Point-of-care ultrasound evaluation of suspected necrotizing enterocolitis in the ED.

Necrotizing enterocolitis (NEC) is a rare but life-threatening diagnosis in infants presenting with bilious emesis, abdominal distension, or bloody stools. Ultrasonography has been advocated as an alternative initial imaging modality to abdominal radiography, and may be superior in the evaluation of NEC. We describe the use of point-of-care ultrasound (PoCUS) in the evaluation of suspected NEC in the emergency department (ED) when the ability to obtain immediate abdominal x-ray (AXR) was delayed due to pandemic conditions. A pre-term infant with history of bowel resection presented with non-bilious emesis, bloody stools, and slight abdominal distension. Evaluation with PoCUS identified pneumatosis intestinalis and pneumoperitoneum, which were confirmed on subsequent AXR. Pneumatosis intestinalis in a neonate is highly suggestive of NEC, but seen by itself, can be associated with milk protein allergy and Food Protein Induced Enterocolitis syndrome (FPIES). Pneumoperitoneum is considered an indication for operative intervention for NEC. The infant was re-admitted to the NICU for suspected NEC. NEC is a rare, but potentially surgical diagnosis in infants as can be FPIES, but not milk protein allergy. NEC can be identifiable using PoCUS to search for a constellation of findings that include pneumatosis intestinalis, pneumoperitoneum, free peritoneal fluid, and portal venous gas. These findings have been previously described in the PoCUS literature for other diseases, but not for a case of suspected NEC presenting to the ED.

Point-of-Care Ultrasound Evaluation of Pediatric Osteomyelitis in the Emergency Department: A Case Series.

ABSTRACT: Musculoskeletal and soft tissue complaints commonly present to the pediatric emergency department and literature supports the use point-of-care ultrasound (POCUS) in the diagnosis of these complaints. The diagnosis of osteomyelitis typically involves laboratory testing with inflammatory biomarkers, imaging with x-ray, and often magnetic resonance imaging with test results often not immediately available. We report a case series of children initially evaluated with POCUS for osteomyelitis. The POCUS may expedite diagnosis and treatment when used as the initial test in children with suspected osteomyelitis in the emergency department.

Point-of-Care Ultrasound for Pediatric Vaginal Obstruction in the Emergency Department: A Case Series.

ABSTRACT: Point-of-care ultrasound can be an effective tool to facilitate the evaluation of abdominal and pelvic pain in children. We present a series of 3 pediatric patients with nonspecific abdominal and pelvic symptoms in whom point-of-care ultrasound expedited diagnosis, guided decision-making, prompted subspecialist consultation, and led to definitive management of vaginal obstruction.

Interpretation of Cardiac Standstill in Children Using Point-of-Care Ultrasound.

STUDY OBJECTIVE: This study aimed to determine the level of agreement among pediatric emergency medicine (PEM) physicians in whether various point-of-care ultrasound (POCUS) video clips represent cardiac standstill in children and to highlight the factors that may be associated with the lack of agreement. METHODS: A single, online, cross-sectional, convenience sample survey was administered to PEM attendings and fellows with variable ultrasound experience. PEM attendings with an experience of 25 cardiac POCUS scans or more were the primary subgroup based on ultrasound proficiency set by the American College of Emergency Physicians. The survey contained 11 unique, 6-second video clips of cardiac POCUS performed during pulseless arrest in pediatric patients and asked the respondent if the video clip represented a cardiac standstill. The level of interobserver agreement was determined using the Krippendorff's α (Kα) coefficient across the subgroups. RESULTS: A total of 263 PEM attendings and fellows completed the survey (9.9% response rate). Of the 263 total responses, 110 responses were from the primary subgroup of experienced PEM attendings with at least 25 previously seen cardiac POCUS scans. Across all video clips, PEM attendings with 25 scans or more had an acceptable agreement (Kα=0.740; 95% CI 0.735 to 0.745). The agreement was the highest for video clips wherein the wall motion corresponded to the valve motion. However, the agreement fell to unacceptable levels (Kα=0.304; 95% CI 0.287 to 0.321) across video clips wherein the wall motion occurred without the valve motion. CONCLUSION: There is an overall acceptable interobserver agreement when interpreting cardiac standstill among PEM attendings with an experience of at least 25 previously reported cardiac POCUS scans. However, factors that may influence the lack of agreement include discordances between the wall and valve motion, suboptimal views, and the lack of a formal reference standard. More specific consensus reference standards of pediatric cardiac standstill may help to improve interobserver agreement moving forward and should include more specific details regarding the wall and valve motion.

