Updates on the clinical integration of point-of-care ultrasound in pediatric emergency medicine.

PURPOSE OF REVIEW: There is expanding evidence for point-of-care ultrasound (POCUS) use in pediatric emergency medicine - this review highlights the benefits and challenges in the clinical integration of high-yield POCUS applications. Specifically, it will delve into POCUS applications during resuscitations, controversies of Focused Assessment with Sonography for Trauma (FAST) in pediatric trauma, POCUS-guided procedures, and examples of clinical pathways where POCUS can expedite definitive care. RECENT FINDINGS: POCUS can enhance diagnostic accuracy and aid in management of pediatric patients in shock and help identify reversible causes during cardiac arrest. The use of the FAST in pediatric blunt abdominal trauma remains nuanced - its proper use requires an integration with clinical findings and an appreciation of its limitations. POCUS has been shown to enhance safety and efficacy of procedures such as nerve blocks, incision & drainage, and intravenous access. Integrating POCUS into pathways for conditions such as intussusception and testicular torsion expedites downstream care. SUMMARY: POCUS enhances diagnostic efficiency and management in pediatric patients arriving at the ED with undifferentiated shock, cardiac arrest, or trauma. Additionally, POCUS improves procedural success and safety, and is integral to clinical pathways for expediting definitive care for various pediatric emergencies. Future research should continue to focus on the impact of POCUS on patient outcomes, ensuring user competency, and the expansion of POCUS into diverse settings.

The Outcome of Cerumen Removal in the Pediatric Emergency Department.

OBJECTIVE: Cerumen obstructs the visualization of the tympanic membrane (TM) in up to 40% of children, sometimes posing a challenge to rule out the diagnosis of acute otitis media (AOM) as the source of otalgia (for verbal children), irritability, fever, and febrile seizures. We aim to determine the rate at which removing the cerumen from blocking the view of the TM could change the management of these patients in the pediatric emergency department (PED). METHODS: We retrospectively investigated all medical records of patients who underwent cerumen removal in the PED at a tertiary children's hospital from 2018 to 2019. We analyzed the effect of the procedure on the subsequent workup during their PED visit. RESULTS: Of 482 children who presented to the PED with otalgia, irritability, fever, and/or febrile seizures and who were referred to an otolaryngologist for subsequent treatment after preliminary evaluation in the PED, 176 were included in the study group after having the cerumen removed from one or both ears. Seventy-three of them were given a diagnosis of AOM, 93 had a normal-appearing TM, and 10 had external otitis. Twenty-one percent of those with AOM and 46% of those with a normal TM ( P = 0.008) had blood drawn as part of their workup in their PED visit. The rate of chest x-rays was also significantly less for the AOM group (16% vs 30%, P = 0.03), and they also underwent fewer urine tests ( P = NS). CONCLUSION: Cerumen removal changes the management of children in the PED who present with a possible diagnosis of an ear infection. Cerumen removal could avoid unnecessary laboratory and imaging studies, which could save time, costs, and suffering.

C-Reactive Protein and the Outcome of a Pediatric Emergency Department 7 Days Revisit.

BACKGROUND: Pediatric emergency department (PED) return visits represent an important quality of care metric and constitute a patient-centered outcome. C-reactive protein (CRP) is an inflammatory biomarker that is commonly used as screening tool in the PED. In this study, we assessed the clinical outcomes of children whose levels of CRP are 150 mg/L or higher at the initial PED visit and if such levels could be useful in predicting outcomes at a second PED visit. METHODS: A historical cohort study of all patients who visited the PED between July 2007 and June 2017 and had a CRP value of 150 mg/L or greater in the setting of a febrile illness. Data of patients with a return visit to the PED within 7 days were assessed for an association between laboratory values, diagnosis and clinical outcome. RESULTS: One hundred thirty-six index visits were included in this study. One hundred fifteen (84.6%) of the revisits were discharged after their second visit, and 21 (15.4%) were admitted to the inpatient unit. Admitted patients did not differ from patients who were discharged home in diagnosis and CRP levels, but a difference in white blood cell and absolute neutrophil counts was observed. CONCLUSIONS: The intensity of the inflammatory response, as expressed by the high concentrations of CRP in children, does not seem to predict the outcome at a repeat PED visit within 7 days.