Qualitative Point-of-Care Ultrasound Enema Management for Constipation.

ABSTRACT: We discuss 10 cases where the qualitative evaluation of hard stool in the rectum with point-of-care ultrasound helped guide enema administration in a pediatric emergency department. Point-of-care ultrasound findings were especially valuable in cases where the presenting symptoms were undifferentiated, a language barrier was present, or the guardian and child denied that constipation was an active problem. When sodium phosphate enema administration was done in the pediatric emergency department, evacuation of the rectal stool burden was observed in most cases before final disposition.

Is it Smoke and Mirrors? Detection of Inferior Vena Cava Thrombus by Focused Cardiac Ultrasound.

ABSTRACT: Inferior vena cava assessment is a standard component of focused cardiac ultrasound, traditionally used to qualify intravascular volume status. In this case series, we demonstrate that pediatric focused cardiac ultrasound can also diagnose inferior vena cava thrombi and masses, while distinguishing them from a potentially benign smoke-like artifact.

Point-of-Care Ultrasound for Pulse Checks in Pediatric Cardiac Arrest: Two Illustrative Cases.

ABSTRACT: Cardiac arrest is an infrequent but high-stakes scenario in pediatrics. Manual central pulse checks are unreliable. Point-of-care ultrasound is a noninvasive technique to visualize the heart and central vessels during resuscitation. We describe 2 cases in which point-of-care ultrasound helped aid management decisions in pediatric cardiac arrest.

The Feasibility of Using Point-of-Care Ultrasound During Cardiac Arrest in Children: Rapid Apical Contractility Evaluation.

INTRODUCTION: Resuscitation guidelines emphasize minimal interruption of compressions during cardiopulmonary resuscitation. Point-of-care ultrasound (POCUS) enables the clinician to visualize cardiac contractility and central artery pulsatility. The apical 4-chamber (A4), subxiphoid (SX), and femoral artery views may be used when defibrillator pads or active compressions preclude parasternal cardiac views. We hypothesized that clinicians can rapidly obtain interpretable POCUS views in healthy children from the A4, SX, and femoral positions. METHODS: A prospective study of pediatric emergency medicine providers in an urban academic hospital was performed. Stable patients of 12 years or younger were scanned. Sonologists were each allotted 10 seconds to acquire A4, SX, and femoral views. Two attempts at each view were allowed. The primary outcome was whether cardiac and femoral artery scans were interpretable for contractility and pulsatility, respectively. The secondary outcome was whether cardiac scans were interpretable for effusion or right ventricular strain. A POCUS expert reviewed scans to confirm interpretability. RESULTS: Twenty-two sonologists performed a total of 50 scans on 22 patients. A view that was interpretable for contractility was obtained on the first attempt in 86% of A4 and 94% of SX scans. A femoral view that was interpretable for pulsatility was obtained on the first attempt in 74% of scans. Expert review was concordant with sonologist interpretation. CONCLUSIONS: Pediatric emergency medicine physicians can obtain interpretable cardiac and central artery views within 10 seconds most of the time. Point-of-care ultrasound has the potential to enhance care during pediatric resuscitation. Future studies on the impact of POCUS pulse checks in actual pediatric resuscitations should be performed.

Ultrasound-Guided Regional Anesthesia of the Femoral Nerve in the Pediatric Emergency Department.

