Point-of-Care Ultrasound and the Discovery of Pulmonary Arterial Hypertension in a Teenager.

ABSTRACT: We present a case of a teenage patient with new-onset cardiac symptoms discovered to have primary pulmonary arterial hypertension. Point-of-care ultrasound used early in the patient's presentation identified significant right-sided heart dilatation and dysfunction despite the patient's relatively unrevealing physical examination. This article emphasizes the utility of performing focused cardiac ultrasound in pediatric patients early in their presentation. We briefly review focused cardiac ultrasound technique and highlight relevant literature.

Cardiac point-of-care ultrasound reveals unexpected, life-threatening findings in two children.

BACKGROUND: The diagnosis of pericardial effusion with cardiac tamponade can at times be elusive in pediatric patients since it is relatively uncommon. Point-of-care ultrasound (POCUS) can readily be performed at the bedside to assess for the presence of a pericardial effusion, tamponade, and can occasionally yield unexpected results. CASE PRESENTATION: Two cases where POCUS unexpectedly identified pericardial effusions, with one patient who also had an anterior mediastinal mass. CONCLUSIONS: Though underutilized, cardiac POCUS in children can be immediately life-saving and drastically change the clinical management at the patient's bedside.

Interpretation Accuracy and Interrater Agreement of Pediatric Skin and Soft Tissue Point-of-Care Ultrasound Images among Residents and Faculty.

BACKGROUND: Point-of-care ultrasound (POCUS) is commonly used to facilitate care in the emergency department. Acquired images are often reviewed by local experts for educational and quality assurance purposes. However, no published study has examined the accuracy and reliability of POCUS image interpretation by multiple reviewers. OBJECTIVES: We studied the accuracy and interrater agreement among expert and trainee reviewers of prerecorded pediatric skin and soft tissue (SST) POCUS images. METHODS: POCUS faculty and emergency medicine (EM) residents blindly reviewed deidentified pediatric SST POCUS images and indicated whether a drainable fluid collection was present, absent, or indeterminate. This was then compared with the gold standard based on discharge diagnoses and telephone follow-up. Images rated as indeterminate were excluded from the initial analysis. Sensitivity analysis assuming indeterminate answers were inaccurate was subsequently conducted. RESULTS: In phase 1, 6 pediatric EM POCUS directors reviewed 168 images. The overall accuracy was 79.7% (range 66.1-86.0%). The mean Cohen's kappa was 0.58 (range 0.24-0.84). Sensitivity analysis yielded an overall accuracy of 71.3% (range 56.5-76.9%) and a Cohen's kappa of 0.43 (range 0.20-0.59). In phase 2, 6 general EM POCUS faculty and 20 EM residents reviewed 120 images. The overall accuracy among residents was 72.2% (range 51.4-84.7%) and among faculty was 83.6% (range 77.9-88.8%). Sensitivity analysis yielded an overall resident accuracy of 63.0% (range 49.5-80.7) and an overall faculty accuracy of 73.9% (range 67.0-79.8%). Fleiss' kappa was 0.322 for residents and 0.461 for faculty. CONCLUSIONS: We found moderate accuracy and fair to good interrater agreement among POCUS faculty and EM residents reviewing pediatric SST POCUS images.

Point-of-Care Ultrasound for the Pediatric Hospitalist's Practice.

Point-of-care ultrasound (POCUS) has the potential to provide real-time valuable information that could alter diagnosis, treatment, and management practices in pediatric hospital medicine. We review the existing pediatric POCUS literature to identify potential clinical applications within the scope of pediatric hospital medicine. Diagnostic point-of-care applications most relevant to the pediatric hospitalist include lung ultrasound for pneumothorax, pleural effusion, pneumonia, and bronchiolitis; cardiac ultrasound for global cardiac function and hydration status; renal or bladder ultrasound for nephrolithiasis, hydronephrosis, and bladder volumes; soft tissue ultrasound for differentiating cellulitis from abscess; and procedural-guidance applications, including line placement, lumbar puncture, and abscess incision and drainage. We discuss POCUS applications with reviews of major pathologic findings, research gaps, the integration of POCUS into practice, and barriers to implementation.

