Treatment-Resistant Wide-Complex Tachycardia in a Three-Year-Old Girl.

Wide-complex, monomorphic tachycardias represent a range of tachyarrhythmias. Such patients can present asymptomatically and hemodynamically stable, while others are in shock. The etiology of the rhythm can be difficult to determine in the emergency department, and although electrocardiogram findings may be helpful, a workup after stabilization may be necessary to determine the cause. Treatment is therefore dependent on hemodynamic status and follows a stepwise approach, as initial therapies may be ineffective. We present the case of a three-year-old girl with wide-complex tachycardia which was exceedingly refractory to preliminary treatments and required trials of multiple treatment approaches to achieve conversion to normal sinus rhythm.

Learning Pediatric Point-of-Care Ultrasound: How Many Cases Does Mastery of Image Interpretation Take?

OBJECTIVES: Using an education and assessment tool, we examined the number of cases necessary to achieve a performance benchmark in image interpretation of pediatric soft tissue, cardiac, lung, and focused assessment with sonography for trauma (FAST) point-of-care ultrasound (POCUS) applications. We also determined interpretation difficulty scores to derive which cases provided the greatest diagnostic challenges. METHODS: Pediatric emergency physicians participated in web-based pediatric POCUS courses sponsored by their institution as a credentialing priority. Participants deliberately practiced cases until they achieved diagnostic interpretation scores of combined 90% accuracy, sensitivity, and specificity. RESULTS: Of the 463 who enrolled, 379 (81.9%) completed cases. The median (interquartile range) number of cases required to achieve the performance benchmark for soft tissue was 94 (68-128); cardiac, 128 (86-201); lung, 87 (25-118); and FAST, 93 (68-133) (P < 0001). Specifically, cases completed to achieve benchmark were higher for cardiac relative to other applications (P < 0.0001 for all comparisons). In soft tissue cases, a foreign body was more difficult to diagnose than cobblestoning and hypoechoic collections (P = 0.036). Poor cardiac function and abnormal ventricles were more difficult to interpret with accuracy than normal (P < 0.0001) or pericardial effusion cases (P = 0.01). The absence of lung sliding was significantly more difficult to interpret than normal lung cases (P = 0.028). The interpretation difficulty of various FAST imaging findings was not significantly different. CONCLUSIONS: There was a significant variation in number of cases required to reach a performance benchmark. We also identified the specific applications and imaging findings that demonstrated the greatest diagnostic challenges. These data may inform future credentialing guidelines and POCUS learning interventions.

Point-of-care lung ultrasound is more reliable than chest X-ray for ruling out acute chest syndrome in sickle cell pediatric patients: A prospective study.

BACKGROUND: Acute chest syndrome (ACS) is a leading cause of morbidity and mortality in sickle cell patients, and it is often challenging to establish its diagnosis. PROCEDURE: This was a prospective observational study conducted in a pediatric emergency (PEM) department. We aimed to investigate the performance characteristics of point-of-care lung ultrasound (LUS) for diagnosing ACS in sickle cell children. LUS by trained PEM physicians was performed and interpreted as either positive or negative for consolidation. LUS results were compared to chest X-ray (CXR) and discharge diagnosis as reference standards. RESULTS: Four PEM physicians performed the LUS studies in 79 suspected ACS cases. The median age was 8 years (range 1-17 years). Fourteen cases (18%) received a diagnosis of ACS based on CXR and 21 (26.5%) had ACS discharge diagnosis. Comparing to CXR interpretation as the reference standard, LUS had a sensitivity of 100% (95% CI: 77%-100%), specificity of 68% (95% CI: 56%-79%), positive predictive value of 40% (95% CI: 24%-56%), and negative predictive value of 100% (95% CI: 92%-100%). Overall LUS accuracy was 73.42% (95% CI: 62%-83%). Using discharge diagnosis as the endpoint for both CXR and LUS, LUS had significantly higher sensitivity (100% vs. 62%, p = .0047) and lower specificity (76% vs.100%, p = .0002). LUS also had lower positive (60% vs.100%, p < .0001) and higher negative (100% vs.77%, p = .0025) predictive values. The overall accuracy was similar for both tests (82% vs. 88%, p = .2593). CONCLUSION: The high negative predictive value, with narrow CIs, makes LUS an excellent ruling-out tool for ACS.

Point-of-care lung ultrasound imaging in pediatric COVID-19.

