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REVIEW

CURRENT
OPINION Advances in point-of-care ultrasound in pediatric
emergency medicine
Rachel A. Gallagher and Jason A. Levy

Purpose of review
Point-of-care ultrasound (POCUS) has become an integral part of emergency medicine practice. Research
evaluating POCUS in the care of pediatric patients has improved the understanding of its potential role in
clinical care.
Recent findings
Recent work has investigated the ability of pediatric emergency medicine (PEM) physicians to perform a
wide array of diagnostic and procedural applications in POCUS ultrasound. Studies have demonstrated
that PEM providers are able to identify an array of diseases, including intussusception, pyloric stenosis and
appendicitis. Novel applications of ultrasound, such as a cardiac evaluation in the acutely ill patient or
identification of skull fractures in the assessment of a patient with head injury, have shown excellent
promise in recent studies. These novel applications have the potential to reshape pediatric diagnostic
algorithms.
Summary
Key applications in PEM have been investigated in the recent publications. Further exploration of the ability
to integrate ultrasound into routine practice will require larger-scale studies and continued growth of
education in the field. The use of ultrasound in clinical practice has the potential to improve safety and
efficiency of care in the pediatric emergency department.
Keywords
emergency ultrasound, pediatric emergency medicine, ultrasound

INTRODUCTION pediatric emergency departments from 57% in 2006


Pediatric emergency medicine (PEM) physicians are to 95%. Soft tissue and focused assessment with
increasingly utilizing point-of-care ultrasound sonography for trauma (FAST) examinations were
(POCUS) in their practice. Reflecting this growing the most frequently performed examination type.
interest in POCUS, there has been a vast increase in With the increase in utilization of POCUS in PEM
published literature in the recent years, including practice, there was a growing need for a PEM ultra-
studies that have identified novel uses as well as sound fellowship curriculum. This need was high-
further explored the ability of PEM providers to lighted by Cohen et al., who found that only 16% of
accurately perform well-established applications. A the programs surveyed had a formal educational
prior article in 2008 outlined the status of the field at program. Vieira et al. [5] answered this need with
that time [1]. In this review, we focus on the liter- a recent published POCUS curriculum providing a
ature produced since that publication and discuss basis for PEM fellowship programs interested in
the potential future directions of POCUS study. developing an educational framework. The authors
outline potential pediatric emergency applications

GROWTH IN THE FIELD


Division of Emergency Medicine, Department of Pediatrics, Children’s
Rates of POCUS utilization in pediatric emergency Hospital Boston, Boston, Massachusetts, USA
departments have changed dramatically over the Correspondence to Rachel A. Gallagher, Division of Emergency Medi-
past 5 years. Two separate surveys of pediatric emer- cine, Children’s Hospital Boston, 300 Longwood Ave, Boston, MA
gency fellowship programs in 2011 and 2008 noted 02115, USA. Tel: +1 617 355 9617; e-mail: Rachel.gallagher@
a significant increase in the use of POCUS in PEM childrens.harvard.edu
practice when compared with prior surveys [2–4]. In Curr Opin Pediatr 2014, 26:265–271
2011, Marin et al. noted an increased rate of use in DOI:10.1097/MOP.0000000000000097

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Emergency and critical care medicine

strong interobserver agreement (kappa range:


KEY POINTS 0.73–0.87) across all three outcomes.
 POCUS has become a routine part of care in the
pediatric emergency department.
Future directions
 PEM physicians have demonstrated the ability to To date, the role of cardiac POCUS evaluation in the
perform a wide array of POCUS applications.
resuscitation of pediatric patients without a pulse
 Further research is required to explore the role of has not been explored. A recent meta-analysis of
POCUS in patient outcomes or in the resuscitation of adult emergency medicine patients undergoing
acutely ill children in the emergency department. cardiopulmonary resuscitation identified a strong
association between cardiac standstill on bedside
ultrasound and decreased patient survival [12]. It
and note that the need for each department will vary is unlikely that a single pediatric emergency depart-
relative to patient population. ment would provide a setting for prospective evalu-
ation of the predictive value of cardiac standstill,
and it may be inappropriate to extrapolate adult
CARDIAC findings to the pediatric population given the vastly
POCUS cardiac examinations focus on evaluation different causes of cardiac arrest in young patients.
for pericardial effusion, cardiac function and cardiac Thus, the finding of cardiac standstill in PEM
standstill. Prior pediatric POCUS literature assessed POCUS will be unlikely to predict outcomes with
the ability of PEM providers to accurately perform certainty, but may offer providers adjunctive infor-
examinations when compared with department of mation during resuscitations and inform decision-
cardiology echocardiograms [6,7]. Numerous case making. Future investigation of the role of cardiac
reports have detailed the impact of bedside cardiac POCUS assessment as part of a protocol to evaluate
ultrasound in the evaluation of critically ill patients pediatric patients with undifferentiated hypoten-
in the pediatric emergency department [8–10]. sion is a potentially fruitful next step.

