pediatrics, Franciscus Gasthuis en Vlietland, Rotterdam, Zuid-Holland, The Netherlands
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Hahn M, Ray J, Hall MM, Coe I, Situ-LaCasse E, Waterbrook AL. Ultrasound in Trauma and Other Acute Conditions in Sports, Part I. Curr Sports Med Rep 2020; 19:486-494. [DOI: 10.1249/jsr.0000000000000774] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Gillon JT, Gorn M, Wilkinson M. Comparison of ultrasound-guided versus fluoroscopy-guided reduction of forearm fractures in children. Emerg Radiol 2020; 28:303-307. [PMID: 33030662 DOI: 10.1007/s10140-020-01862-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/01/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Point-of-care ultrasound (POCUS) can be used to guide and assess reduction of pediatric forearm fractures. In this study, we sought to compare the success rate of ultrasound-guided fracture reduction with fluoroscopy-guided fracture reduction. We also sought to determine whether there are cost or time benefits to using ultrasound instead of fluoroscopy. METHODS The electronic medical records of patients less than 18 years of age presenting to a pediatric emergency department with a forearm fracture between April 2016 and March 2019 were screened for inclusion in this study. A total of 27 ultrasound-guided reductions were identified during this time period and 81 fluoroscopy-guided reductions were randomly selected for comparison. Cost data was provided by the financial department. Reduction success, total length of stay, and costs were compared between the two groups, and multiple linear regression was used to determine the influence of any confounding predictor variables. RESULTS There were no failed reductions in either group. Length of stay was shorter in the POCUS group (221 min) compared with the fluoroscopy group (254 min, p = 0.014), but this significance was lost in the regression model when adjusted for ketamine use. Provider costs ($430 v $442, p = 0.822) and total costs ($1219 v $1204, p = 0.851) were the same between the POCUS group and the fluoroscopy group, respectively. CONCLUSION POCUS appears to be an equally effective imaging modality to guide reduction of forearm fractures as compared to fluoroscopy.
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Affiliation(s)
- Jason T Gillon
- Division of Pediatric Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, TX, USA.
| | - Michael Gorn
- Division of Pediatric Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Matthew Wilkinson
- Division of Pediatric Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, TX, USA
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Ryan ME, Pruthi S, Desai NK, Falcone RA, Glenn OA, Joseph MM, Maheshwari M, Marin JR, Mazzola C, Milla SS, Mirsky DM, Myseros JS, Niogi SN, Partap S, Radhakrishnan R, Robertson RL, Soares BP, Udayasankar UK, Whitehead MT, Wright JN, Karmazyn B. ACR Appropriateness Criteria® Head Trauma-Child. J Am Coll Radiol 2020; 17:S125-S137. [PMID: 32370957 DOI: 10.1016/j.jacr.2020.01.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 01/22/2020] [Indexed: 12/15/2022]
Abstract
Head trauma is a frequent indication for cranial imaging in children. The majority of accidental pediatric head trauma is minor and sustained without intracranial injury. Well-validated pediatric-specific clinical decision guidelines should be used to identify very low-risk children who can safely forgo imaging. In those who require acute imaging, CT is considered the first-line imaging modality for suspected intracranial injury because of the short duration of the examination and its high sensitivity for acute hemorrhage. MRI can accurately detect traumatic complications, but often necessitates sedation in children, owing to the examination length and motion sensitivity, which limits rapid assessment. There is a paucity of literature regarding vascular injuries in pediatric blunt head trauma and imaging is typically guided by clinical suspicion. Advanced imaging techniques have the potential to identify changes that are not seen by standard imaging, but data are currently insufficient to support routine clinical use. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Maura E Ryan
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Sumit Pruthi
- Panel Chair, Vanderbilt Children's Hospital, Nashville, Tennessee
| | | | - Richard A Falcone
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; American Pediatric Surgical Association
| | - Orit A Glenn
- University of California San Francisco, San Francisco, California
| | - Madeline M Joseph
- University of Florida College of Medicine Jacksonville, Jacksonville, Florida; American College of Emergency Physicians
| | | | - Jennifer R Marin
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; Society for Academic Emergency Medicine
| | - Catherine Mazzola
- Rutgers, New Jersey Medical School, Newark, New Jersey; Neurosurgery expert
| | - Sarah S Milla
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - John S Myseros
- Children's National Health System, Washington, District of Columbia; Neurosurgery Expert
| | | | - Sonia Partap
- Stanford University, Stanford, California; American Academy of Pediatrics
| | | | | | - Bruno P Soares
- The University of Vermont Medical Center, Burlington, Vermont
| | | | | | | | - Boaz Karmazyn
- Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana
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Accuracy of Bedside Ultrasound for the Diagnosis of Skull Fractures in Children Aged 0 to 4 Years. Pediatr Emerg Care 2020; 36:e268-e273. [PMID: 29698348 DOI: 10.1097/pec.0000000000001485] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the accuracy of bedside ultrasound (US) performed by emergency physicians for diagnosing skull fractures in children 0 to 4 years old compared with the accuracy of head computed tomography (CT). We also sought to investigate characteristics and precautions associated with US. METHODS This single-center prospective study involved children 0 to 4 years old who had a history of head trauma. Bedside US was performed by emergency medicine physicians, and the results were compared with CT scan interpretations provided by attending radiologists. The accuracy of US for the diagnosis of skull fractures was calculated, and the errors were reviewed. RESULTS A total of 87 patients were enrolled. Skull fracture was present in 13 patients (14.9%), according to CT. Bedside US had a sensitivity and specificity of 76.9% (95% confidence interval [CI], 46.0%-93.8%) and 100% (95% CI, 93.9%-100%), respectively. Overall positive predictive value was 100% (95% CI, 65.5%-100%), and negative predictive value was 96.1% (95% CI, 88.3%-99.0%). Three false-negative cases were observed. CONCLUSIONS Bedside US performed by emergency medicine physicians with short focused US training is a useful tool for diagnosing skull fractures in children 0 to 4 years of age. However, there were 3 false-negative cases. A meticulous examination is needed in the area adjacent to the orbital wall and skull base.