Consensus Core Point-of-care Ultrasound Applications for Pediatric Emergency Medicine Training.

BACKGROUND: Pediatric emergency medicine (PEM) physicians have variably incorporated point-of-care ultrasound (POCUS) into their practice. Prior guidelines describe the scope of POCUS practice for PEM physicians; however, consensus does not yet exist about which applications should be prioritized and taught as fundamental skills for PEM trainees. Members of the PEM POCUS Network (P2Network) conducted a consensus-building process to determine which applications to incorporate into PEM fellowship training. METHODS: A multinational group of experts in PEM POCUS was recruited from the P2Network and greater PEM POCUS community if they met the following criteria: performed over 1,000 POCUS scans and had at least 3 years of experience teaching POCUS to PEM fellows, were a local academic POCUS leader, or completed a formal PEM POCUS fellowship. Experts rated 60 possible PEM POCUS applications for their importance to include as part of a PEM fellowship curriculum using a modified Delphi consensus-building technique. RESULTS: In round 1, 66 of 92 (72%) participants responded to an e-mail survey of which 48 met expert criteria and completed the survey. Consensus was reached to include 18 items in a PEM fellowship curriculum and to exclude two items. The 40 remaining items and seven additional items were considered in round 2. Thirty-seven of 48 (77%) experts completed round 2 reaching consensus to include three more items and exclude five. The remaining 39 items did not reach consensus for inclusion or exclusion. CONCLUSION: Experts reached consensus on 21 core POCUS applications to include in PEM fellowship curricula.

Comparison of Ultrasound Guidance vs. Clinical Assessment Alone for Management of Pediatric Skin and Soft Tissue Infections.

BACKGROUND: Point-of-care ultrasound (POCUS) can potentially help distinguish cellulitis from abscess, which can appear very similar on physical examination but necessitate different treatment approaches. OBJECTIVE: To compare POCUS guidance vs. clinical assessment alone on the management of pediatric skin and soft tissue infections (SSTI) in the emergency department (ED) setting. METHODS: Children ages 6 months to 18 years presenting to participating EDs with SSTIs ≥ 1 cm were eligible. All treatment decisions, including use of POCUS, were at the discretion of the treating clinicians. Patients were divided into those managed with POCUS guidance (POCUS group) and those managed using clinical assessment alone (non-POCUS group). Primary outcome was clinical treatment failure at 7-10 days (unscheduled ED return visit or admission, procedural intervention, change in antibiotics therapy). Secondary outcomes were ED length of stay, discharge rate, use of alternative imaging, and need for procedural sedation. POCUS utility and impact on management decisions were also assessed by treating clinicians. RESULTS: In total, 321 subjects (327 lesions) were analyzed, of which 299 (93%) had completed follow-up. There was no significant difference between the POCUS and non-POCUS groups in any of the primary or secondary outcomes. Management plan was changed in the POCUS group in 22.9% of cases (13.8% from medical to surgical, 9.1% from surgical to medical). Clinicians reported increased benefit of POCUS in cases of higher clinical uncertainty. CONCLUSIONS: Use of POCUS was not associated with decreased ED treatment failure rate or process outcomes in pediatric SSTI patients. However, POCUS changed the management plan in approximately one in four cases.

Icterus and abdominal pain: an unexpected, rare sonographic finding in a Peruvian Emergency Department.

