James W. Tsung

Prospective evaluation of point-of-care ultrasonography for the diagnosis of pneumonia in children and young adults.

OBJECTIVEnTo determine the accuracy of point-of-care ultrasonography for the diagnosis of pneumonia in children and young adults by a group of clinicians.nnnDESIGNnProspective observational cohort study.nnnSETTINGnTwo urban emergency departments.nnnPARTICIPANTSnPatients from birth to age 21 years undergoing chest radiography for suspected community-acquired pneumonia.nnnINTERVENTIONnAfter documenting clinical examination findings, clinicians with 1 hour of focused training used ultrasonography to diagnose pneumonia in children and young adults.nnnMAIN OUTCOMES MEASURESnTest performance characteristics for the ability of ultrasonography to diagnose pneumonia were determined using chest radiography as a reference standard. Subgroup analysis was performed in patients having lung consolidation exceeding 1 cm with sonographic air bronchograms detected on ultrasonography; specificity and positive likelihood ratio (LR) were calculated to account for lung consolidation of 1 cm or less with sonographic air bronchograms undetectable by chest radiography.nnnRESULTSnTwo hundred patients were studied (median age, 3 years; interquartile range, 1-8 years); 56.0% were male, and the prevalence of pneumonia by chest radiography was 18.0%. Ultrasonography had an overall sensitivity of 86% (95% CI, 71%-94%), specificity of 89% (95% CI, 83%-93%), positive LR of 7.8 (95% CI, 5.0-12.4), and negative LR of 0.2 (95% CI, 0.1-0.4) for diagnosing pneumonia by visualizing lung consolidation with sonographic air bronchograms. In subgroup analysis of 187 patients having lung consolidation exceeding 1 cm, ultrasonography had a sensitivity of 86% (95% CI, 71%-94%), specificity of 97% (95% CI, 93%-99%), positive LR of 28.2 (95% CI, 11.8-67.6) and negative LR of 0.1 (95% CI, 0.1-0.3) for diagnosing pneumonia.nnnCONCLUSIONnClinicians are able to diagnose pneumonia in children and young adults using point-of-care ultrasonography, with high specificity.

Accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults.

INTRODUCTIONnInjury is a major cause of death and disability in children and young adults worldwide. X-rays are routinely performed to evaluate injuries with suspected fractures. However, the World Health Organisation estimates that up to 75% of the world population has no access to any diagnostic imaging services. Use of clinician-performed point-of-care ultrasound to diagnose fractures is not only feasible in traditional healthcare settings, but also in underserved or remote settings. Our objective was to determine the accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults presenting to an acute care setting.nnnMETHODSnWe conducted a prospective cohort study of patients aged <25 years that presented to emergency departments with injuries requiring X-rays or CT for suspected fracture. Paediatric emergency physicians with a 1h training session diagnosed fractures by point-of-care ultrasound. X-rays or CT were used as the reference standard to determine test performance characteristics.nnnRESULTSnPoint-of-care ultrasound was performed on 212 children and young adults with 348 suspected fractures. Forty-two percent of all bones imaged were non-long bones. The prevalence rate of fracture was 24%. Overall: sensitivity-73% (95% CI: 62-82%), specificity-92% (95% CI: 88-95%); long bones: sensitivity-73% (58-84%), specificity-92% (86-95%); non-long bones: sensitivity-77% (58-90%); specificity-93% (87-97%); age> or =18 years: sensitivity-60% (39-78%), specificity-92% (87-96%); age<18: sensitivity-78 (65-87%), specificity-93% (87-95)%. Majority of errors in diagnosis (>85%) occurred at the ends-of-bones.nnnCONCLUSIONSnClinicians with focused ultrasound training were able to diagnose fractures using point-of-care ultrasound with a high specificity rate. Specificity rates to rule-in fracture were similar for non-long bone and long bone fractures, as well as in skeletally mature young adults and children with open growth plates. Clinician-performed point-of-care ultrasound accuracy was highest at the diaphyses of long bones, while most diagnostic errors were committed at the ends-of-bones or near joints. Point-of-care ultrasound may serve as a rapid alternative means to diagnose midshaft fractures in settings with limited or no access to X-ray.

A rapid noninvasive method of detecting elevated intracranial pressure using bedside ocular ultrasound: application to 3 cases of head trauma in the pediatric emergency department.

Abstract: Managing pediatric head trauma with elevated intracranial pressure in the acute setting can be challenging. Bedside ocular ultrasound for measuring optic nerve sheath diameters has been recently proposed as a portable noninvasive method to rapidly detect increased intracranial pressure in emergency department patients with head trauma. Prior study data agree that the upper limit of normal optic nerve sheath diameters is 5.0 mm in adults, 4.5 mm in children aged 1 to 15, and 4.0 mm in infants up to 1 year of age. We report the application of this technique to 3 cases of head trauma in the pediatric emergency department.

