Alexander C. Arroyo

Tracheal rapid ultrasound saline test (T.R.U.S.T.) for confirming correct endotracheal tube depth in children.

OBJECTIVE We evaluated the accuracy of tracheal ultrasonography of a saline-inflated endotracheal tube (ETT) cuff for confirming correct ETT insertion depth. METHODS We performed a prospective feasibility study of children undergoing endotracheal intubation for surgery. Tracheal ultrasonography at the suprasternal notch was performed during transient endobronchial intubation and inflation of the cuff with saline, and with the ETT at a correct endotracheal position. Ultrasound videos were recorded at both positions, which were confirmed by fiberoptic bronchoscopy. These videos were shown to two independent blinded reviewers, who determined the presence or absence of a saline-inflated cuff. The primary outcome was accuracy of tracheal ultrasonography for appropriate ETT insertion depth. RESULTS Forty-two patients were enrolled. For correct endotracheal versus endobronchial positioning, pooled results from the reviewers revealed a sensitivity of 98.8% (95% CI=90-100%), a specificity of 96.4% (95% CI=87-100%), a PPV of 96.5% (95% CI=87-100%), a NPV of 98.8% (95% CI=89-100%), a positive likelihood ratio of 32 (95% CI=6-185), and a negative likelihood ratio of 0.015 (95% CI=0.004-0.2). Agreement between reviewers was high (kappa co-efficient=0.93; 95% CI=0.86 to 1). The mean duration of the ultrasound exam was 4.0s (range 1.0-15.0s). CONCLUSIONS Sonographic visualization of a saline-inflated ETT cuff at the suprasternal notch is an accurate and rapid method for confirming correct ETT insertion depth in children.

Clinician-performed abdominal sonography

IntroductionPoint-of-care ultrasonography is increasingly utilized across a wide variety of physician specialties. This imaging modality can be used to evaluate patients rapidly and accurately for a wide variety of pathologic conditions.MethodsA literature search was performed for articles focused on clinician-performed ultrasonography for the diagnosis of appendicitis, gallbladder disease, small bowel obstruction, intussusception, and several types of renal pathology. The findings of this search were summarized including the imaging techniques utilized in these studies.ConclusionClinician performed point-of-care sonography is particularly well suited to abdominal applications. Future investigations may further confirm and extend its utility at the bedside.

Inflating the endotracheal tube cuff with saline to confirm correct depth using bedside ultrasonography.

Although bedside ultrasonography can accurately distinguish esophageal from tracheal intubation, it is not used to establish the correct depth of endotracheal tube insertion. As indirect sonographic markers of endotracheal tube insertion depth have proven unreliable, a method for visual verification of correct tube depth would be ideal. We describe the use of saline to inflate the endotracheal cuff to confirm correct endotracheal tube depth (at the level of the suprasternal notch) by bedside ultrasonography during resuscitation. This rapid technique holds promise during emergency intubation.

Idiopathic infant pyocele: a case report and review of the literature.

BACKGROUND Pyocele is a rare emergent urologic condition that requires rapid recognition and treatment to prevent testicular loss. Cases of pediatric pyocele have not been previously reported in the emergency medicine literature. CASE REPORT We describe a case of a 6-week-old male who presented to the emergency department for a sepsis evaluation. The patient displayed subtle scrotal findings but had an otherwise benign physical examination. Subsequent sonographic imaging suggested a possible scrotal abscess and surgical exploration revealed a pyocele. A literature review of previously reported cases of patients with pyocele is also presented. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: A pyocele is a rare cause of both an acute scrotum and neonatal fever. It is important for emergency physicians to consider this entity when evaluating pediatric patients with fever, particularly those with symptoms related to the scrotum.

The use of point of care ultrasound in the evaluation of pediatric soft tissue neck masses

OBJECTIVE Most soft tissue neck masses represent benign inflammatory or infectious processes; however, in some cases the diagnosis is not clear and a broader differential must be considered. The aim of this study was to compare point-of-care ultrasound (POCUS) to radiology department imaging (RDI) in the diagnosis of soft tissue neck masses. METHODS This prospective pilot study involved a convenience sample of patients ranging in age from 1 month to 18 years of age presenting to the Pediatric Emergency Department (PED) with a soft tissue neck mass. All children who presented to the PED with soft tissue neck mass at times when an investigator was in the department, and who were candidates for enrollment, underwent a POCUS. The managing pediatric emergency medicine (PEM) provider determined whether RDI was indicated. The results of the POCUS sonologist and radiologist were compared. The kappa statistic was used to analyze agreement with p < 0.05 denoting statistical significance. RESULTS Twenty-seven patients were enrolled into the study. Twenty-two received radiology ultrasound (RUS), 3 patients received CT, and 2 patients received both RUS and CT. There was agreement between POCUS and RDI diagnoses in 21/27 cases (78%). Accordingly, overall concordance between POCUS and RDI diagnoses was good: the kappa statistic comparing diagnoses obtained by POCUS versus RDI was 0.69 (p < 0.001). CONCLUSION This prospective pilot study describes the reliability of POCUS as an imaging modality in the management of patients with undifferentiated soft tissue neck masses. POCUS demonstrated good agreement with RDI as a bedside imaging tool in the evaluation of pediatric soft tissue neck masses.

Erratum to: Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

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 Pedi‐ atrics 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.