Paediatric ultrasound

This chapter highlights the increasing use of point-of-care ultrasound (PoCUS) in children. The size and body habitus of infants and children are often ideal for sonographic visualization and make PoCUS an ideal imaging modality for paediatric patients. PoCUS applications that have been traditionally used for adult patients are increasingly being adopted for the care of children. Paediatric-specific applications are also being developed for problems common and unique to paediatrics. Focused abdominal scans for appendicitis, intussusception, and pyloric stenosis are now frequently used in patients presenting with abdominal pain or vomiting. PoCUS can differentiate lung pathology and is helpful in the assessment of suspected skull fractures in non-verbal infants. Ongoing integration of PoCUS into shock, trauma, and triage algorithms support its increasing role in paediatric emergency and critical care.

The abdomen

Abdominal point-of-care ultrasound (PoCUS) for intra-peritoneal fluid in trauma is one of the earliest, and now most accepted, uses of PoCUS in emergency medicine and resuscitation. It is an essential part of the e-FAST (Extended Focused Assessment in Trauma) examination. Abdominal PoCUS can also guide diagnosis and management of right upper quadrant pain and renal colic. PoCUS can also ‘rule in’ (but not ‘rule out’) bowel obstruction and appendicitis. Regardless of the clinical situation, PoCUS is used to answer specific binary questions, rather than to perform an exhaustive survey of the abdomen.

Education and simulation in point-of-care ultrasound

This chapter deals with some of the common questions surrounding training in point-of-care ultrasound (PoCUS)—how does a clinician achieve competence in PoCUS? What educational methods are the most appropriate for PoCUS? What applications should be taught? How can advanced skills be learnt? How can quality be assured and improved? How can low- and high-fidelity simulation help with skills training and maintenance and confidence building, as well as clinical integration and decision-making? Technology is evolving, advancing, and adapting to training needs. While there may be no universally accepted curriculum for training and assessment, a consensus is forming around core theories and practices.

Early pregnancy and pelvic ultrasound

Point-of-care ultrasound (PoCUS) has an important role in the management of vaginal bleeding and/or abdominal pain in early pregnancy. When combined with other clinical parameters, PoCUS enables the treating physician to accurately confirm the presence of an early intrauterine pregnancy (IUP). This chapter provides a suggested algorithm for the use of bedside ultrasound and clinical findings to safely assess patients with first-trimester pregnancy pain or bleeding and rule out an ectopic pregnancy. Both trans-abdominal and trans-vaginal approaches are described in detail.

The chest

Lung ultrasound is more accurate than clinical examination and chest X-ray for pleural disease (e.g. pneumothorax, pleural effusion) and pulmonary disease (e.g. consolidation, pulmonary oedema/fibrosis). Begin with a curved probe with the depth set at 15 cm and with the probe placed perpendicular to the ribs, with ‘filters’ (tissue harmonics and compounding) ideally turned off. M-mode may assist but normally is not required. Change to a linear probe for fine detail (pleural space and subpleural consolidation). Doppler is not normally recommended but has been used to differentiate pleural fluid from thickening and to differentiate the causes of consolidation.

The heart and resuscitation

Focused echocardiography and point-of-care ultrasound are becoming core skills for doctors working in acute care and arguably a key skill set for those with an interest in resuscitation medicine. Echo is the most useful test now available to define the aetiology of shock and to guide fluid/cardiac resuscitation. This chapter aims to teach the core and intermediate skills required to perform echo as non-cardiologists. These skills do not replace the need for a cardiology opinion or a detailed assessment by a trained sonographer or cardiologist, but simply enable those caring for patients to obtain key real-time information as rapidly as possible. The chapter’s focus is not on comprehensive assessment, but on rapidly identifying the causes of shock and acute heart failure and guiding therapy. The emphasis is therefore different from that found in dedicated textbooks on echocardiography written for trainees in cardiology and is at a simpler level.

Introduction and clinical scenarios

Point-of-Care Ultrasound in Emergency Medicine and Resuscitation provides a curriculum-based guide to the integration of ultrasound into everyday practice for clinicians in emergency medicine and critical care medicine and for resuscitation. In addition to describing commonly used protocols, we focus on how ultrasound can be used to help to answer specific clinical questions and provide guidance for procedures at the point of care, augmenting traditional clinical skills. This chapter introduces the general concepts of using ultrasound at the bedside, describes how to use point-of-care ultrasound (PoCUS), and provides clinical scenarios as examples of where PoCUS can improve clinical care.

Pre-hospital point-of-care ultrasound

Over the last two decades, ultrasound has evolved from a modality reserved to certain medical specialties into its current state, with a diversity in both the operator background and clinical applications. This has, in large part, been due to the increasing portability and image quality of ultrasound machines, combined with decreased cost of systems, as well as the fact that physicians from different specialties can become very adept at using ultrasound for diagnostic and procedural applications relevant to their medical field. These characteristics add the aspect for operators to make bedside diagnostic and therapeutic decisions in real time, without having to take the patients out of their environment. Point-of-care ultrasound is therefore a particularly attractive modality in pre-hospital settings as an extension of the comprehensive Airway, Breathing, Circulation, Disability, and Exposure/Extremities (ABCDE) resuscitation.

Ultrasound and procedures

Using ultrasound as an adjunct to a clinical procedure is widespread. This aspect of PoCUS has allowed clinicians to improve the speed and safety of a wide variety of procedures that are performed at the patient’s side, as well as in more traditional interventional environments. There is a large evidence base demonstrating improved safety when ultrasound is used to guide procedures, and this has resulted in widespread adoption by many specialties. Needle guidance to a specific target area is key to the majority of procedures. This chapter will describe the principles required for safe needle guidance and will outline the specific procedures where ultrasound can aid the clinician.

Small parts ultrasound

Small parts ultrasound is the use of PoCUS to evaluate many of the superficial organs such as the eyes, testes, and thyroid gland, among others. Patients presenting with eye complaints display a wide spectrum of pathology, from benign conditions to serious pathology that, if not recognized and treated in a timely fashion, can result in severe sequelae. In emergency medicine, scanning the orbital contents for ophthalmic emergencies, such as retinal detachment, as well as the scrotum and testes for conditions such as testicular torsion are commonly used small parts PoCUS indications.