Reliability and feasibility of optic nerve point-of-care ultrasound in pediatric patients with ventricular shunts.

PURPOSE: To determine the interrater reliability of optic nerve sheath diameter (ONSD) and optic disc elevation (ODE) via ocular ultrasound by emergency and neurosurgery providers in children with ventricular shunts, and to explore the feasibility of acquiring and measuring images. METHODS: Two novices who underwent focused training and one expert in ocular ultrasound independently acquired images and measured ONSD and ODE on the same children, 0-18 years with ventricular shunts, blinded to each other's images and measurements. Patient tolerance, image quality, and time-to-complete exams were recorded. Images meeting a priori defined quality metrics were included. Mixed models and bootstrap analysis were used to obtain inter-rater reliability and 95% confidence intervals. RESULTS: Eighty-one children were enrolled from August 2016 to July 2017, with mean age 9.6 years (SD 5.25, range 5 months-17.7 years). High-quality images (≥ 4 on 7-point quality Likert scale) were obtained in 83% of ONSD assessments and 95% of ODE assessments. The ICCONSD was 0.82 (95% CI 0.76-0.91) for right eyes and 0.73 (95% CI 0.69-0.85) for left, while ICCODE was 0.81 (95% CI 0.75-0.89) for right eyes and 0.85 (95% CI 0.79-0.91) for left. Mean study duration (both eyes) was 2:52 min (SD 54 s). CONCLUSION: Clinicians generated high-quality ocular ultrasound images with excellent interrater reliability when acquiring and measuring images of ONSD and ODE in children with ventricular shunts.

A Case of Esophageal Duplication Cyst Identified on Cardiac Point-of-Care Ultrasound.

ABSTRACT: Esophageal duplication cysts are rare congenital anomalies that are often symptomatic because of compression of surrounding structures. They are commonly diagnosed during childhood, with affected patients often presenting with abdominal pain or chest pain. Point-of-care ultrasound can be used as part of the emergency department evaluation of pediatric chest pain. We present a case of a 6-year-old boy who presented to the emergency department with worsening abdominal and chest pain, where point-of-care cardiac ultrasound identified a cystic structure in the posterior mediastinum.

Accuracy and Interrater Reliability of Point-of-Care Ultrasonography Image Interpretation for Intussusception.

OBJECTIVES: The aim of this study was to determine the accuracy and interrater reliability of (1) point-of-care ultrasound (POCUS) image interpretation for identification of intussusception and (2) reliability of secondary signs associated with intussusception among experts compared with novice POCUS reviewers. METHODS: We conducted a planned secondary analysis of a prospective, convenience sample of children aged 3 months to 6 years who were evaluated with POCUS for intussusception across 17 international pediatric emergency departments between October 2018 and December 2020. A random sample of 100 POCUS examinations was reviewed by novice and expert POCUS reviewers. The primary outcome was identification of the presence or absence of intussusception. Secondary outcomes included intussusception size and the presence of trapped free fluid or echogenic foci. Accuracy was summarized using sensitivity and specificity, which were estimated via generalized mixed effects logistic regression. Interrater reliability was summarized via Light's κ statistics with bootstrapped standard errors (SEs). Accuracy and reliability of expert and novice POCUS reviewers were compared. RESULTS: Eighteen expert and 16 novice POCUS reviewers completed the reviews. The average expert sensitivity was 94.5% (95% confidence interval [CI], 88.6-97.5), and the specificity was 94.3% (95% CI, 90.3-96.7), significantly higher than the average novice sensitivity of 84.7% (95% CI, 74.3-91.4) and specificity of 80.4% (95% CI, 72.4, 86.7). κ was significantly greater for expert (0.679, SE 0.039) compared with novice POCUS reviewers (0.424, SE 0.044; difference 0.256, SE 0.033). For our secondary outcome measure of intussusception size, κ was significantly greater for experts (0.661, SE 0.038) compared with novices (0.397, SE 0.041; difference 0.264, SE 0.029). Interrater reliability was weak for expert and minimal for novice reviewers regarding the detection of trapped free fluid and echogenic foci. CONCLUSIONS: Expert POCUS reviewers demonstrate high accuracy and moderate interrater reliability when identifying intussusception via image interpretation and perform better than novice reviewers.

Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception: A Multicenter, Noninferiority Study of Paired Diagnostic Tests.

