Fever in children aged 3 to 36 Months: management in the emergency department.

The advent of pneumococcal and Haemophilus influenzae vaccines has substantially reduced the risk for occult (unsuspected) serious bacterial infection or invasive bacterial infection in the febrile child. The challenge for emergency clinicians is to identify and treat children with serious illness while avoiding overtreatment. This issue reviews the epidemiology and management of fever in children aged 3 to 36 months, focusing primarily on previously healthy, well-appearing children without a source of fever whose evaluation and management are more ambiguous.

The P2Network-Advancing Pediatric Emergency Care With Point-of-Care Ultrasound.

ABSTRACT: Over the last 2 decades, the use of point-of-care ultrasound (POCUS) in pediatric emergency medicine (PEM) has grown exponentially. In 2014, a group of PEM POCUS leaders met and formed the P2Network. The P2Network provides a platform to build collaborative relationships and share expertise among members from various countries and practice settings. It works with educators and researchers within and outside of the field to advance POCUS practice in PEM. As an organization, the P2Network promotes the evidence-based application of POCUS to facilitate and improve care in the PEM setting and addresses issues related to integration of the PEM POCUS practitioner in this nascent field. The P2Network is building and augmenting its infrastructure for PEM POCUS research and education and has already made some progress in the areas, with published manuscripts and ongoing clinical research studies under its sponsorship. Future goals include developing a PEM POCUS research agenda, formalizing teaching and assessment of PEM POCUS skills, and implementing multicenter research studies on potentially high impact applications.

Students Teaching Students: Student-Led Ultrasound Curriculum in Medical School Education.

Introduction With the expanding use of point-of-care ultrasound throughout medical specialties for the rapid bedside assessment integral to patient care, medical schools have sought to incorporate ultrasound education into their curriculum. Second-year medical students (MS2s) at our institution met this demand by forming the Ultrasound Student Instructor Cadre (USSIC), a longitudinal ultrasound curriculum where MS2s teach first-year medical students (MS1s). The objectives of this study were to assess the ultrasound knowledge of medical students and their perceptions of ultrasound incorporation into their medical education. Methods Our flipped classroom curriculum consisted of four lessons (cardiopulmonary, gastrointestinal, genitourinary, and musculoskeletal) composed of videos, didactic lessons, and hands-on probe-time, with 15-minute pre- and post-assessments. Paired Wilcoxon signed-rank tests were performed to evaluate the differences in the pre- and post-assessment scores for each teaching session. Additionally, an end-of-the-year survey assessed the perceived preparedness and overall satisfaction of the MS1s with the course. Results The differences between the pre- and post-assessments for each teaching session were statistically significant: cardiopulmonary (45.6 ± 16.9% vs. 82.9 ± 9.4%, p < 0.0001, n = 55), gastrointestinal (53.9 ± 18.0% vs. 84.1 ± 13.5%, p < 0.0001, n = 54), genitourinary (68.9 ± 19.1% vs. 91.4 ± 14.4%, p < 0.0001, n = 64), and musculoskeletal (33.6 ± 14.7% vs. 78.2 ± 18.2%, p < 0.0001, n = 55). Conclusion Our study suggests that MS1s met the learning objective for each teaching session. Furthermore, MS1s who became USSIC instructors as MS2s felt more prepared and were more satisfied with the course. This study demonstrates the efficacy of student-led instruction in ultrasound, and we offer our model for adoption into other medical schools.

COVID-19 hospitalization rate in children across a private hospital network in the United States: COVID-19 hospitalization rate in children.

OBJECTIVES: There are limited studies with varying results evaluating the rate of hospitalizations of pediatric patients tested for COVID-19 in the United States. More information in the pediatric COVID-19 literature is needed. The objective of this study was to describe the rates of positive tests, hospitalization, severe disease, and mortality for COVID-19 in children. MATERIAL AND METHODS: We performed a retrospective analysis of data collected from a data warehouse from 184 hospitals across the United States. All cases of pediatric patients who were tested for COVID-19 were analyzed for test positivity, hospitalization, severe disease, and mortality. A separate subgroup analysis for ages < 1 year, 1-4 years, 5-8 years, 9-14 years, and 15-17 years was performed. RESULTS: Of 24,781 patient encounters, we found a test positivity rate of 11.15% (95% CI: 10.76-11.55). There were 142 admissions out of the 2,709 symptomatic patients, 5.24% (95% CI: 4.43-6.15) admission rate. Of those admitted, we found that 54.93% (78/142) were admitted to the PICU, but only 22 of the 142 admissions, 15.49% (95% CI: 9.97-22.51), were determined to have severe COVID-19 disease. One patient died during the study period giving an overall pediatric mortality rate of 0.04% (95% CI: 0.00-0.21). CONCLUSION: In our sample, we found a test positivity rate of 11.15%. We also report a 5.24% hospitalization rate with 15.49% of admitted patients with severe disease. Lastly, we also report a very low mortality rate of 0.04% of all patients who tested positive for COVID-19.