BACKGROUND: There has been limited data regarding the usefulness of lung ultrasound (US) in children with COVID-19. OBJECTIVE: To describe lung US imaging findings and aeration score of 34 children with COVID-19. METHODS: This study included 0-16-year-old patients with confirmed COVID-19, who were admitted between April 19 and June 18, 2020 in two hospitals in the city of Sao Paulo, Brazil. Lung US was performed as part of the routine evaluation by a skilled Pediatric Emergency physician. Clinical and laboratory data were collected and severity classifications were done according to an available clinical definition. The lung US findings were described for each lung field and a validated ultrasound lung aeration score was calculated. Data obtained was correlated with clinical information and other imaging modalities available for each case. RESULTS: Thirty-four confirmed COVID-19 patients had a lung US performed during this period. Eighteen (18/34) had abnormalities on the lung US, but eight of them (8/18) had a normal chest radiograph. Ultrasound lung aeration score medians for severe/critical, moderate, and mild disease were 17.5 (2-30), 4 (range 0-14), 0 (range 0-15), respectively (p = 0.001). Twelve patients (12/34) also had a chest computed tomography (CT) performed; both the findings and topography of lung compromise on the CT were consistent with the information obtained by lung US. CONCLUSION: Point-of-care lung US may have a key role in assessing lung injury in children with COVID-19.

The Variable Journey in Learning to Interpret Pediatric Point-of-care Ultrasound Images: A Multicenter Prospective Cohort Study.

OBJECTIVES: To complement bedside learning of point-of-care ultrasound (POCUS), we developed an online learning assessment platform for the visual interpretation component of this skill. This study examined the amount and rate of skill acquisition in POCUS image interpretation in a cohort of pediatric emergency medicine (PEM) physician learners. METHODS: This was a multicenter prospective cohort study. PEM physicians learned POCUS using a computer-based image repository and learning assessment system that allowed participants to deliberately practice image interpretation of 400 images from four pediatric POCUS applications (soft tissue, lung, cardiac, and focused assessment sonography for trauma [FAST]). Participants completed at least one application (100 cases) over a 4-week period. RESULTS: We enrolled 172 PEM physicians (114 attendings, 65 fellows). The increase in accuracy from the initial to final 25 cases was 11.6%, 9.8%, 7.4%, and 8.6% for soft tissue, lung, cardiac, and FAST, respectively. For all applications, the average learners (50th percentile) required 0 to 45, 25 to 97, 66 to 175, and 141 to 290 cases to reach 80, 85, 90, and 95% accuracy, respectively. The least efficient (95th percentile) learners required 60 to 288, 109 to 456, 160 to 666, and 243 to 1040 cases to reach these same accuracy benchmarks. Generally, the soft tissue application required participants to complete the least number of cases to reach a given proficiency level, while the cardiac application required the most. CONCLUSIONS: Deliberate practice of pediatric POCUS image cases using an online learning and assessment platform may lead to skill improvement in POCUS image interpretation. Importantly, there was a highly variable rate of achievement across learners and applications. These data inform our understanding of POCUS image interpretation skill development and could complement bedside learning and performance assessments.

Point-Of-Care Ultrasound for Lung Assessment in Patients With Severe Scoliosis and Chest Deformities: An Emergency Department Case Series.

BACKGROUND: Diagnosing pneumonia and other lung conditions can be challenging in patients with severe intellectual or physical disabilities or severe chest deformities. Physical examination is sometimes difficult to perform and the frequently requested chest x-ray (CXR) study is often of little value in the diagnostic approach to this population. Point-of-care lung ultrasound (US) is an emerging diagnostic tool with particularly high level of accuracy in detecting pneumonia, pleural effusion, and pneumothorax. CASE REPORT: This case series describes four cases demonstrating the usefulness of point-of-care US in a pediatric emergency department for lung assessment in patients for differentiation and diagnosis of acute causes of acute respiratory symptoms, in whom clinical features or CXR failed to confirm or exclude pulmonary complications. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In patients with chest deformities, pulmonary complications can be disproportionately frequent. Lung US should be recognized as an important adjunctive tool in this subset of patients to detect pneumonia, pleural effusions, and pneumothorax. When used proactively, it can reduce unnecessary radiation exposure, provide more certainty in determining the diagnosis, and, most importantly, inform correct and timely management.

The Canadian Medical Student Ultrasound Curriculum: A Statement From the Canadian Ultrasound Consensus for Undergraduate Medical Education Group.