STUDY OBJECTIVE: To determine the diagnostic accuracy of point-of-care ultrasound (POCUS) performed by experienced clinician sonologists compared to radiology-performed ultrasound (RADUS) for detection of clinically important intussusception, defined as intussusception requiring radiographic or surgical reduction. METHODS: We conducted a multicenter, noninferiority, observational study among a convenience sample of children aged 3 months to 6 years treated in tertiary care emergency departments across North and Central America, Europe, and Australia. The primary outcome was diagnostic accuracy of POCUS and RADUS with respect to clinically important intussusception. Sample size was determined using a 4-percentage-point noninferiority margin for the absolute difference in accuracy. Secondary outcomes included agreement between POCUS and RADUS for identification of secondary sonographic findings. RESULTS: The analysis included 256 children across 17 sites (35 sonologists). Of the 256 children, 58 (22.7%) had clinically important intussusception. POCUS identified 60 (23.4%) children with clinically important intussusception. The diagnostic accuracy of POCUS was 97.7% (95% confidence interval [CI] 94.9% to 99.0%), compared to 99.3% (95% CI 96.8% to 99.9%) for RADUS. The absolute difference between the accuracy of RADUS and that of POCUS was 1.5 percentage points (95% CI -0.6 to 3.6). Sensitivity for POCUS was 96.6% (95% CI 87.2% to 99.1%), and specificity was 98.0% (95% CI 94.7% to 99.2%). Agreement was high between POCUS and RADUS for identification of trapped free fluid (83.3%, n=40/48) and decreased color Doppler signal (95.7%, n=22/23). CONCLUSION: Our findings suggest that the diagnostic accuracy of POCUS performed by experienced clinician sonologists may be noninferior to that of RADUS for detection of clinically important intussusception. Given the limitations of convenience sampling and spectrum bias, a larger randomized controlled trial is warranted.

Pediatric point-of-care ultrasound of optic disc elevation for increased intracranial pressure: A pilot study.

OBJECTIVE: Papilledema is often difficult to detect in children. Ocular point-of-care ultrasound (POCUS) measurement of the optic nerve sheath diameter (ONSD) is a non-invasive test for increased intracranial pressure (ICP), but no consensus exists on normal pediatric ONSD values. Detection of optic disc elevation (ODE, a component of papilledema) using POCUS has recently been qualitatively described. We sought to establish the diagnostic accuracy of different ODE cutoffs to detect increased ICP in children who underwent ocular POCUS in our pediatric emergency department (PED). METHODS: We retrospectively reviewed charts of patients ages 0-18 years who received ocular POCUS in our tertiary PED between 2011 and 2016. Patients were included if their archived POCUS examinations were deemed high-quality by a POCUS expert and they underwent ICP determination within 48 h after ocular POCUS. A blinded POCUS expert measured ODE, optic disc width at mid-height (ODWAMH), and ONSD. Receiver-operator curve analysis was performed for various cutoffs for these measurements in detecting increased ICP. RESULTS: 76 eyes from 40 patients met study criteria. 26 patients had increased ICP. The mean ODE of both eyes (ODE-B) generated the largest area under the curve (0.962, 95% CI 0.890-1). The optimal ODE-B cutoff was 0.66 mm, with a sensitivity of 96% (95% CI 79-100%) and a specificity of 93% (95% CI 79-100%). 1/40 (2.5%) of patients with ODE-B < 0.66 had increased ICP. CONCLUSIONS: ODE-B may represent the optimal ocular POCUS measurement for detecting increased ICP in children, and future prospective studies could more accurately describe the diagnostic performance of different pediatric ODE-B cutoffs.

Point-of-Care Ultrasound Identification of Right-Sided Cardiac Chamber Collapse Associated With Pericardial Effusions Without Hypotension: A Case Series.

ABSTRACT: We present a case series of 6 children in whom point-of-care ultrasound revealed a pericardial effusion with right atrial or ventricular collapse, and show how this may heighten concern for development of pericardial tamponade and expedite care.

Esophageal bougienage in the emergency department with a substitute Hurst dilator.

Impacted esophageal foreign bodies typically first present to the emergency department, with coins being most common in children and food boluses most common in adults. Controversy exists regarding the best treatment options in these cases. We report two cases, one pediatric and one adult, where the use of a novel substitute Hurst dilator constructed of materials regularly found in all EDs was successfully used to treat impacted esophageal foreign bodies.

Using Point-of-Care Ultrasound to Characterize Acute Inguinal Swelling of Young Children in the Pediatric Emergency Department.

Acute inguinal swelling in young children is frequently assumed to be an inguinal hernia, often prompting a bedside reduction attempt. We report 3 cases of inguinal swelling where the use of point-of-care ultrasound changed the patients' management by identifying an alternate diagnosis, thus avoiding unnecessary and painful procedures as well as their associated sedation risks.

