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.

Development of a Consensus-Based Definition of Focused Assessment With Sonography for Trauma in Children.

Importance: The wide variation in the accuracy and reliability of the Focused Assessment With Sonography for Trauma (FAST) and the extended FAST (E-FAST) for children after blunt abdominal trauma reflects user expertise. FAST and E-FAST that are performed by experts tend to be more complete, better quality, and more often clinically valuable. Objective: To develop definitions of a complete, high-quality, and accurate interpretation for the FAST and E-FAST in children with injury using an expert, consensus-based modified Delphi technique. Design, Setting, and Participants: This consensus-based qualitative study was conducted between May 1 to June 30, 2021. It used a scoping review and iterative Delphi technique and involved 2 rounds of online surveys and a live webinar to achieve consensus among a 26-member panel. This panel consisted of international experts in pediatric emergency point-of-care ultrasonography. Main Outcomes and Measures: Definitions of complete, high-quality, and accurate FAST and E-FAST studies for children after injury. Results: Of the 29 invited pediatric FAST experts, 26 (15 men [58%]) agreed to participate in the panel. All 26 panelists completed the 2 rounds of surveys, and 24 (92%) participated in the live and asynchronous online discussions. Consensus was reached on FAST and E-FAST study definitions, and the panelists rated these 5 anatomic views as important and appropriate for a complete FAST: right upper-quadrant abdominal view, left upper-quadrant abdominal view, suprapubic views (transverse and sagittal), and subxiphoid cardiac view. For E-FAST, the same FAST anatomic views with the addition of the lung or pneumothorax view were deemed appropriate and important. In addition, the panelists rated a total of 32 landmarks as important for assessing completeness. Similarly, the panelists rated 14 statements on quality and 20 statements on accurate interpretation as appropriate. Conclusions and Relevance: This qualitative study generated definitions for complete FAST and E-FAST studies with high image quality and accurate interpretation in children with injury. These definitions are similar to those in adults with injury and may be used for future education, quality assurance, and research. Future research may focus on interpretation of trace volumes of abdominal free fluid and the use of serial FAST.

Variability in Point-of-Care Lung Ultrasound Findings in Pediatric COVID-19 Patients: A Multicenter Case Series.

ABSTRACT: Point-of-care ultrasound (POCUS) has been described as a useful tool for identification of coronavirus disease 2019 (COVID-19) in adults and children. Although several case reports describe POCUS findings in children with COVID-19, to our knowledge, there have been no published multicenter case series describing the large heterogeneity in lung POCUS findings in pediatric COVID-19. This series includes 7 symptomatic patients with COVID-19 who had a lung POCUS performed at 6 institutions by pediatric emergency attendings and fellows. The findings were variable, ranging from no findings to the appearance of B-lines, pleural abnormalities, consolidations, and a pleural effusion. Further studies are needed to improve our understanding, characterization, and prognostic correlation of POCUS findings in this novel disease in children.

Assessing the Utility of Urine Testing in Febrile Infants 2 to 12 Months of Age With Bronchiolitis.

BACKGROUND: The utility of testing for urinary tract infection (UTI) in febrile infants with bronchiolitis is indeterminate. OBJECTIVE: The objective of this study was to investigate if the incidence of UTIs in febrile infants 2 to 12 months of age with bronchiolitis is higher than the presumed incidence of asymptomatic bacteriuria and determine risk factors associated with UTIs in this population. METHODS: This prospective multicenter cross-sectional study was conducted in the emergency departments of 6 children's hospitals between November 2011 and June 2015. We obtained a convenience sample of febrile infants with bronchiolitis 2 to 12 months of age who were tested for UTI. Patient characteristics analyzed included age, maximum temperature, duration of fever, ethnicity, sex, and circumcision status. RESULTS: A total of 442 patients (including 86 from a previously published pilot study) were enrolled. Mean age was 5.5 months, 65.2% were Latino, 50.9% were male, and 27.6% of male infants were circumcised. Urinary tract infections were found in 33 patients (7.69%, binomial; 95% confidence interval [CI], 5.19%-10.33%). Urinary tract infections were not related to age, height of temperature, duration of fever, or ethnicity. Uncircumcised males were significantly more likely to have UTIs than circumcised males (7.64% vs 0%, P = 0.03). Odds ratios (ORs) were lower for circumcised males but not uncircumcised males when compared with females (OR, 0.12; CI, 0.0-0.71; P = 0.01 vs OR, 0.77; CI, 0.33-1.74; P = 0.64). CONCLUSIONS: Febrile infants 2 to 12 months of age with bronchiolitis have a clinically significant incidence of UTI, suggesting that UTI evaluation should be considered in these patients.