ACR Appropriateness Criteria® Postmenopausal Acute Pelvic Pain.

Acute pelvic pain is a common presenting complaint in both the emergency room and outpatient settings. Pelvic pain of gynecologic origin in postmenopausal women occurs less frequently than in premenopausal women; however, it has important differences in etiology. The most common causes of postmenopausal pelvic pain from gynecologic origin are ovarian cysts, uterine fibroids, pelvic inflammatory disease, and ovarian neoplasm. Other etiologies of pelvic pain are attributable to urinary, gastrointestinal, and vascular systems. As the optimal imaging modality varies for these etiologies, it is important to narrow the differential diagnosis before choosing the initial diagnostic imaging examination. Transabdominal and transvaginal ultrasound are the best initial imaging techniques when the differential is primarily of gynecologic origin. CT with intravenous (IV) contrast is more useful if the differential diagnosis remains broad. MRI without IV contrast or MRI without and with IV contrast, as well as CT without IV contrast may also be used for certain differential considerations. 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.

Using Point-of-Care Ultrasound to Expedite Diagnosis of Necrotizing Fasciitis: A Case Report.

It is vital that all emergency medicine physicians (EP) are able to perform and evaluate point-of-care ultrasound (POCUS) images when a patient's presentation is concerning for necrotizing fasciitis (NF). We present a case of a 69-year-old man who had initially presented to an outside hospital with testicular edema and difficulty urinating. Consultative ultrasound was interpreted as a hydrocele and bilateral scrotal pearls but failed to identify the sonographic hallmarks of NF (subcutaneous thickening, free fluid, and subcutaneous air). Computed tomography (CT) performed several hours later re-demonstrated free air and fascial thickening in the scrotum prompting transfer to our hospital for a higher level of care. Upon arrival to our emergency department (ED) POCUS showed extensive free air with shadowing, thickened subcutaneous tissue, and fluid collections. The patient was immediately evaluated by general surgery and urology, who took him to the operating room for debridement. This case highlights the challenges EP face when assessing patients with NF. Early-on, clinical findings can be subtle and easily missed. POCUS can aid in the diagnosis of this time-dependent disease process. Therefore, it is paramount that EPs look for and recognize characteristic sonographic findings present in NF to improve the accuracy and timeliness of the diagnosis. Topics: Point-Of-Care Ultrasound, necrotizing fasciitis.

Can emergency physicians perform extended compression ultrasound for the diagnosis of lower extremity deep vein thrombosis?

BACKGROUND: Current point-of-care ultrasound protocols in the evaluation of lower extremity deep vein thrombosis (DVT) can miss isolated femoral vein clots. Extended compression ultrasound (ECUS) includes evaluation of the femoral vein from the femoral vein/deep femoral vein bifurcation to the adductor canal. Our objective is to determine if emergency physicians (EPs) can learn ECUS for lower extremity DVT evaluation after a focused training session. METHODS: Prospective study at an urban academic center. Participants with varied ultrasound experience received instruction in ECUS prior to evaluation. Two live models with varied levels of difficult sonographic anatomy were intentionally chosen for the evaluation. Each participant scanned both models. Pre- and post-study surveys were completed. RESULTS: A total of 96 ultrasound examinations were performed by 48 participants (11 attendings and 37 residents). Participants' assessment scores averaged 95.8% (95% CI 93.3%-98.3%) on the easier anatomy live model and averaged 92.3% (95% CI 88.4%-96.2%) on the difficult anatomy model. There were no statistically significant differences between attendings and residents. On the model with easier anatomy, all but 1 participant identified and compressed the proximal femoral vein successfully, and all participants identified and compressed the mid and distal femoral vein. With the difficult anatomy, 97.9% (95% CI 93.8%-102%) identified and compressed the proximal femoral vein, whereas 93.8% (95% CI 86.9%-100.6%) identified and compressed the mid femoral vein, and 91.7% (95% CI 83.9%-99.5%) identified and compressed the distal femoral vein. CONCLUSION: EPs at our institution were able to perform ECUS with good reproducibility after a focused training session.

Identification of gender differences in ultrasound milestone assessments during emergency medicine residency training: a pilot study.

