The Current State of Advanced Pediatric Emergency Medicine Point-of-Care Ultrasound (POCUS) Training: Exploring Recent POCUS Fellowship Application Trends and Alternate Training Models.

OBJECTIVES: This study aims to assess the current state of advanced pediatric emergency medicine (PEM) point-of-care ultrasound (POCUS) training in North America, including trends in dedicated PEM POCUS fellowships and alternative advanced POCUS training pathways, to better guide future educational efforts within the field. METHODS: We identified and surveyed 22 PEM POCUS fellowship directors across the United States and Canada regarding PEM POCUS fellowship application trends, potential barriers to pursuing additional POCUS training, and novel training models that meet the needs of the PEM POCUS workforce. RESULTS: The past 5 years have seen a growth in both PEM POCUS fellowship program number and trainee positions available, with a general impression by fellowship directors of a high demand for faculty who have these training credentials. However, there was a discordant drop in fellowship applicants and corresponding match rate in 2022, the cause of which is not clear. A number of programs are offering alternative advanced training options including combined PEM/POCUS fellowships and POCUS tracks within PEM fellowship. CONCLUSION: As POCUS use within PEM evolves, a growing number of advanced training options are being developed. Understanding the motivations and barriers for pursuing advanced POCUS training can help to shape these options going forward, to ensure the experience incorporated within each model meets the needs of trainees, the needs of PEM divisions, and the future needs of our field.

Pediatric Emergency Medicine Ultrasound Fellowship Programs.

Point of care ultrasound (POCUS) has undergone important growth in the field of Pediatric Emergency Medicine (PEM) in the last 14 years and is recognized as a critical diagnostic tool in the care of ill and injured children. The first PEM POCUS fellowship was established in 2010. Now, there are currently 30 ultrasound fellowships that offer training to PEM physicians. In 2014, 46 PEM POCUS leaders established the P2 (PEM POCUS) Network (www.P2network.org). This serves as a platform for sharing expertise, building research collaborations, and offering mentorship in the use of POCUS in PEM. In 2019, a multinational group of experts in PEM POCUS published the first consensus guidelines for prioritizing core applications of POCUS, which are fundamental to PEM fellowship training 1. In 2022, the international research priorities for PEM POCUS were published 2. In the same year, the development of a consensus-based definition of focused assessment with sonography for trauma (FAST) in children was established 3.

Point-of-Care Ultrasound in Children With Medical Complexity.

BACKGROUND AND OBJECTIVES: Children with medical complexity (CMC) have significant chronic health conditions that involve congenital or acquired multisystem disease associated with medical fragility, functional limitations, dependence on technology, and high health care utilization. The objective of this study was to describe the indications, applications, and point-of-care ultrasound (POCUS) findings in this population. METHODS: A descriptive study of POCUS scans performed for clinical purposes in CMC admitted to a single pediatric postacute care hospital. All children for whom a POCUS was requested by a medical team provider were eligible for inclusion. RESULTS: One hundred and four POCUS evaluations were performed for 33 patients. Diagnostic groups for the 33 patients included multiple congenital anomalies (41%), neurologic or neuromuscular (31%), prematurity (25%) and cardiac (3%). Lung, cardiac, and diaphragmatic ultrasound accounted for 57% of POCUS requested. POCUS was abnormal in 82% of diaphragmatic, 73% of lung, and 11% of cardiac ultrasounds. Twenty-three percent of POCUS studies were requested to answer a specific clinical question, 56% for follow-up information, and 21% for baseline evaluation. CONCLUSIONS: Lung, diaphragmatic, and cardiac ultrasound were the most prevalent POCUS studies requested in a postacute care hospital. POCUS may offer an expanded role in such patients and settings by answering clinical questions and by providing baseline and follow-up information.

Ultrasound and Influenza: The Spectrum of Lung and Cardiac Ultrasound Findings in Patients with Suspected Influenza A and B.

In patients with influenza, cardiac and lung ultrasound may help determine the severity of illness and predict clinical outcomes. To determine the ultrasound characteristics of influenza and define the spectrum of lung and cardiac findings in patients with suspected influenza A or B, we conducted a prospective observational study in patients presenting to the emergency department at a tertiary care academic institution. An ultrasound protocol consisting of cardiac, lung and inferior vena cava scans was performed within 6 h of admission. We compared the ultrasound findings in cases with positive and negative influenza polymerase chain reaction, while controlling for comorbidities. We enrolled 117 patients, 41.9% of whom (49/117) tested positive for influenza. In those with influenza, ultrasound confirmed preserved left ventricular and right ventricular (RV) function in 81.3% of patients. The most common cardiac pathology was RV dilation (10.4%), followed by left ventricular systolic dysfunction (8.3%). Patients with negative influenza polymerase chain reaction with RV dysfunction demonstrated higher hospital admission than those those with normal RV function (45.1%, 23/51, vs. 17.9%, 5/28; p = 0.016). B-lines were prevalent in both influenza and non-influenza groups (40.8% and 69.1%, respectively; p = 0.013). Lung consolidation was identified in only 8.25% of patients with influenza. In conclusion, in patients with influenza we were unable to define distinct ultrasound features specific to influenza A or B, suggesting that ultrasound may not be beneficial in diagnosing influenza nor in evaluating its severity.

Global point-of-care ultrasound education and training in the age of COVID-19.