Deep Learning Pitfall: Impact of Novel Ultrasound Equipment Introduction on Algorithm Performance and the Realities of Domain Adaptation.

OBJECTIVES: To test deep learning (DL) algorithm performance repercussions by introducing novel ultrasound equipment into a clinical setting. METHODS: Researchers introduced prospectively obtained inferior vena cava (IVC) videos from a similar patient population using novel ultrasound equipment to challenge a previously validated DL algorithm (trained on a common point of care ultrasound [POCUS] machine) to assess IVC collapse. Twenty-one new videos were obtained for each novel ultrasound machine. The videos were analyzed for complete collapse by the algorithm and by 2 blinded POCUS experts. Cohen's kappa was calculated for agreement between the 2 POCUS experts and DL algorithm. Previous testing showed substantial agreement between algorithm and experts with Cohen's kappa of 0.78 (95% CI 0.49-1.0) and 0.66 (95% CI 0.31-1.0) on new patient data using, the same ultrasound equipment. RESULTS: Challenged with higher image quality (IQ) POCUS cart ultrasound videos, algorithm performance declined with kappa values of 0.31 (95% CI 0.19-0.81) and 0.39 (95% CI 0.11-0.89), showing fair agreement. Algorithm performance plummeted on a lower IQ, smartphone device with a kappa value of -0.09 (95% CI -0.95 to 0.76) and 0.09 (95% CI -0.65 to 0.82), respectively, showing less agreement than would be expected by chance. Two POCUS experts had near perfect agreement with a kappa value of 0.88 (95% CI 0.64-1.0) regarding IVC collapse. CONCLUSIONS: Performance of this previously validated DL algorithm worsened when faced with ultrasound studies from 2 novel ultrasound machines. Performance was much worse on images from a lower IQ hand-held device than from a superior cart-based device.

Point-of-Care Ultrasonography for Ankle Injuries in Children.

OBJECTIVES: The aim of the study was to determine whether point-of-care ultrasound (US) can decrease x-rays in children with ankle injuries. Secondary objectives were to determine the test performance characteristics for ankle US, analyze diagnostic errors, and compare US with the Ottawa Ankle Rules (OAR). METHODS: This was a prospective study of children younger than 21 years presenting to an emergency department with an ankle injury requiring x-rays. Pediatric emergency medicine physicians received a 1-hour training session, performed ankle US with a standardized scanning protocol of the distal tibia and fibula, and described the US as positive, negative, or equivocal for fracture. Ankle x-ray interpretation by a radiologist was the reference standard for fracture. RESULTS: One hundred twenty patients with a mean age of 13.5 (±4.0) years were enrolled. Nine patients (7.5%) had an ankle fracture on x-ray, and 56 patients (47%) had open physes. Ankle US would reduce x-rays by 81 (67.5%), missing 2 intra-articular, nondisplaced, tibial fractures in patients with open physes. Ankle US had a sensitivity of 78% (95% confidence interval [CI], 40%-97%), specificity of 71% (95% CI, 62%-79%), likelihood ratio for a positive test of 2.7 (95% CI, 1.7-4.3), and likelihood ratio for a negative test of 0.31 (95% CI, 0.09-1.07). The OAR would reduce x-rays by 21 (17.5%), missing one fracture. Ultrasound with OAR would reduce x-rays by 20 (17%) with no missed fractures. CONCLUSIONS: Point-of-care US has the potential to reduce x-rays for children with ankle injuries; however, nondisplaced, intra-articular tibial fractures may be missed. Ultrasound with OAR may reduce radiographs without missed fractures in this population.

Point-of-Care Ultrasound on Management of Cellulitis Versus Local Angioedema in the Pediatric Emergency Department.