Objectives: Prior literature suggests that incongruities between male and female resident's procedural competency may be explained by gender bias during the evaluation process. There are no known studies investigating gender differences in the assessment of ultrasound-based procedural skills among emergency medicine (EM) residents. The purpose of this study was to evaluate for gender differences in ultrasound milestone assessments among EM residents. Methods: This is a retrospective study including EM residents. Milestone assessment data were collected from a total of 3 Accreditation Council for Graduate Medical Education (ACGME) EM residency programs representing a 3-year period The outcome measures included mean milestone levels, milestone levels at baseline and graduation and differences in milestone achievement between female and male EM residents. An unpaired Student's t-test was used to compare milestone scores between female and male residents. Results: A total of 456 ultrasound milestone evaluations were collected from 91 EM residents (34 females [37%] and 57 males [63%]). No significant differences were noted in the overall mean milestone level between females (2.3±0.6) and males (2.2±0.6) (P=0.387). There were no significant differences noted in the ultrasound milestone level between females (0.8±0.6) and males (0.7±0.7) at baseline (P=0.754). Although it did not reach statistical significance (P=0.197), the increase in the mean ultrasound milestone level from baseline to graduation was greater in males (3.4±0.7) compared to females (3.1±0.7). Conclusion: Overall, there were no statistically significant differences in the mean ultrasound milestone levels between females and males. The rate of ultrasound milestone level achievement during EM residency training at our institution had a slight tendency to be higher for males than females in the observed residency programs; however, this also did not reach statistical significance. Possible gender bias while evaluating ultrasound milestone levels needs to be further studied on a larger scale.

Utility of point-of-care musculoskeletal ultrasound in the evaluation of emergency department musculoskeletal pathology.

BACKGROUND: To evaluate the utilization of point-of-care ultrasound (POCUS) for the assessment of emergency department (ED) patients with musculoskeletal symptoms and the impact of musculoskeletal POCUS on medical decision-making and patient management in the ED. METHODS: This was a retrospective review of ED patients presenting with musculoskeletal symptoms who received a POCUS over a 3.5-year period. An ED POCUS database was reviewed for musculoskeletal POCUS examinations used for medical decision-making. Electronic medical records were then reviewed for demographic characteristics, history, physical examination findings, ED course, additional imaging studies, and impact of musculoskeletal POCUS on patient management in ED. RESULTS: A total of 264 subjects (92 females, 172 males) and 292 musculoskeletal POCUS examinations were included in the final analysis. Most common symptomatic sites were knee (31.8%) and ankle (16.3%). Joint effusion was the most common finding on musculoskeletal POCUS, noted in 33.7% of the patients, and subcutaneous edema/cobblestoning was found in 10.2% of the patients. Muscle or tendon rupture was found in 2.3% of the patients, and 1.9% of the patients had joint dislocation. Bursitis or bursa fluid was found in 3.4% of patients, and tendonitis/tendinopathy was found in 2.3%. Twenty percent of them were ultrasound-guided musculoskeletal procedures, and most of them (73.3%) were arthrocentesis. Of the included studies, all except three either changed or helped guide patient management as documented in the patients' medical records. CONCLUSION: Our study findings illustrate the utility of POCUS in the evaluation of a variety of musculoskeletal pathologies in the ED.

Echogenicity and ultrasound visibility of peripheral nerves of the upper extremity.

AIM: Regional anesthesia with ultrasound-guidance is an excellent option for pain control if nerves are adequately visualized. Gender, body mass index (BMI), history of diabetes, neck and forearm circumference may affect echotexture and visualization. This study evaluates patient characteristics for their ability to predict the echogenicity or visibility of upper extremity peripheral nerves. MATERIAL AND METHODS: This is a prospective observational study. A convenience sample of adult emergency department patients were enrolled. Gender, BMI, history of diabetes, neck circumference and arm circumference were recorded. Sonographic images of the brachial plexus at interscalene and supraclavicular levels, the median, the radial and ulnar nerves were recorded. Three reviewers independently graded the echogenicity and visibility using subjective scales. RESULTS: 395 peripheral nerves were included. Nerves of the forearm (median, ulnar, radial nerves) were found to be more echogenic (OR=9.3; 95% CI: 5.7, 15.3) and visible (OR=10.0; 6.3, 16.0) than more proximal nerves (brachial plexus at interscalene and supraclavicular levels). Gender, BMI, and history of diabetes mellitus were not significantly related to nerve visibility (p=0.9, 0.2, 0.2, respectively) or echogenicity (p=0.3, 0.8, 0.3). Neck circumference was not related to visibility or echogenicity of proximal nerves. Increased forearm circumference improved echogenicity (OR=1.25; 1.09, 1.43) but not visibility of forearm nerves. CONCLUSIONS: Gender, BMI and presence of diabetes were not related to echogenicity or visibility of upper extremity nerves. Increasing forearm circumference was associated with increased echogenicity of the adjacent nerves, but not visibility. Neck circumference was not associated with either nerve visibility or echogenicity of brachial plexus nerve bundles.