Pediatric update INTRAVASCULAR VOLUME ASSESSMENT


More recently, Longjohn et al. [11] prospectively Changes in inferior vena cava (IVC) caliber during
studied PEM provider POCUS cardiac evaluation respiration have been evaluated as a surrogate
in acutely ill patients. They included patients marker for intravascular volume status and have
who required emergent pediatric cardiology consul- been shown to be most accurate at the extremes
tation, including echocardiography, who had fluid of collapsibility [13]. Qualitative assessment of the
refractory hypotension, cardiomegaly newly ident- IVC as compared with quantitative measurement
ified or cardiorespiratory arrest. The authors defined has been found to be the most clinically helpful
a point-of-care echocardiography examination in evaluation of volume status. Visualization of
(POCE) as a qualitative assessment of left ventricle either a completely collapsing IVC indicating hypo-
function and evaluation for pericardial effusion in volemia or a plethoric IVC indicating likely cardiac
the parasternal long and short axis view (Fig. 1). The failure can guide resuscitation interventions [14,15].
study noted excellent accuracy of the POCE when Chen et al. [16] calculated the cross-sectional IVC/
compared with the formal echocardiogram, with a Aorta (Ao) ratio in pediatric patients with dehydra-
sensitivity of 95% and a specificity of 83% and tion. The authors found significant differences

(a) (b)
RV

LV
RV
LA LV

FIGURE 1. (a) Normal parasternal long axis view of the heart (RV: right ventricle, LV: left ventricle, LA: left atrium). (b) Normal
parasternal short axis view of the heart (RV: right ventricle, LV: left ventricle, arrow: mitral valve).

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Advances in point-of-care ultrasound Gallagher and Levy

between dehydrated patients and healthy controls FOCUSED ASSESSMENT WITH


and demonstrated increased ratios after adminis- SONOGRAPHY FOR TRAUMA
tration of intravenous fluids. The FAST examination attempts to identify major
injury by evaluating for intraperitoneal free fluid
Pediatric update (blood) after blunt abdominal trauma (BAT) and
The role of IVC measurement in the assessment of originally included assessment at three separate
intravascular volume status has been studied in abdominal sites (right upper quadrant, left upper
patients with dehydration and in patients under- quadrant and pelvic views) and one subxyphoid
going resuscitation. Levine et al. [17] performed a view of the heart (Fig. 2). In recent years, the FAST
prospective evaluation of pediatric patients in examination has expanded to include thoracic
Rwanda and found the IVC/Ao ratio had preferable views to evaluate for hemothorax and pneumo-
test characteristics (sensitivity of 93% and specificity thorax, referred to as the extended FAST or e-FAST.
of 58%) when compared with both IVC collapsibil- Previous data have suggested that the FAST exami-
ity and the WHO dehydration scale in identification nation in pediatric patients had excellent specificity
of children with severe dehydration. Ng et al. [18] and modest sensitivity [19].
prospectively studied critically ill patients under-
going central venous pressure (CVP) measurements Pediatric update
during resuscitation and found that neither the IVC
Fox et al. [20] prospectively evaluated the test charac-
collapsibility nor the IVC/Ao index was a strong
teristics of FAST in the pediatric population. Over 300
predictor of measured CVP. A significant limitation
patients with BAT were included in analysis, and 23
of the study was the high number of individuals who
had significant free fluid noted either on computed
were mechanically ventilated at the time of IVC
tomography (CT) or in the operating room. FAST
measurements, a factor known to impact IVC assess-
evaluation was noted to have excellent specificity
ment in adult patients.
(96%) for identification of clinically significant free
fluid but poor sensitivity (52%). These results sup-
Future directions ported the conclusion of prior meta-analysis that a
Current literature suggests that single time point IVC positive FAST is very suggestive of intraabdominal
measurements are not a reliable indicator of CVP in injury, whereas a negative FAST should not be used as
acutely ill patients. Despite the limitations of the a screening test, and should be interpreted in the
IVC measurements, a qualitative assessment may context of the clinical picture in the evaluation of
provide important adjunctive information when pediatric patients with BAT.
initially evaluating acutely ill or hypotensive pedia-
tric patients with broad differential diagnoses.
Further study is needed to determine whether the Future directions
predictive value of IVC measurements would Given concerns around ionizing radiation exposure
improve in patients who are not mechanically venti- from CT and potential need for sedation, future
lated or in patients who undergo serial measurements study integrating the FAST examination into an
during resuscitation rather than a single time point algorithm assessing patients with low pretest prob-
assessment. ability of significant injury after BAT may be fruitful

(a) (b)

*
*

x x

FIGURE 2. (a) The focused assessment for sonography in trauma examination: right upper quadrant view with free fluid
(arrows) between the liver () and kidney (X). (b) The focused assessment for sonography in trauma examination: left upper
quadrant view with free fluid (arrows) between the spleen () and kidney (X).

