Rebecca L. Vieira

Bedside Ultrasound in Pediatric Practice

July 1, 2002. Overnight shift in the pediatric emergency department. In 1 room, the fellow is attempting to place a central venous catheter in a 5-year-old boy with presumed septic shock but has been unable to locate the femoral vein with her finder needle. In the next room lies a 7-year-old trauma patient. He is tachycardic with poor perfusion and abrasions on his chest. The team calls for a portable chest radiograph and begins a secondary survey. The resident taps your shoulder. “Can I present a patient?” He describes a 15-year-old girl with lupus complaining of chest pain who is ill appearing, tachycardic, and short of breath. “I ordered labs and chest radiograph.” July 1, 2012. Overnight shift in the pediatric emergency department. In 1 room, the fellow is attempting to place a central venous catheter in a 5-year-old boy with presumed septic shock. Using bedside ultrasound, she makes adjustments with her finder needle until she sees it enter the femoral vein. In the next room lies a 7-year-old trauma patient. He is tachycardic with poor perfusion and abrasions on his chest. The team performs an extended focused assessment with sonography for trauma examination, which reveals free fluid in Morison’s pouch and no pneumothorax. A computed tomography scan of the abdomen is prioritized, and type O negative blood is ordered. The resident taps your shoulder. “Can I present a patient?” He describes a 15-year-old girl with lupus complaining of chest pain who is ill appearing, tachycardic, and short of breath. “I did a bedside ultrasound, and she has a pericardial effusion.” In 2002, many … Address correspondence to Rebecca Vieira, MD, RDMS, Division of Emergency Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: rebecca.vieira{at}childrens.harvard.edu

Pediatric Emergency Medicine Fellow Training in Ultrasound: Consensus Educational Guidelines

The importance of point-of-care emergency ultrasound (EUS) to the practice of emergency medicine (EM) is well established, and mounting research continues to demonstrate how EUS can benefit pediatric emergency department (ED) patients. As members of the EM community, pediatric EM (PEM) physicians should understand the potential value of EUS and seek opportunities to incorporate EUS into their daily practice. Currently, EUS education and training is at an early developmental stage for PEM fellows and varies greatly between programs. The goal of this article is to provide consensus education guidelines and to describe a sample curriculum that can be used by PEM fellowship programs when developing or revising their US training curricula. The authors recognize that programs may be at different stages of EUS development and will consequently need to tailor curricula to individual institutional needs and capabilities. This guideline was developed through a collaborative process between EUS educators and members of the American Academy of Pediatrics Section of EM Fellowship Directors Subcommittee. The guideline includes the following topics: important considerations regarding EUS in PEM, PEM US program framework, PEM US curriculum, PEM US education program, and competency assessment.

Point-of-Care Ultrasonography by Pediatric Emergency Physicians

Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.

An Educational Intervention to Improve Ultrasound Competency in Ultrasound-Guided Central Venous Access.

Objective Ultrasound (US) guidance for central venous catheter (CVC) placement results in improved success and overall safety, but is a new skill for pediatric emergency medicine (PEM) physicians. No study to date has used simulation-based learning to evaluate the ability of PEM providers to perform US-guided CVC placement. Our objective was to assess the competency of physicians in a rarely performed procedure, US-guided CVC placement, before and after an educational intervention using simulation-based mastery learning. Methods We performed a prospective cohort study evaluating change in PEM physician competency in US-guided CVC placement before and after an educational intervention. Subjects participated in a curriculum composed of 3 sessions: an intervention session, a 2-month follow-up session, and a 12-month follow-up session. At each session, subjects were observed using US to guide CVC placement on a simulation model and technical skill was scored using a validated direct-observation checklist. Competency was defined as successfully completing 7 critical items on the checklist. Results Of the 28 PEM physicians participating, competency improved from 32% at preintervention to 93% at 2-month follow-up (difference, 62%; 95% confidence interval, 36%–84%). At 12-month follow-up, competency remained high (85%; difference, 53%; 95% confidence interval, 32%–75%). Conclusions Physician competency in US-guided CVC placement improved with a simulation-based educational intervention, and the effect was maintained over time. This study may serve as a model for outcomes-based education and certification in rarely performed procedures in pediatrics.

Bedside hip ultrasonography in the pediatric emergency department: a tool to guide management in patients presenting with limp.