The COVID-19 pandemic has disrupted traditional global point-of-care ultrasound (POCUS) education and training, as a result of travel restrictions. It has also provided an opportunity for innovation using a virtual platform. Tele-ultrasound and video-conferencing are alternative and supportive tools to augment global POCUS education and training. There is a need to support learners and experts to ensure that maximum benefit is gained from the use of these innovative modalities.

Detecting Ventilator-Induced Diaphragmatic Dysfunction Using Point-of-Care Ultrasound in Children With Long-term Mechanical Ventilation.

Long-term mechanical ventilation (MV) is defined as the use of MV for more than 6 hours per day for at least 3 weeks. Children requiring long-term MV include those with neuromuscular disease, central dysregulation, or lung dysfunction. Such children with medical complexity may be at risk for ventilator-induced diaphragmatic dysfunction. Ventilator-induced diaphragmatic dysfunction has been described in adult patients requiring acute MV with ultrasound (US). At this time, diaphragmatic US has not been evaluated in the pediatric post-acute care setting or incorporated into weaning strategies. We present 24 cases of children requiring long-term MV who underwent diaphragmatic US examinations to evaluate for ventilator-induced diaphragmatic dysfunction.

The Use of Point-of-Care Ultrasound to Evaluate Pulsus Paradoxus in Children With Asthma.

Pulsus paradoxus (PP) is defined as a fall of systolic blood pressure of greater than 10 mm Hg during the inspiratory phase of respiration. Measurement of PP is recommended by national and international asthma guidelines as an objective measure of asthma severity but is rarely used in clinical practice. Cardiac point-of-care ultrasound with pulsed wave Doppler imaging measuring respiratory-phasic changes of mitral valve inflow velocities is well described in cardiac tamponade as "sonographic" PP. We present 10 cases of acute asthma presenting to an emergency department showing the finding of sonographic determined PP in the apical 4-chamber view of the heart on pulsed wave Doppler imaging.

Dyspnea in an Otherwise Healthy 18-year-old: The Importance of Point-of-care Ultrasonography.

A healthy 18-year-old male presented to the emergency department with chest pain, palpitations, and dyspnea. His exam was unremarkable; however, point-of-care ultrasound (POCUS) revealed right ventricular strain with a D-sign and enlarged right ventricle. He subsequently reported a history of factor V Leiden. His D-dimer was markedly elevated, and a computed tomography angiogram of the chest demonstrated submassive pulmonary embolism (PE). He was taken to the catheterization lab for directed thrombolysis and was discharged in good condition two days later. Factor V Leiden is the most common genetic cause of venous thromboembolism. POCUS can facilitate rapid diagnosis and risk stratification of patients with acute PE.

Drinking to toxicity: college students referred for emergency medical evaluation.

BACKGROUND: In 2009, a university adopted a policy of emergency department transport of students appearing intoxicated on campus. The objective was to describe the change in ED referrals after policy initiation and describe a group of students at risk for acute alcohol-related morbidity. METHODS: A retrospective cohort of university students during academic years 2007-2011 (September-June) transported to local ED's was evaluated. Data were compared 2 years prior to initiation of the policy and 3 years after and included total number of ED transports and blood or breath alcohol level. RESULTS: 971 Students were transported to local ED's. The mean number of yearly transports 2 years prior to policy initiation was 131 and 3 years after was 236 (56 % increase, p < 0.01). 92 % had a blood or breath alcohol level obtained. The mean alcohol level was 193 mg/dL. Twenty percent of students had alcohol levels greater than 250 mg/dL. CONCLUSIONS: Adoption of a university alcohol policy was followed by a significant increase in ED transports of intoxicated students. College students identified as intoxicated frequently drank to toxicity.

Advance provision of emergency contraception in an urban pediatric emergency department.

STUDY OBJECTIVE: To assess whether a policy and educational intervention in an urban, pediatric emergency department (ED) increases advance provision of emergency contraception (EC) to patients. DESIGN/SETTING/PARTICIPANTS: A pre- and post-intervention, retrospective chart review was conducted in an urban, pediatric ED assessing provider care of sexually active female adolescents and young adults. INTERVENTION/MAIN OUTCOME MEASURES: A policy was instituted recommending that ED providers prescribe EC and provide an educational handout to all sexually active female adolescents and young adults. ED providers were educated about EC and this policy. Charts, subsequently reviewed, included sexually active female patients, age 13-21 years, presenting to the ED status post sexual assault, seeking EC, or with an abdominal, gynecologic, or urologic complaint. Student's t-tests, Pearson's chi-square and Fisher's Exact tests compared pre- and post-intervention provider and patient characteristics and outcomes. RESULTS: The mean age of the patient sample was 18.8 years (SD=1.7), 83% were Black or Hispanic, 43% were previously pregnant, 25% reported not using birth control. Last unprotected sexual intercourse was not documented for 87% of patients presenting with medical complaints. There was no difference in the advance prescribing of EC or the provision of the educational handout to patients pre- (3.3%) or post- (5.6%) intervention (P = 0.73). CONCLUSIONS: Despite a policy and an educational intervention for providers, little change occurred in advance EC prescribing in an urban, pediatric ED. Additionally, many providers were not documenting last unprotected sexual intercourse, potentially missing an opportunity to treat patients with EC at the time of their visit.

Screening emergency department patients for under-immunized adolescents.

Among 200 adolescents presenting to an emergency department in a city with high vaccination coverage, 11 (6%) were seronegative to rubella or varicella. Seronegative adolescents were older and more likely to be immigrants. ED screening for under-immunized adolescents may have a low yield in settings with high vaccine coverage.