A novel training simulator for portable ultrasound identification of incorrect newborn endotracheal tube placement - observational diagnostic accuracy study protocol.

BACKGROUND: Endotracheal tube (ETT) placement is a critical procedure for newborns that are unable to breathe. Inadvertent esophageal intubation can lead to oxygen deprivation and consequent permanent neurological impairment. Current standard-of-care methods to confirm ETT placement in neonates (auscultation, colorimetric capnography, and chest x-ray) are time consuming or unreliable, especially in the stressful resuscitation environment. Point-of-care ultrasound (POCUS) of the neck has recently emerged as a powerful tool for detecting esophageal ETTs. It is accurate and fast, and is also easy to learn and perform, especially on children. METHODS: This will be an observational diagnostic accuracy study consisting of two phases and conducted at the Aga Khan University Hospital in Karachi, Pakistan. In phase 1, neonatal health care providers that currently perform standard-of-care methods for ETT localization, regardless of experience in portable ultrasound, will undergo a two-hour training session. During this session, providers will learn to detect tracheal vs. esophageal ETTs using POCUS. The session will consist of a didactic component, hands-on training with a novel intubation ultrasound simulator, and practice with stable, ventilated newborns. At the end of the session, the providers will undergo an objective structured assessment of technical skills, as well as an evaluation of their ability to differentiate between tracheal and esophageal endotracheal tubes. In phase 2, newborns requiring intubation will be assessed for ETT location via POCUS, at the same time as standard-of-care methods. The initial 2 months of phase 2 will include a quality assurance component to ensure the POCUS accuracy of trained providers. The primary outcome of the study is to determine the accuracy of neck POCUS for ETT location when performed by neonatal providers with focused POCUS training, and the secondary outcome is to determine whether neck POCUS is faster than standard-of-care methods. DISCUSSION: This study represents the first large investigation of the benefits of POCUS for ETT confirmation in the sickest newborns undergoing intubations for respiratory support. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03533218. Registered May 2018.

Reliability of Neck Mass Point-of-Care Ultrasound by Pediatric Emergency Physicians.

OBJECTIVES: Neck masses are a common reason for presentations to the pediatric emergency department (PED). We sought to determine the agreement and time difference between point-of-care ultrasound (POCUS) imaging by pediatric emergency physicians compared to radiology department imaging for children with neck masses in the PED. METHODS: We performed a retrospective study of patients aged 0 to 18 years presenting to our tertiary PED who received both POCUS by a pediatric emergency physician and radiology department imaging. Charts were reviewed for POCUS diagnoses, final diagnoses, and imaging time metrics. RESULTS: Seventy-five patients met the study criteria. In 58 of 75 cases there was agreement between the POCUS diagnosis and final diagnosis (κ = 0.71; 95% confidence interval, 0.6-0.83). There was agreement in 25 of the 28 cases in which POCUS examinations were performed by PED physicians with fellowship training in POCUS (κ = 0.87; 95% confidence interval, 0.72-1.00). The results for POCUS were generated in a median of 115 minutes (interquartile range, 68-185 minutes) before radiology department imaging results. CONCLUSIONS: Point-of-care ultrasound imaging by pediatric emergency physicians for children with neck masses is a promising new POCUS application that may be able to save time in the PED.

A Multi-institutional Case Series With Review of Point-of-Care Ultrasound to Diagnose Malrotation and Midgut Volvulus in the Pediatric Emergency Department.

Point-of-care ultrasound can be used to screen for malrotation with and without volvulus in the newborn with bilious vomiting, as well as children with unexplained intermittent abdominal pain. We discuss cases where infants and children presenting to pediatric emergency departments with bilious vomiting and/or intermittent abdominal pain were initially screened for small bowel pathology with point-of-care ultrasound. Bedside findings suggestive of midgut volvulus were confirmed with radiology-performed ultrasound or upper gastrointestinal fluoroscopy. In all cases, operative findings were consistent with malrotation of the small bowel with or without evidence of midgut volvulus.

Does oral radiocontrast affect image quality of abdominal sonography?

