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.

The Impact of Bedside Cardiac Point-of-Care Ultrasound on the Utilization of Cardiology Subspecialty Resources in a Pediatric Emergency Department.

OBJECTIVE: This study sought to determine the impact of cardiac point-of-care ultrasound (cPOCUS) in a pediatric emergency department (ED) on cardiology subspecialty utilization for subjects with chest pain or syncope. Diagnostic yield of cPOCUS and transthoracic echocardiograms (TTEs) for these subjects was also examined. METHODS: A retrospective chart review of subjects presenting to a tertiary pediatric ED with chest pain or syncope 1 year before (2015, pre-cPOCUS group) and 1 year after (2017, cPOCUS group) introduction of cPOCUS was conducted. Subjects aged 2 to 18 years evaluated for these symptoms were included. Those with known heart defects, prior abnormal TTE, or asthma exacerbation at presentation were excluded. In both groups, cardiology subspecialty utilization was assessed by determining whether cardiology referrals, cardiology consultations, or follow-up TTEs were completed. Results of TTEs were reviewed and classified as incidental (no follow-up needed), minor (follow-up needed, but intervention unlikely), moderate (nonurgent intervention needed), and severe (hospitalization/urgent intervention needed). Cardiac point-of-care ultrasound results were compared with any follow-up TTEs. Data were analyzed using χ 2 or Student t test as appropriate. RESULTS: A total of 1230 subjects were analyzed: 595 pre-cPOCUS and 635 cPOCUS group. There was no significant difference in TTEs (42 vs 46), cardiology consultations (36 vs 37), or cardiology referrals (47 vs 37) between groups. Of 67 cPOCUS scans performed, 63 were normal, 3 showed small pericardial effusion, and 2 demonstrated left ventricular dysfunction. Of 88 TTEs in both groups (0.7% subjects), 76 were normal, 5 had incidental, 6 had minor, and 1 had a severe finding present on cPOCUS (0.08% subjects; 95% confidence interval, 0%-0.45%). CONCLUSIONS: The introduction of cPOCUS did not increase cardiology subspecialty utilization in subjects presenting to the pediatric ED with chest pain or syncope. Cardiac point-of-care ultrasound may be useful in evaluating global biventricular systolic function and effusion in this population.

Evaluation of COVID-19-Associated Myocarditis Via Point-of-Care Ultrasound in a Pediatric Patient.

ABSTRACT: Coronavirus disease 2019 (COVID-19)-associated myocarditis has been reported from the onset of the pandemic. The presumed etiology is direct damage to the myocardium from severe acute respiratory syndrome coronavirus 2. Common findings include electrocardiogram abnormalities, elevated cardiac markers, and diminished cardiac function. This can lead to heart failure and cardiogenic shock with resultant poor perfusion. Thus, myocarditis has been recognized as a cause of death in patients with COVID-19. Unfortunately, it is difficult to predict the prevalence of myocarditis in these patients given the relative novelty of the pandemic and the lack of available data. Point-of-care ultrasound (POCUS) has been shown to be a useful modality to investigate lung pathology in patients with COVID-19. Bedside cardiac POCUS can also be used to investigate cardiac pathology. This case describes a pediatric patient with COVID-19 who had evidence of myocarditis on POCUS in the pediatric emergency department.

The effectiveness of a longitudinal ultrasound curriculum for general pediatricians working in a Puerto Rican emergency department: a pilot study.

BACKGROUND: The Hospital Pediatrico Universitario (HOPU) is the principal institution in Puerto Rico offering medical services to the children of the island and the Caribbean. There is limited use of point-of-care ultrasound (PoCUS) in their emergency department (ED) and obtaining an ultrasound through radiology is prohibitively time consuming. The objective of this study is to increase PoCUS knowledge and comfort by the ED physicians in the HOPU pediatric emergency department. RESULTS: Thirteen general pediatricians completed the entire PoCUS course, but only 10 completed both the pre- and post-tests and therefore included in the analysis (N = 10). Pretest scores ranged from 30 to 63.3% with a mean of 41.6% [standard deviation (SD) 9.95]. The posttest scores ranged from 55 to 96%, with a mean of 66.1% (SD 12.26). The mean difference in scores was 24.42% (95% confidence interval 17.9, 30.9) with a significance of p < 0.05 and range of 8.3-36.6%. Physician experience and confidence with each topic improved from baseline. After the course, the majority of the participants (> 70%) had at least some confidence in 5 of the 6 topics. CONCLUSIONS: In EDs with limited resources, a longitudinal PoCUS educational curriculum is effective in improving the knowledge and comfort of physicians with limited PoCUS experience. The effectiveness of scheduled, repeated courses to refresh and refocus participants was highlighted following the unexpected challenges encountered during the course, including multiple natural disasters.