Use of Cardiac Point-of-Care Ultrasound in the Pediatric Emergency Department.

OBJECTIVES: We sought to describe the test characteristics of cardiac point-of-care ultrasound (POCUS) performed by pediatric emergency medicine (PEM) physicians after structured cardiac POCUS training. METHODS: We evaluated the use of clinically indicated cardiac POCUS by PEM physicians in a single tertiary care pediatric emergency department after implementation of a focused cardiac POCUS training curriculum. The test characteristics of the sonologist interpretation were compared with expert POCUS review, by PEM physicians who have completed PEM POCUS fellowship training, for the assessment of both pericardial effusion and left ventricular systolic dysfunction. RESULTS: A total of 1241 cardiac POCUS examinations were performed between July 2015 and December 2017, of which 456 were clinically indicated and underwent expert POCUS review and comprised the study sample. These examinations were performed by 33 different PEM attending sonologists. Chest pain (52%), dyspnea (20%), and tachycardia (18%) were the most common indications for cardiac POCUS. Prevalence of pericardial effusion and global systolic dysfunction based on expert POCUS review were 11% (48/443) and 4% (16/435), respectively. Real-time cardiac POCUS interpretation had a sensitivity and specificity of 100% and 99.5%, respectively, for both pericardial effusion and left ventricular systolic dysfunction when compared with expert POCUS review. CONCLUSIONS: Cardiac POCUS is both sensitive and specific for identifying pericardial effusion and left ventricular systolic dysfunction when performed by PEM attendings with focused training.

Yield of Plain Radiography in Addition to Ultrasound Among Children with Hip Pain.

BACKGROUND: Children with limp or hip pain often undergo radiographs and ultrasound as part of their initial evaluation. Previous research suggests that hip radiography may have limited utility, and early use of ultrasound may safely reduce the use of radiographs. OBJECTIVES: We sought to assess the utility of radiography in addition to ultrasound by evaluating the rate of bony abnormalities present on hip radiographs among children with and without effusion on ultrasound. We also assessed the agreement of point-of-care and Radiology-performed ultrasounds for the detection of effusion. METHODS: This is a retrospective cohort study of children presenting to a pediatric emergency department with acute atraumatic limp or hip pain. Data from patients who received both hip ultrasound and hip radiography as part of their evaluation were analyzed. We included both point-of-care and Radiology-performed hip ultrasounds. RESULTS: We identified 134 patients who received both hip ultrasound and hip radiographs. Sixty-eight patients (51%) had a hip effusion present on ultrasound and none of these had bony abnormalities on radiography (0%, 95% confidence interval 0-5.3%). Of the 66 patients (49%) who had no effusion on hip ultrasound, 2 patients were found to have a bony abnormality (3%, 95% confidence interval 0.4-10.5%). For patients who received both point-of-care and Radiology-performed ultrasound, the overall agreement for diagnosis of effusion was 92.6% (kappa = 0.82). CONCLUSIONS: We observed that no children with an effusion on ultrasound had bony pathology on plain radiography, suggesting that the routine performance of hip radiography may not be indicated in all children. Future studies are needed to evaluate the negative predictive value of effusion in larger numbers of patients with known bony abnormalities.

Does Point-of-Care Gastric Ultrasound Correlate With Reported Fasting Time?

OBJECTIVE: Traditionally, patient-reported fasting time has been the primary objective presedation measure of aspiration risk. Recently, gastric ultrasound has been used to assess gastric volume for the determination of aspiration risk in patients undergoing anesthesia in the operative setting. We sought to determine the correlation of gastric volume estimated by point-of-care ultrasound (POCUS) to reported fasting time. METHODS: We included children 4 to 18 years of age who presented with an acute traumatic injury. Enrolled children underwent POCUS to calculate gastric volume, which was calculated using a validated formula: Volume (mL) = -7.8 + (3.5 × Cross-sectional Area [CSA]) + (0.127 × Age in months). The CSA was measured (CSA = (anterior-posterior diameter × craniocaudal diameter × π)/4). We analyzed the relationship between time since last reported oral intake and measured gastric volume using Spearman rank correlation (ρ). RESULTS: A total of 103 patients with a median age of 10.5 years (interquartile range, 7.3-13.7 years) were enrolled. The gastric antrum was identified and measured in 88 (85%) patients; air obstructing the posterior surface of the gastric antrum prevented measurement in 14 of the 15 remaining patients. We observed a weak inverse correlation between fasting time (either liquid or solid) and estimated gastric volume (ρ = -0.33), with no significant difference based on type of intake (solids, ρ = 0.28; liquids, ρ = 0.22). CONCLUSION: Gastric volume can be estimated by POCUS and is not strongly correlated with fasting time in children in the emergency department setting.