OBJECTIVE: Emergency Department patients with abdominal pain may require both an ultrasound (US) and computed tomography (CT) for an accurate diagnosis. Patients are often asked to drink oral radiocontrast while awaiting ultrasound, in order to better expedite a CT in the case of a non-diagnostic US. The impact of oral radiocontrast on US image quality has not been studied. We compared the quality of US images obtained before and after the ingestion of oral radiocontrast in healthy adult volunteers. METHODS: This was a prospective study in which adult volunteer subjects underwent sonographic studies of the aorta, the right upper quadrant, the right lower quadrant, and the Focused Assessment with Sonography in Trauma (FAST) examination. Initial studies were performed prior to ingestion of oral radiocontrast, with subsequent imaging occurring at 1 and 2hour post-ingestion. All of the images from the sonographic exams were randomized and subsequently scored for quality by two emergency ultrasound fellowship trained emergency physicians with extensive experience in performing and interpreting US. RESULTS: 638 images from 240 exams were obtained from 20 subjects at three time points. Six exams were not scored due to inadequate images. There were no significant differences in image quality for any of the US exam types after the ingestion of oral radiocontrast at 1 and 2h. CONCLUSION: Ingestion of oral radiocontrast did not affect image quality of four common abdominal ultrasound examinations.

Comparison of Ultrasound Guidance vs. Clinical Assessment Alone for Management of Pediatric Skin and Soft Tissue Infections.

BACKGROUND: Point-of-care ultrasound (POCUS) can potentially help distinguish cellulitis from abscess, which can appear very similar on physical examination but necessitate different treatment approaches. OBJECTIVE: To compare POCUS guidance vs. clinical assessment alone on the management of pediatric skin and soft tissue infections (SSTI) in the emergency department (ED) setting. METHODS: Children ages 6 months to 18 years presenting to participating EDs with SSTIs ≥ 1 cm were eligible. All treatment decisions, including use of POCUS, were at the discretion of the treating clinicians. Patients were divided into those managed with POCUS guidance (POCUS group) and those managed using clinical assessment alone (non-POCUS group). Primary outcome was clinical treatment failure at 7-10 days (unscheduled ED return visit or admission, procedural intervention, change in antibiotics therapy). Secondary outcomes were ED length of stay, discharge rate, use of alternative imaging, and need for procedural sedation. POCUS utility and impact on management decisions were also assessed by treating clinicians. RESULTS: In total, 321 subjects (327 lesions) were analyzed, of which 299 (93%) had completed follow-up. There was no significant difference between the POCUS and non-POCUS groups in any of the primary or secondary outcomes. Management plan was changed in the POCUS group in 22.9% of cases (13.8% from medical to surgical, 9.1% from surgical to medical). Clinicians reported increased benefit of POCUS in cases of higher clinical uncertainty. CONCLUSIONS: Use of POCUS was not associated with decreased ED treatment failure rate or process outcomes in pediatric SSTI patients. However, POCUS changed the management plan in approximately one in four cases.

Point-of-care ultrasound detection of acute scaphoid fracture.

In cases of traumatic wrist pain, emergency physicians must maintain a high index of suspicion for scaphoid fractures due to their potential for serious complications. A growing body of literature supports the use of point-of-care ultrasonography by emergency physicians in the evaluation of potential fractures. We report a case of a pediatric scaphoid fracture that was initially not visualized on x-ray and was subsequently detected using point-of-care ultrasound in the ED.

Thyrotoxic periodic paralysis in a pediatric patient.

Thyrotoxic periodic paralysis is a reversible metabolic disorder that is characterized by acute muscle weakness and hypokalemia. It predominantly affects males of Asian descent. We describe the youngest such patient yet reported, a 13-year-old Asian male with a history of transient attacks of weakness who presented to our emergency department with weakness in his extremities and mild tachycardia. Laboratory test results initially revealed marked hypokalemia and later confirmed associated hyperthyroidism. Correction of the hypokalemia reversed the patient's weakness in the emergency department.

Diagnostic utility of point-of-care ultrasound and optical coherence tomography for papilloedema in children: a prospective pilot study.

BACKGROUND/AIMS: Papilloedema is an important sign of serious neurological disease, but it can be difficult to detect on funduscopy. The purpose of this study was to determine the diagnostic accuracy of point-of-care ultrasound (POCUS) and optical coherence tomography (OCT) for detecting papilloedema in children. METHODS: This was a prospective observational study at a tertiary care paediatric hospital. Patients were eligible for the study if they underwent a lumbar puncture with opening pressure and had high-quality POCUS and OCT imaging. RESULTS: A total of 63 eyes from 32 patients were included in the study, 41 (65%) with papilloedema and 22 (35%) without. There were statistically significant differences between the groups in the optic disc elevation (ODE) (p<0.001) and optic nerve sheath diameter (ONSD) (p<0.001) on POCUS, and in the average retinal nerve fibre layer (rNFL) thickness on OCT (p<0.001). Average rNFL thickness had the highest diagnostic accuracy with an area under the curve (AUC) of 0.999 and a 100% sensitivity and 95% specificity for papilloedema (threshold value of ≥108 µm). ODE had an AUC of 0.866 and a 93% sensitivity and 55% specificity (threshold value of ≥0.5 mm). ONSD had an AUC of 0.786 and a 93% sensitivity and 45% specificity (threshold value of ≥5.5 mm). CONCLUSION: Both OCT and POCUS are potentially useful tools to help diagnose papilloedema in children. Larger studies are needed to further define the role and accuracy of POCUS and OCT in assessing papilloedema in children.