OBJECTIVES: Femur fractures are painful, and use of systemic opioids and other sedatives can be dangerous in pediatric patients. The fascia iliaca compartment nerve block and femoral nerve block are regional anesthesia techniques to provide analgesia by anesthetizing the femoral nerve. They are widely used in adult patients and are associated with good effect and reduced opioid use. Ultrasound (US) guidance of nerve blocks can increase their safety and efficacy. We sought to report on the use and safety of US-guided regional anesthesia of the femoral nerve performed by emergency physicians for femur fractures in 6 pediatric emergency departments. METHODS: Records were queried at 6 pediatric EDs across North America to identify patients with femur fractures managed with US-guided regional anesthesia of the femoral nerve between January 1, 2016, and May 1, 2021. Data were abstracted regarding demographics, injury pattern, nerve block technique, and analgesic use before and after nerve block. RESULTS: Eighty-five cases were identified. Median age was 5 years (interquartile range, 2-9 years). Most patients were male and had sustained blunt trauma (59% low-mechanism falls). Ninety-four percent of injuries were managed operatively. Most patients (79%) received intravenous opioid analgesia before their nerve block. Ropivacaine was the most common local anesthetic used (69% of blocks). No procedural complications or adverse effects were identified. CONCLUSIONS: Ultrasound-guided regional anesthesia of the femoral nerve is widely performed and can be performed safely on pediatric patients by emergency physicians and trainees in the pediatric emergency department.

Serum Myostatin among Excessive Drinkers.

Myostatin acts as a negative regulator of muscle growth. Its effect on fat mass is subject to debate. Among alcoholics, there is a high prevalence of muscle atrophy, and increased fat deposition has been also described in these patients. Myostatin could be involved in these alterations, but its relationships with body composition have been scarcely studied in alcoholic patients. To analyze the behavior of myostatin among alcoholics and its relationship with alcohol intake, liver function, and body composition. We investigated serum myostatin in 59 male patients and 18 controls. Patients were all heavy drinkers admitted with organic complications related to excessive ethanol ingestion. Densitometry analysis was used to assess body composition in 46 patients. Handgrip was assessed in 51 patients. Patients showed lower myostatin values than controls (Z = 3.80; p < 0.001). There was a significant relationship between myostatin and fat at the right leg (ρ = 0.32; p = 0.028), left leg (ρ = 0.32; p = 0.028), trunk (ρ = 0.31, p = 0.038), total fat proport ion (ρ = 0.33, p = 0.026), and gynecoid fat distribution (ρ = 0.40, p = 0.006) but not with lean mass (total lean ρ = 0.07; p = 0.63; trunk lean ρ = 0.03; p = 0.85; lower limbs ρ = 0.08; p = 0.58; upper limbs ρ = 0.04 p = 0.82; android ρ = 0.02; p = 0.88, or gynoid lean mass ρ = 0.20; p = 0.19). In total, 80.43% of patients showed at least one criterion of osteosarcopenic adiposity (OSA). Myostatin was related to OSA obesity. We also observed higher myostatin values among patients with body mass index > 30 kg/m2. Serum myostatin was lower among excessive drinkers, and it was related to increased fat deposition among these patients but not to lean mass, handgrip, or bone mineral density.

Clinical decision rule for obtaining peripheral blood cultures in febrile oncology patients.

BACKGROUND: The utility of peripheral blood cultures in pediatric oncology patients presenting with fever is controversial. A recent systematic review showed that about one in 40 bloodstream infections (BSIs) would be missed if only central venous line (CVL) cultures are obtained. OBJECTIVE: To derive a clinical decision rule for obtaining peripheral blood cultures in pediatric oncology patients presenting to a pediatric emergency department (PED) with fever and a CVL. DESIGN/METHOD: A retrospective chart review was performed on pediatric oncology patients referred to the PED for fever while on therapy. Logistic regression with a random intercept was used to determine independent predictors of BSI and generate a prediction model for obtaining peripheral blood cultures. The decision rule was generated from the best performance as measured by a receiver operator curve. Bootstrapping analysis was performed for internal validation. RESULTS: Predictors that were significant and independently associated with positive peripheral blood cultures included vasopressor support (odds ratio [OR] 16.5, 95% confidence interval [CI]: 2.80-97.71), acute myeloid leukemia (AML) diagnosis (OR 6.9, 95% CI: 1.81-25.98), hypotension (OR 4.0, 95% CI: 1.05-15.17), mucositis (OR 8.2, 95% CI: 2.48-27.01), and maximum temperature in PED ≥39°C (OR 6.6, 95% CI: 2.36-18.20). The area under the curve (AUC) for this model was 0.90 (95% CI: 0.82-0.97) in the derivation cohort and 0.90 (95% CI: 0.81-0.98) after the internal validation. CONCLUSIONS: We derived a clinical prediction model for deciding when to obtain peripheral blood cultures in febrile oncology patients with CVLs on active therapy. Future studies should focus on prospective and external validation of this diagnostic prediction tool.

