Point-of-Care Ultrasound for the Diagnosis of Skull Fractures in Children Younger Than Two Years of Age.

OBJECTIVES: To determine the accuracy of skull point-of-care ultrasound (POCUS) for identifying fractures in children younger than 2 years of age with signs of head trauma, and the ability of POCUS to identify the type and depth of fracture depression. STUDY DESIGN: This was a multicenter, prospective, observational study of children younger than 2 years of age with nontrivial mechanisms of injury and signs of scalp/skull trauma. Patients were enrolled if they underwent computed tomography (CT). Patients underwent clinical evaluation, in addition to a cranial POCUS in the emergency department (ED). From the POCUS examinations, we documented whether fractures were present or absent, their location, characteristics, and depth. POCUS and CT findings were compared to calculate the diagnostic accuracy. RESULTS: We enrolled a convenience sample of 115 of 151 (76.1%) eligible patients. Of the 115 enrolled, 88 (76.5%) had skull fractures. POCUS had a sensitivity of 80 of 88 (90.9%; 95% CI 82.9-96.0) and a specificity of 23 of 27 (85.2%; 95% CI 66.3-95.8) for identifying skull fractures. Agreement between POCUS and CT to identify the type of fracture as linear, depressed, or complex was 84.4% (97 of 115) with a kappa of 0.75 (95% CI 0.70-0.84). CONCLUSIONS: POCUS performed by emergency physicians may identify the type and depth of fractures in infants with local physical signs of head trauma with substantial accuracy. Emergency physicians should consider POCUS as an adjunct to clinical evaluation and prediction rules for traumatic brain injuries in children younger than 2 years of age.

Ability of emergency ultrasonography to detect pediatric skull fractures: a prospective, observational study.

BACKGROUND: Blunt head trauma is a common reason for medical evaluation in the pediatric Emergency Department (ED). The diagnostic work-up for skull fracture, as well as for traumatic brain injury, often involves computed tomography (CT) scanning, which may require sedation and exposes children to often-unnecessary ionizing radiation. OBJECTIVES: Our objective was to determine if bedside ED ultrasound is an accurate diagnostic tool for identifying skull fractures when compared to head CT. METHODS: We present a prospective study of bedside ultrasound for diagnosing skull fractures in head-injured pediatric patients. A consecutive series of children presenting with head trauma requiring CT scan was enrolled. Cranial bedside ultrasound imaging was performed by an emergency physician and compared to the results of the CT scan. The primary outcome was to identify the sensitivity, specificity, and predictive values of ultrasound for skull fractures when compared to head CT. RESULTS: Bedside emergency ultrasound performs with 100% sensitivity (95% confidence interval [CI] 88.2-100%) and 95% specificity (95% CI 75.0-99.9%) when compared to CT scan for the diagnosis of skull fractures. Positive and negative predictive values were 97.2% (95% CI 84.6-99.9%) and 100% (95% CI 80.2-100%), respectively. CONCLUSIONS: Compared to CT scan, bedside ultrasound may accurately diagnose pediatric skull fractures. Considering the simplicity of this examination, the minimal experience needed for an Emergency Physician to provide an accurate diagnosis and the lack of ionizing radiation, Emergency Physicians should consider this modality in the evaluation of pediatric head trauma. We believe this may be a useful tool to incorporate in minor head injury prediction rules, and warrants further investigation.

The impact of implementing the single provider model of emergency medicine in a paediatric hospital: a retrospective cohort analysis.

STUDY OBJECTIVE: The Meyer Pediatric Hospital in Florence, Italy recently implemented the single provider model of emergency medicine. Prior to these changes, patients were triaged to a paediatric surgeon or paediatrician based on the complaint. The authors assess the outcomes of patients evaluated by surgeons prior to this change and compare them with those of patients seen by emergency physicians. METHODS: A retrospective, cohort study was performed reviewing patients seen in the emergency department between 2005 and 2008 for the three most common surgical complaints encountered before the systems change: head trauma, testicular pain and abdominal pain. Outcomes include misdiagnoses, consultation rates, dispositions, imaging, interventions and surgeries. RESULTS: A total of 2415 patient visits were included. Emergency physicians saw more patients (1388 vs 1027) and obtained more consultations (25.6% vs 8.1%) than surgeons. Patients triaged directly to surgeons were more likely to be admitted to the hospital (10.3% vs 7.6%), undergo urgent interventions (9.5% vs 6.7%), undergo surgery (8.0% vs 4.8%), have more radiographic images to evaluate head trauma (12.1% vs 5.3%), be misdiagnosed (1.0% vs 0.3%) and have more plain films for abdominal pain (3.1% vs 1.3%). There is an overall trend towards fewer missed diagnoses by emergency physicians (0.3% vs 0.9%), but this difference is only statistically significant in the abdominal pain subset analysis (p=0.032, combined data p=0.052). CONCLUSIONS: The single provider model of emergency medicine where emergency physicians manage all patients presenting to the emergency department appears to be a safe and efficient model of emergency medical care.