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Sorensen B, Hunskaar S. Point-of-care ultrasound in primary care: a systematic review of generalist performed point-of-care ultrasound in unselected populations. Ultrasound J 2019; 11:31. [PMID: 31749019 PMCID: PMC6868077 DOI: 10.1186/s13089-019-0145-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/21/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Both the interest and actual extent of use of point-of-care ultrasound, PoCUS, among general practitioners or family physicians are increasing and training is also increasingly implemented in residency programs. However, the amount of research within the field is still rather limited compared to what is seen within other specialties in which it has become more established, such as in the specialty of emergency medicine. An assumption is made that what is relevant for emergency medicine physicians and their populations is also relevant to the general practitioner, as both groups are generalists working in unselected populations. This systematic review aims to examine the extent of use and to identify clinical studies on the use of PoCUS by either general practitioners or emergency physicians on indications that are relevant for the former, both in their daily practice and in out-of-hours services. METHODS Systematic searches were done in PubMed/MEDLINE using terms related to general practice, emergency medicine, and ultrasound. RESULTS On the extent of use, we identified 19 articles, as well as 26 meta-analyses and 168 primary studies on the clinical use of PoCUS. We found variable, but generally low, use among general practitioners, while it seems to be thoroughly established in emergency medicine in North America, and increasingly also in the rest of the world. In terms of clinical studies, most were on diagnostic accuracy, and most organ systems were studied; the heart, lungs/thorax, vessels, abdominal and pelvic organs, obstetric ultrasound, the eye, soft tissue, and the musculoskeletal system. The studies found in general either high sensitivity or high specificity for the particular test studied, and in some cases high total accuracy and superiority to other established diagnostic imaging modalities. PoCUS also showed faster time to diagnosis and change in management in some studies. CONCLUSION Our review shows that generalists can, given a certain level of pre-test probability, safely use PoCUS in a wide range of clinical settings to aid diagnosis and better the care of their patients.
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Affiliation(s)
- Bjarte Sorensen
- Hjelmeland General Practice Surgery, Prestagarden 13, 4130, Hjelmeland, Norway.
| | - Steinar Hunskaar
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Bergen, Norway
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Intent of health care providers to adopt a clinical decision support tool in the management of minor pediatric head injuries. J Am Assoc Nurse Pract 2019; 32:168-175. [PMID: 30951010 DOI: 10.1097/jxx.0000000000000208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Radiographic neuroimaging in minor pediatric head injuries contains risks of radiation-induced malignancy. The Pediatric Emergency Care Applied Research Network (PECARN) head injury protocol identifies head-injured children who are at very low risk of clinically important traumatic brain injuries and can safely not receive a head computed tomography (CT) scan. LOCAL PROBLEM The identified urgent care facility had no facility-wide protocol to manage head injuries. METHODS The purpose of the evidence-based practice project was to educate health care providers on the risks of indiscriminate head CT prescription and the utility of the PECARN head injury protocol in the management of minor pediatric head injuries. INTERVENTIONS A knowledge assessment was conducted using pre- and posttests and the likelihood to adopt the PECARN head injury protocol in clinical practice was evaluated using the Evidence-Based Practice Attitude Scale. Additionally, rates of head CT scans ordered that were inappropriate according to the PECARN head injury protocol were calculated postproject and compared with preproject rates. RESULTS Data analysis was performed using descriptive statistics. Findings included increase in provider knowledge on the use of the PECARN head injury protocol and high likelihood of intent to adopt the PECARN head injury protocol in clinical practice. In addition, rates of head CT prescription postproject were lower than preproject rates, and 82.61% of CT scans ordered postproject were appropriate according to the PECARN head injury protocol. CONCLUSIONS Using the PECARN head injury protocol was associated with consistency of care, reduced unnecessary health care resource utilization, and health care costs.