Ultrasound-guided placement of peripherally inserted intravenous catheters increase catheter dwell time in children.

OBJECTIVE: To compare the dwell times of ultrasound-guided and non-ultrasound-guided short peripheral intravenous catheters in hospitalized children. METHODS: This was a retrospective analysis of data from 256 ultrasound-guided and 287 traditional peripheral intravenous catheters placed in hospitalized children between 1 September2016 and 31 October 2016 at a free-standing children's hospital with a 10-member vascular access team. A two-sample independent t test and Kaplan-Meier estimator were used to assess differences in dwell times between the ultrasound-guided peripheral intravenous catheters and non-ultrasound-guided peripheral intravenous catheters. Child age, peripheral intravenous catheter location, and subjective difficulty of placement were also analyzed. RESULTS: There was a significant difference in mean hours of dwell time for ultrasound-guided versus non-ultrasound-guided peripheral intravenous catheters (96.06 vs 59.39, p < 0.001). Mean increase in dwell time was 36.68 h (95% CI: [24.14-49.22]). Median dwell times (50% probability of survival) for ultrasound-guided and non-ultrasound-guided peripheral intravenous catheters were 118 h (95% CI: [95-137]) and 71 h (95% CI: [61-79]), respectively. None of the additional covariates were significant predictors of dwell time. CONCLUSION: Peripheral intravenous catheters placed using ultrasound-guided methods had a significantly longer dwell time than those placed using non-ultrasound-guided methods in a cohort of hospitalized pediatric patients. This is in line with the findings in the adult literature and may suggest a need to increase the use of ultrasound-guided method for peripheral intravenous catheter placement in pediatric practice.

Evaluating Changes in Diagnostic Accuracy of Ultrasound for Appendicitis: Does Practice Make Perfect?

BACKGROUND: Ultrasound (US) is the preferred method of initial evaluation for appendicitis in pediatrics. However, limited accuracy of US for appendicitis is an obstacle to implementation of US-first protocols at facilities less experienced with US. OBJECTIVES: The primary objective was to demonstrate changes in diagnostic accuracy of US for appendicitis over time, after implementation of an US-first protocol. Secondary objectives included evaluating trends in utilization and factors associated with accuracy of US. METHODS: We reviewed 5 years of pediatric emergency department encounters that included US evaluations for appendicitis. The primary outcome was conclusive US (fully visualized normal appendix or unequivocal appendicitis) vs. equivocal US (partially visualized or nonvisualized appendix). We also analyzed rates of conclusive US over time; accuracy, sensitivity, and specificity of US for appendicitis; and associations of US accuracy with patient gender, body mass index, and ultrasonographer's experience. RESULTS: A conclusive US report was found in 267 of 1058 encounters (25.2%); overall accuracy rate was 24.5%. Over 5 years, the diagnostic accuracy of US for appendicitis improved significantly from 13.9% to 31.5% (p = 0.001). Overall sensitivity was 80.7% and specificity was 77.6%. Male gender and dedicated US of the appendix were significantly associated with conclusive US (ps < 0.001). Higher body mass index was significantly associated with equivocal US (p < 0.001). Ultrasonographer experience was not significantly associated with conclusive US (p = 0.22). CONCLUSIONS: An US-first imaging protocol for appendicitis in children shows chronologic improvement in diagnostic accuracy. This may provide encouragement to facilities using computed tomography-based diagnostic protocols to implement US-first protocols to reduce childhood radiation exposure.

The Utility of Cranial Ultrasound for Detection of Intracranial Hemorrhage in Infants.