Ultrasound-assisted Lumbar Puncture for Obese Pediatric Oncology Patients: A Feasibility Study.

Lumbar punctures (LPs) are performed frequently on children with leukemia and lymphoma as part of the standard of care. They are typically performed by pediatric oncology providers for both diagnostic and therapeutic interventions with the aid of moderate or deep sedation. Point-of-Care Ultrasound (POCUS) has emerged as a promising strategy to aid in LP procedures and has been found to be associated with lower number of attempts, and higher success rates. We describe our experience using POCUS to assist with LPs in a subgroup of pediatric oncology patients identified to be procedurally difficult secondary to obesity. This collaboration was well received and resulted in successful LPs in most (8/9) cases. This is a promising modality to improve the delivery of care and LP success in pediatric oncology patients.

Point-of-Care Ultrasound to Evaluate the Acute Abdomen: A Case of Bowel Perforation After Unknown Single Magnet Ingestion.

ABSTRACT: We report the case of a 3-year-old boy who presented to the pediatric emergency department in undifferentiated shock with an acute abdomen. Point-of-care ultrasound revealed viscous perforation with a large amount of free fluid. Intraoperatively, a single magnet was discovered as the likely cause of bowel perforation and the resulting state of shock.

Agreement With Pediatric Suprapatellar Bursa Effusion Assessments by Point-of-Care Ultrasound After Remote Training.

BACKGROUND: The ease of instruction for point-of-care ultrasound (POCUS) to detect suprapatellar bursa (SPB) effusions in pediatric patients is unknown. Considering in person limitations because of the coronavirus pandemic, strategies for POCUS education by remote learning are necessary. METHODS: We crafted a 90-minute didactic training that was presented via a remote learning format. The main outcome of interest was the interobserver reliability of SPB effusion assessment by novice sonologists compared with POCUS faculty. Novice sonologists were pediatric emergency medicine (PEM) fellows. Pediatric emergency medicine fellows interpreted longitudinal SPB examinations obtained in our pediatric emergency department from July 2013 to June 2020. Assessments were performed 2 months after the remote training. Pediatric emergency medicine fellows had a limited experience performing these musculoskeletal scans and were blinded to POCUS faculty and each other's assessments. Interobserver reliability was assessed with Cohen κ coefficient. Second, we calculated test characteristics of knee radiography compared with PEM POCUS faculty determination of SPB effusion by ultrasound. We further explored how effusion size measured by POCUS impacted the diagnosis by knee radiography. A receiver operator characteristic curve of knee radiography diagnosis of SPB effusion was created using the maximal height of SPB effusion by POCUS as the predictor variable. RESULTS: A total of 116 SPB scans in 71 patients were assessed. From this group, 70 scans were of affected knees and 46 scans were of contralateral, asymptomatic knees. The mean age of patients was 10 years and 46% were girl. The prevalence of SPB effusions was 42%. The κ coefficients between the 3 novice sonologists and POCUS faculty were 0.75 (0.62-0.87), 0.77 (0.65-0.89), and 0.83 (0.72-0.93) with 88%, 89%, and 91% agreement. Knee radiography exhibited an overall sensitivity of 65% (95% confidence interval [CI], 46-79%), specificity of 84% (95% CI, 60-97%), negative predictive value of 55% (95% CI, 43-66%), and positive predictive value of 88% (95% CI, 73-96%) to diagnose SPB effusions. The area under the receiver operator characteristic curve was 0.850. With an SPB height cutoff of 4 mm as true positives, radiography had a sensitivity of 81% and a specificity of 83%. CONCLUSIONS: After a remote teleconference didactic session, PEM fellows were able to successfully diagnose SPB effusions using a longitudinal view with substantial interobserver reliability. Knee radiography exhibited limited sensitivity to rule out SPB effusions.