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Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, Turner M, Benzel EC, Suskauer SJ, Giza CC, Joseph M, Broomand C, Weissman B, Gordon W, Wright DW, Moser RS, McAvoy K, Ewing-Cobbs L, Duhaime AC, Putukian M, Holshouser B, Paulk D, Wade SL, Herring SA, Halstead M, Keenan HT, Choe M, Christian CW, Guskiewicz K, Raksin PB, Gregory A, Mucha A, Taylor HG, Callahan JM, DeWitt J, Collins MW, Kirkwood MW, Ragheb J, Ellenbogen RG, Spinks TJ, Ganiats TG, Sabelhaus LJ, Altenhofen K, Hoffman R, Getchius T, Gronseth G, Donnell Z, O'Connor RE, Timmons SD. Diagnosis and Management of Mild Traumatic Brain Injury in Children: A Systematic Review. JAMA Pediatr 2018; 172:e182847. [PMID: 30193325 DOI: 10.1001/jamapediatrics.2018.2847] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE In recent years, there has been an exponential increase in the research guiding pediatric mild traumatic brain injury (mTBI) clinical management, in large part because of heightened concerns about the consequences of mTBI, also known as concussion, in children. The CDC National Center for Injury Prevention and Control's (NCIPC) Board of Scientific Counselors (BSC), a federal advisory committee, established the Pediatric Mild TBI Guideline workgroup to complete this systematic review summarizing the first 25 years of literature in this field of study. OBJECTIVE To conduct a systematic review of the pediatric mTBI literature to serve as the foundation for an evidence-based guideline with clinical recommendations associated with the diagnosis and management of pediatric mTBI. EVIDENCE REVIEW Using a modified Delphi process, the authors selected 6 clinical questions on diagnosis, prognosis, and management or treatment of pediatric mTBI. Two consecutive searches were conducted on PubMed, Embase, ERIC, CINAHL, and SportDiscus. The first included the dates January 1, 1990, to November 30, 2012, and an updated search included December 1, 2012, to July 31, 2015. The initial search was completed from December 2012 to January 2013; the updated search, from July 2015 to August 2015. Two authors worked in pairs to abstract study characteristics independently for each article selected for inclusion. A third author adjudicated disagreements. The risk of bias in each study was determined using the American Academy of Neurology Classification of Evidence Scheme. Conclusion statements were developed regarding the evidence within each clinical question, and a level of confidence in the evidence was assigned to each conclusion using a modified GRADE methodology. Data analysis was completed from October 2014 to May 2015 for the initial search and from November 2015 to April 2016 for the updated search. FINDINGS Validated tools are available to assist clinicians in the diagnosis and management of pediatric mTBI. A significant body of research exists to identify features that are associated with more serious TBI-associated intracranial injury, delayed recovery from mTBI, and long-term sequelae. However, high-quality studies of treatments meant to improve mTBI outcomes are currently lacking. CONCLUSIONS AND RELEVANCE This systematic review was used to develop an evidence-based clinical guideline for the diagnosis and management of pediatric mTBI. While an increasing amount of research provides clinically useful information, this systematic review identified key gaps in diagnosis, prognosis, and management.
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Affiliation(s)
| | | | - Kelly Sarmiento
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew J Breiding
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tamara M Haegerich
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gerard A Gioia
- Children's National Health System, George Washington University School of Medicine, Washington, DC
| | | | | | - Stacy J Suskauer
- Kennedy Krieger Institute, Johns Hopkins University , Baltimore, Maryland.,Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher C Giza
- UCLA Steve Tisch BrainSPORT Program, University of California, Los Angeles, Mattel Children's Hospital, Los Angeles.,David Geffen School of Medicine at University of California, Los Angeles
| | | | - Catherine Broomand
- Kaiser Permanente, Center for Neuropsychological Services, Roseville, California
| | | | - Wayne Gordon
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Karen McAvoy
- Rocky Mountain Hospital for Children, Denver, Colorado
| | - Linda Ewing-Cobbs
- Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston
| | | | - Margot Putukian
- Princeton University, University Health Service, Princeton, New Jersey
| | | | - David Paulk
- Kaiser Permanente, Center for Neuropsychological Services, Roseville, California
| | - Shari L Wade
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | | | - Meeryo Choe
- UCLA Steve Tisch BrainSPORT Program, University of California, Los Angeles, Mattel Children's Hospital, Los Angeles.,David Geffen School of Medicine at University of California, Los Angeles
| | - Cindy W Christian
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | | | - P B Raksin
- John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois
| | - Andrew Gregory
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Anne Mucha
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Pittsburgh, Pennsylvania
| | - H Gerry Taylor
- Nationwide Children's Hospital Research Institute, Columbus, Ohio
| | - James M Callahan
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - John DeWitt
- Jameson Crane Sports Medicine Institute and School of Health and Rehabilitation Sciences, The Ohio State University Wexner Medical Center, Columbus
| | - Michael W Collins
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Pittsburgh, Pennsylvania
| | | | - John Ragheb
- Nicklaus Children's Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | | | - T J Spinks
- St. Joseph's Children's Hospital, Department of Pediatric Neurosurgery, Tampa, Florida
