Faculty Bibliography

Study Objectives: To evaluate clinical decisionmaking by emergency physicians using IVC US in children undergoing ED evaluation of dehydration from GI losses. Dehydration from gastroenteritis is a leading cause of death in children <5 years worldwide. US assessment of the IVC may correlate with severity of dehydration and assist in clinical decision making. Methods: We conducted a prospective cohort study of US imaging of the IVC in pediatric patients with suspected dehydration from vomiting and/or diarrhea. The IVC was imaged in the sagittal plane at the junction of the right atrium and along the length of the IVC extending into the liver, assessing for 100% collapse of the walls of the IVC with tidal breathing. Patients < 21 yrs. presenting with vomiting requiring ondansetron or diarrhea with concern for dehydration were eligible for study inclusion. Patients enrolled from 10/2015-12/2016. Clinical dehydration scores, pre-test (before IVC US) and post-test (after IVC US) probabilities of dehydration requiring IV fluids were recorded by 5 treating sonologists that enrolled patients into the study. Primary outcomes assessed included: IV vs PO fluid rehydration, ED length of stay (LOS) and disposition (admission or discharge). Results: One hundred twelve patients were enrolled, median age was 5 years (S.D +/-6), and 49.1% were female. By clinical dehydration score, 61.6% (n/N=69/112; 95% CI: 51.9-70.6%), 36.6% (n/N=41/112; 95% CI: 27.7-46.2%), and 0.01% (n/N=2/112; 95% CI: 0.0-0.06%) were minimally, moderately and severely dehydrated respectively. The majority of patients received oral rehydration 79.4% (n/N 89/112; 95 CI: 70.8-86.5%) and 20.5% (n/N=23/112; 95% CI: 13.5-29.2%) received IV fluid rehydration. Only 4.4% (n/N=5/112; 95% CI: 0.1-8.3%) were admitted and no discharged patient returned to the ED for failure to rehydrate. The distribution of pre-test to post-test probabilities in children with suspected dehydration requiring IV fluids is presented in matrix Figure 1. Overall, IVC US altered pre-test probabilities for requiring IV fluid rehydration by decreasing in 51.8% (n/N=58/112; 95% CI: 42.1-61.3%), increasing in 25% (n/N=26/112; 95% CI: 17.3-34.1), and left unchanged in 23.2% (n/N=28/112; 95% CI: 15.8-32.1%). IVC US was attributed to changing management in 15.2% (n/N=17/112; 95% CI: 9.1-23.2%) patients; from PO to IV fluid rehydration in 6.3% (n/N=7/112) children and from IV to PO rehydration in 8.9% (n/N=10/112) patients. Conclusions: US changes pre-test to post-test probabilities for requiring IV fluid rehydration in the majority of children with suspected dehydration, but in a population of mildly to moderately dehydrated children actual management change with respect to IV vs PO rehydration was infrequent. [Image Presented]

Background/UNASSIGNED:Ultrasound scan has gained attention for diagnosing appendicitis due to its avoidance of ionizing radiation. However, studies show that ultrasound scan carries inferior sensitivity to computed tomography scan. A non-diagnostic ultrasound scan could increase the time to diagnosis and appendicectomy, particularly if follow-up computed tomography scan is needed. Some studies suggest that delaying appendicectomy increases the risk of perforation. Objective/UNASSIGNED:To investigate the risk of appendiceal perforation when using ultrasound scan as the initial diagnostic imaging modality in children with suspected appendicitis. Methods/UNASSIGNED:We retrospectively reviewed 1411 charts of children ≤17 years old diagnosed with appendicitis at two urban academic medical centers. Patients who underwent ultrasound scan first were compared to those who underwent computed tomography scan first. In the sub-group analysis, patients who only received ultrasound scan were compared to those who received initial ultrasound scan followed by computed tomography scan. Main outcome measures were appendiceal perforation rate and time from triage to appendicectomy. Results/UNASSIGNED:In 720 children eligible for analysis, there was no significant difference in perforation rate between those who had initial ultrasound scan and those who had initial computed tomography scan (7.3% vs. 8.9%, p = 0.44), nor in those who had ultrasound scan only and those who had initial ultrasound scan followed by computed tomography scan (8.0% vs. 5.6%, p = 0.42). Those patients who had ultrasound scan first had a shorter triage-to-incision time than those who had computed tomography scan first (9.2 (IQR: 5.9, 14.0) vs. 10.2 (IQR: 7.3, 14.3) hours, p = 0.03), whereas those who had ultrasound scan followed by computed tomography scan took longer than those who had ultrasound scan only (7.8 (IQR: 5.3, 11.6) vs. 15.1 (IQR: 10.6, 20.6), p < 0.001). Children < 12 years old receiving ultrasound scan first had lower perforation rate (p = 0.01) and shorter triage-to-incision time (p = 0.003). Conclusion/UNASSIGNED:Children with suspected appendicitis receiving ultrasound scan as the initial diagnostic imaging modality do not have increased risk of perforation compared to those receiving computed tomography scan first. We recommend that children <12 years of age receive ultrasound scan first.