Feasibility of correlating the pulse check with focused point-of-care echocardiography during pediatric cardiac arrest: A case series

Rapidly determining whether an unresponsive child is in cardiac arrest or in shock, and requiring cardiopulmonary resuscitation can be problematic. The pulse check in children has been shown to be unreliable, not only for laypersons, but also for healthcare providers. The recommendation for checking the pulse in unresponsive children has been eliminated for laypersons in the latest edition of the Emergency Cardiovascular Care guidelines. Thus the decision to initiate cardiopulmonary resuscitation in children, with the goal of delivering effective chest compressions, can be fraught with uncertainty. Despite the use of pediatric advanced life support guidelines developed by the American Heart Association and the American Academy of Pediatrics, management and decision making during resuscitation of children in cardiac arrest can be challenging. Outcomes for out-of-hospital pediatric cardiac arrest remain poor. The decision to end resuscitation in children, often an emotionally charged situation, can also be particularly difficult for physicians. Information from focused point-of-care echocardiography that allows for correlation with the presence or absence of a pulse and real time assessment of resuscitation may help direct and optimize the delivery of resuscitative interventions. We report our preliminary clinical observations of using focused point-of-care echocardiography to correlate with the pulse check during resuscitation in a series of pediatric cardiac arrests.

Point-of-Care Sonographic Detection of Left Endobronchial Main Stem Intubation and Obstruction Versus Endotracheal Intubation

Objective. Determining the correct position of endotracheal tubes in critically ill patients may be complicated by external factors such as noise, body habitus, and the need for ongoing resuscitation. Multiple detection techniques have been developed to determine the correct endotracheal tube position, recently including the use of sonography to evaluate lung expansion and diaphragmatic excursion. These techniques have also been applied to diagnosis of right endobronchial main stem intubation, which may be confused with a unilateral pneumothorax in some cases. Methods. We describe the sonographic findings in a case series of endobronchial main stem intubations and obstruction, highlighting the utility of this sonographic application. Previous literature and future applications are discussed. Results. Sonographic detection of the sliding lung sign, the lung pulse, and diaphragmatic excursion can accurately detect main stem bronchial intubation as well as bronchial obstruction. Conclusions. Clinical use of lung sonography may decrease the need for chest radiography and may allow more rapid diagnosis of main stem intubation and bronchial obstruction.

Prospective application of clinician-performed lung ultrasonography during the 2009 H1N1 influenza A pandemic: distinguishing viral from bacterial pneumonia

BackgroundEmergency department visits quadrupled with the initial onset and surge during the 2009 H1N1 influenza pandemic in New York City from April to June 2009. This time period was unique in that >90% of the circulating virus was surveyed to be the novel 2009 H1N1 influenza A according to the New York City Department of Health. We describe our experience using lung ultrasound in a case series of patients with respiratory symptoms requiring chest X-ray during the initial onset and surge of the 2009 H1N1 influenza pandemic.MethodsWe describe a case series of patients from a prospective observational cohort study of lung ultrasound, enrolling patients requiring chest X-ray for suspected pneumonia that coincided with the onset and surge of the 2009 H1N1 influenza pandemic.ResultsTwenty pandemic 2009 H1N1 influenza patients requiring chest X-ray were enrolled during this time period. Median age was 6.7 years. Lung ultrasound via modified Bedside Lung Ultrasound in Emergency protocol assisted in the identification of viral pneumonia (n = 15; 75%), viral pneumonia with superimposed bacterial pneumonia (n = 7; 35%), isolated bacterial pneumonia only (n = 1; 5%), and no findings of viral or bacterial pneumonia (n = 4; 20%) in this cohort of patients. Based on 54 observations, interobserver agreement for distinguishing viral from bacterial pneumonia using lung ultrasound was ĸ = 0.82 (0.63 to 0.99).ConclusionsLung ultrasound may be used to distinguish viral from bacterial pneumonia. Lung ultrasound may be useful during epidemics or pandemics of acute respiratory illnesses for rapid point-of-care triage and management of patients.

Emergency department diagnosis of pediatric hip effusion and guided arthrocentesis using point-of-care ultrasound.

Children with complaints of hip pain, a painful limp, or refusal to weight bear commonly present to the Emergency Department (ED). The ability to use point-of-care ultrasound in the ED to diagnose a hip joint effusion and to guide arthrocentesis can be helpful to facilitate diagnosis and management of these children. The capsular-synovial thickness of the hip is measured from the anterior bony cortical surface to the posterior surface of the iliopsoas muscle at the concavity of the femoral neck. A capsular-synovial thickness>5 mm, or >2 mm difference compared to the asymptomatic contralateral hip are the described sonographic criteria for hip joint effusion in children. We report on the use of point-of-care ultrasound to diagnose hip effusion and to guide arthrocentesis in a series of pediatric patients presenting with hip pain to the ED.

