Point-of-care Ultrasound: A New Tool for the Identification of Gastric Foreign Bodies in Children?

The most practical diagnostic imaging for detecting body packers during the drug trafficking: Ultrasonography

INTRODUCTION

Body packing is one of the most common methods used in the transboundary trafficking of illicit drugs. These drugs are packaged in capsules and taken orally or inserted into the rectum or vagina. Its diagnosis is, therefore, difficult. Methods like x-ray, ultrasonography, and computed tomography (CT) are usually used to diagnose body packers. This study aimed to evaluate the diagnostic power and feasibility of ultrasonography as a diagnostic tool in patients who have a suspicion of being body packers.

METHODS

This study is designed as a prospective and single-centered case-control study in the emergency department of a training and research hospital. Cases admitted to the emergency department with suspicion of being a body packer were included in the study. The data obtained was recorded on the study form. p < 0.05 was accepted as statistically significant.

RESULTS

One hundred and one patients were included in the study; 76.2% (n = 77) were male. Packages were detected in 56.5% (n = 57) of the cases. Ultrasonography was found to be significantly useful in evaluating the presence of intra-abdominal packages. Ultrasonography had 92.4% sensitivity and 97.8% specificity in evaluating the presence of packs.

CONCLUSION

CT is frequently used to diagnose patients admitted to the emergency departments with suspected body packing. In our study, ultrasonography is an advantageous imaging method, given its success rate, radiation-free nature, and low cost. We have found ultrasonography to be a successful imaging modality in examining patients suspected of being body packers for the presence of packs, and it can replace CT in clinics.

Ultrasound evaluation of intraluminal magnets in an ex vivo model

PURPOSE

The management of foreign body ingestion proves to be a challenge. Magnets pose a unique set of risks when ingested due to their attractive forces and subsequent risk of adherence, pressure necrosis, and perforation complications. Radiographs only provide a limited snapshot in the setting of multiple magnet ingestion when the risk of complication is highest. We hypothesize that abdominal ultrasound (US) has the potential to supplement radiographs in assessing ingested magnets by determining the presence of bowel loop entrapment and of any extraluminal fluid.

METHODS

We recreated various scenarios of magnet configurations using animal cadaveric bowel models. X-ray and US images were obtained in various bowel-magnet orientations.

RESULTS

We identified several key US features to suggest bowel wall tethering. These include direct visualization of bowel wall entrapment between magnets (what we term the "dangerous V sign"), anti-dependent positions of the magnets, and inability to separate loops of bowel with compression.

CONCLUSION

These findings could potentially provide valuable information when directing the urgency of intervention in foreign body ingestion. Ultrasound may supplement and improve the current guidelines in management of magnet ingestion.

Point-of-Care Ultrasound for the Diagnosis of Pediatric Foreign Body Ingestion: A Narrative Review and Illustrative Case Report

PURPOSE

Foreign body ingestion (FBI) is a frequent concern in emergency departments. Clinical guidelines recommend performing plain x-rays as the primary modality of diagnosis. Although point-of-care ultrasound (PoCUS) has increasingly been integrated into the daily practice of emergency medicine, it has been poorly investigated in the diagnostic approach for FBI.This review aims to highlight the current state of PoCUS use for pediatric FBI.The following research question was considered in this narrative review: Is PoCUS useful for FBI management?

METHODS

A literature search was conducted to identify articles reporting PoCUS use for the management of FBI. All articles were assessed for quality by 2 reviewers.

MAIN RESULTS

The 14 selected articles reported 52 FBI cases in which PoCUS successfully identified and located the ingested FB. Point-of-care ultrasound was used either as the primary imaging technique or after positive or negative x-ray findings. In 5 cases (9.6%), PoCUS was the only modality used for the diagnosis. Of these cases, 3 (60%) underwent a successful procedure to remove the FB and 2 (40%) received conservative treatment without complications.

CONCLUSIONS

This review suggests that PoCUS might be a reliable modality for the initial management of FBI. PoCUS can locate, identify, and evaluate the size of the FB in a wide range of materials and gastrointestinal locations. Point-of-care ultrasound could eventually become the go-to modality in the case of radiolucent FB, thus avoiding the use of radiation. Further studies are nevertheless required to validate PoCUS use for FBI management.