| | | | | | | | | | - Tom Getchius
- American Academy of Neurology, Minneapolis, Minnesota
| | | | - Zoe Donnell
- ICF, Social Marketing Group, Rockville, Maryland
| | | | - Shelly D Timmons
- Penn State University, Milton S. Hershey Medical Center, Hershey
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Gonzalez LK, Yellin S, Arroyo AC. Point-of-Care Ultrasound in the Pediatric Emergency Department: Where We're at, Where We're Going. Adv Pediatr 2018; 65:121-142. [PMID: 30053920 DOI: 10.1016/j.yapd.2018.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Laura K Gonzalez
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Maimonides Medical Center, 4082 10th Avenue, Brooklyn, NY 11219, USA
| | - Sharon Yellin
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, New York Presbyterian Brooklyn Methodist Hospital, 506 6th Street, Brooklyn, NY 11215, USA
| | - Alexander C Arroyo
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Maimonides Medical Center, 4082 10th Avenue, Brooklyn, NY 11219, USA.
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15
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Parri N, Crosby BJ, Mills L, Soucy Z, Musolino AM, Da Dalt L, Cirilli A, Grisotto L, Kuppermann N. Point-of-Care Ultrasound for the Diagnosis of Skull Fractures in Children Younger Than Two Years of Age. J Pediatr 2018; 196:230-236.e2. [PMID: 29499992 DOI: 10.1016/j.jpeds.2017.12.057] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 10/30/2017] [Accepted: 12/19/2017] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To determine the accuracy of skull point-of-care ultrasound (POCUS) for identifying fractures in children younger than 2 years of age with signs of head trauma, and the ability of POCUS to identify the type and depth of fracture depression. STUDY DESIGN This was a multicenter, prospective, observational study of children younger than 2 years of age with nontrivial mechanisms of injury and signs of scalp/skull trauma. Patients were enrolled if they underwent computed tomography (CT). Patients underwent clinical evaluation, in addition to a cranial POCUS in the emergency department (ED). From the POCUS examinations, we documented whether fractures were present or absent, their location, characteristics, and depth. POCUS and CT findings were compared to calculate the diagnostic accuracy. RESULTS We enrolled a convenience sample of 115 of 151 (76.1%) eligible patients. Of the 115 enrolled, 88 (76.5%) had skull fractures. POCUS had a sensitivity of 80 of 88 (90.9%; 95% CI 82.9-96.0) and a specificity of 23 of 27 (85.2%; 95% CI 66.3-95.8) for identifying skull fractures. Agreement between POCUS and CT to identify the type of fracture as linear, depressed, or complex was 84.4% (97 of 115) with a kappa of 0.75 (95% CI 0.70-0.84). CONCLUSIONS POCUS performed by emergency physicians may identify the type and depth of fractures in infants with local physical signs of head trauma with substantial accuracy. Emergency physicians should consider POCUS as an adjunct to clinical evaluation and prediction rules for traumatic brain injuries in children younger than 2 years of age.
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Affiliation(s)
- Niccolò Parri
- Department of Pediatric Emergency Medicine and Trauma Center, Meyer Children's Hospital, Firenze, Italy.
| | - Bradley J Crosby
- Emergency Department, Dixie Regional Medical Center, St. George, UT
| | - Lisa Mills
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA
| | - Zachary Soucy
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA
| | - Anna Maria Musolino
- Emergency Department, Bambino Gesù Children's Hospital, IRCCS Rome, Rome, Italy
| | - Liviana Da Dalt
- Department of Woman's and Child's Health, University of Padova, Padova, Italy
| | - Angela Cirilli
- Department of Emergency Medicine, Long Island Jewish Medical Center & Cohen Children's Medical Center, New Hyde Park, NY
| | - Laura Grisotto
- Department of Statistics G. Parenti, University of Florence and ISPO Cancer Prevention and Research Institute, Florence, Italy
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA; Department of Pediatrics, University of California, Davis School of Medicine, Sacramento, CA
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16
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Wang H, Zhou Y, Liu J, Ou L, Han J, Xiang L. Traumatic skull fractures in children and adolescents: A retrospective observational study. Injury 2018; 49:219-225. [PMID: 29203200 DOI: 10.1016/j.injury.2017.11.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 11/29/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate the epidemiological features of child and adolescent (≤18 years old) patients managed for traumatic skull fractures (TSKFs) and associated traumatic brain injury (TBI). DESIGN 393 Patients who were children and adolescent who had TSKFs admitted to our university affiliated hospitals between January 2003 and December 2010. The incidence and patterns were summarized with respect to different age group, admission time and etiology. SETTING Two university-affiliated hospitals from January 2003 to May 2010. RESULTS The most common etiologies were motor vehicle collisions (MVCs) (166, 42.2%) and high fall (101, 25.7%). The most common skull fracture sites were parietal fractures (n=111, 28.2%) and basilar skull fracture (n=111, 28.2%). A total of 300 (76.3%) patients suffered TBI and 23 (5.9%) patients suffered OCI. The most common intracranial hemorrhage was epidural hemorrhage (n=94, 23.9%). The frequencies of emergency admission, medical insurance and associated injuries were 56.2% (n=221), 22.4% (n=88) and 37.2% (n=146). The frequencies of TBI and associated injuries were significantly increased from 53.45% to 76.3% and from 6.9% to 41.6% with age, respectively. CONCLUSIONS MVCs were the most common etiologies. Parietal and basilar skull fractures, epidural hemorrhages were the most common fracture sites and intracranial hemorrhage.