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.

A well-appearing 3-year-old boy presented to the pediatric emergency department 2 hours after a presumed hydrocarbon ingestion. He was referred to the emergency department by his pediatrician after consultation with the local poison control center after possibly ingesting ylang ylang (Cananga odorata) fragrance oil. The child was asymptomatic with a normal physical examination. Point-of-care lung ultrasound identified focal hydrocarbon pneumonitis in the right lung and demonstrated resolution of these findings. Utilization of point-of-care ultrasound resulted in a shorter emergency department length of stay and the avoidance of radiation exposure from serial chest x-rays.

BACKGROUND: Chest x-ray (CXR) is the test of choice for diagnosing pneumonia. Lung ultrasound (LUS) has been shown to be accurate for diagnosing pneumonia in children and may be an alternative to CXR. Our objective was to determine the feasibility and safety of substituting LUS for CXR when evaluating children with suspected pneumonia. METHODS: We conducted a randomized control trial comparing LUS to CXR in 191 children from birth to 21 years of age with suspected pneumonia in an emergency department. Patients in the investigational arm received a LUS. If there was clinical uncertainty after ultrasound, clinicians had the option to obtain CXR. Patients in the control arm underwent sequential imaging with CXR followed by LUS. Primary outcome was the rate of CXR reduction; secondary outcomes were missed pneumonia, subsequent unscheduled healthcare visits, and adverse events between investigational and control arms. RESULTS: There was a 38.8% reduction (95% CI, 30.0 to 48.9%) in CXR among investigational subjects compared to no reduction (95% CI, 0.0 to 3.6%) in the control group. Novice and experienced clinician-sonologists achieved 30.0% and 60.6% reduction in CXR use, respectively. There were no cases of missed pneumonia among all study participants (investigational arm 0%; 95% CI: 0.0-2.9%; control arm 0%; 95% CI 0.0-3%) or differences in adverse events, or subsequent unscheduled healthcare visits between arms. CONCLUSIONS: It may be feasible and safe to substitute LUS for CXR when evaluating children with suspected pneumonia with no missed cases of pneumonia or increase in rates of adverse events.

Soft tissue infections and angioedema from insect bites and stings may be difficult to differentiate by inspection. We present sonographic findings of 4 cases of soft tissue swelling from insect bites and stings suggestive of angioedema. Sonographic features of soft tissue angioedema consist of thickened subcutaneous tissue layers with multiple linear, horizontal, striated, and hypoechoic lines following the tissue planes between soft tissue layers. In addition to the history and physical examination, sonographic findings may assist in differentiating between local allergic reactions and cellulitis in patients with insect bites and stings. Further study is warranted for clinical application.