BACKGROUND: The use of point-of-care ultrasound (POCUS) has become increasingly important in resource-limited settings. It can rapidly diagnose both tropical infectious diseases and more common pathology at the bedside. In these practice settings, POCUS can have a significant impact on management strategies and patient care. Ultrasonography has been the gold standard for the diagnosis and staging of Echinococcus disease. However, even in the "classic" clinical scenario and setting, the clinician must maintain a broad differential diagnosis. Point-of-care ultrasound can be helpful in performing the rapid diagnosis and therefore direct appropriate treatment strategies based on the results. CASE PRESENTATION: We present a case of a 27-year-old woman presenting to an emergency department in Peru with jaundice and abdominal pain. Initially given the region of her origin, the working diagnosis was an Echinococcus cyst. However, when POCUS was performed, the findings were not consistent with hydatid disease. Ultimately, surgical pathology revealed a choledochal cyst, a rare finding in adulthood. CONCLUSIONS: This case initially appears as a "classic" finding of Echinococcus disease. It is important for the clinician sonographer to appreciate the features consistent with Echinococcus cysts and distinguish from those features that are more consistent with other pathology.

Cerebral tissue oximetry levels during prehospital management of cardiac arrest - A prospective observational study.

INTRODUCTION: Near-infrared spectroscopy (NIRS) enables continuous monitoring of regional oximetry (rSO2). The aim of this study was to describe dynamics of regional cerebral oximetry levels during out of hospital cardiac arrest (OHCA) resuscitation, specifically around the time of restoration of spontaneous circulation (ROSC). METHODS: This prospective observational study was performed in the prehospital setting during cardio-pulmonary resuscitation (CPR) of OHCA patients. In the three-year study period, two-hundred eighty OHCA's were responded to; rSO2 was continuously measured throughout CPR and after attaining ROSC. RESULTS: Final data analysis included 53 patients. Continuous rSO2dynamics were described and data was compared amongst ROSC (22 cases) and no-ROSC (31 cases) groups. Initial rSO2levels were below 15% (not detectable) in both groups. With ongoing CPR, rSO2levels were higher in the ROSC group (median 22% vs. 14% in no-ROSC group, p = 0.030). Until ROSC, rSO2levels were higher throughout CPR before ROSC (mean maximal value 47% at ROSC vs. 31% no-ROSC, p < 0.01). Furthermore, we found a pattern of significant, rapid and sustained rise in rSO2levels minutes prior to ROSC and normalization thereafter. CONCLUSIONS: Initial rSO2levels during OHCA are generally undetectable by the time EMS teams initiate CPR. With CPR, rSO2levels rise and are higher during CPR in patients who later achieve ROSC. Patients who achieve ROSC exhibit significant, rapid, and sustained rise in rSO2minutes prior to attaining ROSC, and normalization of rSO2 levels thereafter. Persistently low levels of rSO2 during CPR likely portend poor neurologic outcomes.

Measuring the Transrectal Diameter on Point-of-Care Ultrasound to Diagnose Constipation in Children.

OBJECTIVES: The aim of the study was to determine the test performance characteristics for point-of-care ultrasound in diagnosing constipation, through measuring the transrectal diameter (TRD). We sought to develop a sonographic numeric cutoff value for diagnosing constipation. Secondary objectives included whether certain patient characteristics would affect the TRD measurement and the accuracy of the TRD in comparison with abdominal radiographs. METHODS: We conducted a prospective, cohort study of pediatric patients between the age of 4 and 17 years, presenting with abdominal pain to a pediatric emergency department. A point-of-care ultrasound was performed with a phased array transducer (5-1 MHz). In addition to a thorough history and physical examination, each patient was administered with the Rome III questionnaire, which served as the criterion standard for the diagnosis of constipation. Radiographs and enema treatments were performed at the discretion of the treating attending physician. When enemas were administered, a postenema TRD measurement was obtained. RESULTS: Fifty subjects were "constipated" or "nonconstipated," as determined by the Rome III questionnaire. A TRD cutoff of 3.8 cm or greater correlated with the diagnoses of constipation (P < 0.001). Ultrasound-diagnosed constipation had a sensitivity of 86% (95% confidence interval, 69%-96%), specificity of 71% (95% CI, 53%-85%), negative predictive value of 0.87 (95% CI, 0.68-0.95), and positive predictive value of 0.70 (95% CI, 0.52-0.84). The TRD measurement was not affected by patient physical characteristics or bladder fullness. In 7 patients, an enema was administered. There was an overall mean (SD) decrease of 1.22 (1.62) cm; this difference was not statistically significant (P = 0.093). Abdominal radiographs were performed in 25 patients. When compared with abdominal radiographs, ultrasound had a higher specificity of 71% (95% CI, 53%-85%), but this difference was not statistically significant. Ultrasound performed similarly to abdominal radiographs with regard to sensitivity 86% (95% CI, 67%-95%), positive predictive value of 0.70 (95% CI, 0.52-0.84), and negative predictive value of 0.87 (0.68-0.95). In 22 of 25 patients who received radiographs, the ultrasound diagnosis was the same as the radiologist read of the radiographs. Potentially, 88% of radiographs could have been avoided in these patients. CONCLUSIONS: In pediatric patients with abdominal pain, there is a strong correlation of an enlarged TRD with constipation. Our results suggest that point-of-care ultrasound is a useful adjunct for diagnosing constipation and has the potential to replace the use of abdominal radiographs.