Original Research: Chest InfectionsFeasibility and Safety of Substituting Lung Ultrasonography for Chest Radiography When Diagnosing Pneumonia in Children: A Randomized Controlled Trial

BACKGROUNDnChest radiography (CXR) is the test of choice for diagnosing pneumonia. Lung ultrasonography (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 suspected of having pneumonia.nnnMETHODSnWe conducted a randomized control trial comparing LUS with CXR in 191 children from birth to 21 years of age suspected of having pneumonia in an ED. Patients in the investigational arm underwent LUS. If there was clinical uncertaintyxa0after ultrasonography, physicians had the option to perform CXR. Patients in thexa0control arm underwent sequential imaging with CXR followed by LUS. The primary outcomexa0was the rate of CXR reduction; secondary outcomes were missed pneumonia, subsequent unscheduled health-care visits, and adverse events between the investigational and control arms.nnnRESULTSnThere was a 38.8%xa0reduction (95%xa0CI, 30.0%-48.9%) in CXR among investigational subjects compared with no reduction (95%xa0CI, 0.0%-3.6%) in the control group. Novice and experienced physician-sonologists achieved 30.0%xa0and 60.6%xa0reduction in CXR use, respectively. There were no cases of missed pneumonia among all study participants (investigational arm, 0.0%: 95%xa0CI, 0.0%-2.9%; control arm, 0.0%: 95%xa0CI, 0.0%-3.0%), or differences in adverse events, or subsequent unscheduled health-care visits between arms.nnnCONCLUSIONSnIt may be feasible and safe to substitute LUS for CXR when evaluating children suspected of having pneumonia with no missed cases of pneumonia or increase in rates of adverse events.nnnTRIAL REGISTRYnClinicalTrials.gov; No.: NCT01654887; URL: www.clinicaltrials.gov.

Feasibility of point-of-care colour Doppler ultrasound confirmation of intraosseous needle placement during resuscitation ☆

INTRODUCTIONnIntraosseous needle insertion for vascular access is a standard procedure used in paediatric resuscitation. The introduction of newer automated intraosseous devices has recently expanded its role to include resuscitation in patients of all ages. Managing resuscitation can be challenging and a misplaced intraosseous needle may confound effective resuscitation. Colour Doppler ultrasound has been recently proposed as a method to confirm intraosseous needle placement. The ability to rapidly determine the correct position of an intraosseous needle during resuscitation would allow the delivery of medication or fluid infusion into the vascular space to be verified, thus optimizing resuscitation. Furthermore, complications from intraosseous infusion extravasating into soft tissues, such as compartment syndrome, or tissue necrosis can be avoided.nnnMETHODSnWe describe the point-of-care sonographic technique and colour Doppler ultrasound findings of intraosseous needle confirmation in a case series of critically ill patients requiring resuscitation, highlighting the utility of this sonographic application.nnnRESULTSnColour Doppler ultrasound detected extraosseous flow in incorrectly positioned intraosseous needles, and intraosseous flow in correctly positioned intraosseous needles in six critically ill patients requiring resuscitation.nnnCONCLUSIONSnThe use of point-of-care colour Doppler ultrasound to determine the location of both manually inserted or automated placement of intraosseous access during resuscitation is feasible, can be rapidly performed, may verify delivery of resuscitative medications or infusions, and avoid complications from extravasation.

Feasibility of Emergency Physician Diagnosis of Hypertrophic Pyloric Stenosis Using Point-of-Care Ultrasound: A Multi-Center Case Series

Hypertrophic pyloric stenosis (HPS) is an acute abdominal emergency in infants that often presents to Emergency Departments. The clinical diagnosis of HPS relies on palpation of an olive-sized mass in the right upper quadrant of an infant with a history of projectile vomiting. However, studies have shown that clinicians cannot detect the olive in 11% to 51% of cases. Ultrasonography is the imaging modality of choice to diagnose HPS. HPS has a highly characteristic sonographic appearance that makes it readily identifiable on ultrasound. To our knowledge, there have been no reports documenting the ability of Emergency Physicians to diagnose HPS using point-of-care ultrasound. We present a multi-center case series (n = 8) of HPS diagnosed by Emergency Physician-performed ultrasound. We review the technique of incorporating point-of-care ultrasound into the physical examination of infants with suspected HPS and discuss the possible role of point-of-care ultrasound in the management of these patients.