Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5795_Библиотеки_им_академика_М_И_Перельмана.pdf
ab
4 Contrast-Enhanced US, andUltrasound Elastography inChildhood
75
Not only affects initial compression but also after compression (i.e., relax-
ation)—then measuring re-expansibility of tissue, potentially giving further information on tissue character.
4.2.2 Applications
According to initial observations, promising method for improved detection and
characterisation of focal lesions and diffuse (brotic) parenchymal changes also in
infants and children, particularly the liver—possibly also in other organs, e.g. testis,
(transplant) kidney, thyroid gland, bowel wall.
4.2.2.1 Focal Lesions
In adults most experience in breast and prostate cancer.
TE and SWE used for differentiating focal pathologies in children.
• 2D-SWE example: for differentiation between benign and malignant lesions
(e.g., liver haemangioma and hepatoblastoma).
• TE example: semiquantitative data in focal thyroid or lymph node lesions
(Fig.4.13).
In 15-year-old boy with goitre SWE demonstrates quite stiff tissue behaviour of
a nodular area, suspect for malignancy. Final histological diagnosis = thyroid
carcinoma.
4.2.2.2 Diffuse Changes
Most experience in adults and children exist in liver.
Reference data for TE and SWE for liver, spleen, kidney published
• Comparison between various methods, machines, probes not possible!
Standardization is necessary, but difcult.
Fig. 4.13 Sonoelastography (Strain Elastography—SWE) of the thyroid gland. A nodular mass
lesion of the thyroid galnd depictedon B-Mode US (a) is clearly delinated on US-elastography (b)
showing a different and higher stffness than the surrounding thyroid tissue
76
M. Riccabona and H. J. Mentzel
ab
Fig. 4.14 Shear weave elastography of the liver: (a) 11-year-old girl with Alpha-1-Antitrypsin-
deciency. Increased stiffness of >30kPa based on elevated shear wave velocities, corresponding
with severe liver brosis/cirrhosis and consistent with the macro-nodular pattern of the liver parenchyma on grey scale imaging. (b) 11-year-old boy with cystic brosis. Slightly increased stiffness
(15.7kPa) corresponding to liver brosis in cystic brosis associated liver disease (CFLD)
Note Temperature, nutrition status, transducer choice and position, etc. may inu-
ence measurement results. Normal values change with equipment and transducer=difcult to compare.
4.2.2.3 Possible Indications—Summary
• Liver applications: liver brosis, evaluation of cystic brosis associated liver disease, biliary atresia, veno-occlusive disease, chronic hepatitis, haemochromatosis, alpha 1-antitrypsin deciency, liver transplantation (Fig.4.14).
• First promising results also in children with diffuse liver parenchymal disease.
• Limited experience in renal transplants, pyelonephritis, dilated urinary tracts.
• Classication and differentiation of diffuse tissue changes or diffusely inltrating disease more difcult but increasingly investigated relies on established normal values for different tissues or organs (glands, muscles, parenchymal
abdominal organs, lymph nodes).
Paediatric Limited Field ofView US/Point
ofCare US (POCUS) andEmergency US:
When, How andforWhat
MichaelRiccabona, GerolfSchweintzger, andBrianColey
Definition
This chapter comprises all US applications that are not “standard detailed investigations” but used in more clinically focused settings—to just answer a simple question
(e.g. a bump—cystic or solid) and as orienting rst information to strategise further
management and treatment, also to decide on potentially necessary further imaging—thus a quick extension of the initial clinical assessment as done using a stethoscope revealing otherwise inaccessible valuable information—therefore sometimes
also called ”sonoscope”. Other names are point of care (emergency) US (POCUS),
focused US, limited eld US and many others.