Point-of-care Head and Neck Sonography for Clinical Problem-solving: Impact of One-day Training Sessions on Medical Student Education.

Introduction The curriculum for medical student education is continuously evolving to emphasize knowledge acquisition with critical problem-solving skills. Medical schools have started to implement curricula to teach point-of-care ultrasound skills. To our knowledge, the expansion into head and neck sonography for medical student education is novel and has never been studied. Our objective was to determine the feasibility of implementing point-of-care head and neck sonography and critical problem-solving instruction for medical student education. Methods This was a cross-sectional study enrolling third-year medical students with minimal prior ultrasound experience. A one-day educational curriculum focusing on the use of head and neck ultrasound for clinical problem-solving was integrated into one of the week-long intersessions. The components of point-of-care ultrasound workshop included asynchronous learning, one-hour didactic lecture, followed by a pre-test assessment, then a one-day hands-on workshop, and finally a post-test assessment administered at the end of the training session. Results A total of 123 subjects participated in this study. Ninety-one percent completed the questionnaire prior to the workshop and 83% completed the post-test questionnaire. The level of comfort with using an ultrasound system significantly increased from 31% to 92%. Additionally, the comfort level in interpreting ultrasound images also significantly increased from 21% to 84%. Eighty-nine percent (95% CI, 86%-97%) had an interest in learning ultrasound and would enroll in an optional ultrasound curriculum if given the opportunity. Knowledge of specific ultrasound applications also increased from 60% (after asynchronous learning and lectures) to 95% (after additional hands-on sonographic training). Conclusion At our institution, we successfully integrated point-of-care head and neck sonography and critical problem-solving instruction for medical student education.

Multimodular Ultrasound Orientation: Residents' Confidence and Skill in Performing Point-of-care Ultrasound.

Introduction The objectives of this study were to determine if a multimodular introductory ultrasound course improved emergency medicine intern confidence in performing a point-of-care ultrasound and if our educational objectives could be met with our chosen structure. Methods This is a prospective, observational study evaluating three consecutive incoming emergency medicine residency classes from three residency programs. A one-day introductory ultrasound course was delivered. The course consisted of 1) flipped classroom didactics, 2) in-person, case-based interactive teaching sessions, and 3) check-listed, goal-driven, hands-on instruction. Results Over three years, 73 residents participated in this study. There was no significant difference in performance on the written test (p = 0.54) or the skills assessment (p = 0.16) between years. Performance on the written pre-test was not a predictor of performance on the skills test (R2 = 0.028; p = 0.19). Prior to training, residents were most confident in performing a focused assessment with sonography for trauma examination (median confidence 5.5 (interquartile range (IQR): 3 - 7) on a 10-point Likert scale where 1 represents low confidence and 10 represents high confidence). They reported the lowest confidence in performing a cardiac ultrasound (3 (IQR: 2 - 6)). Following training, residents reported increased confidence with all applications (p < 0.001). Eighty-five percent (confidence interval (CI): 73, 92) of residents agreed that the online ultrasound lectures effectively teach point-of-care ultrasound applications and 98% (CI: 88, 100) agreed that case-based interactive sessions helped them understand how ultrasound changes the management of acutely ill patients. Conclusions A written test of knowledge regarding the use of point-of-care ultrasound does not correlate with procedural skills at the start of residency, suggesting that teaching and evaluation of both types of skills are necessary. Following a multimodular introductory ultrasound course, residents showed increased confidence in performing the seven basic ultrasound applications. Residents reported that an asynchronous curriculum and case-based interactive sessions met the learning objectives and effectively taught point-of-care ultrasound applications.

Point of Care Ultrasound Diagnosis of Upper Gastrointestinal Bleeding.

A 28-year-old male was brought to the emergency department by the Emergency medical services (EMS) after being found unconscious and unresponsive. Upon arrival, he was hypotensive, intubated with a Glasgow Coma Scale (GCS) 3T, without the signs of trauma or the evidence of bleeding. A focused assessment with sonography in trauma (FAST), point-of-care ultrasound (POCUS) was performed, obscuring part of the spleen from the distended stomach, which was filled with the heterogeneous contents, with the internal movement being identified. This was found to be blood after orogastric (OG) tube was placed for suction. The bedside endoscopy confirmed active variceal bleeding. This case illustrates the potential utility of the ultrasound in detecting the upper gastrointestinal bleeding.