Point-of-Care Ultrasound Integrated Into a Staged Diagnostic Algorithm for Pediatric Appendicitis.

OBJECTIVES: We hypothesized that point-of-care ultrasound (POCUS) is as accurate as radiology-performed ultrasound in evaluating children with clinical concern for appendicitis. As part of a staged approach, we further hypothesized that POCUS could ultimately decrease computed tomography (CT) utilization. METHODS: This was a prospective, convenience sampling of patients aged 2 to 18 years presenting with abdominal pain to a pediatric emergency department. Those patients with prior abdominal imaging, pregnant, or unable to tolerate the examination were excluded. An algorithm was followed: POCUS was first performed, followed by a radiology-performed ultrasound, and then a CT as necessary. The main outcome measure was the accuracy of the POCUS in diagnosing of appendicitis. This was compared with radiology-performed ultrasound. We also examined whether certain patient or clinical characteristics influenced the performance of POCUS. Lastly, we determined the amount by which CT scans were decreased through this staged algorithm. RESULTS: Forty patients were enrolled and underwent a POCUS examination. A total of 16 (40%) had pathology-confirmed appendicitis. Point-of-care ultrasound had a sensitivity of 93.8% (95% confidence interval [CI], 69.7%-98.9%) and specificity of 87.5% (95% CI, 67.6%-97.2%). Radiology-performed ultrasound had a sensitivity of 81.25% (95% CI, 54.3%-95.7%) and specificity of 100% (95% CI, 85.6%-100%). The radiology-performed and POCUS examinations had very good agreement (κ = 0.83, P < 0.0005). Patient characteristics including body mass index did not have an affect on the POCUS. However, POCUS identified all patients with an Alvarado score higher than 6. Overall, the reduction in CT examinations was 55%. CONCLUSIONS: In pediatric patients presenting with clinical concern for acute appendicitis, a staged algorithm that incorporates POCUS is accurate and has the potential to decrease CT scan utilization.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence.

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

Point-of-Care Ultrasonography for the Rapid Diagnosis of Intussusception: A Case Series.

We present a case series describing an infant and a child who presented with abdominal discomfort and their conditions were diagnosed with intussusception by point-of-care ultrasound. These cases illustrate how point-of-care ultrasound led to the expeditious diagnosis of intussusception.

Neonatal Gallstones Serendipitously Discovered by Point-of-Care Ultrasound in the Pediatric Emergency Department.

Cholelithiasis in children was once thought to be uncommon, but the prevalence has increased in recent years. We present a case of a 3-month-old infant brought to the pediatric emergency department for vomiting and increased fussiness. A point-of-care ultrasound was performed to rule out pyloric stenosis but revealed multiple stones within the gallbladder. Ultrasound findings and a review of technique for ultrasound of the gallbladder are presented.

Point-of-Care Ultrasonography for Appendicitis Uncovers Two Alternate Diagnoses.