5.1 Requirements
5
• Equipment capable of producing sufcient image quality, preferably portable or
hand-held
• Transducer adequate for targeted area and age group, documentation facilities, US gel
M. Riccabona (*)
Department of Radiology, Division of Pediatric Radiology, Medical University Graz
and University Hospital Graz, Graz, Austria
e-mail: michael.riccabona@klinikum-graz.at
G. Schweintzger
Abteilung fur Kinder und Jugendliche Neonatologische und Padiatrische Intensivstation,
LKH Leoben/Eisenerz, Leoben, Austria
e-mail: Gerolf.Schweintzger@lkh-leoben.at
B. Coley
Department of Radiology, Cincinnati Children’s Hospital Medical Center,
Cincinnati, OH, USA
e-mail: brian.coley@cchmc.org
© Springer Nature Switzerland AG 2020
M. Riccabona (ed.), Pediatric Ultrasound,
https://doi.org/10.1007/978-3-030-47910-7_5
77
78
M. Riccabona et al.
• Other requirements as dened for general US examinations helpful
– particularly option to darken room to avoid mirroring in screen, etc.
– bi-color images may improve visualisation in non-darkened settings.
• Adequate education and training/skills of examiner
• Knowledge of topographic anatomy and proper US access
• Knowledge about diseases, differential diagnosis management needs and respective US appearance
Note To do a fast, focused exam (“Sonoscope”) often believed to be easy and thus
can be done by everybody—nevertheless, the more experience one has (both in
device/transducer handling as well as in performing and reading US), the quicker
and more reliable limited eld US will be.
5.2 Typical Applications
Often used in emergency settings, in out-patient ofce for rst assessment, in eld
ofces and in outreach settings; increasingly also in emergency unit, operation
theatre, ICU, or rescue vehicle. Details about (e)FAST and (e)RUSH follow below.
Some typical clinic queries where a “Sonoscope” may be useful (Fig.5.1):
• Bladder full—empty? Renal collecting system dilated? …
• Dilated cerebral ventricles? Gross-brain haemorrhage? …
• Pneumothorax? Pleural effusion? Large lung consolidation? Thymus? …
• Pericardial effusion? Cardiac contractility and lling?
• Hepatosplenomegaly? Gallstone?
• Ascites or free peritoneal uid?
• Gut peristalsis?
• Appendix (or other bowel) visible or thickened? ...
• Cystic or solid lump/bump? Joint effusion? Fracture? Thickened tendon sheath?
• Vessel patency? Thrombosis?
In all these conditions limited eld US can answer basic questions—thus
Note
helpful for differential and deciding on management. However, one has to state that
this was just an orienting POCUS with a limited area examined—not replacing a
comprehensive detailed US examination.
Document ndings, not only for medical legal issues but also for second opinion
or remote reading, and follow-up evaluation.
Be aware that this approach is prone to bias, as clinical picture may predene
expectations and reduce readiness to discover other pathology—intrinsically dangerous for patient. Furthermore, standard structured assessment of entire organ system not usually performed in these settings, which would help to overcome some of
this potential bias.
ab c
5 Paediatric Limited Field of View US/Point of Care US (POCUS) and Emergency US…
def
79
gh
jkl
mn o
p
s
i
qr
t
u
Fig. 5.1 Typical ndings in common queries for sonoscope/focused US at (N)ICU, emergency
ward, paediatric admission, or follow-up: Neonate with respiratory distress syndrome (a) or multiple grouped B-lines in alveolo-interstitial syndrome (b); equivocal chest lm (c) with respective
US (d) demonstrating slightly irregular and large textured thymus; (e) colic with dilated collecting
system and distal ureteric pre-ostial concrement (arrow, f); ureteric JJ-drain position after surgery
in collecting system as well as proximal (g) and distal (h) ureter, (i) pericardial effusion in hypertrophic cardiomyopathy, (j) free peritoneal air (arrow, observe curtain sign); ileocoecal intussusception (k)—not to be confused with transient ileoileal intussusception (note size, D < 2 cm) (l),
cholecystolithiasis with sludge (m), splenic injury (arrow, n), (o) hip effusion (asterix) in limping
child with painful hip, pneumonia with effusion (p), cerebral haemorrhagic infarction with beginning PVL (q) and dilated ventricles with sedimented blood (r), ovarian torsion (s), perforated
appendicitis (t), or abscess with stula tract to lymph node (u)
80
M. Riccabona et al.
5.3 “FAST” US (Focused Assessment withSonography
forTrauma)
Established as initial orienting imaging tool in severe trauma focusing on detection
of free abdominal uid, also includes pleura and pericardium.
eFAST (= extended FAST): IVC, abdominal aorta and pneumothorax/lung added.
