Lung Ultrasound to Detect Pneumothorax or Mainstem Intubation

Chapter 2 covers the use of lung ultrasound to detect pneumothorax and mainstem intubation. In healthy patients, a layer of visceral pleura will slide on the parietal pleura with every breath. This can be readily imaged with a handheld ultrasound probe at the point of care, and this information can be used for diagnosis of pneumothorax or mainstem intubation. Lung ultrasound can also help the clinician to visualize pleural effusions or pulmonary edema. When trying to diagnose pneumothorax by imaging, lung ultrasound is more accurate for ruling pneumothorax in (level B evidence) or out (level A evidence) than supine anterior chest radiograph.

Pediatric Musculoskeletal Radiology

Chapter 14 examines radiologic images for common and uncommon pediatric musculoskeletal disorders. These include pediatric fractures such as buckle fractures; bowing and greenstick fractures; growth plate, stress, and elbow fractures; avulsion injuries of the pelvis and hip; knee injuries; and nonaccidental trauma. The chapter goes on to look at infection and inflammation, including osteomyelitis, septic arthritis, transient synovitis, and juvenile idiopathic arthritis. Congenital and developmental disorders covered include developmental dysplasia of the hip, slipped capital femoral epiphysis, Legg-Calvé-Perthes disease, Blount disease, congenital foot deformities, scoliosis, neurofibromatosis, osteogenesis imperfecta, osteopetrosis, and dwarfism. Metabolic disorders include rickets, scurvy, lead poisoning, Gaucher disease, and mucopolysaccharidoses. Neoplastic and other aggressive lesions include osteosarcoma, Ewing sarcoma, osteoid osteoma, eosinophilic granuloma, osteochondroma, enchondroma, nonossifying fibromas/fibrous cortical defects, fibrous dysplasia, aneurysmal bone cysts, and unicameral (simple) bone cysts.

Transversus Abdominis Plane and Rectus Sheath Blocks

Chapter 9 discusses truncal peripheral nerve blocks, which are utilized for supplemental analgesia for abdominal surgeries by providing local anesthesia to the anterior abdominal wall. These blocks are adjuvants because they will not block visceral pain. Unilateral analgesia to the skin, muscles, and parietal peritoneum of the abdominal wall is achieved. The transversus abdominis plane block (TAP) reliably provides analgesia to the lower abdominal wall in the T10–L1 distribution. Rectus sheath blocks anesthetize the terminal branches of the lower thoracic intercostal nerves and provide midline analgesia from the xiphoid process to the umbilicus. Surgical indications for TAP blocks include laparotomies, laparoscopies, inguinal hernia repairs, and appendectomies. Rectus sheath block indications include midline surgeries such as single-port appendectomies and umbilical hernia repairs.

Pediatric Gastrointestinal Radiology

Chapter 12 examines radiologic images for common and uncommon pediatric gastrointestinal disorders. These include neonatal high bowel obstructions such as midgut malrotation and volvulus, duodenal atresia, duodenal web, annular pancreas, and pyloric stenosis. The chapter goes on to look at neonatal low bowel obstruction, including ileal disease such as ileal atresia and meconium ileus and colonic disease such as Hirschsprung disease and meconium plug. We then look at causes of pediatric bowel obstruction in older patients, such as intussusception, appendicitis, enteric duplication cysts, and inguinal hernia. Additional neonatal disorders discussed include necrotizing enterocolitis, and meconium peritonitis. Diseases of the pancreas examined include cystic fibrosis and pancreatitis. Liver tumors reviewed are infantile hepatic hemangioma and hepatoblastoma. Diseases of the biliary system looked at include choledochal cysts and biliary cysts, and biliary atresia. Splenic abnormalities examined include polysplenia and asplenia, heterotaxy syndromes, and sickle cell disease.