OBJECTIVE: The objective of this study was to evaluate the sensitivity and specificity of cranial ultrasound (CUS) for detection of intracranial hemorrhage (ICH) in infants with open fontanels. METHODS: This was a retrospective study of infants younger than 2 years who had a CUS performed for the evaluation of potential ICH. We excluded patient with CUSs that were done for reasons related to prematurity, transplant or oncologic evaluations, routine follow-up or preoperative screen, or congenital and known perinatal anomalies. Two clinicians independently classified each of the patients with ICH into significant or insignificant based on the radiology reports. RESULTS: Of 4948 CUS studies performed during the 5-year study period, 283 studies fit the inclusion criteria. Patient age ranged from 0 to 458 days, with a median of 33 days. There were 39 total cases of ICH detected, with 27 significant bleeds and 12 insignificant bleeds. Using computed tomography, magnetic resonance imaging, or clinical outcome as criterion standard, the overall ultrasound sensitivity and specificity for bleed were 67% (confidence interval [CI], 50%-81%) and 99% (CI, 97%-100%), respectively. For those with significant bleeds, the overall sensitivity was 81% (CI, 62%-94%), and for those with insignificant bleeds, it was 33% (CI, 1%-65%). CONCLUSIONS: The sensitivity of CUS is inadequate to justify its use as a screening tool for detection of ICH in young infants.

Child With Red Eye and Blurry Vision.

Point-of-care ocular ultrasound can provide the clinician with more information about potential intraorbital and extraocular pathology, especially in cases when direct visualization of the eye is limited. This case report describes the findings in a pediatric patient who presented with a 1-month history of eye injection and worsening blurry vision. After point-of-care ultrasound demonstrated abnormal debris in the posterior vitreous cavity, subsequent evaluation revealed a diagnosis of pars planitis.

The use of ultrasound for peripheral IV placement by vascular access team nurses at a tertiary children's hospital.

PURPOSE: Children receiving treatment in the hospital frequently require intravenous (IV) access. Placement of short peripheral catheters can be painful and challenging especially in those children who have difficult access. Many children's hospitals have teams of specialized vascular access nurses experienced in peripheral catheter insertion, and at times use vein visualization devices, including ultrasound (US), to assist in peripheral IV placement. Our objectives were to describe the prevalence and success rate of US-guided peripheral IV placement by vascular access team nurses at a single tertiary children's hospital. METHODS: We retrospectively reviewed quality assurance data kept by our institution's vascular access team between February, 2014 and March, 2014. Data extracted included: age, gender, number of attempts, if difficult, if ultimately successful and modality used to aid IV placement. Descriptive statistics and chi-square tests were used to analyze and report data. RESULTS: There were 1111 patient-nurse encounters reported for peripheral IV placement over a six-week period, and a total of 1579 attempts. Ultimately 84% of the patients had successful IV placement. Overall, visualization and palpation was the most frequently used technique (50.1%), followed by near-infrared light (40.6%), US (8.0%), and transillumination (1.3%). The success rate of US (60% overall and 59.2% difficult) was not significantly different from other advanced visualization techniques. CONCLUSIONS: Vascular access team nurses use US infrequently for peripheral IV placement, including in children with difficult access. Methods to increase its skillful use in difficult access patients and improve successful IV placements should be explored.

Point-of-Care Thoracic Ultrasonography in the Diagnosis and Management of Kaposiform Lymphangiomatosis.

Kaposiform lymphangiomatosis is a generalized lymphatic disorder complicated by consumptive coagulopathy and pericardial and pleural effusions. We present the case of a 13-year-old female adolescent given a diagnosis of a large pleural effusion by point-of-care thoracic ultrasonography, which led to further evaluation and diagnosis of this rare disorder. We review the use of point-of-care thoracic ultrasonography for the diagnosis of pleural effusion.

Point-of-Care Ultrasound Diagnosis of Diaphragmatic Hernia in an Infant With Respiratory Distress.

Neonatal respiratory distress is an emergent condition with a wide differential diagnosis. A 12-day-old newborn presented to the emergency department in respiratory distress. Point-of-care ultrasound allowed clinicians to rapidly exclude cardiac disease and pneumothorax as possible causes of the patient's respiratory distress, and expedited the identification of congenital diaphragmatic hernia. The ultrasound findings and technique, epidemiology, pathophysiology, and radiological diagnosis of congenital diaphragmatic hernia are reviewed.

Learning Curves for Ultrasound Assessment of Lumbar Puncture Insertion Sites: When is Competency Established?