Interrater reliability of pediatric point-of-care lung ultrasound findings.

OBJECTIVE: We sought to assess interrater reliability (IRR) of lung point-of-care ultrasound (POCUS) findings among pediatric patients with suspected pneumonia. METHODS: A convenience sample of patients between the ages of 6 months and 18 years with a clinical suspicion of pneumonia had a lung ultrasound performed by a POCUS-credentialed emergency medicine physician with subsequent expert review. Each lung zone was assessed as either normal or abnormal, and specific ultrasound findings were recorded. IRR was assessed by intraclass correlation coefficient (ICC) and kappa statistics. RESULTS: Seventy-one patients, with a total of 852 lung zones imaged, were included. The sonographer assessment of normal versus abnormal, across each of the zones, demonstrated moderate agreement with ICC 0.46 (95% CI: 0.41, 0.52) and kappa 0.56. Right-sided zones demonstrated moderate agreement [0.43 (CI 0.35, 0.51)] while left-sided zones, specifically left-sided anterior zones, showed only fair agreement [0.36 (0.28, 0.44)]. IRR varied between specific findings: ICC for B-lines 0.52 (95% CI: 0.46, 0.57), pleural effusion 0.40 (0.34, 0.45), consolidation 0.39 (0.33, 0.44), subpleural consolidation 0.31 (0.25, 0.37), and pleural line irregularity 0.16 (0.10, 0.23). A composite indicator of typical pneumonia findings (consolidation, B-lines, and pleural effusion) demonstrated moderate [ICC 0.52 (0.46, 0.57)] reliability. CONCLUSIONS: We found moderate interrater reliability of lung POCUS findings for the assessment of pediatric patients with suspected pneumonia. B-lines had the highest reliability. Further assessment of lung POCUS is necessary to guide proper training and optimal scanning techniques to ensure adequate reliability of ultrasound findings in the assessment of pediatric pneumonia.

Peritoneal fluid localization on FAST examination in the pediatric trauma patient.

OBJECTIVE: To determine the location of intraperitoneal free fluid on FAST exam in pediatric patients undergoing evaluation for trauma. METHODS: Retrospective review of all FAST exams positive for intraperitoneal free fluid performed in patients sustaining trauma between August 2009 and February 2016 in an urban pediatric emergency department. Positive results were categorized into one of nine potential intraperitoneal locations; 4 each in the right and left upper quadrants, and the pelvis. RESULTS: One hundred and three complete positive studies were reviewed. The median age of patients was 10years (IQR 7-14) with 66% being male. Ninety-five percent had fluid present in the pelvis, 35% had fluid present in the RUQ, and 16.5% had fluid present in the LUQ. Overall, the most frequent location of fluid outside of the pelvis was found at the inferior tip of the liver, present in 83.3% of patients with fluid in the RUQ and 29% of all patients with a positive FAST. CONCLUSIONS: The majority of pediatric trauma patients with a positive FAST exam will exhibit free fluid in the pelvis. Particular attention should be directed to the inferior tip of the liver in children as this represents the most common location for fluid collection outside the pelvis.

An Educational Intervention to Improve Ultrasound Competency in Ultrasound-Guided Central Venous Access.