Only these dened areas are assessed, free uid is noted, potentially also size and
pulsatility of upper abdominal aorta/IVC noted.
No time wasted trying to nd organ injuries—in more stable settings or for triage
in mass trauma the latter can, however, be attempted.
• Usually performed at rescue units or emergency room in early initial assessment—before CT.
• Sensitive for detecting free uid.
• Location of free uid does not necessarily dene region of injury or injured organ.
How to do—standardised sections (see also www.aium.org/resources/guidelines/
fast.pdf) (Fig.5.2):
• Pelvic view (= retrovesical, retrouterine, or Douglas pouch view) (see Fig.5.2-1).
– Assessment of most dependent peritoneal space for free uid through uid-
lled bladder (can be lled via Foley catheter, if necessary) (Fig.5.2e).
– If sufcient time, bladder scanned entirely (both sagittal + transverse planes).
• Right upper quadrant view (= liver, perihepatic, Morison pouch, or right ank
view) (see Fig.5.2-2).
– Uses liver as US window to assess kidney + hepatorenal space (Morison
pouch) for free uid (Fig.5.2c).
– Cephalad movement of transducer for right pleural space (effusion?), caudal
transducer movement for inspecting right kidney + right paracolic gutter (free
uid?).
• Left upper quadrant view (= perisplenic or left ank view) (see Fig.5.2-4).
– Uses spleen as US window to perisplenic space, also below the diaphragm,
and splenorenal recess.
– Scanning cephalad = left pleural space (free uid? (Fig.5.2b), scanning cau-
dad = left kidney + left paracolic gutter (free uid?).
• Pericardial view (= subcostal or subxiphoid view) (see Fig.5.2-3).
– Uses left liver lobe for analysis of heart + pericardiac space
(Fig.5.2d, pericardic effusion).
– Both sagittal and transverse 4-chamber planes may be used.
– Angulation allows visualising IVC + hepatic veins.
e
5 Paediatric Limited Field of View US/Point of Care US (POCUS) and Emergency US…
81
5
a
3
2
c
4
1
d
b
Fig. 5.2 Schematic drawing demonstrating standard transducer positions for (e)FAST, with some
respective typical US ndings at respective location
• Anterior thoracic view (see Fig.5.2-5).
– Sliding sign? (pneumothorax best assessed at second or third intercostal
space, Fig.5.2a).
– Potentially use other intercostal spaces for lung and pleura.
Additional dedicated views:
• Right and left pericolic gutter view = longitudinal/transverse views inferior to
kidney—may reveal free uid surrounding the bowel.
• Pleural space views—angulation and cephalad movement.
– uid more echogenic or complex if haemorrhagic, proteinaceous, or
infectious.
– upright position may improve detection of pleural uid.
• Parasternal view: visualisation of the heart if subcostal view is suboptimal.
• Apical view: visualisation of pericardial uid.
– Transducer at left nipple line aiming toward spine.
82
M. Riccabona et al.
a
Fig. 5.3 M M-mode trace to document pulsatility of IVC (a), abdominal aorta (b) and diaphrag-
matic respiratory motion (c)
b
c
Supplemental views (also useful for eRUSH—see below):
• Inferior Vena Cava Views—IVC accessible by subxiphoid or right lateral
approach.
– Assessment of intravascular volume status.
Hypovolemic (e.g. secondary to massive haemorrhage).
Severe uid overload (e.g. by over-infusion).
Pulsatility or motion can be documented by m-mode (Fig.5.3).