Point-of-Care Thoracic Ultrasound in Children: New Advances in Pediatric Emergency Setting

Point-of-care thoracic ultrasound at the patient's bedside has increased significantly recently, especially in pediatric settings. Its low cost, rapidity, simplicity, and repeatability make it a practical examination to guide diagnosis and treatment choices, especially in pediatric emergency departments. The fields of application of this innovative imaging method are many and include primarily the study of lungs but also that of the heart, diaphragm, and vessels. This manuscript aims to describe the most important evidence for using thoracic ultrasound in the pediatric emergency setting.

Management of Gastrointestinal Foreign Bodies with Brief Review of the Guidelines

Foreign body (FB) ingestion is a common health problem that affects children more than adults. According to gastroenterologists' guidelines, the management of FB ingestion differs slightly between adult and children. This review aimed to compile adult and children guidelines and establish an understandable association to reveal the requirements and timing of the endoscopic procedure, which is the most effective and least complicated technique for gastrointestinal FBs. Coins, pins, and chicken and fish bones have been the most commonly ingested FBs. However, with their increasing use in recent years, large batteries with lithium-ion conversion, stronger magnets composed of rare earth metals, such as neodymium, and superabsorbent objects have become the most morbid and mortal, necessitating new management strategies. Although the approach to gastrointestinal FBs is controversial, with different treatment options available in different disciplines, many studies have demonstrated the efficacy and safety of endoscopic procedures. Many factors influence the timing of endoscopy, including the nature, size, and location of the ingested object and the patient's clinical condition.

Gastric Point-of-Care Ultrasound in Acutely and Critically Ill Children (POCUS-ped): A Scoping Review

Introduction

Point-of-care ultrasound (POCUS) use is increasing in pediatric clinical settings. However, gastric POCUS is rarely used, despite its potential value in optimizing the diagnosis and management in several clinical scenarios (i.e., assessing gastric emptying and gastric volume/content, gastric foreign bodies, confirming nasogastric tube placement, and hypertrophic pyloric stenosis). This review aimed to assess how gastric POCUS may be used in acute and critically ill children.

Materials and Methods

An international expert group was established, composed of pediatricians, pediatric intensivists, anesthesiologists, radiologists, nurses, and a methodologist. A scoping review was conducted with an aim to describe the use of gastric POCUS in pediatrics in acute and critical care settings. A literature search was conducted in three databases, to identify studies published between 1998 and 2022. Abstracts and relevant full texts were screened for eligibility, and data were extracted, according to the JBI methodology (Johanna Briggs Institute).

Results

A total of 70 studies were included. Most studies (n = 47; 67%) were conducted to assess gastric emptying and gastric volume/contents. The studies assessed gastric volume, the impact of different feed types (breast milk, fortifiers, and thickeners) and feed administration modes on gastric emptying, and gastric volume/content prior to sedation or anesthesia or during surgery. Other studies described the use of gastric POCUS in foreign body ingestion (n = 6), nasogastric tube placement (n = 5), hypertrophic pyloric stenosis (n = 8), and gastric insufflation during mechanical ventilatory support (n = 4). POCUS was performed by neonatologists, anesthesiologists, emergency department physicians, and surgeons. Their learning curve was rapid, and the accuracy was high when compared to that of the ultrasound performed by radiologists (RADUS) or other gold standards (e.g., endoscopy, radiography, and MRI). No study conducted in critically ill children was found apart from that in neonatal intensive care in preterms.

Discussion

Gastric POCUS appears useful and reliable in a variety of pediatric clinical settings. It may help optimize induction in emergency sedation/anesthesia, diagnose foreign bodies and hypertrophic pyloric stenosis, and assist in confirming nasogastric tube placement, avoiding delays in obtaining confirmatory examinations (RADUS, x-rays, etc.) and reducing radiation exposure. It may be useful in pediatric intensive care but requires further investigation.

Age-Related Changes in Upper Airway Anatomy Via Ultrasonography in Pediatric Patients

PURPOSE

Ultrasonography is a portable, noninvasive tool that may be used to evaluate the upper airway. The purpose of our study was to present a systematic approach to identify salient features of the pediatric airway and determine whether ultrasonography can identify anatomical changes that occur with growth and development.

