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24 Pediatric-Specic Point of Care US Management
387
Pediatric Abdominal Complaints
Abdominal pain is one of the most common complaints of children presenting to the
emergency department, with appendicitis being the most common surgical diagnosis. Although appendicitis is not exclusive to pediatric patients, the clinical diagnosis in children can be particularly challenging, given the difculty of examining
pre-verbal children, as well as the overlap of symptoms with other, more benign
etiologies. Studies of point-of-care ultrasound for the evaluation of pediatric appendicitis have demonstrated high specicity, thereby making the point-of-care ultrasound a “rule-in” exam [5, 6]. Point-of-care ultrasound diagnoses of pyloric stenosis
and intussusception have also been studied with ndings suggesting the exams can
be learned easily and diagnoses made accurately [7, 8].
Pre-urethral (Bladder Size) Catheterization
The standard of care for obtaining sterile urine from children unable to provide
a clean catch specimen is urethral catheterization. Initial catheterization
attempts may result in a 28% failure rate due to lack of urine in the bladder at
the time of catheterization [9]. Chen, etal. demonstrated an increase in the rate
of successful catheterizations with the use of point-of-care ultrasound prior to
catheterization [9].
Given the frequency of urethral catheterization in pediatric patients, bedside
nurse-use of point-of-care bladder ultrasound may also be an opportunity to improve
care and patient ow and deserves further study.
Head Trauma
In children with head trauma, the presence of a skull fracture is associated with
signicantly increased odds of intracranial injury [10]. Two studies have demonstrated high specicity of point-of-care ultrasound for the evaluation of skull fractures in head-injured children [11, 12].
Musculoskeletal Complaints
Musculoskeletal complaints are common reasons for pediatric emergency care.
Atraumatic leg pain or limp in the pediatric patient can be a manifestation of several
disease processes. Although not specic to the type of effusion, point-of-care ultrasound of the hip can be used to determine if a hip effusion is present and potentially
388
narrow the differential diagnosis [13]. A common mechanism of injury for children
is a “fall on an outstretched hand” (FOOSH), with the pediatric elbow being particularly vulnerable to this mechanism. In the setting of most elbow fractures, hemarthrosis will lead to displacement of the posterior fat pad. Point-of-care ultrasound
has been shown to be a sensitive screening tool for the evaluation of an elevated fat
pad in pediatric patients with upper extremity trauma [14]. In addition, point-ofcare ultrasound may be particularly useful to evaluate for forearm fractures in children with arm pain, but no obvious deformity [15, 16], as well as for assessment of
fracture realignment during fracture reduction [17].
J.R. Marin
FAST
The Focused Assessment with Sonography in Trauma (FAST) is widely accepted as
standard of care in the evaluation of the adult trauma patient. Numerous studies
highlight the accuracy as well as utility of the FAST exam in rapidly identifying
hemoperitoneum. The evidence in pediatric patients is not as robust. While the specicity is quite high (98%), the sensitivity (20%) and negative predictive value (78%)
are not sufcient for the FAST to be used as a screening tool in children [18]. The
inconsistency in the performance of and utility of the FAST exam in children is due
to several factors. First, up to 37% of pediatric abdominal injuries lack hemoperitoneum as evaluated by CT [19]. Therefore, a lack of free uid does not exclude
intraabdominal injury. In addition, the presence of free uid during the FAST exam
may not obviate the need for CT imaging, even in the hemodynamically unstable
patient. This is because the FAST does not distinguish between solid organ and hollow viscous injuries, which often require different management strategies.
Specically, the vast majority of solid organ injuries are managed conservatively
without surgical intervention, while many hollow viscous injuries require operative
intervention [20, 21]. Improvements in the accuracy of the FAST have been noted
with combining the FAST with physical examination ndings, [22] transaminase
levels, [23] and performing serial FAST exams [24]. At this time, more research is
needed into the utility of the FAST for pediatric trauma as measured by patientrelevant outcomes.
Soft Tissue Infections
Soft tissue infections represent a spectrum of disease from a cellulitis treated with
systemic antibiotics to an abscess requiring incision and drainage. Given the potential
need for sedation particularly in very young patients, an accurate diagnosis is important. Several studies have demonstrated the utility and improved diagnostic accuracy
of point-of-care ultrasound compared with clinical examination in children [25–27].
24 Pediatric-Specic Point of Care US Management
389
Pneumonia
An adequate lung exam can be difcult in young children presenting with respiratory distress, fever, and/or hypoxemia. Point-of-care ultrasound has been shown to
be highly specic for pneumonias in pediatric patients and may reduce the number
of chest radiographs in some cases [28, 29]. In addition to identifying pneumonias,
point-of-care ultrasound may also be valuable in assessing for parapneumonic
effusions.