Point-of-Care Ultrasound Curriculum for Endotracheal Tube Confirmation for Pediatric Critical Care Transport Team Through Remote Learning and Teleguidance.

OBJECTIVE: Point-of-care ultrasound (POCUS) is used to manage patients in real time. This study aimed to teach pediatric critical care team members to use POCUS for endotracheal tube (ETT) placement confirmation. A secondary aim was to assess the feasibility of a remote curriculum for this purpose. METHODS: The Kern 6-step approach was used. The curriculum involved virtual didactics, asynchronous learning modules, and remote hands-on sessions using teleguidance with the Butterfly IQ+ probe, Butterfly Network, Inc, Guilford, CT. Participants learned direct and indirect methods of ETT placement confirmation and were directed to practice independently. Outcomes included attitudes and satisfaction, knowledge and skills acquisition and retention, and the use of POCUS on shift. RESULTS: Ten participants completed the curriculum. The average knobology and quiz scores improved by 29.3% and 20.8%, respectively. Improvement was sustained at re-evaluation. Seven of 10 participants performed independent scans. At the 3-month reassessment, most demonstrated mastery of thoracic scans. All required prompting for satisfactory tracheal scans. All felt positively toward POCUS and the remote curriculum. CONCLUSION: Pediatric critical care team members acquired and retained knowledge and skills for POCUS basics and ETT placement confirmation through a remote curriculum. Participants were satisfied with the course. Further studies are needed to reassess longer-term knowledge and skill retention and the effects on patient outcomes.

POCUS Case Review: Considering Superior Mesenteric Artery Syndrome in the Pediatric Emergency Department.

ABSTRACT: We report a case of a 16-year-old adolescent girl who presented to the pediatric emergency department for worsening abdominal pain and vomiting and had significant weight loss over the previous 4 months. Point-of-care ultrasound was used to assess for signs of superior mesenteric artery syndrome.

Evaluation of a Focused Cardiac Ultrasound Protocol in a Pediatric Emergency Department.

OBJECTIVES: The objective of this study was to evaluate the implementation of a focused cardiac ultrasound (FoCUS) protocol in a pediatric emergency department (PED). METHODS: We conducted a cross-sectional, observational, quality improvement project in a PED of an urban tertiary care children's hospital. A FoCUS protocol was collaboratively developed by pediatric cardiology and pediatric emergency medicine. This included a reference document with definitions, indications, image acquisition guidelines, and interpretation expectations. We measured physician-sonographer performance against pediatric cardiologist interpretation of stored cine clips as our reference standard. Focused cardiac ultrasound interpretation was dichotomized for the presence or absence of pericardial effusion, depressed left ventricular function, and chamber size abnormalities. Run charts were used to compare the number FoCUS performed each month and the quality of captured cine clips with those from the previous year. RESULTS: Ninety-two FoCUSs were performed by 34 different physician-sonographers from January to December 2016. The prevalence of FoCUS abnormalities was 18.5%. For pericardial effusion, sensitivity was 100% (95% confidence interval [CI], 48%-100%) and specificity was 99% (95% CI, 94%-100%). For depressed function, sensitivity was 100% (95% CI, 54%-100%) and specificity was 99% (95% CI, 94%-100%). For chamber size abnormalities, sensitivity was 100% (95% CI, 54%-100%) and specificity was 95% (95% CI, 89%-99%). The median number of monthly FoCUS increased from 1 (preprotocol) to 5 (postprotocol), and the median rate of adequate studies increased from 0% to 55%. CONCLUSIONS: We report the collaborative development and successful implementation of a PED FoCUS protocol. Physician-sonographer interpretation of FoCUS yielded acceptable results. Improvements in FoCUS utilization and cine clip adequacy were observed.