Note (e)FAST never eliminates possibility of injury or uid collections. May be
repeated for reassessment and evaluating therapy response
5.4 “(e)RUSH” (Rapid Ultrasound inShock andHypoxia)
Coming from adult imaging for early assessment and triage/DDx of, e.g. cardiac
arrest, heart attack, pulmonary artery embolism, septic shock, other non-traumatic
reasons for shock of unknown origin (Fig.5.4):
• Similarly to (e)FAST: short focused assessment of major parameters, assessing
– Pleural and pericardial effusion.
– Pneumothorax.
– Cardiac function and volume load—also with rpect to abdominal vessels.
• eRUSH (extended RUSH): include free abdominal uid and major peripheral
vessels.
– For example, brachial or inguinal/femoral artery…
• Semi-automatic devices that guide through investigation and calculate indices to
estimate patient risk or propose diagnosis have recently become available.
A
D
F
5 Paediatric Limited Field of View US/Point of Care US (POCUS) and Emergency US…
8
G
5
6
83
3
4
B
C
2
1
7
E
Fig. 5.4 (e)RUSH: Schematic drawing demonstrating standard transducer positions for (e)RUSH,
with some respective typical US ndings at respective location. 1 = pelvis/bladder view, 2 + 3 =
abdominal aorta slide view and IVC, 4 = right upper ank (kidney, liver, Morrison’s, pleura/Chest),
5 + 6 = heart (parasternal longitudinal and apical four chamber), 7 = left upper quadrant (spleen
kidney, pleura/chest), 8 = ventral upper chest/pulmonary view. (a) Lung consolidation, (b) urinoma around right kiney, (c) IVC size and pulsatility, (d) blasser with some retrovesical uid, (e)
cross section of abdomional aorta, (f) spleen with some uid in spleno-renal space, adnm atelectasis of lower lung, (g) huge pericardic effusion
• Intrinsically in paediatric US (these conditions are rather rare) RUSH not as well
established.
– May be useful approach at emergency room in situations with unclear shock
for early triage and rst diagnostic signs.
5.5 Miscellaneous Other Typical POCUS/
Sonoscope Applications
Other typical applications of POCUS/sonoscope are bedside exams particularly at
the (N)ICU—e.g. checking for lung conditions and effusions, or at the admission
when trying to retrieve some basic information to decide which path to follow for
further work-up.
84
M. Riccabona et al.
Or sonoscope/focused US used in paediatric or paediatric surgery ofces as rst
test to then strategise further management, indicate further tests, or proceed to
prompt treatment.
For focused US in the paediatric abdomen different approaches are suggested—some start with the bladder (and retrovesical space (female genitalia) and
then work their way circular around—over the right ank (checking for intussusception on the way up, kidney, liver, possibly pleural effusion, etc.) to the upper
abdominal midline (pancreas, left liver lobe, pylorus, pericardiac effusion) ending
in left ank (spleen, left kidney, pancreatic tail, pleural space); others continue
after the bladder in the upper abdominal midline working their way to left and
right ank thereafter.
Note Important to routinely cover all spaces and only afterwards focus on specic
pathology if needed, to avoid missing some important ndings by ending the examination as soon as one has found something.
Some typical examples (see Fig.5.1):
• A lump/bump—cystic or solid? Well dened?
• History of injury—foreign body? Abscess or infection?
• Persistent cough with fever—gross pneumonia? Effusion?
• Before bladder puncture—baller full?
• After voiding—residual urine?
• Limping child with hip pain—hip effusions?
• Infant with large head—dilated ventricles/hydrocephalus?
Depending on result of this initial orienting US: proceed to detailed US,
additional imaging (radiography, MRI, CT), further laboratory tests, or
treatment.
5.6 Restrictions, Pitfalls andRisks ofLimited Field US
As with any US examination, equipment must be appropriate for task, and operator must be well-trained in US examination and interpretation. Many clinical societies now have education and training guidelines for the kinds of examinations
relevant to their specialties, and practical experience is gained during residency
training. Ideally, organisations will have a collaborative multidisciplinary oversight to ensure overall quality of US for patients, provide stewardship of equipment, and provide relevant infrastructure to allow storage and sharing of images
and reports.