Joanna S. Cohen

Sports-related concussions in pediatrics

Purpose of review Mild traumatic brain injury (mTBI) accompanied by concussion is a common presenting complaint among children presenting to emergency departments (EDs). There is wide practice variation regarding diagnosis and management of sports-related concussions in children. Our aim is to review the most recent evidence and expert recommendations regarding initial diagnosis and management of sports-related concussions in children. Recent findings Previous classifications and return-to-play guidelines for sports-related concussions in children were inadequate and have been abandoned. The most recent recommendations, from the Third International Conference on Concussion in Sport (CIS), reinforce an individualized evaluation of the athletes neurocognitive functioning, symptoms and balance. They further reinforce a step-wise approach in the return-to-play process once neurocognitive function has returned to baseline and all symptoms have resolved. The need for a standardized and objective tool to aid in the initial evaluation and diagnosis of mTBI in the clinical setting led to the development of the Acute Concussion Evaluation (ACE) protocol, which is currently being modified for specific use in the ED. Computed tomography (CT) in the acute setting is not likely to be useful for children with mTBI. Newer functional imaging techniques may prove relevant in the future. Summary Further research on both the incidence of sports-related concussions in children and management paradigms is needed. The role of novel imaging modalities in clinical assessment also needs to be elucidated. An individualized approach to evaluation and management of sports-related concussions is recommended. It should incorporate standard symptom assessment, neuropsychological testing and postural stability testing.

Bedside ultrasound education in pediatric emergency medicine fellowship programs in the United States.

Objectives As the use of bedside ultrasound becomes more prevalent in pediatric emergency departments, the need for a national curriculum for fellows’ training in pediatric emergency medicine (PEM) has increased. The objectives of this study were to describe the current state of bedside ultrasound education among existing PEM fellowship programs and to explore the interest in a national curriculum. Methods A 20-question survey was sent to all 57 PEM fellowship directors in the United States in February 2011. Weekly reminders were sent for 4 weeks. Results The response rate was 58% (33/57). Although 91% of respondents reported having an ultrasound machine available, only 16% reported an ultrasound curriculum designed specifically for PEM. Another 25% reported no curriculum, and 28% use a curriculum designed for general emergency medicine physicians. Most (>83%) directors thought an ultrasound curriculum for PEM fellows should include the focused assessment with sonography for trauma, bladder size assessment, soft tissue foreign body localization, skin and soft tissue infection evaluation, guidance for central and peripheral line insertion, and arthrocentesis. Some directors (40%–68%) thought that cardiac ultrasound, thoracic ultrasound, abdominal ultrasound, lumbar puncture guidance, fracture reduction, nerve blocks, and testicular ultrasounds should also be included. Forty-two percent plan to create a bedside ultrasound curriculum in the next 5 years, and 40% reported the lack of a national curriculum as a barrier to creating a curriculum. Conclusions Bedside ultrasound use in pediatric emergency departments is very common, and PEM fellowship directors would welcome the development of a standard curriculum.

Ultrasound-guided intra-articular lidocaine block for reduction of anterior shoulder dislocation in the pediatric emergency department

Abstract We report a case of successful reduction of an anterior shoulder dislocation after ultrasound-guided intra-articular lidocaine (IAL) block with subsequent sonographic confirmation of reduction. Current literature suggests that IAL can provide similar levels of analgesia as intravenous sedation, and IAL block is associated with lower complication rates and shorter emergency department stays. However, these studies may be limited by uncertainty about the accuracy of landmark-based glenohumeral injections. The use of beside ultrasound may improve the effectiveness of IAL block for reduction of anterior shoulder dislocation and provide a mechanism for immediate postreduction evaluation of the placement of the humeral head.

ULTRASOUND-GUIDED ARTHROCENTESIS OF THE ELBOW: A POSTERIOR APPROACH

BACKGROUND Identification of fluid in the elbow joint by physical examination alone can be challenging. Ultrasound can assist in the diagnosis of elbow effusion, and guide aspiration of the effusion. OBJECTIVES We illustrate the anatomy and ultrasound guidance technique of a posterior approach to elbow arthrocentesis using examples of normal and pathologic elbow joint ultrasound images. DISCUSSION The posterior distal humerus at the level of the olecranon fossa provides an excellent acoustic window into the joint space. This location also provides a safe path for the performance of ultrasound-guided arthrocentesis. CONCLUSION Ultrasound-guided arthrocentesis of the elbow from a posterior approach is a helpful technique to guide the aspiration of the painful swollen elbow.