Reevaluation of FAST Sensitivity in Pediatric Blunt Abdominal Trauma Patients: Should We Redefine the Qualitative Threshold for Significant Hemoperitoneum?

BACKGROUND: The utility of the focused assessment with sonography in trauma (FAST) examination in hemodynamically stable pediatric blunt abdominal trauma (BAT) patients is controversial.We report our 3-year experience with FAST performance to detect greater than physiologic amounts of intraperitoneal fluid after BAT. METHODS: We performed a retrospective chart review of all FAST examinations performed from July 2015 to June 2018 at a level I pediatric trauma center. The main outcome of interest was the performance of a concerning FAST (cFAST) compared with a computed tomography scan diagnosis for greater than physiologic levels of free fluid (FF) and clinical follow-up. A cFAST was defined by the presence of any FF in the upper abdomen or by a moderate to large amount of FF present in the pelvis. The interobserver reliability of cFASTwas assessed with Cohen κ coefficient. Locations of FF were assessed. RESULTS: A total of 448 FAST cases were eligible for review. The median age was 11 years with 64% male. Thirty-one FAST examinations (6.9%) were positive for some amount of FF; 18 (4.0%) were cFASTs. In the cFAST group, 11 patients (61%) were hemodynamically stable. The cFAST had a sensitivity of 89% (95% confidence interval [CI], 65%-99%), specificity of 99% (95% CI, 98%-100%), positive predictive value of 89% (95% CI, 67%-97%), and negative predictive value of 99% (95% CI, 98%-100%). The positive and negative likelihood ratios were 191 (95% CI, 47-769) and 0.11 (95% CI, 0.03-0.41). The κ coefficient for cFASTwas 0.72 with 86% agreement. Free fluid on cFAST cases was observed in the pelvis (78%), right upper quadrant (44%), and left upper quadrant (44%). CONCLUSIONS: In pediatric BAT patients, a cFAST has acceptable sensitivity and remains a highly specific test to rule in greater than physiologic quantities of FF with confidence.

Sound and Air: Ultrasonographic Measurements of Pediatric Chest Wall Thickness and Implications for Needle Decompression of Tension Pneumothorax.

OBJECTIVES: Needle decompression is potentially life-saving in cases of tension pneumothorax. Although Advanced Trauma Life Support recommends an 8-cm needle for decompression for adults, no detailed pediatric guidelines exist, specifically regarding needle length or site of decompression. METHODS: Point-of-care ultrasound was used to measure chest wall thickness (CWT), the distance between skin and pleural line, bilaterally at the second intercostal midclavicular line and the fourth intercostal anterior axillary line in children of various ages and sizes. Patients were grouped based on Broselow tape weight categories. Measurements were compared between left versus right sides at the 2 anatomic sites. Interclass correlation coefficients were calculated to assess for interrater reliability. RESULTS: A convenience sample of 163 patients from our emergency department was enrolled. For patients who fit into Broselow tape categories, CWT at the second intercostal midclavicular line ranged from 1.11 to 1.91 cm and at the fourth intercostal anterior axillary line ranged from 1.13 to 1.92 cm. In patients larger than the largest Broselow category, 77% had a CWT less than the length of a standard 1.25-in (3.175 cm) catheter. There were no significant differences in the measurements of CWT based on laterality nor anatomic site. CONCLUSIONS: The standard 1.25-in (3.175 cm) catheters are sufficient to treat most tension pneumothoraces in pediatric patients.

Point-of-Care Ultrasound Identification of Right-Sided Cardiac Chamber Collapse Associated With Pericardial Effusions Without Hypotension: A Case Series.

ABSTRACT: We present a case series of 6 children in whom point-of-care ultrasound revealed a pericardial effusion with right atrial or ventricular collapse, and show how this may heighten concern for development of pericardial tamponade and expedite care.

Terminal Ileitis Presenting With a Spontaneously Reduced Ileocolic Intussusception Diagnosed by Point-of-Care Ultrasonography.

