We have started partnering with EB Medicine to provide you with some great content. For our first post, we will cover the use of point of care ultrasound (POCUS) for the pediatric trauma patient.
Before we dive into the content make sure to click this link to access the article (Pediatric Trauma EXTRA!) that we are referencing for free! Please note, if you do not have a subscription with EB Medicine you will not be able to get the associated CME. However, check out the end of our show notes to learn how you can get access and at a great discount.
The publication with EB Medicine is 50 pages of excellent content so we will focus on the highlights. We commonly use POCUS in both adult and pediatric patients given its ability to rapidly diagnose patients at the bedside, improve patient throughput, avoiding radiation (especially important in children), being accessible in austere environments (including the prehospital realm), and overall increased access thanks to less expensive technology being available. Training is also becoming a part of many educational programs as well as being made more available to those who are already clinically practicing.
A significant portion of the literature on ultrasound, particularly for trauma, has been derived from adults. However, more data is becoming available on pediatric patients including some roles that may be more unique to them such as diagnosing certain fractures. Two such fractures that are specifically covered in this issue of EB Medicine are skull fractures and forearm fractures.
Skull x-rays are only 38% sensitive based on a BMJ paper but do have 95% specificity. Rabiner et al. pooled data and found a sensitivity of 94% and a specificity of 96% with ultrasound. A 2013 study by Parri et al. found this to be even higher with a 100% sensitivity and 95% specificity with only one false positive. The finding of a skull fracture, especially by ultrasound, can help us further risk stratify patients and their potential need for other imaging such as CT or MRI.
In the realm of forearm fractures, the one we usually discuss is the distal radius. There have been multiple small studies but in a meta-analysis of studies through July 2015 by Chartier et al. they found a sensitivity and specificity of approximately 93%. Gordian et al. in 2017 compared this and other skeletal injuries to "standard imaging" (X-ray, CT, MRI) and found that ultrasound to be comparable. Additionally, ultrasound can help with successful reductions with this being effective in up to 94% of cases.
There are certain pitfalls to consider when using POCUS on children. An easy example is with forearm fractures in particular. When looking for a fracture, we are looking for a disruption of the cortex. Joints and growth plates will also appear as disruptions of the cortex. However, these are smooth, curved ends. The fracture should looked jagged. When in doubt, compare the contralateral side. See the above examples for further review.
While discussed in the EB Medicine issue, POCUS assessment of the IVC should not be used as the sole assessment for hydration status in children. The data is limited and of debate in adults, but there is even less to support the practice of IVC evaluation in children. However, as future studies are completed this may change practice.
Classically, in trauma, the extended focused assessment with sonography in trauma (eFAST) has become a staple of emergency medicine. It is a relatively easy exam to perform and can help significantly in patient management especially in resource limited environments. Traditionally, the abdominal portion of the exam is to look for free fluid. However, this exam in pediatric patients has been shown to be unreliable. In a study by Scaife et al in 2013 it was found that a third of these patients will have a falsely negative exam. As other articles have discussed, this does not necessarily mean we should get rid of the eFAST exam but rather be wary of the negative exams and use this more as a "rule-in" tool.
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