Diagnostic accuracy of point-of-care ultrasonography for intussusception in children: A systematic review and meta-analysis

OBJECTIVES

Ileocolic intussusception can be challenging to diagnose due to vague complaints, but rapid diagnosis and treatment can help prevent morbidity and mortality. Prior research has focused on radiologic ultrasound, with more recent studies focusing on point-of-care ultrasonography (POCUS). This systematic review and meta-analysis assesses the diagnostic accuracy of POCUS for children with suspected ileocolic intussusception.

METHODS

PubMed, Embase, CINAHL, LILACS, the Cochrane databases, Google Scholar, conference abstracts, and bibliographies of selected articles were searched for studies evaluating the accuracy of POCUS for the diagnosis of intussusception in children. Data were dual extracted into a predefined worksheet, and quality analysis was performed with the QUADAS-2 tool. Data were summarized, and a meta-analysis was performed.

RESULTS

Eleven studies (n = 2400 children) met our inclusion criteria. Overall, 14.4% of children had intussusception. POCUS was 95.1% (95% CI: 90.3% to 97.2%) sensitive and 98.1% (95% CI: 95.8% to 99.2%) specific with a positive likelihood ratio of 50 (95% CI: 23 to 113) and a negative likelihood ratio of 0.05 (95% CI: 0.03 to 0.09).

CONCLUSIONS

POCUS has excellent diagnostic accuracy for intussusception in children presenting to the emergency department.

Point-of-Care Ultrasound Findings in Multisystem Inflammatory Syndrome in Children: A Cross-Sectional Study

OBJECTIVES

Multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 is a novel pediatric condition with significant morbidity and mortality. The primary objective of this investigation was to describe the point-of-care ultrasound (POCUS) findings in patients evaluated in the emergency department (ED) who were diagnosed with MIS-C.

METHODS

A retrospective cross-sectional study was conducted including patients <21-years-old who had POCUS performed for clinical care in a pediatric ED and were diagnosed with MIS-C. Point-of-care ultrasound studies were performed by pediatric emergency medicine attending physicians or fellows. Data abstracted by chart review included patient demographics, clinical history, physical examination findings, diagnostic test results, the time POCUS studies and echocardiograms were performed, therapies administered, and clinical course after admission.

RESULTS

For the 24 patients included, 17 focused cardiac ultrasound, 9 lung POCUS, 7 pediatric modified rapid ultrasound for shock and hypotension, 1 focused assessment with sonography for trauma, 1 POCUS for suspected appendicitis, and 1 ocular POCUS were performed by 13 physicians. Point-of-care ultrasound identified impaired cardiac contractility in 5 patients, large intraperitoneal free fluid with inflamed bowel in 1 patient, and increased optic nerve sheath diameters with elevation of the optic discs in 1 patient. Trace or small pericardial effusions, pleural effusions, and intraperitoneal free fluid were seen in 3 patients, 6 patients, and 4 patients, respectively.

CONCLUSIONS

This study demonstrates the spectrum of POCUS findings in MIS-C. Prospective studies are needed to help delineate the utility of incorporating POCUS into an ED management pathway for patients with suspected MIS-C.

Point-of-Care Ultrasound of a Shoulder Effusion in a Child With Septic Arthritis: A Case Report

ABSTRACT

Point-of-care musculoskeletal ultrasound can facilitate diagnosis of joint effusions and help guide management of suspected septic joints. This case report describes a previously healthy pediatric patient with acute onset shoulder pain and fever who was found to have leukocytosis and bacteremia. Point-of-care ultrasound (POCUS) demonstrated a unilateral shoulder joint effusion. After POCUS was performed, purulent fluid was aspirated from the joint, and she was diagnosed with a septic shoulder. We review the ultrasound technique, sonographic findings, and literature regarding POCUS for shoulder effusions.

National Variation in EMS Response and Antiepileptic Medication Administration for Children with Seizures in the Prehospital Setting

BACKGROUND AND OBJECTIVES

Prehospital Advanced Life Support (ALS) is important to improve patient outcomes in children with seizures, yet data is limited regarding national prehospital variation in ALS response for these children. We aimed to determine the variation in ALS response and prehospital administration of antiepileptic medication for children with seizures across the United States.

METHODS

We analyzed children <19 years with 9-1-1 dispatch codes for seizure in the 2019 National Emergency Medical Services Information System dataset. We defined ALS response as ALS-paramedic, ALS-Advanced Emergency Medical Technician, or ALS-intermediate responses. We conducted regression analyses to identify associations between ALS response (primary outcome), antiepileptic administration (secondary outcome) and age, gender, location, and US census regions.