OBJECTIVES: To evaluate whether ultrasound can differentiate between cellulitis and angioedema from insect bites in pediatric patients. METHODS: A prospective, pre-post study in an urban pediatric emergency department of patients younger than 21 years with soft tissue swelling from insect bites without abscesses were enrolled. Treating physician's pretest opinions regarding the diagnosis and need for antibiotics were determined. Ultrasound of the affected areas was performed, and effects on management were recorded. Further imaging, medications, and disposition were at the discretion of the enrolling physician. Phone call follow-ups were made within a week of presentation. RESULTS: Among 103 patients enrolled with soft tissue swelling secondary to insect bites, ultrasound changed the management in 27 (26%) patients (95% confidence interval [CI], 18-35%). Of the patients who were indeterminate or believed to require antibiotics, ultrasound changed management in 6 (23%) of 26 patients (95% CI, 6%-40%). In those patients who were believed not to require antibiotics, ultrasound changed management in 12 (16%) 77 patients (95% CI, 7%-24%). Patients with diagnosis of local angioedema achieved symptom resolution 1.4 days sooner than patients diagnosed with cellulitis (mean, -1.389; 95% CI, -2.087 to -0.690; P < 0.001). No patient who was initially diagnosed as local angioedema received antibiotics upon patient follow-up. CONCLUSIONS: Point-of-care ultrasound changed physician management in 1 of 4 patients in the pediatric emergency department with soft tissue swelling secondary to insect bites. Ultrasound may guide the management in these patients and lead to improved antibiotic stewardship in conjunction with history and physical examination.

Interobserver Agreement of Inferior Vena Cava Ultrasound Collapse Duration and Correlated Outcomes in Children With Dehydration.

OBJECTIVE: Dehydration is a common concern in children presenting to pediatric emergency departments and other acute care settings. Ultrasound (US) of the inferior vena cava (IVC) may be a fast, noninvasive tool to gauge volume status, but its utility is unclear. Our objectives were to determine the interobserver agreement of IVC collapse and collapse duration, then correlate IVC collapse with the outcome of intravenous (IV) versus oral (PO) rehydration. METHODS: We conducted a prospective study by enrolling patients 0 to 21 years old with emesis requiring ondansetron or diarrhea requiring IV hydration. Clinical operators interpreted US examinations in real time to determine whether the IVC was collapsed. Two blinded reviewers interpreted the US videos to determine IVC collapse and collapse duration. Cohen's kappa(κ) was calculated for reviewer-reviewer and reviewer-operator agreement. Primary outcomes were PO versus IV rehydration, and admitted versus discharged. RESULTS: One hundred twelve patients were enrolled, and 102 had complete data for analysis. The mean age was 7.2 years with 51% female. Twenty-nine patients received IV hydration. The reviewer-operator agreement for IVC collapse was κ = 0.57 (95% confidence interval [CI], 0.38-0.75) and interreviewer agreement was κ = 0.93 (95% CI, 0.83-1.0). The interreviewer agreement for collapse duration was κ = 0.66 (95% CI, 0.51-0.82). All patients with noncollapsed IVCs tolerated PO hydration. The likelihood of receiving IV hydration was correlated with the duration of IVC collapse (P = 0.034). CONCLUSIONS: Based on a novel dynamic measure of IVC collapse duration, children with increasing duration of IVC collapse correlated positively with the need for IV rehydration. Noncollapsing IVCs on US were associated with successful PO rehydration without need for IV fluids or emergency department revisits.

Acupuncture as a Nonpharmacologic Treatment for Pain in a Pediatric Emergency Department.

OBJECTIVES: With epidemic opioid deaths and abuse in the United States, government agencies recommend nonpharmacological treatments for pain. However nonopioid treatment options for moderate to severe pain in the pediatric emergency department (PED) are limited. Acupuncture has been shown to be effective for pain. The objective of this study was to evaluate the feasibility of using traditional acupuncture (TA) and battlefield acupuncture (BFA) in the treatment of pain in the PED. METHODS: A pediatric cohort treated with acupuncture for pain in an urban PED was assessed. All subjects received TA or BFA as treatment, and pre/postacupuncture pain scores, feedback, and adverse events were assessed. The primary outcome was a change in pain score. RESULTS: Twelve patients received BFA, and 13 received TA for these pain conditions: headaches, sciatica, paraphimosis, torticollis, joint pains (knee, shoulder, jaw), sprains (foot, wrist, thumb), dysmenorrhea, otitis externa, sickle cell, and muscle knot. The mean ± SD pain score change, 5.8 ± 2.5 (P < 0.05; 95% confidence interval, 4.9-7.0), was clinically and statistically significant. Over 90% of subjects reported significant improvement or resolution of pain; 96% were satisfied with pain relief and would receive acupuncture again. Two adverse events were noted: one patient reported dizziness, and another, a tinge of blood at 1 of 90 needled points. CONCLUSIONS: This study suggests that acupuncture is a potential nonpharmacologic therapeutic option for acute pain management in the PED.