Diagnostic accuracy of point-of-care ultrasound compared to standard-of-care methods for endotracheal tube placement in neonates.

INTRODUCTION: Point-of-care ultrasound (POCUS) is a valuable tool to determine endotracheal tube (ETT) placement; however, few studies have compared it with standard confirmation methods. We evaluated the diagnostic accuracy of POCUS and time-to-interpretation for correct identification of tracheal versus esophageal intubations compared to a composite of standard-of-care methods in neonates. METHODS: A cross-sectional study was conducted in the Neonatal Intensive Care Unit (NICU) at Aga Khan University Hospital Karachi, Pakistan. All required intubations were performed as per NICU guidelines. The clinical team simultaneously determined the ETT placement using standard-of-care methods (auscultation, colorimetric capnography, and chest X-ray) by POCUS. In addition, the clinical team was blinded to the POCUS images. Timings were recorded for each method by independent study staff. RESULTS: A total of 348 neonates were enrolled in the study. More than half (58%) of intubations were in an emergency scenario. POCUS user interpretation showed 100% sensitivity and 94% specificity using an expert as the reference standard. We found a 99.4% agreement (Kappa: 0.96; p < 0.001). Diagnostic accuracy of POCUS compared with at least two standard-of-care methods demonstrated 99.7% sensitivity, 91% specificity, and 98.9% agreement (Kappa:0.93; p < 0.001). The median time required for POCUS interpretation was 3.0 (interquartile range [IQR] 3.0-4.0) seconds for tracheal intubation. The time recorded for auscultation and capnography was 6.0 (IQR 5.0-7.0) and 3.0 (IQR 3.0-4.0), respectively. CONCLUSION: POCUS is a rapid and reliable method of identifying ETT placement in neonates. Early and correct identification of airway management is critical to save lives and prevent mortality and morbidity.

Development of a Consensus-Based Definition of Focused Assessment With Sonography for Trauma in Children.

Importance: The wide variation in the accuracy and reliability of the Focused Assessment With Sonography for Trauma (FAST) and the extended FAST (E-FAST) for children after blunt abdominal trauma reflects user expertise. FAST and E-FAST that are performed by experts tend to be more complete, better quality, and more often clinically valuable. Objective: To develop definitions of a complete, high-quality, and accurate interpretation for the FAST and E-FAST in children with injury using an expert, consensus-based modified Delphi technique. Design, Setting, and Participants: This consensus-based qualitative study was conducted between May 1 to June 30, 2021. It used a scoping review and iterative Delphi technique and involved 2 rounds of online surveys and a live webinar to achieve consensus among a 26-member panel. This panel consisted of international experts in pediatric emergency point-of-care ultrasonography. Main Outcomes and Measures: Definitions of complete, high-quality, and accurate FAST and E-FAST studies for children after injury. Results: Of the 29 invited pediatric FAST experts, 26 (15 men [58%]) agreed to participate in the panel. All 26 panelists completed the 2 rounds of surveys, and 24 (92%) participated in the live and asynchronous online discussions. Consensus was reached on FAST and E-FAST study definitions, and the panelists rated these 5 anatomic views as important and appropriate for a complete FAST: right upper-quadrant abdominal view, left upper-quadrant abdominal view, suprapubic views (transverse and sagittal), and subxiphoid cardiac view. For E-FAST, the same FAST anatomic views with the addition of the lung or pneumothorax view were deemed appropriate and important. In addition, the panelists rated a total of 32 landmarks as important for assessing completeness. Similarly, the panelists rated 14 statements on quality and 20 statements on accurate interpretation as appropriate. Conclusions and Relevance: This qualitative study generated definitions for complete FAST and E-FAST studies with high image quality and accurate interpretation in children with injury. These definitions are similar to those in adults with injury and may be used for future education, quality assurance, and research. Future research may focus on interpretation of trace volumes of abdominal free fluid and the use of serial FAST.