BACKGROUND: Ultrasound (US) can be used to improve lumbar puncture (LP) success. How to achieve competency in LP US has not been defined. Cumulative sum statistics (CUSUM) characterized competency acquisition in other skills. OBJECTIVES: Identify the learning curve for 80% success rate in LP US insertion site (IS) identification among pediatric emergency medicine fellows. METHODS: This prospective study took place in a single pediatric emergency department. Fellows with limited ultrasound experience received didactics, training, and three proctored examinations. Skills were evaluated in three 2-h sessions: using US, subjects identified LP ISs on a convenience sample of patients ages 0-20 years old. Subjects' IS markings were compared to markings by an expert, an emergency US fellowship-trained attending. Successful IS identification was defined as markings within 2 mm or 5 mm of the expert mark in infants and older children, respectively. A second expert marked 17 cases for interrater agreement. CUSUM was used to analyze individual learning curves. RESULTS: Five fellows evaluated 72 patients (mean age 11.4 years [SD = 4, range 3-20], mean body mass index 20.5 [SD = 4.4, range 13.1-37.7]) over a 3-month period. Mean number of attempts per fellow was 14.4 ± 3.1 (R 11-19); mean time to landmark identification was 72 ± 46 s (R 27-240). The two experts demonstrated 100% observed agreement. Aggregate success rate for all fellows was 75% (54/72). Four fellows showed learning curves that trended toward, but did not achieve, the acceptable success rate of 80%. CONCLUSIONS: Nineteen attempts are insufficient among fellows to achieve competency in US-guided LP IS identification.

Assessing the Utility of Urine Testing in Febrile Infants Aged 2 to 12 Months With Bronchiolitis.

OBJECTIVES: The aims of the study were to investigate whether the prevalence of urinary tract infections (UTIs) in febrile infants aged 2 to 12 months with bronchiolitis is higher than the presumed prevalence of asymptomatic bacteriuria (1%) in similarly aged patients and thus to determine whether UTI testing is necessary for these patients. METHODS: This was a prospective cohort study in which we enrolled a convenience sample of febrile infants aged 2 to 12 months with a clinical diagnosis of bronchiolitis. All patients were seen in the emergency department at a large children's hospital between November 1, 2011 and April 15, 2012, had reported or documented fever higher than 38°C, and had urine collected for determination of the presence of UTI. After the conclusion of enrollment, a chart review was conducted to assess missed cases. RESULTS: Positive urine cultures were found in 6/90 (6.7%) patients (confidence interval, 2.5%-13.9%). The positive urine cultures and urinalysis results were found in 4/90 (4.5%) patients (confidence interval, 1.2%-11%). CONCLUSIONS: In our patient population, a significant proportion of infants aged 2 to 12 months who present with bronchiolitis and fever have a concurrent UTI. Obtaining a urine specimen for UTI testing should be considered in infants aged 2 to 12 months with bronchiolitis and fever. A larger multicenter study is needed to further assess the risk factors for UTIs in this patient population.

Web-based teaching in point-of-care ultrasound: an alternative to the classroom?

OBJECTIVES: To evaluate two educational methods for point-of-care ultrasound (POC US) in order to: 1) determine participant test performance and attitudes in using POC US and 2) compare cost and preparation time to run the courses. METHODS: This was a pilot study conducted at a county teaching hospital. Subjects were assigned to participate in either a large group course with live classroom lectures (Group A) or a group asked to watch 4.5 hours of online prerecorded lectures (Group B). Both groups participated in small-group hands-on training after watching the lectures. Both groups took a pre- and post-course exam, and completed course surveys. Cost and time spent running the courses were also compared. RESULTS: Forty-seven physicians participated in the study. The pre-test and post-test scores between the two groups did not differ significantly. Of those with prior ultrasound experience, the majority of both groups preferred to continue classroom-based teaching for future courses. Interestingly, in the groups who had no ultrasound experience prior to their course participation, there was a higher percentage who preferred web-based teaching. Lastly, Group B was shown to have the potential to take less preparatory time when compared to Group A. CONCLUSION: A web-based curriculum in POC US appears to be a promising and potentially time saving alternative to live classroom lectures and seems to offer similar educational benefits for the postgraduate learner.