Ultrasound Physics and Ultrasound Machine Functionality

Chapter 1 reviews basic ultrasound physics and introduces ultrasound machine functionality. Ultrasound medical imaging (also known as sonography) is a diagnostic imaging tool that uses high-frequency sound waves to create images of structures in the body. It can show details that a still image like a radiograph cannot, such as blood flow or needle guidance to a nerve. Several tools and techniques are useful in acquiring the best ultrasound image. The chapter covers the functions of many ultrasound machine knobs, machine operation, ultrasound operating modes, and ultrasound image optimization. It also examines different types of ultrasound probes and their uses.

Ultrasound Guided Peripheral Intravenous Line Placement Using the Incremental Advancement Method

Chapter 4 discusses the dynamic use of ultrasound to guide the placement of a peripheral intravenous (IV) line. Ultrasound can be used to guide placement of multiple types of vascular access. Arteries and veins are sonographically similar in cross section: hyperechoic circles with hypoechoic interiors. Arteries are thicker walled and characteristically pulsatile. Veins are more susceptible to compression. Doppler or color flow can distinguish the amplitude and direction of flow. Skill with placing peripheral ultrasound guided IV lines in patients with difficult IV access can often help the practitioner avoid the need to place a central line, assuming the central line is not needed for other indications.

Arterial Line Placement

Chapter 5 covers the fundamentals and techniques of arterial line placement, including the palpation technique, ultrasound guided arterial line placement, and the cutdown technique. Arterial line placement involves inserting a catheter into a peripheral artery, most commonly the radial or femoral artery. Arterial lines provide beat-to-beat blood pressure monitoring as well as a readily available means of obtaining blood samples to check arterial blood gas measurements and other labs. Cannulation of the ulnar, brachial, axillary, posterior tibial, dorsalis pedis, and umbilical (in neonates) arteries has also been described, although these sites may be higher risk. Although the techniques described in this chapter focus on the radial, femoral, and posterior tibial approaches, many of the general principles apply to the other arteries as well.

Ilioinguinal and Iliohypogastric Nerve Blocks

Chapter 8 covers ilioinguinal and iliohypogastric nerve blocks. These techniques involve the injection of local anesthetic into the facial layer between the internal oblique and transversus abdominis muscles, with the goal of anesthetizing the nerves that originate from the L1 spinal root. This block provides analgesia to the skin over the lower abdomen where it joins with the upper pelvis, to the upper pelvis, and along the middle portion of the thigh. Historically, a blind technique was utilized, during which the needle was inserted until a palpable “fascial click” was felt. This approach had an estimated 20 to 30% failure rate as well as a higher risk for iatrogenic small bowel and colonic puncture. An ultrasound guided approach reduces the risk for complications and has been shown to be successful, reducing postoperative analgesia requirements as well as reducing the volume of local anesthetic required.

Pediatric Genitourinary Radiology

Chapter 13 examines radiologic images for common and uncommon pediatric genitourinary disorders. These include pediatric congenital disorders such as renal agenesis, autosomal recessive polycystic kidney disease, multicystic dysplastic kidney, horseshoe kidney/cross-fused ectopia, prune belly syndrome, congenital uteropelvic junction obstruction, vesicoureteral reflux, duplicated collecting system, ureterocele, urachal anomalies, bladder exstrophy, and posterior urethral valves. The chapter goes on to look at neuroblastoma and Wilms tumor. Reproductive disorders are also examined, such as ovarian torsion, testicular torsion, epididymo-orchitis, hydrocele, varicocele, testicular tumors, and sacrococcygeal teratoma. This chapter covers the clinical features and anatomy associated with these disorders as well as their diagnosis based on radiologic imaging.

Gastric Ultrasound and Assessment of Gastric Contents in Incompletely Fasted Patients

Chapter 3 discusses the use of gastric ultrasound and assessment of gastric contents in incompletely fasted patients. In children, fasting status can be difficult to ascertain because children may have eaten on the morning of surgery without their parent’s knowledge. In addition, children with disorders such as gastroparesis or incomplete gastric emptying may have increased stomach contents. Although rare, aspiration of gastric contents can occur with general anesthesia or sedation in children, potentially leading to morbidity. Gastric ultrasound can be used preoperatively to assess stomach contents in children when there is a suspicion for gastroparesis, incomplete gastric emptying, or incorrectly reported fasting times.