Features of COVID-19 post-infectious cytokine release syndrome in children presenting to the emergency department.

The 2019 coronavirus disease (COVID-19) has not appeared to affect children as severely as adults. However, approximately 1 month after the COVID-19 peak in New York City in April 2020, cases of children with prolonged fevers abruptly developing inflammatory shock-like states have been reported in Western Europe and the United States. This case series describes four previously healthy children with COVID-19 infection confirmed by serologic antibody testing, but negative by nasopharyngeal RT-PCR swab, presenting to the Pediatric Emergency Department (PED) with prolonged fever (5 or more days) and abrupt onset of hemodynamic instability with elevated serologic inflammatory markers and cytokine levels (IL-6, IL-8 and TNF-α). Emergency physicians must maintain a high clinical suspicion for this COVID-19 associated post-infectious cytokine release syndrome, with features that overlap with Kawasaki Disease (KD) and Toxic Shock Syndrome (TSS) in children with recent or current COVID-19 infection, as patients can decompensate quickly.

Unmasking the Lung Pulse for Detection of Endobronchial Intubation.

The ultrasound lung pulse for detecting endobronchial intubation was first described in 2003 in the only study to date assessing its accuracy. It refers to rhythmic movement of the visceral pleura along the stationary parietal pleura as cardiac vibrations transmit through a motionless, airless lung. Compared to delayed visualization on chest radiography, this artifact immediately detects physiologic atelectasis. There is a scarcity of studies assessing the lung pulse, while several others that encountered this artifact did not even identify it. The lung pulse is useful for immediate detection of endobronchial intubation, but it remains unrecognized and underused by physicians.

Point-of-care ultrasound diagnosis of small bowel-small bowel vs ileocolic intussusception.

BACKGROUND: Identification of intussusception is feasible with emergency department (ED) point-of-care ultrasound (PoCUS) due to its ease-of-use and high accuracy. Little is known about the clinical characteristics and outcomes of small bowel-small bowel intussusception (SB-SBI) relative to ileocolic intussusception (ICI) identified by PoCUS. METHODS: We conducted a retrospective cohort study at a single, tertiary care, urban pediatric ED of intussusception identified by PoCUS. Demographic information, clinical data, and outcomes, including clinical course, intussusception characteristics, recurrence rates, and interobserver agreement (Cohen's kappa), were evaluated. RESULTS: ED PoCUS identified thirty-seven patients with intussusception over a 4-year period. Twenty-one patients (57%) identified were SB-SBI. The median age was 54 months (IQR 35-76 months) for SB-SBI and 8 months (IQR 5.8-13.5 months) for ICI. The mean diameter was 1.68 cm (SD 0.52 cm) for SB-SBI and 2.74 cm (SD 0.43 cm) for ICI (p < 0.05). Two of 21 (9.5%) SB-SBI subjects required surgical intervention, while the rest spontaneously reduced. Fourteen of 16 (88%) ICI subjects required intervention. There were two (9.5%) recurrences of SB-SBI and 1 (6.3%) recurrence of ICI confirmed on PoCUS. Cohen's kappa was 0.85 (95% CI 0.68-1.0). CONCLUSIONS: SB-SBI may be identified more frequently than previously thought when screened with ED PoCUS. Older children with SB-SBI may have underlying lead-points and may require surgical intervention. PoCUS can help differentiate between variants of intussusception that range from a surgical emergency to a transient source of abdominal pain that may be recurrent and otherwise unexplained, allowing clinicians to better manage these patients accordingly.