OBJECTIVE: Ultrasound (US) guidance for central venous catheter (CVC) placement results in improved success and overall safety, but is a new skill for pediatric emergency medicine (PEM) physicians. No study to date has used simulation-based learning to evaluate the ability of PEM providers to perform US-guided CVC placement.Our objective was to assess the competency of physicians in a rarely performed procedure, US-guided CVC placement, before and after an educational intervention using simulation-based mastery learning. METHODS: We performed a prospective cohort study evaluating change in PEM physician competency in US-guided CVC placement before and after an educational intervention. Subjects participated in a curriculum composed of 3 sessions: an intervention session, a 2-month follow-up session, and a 12-month follow-up session. At each session, subjects were observed using US to guide CVC placement on a simulation model and technical skill was scored using a validated direct-observation checklist. Competency was defined as successfully completing 7 critical items on the checklist. RESULTS: Of the 28 PEM physicians participating, competency improved from 32% at preintervention to 93% at 2-month follow-up (difference, 62%; 95% confidence interval, 36%-84%). At 12-month follow-up, competency remained high (85%; difference, 53%; 95% confidence interval, 32%-75%). CONCLUSIONS: Physician competency in US-guided CVC placement improved with a simulation-based educational intervention, and the effect was maintained over time. This study may serve as a model for outcomes-based education and certification in rarely performed procedures in pediatrics.

Development and evaluation of a program for the use of ultrasound for central venous catheter placement in a pediatric emergency department.

BACKGROUND: A growing body of literature supports the use of ultrasound (US) to assist central venous catheter (CVC) placement, and in many settings, this has become the standard of care. However, this remains a relatively new and uncommonly performed procedure for pediatric emergency medicine physicians. OBJECTIVES: This study aims to describe the change over time in percentage of CVC procedures performed with US assistance per 10,000 patient visits in a pediatric emergency department. METHODS: We describe the development of an emergency US program in a pediatric emergency department and investigate how US use for CVC placement in internal jugular and femoral veins changed from July 2007, when US became available, until December 2011. Data related to CVC procedures were obtained from a procedure database maintained for quality assurance purposes. RESULTS: The percentage of CVC procedures performed with US assistance increased significantly over time (P < 0.001). CONCLUSIONS: The development of an emergency US program was associated with significantly increased physician use of US for CVC placement.

Bedside ultrasonography to identify hip effusions in pediatric patients.

STUDY OBJECTIVE: We determine whether pediatric emergency physicians can use bedside ultrasonography to accurately identify hip effusions in pediatric patients. METHODS: This was a prospective study conducted in the emergency department (ED) of an urban tertiary care freestanding pediatric hospital. A convenience sample of children younger than 18 years and who required hip ultrasonography as part of their ED evaluation was enrolled. Pediatric emergency physicians with focused ultrasonographic training performed bedside ultrasonography on patients' symptomatic and contralateral hips and categorized the findings as "effusion" or "no effusion," according to a priori definitions. Physicians rated their confidence for each bedside ultrasonographic result on a scale of 1 (not confident) to 5 (very confident). Bedside ultrasonographic results were compared with the radiology department's ultrasonographic results, which were considered the criterion standard. Standard performance metrics (sensitivity, specificity, and positive and negative predictive values) were calculated. RESULTS: Three physicians enrolled patients. Twenty-eight patients were enrolled, and 55 hips were studied. In all hips (both symptomatic and contralateral), bedside ultrasonography had a sensitivity of 80% (95% confidence interval [CI] 51% to 95%), a specificity of 98% (95% CI 85% to 99%), a positive predictive value of 92% (95% CI 62% to 99%), and a negative predictive value of 93% (95% CI 79% to 98%). In the 28 symptomatic hips, bedside ultrasonography had a sensitivity of 85% (95% CI 54% to 97%), a specificity of 93% (95% CI 66% to 99%), a positive predictive value of 92% (95% CI 60% to 99%), and negative predictive value of 88% (95% CI 60% to 98%). When physician self-rated confidence was high, the sensitivity of bedside ultrasonography in symptomatic hips was 90% (95% CI 54% to 99%), the specificity was 100% (95% CI 70% to 100%), the positive predictive value was 100% (95% CI 63% to 100%), and the negative predictive value was 92% (95% CI 62% to 99%). CONCLUSION: With focused training, pediatric emergency physicians were able to use bedside ultrasonography to identify hip effusions in pediatric ED patients.