Abstract We present a case of a 3-year-old girl brought to the emergency department for evaluation of limp after falling off the monkey bars 1 day prior. X-rays of the entire left lower extremity were normal with no evidence of fracture, dislocation, or effusion. Point-of-care ultrasound of the left hip demonstrated a hip effusion, which prompted further imaging, ultimately revealing an occult fracture of the left proximal femoral metaphysis. This case demonstrates the ability of point-of-care ultrasound to guide the management of patients presenting to the pediatric emergency department with musculoskeletal complaints.

Development and evaluation of a program for the use of ultrasound for central venous catheter placement in a pediatric emergency department.

Background A growing body of literature supports the use of ultrasound (US) to assist central venous catheter (CVC) placement, and in many settings, this has become the standard of care. However, this remains a relatively new and uncommonly performed procedure for pediatric emergency medicine physicians. Objectives This study aims to describe the change over time in percentage of CVC procedures performed with US assistance per 10,000 patient visits in a pediatric emergency department. Methods We describe the development of an emergency US program in a pediatric emergency department and investigate how US use for CVC placement in internal jugular and femoral veins changed from July 2007, when US became available, until December 2011. Data related to CVC procedures were obtained from a procedure database maintained for quality assurance purposes. Results The percentage of CVC procedures performed with US assistance increased significantly over time (P < 0.001). Conclusions The development of an emergency US program was associated with significantly increased physician use of US for CVC placement.

Utility of Ultrasound Guidance for Central Venous Access in Children

Background Placement of a central venous catheter (CVC) in a pediatric patient is an important skill for pediatric emergency medicine physicians but can be challenging and time consuming. Ultrasound (US) guidance has been shown to improve success of central line placement in adult patients. Objectives This article aims to review the literature and evaluate the benefit of US guidance in the placement of CVCs, specifically in pediatric emergency department patients, and to review the procedure. Results Four meta-analyses of US-guided CVC placement in adult patients concluded that US guidance reduces placement failure, decreases complications, and decreases the need for multiple attempts. Two studies in the emergency department setting support these conclusions. Pediatric-specific data related to US-guided CVC placement include data suggesting a benefit with US guidance, as well as data indicating no difference in outcome measures when US guidance is used compared with the landmark technique. Conclusions The evidence surrounding US-guided CVC insertion supports its use in adult patients. Pediatric-specific literature is sparse and includes mixed results. As more pediatric emergency physicians adopt the use of point-of-care US, we expect an increase in data supporting its use for CVC placement in pediatric emergency department patients.

Peritoneal fluid localization on FAST examination in the pediatric trauma patient

Objective: To determine the location of intraperitoneal free fluid on FAST exam in pediatric patients undergoing evaluation for trauma. Methods: Retrospective review of all FAST exams positive for intraperitoneal free fluid performed in patients sustaining trauma between August 2009 and February 2016 in an urban pediatric emergency department. Positive results were categorized into one of nine potential intraperitoneal locations; 4 each in the right and left upper quadrants, and the pelvis. Results: One hundred and three complete positive studies were reviewed. The median age of patients was 10 years (IQR 7–14) with 66% being male. Ninety‐five percent had fluid present in the pelvis, 35% had fluid present in the RUQ, and 16.5% had fluid present in the LUQ. Overall, the most frequent location of fluid outside of the pelvis was found at the inferior tip of the liver, present in 83.3% of patients with fluid in the RUQ and 29% of all patients with a positive FAST. Conclusions: The majority of pediatric trauma patients with a positive FAST exam will exhibit free fluid in the pelvis. Particular attention should be directed to the inferior tip of the liver in children as this represents the most common location for fluid collection outside the pelvis.

Bedside ultrasonography in the pediatric emergency department: the focused assessment with sonography in trauma examination uncovers an occult intra-abdominal tumor.

Abstract We present a case of a 3-year-old male with history of minor trauma, who was brought in by ambulance from the playground where he had an acute mental status change and was noted to be hypotensive on initial evaluation. History and examination did not indicate a clear etiology of his symptoms. Point-of-care emergency ultrasonography revealed free fluid in the abdomen and expedited the care of the child’s unexpected intra-abdominal hemorrhage from an occult abdominal tumor. This case demonstrates the ability of practitioners to expedite and focus care with the use of rapid assessment with ultrasonography in the pediatric emergency department.

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.