Point-of-care ultrasound can be used in the initial workup of ileocolic (IC) intussusception. In general, these lesions require immediate attention and reduction to prevent ischemic bowel injury. We discuss the case of a 27-month-old boy whose IC intussusception was found to spontaneously reduce before a radiology performed ultrasound and the planned air enema reduction procedure. Radiology ultrasound revealed significant inflammatory changes of the terminal ileum. The incidence of spontaneous reduction of IC intussusception is not definitively known. It is important to be familiar with the possibility of spontaneous reduction as children are often referred to academic centers for radiological or surgical reduction. This may also impact the sensitivity of studies that evaluate test characteristics of point-of-care ultrasound compared with radiology performed ultrasound for the diagnosis of IC intussusception. We review the diagnostic technique for IC intussusception and the importance of a prereduction ultrasound immediately before image-guided pressure reduction attempt.

Accuracy of Remote Interpretation of Pediatric Emergency Ultrasound Over Third Generation Networks Across Continents.

OBJECTIVE: This study aimed to evaluate live-stream videos for evaluation of pediatric emergency medicine ultrasound using a third generation (3G) network. METHODS: The interrater reliability of a remote 3G network live-streaming assessment of ultrasound scans for abdominal free fluid, intussusception, and hip effusions was evaluated. Fifty-eight deidentified 6-second video clips in .mp4 format of focused assessment with sonography in trauma scans were downloaded to a laptop. A "bedside" ultrasound expert evaluated each scan and marked it positive or negative for the presence of free fluid. Using an iPhone 3G, Skype was used to connect to the second ultrasound expert located in Addis Ababa, Ethiopia, who reviewed the same scans. When the remote expert returned to the United States, evaluation of the scans was repeated as a second bedside reviewer. Interrater reliability was assessed using the κ statistic and percent agreement. This process was repeated for 44 intussusception scans and 28 hip effusion scans. RESULTS: The κ values (95% confidence interval) between the bedside and remote evaluators for focused assessment with sonography in trauma, intussusception, and hip effusion were 0.748 (0.576-0.92), 0.816 (0.648-0.984), and 0.764 (0.519-1.0), respectively. The percent agreements after adjusting for chance were 86%, 80%, and 88%, respectively. The κ values between the bedside assessments by each evaluator were 0.851 (0.71-0.992), 0.8 (0.616-0.984), and 0.747 (0.479-0.884), respectively. The percent agreements after adjusting for chance were 92%, 81%, and 88%, respectively. CONCLUSIONS: Live-stream video conference using cellphones over 3G network is a feasible and accurate method for consultation of ultrasound scans from a remote location.

Use of Point-of-Care Ultrasound to Assess and Guide Renal Stent Repositioning in the Pediatric Emergency Department.

Point-of-care ultrasound can be used as an assessment tool during the evaluation of children with renal colic. We discuss the case of a 7-year-old girl presenting to the pediatric emergency department with left flank pain, vomiting, and urinary incontinence status post-left renal stent placement. Renal ultrasound revealed ureteral obstruction caused by renal stent displacement. Point-of-care ultrasound performed by pediatric emergency department physicians was used to assess renal stent location, repositioning, and confirmation of the new location by the urology team. We discuss the role of transabdominal point-of-care ultrasound for the evaluation and treatment of the symptomatic child with recent ureter stent placement.

A Multi-institutional Case Series With Review of Point-of-Care Ultrasound to Diagnose Malrotation and Midgut Volvulus in the Pediatric Emergency Department.

Point-of-care ultrasound can be used to screen for malrotation with and without volvulus in the newborn with bilious vomiting, as well as children with unexplained intermittent abdominal pain. We discuss cases where infants and children presenting to pediatric emergency departments with bilious vomiting and/or intermittent abdominal pain were initially screened for small bowel pathology with point-of-care ultrasound. Bedside findings suggestive of midgut volvulus were confirmed with radiology-performed ultrasound or upper gastrointestinal fluoroscopy. In all cases, operative findings were consistent with malrotation of the small bowel with or without evidence of midgut volvulus.