We present two cases of pediatric patients initially presenting with a clinical suspicion of acute appendicitis. In these cases, point-of-care ultrasonography was performed early in the patient's emergency department course, leading to alternate diagnoses. This article highlights a role for point-of-care ultrasound in the diagnoses of two alternate conditions that clinically mimic appendicitis: Meckel diverticulitis and acute ileocecitis. We offer a brief overview of terminology, relevant literature, and ultrasound scanning technique for the right-lower-quadrant point-of-care ultrasound evaluation.

The Use of Point-of-Care Ultrasound to Evaluate for Intestinal Foreign Bodies in the Pediatric Emergency Department.

We present the use of point-of-care ultrasound to evaluate two patients with examinations concerning for appendicitis who were found to have multiple magnets ingested and subsequent bowel perforations. These cases illustrate the consequences of magnet ingestion as well as the application of point-of-care ultrasound for the identification of intestinal foreign bodies in children.

Change in intraocular pressure during point-of-care ultrasound.

INTRODUCTION: Point-of-care ocular ultrasound (US) is a valuable tool for the evaluation of traumatic ocular injuries. Conventionally, any maneuver that may increase intraocular pressure (IOP) is relatively contraindicated in the setting of globe rupture. Some authors have cautioned against the use of US in these scenarios because of a theoretical concern that an US examination may cause or exacerbate the extrusion of intraocular contents. This study set out to investigate whether ocular US affects IOP. The secondary objective was to validate the intraocular pressure measurements obtained with the Diaton® as compared with standard applanation techniques (the Tono-Pen®). METHODS: We enrolled a convenience sample of healthy adult volunteers. We obtained the baseline IOP for each patient by using a transpalpebral tonometer. Ocular US was then performed on each subject using a high-frequency linear array transducer, and a second IOP was obtained during the US examination. A third IOP measurement was obtained following the completion of the US examination. To validate transpalpebral measurement, a subset of subjects also underwent traditional transcorneal applanation tonometry prior to the US examination as a baseline measurement. In a subset of 10 patients, we obtained baseline pre-ultrasound IOP measurements with the Diaton® and Tono-Pen®, and then compared them. RESULTS: The study included 40 subjects. IOP values during ocular US examination were slightly greater than baseline (average +1.8mmHg, p=0.01). Post-US examination IOP values were not significantly different than baseline (average -0.15mmHg, p=0.42). In a subset of 10 subjects, IOP values were not significantly different between transpalpebral and transcorneal tonometry (average +0.03mmHg, p=0.07). CONCLUSION: In healthy volunteer subjects, point-of-care ocular US causes a small and transient increase in IOP. We also showed no difference between the Diaton® and Tono-Pen® methods of IOP measurement. Overall, the resulting change in IOP with US transducer placement is considerably less than the mean diurnal variation in healthy subjects, or pressure generated by physical examination, and is therefore unlikely to be clinically significant. However, it is important to take caution when performing ocular ultrasound, since it is unclear what the change in IOP would be in patients with ocular trauma.

Point-of-care ultrasonography for the identification of 2 children with optic disc drusen mimicking papilledema.

We present 2 cases of asymptomatic patients who were found to have raised and blurred optic discs on physical examination, suggestive of papilledema. Evaluation in the emergency department revealed 2 well-appearing children with normal vital signs and neurologic evaluation results, without symptoms of increased intracranial pressure. Point-of-care ocular ultrasonography was performed on both children, demonstrating calcification at the optic nerve, which is diagnostic of optic disc drusen. Optic disc drusen is caused by the deposition of calcified axonal debris and is often buried within the optic disc in pediatric patients. It can cause some changes in visual acuity and visual fields, but patients who are otherwise asymptomatic can be easily diagnosed through point-of-care ultrasound, thereby sparing patients an aggressive workup if their clinical picture is otherwise reassuring.

Botfly larva masquerading as periorbital cellulitis: identification by point-of-care ultrasonography.

Myiasis, or the infiltration of the botfly larvae, is a relatively frequent problem encountered by travelers to parts of Latin America. This is a novel case report that documents a Dermatobia hominis infestation of the left facial region with secondary periorbital cellulitis diagnosed by point-of-care ultrasonography.