You are working in a small community ED on an overnight shift. It is 2:00 AM, and an 8-year-old boy with no significant past medical history arrives with his parents after 2 days of abdominal pain and vomiting that has worsened over the past 24 hours. They deny fever or a change in his bowel movements. His triage vital signs are normal, other than a temperature of 37.8°C. He is lying on the stretcher, reluctant to move. His head and neck, cardiac, respiratory, and skin examinations are all normal. His abdominal examination reveals a soft abdomen, with tenderness at McBurney point and a positive Rovsing sign. You believe your patient has appendicitis. Your practice is to send the patient for an ultrasound as the first diagnostic test; however, ultrasound is not available overnight at your hospital. You want to avoid radiation exposure for this child, but you also want to quickly disposition the patient to the operating room if appendicitis is confirmed. You order basic laboratory work, a urinalysis, intravenous morphine, ondansetron, and normal saline to relieve the patient’s symptoms. You consider performing a bedside emergency ultrasound…
While discussing the plan for an ultrasound to assess for appendicitis in your patient, you are called overhead to the resuscitation room. On arrival, visibly concerned EMTs are placing a 3-year-old girl on a stretcher. She is in extreme respiratory distress. Her parents say that she had a “cold” for 10 days. Over the last several days, she developed progressively increasing difficulty breathing. For the last 2 days, she has been crying more than usual and today had a sudden increase in respiratory distress as well as increasing lethargy. Her parents called the ambulance when they found her difficult to arouse. On your initial assessment, you note that she only moans in response to stimulation, and she has markedly increased work of breathing, with intercostal retractions and nasal flaring, despite being on a nonrebreather mask. Her peripheral pulses are weak and thready, and her capillary refill is 5 seconds. She is placed on a cardiac monitor, and has the following vital signs: temperature, 37.3°C; blood pressure, 50/20 mm Hg; heart rate, 170 beats/min; respiratory rate, 50 breaths/min; and oxygen saturation, 98% on nonrebreather mask. The nurses place 2 intravenous lines and draw laboratory tests. The physical examination reveals clear lungs. You cannot appreciate heart sounds, but note jugular venous distention and hepatomegaly. You order a portable chest x-ray, ECG, and a 20-cc/kg bolus of normal saline. You consider cardiac tamponade as your most likely diagnosis and would like an echocardiogram performed as soon as possible to confirm the diagnosis. However, you also believe the patient may be too unstable to wait for the on-call cardiologist to arrive. While the fluid bolus is being administered and you are awaiting the other studies, you consider an emergency ultrasound for immediate diagnosis.
Over the last 2 decades, the use of ultrasound by emergency clinicians, as well as other specialists at the point of care, has become increasingly common. Emergency ultrasound can be used as a diagnostic test and also to visualize anatomy for procedural guidance. It allows the emergency clinician to rapidly rule in or rule out disease processes and guide ongoing investigation and management of patients in the emergency department (ED). It is a skill required by the Accreditation Council for Graduate Medical Education for emergency medicine residency training,1 and it is supported by many organizations, including the American Medical Association, the American Academy of Pediatrics, the American College of Emergency Physicians (ACEP), the American Board of Emergency Medicine, and the American Institute for Ultrasound in Medicine.