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Affiliation(s)
- Hongwei Wang
- Department of Orthopedics, General Hospital of Shenyang Military Area Command of Chinese PLA, Shenyang, Liaoning 110016, China; State Key Laboratory of Robotics, Shenyang Institute of Automation, Chinese Academy of Science, Shenyang, Liaoning 110016, China; State Key Laboratory of Materials Processing and Die & Mould Technology, Huazhong University of Science and Technology, Wuhan, Hubei 430074, China.
| | - Yue Zhou
- Department of Orthopedics, Xinqiao Hospital, the Third Military Medical University, Chongqing 400037, China
| | - Jun Liu
- Department of Orthopedics, General Hospital of Shenyang Military Area Command of Chinese PLA, Shenyang, Liaoning 110016, China
| | - Lan Ou
- Department of Radiology, Southwest Hospital, the Third Military Medical University, Chongqing 400038, China
| | - Jianda Han
- State Key Laboratory of Robotics, Shenyang Institute of Automation, Chinese Academy of Science, Shenyang, Liaoning 110016, China
| | - Liangbi Xiang
- Department of Orthopedics, General Hospital of Shenyang Military Area Command of Chinese PLA, Shenyang, Liaoning 110016, China
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Abstract
OBJECTIVE The objective of this study was to evaluate the sensitivity and specificity of cranial ultrasound (CUS) for detection of intracranial hemorrhage (ICH) in infants with open fontanels. METHODS This was a retrospective study of infants younger than 2 years who had a CUS performed for the evaluation of potential ICH. We excluded patient with CUSs that were done for reasons related to prematurity, transplant or oncologic evaluations, routine follow-up or preoperative screen, or congenital and known perinatal anomalies. Two clinicians independently classified each of the patients with ICH into significant or insignificant based on the radiology reports. RESULTS Of 4948 CUS studies performed during the 5-year study period, 283 studies fit the inclusion criteria. Patient age ranged from 0 to 458 days, with a median of 33 days. There were 39 total cases of ICH detected, with 27 significant bleeds and 12 insignificant bleeds. Using computed tomography, magnetic resonance imaging, or clinical outcome as criterion standard, the overall ultrasound sensitivity and specificity for bleed were 67% (confidence interval [CI], 50%-81%) and 99% (CI, 97%-100%), respectively. For those with significant bleeds, the overall sensitivity was 81% (CI, 62%-94%), and for those with insignificant bleeds, it was 33% (CI, 1%-65%). CONCLUSIONS The sensitivity of CUS is inadequate to justify its use as a screening tool for detection of ICH in young infants.
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18
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Da Dalt L, Parri N, Amigoni A, Nocerino A, Selmin F, Manara R, Perretta P, Vardeu MP, Bressan S. Italian guidelines on the assessment and management of pediatric head injury in the emergency department. Ital J Pediatr 2018; 44:7. [PMID: 29334996 PMCID: PMC5769508 DOI: 10.1186/s13052-017-0442-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/18/2017] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE We aim to formulate evidence-based recommendations to assist physicians decision-making in the assessment and management of children younger than 16 years presenting to the emergency department (ED) following a blunt head trauma with no suspicion of non-accidental injury. METHODS These guidelines were commissioned by the Italian Society of Pediatric Emergency Medicine and include a systematic review and analysis of the literature published since 2005. Physicians with expertise and experience in the fields of pediatrics, pediatric emergency medicine, pediatric intensive care, neurosurgery and neuroradiology, as well as an experienced pediatric nurse and a parent representative were the components of the guidelines working group. Areas of direct interest included 1) initial assessment and stabilization in the ED, 2) diagnosis of clinically important traumatic brain injury in the ED, 3) management and disposition in the ED. The guidelines do not provide specific guidance on the identification and management of possible associated cervical spine injuries. Other exclusions are noted in the full text. CONCLUSIONS Recommendations to guide physicians practice when assessing children presenting to the ED following blunt head trauma are reported in both summary and extensive format in the guideline document.