Venous Access
Infants, children with complex medical conditions, and those with hypovolemia can
present challenges when trying to obtain venous access. Ultrasound-guidance for
peripheral venous access may be particularly useful in pediatric patients with difcult access [30]. In addition, although not yet studied in pediatric patients, point-ofcare ultrasound may be an additional adjunct for bedside nurses placing intravenous
catheters.
Equipment
Physicians who perform pediatric point-of-care examinations should have access
to appropriate equipment to perform these exams. Despite the reduction in the
cost of portable ultrasound machines in the last decade, the cost remains signicant enough that physicians should plan to delineate the value of point-of-care
ultrasound for departments and/or hospitals. In addition to the return costs from
billing revenue, there are improvements in quality benchmarks worth highlighting, such as reduced lengths of stay, [6] complication rates, [31] and improved
patient satisfaction [32]. Further, use of some point-of-care ultrasound examinations may translate into fewer computed tomography scans [6, 33] and, therefore,
radiation exposure. In pediatrics, specically, there are often hospital foundations,
or donor programs, which may be valuable sources of funding for such equipment. One strategy is for departments to begin use of point-of-care ultrasound as
a quality improvement initiative with initial focus on a single exam that is widely
applicable to the patient population and easy to learn, such as bladder volume
assessment.
For most examinations (e.g., appendicitis, intussusception, pyloric stenosis, hip
effusions, fractures, vascular access, soft tissue) in pediatric patients, a high frequency, linear array transducer will provide ideal resolution and sufcient penetration. In addition, for point-of-care ultrasound examinations in infants and toddlers,
390
J.R. Marin
it is useful to have different sized linear transducers available (Fig.24.1) with different lengths. This is such that for smaller surface areas, the operator can ensure the
entire surface of the probe makes contact with the skin (e.g., infant arm for peripheral vascular access).
The FAST and cardiac examinations require use of a low frequency phased array
or curvilinear transducer, as well as for select examinations in obese or older adolescents. For infants and toddlers, the optimal frequency range may be higher, so
frequencies of 3–7MHz, for example, may be considered.
Regardless of the probe, review of the near-eld and far-eld resolution in a
variety of patient size is even more important in pediatrics. With ages from newborn
to 21years, the acoustical transmission will vary tremendously, especially in the
near eld.
In addition to equipment needed in order to perform point-of-care ultrasound
examinations, departments should invest in training equipment, such as ultrasoundcompatible phantoms and simulators. This equipment represents an opportunity for
collaboration and cost-savings through resource sharing with other specialties in the
hospital (See Chap. 12 – Ultrasound Equipment and Purchase).
Fig. 24.1 Examples of linear array transducers
24 Pediatric-Specic Point of Care US Management
391
Managing Anxiety/Pain
Depending on the child and examination being performed, a point-of-care ultrasound examination may provoke anxiety and/or cause discomfort or pain. Depending
on the age of the child, it is often helpful to explain the examination and compare it
to things the child can relate to such as a computer game or comparing the image
screen with a television. Having the child hold the transducer and apply it to himself
or herself or a family member can also ameliorate fears. Other tools to reduce anxiety include child life specialists who are trained to distract and redirect patients for
procedures. Toys, smartphones, or tablets which a parent or guardian can help hold
can also serve as distraction tools. Use of warm ultrasound gel is imperative when
performing point-of-care ultrasound in children, as it reduces the shock of the cool
gel applied. In cases of particularly painful exams (e.g., soft tissue infections),
stand-off pads, or alternatively, copious gel (Fig. 24.2) can be used as a barrier
between the transducer and the patient’s skin and may make for a pain-free
Fig. 24.2 Copious gel can be used over tender areas to reduce pain from the ultrasound exam
392
experience. For exams where direct pressure is unavoidable, and necessary, such as
with the evaluation for appendicitis, it is important to provide systemic analgesia to
the patient prior the exam in order to obtain adequate images. There are occasions
where, despite efforts to reduce anxiety and pain, the child will not remain still for
the examination. In these cases, the child should be appropriately restrained, as with
other procedures, such as intravenous line placement or lumbar puncture, in order
to obtain quality images worthy of interpretation.