METHODS

We present a prospective, observational trial where patients included were between 1 day and 10 years of age presenting for elective surgery who had no known history of unfavorable airway pathology. We sequentially obtained 5 ultrasound views under anesthesia: (1) sagittal sternal notch view of the trachea, (2) sagittal longitudinal view of trachea (LT), (3) axial view at the level of the vocal cords (AVC), (4) axial view at the level of the cricoid membrane (AC), and (5) sagittal longitudinal submental space view (SM). A broadband linear array transducer was used to identify airway structures and perform measurements.

RESULTS

Eighty-four percent of enrolled patients underwent airway imaging and were analyzed using multiple regression and Spearman correlation (ρ). In view 1, tracheal diameter via sagittal sternal notch view was immeasurable because of air disturbance. In the LT view, the distance from the skin to the cricothyroid membrane (LT1) did not statistically increase with age in days (P = 0.06); however, the distance from the cricoid to thyroid cartilage (LT2) did correlate to age (P < 0.001; 99% confidence interval [CI], 1.8 × 10-5, 7.7 × 10-5; ρ = 0.77, P = 0.001). We found a statistically significant relationship between age and the distance between the anterior and posterior commissures (AVC2; P < 0.001; 99% CI, 1.0 × 10-4, 1.7 × 10-4; ρ = 0.80, P < 0.001), the distance from the skin to the posterior commissure (AVC3; P < 0.001; 99% CI, 9.6 × 10-5, 2.0 × 10-4; ρ = 0.73, P < 0.001), the distance to the cricoid cartilage (AC; P < 0.001; 99% CI, 2.0 × 10-5, 7.7 × 10-5; ρ = 0.66, P < 0.001), and the distance from the tongue base to the soft palate (SM2; P < 0.001; 9% CI, 1.8 × 10-4, 3.9 × 10-4; ρ = 0.85, P < 0.001). There were no significant relationships between age and AVC1 (P = 0.16) and SM1 (P = 0.44).

CONCLUSIONS

Airway ultrasound is a feasible tool to evaluate the pediatric airway in children younger than 10 years; however, the detection of age-related changes of certain structures is limited to select measurements.

Non-radiologist-performed abdominal point-of-care ultrasonography in paediatrics - a scoping review

BACKGROUND

Historically, US in the paediatric setting has mostly been the domain of radiologists. However, in the last decade, there has been an uptake of non-radiologist point-of-care US.

OBJECTIVE

To gain an overview of abdominal non-radiologist point-of-care US in paediatrics.

MATERIALS AND METHODS

We conducted a scoping review regarding the uses of abdominal non-radiologist point-of-care US, quality of examinations and training, patient perspective, financial costs and legal consequences following the use of non-radiologist point-of-care US. We conducted an advanced search of the following databases: Medline, Embase and Web of Science Conference Proceedings. We included published original research studies describing abdominal non-radiologist point-of-care US in children. We limited studies to English-language articles from Western countries.

RESULTS

We found a total of 5,092 publications and selected 106 publications for inclusion: 39 studies and 51 case reports or case series on the state-of-art of abdominal non-radiologist point-of-care US, 14 on training of non-radiologists, and 1 each on possible harms following non-radiologist point-of-care US and patient satisfaction. According to included studies, non-radiologist point-of-care US is increasingly used, but no standardised training guidelines exist. We found no studies regarding the financial consequences of non-radiologist point-of-care US.

CONCLUSION

This scoping review supports the further development of non-radiologist point-of-care US and underlines the need for consensus on who can do which examination after which level of training among US performers. More research is needed on training non-radiologists and on the costs-to-benefits of non-radiologist point-of-care US.

Pediatrician performed point-of-care ultrasound for the detection of ingested foreign bodies: case series and review of the literature

PURPOSE

Foreign body (FB) ingestions represent a common problem in children. History and physical examination are commonly not enough to diagnose a foreign body ingestion; therefore, conventional radiography is routinely used to detect them. Point-of-care ultrasound is widely used in the emergency department for several diagnostic applications but there are few articles describing the possibility to use point-of-care ultrasound to detect ingested foreign bodies, and the necessary training to get competent in this application. The main objective of this paper is to illustrate the use of point-of-care ultrasound (POCUS) to detect ingested foreign bodies. The secondary objective is to describe a limited training, necessary for emergency pediatricians, to obtain this skill.