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Affiliation(s)
- Liviana Da Dalt
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Niccolo' Parri
- Department of Pediatric Emergency Medicine and Trauma Center, Meyer University Children's Hospital, Florence, Italy
| | - Angela Amigoni
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Agostino Nocerino
- Department of Pediatrics, S. Maria della Misericordia University Hospital, University of Udine, Udine, Italy
| | - Francesca Selmin
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Renzo Manara
- Department of Radiology, Neuroradiology Unit, University of Salerno, Salerno, Italy
| | - Paola Perretta
- Neurosurgery Unit, Regina Margherita Pediatric Hospital, Torino, Italy
| | - Maria Paola Vardeu
- Pediatric Emergency Department, Regina Margherita Pediatric Hospital, Torino, Italy
| | - Silvia Bressan
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy.
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19
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Tamada I, Mori T, Inoue N, Shido H, Aoki M, Nakamura Y, Kamogawa R. An Algorithmic Approach Using Ultrasonography in the Diagnosis of Pediatric Nasal Bone Fracture. J Craniofac Surg 2017; 28:84-87. [PMID: 27906845 DOI: 10.1097/scs.0000000000003217] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Ultrasonography (US) was recently reported as a reliable modality for diagnosing nasal bone fractures. However, whether US is reliable as a screening tool in the pediatric emergency department (ED) remains unknown. This prospective cohort study had a 2-fold aim: to assess the utility of US in the diagnosis of pediatric nasal bone fracture, and to evaluate the validity of our protocol for managing pediatric nasal bone fractures (Fuchu-Kids algorithm). PATIENTS AND METHODS Among the patients who presented at the ED with facial trauma, those with a suspected nasal bone fracture were enrolled in the study. Patients were treated according to Fuchu-Kids algorithm, and the validity of the protocol using US imaging was evaluated. RESULTS Among 81 patients who were enrolled during the 1-year study period, 63 patients were able to complete the process described in our protocol for further examination. The diagnostic power of the Fuchu-Kids algorithm had a sensitivity of 91.7%, a specificity of 92.3%, a positive predictive value (PPV) of 88%, and a negative predictive value (NPV) of 94.7%. However, when the performance of US was assessed as a single examination, its sensitivity, specificity, PPV, and NPV were 75%, 92.3%, 85.7%, and 85.7%, respectively. CONCLUSION Using our algorithm, the majority of patients with nasal bone fracture were successfully diagnosed and screened out successfully. Repeated US imaging is effective when clinical symptoms persist even if the first US imaging was negative for nasal bone fracture. However, a detailed medical interview and clinical examination are mandatory, regardless of the use of US.
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Affiliation(s)
- Ikkei Tamada
- *Department of Plastic and Reconstructive Surgery, Tokyo Metropolitan Children's Medical Center †Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
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20
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Abstract
Point-of-care ultrasound has become a valuable tool for pediatric emergency physicians, with an increasing number of indications being described. In this case presentation, we demonstrate the use of point-of-care ultrasound in the pediatric emergency department to diagnose ventriculomegaly in an infant presenting with a seizure.
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21
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Point-of-Care Ultrasound for the Detection of Traumatic Intracranial Hemorrhage in Infants: A Pilot Study. Pediatr Emerg Care 2017; 33:18-20. [PMID: 26308609 DOI: 10.1097/pec.0000000000000518] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Computed tomography is the criterion standard imaging modality to detect intracranial hemorrhage (ICH) in children and infants after closed head injury, but its use can be limited by patient instability, need for sedation, and risk of ionizing radiation exposure. Cranial ultrasound is used routinely to detect intraventricular hemorrhage in neonates. We sought to determine if point-of-care (POC) cranial ultrasound performed by emergency physicians can detect traumatic ICH in infants. METHODS Infants with ICH diagnosed by computed tomography were identified. For every infant with an ICH, 2 controls with symptoms and diagnoses unrelated to head trauma were identified. Point-of-care cranial ultrasound was performed by an emergency physician on all patients, and video clips were recorded. Two ultrasound fellowship-trained emergency physicians, blinded to the patients' diagnosis and clinical status, independently reviewed the ultrasound clips and determined the presence or absence of ICH. RESULTS Twelve patients were included in the study, 4 with ICH and 8 controls. Observer 1 identified ICH with 100% sensitivity (95% confidence interval [CI], 40%-100%) and 100% specificity (95% CI, 60%-100%). Observer 2 identified ICH with 50% sensitivity (95% CI, 9%-98%) and 87.5% specificity (95% CI, 47%-99%). Agreement between observers was 75%, κ = 0.4 (P = 0.079; 95% CI, 0-0.95). CONCLUSIONS Traumatic ICH can be identified with POC cranial ultrasound by ultrasound fellowship-trained emergency physicians. Although variations between observers and wide confidence intervals preclude drawing meaningful conclusions about sensitivity and specificity from this sample, these results support the need for further investigation into the role of POC cranial ultrasound.
