Point-of-Care Ultrasound, an Unexpected Cardiac Mass in a Neonate.

ABSTRACT: Neonatal cardiac masses are uncommon and often not obvious based on physical examination or plain radiography. The objective of this clinical case report is to demonstrate how cardiac point-of-care ultrasound was pivotal in the clinical course of a seemingly well neonate with vague symptoms. A 6-week-old male infant presented to the emergency department with fatigue and pallor that was reported to have resolved before arrival. In the emergency department, he had a normal physical examination and stable vital signs. Cardiac point-of-care ultrasound was performed and demonstrated a mass near the mitral valve. These ultrasound findings prompted additional evaluation, cardiology consultation, admission, and subsequent diagnosis of a rhabdomyoma due to tuberous sclerosis.

Establishing the international research priorities for pediatric emergency medicine point-of-care ultrasound: A modified Delphi study.

BACKGROUND: The Pediatric Emergency Medicine (PEM) Point-of-care Ultrasound (POCUS) Network (P2Network) was established in 2014 to provide a platform for international collaboration among experts, including multicenter research. The objective of this study was to use expert consensus to identify and prioritize PEM POCUS topics, to inform future collaborative multicenter research. METHODS: Online surveys were administered in a two-stage, modified Delphi study. A steering committee of 16 PEM POCUS experts was identified within the P2Network, with representation from the United States, Canada, Italy, and Australia. We solicited the participation of international PEM POCUS experts through professional society mailing lists, research networks, social media, and "word of mouth." After each round, responses were refined by the steering committee before being reissued to participants to determine the ranking of all the research questions based on means and to identify the high-level consensus topics. The final stage was a modified Hanlon process of prioritization round (HPP), which emphasized relevance, impact, and feasibility. RESULTS: Fifty-four eligible participants (16.6%) provided 191 items to Survey 1 (Round 1). These were refined and consolidated into 52 research questions by the steering committee. These were issued for rating in Survey 2 (Round 2), which had 45 participants. At the completion of Round 2, all questions were ranked with six research questions reaching high-level consensus. Thirty-one research questions with mean ratings above neutral were selected for the HPP round. Highly ranked topics included clinical applications of POCUS to evaluate and manage children with shock, cardiac arrest, thoracoabdominal trauma, suspected cardiac failure, atraumatic limp, and intussusception. CONCLUSIONS: This consensus study has established a research agenda to inform future international multicenter PEM POCUS trials. This study has highlighted the ongoing need for high-quality evidence for PEM POCUS applications to guide clinical practice.

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.

Point-of-Care Ultrasound Assessment of Orbital Rhabdomyosarcoma in a Pediatric Patient.

ABSTRACT: Rhabdomyosarcoma is the most common soft tissue tumor in children and orbital lesions account for 10% of these diagnoses. This case describes a young boy who presented with eyelid swelling that was initially concerning for an expanding hematoma given a history of recent trauma to the eye. Point-of-care ultrasound identified 2 distinct lesions surrounding the globe, which prompted further investigation, including ophthalmology consult and computed tomography. The case presented highlights the initial misdiagnosis on both point-of-care ultrasound and computed tomography and the importance of using color Doppler on ultrasound to distinguish an orbital rhabdomyosarcoma from a posttraumatic hematoma.

A cadaveric model for transesophageal echocardiography transducer placement training: A pilot study.

BACKGROUND: Transesophageal echocardiography (TEE) is used in the emergency department to guide resuscitation during cardiac arrest. Insertion of a TEE transducer requires manual skill and experience, yet in some residency programs cardiac arrest is uncommon, so some physicians may lack the means to acquire the manual skills to perform TEE in clinical practice. For other infrequently performed procedural skills, simulation models are used. However, there is currently no model that adequately simulates TEE transducer insertion. The aim of this study is to evaluate the feasibility and efficacy of using a cadaveric model to teach TEE transducer placement among novice users. METHODS: A convenience sample of emergency medicine residents was enrolled during a procedure education session using cadavers as tissue models. A pre-session assessment was used to determine prior knowledge and confidence regarding TEE manipulation. Participants subsequently attended a didactic and hands-on education session on TEE placement. All participants practised placing the TEE transducer until they were able to pass a standardized assessment of technical skill (SATS). After the educational session, participants completed a post-session assessment. RESULTS: Twenty-five residents participated in the training session. Mean assessment of knowledge improved from 6.2/10 to 8.7/10 (95% confidence interval [CI] of knowledge difference 1.6-3.2, P<0.001) and confidence improved from 1.6/5 to 3.1/5 (95% CI of confidence difference 1.1-2.0, P<0.001). There was no relationship between training level and the delta in knowledge or confidence. CONCLUSIONS: In this pilot study, the use of a cadaveric model to teach TEE transducer placement methods among novice users is feasible and improves both TEE manipulation knowledge and confidence levels.

The Efficacy of a Brief Educational Training Session in Point-of-Care Pediatric Hip Ultrasound.