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Emergency and critical care medicine

despite its limited sensitivity. Additionally, the FAST intussusception and pyloric stenosis often require
examination protocol can be adapted for critically ill either exposure to ionizing radiation or transport to
patients without history of trauma in whom a pediatric center.
unstable vital signs require prompt assessment.
Other algorithms in adult populations, such as Pediatric update
the rapid ultrasound for shock and hypotension
There are no published studies of PEM physician-
(RUSH), describe this evolving use of POCUS. In
performed POCUS for appendicitis in children. Fox
adult patients, Jones et al. [21] noted decreased time
et al. [25] performed a prospective evaluation of the
to definitive diagnosis in patients presenting with
test characteristics of POCUS in the emergency
hypotension of unclear cause who underwent
department, enrolling 132 patients, 42 of whom
immediate POCUS when compared with patients
were below 18 years of age. The study protocol
undergoing delayed POCUS. A similar study in
limited the evaluation to a 5-min scan of the right
pediatric patients would be an excellent way to
lower quadrant and found a sensitivity of 74% and
demonstrate the ability of ultrasound to improve
specificity of 85% in their population.
patient care by guiding therapy. Case reports in
Pyloric stenosis was noted in a case series to be
pediatrics have highlighted this potential appli-
adequately performed by providers with POCUS
cation, but large-scale study is lacking [22,23].
training in other modalities by Malcom et al. [26].
A prospective study of POCUS evaluation of pyloric
PEDIATRIC ABDOMEN stenosis by PEM providers demonstrated sensitivity
and specificity of 100% and 100%, respectively [27].
Ultrasound is increasingly utilized as the first-line
Uninterpretable scans were not included in the
imaging test in the evaluation of suspected appen-
final analysis.
dicitis [24]. Ability to identify an inflamed, dilated,
A prospective study of PEM providers perform-
non-perforated appendix on ultrasound precludes
ing POCUS examination in 82 patients undergoing
the need for a CT scan and the associated risks
evaluation for intussusception noted a sensitivity of
of ionizing radiation. Pyloric stenosis and intussus-
85% and a specificity of 97% when compared with
ception are diseases usually unique to the pediatric &
diagnostic radiology ultrasound [28 ].
population, and both conditions are also diag-
nosed with sonography (Figs. 3 and 4). Many chil-
dren are evaluated for these pediatric abdominal Future directions
diseases during off hours at institutions without Expedited diagnosis of all three abdominal diseases
access to 24-h per day ultrasound capabilities. As a with POCUS by the PEM provider could decrease
result, evaluation and treatment of appendicitis,

FIGURE 4. Ultrasound image of pyloric stenosis: caliper A


FIGURE 3. Ultrasound image of intussusception: transverse measures muscle wall thickness. Measurements greater than
cross-section of the bowel demonstrating the whirling pattern 3 mm are abnormal. Caliper B measures channel length.
created by the invagination of the bowel loops. Measurements greater than 17 mm are abnormal.

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Advances in point-of-care ultrasound Gallagher and Levy

