Bedside ultrasound, or point-of-care ultrasound (POCUS), is a critical adjunct to both diagnosis and procedure guidance, and its use is becoming more common in pediatric emergency departments (EDs).1,2 POCUS was first introduced to the ED more than 20 years ago. It is now widely used in adult emergency medicine, with abundant literature supporting its use. In 2001, the Accreditation Council for Graduate Medical Education mandated that emergency medicine residencies train residents in bedside ultrasound. Although less ubiquitous in the pediatric ED, its use and the pediatric emergency medicine literature supporting its use are rapidly increasing. More than 90% of pediatric emergency medicine fellowships now use bedside ultrasound.3 As of 2013, training in POCUS is an American Board of Pediatrics requirement for pediatric emergency medicine fellowship programs.4 In addition, consensus educational guidelines and a model curriculum have been published.5 The need for training and a curriculum in pediatric emergency medicine ultrasonography has been endorsed not only by the American Board of Pediatrics, but also by the American Academy of Pediatrics, Society of Academic Emergency Medicine, American College of Emergency Physicians, and the World Interactive Network Focused on Critical Ultrasound.6
Ultrasound is an ideal imaging modality in children for many reasons. Obtaining optimal ultrasound images in pediatric patients is easier because children are generally thinner and smaller than adults. POCUS is performed at the bedside and can be repeated as needed as a patient’s clinical condition changes. This portability adds a safety factor to POCUS, as potentially unstable patients do not need to go to the radiology suite for a formal radiological study. In addition, unlike computed tomography (CT) and magnetic resonance imaging, bedside ultrasound allows caregivers and staff members from child life to remain with patients throughout the examination, which may obviate the need for sedation. Most importantly, ultrasound does not expose a child to any ionizing radiation.
This issue of Pediatric Emergency Medicine Practice will provide techniques and tips for the use of POCUS to guide various ED procedures including common procedures (ie, peripheral line placement, lumbar puncture, bladder catheterization, and foreign body removal) and procedures that are more rare and resuscitative (ie, central line placement, paracentesis, and pericardiocentesis).
A 10-month-old girl presents with vomiting and diarrhea for 3 days. She has had 10 to 15 episodes of nonbilious nonbloody emesis and 5 to 10 episodes of nonbloody diarrhea each day. Her mother brings her to the ED because she has had only 1 wet diaper in the past 12 hours. On examination, she is awake but appears tired. She is afebrile and mildly tachycardic. She cries when examined, but has no tears. Her mucous membranes are dry and her capillary refill is 3 seconds. The remainder of her examination is unremarkable and her bedside glucose is 103 mg/dL. You discuss with the mother the need for a peripheral line, IV fluids to rehydrate her daughter, and a blood draw to check electrolytes. The nurses attempt to place an IV line 3 times but are unsuccessful. They report difficulty finding a vein because the girl is dehydrated. What are your options now? Should you try to place the line using a traditional technique? Would placing a line under ultrasound guidance be faster and more likely to succeed? When placing an ultrasound-guided IV line, is it better to use ultrasound to mark a vein's location or to cannulate the vein using ultrasound guidance in real time? Are there certain vein characteristics you should note when choosing a vein to cannulate? Can any peripheral vein be used for ultrasound-guided line placement?
A literature search was performed in PubMed, using the search terms ultrasound, peripheral, cannulation, access, and emergency, limited to human studies. This search yielded 49 articles, 12 of which were found to be relevant.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
Sophia Lin, MD, RDMS
June 2, 2016
July 1, 2019
Upon completion of this article, you should be able to:
Date of Original Release: June 1, 2016. Date of most recent review: May 15, 2016. Termination date: June 1, 2019.
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