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22
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Marin JR, Abo AM, Arroyo AC, Doniger SJ, Fischer JW, Rempell R, Gary B, Holmes JF, Kessler DO, Lam SHF, Levine MC, Levy JA, Murray A, Ng L, Noble VE, Ramirez-Schrempp D, Riley DC, Saul T, Shah V, Sivitz AB, Tay ET, Teng D, Chaudoin L, Tsung JW, Vieira RL, Vitberg YM, Lewiss RE. Pediatric emergency medicine point-of-care ultrasound: summary of the evidence. Crit Ultrasound J 2016; 8:16. [PMID: 27812885 PMCID: PMC5095098 DOI: 10.1186/s13089-016-0049-5] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 09/01/2016] [Indexed: 12/19/2022] Open
Abstract
The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers. To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations. Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.
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Affiliation(s)
- Jennifer R. Marin
- Children’s Hospital of Pittsburgh, 4401 Penn Ave, AOB Suite 2400, Pittsburgh, PA 15224 USA
| | - Alyssa M. Abo
- Children’s National Medical Center, Washington DC, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Lorraine Ng
- Morgan Stanley Children’s Hospital, New York, NY USA
| | | | | | | | | | | | | | | | - David Teng
- Cohen Children’s Medical Center, New Hyde Park, USA
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23
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O'Brien AJ, Brady RM. Point-of-care ultrasound in paediatric emergency medicine. J Paediatr Child Health 2016; 52:174-80. [PMID: 27062620 DOI: 10.1111/jpc.13098] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2015] [Indexed: 12/13/2022]
Abstract
Point-of-care ultrasound (POC US) is an adjunct to clinical paediatric emergency medicine practice that is rapidly evolving, improving the outcomes of procedural techniques such as vascular access, nerve blocks and fluid aspiration and showing the potential to fast-track diagnostic streaming in a range of presenting complaints and conditions, from shock and respiratory distress to skeletal trauma. This article reviews the procedural and diagnostic uses, both established and emerging, and provides an overview of the necessary components of quality assurance during this introductory phase.
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Affiliation(s)
- Adam J O'Brien
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria
| | - Robyn M Brady
- Emergency Department, Lady Cilento Children's Hospital, Brisbane, Australia
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24
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Pal'a A, Kapapa M, Posovszky C, Röderer G, König R, Woischneck D, Wirtz CR, Kapapa T. Head Injury in Children: Has a Change in Circumstances Caused an Increase in Treatment Numbers? J Child Neurol 2015; 30:1153-8. [PMID: 25370862 DOI: 10.1177/0883073814554655] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 09/14/2014] [Indexed: 11/15/2022]
Abstract
The number of hospitalizations for head injuries in children is rising. The exact causes remain unclear. We analyzed data of children aged between 0 and 18 years who sustained a head injury between 2010 and 2011. The analysis focused on data related to demographics, trauma mechanism, clinical course, results of imaging scans, concomitant injuries, and outcome. A total of 794 inpatient cases of head injury were treated. The leading mechanism of injury was a fall (at home) primarily at the age of 1 to 4 years (46.5%), with the majority of the children sustaining a mild brain injury (764, 96.2%). Neurosurgery was performed in 21 (2.64%) cases; average hospital stay was 2.9 days (range: 0-68 days). This study is not able to confirm that children are increasingly being brought to the hospital by their parents because of new trauma mechanisms or parents' uncertainty, nor can we confirm that the number of nonaccidental injuries is rising.
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Affiliation(s)
- Andrej Pal'a
- Department of Neurosurgery, University of Ulm, Ulm, Germany
| | - Melanie Kapapa
- Department of Pediatric Surgery, University of Ulm, Ulm, Germany
| | | | - Götz Röderer
- Department of Traumatology and Plastic Surgery, University of Ulm, Ulm, Germany
| | - Ralph König
- Department of Neurosurgery, University of Ulm, Ulm, Germany
| | | | | | - Thomas Kapapa
- Department of Neurosurgery, University of Ulm, Ulm, Germany
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25
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Burke K, Christian W. Question 1: Is ultrasound scanning as sensitive as CT in detecting skull fractures in children presenting following head injury? Arch Dis Child 2014; 99:958-60. [PMID: 24994861 DOI: 10.1136/archdischild-2014-306159] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | - William Christian
- Paediatric Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
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26
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Abstract
PURPOSE OF REVIEW Point-of-care ultrasound (POCUS) has become an integral part of emergency medicine practice. Research evaluating POCUS in the care of pediatric patients has improved the understanding of its potential role in clinical care. RECENT FINDINGS Recent work has investigated the ability of pediatric emergency medicine (PEM) physicians to perform a wide array of diagnostic and procedural applications in POCUS ultrasound. Studies have demonstrated that PEM providers are able to identify an array of diseases, including intussusception, pyloric stenosis and appendicitis. Novel applications of ultrasound, such as a cardiac evaluation in the acutely ill patient or identification of skull fractures in the assessment of a patient with head injury, have shown excellent promise in recent studies. These novel applications have the potential to reshape pediatric diagnostic algorithms. SUMMARY Key applications in PEM have been investigated in the recent publications. Further exploration of the ability to integrate ultrasound into routine practice will require larger-scale studies and continued growth of education in the field. The use of ultrasound in clinical practice has the potential to improve safety and efficiency of care in the pediatric emergency department.