J.R. Marin
Point-of-Care Ultrasound byPediatric Emergency Medicine
Physicians
In the last decade, there has been tremendous growth in pediatric emergency medicine (PEM) physician-performed point-of-care ultrasound. Nonetheless, the eld
is relatively new and still growing. In contrast to emergency physicians who receive
training in point-of-care ultrasound during residency, point-of-care ultrasound
training has only recently been incorporated into PEM fellowship training programs [34]. Comparable to the American College of Emergency Physicians
Ultrasound Guidelines [3], and Council of Emergency Medicine Residency
Directors recommendations for residency training [35], guidelines are now available for PEM physicians and fellow trainees. Vieira etal. [36] described educational guidelines and a sample curriculum for PEM fellowship training programs.
In 2014, the American Academy of Pediatrics, in collaboration with the Society for
Academic Emergency Medicine, American College of Emergency Physicians, and
the World Interactive Network Focused on Critical Ultrasound, published the rst
national statements on PEM-performed point-of-care ultrasound [37, 38]. These
documents outline considerations for those seeking to begin a PEM point-of-care
ultrasound program. For those seeking additional ultrasound training, many programs offer one-year PEM- specic ultrasound fellowships. Finally, physicians
who perform pediatric point-of- care ultrasound are encouraged to join the P2
Network, an international organization dedicated to pediatric point-of-care ultrasound (p2network.com).
Interdepartmental Considerations andCredentialing
It is useful to collaborate with other pediatric subspecialties, particularly when initiating a pediatric point-of-care ultrasound program. Depending on the practice
environment, physicians outside of emergency medicine may not be familiar with
the concept of emergency medicine-performed ultrasound. As its use remains relatively new in PEM, it is important to educate others regarding the precedent already
24 Pediatric-Specic Point of Care US Management
set forth in emergency medicine as well as the aforementioned PEM guidelines.
Additionally, other pediatric specialties, such as cardiology and radiology, may be
valuable resources for those seeking to learn pediatric exams.
Credentialing considerations for the PEM physician include applications unique
to the pediatric patient, inclusion of ultrasound applications that affect the range of
pediatric patients (neonate to adolescent), and the point-of-care paradigm versus
comprehensive ultrasound examinations, such as those done in radiology departments (See Chap. 20 – Credentialing and Privileging).
393
Pitfalls
1. Failure to understand the test characteristics of pediatric point-of-care ultra-
sound examinations and the utility of the exam. Specically, most exams are
used to rule-in pathology, and therefore should not be used as screening exams.
2. Failure to appreciate size-specic considerations in children. An appropriate
transducer should be selected for very small children in order to adequately and
optimally visualize anatomy and successfully perform procedures.
3. Failure to distract a patient sufciently or keep a patient still during the exam in
order to obtain adequate images.
4. Failing to gain sufcient experience with positive exams given the relatively low
incidence of certain pediatric pathology.
Key Recommendations
1. Ultrasound should often be considered as the rst imaging modality in pediatric
patients and is in keeping with the ALARA principle of reducing radiation
exposure.
2. Emergency physicians should consider point-of-care ultrasound in children with
abdominal complaints, prior to urethral catheterizations, in the evaluation for a
skull fracture, for children with a limp or fall on an outstretched arm, for soft
tissue infections, and for children with respiratory distress.
3. Different from adult POC US, a linear array transducer is the optimal transducer
for the majority of pediatric-specic examinations and departments should have
multiple sizes available to accommodate different patient ages. One curvilinear
or phased array probe should be available for torso applications such as cardiac
and FAST examinations.
4. Utilize tools such as distraction techniques, child life specialists to assuage fears
and anxiety, and take steps, such as the application of copious warm gel, to minimize pain and discomfort of certain ultrasound exams.
394
J.R. Marin
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Chapter 25
Ultrasound inDisaster andPre-hospital Use
HaleyCochrane andHeidi H.Kimberly
Emergency POC Ultrasound DuringDisaster andMass
Casualty Incidents
Objectives
• Review the utility and limitations of emergency ultrasound during disaster and
mass casualty incidents
• Understand the importance of including emergency ultrasound during disaster
preparation and protocol development
Introduction
Disaster and mass casualty incidents (MCI) are unfortunately becoming more common worldwide. These events, while unpredictable, can be prepared for with emergency management plans and disaster drills. Point of care US (POC US) can be a
valuable tool in patient triage, evaluation and management during disaster scenarios
both in the prehospital and hospital environment. Its use has been driven by the
established role of ultrasound in emergency and trauma evaluation and the widened
availability and portability of ultrasound technology. Emergency ultrasound should
be included as part of comprehensive disaster preparedness planning.
H. Cochrane, MBBS (*)
Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
e-mail: HCOCHRANE@PARTNERS.ORG
H.H. Kimberly, MD, FACEP
Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, USA
V. S. Tayal et al. (eds.), Ultrasound Program Management,
https://doi.org/10.1007/978-3-319-63143-1_25
397© Springer International Publishing AG 2018