Pediatric emergency ultrasound has been slower to progress than adult emergency ultrasound. Of the 95 emergency ultrasound fellowships currently listed on the Emergency Ultrasound Fellowships website (www.eusfellowships.com), only 5 are pediatric-specific. However, the pediatric patient is arguably more suited for emergency ultrasound than the adult patient. Children generally have a smaller body habitus than adults and, therefore, less tissue for the ultrasound beams to penetrate. This often leads to clearer images of the different organ systems, which should yield better diagnostic accuracy. There are sparse data to support this, however, due to a lack of comparative studies of the populations. The largest meta-analyses pool together adult and pediatric patients without assessing the diagnostic accuracy of this testing separately in adults and children, even for the most basic emergency ultrasound technique, the focused assessment with sonography in trauma (FAST) examination.2-7
Children are an ideal target population in which to increase the use of emergency ultrasound. Exposure to ionizing radiation from computed tomography (CT) scans may lead to an increased incidence of cancer.8-10 Pediatric cells divide at a faster rate than adult cells, and, therefore, pediatric patients have a greater risk of harm from ionizing radiation as compared to adults. The number of CT scans performed overall has increased 5-fold over the last 20 years, and it is widely believed that we will see an increased incidence of cancer directly linked to medical imaging.11 One large retrospective epidemiological study found a small, but significant, increase in cancer related to CT scanning in the first decade of life. The study predicted that there would be 2 cases of excess cancer (cancer that would not have occurred without the CT scans) per 10,000 CT scans in the decade following the first CT scan in patients aged < 10 years.12 With an estimated 4 million CT scans being completed annually in pediatric patients,13 it is incumbent on healthcare providers to find alternate diagnostic methods for these patients.
Ultrasound has been shown to have a high diagnostic accuracy for many pathologies, without the associated risks of ionizing radiation. Diagnostic ultrasound in pediatric patients has been traditionally in the domain of pediatric radiologists and technicians who are skilled in the interpretation of ultrasound for pediatric-specific pathologies. Many centers do not have access to pediatric radiologists or do not have access to pediatric ultrasound during evening and night hours. These centers generally transfer pediatric patients who need medical and surgical care to tertiary care centers with pediatricians and pediatric surgeons. If the emergency clinician can make or rule out a diagnosis at the bedside, transfer to the appropriate facility can be expedited and unnecessary transfers avoided.
Before pediatric data became available, most of the evidence for the utility of pediatric emergency ultrasound was derived from adult literature and applied to the pediatric patient. However, there are important differences in the efficacy of pediatric emergency ultrasound compared to adult emergency ultrasound. While the FAST examination is the most widely used and accepted emergency ultrasound modality in adults, its diagnostic accuracy in children has been shown to be poor.2,14 There are also pediatric-specific applications, such as hypertrophic pyloric stenosis and intussusception, that require pediatric data. Therefore, pediatric-specific data are crucial for the growth of emergency ultrasound in the pediatric setting. Such data are needed before emergency ultrasound modalities that may be standard in the adult population can be safely recommended for children. Fortunately, the emergency ultrasound field is growing very rapidly, and more emergency ultrasound research is being explored than ever before. It is, therefore, expected that more pediatric emergency ultrasound data will be available in the near future. This issue will focus on the pediatric-specific emergency ultrasound literature. Where there is a paucity of pediatric data in the emergency setting, adult emergency ultrasound data or pediatric radiology data will be presented.
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 will be included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.
Joshua Guttman, MD, FRCPC; Bret P. Nelson, MD, RDMS, FACEP;
January 2, 2016
February 1, 2019
Upon completion of this article, you should be able to:
Physician CME Information
Date of Original Release: January 2, 2015. Date of most recent review: December 15, 2015. Termination date: January 2, 2018.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the Essential Areas and Policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAP Accreditation: This continuing medical education activity has been reviewed by the American Academy of Pediatrics and is acceptable for a maximum of 48 AAP credits per year. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.
AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical ED presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the newsletter, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Guttman, Dr. Gold, Dr. Mailhot, Dr. Vella, Dr. Wang, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Dr. Nelson disclosed the following: consulting fees from Simulab, Inc.
Commercial Support: This issue of Pediatric Emergency Medicine Practice did not receive any commercial support.
Earning Credit: Two Convenient Methods: (1) Go online to www.ebmedicine.net/CME and click on the title of this article. (2) Mail or fax the CME Answer And Evaluation Form with your June and December issues to EB Medicine.
Hardware/Software Requirements: You will need a Macintosh or PC with internet capabilities to access the website.
Additional Policies: For additional policies, including our statement of conflict of interest, source of funding, statement of informed consent, and statement of human and animal rights, visit https://www.ebmedicine.net/policies.