Updates on the clinical integration of point-of-care ultrasound in pediatric emergency medicine.

PURPOSE OF REVIEW: There is expanding evidence for point-of-care ultrasound (POCUS) use in pediatric emergency medicine - this review highlights the benefits and challenges in the clinical integration of high-yield POCUS applications. Specifically, it will delve into POCUS applications during resuscitations, controversies of Focused Assessment with Sonography for Trauma (FAST) in pediatric trauma, POCUS-guided procedures, and examples of clinical pathways where POCUS can expedite definitive care. RECENT FINDINGS: POCUS can enhance diagnostic accuracy and aid in management of pediatric patients in shock and help identify reversible causes during cardiac arrest. The use of the FAST in pediatric blunt abdominal trauma remains nuanced - its proper use requires an integration with clinical findings and an appreciation of its limitations. POCUS has been shown to enhance safety and efficacy of procedures such as nerve blocks, incision & drainage, and intravenous access. Integrating POCUS into pathways for conditions such as intussusception and testicular torsion expedites downstream care. SUMMARY: POCUS enhances diagnostic efficiency and management in pediatric patients arriving at the ED with undifferentiated shock, cardiac arrest, or trauma. Additionally, POCUS improves procedural success and safety, and is integral to clinical pathways for expediting definitive care for various pediatric emergencies. Future research should continue to focus on the impact of POCUS on patient outcomes, ensuring user competency, and the expansion of POCUS into diverse settings.

Coarctation of the Aorta in Adolescence: Significance of Detailed Cardiac Examination in Pediatric Hypertension.

ABSTRACT: Although coarctation of the aorta (CoAo) is a congenital anomaly, it can pose a diagnostic challenge in those presenting beyond neonatal period, as some patients can remain asymptomatic until complications of hypertension develop later in life. Careful physical examination can play an important role in timely diagnosis and prevention of complications.We present 2 cases of adolescents with undiagnosed CoAo who both presented with nonspecific headaches and hypertension. Both were initially misdiagnosed as essential hypertension until careful detailed physical examination later detected weak/absent femoral pulses and discrepancy in upper and lower limb blood pressures. These findings raised the clinical suspicion of CoAo, which was confirmed on further investigations.Our cases highlight the importance of considering CoAo in the differential diagnosis of hypertension in adolescents. These cases also stress the significance of detailed cardiac examination including 4-limb blood pressure and femoral pulses in a patient presenting to the emergency department with high blood pressure irrespective of the primary complaint.

Building Emergency Medicine Trainee Competency in Pediatric Musculoskeletal Radiograph Interpretation: A Multicenter Prospective Cohort Study.

OBJECTIVES: As residency programs transition from time- to performance-based competency standards, validated tools are needed to measure performance-based learning outcomes and studies are required to characterize the learning experience for residents. Since pediatric musculoskeletal (MSK) radiograph interpretation can be challenging for emergency medicine trainees, we introduced Web-based pediatric MSK radiograph learning system with performance endpoints into pediatric emergency medicine (PEM) fellowships and determined the feasibility and effectiveness of implementing this intervention. METHODS: This was a multicenter prospective cohort study conducted over 12 months. The course offered 2,100 pediatric MSK radiographs organized into seven body regions. PEM fellows diagnosed each case and received feedback after each interpretation. Participants completed cases until they achieved a performance benchmark of at least 80% accuracy, sensitivity, and specificity. The main outcome measure was the median number of cases completed by participants to achieve the performance benchmark. RESULTS: Fifty PEM fellows from nine programs in the US and Canada participated. There were 301 of 350 (86%) modules started and 250 of 350 (71%) completed to the predefined performance benchmark during the study period. The median (interquartile range [IQR]) number of cases to performance benchmark per participant was 78 (60-104; min = 56, max = 1,333). Between modules, the median number of cases to achieve the performance benchmark was different for the ankle versus other modules (ankle 366 vs. other 76; difference = 290, 95% confidence interval [CI] = 245 to 335). The performance benchmark was achieved for 90.7% of participants in all modules except the ankle/foot, where 34.9% achieved this goal (difference = 55.8%, 95% CI = 45.3 to 66.3). The mean (95% CI) change in accuracy, sensitivity, and specificity from baseline to performance benchmark was +14.6% (13.4 to 15.8), +16.5% (14.8 to 18.1), and +12.6% (10.7 to 14.5), respectively. Median (IQR) time on each case was 31.0 (21.0-45.3) seconds. CONCLUSIONS: Most participants completed the modules to the performance benchmark within 1 hour and demonstrated significant skill improvement. Further, there was a large variation in the number of cases completed to achieve the performance endpoint in any given module, and this impacted the feasibility of completing specific modules.