time to definitive treatment and potentially reduce skull fracture significantly increases the risk of intra-
morbidity. The studies evaluating the ability of cranial injury [34]. POCUS for skull fracture as part
POCUS to accurately diagnose these diseases were of a risk stratification algorithm could have a
small, and multicenter investigations are needed. notable impact in honing our ability to reliably
With increased training in these pediatric-specific identify patients who need definitive imaging,
applications, it may be feasible that the general and further study is needed to elucidate this poten-
emergency medicine physician could provide a tial POCUS application.
more definitive evaluation for pediatric patients
and obviate the need for CT or interfacility transfer.
VASCULAR ACCESS
In 2001, the Association for Healthcare Research
SKULL FRACTURES and Quality named ultrasound guidance of central
Evaluation of pediatric head injury aims to identify venous catheter (CVC) placement as one of 11 most
clinically significant intracranial injury while min- underutilized practices that can enhance patient
imizing unnecessary testing. The presence of a skull safety [35]. Prior studies in adults have shown that
fracture increases the risk of intracranial injury sig- ultrasound assistance for CVC placement is associ-
nificantly in pediatric patients with closed head ated with a shorter time to placement, a decrease in
injury. Ultrasound provides an excellent adjunct complication rates and a decrease in number of
in the evaluation of these patients to identify frac- attempts in a variety of clinical settings [36,37]. In
tures without the risks associated with ionizing adult patients, ultrasound guidance has also been
radiation or sedation seen with other imaging shown to improve success rates of peripheral intra-
modalities. Fractures can be identified on ultra- venous catheter (PIV) placement in patients with
sound as a cortical discontinuity along the hyper- difficult access [38].
echoic plane of the skull bone contour. In the
growing pediatric skeleton, suture planes can com-
plicate the identification of fractures, but evaluation Pediatric update
of the contralateral anatomy or tracking suture lines Multiple pediatric studies have demonstrated the
to the fontanelle can clarify image interpretation. superior success rates of CVC placements with the
use of ultrasound guidance. A prospective study
of senior anesthesia residents performing femoral
Pediatric update vein catheterizations for pediatric cardiac surgery
Four recent publications have evaluated the role patients noted improved success rates and shorter
of POCUS in the evaluation of skull fractures time required when compared with landmark tech-
&
[29–31,32 ]. All have been prospective evaluations nique [39]. The use of ultrasound guidance also led
in pediatric emergency departments, and each had a to decreased number of sites attempted and overall
relatively small sample size. Rabiner et al., in the attempts in a pediatric ICU setting [40]. In contrast
most recent study, pooled results from the previous to the established benefit of ultrasound for central
studies with their own data and analyzed the POCUS access, few studies have focused on the role of ultra-
assessment of 185 patients. They demonstrated a sound in PIV placement for children. The largest
sensitivity of 94% and a specificity of 96% for frac- randomized controlled trial evaluated nurses plac-
ture identification in all patients undergoing evalu- ing traditional versus ultrasound-guided PIVs in
ation for skull fracture. In addition to two false- patients who were considered to have difficult
positive cases, the authors noted a false negative access. Training was limited to a brief 15-min didac-
because of a fracture present lateral to the hema- tic, and a two-person technique was utilized. The
toma and encouraged ultrasound imaging of sur- study did not show a statistically significant differ-
rounding bony anatomy. ence in success rate but did show a reduction in
attempts and time for the procedure [41].

Future directions
A recent large, multicenter trial provided an easily Future directions
utilized algorithm to assist clinicians in risk strat- Given the robust data in support of ultrasound
ification of pediatric patients with head injury and guidance for CVCs in adults and children, a pro-
specifically indicated which patients should not spective randomized pediatric study does not seem
undergo head imaging with CT, but had less robust warranted. The role of ultrasound guidance in PIV
recommendations around who definitively should placement in pediatrics, on the other hand, does
[33]. Prior studies have shown that the presence of a warrant further study to determine the potential

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Emergency and critical care medicine

impact of POCUS for establishing vascular access both essential parts of a successful POCUS program
and the patient characteristics that may be most [45]. Future growth of the field will rely not only on
associated with successful ultrasound-guided peri- continued research but also on improvement in
pheral cannulation. departmental infrastructure to ensure high-quality
POCUS.
The next stage of study should broaden focus
ABSCESS not only to explore the ability of PEM providers to
The decision to incise and dissect an area of soft accurately perform POCUS, but also to evaluate the
tissue infection concerning for abscess has typically impact of POCUS on patient outcomes. Very few
been based on history and physical examination pediatric studies have examined the impact of
characteristics. In pediatric patients, who often POCUS on length of stay, patient satisfaction and
require sedation for the procedure, the accuracy of other aspects of patient throughput, but initial
identifying a fluid collection has elevated import- investigations have proved promising [46]. For diag-
ance to mitigate risk and discomfort of unnecessary nostic applications, larger-scale studies are needed
drainage procedures. POCUS provides an added tool to explore outcomes, such as time to the operating
to assess for the presence of a drainable fluid collec- room for surgical conditions or time to intervention
tion and evaluate the surrounding soft tissue. for conditions treated in the emergency depart-
ment.

Pediatric update
Acknowledgements
Two recent pediatric studies have appraised POCUS None.
evaluation of superficial skin and soft tissue infec-
tion. Marin et al. [42,43] provided a 6-h training Conflicts of interest
program for PEM providers, who then performed
There are no conflicts of interest.
independent ultrasound examinations of superficial
skin infections. The authors found that, in soft
tissue lesions without obvious abscess, ultrasound REFERENCES AND RECOMMENDED
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