Sonographic Evaluation and Monitoring of Pneumoperitoneum After Air Enema Reduction for Intussusception.

Abdominal radiography and computed tomography scans are standard tests to diagnose pneumoperitoneum. With the growing availability of point-of-care ultrasound, pneumoperitoneum may be diagnosed in settings without easy access to radiography or computed tomography, such as in overcrowded emergency departments or resource-poor environments. The use of point-of-care ultrasound to diagnose or monitor pneumoperitoneum has been described in adult but not pediatric patients. We present a case of point-of-care ultrasound detection of pneumoperitoneum and monitoring for tension pneumoperitoneum, after failed air enema reduction for intussusception in an infant.

Lung Consolidation Locations for Optimal Lung Ultrasound Scanning in Diagnosing Pediatric Pneumonia.

OBJECTIVES: Lung ultrasound (US) has been shown to be accurate in diagnosing pneumonia in children. Evidence to inform an optimal scanning protocol is limited. Our objective is to describe an optimized lung US scanning protocol for pediatric pneumonia based on the anatomic location and transducer orientation. METHODS: We performed a secondary analysis of data and images from 2 prospective lung US studies for the emergency department diagnosis of pneumonia in children (0-21 years). The anatomic location of each lung consolidation was mapped to 1 or more of 6 anatomic zones on the chest, noting the transducer orientation (sagittal or transverse) in which it was identified. RESULTS: Seventy-eight patients were included; 51% were female, and the median age was 3 years (interquartile range, 1-7 years). Overall, 46.5% (95% CI confidence interval [CI], 37.9%-55.1%) of lung zones with a visible consolidation were posterior; 31.0% (95% CI, 23.0%-39.0%) were anterior; and 22.5% (95% CI, 15.3%-29.1%) were axillary. A total of 54.3% (95% CI, 45.7%-62.9%) of affected lung zones were in the lower lung compared to the upper lung (8.5%; 95% CI, 3.7%-13.3%) and middle lung (37.2%; 95% CI, 28.9%-45.5%). Most lung consolidations were seen in both transducer orientations: 96.2% (95% CI, 92.0%-100%) of patients had a visible consolidation on the transverse view, whereas 85.9% (95% CI, 78.2%-93.6% had a consolidation on the sagittal view. CONCLUSIONS: Efficient lung US scanning may start with the posterior, anterior, and then lateral chest zones if no pneumonia is identified. A transverse transducer orientation detects more pneumonia than a sagittal orientation. Omission of either orientation or any lung zone may miss pneumonia.

Auricular Acupuncture in Emergency Department Treatment of Acute Pain.

The National Institutes of Health and the World Health Organization note that acupuncture is a safe and effective treatment for pain. Nonopioid treatment options for moderate to severe acute pain in the emergency department (ED) are limited. Additional strategies for managing acute pain in the ED are needed. Auricular Battlefield Acupuncture has been described as a simple, safe, rapid, and effective analgesic option to opioid medications in managing acute pain. We describe 4 cases in which emergency physicians with brief training performed this auricular acupuncture protocol to treat patients with acute pain in EDs when opioid analgesia was not an acceptable option.

Evaluation and Monitoring of a Child With Hydrocarbon Pneumonitis Using Point-of-Care Lung Ultrasound in the Pediatric Emergency Department.

A well-appearing 3-year-old boy presented to the pediatric emergency department 2 hours after a presumed hydrocarbon ingestion. He was referred to the emergency department by his pediatrician after consultation with the local poison control center after possibly ingesting ylang ylang (Cananga odorata) fragrance oil. The child was asymptomatic with a normal physical examination. Point-of-care lung ultrasound identified focal hydrocarbon pneumonitis in the right lung and demonstrated resolution of these findings. Utilization of point-of-care ultrasound resulted in a shorter emergency department length of stay and the avoidance of radiation exposure from serial chest x-rays.

Avoiding Computed Tomography Scans By Using Point-Of-Care Ultrasound When Evaluating Suspected Pediatric Renal Colic.