METHODS

This is a case series of eight pediatric patients who presented to the pediatric Emergency Department (ED), with suspected ingestion of FB, and were assessed with POCUS. Physician sonographers were two pediatricians and three residents in pediatrics working in two Italian Pediatric EDs. All sonographers participated in a 2-day POCUS workshop which included the most common pediatric POCUS applications.

RESULTS

POCUS, performed by emergency pediatricians who participated to a limited training, allowed to always identify the foreign bodies ingested.

CONCLUSIONS

We demonstrate that an appropriate and limited training allows pediatric emergency physicians to correctly identify foreign body in the esophagus or stomach. Point-of-care ultrasound in foreign body ingestion in the Emergency Department may allow to prioritize the escalation of care in children and it can contribute to reduce the time to endoscopic management when needed.

Application of point-of-care ultrasound for different types of esophageal foreign bodies: three case reports: A CARE-compliant article

RATIONALE

Esophageal point-of-care ultrasound (POCUS) has recently been reported as a useful, quick, safe, and simple technique to detect esophageal foreign bodies (FBs). However, case series to detect esophageal FB using POCUS have been rarely reported. Chicken bones and pills, especially, have not yet been reported as esophageal FBs. The objective of this case series was to describe the POCUS findings of 3 different materials-food, pill, and chicken bone.

PATIENT CONCERNS

Case 1, a 75-year-old woman with odynophagia and neck pain occurring 30 min after eating chicken porridge; Case 2, a 32-year-old woman with neck discomfort occurring 2 h after taking a pill; Case 3, a 29-year-old woman reporting FB sensation in the neck that occurred 1 h after eating sausage and rice soup.

DIAGNOSIS

Case 1. Cervical esophageal FB (chicken bone), Case 2. Cervical esophageal FB (oral pill), Case 3. Cervical esophageal FB (food).

INTERVENTIONS

Case 1. POCUS, urgent esophagogastroduodenoscopy (EGD) with alligator forceps. POCUS findings; hyperechoic material (suspected FB) that did not disappear by swallowing and esophageal dilatation with pooling of secretions. Case 2. POCUS. POCUS findings; hypoechoic material (suspected FB) that did not disappear by swallowing, and esophageal bulging above the FB, especially observed in the longitudinal view. Case 3. POCUS. POCUS findings; hyperechoic material (suspected FB) with reverberation artifact that did not disappear with swallowing efforts. Prior FB esophageal bulging with persistent air-fluid level was especially observed in the longitudinal view.

OUTCOMES

Case 1. FB was removed by EGD with alligator forceps. Case 2. Symptoms disappeared under observation without EGD. Follow-up POCUS revealed normalized bulging esophagus. Case 3. These symptoms improved after vomiting a large piece of food material. Three patients were discharged without complications.

LESSONS

In this case series, the impacted materials were chicken bone, pill, and food. However, POCUS findings were similar (esophageal dilation, hyperechoic or hypoechoic lesion with mixed echogenic contents in food or secretion, and no change with swallowing efforts). A longitudinal view was useful to assume the presence of cervical esophageal FB in all three cases. Thus, POCUS findings could be indirect signs of a FB in the esophagus.

Point of care ultrasonography in the pediatric emergency department

IMPORTANCE

Point-of-care ultrasonography (POCUS) allows to obtain real-time images to correlate with the patient's presenting signs and symptoms. It can be used by various specialties and may be broadly divided into diagnostic and procedural applications.

OBJECTIVE

We aimed at reviewing current knowledge on the use of POCUS in Pediatric Emergency Departments (PEDs).

FINDINGS

US diagnostic capacity in paediatric patients with suspected pneumonia has been studied and debated whereas literature regarding the usefulness of point-of-care echocardiography in the pediatric setting is still limited. Similarly, Focused Assessment with Sonography for Trauma (FAST) has become a standard procedure in adult emergency medicine but it is still not well codified in the pediatric practice. Concerning procedural applications of POCUS we identified 4 main groups: peripheral vascular access, bladder catheterizations, identification and drainage of abnormal fluid collections and foreign body identification.

CONCLUSIONS AND RELEVANCE

Bedside emergency ultrasound is routinely used by adult emergency physicians and in the last 10 years its application is recognized and applied in PED. Pediatric emergency physicians are encouraged to familiarize with POCUS as it is a safe technology and can be extremely helpful in performing diagnosis, managing critical situations and guiding procedures, which results in globally improving pediatric patients care.