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27
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Abstract
PURPOSE OF REVIEW Our objective is to highlight recent literature investigating low-radiation diagnostic strategies in the evaluation of pediatric trauma. RECENT FINDINGS In the area of minor head injury, research has focused on implementation of validated clinical decision rules into practice to reduce unnecessary computed tomography scans. Clinical observation may also serve as an adjunct to initial assessment and a potential substitute for computed tomography imaging. Subgroups of children with special needs or severe injury mechanisms may also be safely characterized by the clinical decision rule and spared radiation exposure. Physical examination techniques may be useful in diagnosing mandibular fractures. In addition, evidence suggests that plain radiography for evaluation of blunt thoracic trauma may be sufficient in many cases, and computed tomography could be reserved for those with abnormal radiographs, high-risk mechanisms, or abnormal physical findings. Clinical decision rules are able to predict intra-abdominal injury with high sensitivity. Data suggest that skeletal surveys may be modified to limit radiation exposure in the case of suspected nonaccidental trauma. SUMMARY More research is needed in development of pediatric-specific clinical decision rules and risk stratification and in testing low-radiation diagnostic modalities in the pediatric trauma population.
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28
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29
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Rabiner JE, Friedman LM, Khine H, Avner JR, Tsung JW. Accuracy of point-of-care ultrasound for diagnosis of skull fractures in children. Pediatrics 2013; 131:e1757-64. [PMID: 23690519 DOI: 10.1542/peds.2012-3921] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To determine the test performance characteristics for point-of-care ultrasound performed by clinicians compared with computed tomography (CT) diagnosis of skull fractures. METHODS We conducted a prospective study in a convenience sample of patients ≤21 years of age who presented to the emergency department with head injuries or suspected skull fractures that required CT scan evaluation. After a 1-hour, focused ultrasound training session, clinicians performed ultrasound examinations to evaluate patients for skull fractures. CT scan interpretations by attending radiologists were the reference standard for this study. Point-of-care ultrasound scans were reviewed by an experienced sonologist to evaluate interobserver agreement. RESULTS Point-of-care ultrasound was performed by 17 clinicians in 69 subjects with suspected skull fractures. The patients' mean age was 6.4 years (SD: 6.2 years), and 65% of patients were male. The prevalence of fracture was 12% (n = 8). Point-of-care ultrasound for skull fracture had a sensitivity of 88% (95% confidence interval [CI]: 53%-98%), a specificity of 97% (95% CI: 89%-99%), a positive likelihood ratio of 27 (95% CI: 7-107), and a negative likelihood ratio of 0.13 (95% CI: 0.02-0.81). The only false-negative ultrasound scan was due to a skull fracture not directly under a scalp hematoma, but rather adjacent to it. The κ for interobserver agreement was 0.86 (95% CI: 0.67-1.0). CONCLUSIONS Clinicians with focused ultrasound training were able to diagnose skull fractures in children with high specificity.
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Affiliation(s)
- Joni E Rabiner
- Albert Einstein College of Medicine, Bronx, NY 10467, USA.
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30
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Trauma ultrasound in civilian tactical medicine. Emerg Med Int 2012; 2012:781570. [PMID: 23243509 PMCID: PMC3517827 DOI: 10.1155/2012/781570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 11/15/2012] [Indexed: 11/18/2022] Open
Abstract
The term “tactical medicine” can be defined in more than one way, but in the nonmilitary setting the term tactical emergency medical services (TEMS) is often used to denote medical support operations for law enforcement. In supporting operations involving groups such as special weapons and tactics (SWAT) teams, TEMS entail executing triage, diagnosis, stabilization, and evacuation decision-making in challenging settings. Ultrasound, now well entrenched as a part of trauma evaluation in the hospital setting, has been investigated in the prehospital arena and may have utility in TEMS. This paper addresses potential use of US in the tactical environment, with emphasis on the lessons of recent years' literature. Possible uses of US are discussed, in terms of both specific clinical applications and also with respect to informing triage and related decision making.
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