BACKGROUND: Although renal colic in children in the United States remains relatively uncommon compared to in adults, its incidence has nearly doubled from 1999 to 2008. Noncontrast computed tomography (CT) is the current standard for the evaluation of suspected renal colic, given its high sensitivity and specificity. However, the greater lifetime risk of radiation-induced cancer from CT in pediatric patients has led to efforts to minimize radiation exposure. Additionally, pediatric renal colic is often recurrent, which might require multiple imaging studies during their lifetime. Point-of-care ultrasound (POCUS) by emergency physicians avoids radiation, has a low marginal cost, can be performed concurrently with other management, and allows for earlier diagnosis and more rapid treatment of renal colic. Adult randomized controlled trial evidence supports using POCUS as the initial approach to imaging and management of suspected renal colic. However, there remain limited data on POCUS in children for renal colic. CASE REPORT: This is a case series where the sonographic findings of hydronephrosis, ureteral jets, "twinkling artifact," and the identification of urinary tract stones were used to evaluate adolescent and pediatric patients with renal colic. We report five cases of renal colic in adolescent and pediatric patients where urolithiasis was confirmed by using POCUS and irradiation by CT was avoided in all 5 patients. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POCUS can provide information about the presence or absence of urinary tract stones as well as obstruction of the collecting system without the cost and radiation exposure of CT.

Ultrasound findings of the elbow posterior fat pad in children with radial head subluxation.

OBJECTIVE: The aim of this study was to determine whether elbow ultrasound findings of the posterior fat pad (PFP) are present in patients with diagnosis of radial head subluxation (RHS). METHODS: This was a prospective study of children presenting to an urban pediatric emergency department diagnosed clinically with RHS. Physicians received a 1-hour training session on musculoskeletal ultrasound including the elbow. Before performing reduction for RHS, the physicians performed a brief, point-of-care elbow ultrasound using a high-frequency linear transducer probe in both longitudinal and transverse views to evaluate for PFP elevation and lipohemarthrosis (LH). Successful clinical reduction with spontaneous movement of injured extremity served as the criterion standard for RHS. Clinical telephone follow-up was performed to ascertain outcomes. RESULTS: Forty-two patients were enrolled with a mean age of 22.3 (11.8) months. The mean time to presentation was 7 (9.2) hours, and 9/42 (21%) children had previous history of RHS. The majority of patients (35/42, 83%; 95% confidence interval (CI), 69%-92%) had a normal elbow ultrasound. Of 42 patients, 6 (14%; 95% CI 6%-28%) had an elevated PFP and 2 (5%; 95% CI, 0.5%-17%) had LH. Clinical reduction was successful in 100% of patients, and there were no complications reported on follow-up. CONCLUSIONS: The majority of children with RHS have a normal PFP on elbow ultrasound, but elevated PFP and LH are possible findings. Reduction maneuvers for RHS may be attempted in patients with a normal elbow ultrasound when the diagnosis of RHS or elbow fracture is uncertain.

Point-of-care ultrasound for assisting in needle aspiration of spontaneous pneumothorax in the pediatric ED: a case series.

There is controversy regarding needle aspiration for primary spontaneous pneumothorax (PSP), with contradictory recommendations between the American College of Chest Physicians consensus statement (2001), which suggests that needle aspiration has little place in the management of PSP, and the British Thoracic Society guidelines (2010), which recommend that needle aspiration be attempted first for all cases of PSP where drainage is deemed necessary. Studies have shown that there is no significant difference between needle aspiration and tube thoracostomy with regard to safety, rates of immediate success, and early failure and has the advantages of decreasing pain and reducing rates of hospital admission and duration of hospital stay compared with tube thoracostomy. Point-of-care ultrasound (US) can facilitate needle aspiration by decreasing the risk of complications and detect pneumothorax resolution during or re-expansion after the procedure. This is a case series where the sonographic finding of the "lung point" on point-of-care US was used to facilitate needle aspiration to monitor pneumothorax resolution during or re-expansion after the procedure. We report 3 cases of PSP in adolescents presenting to the pediatric emergency department (ED), where needle aspiration was safely performed by using US to track the sonographic finding of the lung point. This technique allows the determination of pneumothorax resolution or re-expansion in real time. Point-of-care US may assist in the evaluation and management of spontaneous pneumothorax in the pediatric ED. Ultrasound-assisted needle aspiration may be a safe and less painful option for pediatric ED patients with PSP.