RESULTS

Of 147,821 pediatric calls for seizures, 88% received ALS responses. Receipt of ALS response was associated with urbanicity, with wilderness (adjusted odds ratio [aOR] 0.44, 0.39-0.49) and rural (aOR 0.80, 0.75-0.84) locations less likely to have ALS responses than urban areas. Of 129,733 emergency medical service (EMS) activations with an ALS responder's impression of seizure, antiepileptic medications were administered in 9%. Medication administration was independently associated with age (aOR 1.008, 95% confidence interval [CI] 1.005-1.010) and gender (aOR 1.22, 95% CI 1.18-1.27), with females receiving medications more than males. Of the 11,698 children who received antiepileptic medications, midazolam was the most commonly used (83%).

CONCLUSION

The majority of children in the US receive ALS responses for seizures. Although medications are infrequently administered, the majority who received medications had midazolam given, which is the current standard of care. Further research should determine the proportion of children who are continuing to seize upon EMS arrival and would most benefit from immediate treatment.

Interobserver agreement of an ED PoCUS video training dataset of normal appendix and appendicitis in children

BACKGROUND

Educational video datasets can be an effective method for training in emergency department (ED) point-of-care ultrasound (PoCUS). A video dataset for normal appendix and appendicitis in children using ED PoCUS images was developed to assess interobserver agreement, as measured by Cohen's Kappa on key sonographic findings.

METHODS

Three sets of 25 ED PoCUS videos were selected and curated from pediatric patients with normal appendix and acute appendicitis. Four participant ED sonologist-physicians were trained on the first set of 25 videos showing normal appendix or normal bowel in patients without appendicitis to note if normal appendix was seen in any part or in it's entirety from tip-to-cecum. They were then tested on the second set of similar videos. A third set of 25 videos from patients who had appendicitis where participant sonologists were asked to note if appendicitis was present or absent, with and without appendicolith or perforation. Cohen's Kappa was calculated in aggregate and stratified by experience vs. novice against a senior sonologist-physician aware of all patient outcomes for visualization of: 1. any part of normal appendix, 2. normal appendix visualized from tip to cecum 3. any part of appendicitis, 4. appendicolith, 5. appendiceal perforation.

RESULTS

Cohen's Kappa for any part of normal appendix, 0.71, 95% CI (0.58-0.85); normal appendix tip-to-cecum, 0.43, 95% CI (0.19-0.67), appendicitis, 0.53, 95%CI (0.34-0.70), appendicolith, 0.63, 95%CI (0.43-0.84), perforated appendicitis, 0.46, 95%CI (0.22-0.70). Stratified by experienced vs. novice: any part of normal appendix, 0.75 vs. 0.68; normal appendix tip-to-cecum, 0.50 vs. 0.36; appendicitis, 0.78 vs. 0.31; appendicolith, 0.75 vs. 0.5; perforated appendicitis, 0.5 vs 0.42.

CONCLUSIONS

This educational video dataset may be used to train sonologist-physicians in ED PoCUS scanning for normal appendix and appendicitis in children. Sonologist experience affected interobserver agreement with respect to visualization of entire normal appendix and appendicitis.

Verbal Autopsy to Assess Postdischarge Mortality in Children With Suspected Sepsis in Uganda

BACKGROUND

Reducing child mortality in low-income countries is constrained by a lack of vital statistics. In the absence of such data, verbal autopsies provide an acceptable method to determining attributable causes of death. The objective was to assess potential causes of pediatric postdischarge mortality in children younger than age 5 years (under-5) originally admitted for suspected sepsis using verbal autopsies.

METHODS

Secondary analysis of verbal autopsy data from children admitted to 6 hospitals across Uganda from July 2017 to March 2020. Structured verbal autopsy interviews were conducted for all deaths within 6 months after discharge. Two physicians independently classified a primary cause of death, up to 4 alternative causes, and up to 5 contributing conditions using the Start-Up Mortality List, with discordance resolved by consensus.

RESULTS

Verbal autopsies were completed for 361 (98.6%) of the 366 (5.9%) children who died among 6191 discharges (median admission age: 5.4 months [interquartile range, 1.8-16.7]; median time to mortality: 28 days [interquartile range, 9-74]). Most deaths (62.3%) occurred in the community. Leading primary causes of death, assigned in 356 (98.6%) of cases, were pneumonia (26.2%), sepsis (22.1%), malaria (8.5%), and diarrhea (7.9%). Common contributors to death were malnutrition (50.5%) and anemia (25.7%). Reviewers were less confident in their causes of death for neonates than older children (P < .05).