BACKGROUND: Pediatric limp is a common presenting complaint to emergency departments. Despite this, diagnosis can be difficult in young patients with no history of trauma. Ultrasound can be used to identify a hip effusion, which may be the etiology of limp in pediatric patients. Brief educational training sessions have successfully been used to introduce novice ultrasound users to point-of-care (POC) ultrasound; however, the education of POC hip ultrasound is underexplored, and the efficacy of educational training sessions in this domain remains unknown. OBJECTIVE: To evaluate the feasibility and efficacy of using a brief educational training session to teach novice ultrasound users to identify hip anatomy and effusions. METHODS: Medical and physician assistant students were enrolled during an ultrasound education conference. A pretest evaluated prior knowledge, experience, and confidence level regarding POC hip ultrasound. Students attended a brief didactic session and then completed an objective structured assessment of technical skill as well as a posttest. RESULTS: Twenty-eight students naive to hip ultrasound participated in this study. Levels of training included medical and physician assistant students. Mean test scores increased from the pretest (4.8 of 9, SD = 1.6) to the posttest (7.9 of 9, SD = 0.72) (P < 0.001). Average objective structured assessment of technical skill was 4.6 of 5 (SD, 0.75; 95% confidence interval, 4.3-4.9). After the sessions, confidence levels in identifying landmarks, joint space, and a joint effusion significantly increased (P < 0.001). CONCLUSIONS: Pediatric hip ultrasound knowledge, performance, skills, and confidence improved as demonstrated by novice ultrasound users after a brief educational training session. Our study shows that a brief, targeted educational intervention was a feasible and effective method of introducing pediatric POC hip ultrasound to novices.

Children with under-diagnosed asthma presenting to a pediatric emergency department.

BACKGROUND: Undiagnosed asthma in children presenting to the emergency department (ED) for respiratory illnesses might be associated with subsequent asthma morbidity and repeat ED visits. OBJECTIVE: To examine the prevalence of undiagnosed asthma among children presenting for ED care, and explore associations with sociodemographic and clinical characteristics. METHODS: We surveyed parents of children ages 2-17 years seeking ED care for respiratory symptoms (including asthma) regarding sociodemographic characteristics, asthma symptoms, prior asthma care and morbidity, and prior asthma diagnosis. Undiagnosed asthma was defined as a positive screening for asthma and no prior diagnosis. We compared sociodemographic and clinical factors of those with diagnosed versus undiagnosed asthma using chi-square, t-tests and multivariable logistic regression model. RESULTS: Of 362 children, 36% had undiagnosed asthma. Undiagnosed children were younger, had younger parents, and had parents less likely to speak English versus diagnosed children (all p < 0.05). Among undiagnosed children, 42% had moderate or severe asthma and 66% reported ≥1 exacerbation in the prior 12 months. Parent-reported controller medication use was higher among diagnosed versus undiagnosed children (60% vs. 21%, p=.001). In a multivariable logistic regression (adjusting for insurance, education, income and preferred language), no controller usage (aOR 4.26), no asthma exacerbations in the prior year (aOR 2.41) and younger age (aOR 0.76) were significantly associated with undiagnosed asthma. CONCLUSION: Children presenting to the ED with undiagnosed asthma commonly experience significant prior asthma morbidity. Strategies to improve asthma diagnosis and messaging to their parents may reduce future morbidity.

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.

Use of a validated asthma questionnaire to increase inhaled corticosteroid prescribing in the pediatric emergency department.

BACKGROUND: Asthma guidelines recommend assessment of asthma control and treatment with an ICS when appropriate. Children seen for asthma in the ED often have poorly controlled asthma. Validated questionnaires are rarely used in the ED and ICS are prescribed at less than 5% of ED asthma encounters, leaving many children at risk for continued poor outcomes. OBJECTIVE: To determine if use of a validated asthma questionnaire can increase the proportion of children who receive an ICS prescription during an ED asthma visit. METHODS: We administered a validated asthma questionnaire (Pediatric Asthma Control and Communication Instrument-ED version [PACCI-ED]) to parents of children 2 - 17 years old presenting for asthma care at a large, urban, academic pediatric ED. Based on national asthma guidelines, the PACCI-ED results were used to determine ICS dose recommendations. ED physicians reviewed the PACCI-ED results and ICS dose recommendations and chose whether to prescribe an ICS upon discharge. ICS prescribing rates during the intervention period were assessed via medical record review and compared to historical controls. We also surveyed parents to examine the association of sociodemographic factors with receipt of an ICS prescription, and surveyed physicians regarding their prescribing decisions. RESULTS: Thirteen physicians and seventy-nine children participated. Historically, the ICS prescribing rate for asthma exacerbations discharged from the ED was 13%. The intervention increased ICS prescribing to 56% (p < 0.001). Children with ≥2 asthma exacerbations in the prior year (p < 0.02) and those with moderate-severe persistent asthma (p < 0.02) were more likely to receive an ICS prescription. There were no statistically significant differences in ICS prescribing by sociodemographic characteristics. CONCLUSION: A validated asthma questionnaire increased ICS prescribing for children presenting for to the ED for asthma care. Additional strategies are needed to promote prescribing in this setting and ensure that all eligible children receive guideline-based asthma care.

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.

Asthma specialist care preferences among parents of children receiving emergency department care for asthma.

Objective: To learn factors associated with desire for asthma specialist care among parents of children seeking emergency department (ED) care for asthma, and if referral was indicated based on national asthma guidelines. Methods: We surveyed parents of children ages 0-18 years seeking pediatric ED asthma care, then comparisons were made according to parental level of interest in asthma specialist care, with regard to socio-demographics, asthma morbidity and care, by chi-squared and logistic regression. Results: Of 149 children, 20% reported specialist care, but 75% met guideline criteria for referral. About 80% of parents not seeing an asthma specialist expressed a desire to see one. Higher rates of prior urgent care visits (48% vs. 22%, p = 0.03), ED visits (82% vs. 35%, p < 0.001) and oral steroid use (53% vs. 22%, p = 0.009) were reported by parents who desired an asthma specialist compared with parents who did not. 87% of parents not seeing a specialist attributed this to a perceived lack of necessity by their primary care provider. An ED visit within the prior 12 months was the most significant predictor in parental desire for specialist care (odds ratio 9.75; 95% CI 3.42-27.76) in adjusted logistic regression models. Conclusion: High rates of parental preference for asthma specialist care suggest that directly querying parents may be an efficient method to identify children appropriate for specialist care in the ED.