The Variability of Preferred Infant Lumbar Puncture Insertion Site Between Novice and Experienced Physicians.

BACKGROUND: We sought to determine if vertebral interspace selection for performance of infant lumbar puncture (LP) varies between less experienced trainees and more experienced pediatric emergency medicine (PEM) attending physicians. METHODS: We performed an observational prospective study using a convenience sample of infants aged 0 to 12 months presenting to a single emergency department. Trainees with limited LP experience (defined as less than 10 infant LPs performed) marked their preferred LP insertion site with an invisible ultraviolet pen. PEM attending physicians subsequently marked their preferred LP insertion site with a visible pen. A trained sonographer then performed a bedside ultrasound to confirm interspace concordance or discordance. Our primary outcome was the proportion of concordant marked insertion sites. RESULTS: Of the 110 patients enrolled, 102 (92.8%) completed study procedures. Trainee and PEM attending LP interspace markings were concordant in 27% of cases. Trainees marked a preferred interspace below the level of the attending in 55% of patients: 29 (28.4%) marked one spot inferior, 20 (19.6%) marked two spots inferior, and seven (6.9%) marked three spots inferior in relation to the attending. CONCLUSIONS: There is variability of preferred LP insertion site based on provider experience. Trainees with limited LP experience tended to mark insertion spaces more caudal than those marked by the attending physicians in an area where the subarachnoid space is slightly smaller.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence.

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.

Ultrasound assistance for central venous catheter placement in a pediatric emergency department improves placement success rates.

OBJECTIVES: The use of ultrasound (US) has been shown to improve success rates and reduce complications of central venous catheter (CVC) placement in adult emergency department (ED) patients. The authors sought to determine if US assistance for CVC placement is associated with an increased success rate in pediatric ED patients. METHODS: This was a retrospective cohort study of CVC placement in a pediatric ED from January 2003 to October 2011. Data were extracted from a procedure log created to record details entered by physicians at the time of CVC placement, including indication, location, complications, and information regarding use of US. All femoral vein and internal jugular vein CVC placement attempts performed by, assisted with, or directly supervised by pediatric emergency physicians (EPs) were included. Characteristics of procedures performed with and without US assistance were compared, controlling for patient and physician factors. The primary outcome was the success rate of CVC placement. RESULTS: There were 168 patients undergoing CVC placement attempts. The proportion of successful placement attempts was significantly higher when using US assistance (96 of 98) compared to those without (55 of 70; 98% vs. 79%, odds ratio [OR] = 13.1, 95% confidence interval [CI] = 2.9 to 59.4). When controlling for patient- and physician-specific factors, success rates remained significantly higher. CONCLUSIONS: Ultrasound assistance was associated with greater likelihood of success in CVC placement in a pediatric ED.

Pediatric emergency medicine fellow training in ultrasound: consensus educational guidelines.

The importance of point-of-care emergency ultrasound (EUS) to the practice of emergency medicine (EM) is well established, and mounting research continues to demonstrate how EUS can benefit pediatric emergency department (ED) patients. As members of the EM community, pediatric EM (PEM) physicians should understand the potential value of EUS and seek opportunities to incorporate EUS into their daily practice. Currently, EUS education and training is at an early developmental stage for PEM fellows and varies greatly between programs. The goal of this article is to provide consensus education guidelines and to describe a sample curriculum that can be used by PEM fellowship programs when developing or revising their US training curricula. The authors recognize that programs may be at different stages of EUS development and will consequently need to tailor curricula to individual institutional needs and capabilities. This guideline was developed through a collaborative process between EUS educators and members of the American Academy of Pediatrics Section of EM Fellowship Directors Subcommittee. The guideline includes the following topics: important considerations regarding EUS in PEM, PEM US program framework, PEM US curriculum, PEM US education program, and competency assessment.