OBJECTIVES: The role of clinician-performed ultrasonography (US) for suspected appendicitis is unclear. Published data conclude that US has high specificity to rule in the diagnosis of appendicitis, with variable sensitivity to rule it out. Newer data suggest that point-of-care (POC) US may have similar test characteristics. Our objective was to evaluate the effect of POC US in children with suspected appendicitis and its effect on emergency department (ED) length of stay (LOS) and computed tomography (CT) utilization. METHODS: This was a prospective observational convenience sample of children with suspected appendicitis requiring imaging evaluation that adhered to the Standards for the Reporting of Diagnostic accuracy studies (STARD) criteria. Outcomes were determined by operative or pathology report in those who had appendicitis, and 3-week phone follow-up in those patients who were nonoperative. Differences in ED LOS were analyzed by one-way analysis of variance (ANOVA) between patients who received dispositions after POC US, radiology US, or CT. Test performance characteristics were calculated for all imaging modalities. RESULTS: Among 150 enrolled patients, 50 had appendicitis (33.3%). There were no missed cases of appendicitis in discharged patients at 3-week phone follow-up, nor negative laparotomies in those who went to the operating room. Those who had dispositions after POC US (n = 25) had a significantly decreased mean ED LOS (154 minutes, 95% confidence interval [CI] = 115 to 193 minutes) compared with those requiring radiology US (288 minutes, 95% CI = 257 to 319 minutes) or CT scan (487 minutes; 95% CI = 434 to 540 minutes). Baseline CT rate was 44.2% (95% CI = 30.7% to 57.7%) prior to study start and decreased to 27.3% (95% CI = 20.17% to 34.43%) during the study. CTs were avoided in four patients with conclusive POC US results and inconclusive radiology US results. The sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for POC US were 60% (95% CI = 46% to 72%), 94% (95% CI = 88% to 97%), 10 (95% CI = 4 to 23), and 0.4 (95% CI = 0.3 to 0.6). For radiology US they were 63% (95% CI = 48% to 75%), 99% (95% CI = 94% to 99%), 94 (95% CI = 6 to 1,500), and 0.4 (95% CI = 0.3 to 0.6); and for CT they were 83% (95% CI = 58% to 95%), 98% (95% CI = 85% to 99%), 45 (95% CI = 3 to 707), and 0.2 (95% CI = 0.05 to 0.5). CONCLUSIONS: It may be feasible to reduce ED LOS and avoid CT scan when using POC US to evaluate children with suspected appendicitis. Test characteristics for POC US have high specificity to rule in appendicitis, similar to radiology US. Addition of POC US prior to sequential radiology imaging was safe, without missed cases of appendicitis or negative laparotomies.

Twin partial hydatidiform molar pregnancy with a viable fetus is an uncommon occurrence. Presentations of molar pregnancies include vaginal bleeding, unusually elevated β-human chorionic gonadotropin level, and preeclampsia. Previous descriptions of twin molar and fetus pregnancies in the literature have been described in the outpatient obstetric setting. We present a case of partial molar pregnancy with a viable fetus detected with emergency ultrasound in a pediatric emergency department.

OBJECTIVES/OBJECTIVE:Computed tomographic (CT) scans are an accepted radiographic mode to the diagnosis of appendicitis. Radiologists play a critical role in its diagnostic accuracy. The purpose of this study was to determine whether there is a difference in the diagnostic accuracy between pediatric and general radiologists interpreting pediatric abdominal/pelvic CT scans for appendicitis. METHODS:Computed tomographic scans of 10 patients (5 with appendicitis and 5 without appendicitis) were presented on a password-protected Web site. Radiologists rated the CT scans for the likelihood of appendicitis on a grading scale from 1 to 5. RESULTS:This is a report of data from 6 pediatric radiologists and 13 general radiologists. For appendicitis cases, the pediatric radiologists gave a "positive" interpretation in 26 (87%) of the cases, whereas the general radiologists gave a "positive" interpretation in 57 (89%) of the cases. Of the true positives, pediatric radiologists rated 25 (96%) of 26 as a high likelihood of appendicitis with a score of 1, whereas general radiologists rated 44 (77%) of 57 as high likelihood. In cases without appendicitis, the pediatric radiologists had a true negative interpretation rate of 83%, and the general radiologists had a true negative interpretation rate of 73%. Of the true negatives, pediatric radiologists rated 22 (88%) of 25 with a rating of 4, being "no appendicitis," whereas the general radiologists rated 39 (85%) of 46 with a rating of 4. CONCLUSIONS:There is a similar accuracy rate in the interpretation of CT scans positive for appendicitis between general and pediatric radiologists, but pediatric radiologists were more definitive.