CONCLUSIONS

Postdischarge mortality frequently occurred in the community in children admitted for suspected sepsis in Uganda. Analyses of the probable causes for these deaths using verbal autopsies suggest potential areas for interventions, focused on early detection of infections, as well as prevention and treatment of underlying contributors such as malnutrition and anemia.

Point-of-care ultrasound evaluation of suspected necrotizing enterocolitis in the ED

Necrotizing enterocolitis (NEC) is a rare but life-threatening diagnosis in infants presenting with bilious emesis, abdominal distension, or bloody stools. Ultrasonography has been advocated as an alternative initial imaging modality to abdominal radiography, and may be superior in the evaluation of NEC. We describe the use of point-of-care ultrasound (PoCUS) in the evaluation of suspected NEC in the emergency department (ED) when the ability to obtain immediate abdominal x-ray (AXR) was delayed due to pandemic conditions. A pre-term infant with history of bowel resection presented with non-bilious emesis, bloody stools, and slight abdominal distension. Evaluation with PoCUS identified pneumatosis intestinalis and pneumoperitoneum, which were confirmed on subsequent AXR. Pneumatosis intestinalis in a neonate is highly suggestive of NEC, but seen by itself, can be associated with milk protein allergy and Food Protein Induced Enterocolitis syndrome (FPIES). Pneumoperitoneum is considered an indication for operative intervention for NEC. The infant was re-admitted to the NICU for suspected NEC. NEC is a rare, but potentially surgical diagnosis in infants as can be FPIES, but not milk protein allergy. NEC can be identifiable using PoCUS to search for a constellation of findings that include pneumatosis intestinalis, pneumoperitoneum, free peritoneal fluid, and portal venous gas. These findings have been previously described in the PoCUS literature for other diseases, but not for a case of suspected NEC presenting to the ED.

Evaluation of Focused Assessment With Sonography for Trauma Completeness of Children in the Clinical Setting

OBJECTIVES

We evaluated the completeness of real-world Focused Assessment with Sonography for Trauma (FAST) in children after blunt abdominal trauma by benchmarking against established expert guidelines.

METHODS

We conducted a retrospective cohort study, analyzing a random sample of FASTs from two urban pediatric emergency departments. Two experts reviewed and labeled all FASTs for completeness using a predefined guideline of 5 anatomic views and 30 landmarks. We compared frequencies of views and landmarks as medians with interquartile ranges.

RESULTS

We analyzed 200 FASTs, consisting of 1636 video clips, performed by 31 clinicians representing 198 children with a median age of 10 years (IQR 5,14). Over half of FASTs (52%) had all 5 views. The right upper quadrant view was most commonly visualized (96.5%), and suprapubic sagittal was least (65%). None of the FASTs included all 30 landmarks, ranging from 0 to 28 and median of 19 (IQR 15,23). The least visualized landmark of the right and left upper quadrants was caudal liver edge (60%) and splenic tip (64%), respectively. In the pericardial view, it was left atrium (45%). In both transverse and sagittal pelvic views, retro-uterine space was least visualized in girls, 21 and 29% respectively.

CONCLUSIONS

In our study, most FAST views and landmarks were visualized. However, the pelvic sagittal view was the least frequently visualized view, and caudal liver edge was the least visualized landmark. Future research should evaluate if variability in visualizing FAST views and landmarks correlates with inconsistencies in diagnostic test performance.

Point-of-Care Ultrasound for Pediatric Vaginal Obstruction in the Emergency Department: A Case Series

ABSTRACT

Point-of-care ultrasound can be an effective tool to facilitate the evaluation of abdominal and pelvic pain in children. We present a series of 3 pediatric patients with nonspecific abdominal and pelvic symptoms in whom point-of-care ultrasound expedited diagnosis, guided decision-making, prompted subspecialist consultation, and led to definitive management of vaginal obstruction.

A Rare Complication of Anomalous Left Coronary Artery From the Pulmonary Artery Identified by Point-of-Care Ultrasound

ABSTRACT

Point-of-care ultrasound is a valuable tool in the evaluation of undifferentiated respiratory distress in children. This case report describes a 9-month-old male infant who presented with 4 months of progressively worsening cough and was found to be tachypneic in the emergency department. Chest radiography revealed complete opacification of the left hemithorax with cardiomegaly. Point-of-care ultrasound demonstrated atelectasis of the entire left lung and severe dilation of the left ventricle with poor function. Electrocardiogram and echocardiogram findings were consistent with a diagnosis of anomalous left coronary artery from the pulmonary artery. The patient underwent successful cardiac surgery to improve myocardial perfusion. Bronchoscopy visualized the etiology of his atelectasis, pulsatile compression of the left mainstem bronchus by the dilated heart. Focused cardiac and lung ultrasound techniques, as well as pertinent sonographic findings, are reviewed.