P-Glycoprotein Transporter Expression on A549 Respiratory Epithelial Cells Is Positively Correlated With Intracellular Dexamethasone Levels

Background Several mechanisms of glucocorticoid resistance in asthma have been proposed. P-glycoprotein (P-gp), a ubiquitous efflux transport protein, is associated with variability in the disposition of many drugs and interindividual variability in drug treatment response. This study was undertaken to determine the effect of P-gp expression on glucocorticoid efflux from airway epithelial cells. Hypothesis Decreasing respiratory epithelial P-gp expression in dexamethasone-exposed airway epithelial cells in vitro will increase intracellular dexamethasone concentration. Methods A549 lung epithelial cells, transfected with small interfering RNA (siRNA) targeted at messenger RNA for the gene encoding P-gp, were exposed to 100-nM dexamethasone for 15 minutes. Transfection efficiency of siRNA, P-gp expression, and intracellular dexamethasone were measured with flow cytometry. Results Cells transfected with both negative siRNA and siRNA targeted at P-gp exhibited a positive correlation of P-gp expression with intracellular dexamethasone. The mean ± SEM correlation coefficients were 0.78 ± 0.07 for cells transfected with negative siRNA and 0.79 ± 0.08 for cells transfected with siRNA targeted at P-gp. Discussion Contrary to our hypothesis, the positive correlation between P-gp expression and intracellular dexamethasone suggests that P-gp is not a primary transporter of glucocorticoids from airway epithelial cells. Increased P-gp expression is unlikely to be an important mechanism of glucocorticoid resistance in asthma.

US Emergency Department Trends in Imaging for Pediatric Nontraumatic Abdominal Pain.

This cross-sectional study explores national trends in ED use of diagnostic imaging for nontraumatic abdominal pain from 2007 to 2014. OBJECTIVES: To describe national emergency department (ED) trends in computed tomography (CT) and ultrasound imaging for the evaluation of pediatric nontraumatic abdominal pain from 2007 through 2014. METHODS: We used data from the National Hospital Ambulatory Medical Care Survey to measure trends in CT and ultrasound use among children with nontraumatic abdominal pain. We performed multivariable logistic regression to measure the strength of the association of ED type (pediatric versus general ED) with CT and ultrasound use adjusting for potential confounding variables. RESULTS: Of an estimated 21.1 million ED visits for nontraumatic abdominal pain, 14.6% (95% confidence interval [CI], 13.2%–16.0%) had CT imaging only, 10.9% (95% CI, 9.7%–12.1%) had ultrasound imaging only, and 1.9% (95% CI, 1.4%–2.4%) received both CT and ultrasound. The overall use of CT and ultrasound did not significantly change over the study period (P trend .63 and .90, respectively). CT use was lower among children treated in pediatric EDs compared with general EDs (adjusted odds ratio 0.34; 95% CI, 0.17–0.69). Conversely, ultrasound use was higher among children treated in pediatric EDs compared with general EDs (adjusted odds ratio 2.14; 95% CI, 1.29–3.55). CONCLUSIONS: CT imaging for pediatric patients with nontraumatic abdominal pain has plateaued since 2007 after the steady increase seen in the preceding 9 years. Among this population, an increased likelihood of CT imaging was demonstrated in general EDs compared with pediatric EDs, in which there was a higher likelihood of ultrasound imaging. Dissemination of pediatric-focused radiology protocols to general EDs may help optimize radiation exposure in children.

Incidental renal mass found on focused assessment with sonography in trauma

AbstractWe present the case of a 9-year-old female who presented after minor blunt abdominal trauma during a sporting event. On focused assessment with sonography for trauma, she was found to have an incidental renal mass, which was ultimately diagnosed as a renal cell carcinoma. In this report, we focus on the use of bedside ultrasound as a screening test and the management of incidental findings.

Diagnosis of an Intraventricular Cyst Using Point-of-Care Cranial Ultrasound in the Pediatric Emergency Department.

Abstract A 2-month-old previously healthy male infant presents with 2 days of unusual eye movements and increased fatigue. During evaluation in the pediatric emergency department, point-of-care cranial ultrasound identified a cyst-like mass. Subsequent magnetic resonance imaging confirmed the presence of a cyst within the third ventricle causing obstructive hydrocephalus.

The Utility of Bedside Lung Ultrasound Findings in Bronchiolitis.

Objectives Recent literature suggests that bedside lung ultrasound may have a role in the evaluation of infants with bronchiolitis. B lines, which are multiple and diffuse vertical artifacts spreading from the lung pleural interface to the edge of the ultrasound screen, have been associated with thickened interlobular septa, extravascular lung water, and diffuse parenchymal disease. The aims of this study were (1) to describe the prevalence of B lines in children younger than 24 months presenting to the emergency department with wheezing, (2) to determine the interrater reliability of lung ultrasound findings in this setting, and (3) to determine the association of B lines with atopy and other clinical findings. Methods This was a pilot, prospective, observational study of a convenience sample of patients younger than 2 years presenting with wheezing to a large academic pediatric hospital emergency department. Investigators performed lung ultrasound examinations, and a second provider reviewed the ultrasound examinations to determine interrater reliability. We performed univariate analyses to test for associations between ultrasound findings and atopy, acute illness severity, age, and treatment response. Results Studies were obtained on 29 patients (mean [SD] age, 291 [187] days; 62% male). Twenty-one patients (72%) had compact B lines. B lines were significantly associated with older age and an absence of atopic features. There was poor correlation of lung ultrasound examination interpretation among enrolling providers. Conclusions In this small sample of patients with bronchiolitis, B lines were associated with older age and an absence of atopic features. Lung ultrasound interpretation had poor interrater reliability.