OBJECTIVES: This study sought to establish by expert review a consensus-based, focused ultrasound curriculum, consisting of a foundational set of focused ultrasound skills that all Canadian medical students would be expected to attain at the end of the medical school program. METHODS: An expert panel of 21 point-of-care ultrasound and educational leaders representing 15 of 17 (88%) Canadian medical schools was formed and participated in a modified Delphi consensus method. Experts anonymously rated 195 curricular elements on their appropriateness to include in a medical school curriculum using a 5-point Likert scale. The group defined consensus as 70% or more experts agreeing to include or exclude an element. We determined a priori that no more than 3 rounds of voting would be performed. RESULTS: Of the 195 curricular elements considered in the first round of voting, the group reached consensus to include 78 and exclude 24. In the second round, consensus was reached to include 4 and exclude 63 elements. In our final round, with 1 additional item added to the survey, the group reached consensus to include an additional 3 and exclude 8 elements. A total of 85 curricular elements reached consensus to be included, with 95 to be excluded. Sixteen elements did not reach consensus to be included or excluded. CONCLUSIONS: By expert opinion-based consensus, the Canadian Ultrasound Consensus for Undergraduate Medical Education Group recommends that 85 curricular elements be considered for inclusion for teaching in the Canadian medical school focused ultrasound curricula.

Predicting Thoracic Injury in Children With Multitrauma.

OBJECTIVES: Previous pediatric trauma studies focused on predictors of abnormal chest radiographs or included patients with low injury severity. This study identified predictors of thoracic injury (TI) diagnoses in a high-risk population and determined TI rate without predictors. METHODS: This study was a retrospective trauma registry analysis of previously healthy children aged 0 to 17 years with multisystem blunt trauma requiring trauma team activation and chest radiography who were divided into those with and without TI. Plausible TI predictors included Glasgow Coma Scale score of 13 or less, abnormal thoracic symptoms/signs, abnormal chest auscultation, respiratory distress/ rate higher than the 95th percentile, oxygen saturation less than 95%, abnormal abdominal signs/symptoms, tachycardia higher than the 95th percentile, blood pressure lower than the 5th percentile, and femur fracture. RESULTS: One hundred forty-one (29%) of 493 eligible patients had TI. Independent TI predictors include thoracic symptoms/signs (odds ratio [OR], 6.0; 95% confidence interval [CI], 3.6-10.1), abnormal chest auscultation (OR, 3.5; 95% CI, 2.0-6.2), saturation less than 95% (OR, 3.1; 95% CI, 1.8-5.5), blood pressure lower than the 5th percentile (OR, 3.7; 95% CI, 1.1-12.2), and femur fracture (OR, 2.5; 95% CI, 1.2-5.4). Six (5%) of 119 children (95% CI, 0.01-0.09) without predictors had TI. CONCLUSIONS: Predictors of TI include thoracic symptoms/signs, abnormal chest auscultation, saturation less than 95%, blood pressure lower than the 5th percentile, and femur fracture. Because an important portion of children without predictors had TI, chest radiography should remain part of pediatric trauma resuscitation.

Emergency Point-of-Care Ultrasound Diagnosis of Diaphragmatic Hernia in the Pediatric Emergency Department.

We present a case series of 2 patients who presented to a pediatric emergency department with history and symptoms suggestive of diaphragmatic hernia. Point-of-care ultrasound was used at the bedside to demonstrate the presence of bowel in the thorax and accurately guided the care of these children.

Concussion and its management: What do parents know?

OBJECTIVES: To determine the sensitivity of parental suspicion of concussion relative to paediatric emergency physicians in children who presented to an emergency department (ED) with a head injury. A secondary objective was to examine the variables associated with parental suspicion of concussion concordant with that of a physician. METHODS: Parents of children five to 18 years of age presenting to an urban paediatric ED with a nonstructural head injury completed a 24-item questionnaire. RESULTS: Of the 577 eligible parents, 495 (85.8%) consented to participate. The sensitivity of parental suspicion for concussion was 40.0% (95% CI 33.2% to 47.2%), while the specificity was 58.3% (95% CI 52.4% to 64.0%). The variable of child age ≥10 years was associated with an increased odds (OR 3.0) of a parental suspicion of concussion concordant with that of a physician; parent age, parent sex, mechanism of head injury and history of concussion in the child were not. Although 453 (91.5%) parents would stop activity if they believed their child sustained a concussion, only 159 (32.1%) were familiar with return-to-play guidelines. CONCLUSIONS: Parents often did not suspect a concussion when it was ultimately diagnosed by a paediatric emergency physician, although they were more likely to do so in older children. Only approximately one-third were aware of return-to-play guidelines. To enhance the potential for parent-driven advocacy in the recognition and management of concussion, these data support the need for increased parental education on this injury.

OBJECTIFS: Déterminer la sensibilité des soupçons des parents à l'égard des commotions cérébrales par rapport aux constatations des médecins d'urgence en pédiatrie auprès des enfants qui avaient consulté à l'urgence en raison d'une commotion cérébrale. Un objectif secondaire consistait à examiner les variables associées aux soupçons des parents à l'égard des commotions cérébrales qui concordaient avec les constatations d'un médecin. MÉTHODOLOGIE: Les parents d'enfants de cinq à 18 ans qui ont consulté dans une salle d'urgence pédiatrique en milieu urbain à cause d'une lésion cérébrale non structurelle ont rempli un questionnaire en 24 questions. RÉSULTATS: Sur les 577 parents admissibles, 495 (85,8 %) ont consenti à participer. La sensibilité des soupçons des parents à l'égard des commotions cérébrales s'élevait à 40,0 % (95 % IC 33,2 % à 47,2 %), tandis que la spécificité s'élevait à 58,3 % (95 % IC 52,4 % à 64,0 %). La variable de l'âge des enfants de dix ans ou plus s'associait à une plus forte possibilité (rapport de cote de 3,0) que les soupçons de commotion cérébrale des parents concordent avec les constatations du médecin. L'âge du parent, son sexe, le mécanisme de lésion cérébrale et des antécédents de commotion cérébrale chez l'enfant ne s'y associaient pas. Même si 453 parents (91,5 %) interrompraient les activités de leur enfant s'ils croyaient que celui-ci avait subi une commotion, seulement 159 (32,1 %) connaissaient les lignes directrices de retour au jeu. CONCLUSIONS: Souvent, les parents n'avaient pas soupçonné la commotion cérébrale dont leur enfant était victime avant qu'un médecin d'urgence en pédiatrie la diagnostique, mais ils étaient plus susceptibles de s'en douter chez des enfants plus âgés. Seulement environ le tiers connaissait les lignes directrices de retour au jeu. Pour accroître le potentiel de dépistage et de prise en charge des commotions cérébrales, ces données soutiennent la nécessité d'accroître l'éducation des parents à ce sujet.

Point-Of-Care Ultrasound Findings Associated With Foreign Body Aspiration in the Pediatric Emergency Department.

Point-of-care ultrasound (POCUS) continues to generate new and interesting clinical findings as its use expands in the pediatric emergency department. This case report describes the novel findings identified during a POCUS focused lung examination of a pediatric patient with suspected foreign body aspiration.

Point-of-Care Ultrasound Diagnosis of Bilateral Retinal Detachment Associated With Vogt-Koyanagi-Harada Disease in the Pediatric Emergency Department.

We report a case of a 16-year-old girl with acute visual complaints who was diagnosed with bilateral retinal detachment using point-of-case ultrasound and ultimately was diagnosed with Vogt-Koyanagi-Harada disease. This case illustrates the use of point-of-care ultrasound by the pediatric emergency physician to recognize the ocular abnormality associated with this rare disease.

Point-of-Care Ultrasound Findings Associated With Langerhans Cell Histiocytosis in the Pediatric Emergency Department.

Langerhans cell histiocytosis is a rare disease characterized by clonal proliferation of Langerhans-type cells, causing local or systemic effects. One of the most affected sites in children is the skull. We describe 2 cases of children presenting to the pediatric emergency department with symptoms isolated to the scalp and the point-of-care focused skull ultrasound findings, which assisted in the diagnosis of Langerhans cell histiocytosis in both cases.

The diagnosis of concussion in a pediatric emergency department.

OBJECTIVES: To compare the proportion of children diagnosed with a concussion by pediatric emergency physicians vs the proportion who met criteria for this injury as recommended by Zurich Fourth International Conference on Concussion consensus statement and to determine clinical variables associated with a physician diagnosis of a concussion. STUDY DESIGN: This was a prospective, cross-sectional study conducted at a tertiary care pediatric emergency department. We enrolled children ages 5 through 17 who presented with a head injury and collected data on demographics, mechanism of injury, head injury-related symptoms/signs, physician diagnosis, and discharge advice. RESULTS: We identified 495 children whose mean age was 10.1 years (SD 3.4 years); 308 (62.2%) were male. Emergency physicians diagnosed concussion in 200 (40.4%; 95% CI 36.1, 44.7) children, and 443 (89.5%; 95% CI 86.8, 92.2) met criteria for concussion in accordance with the Zurich consensus statement (P<.0001). Age≥10 years (OR 1.8), presentation≥1 day after injury (OR 2.4), injury from collision sports (OR 5.6), and symptoms of headache (OR 2.2) or amnesia (OR 3.4) were the variables significantly associated with an emergency physician's diagnosis of concussion. CONCLUSIONS: Pediatric emergency physicians diagnosed concussion less often relative to international consensus-based guidelines and used a limited number of variables to make this diagnosis compared with current recommendations. Thus, pediatric emergency physicians may be missing cases of concussion and the corresponding opportunity to provide critical advice for cognitive and physical management.