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- All right, I think we'll go ahead and get started here.

So my name is Chris Pennell.

I'll be moderating this webinar today.

The Sonosite webinar is called, A Point-of-Care Ultrasound

for Diagnosing Pediatric Appendicitis.

Before we begin, please be advised

that all attendees are muted.

You can type your questions into the Q&A box at the toolbar,

located at the bottom or side of your screen,

and we'll conduct a Q&A session

at the end of this presentation.

This webinar will be recorded

and archived for future reference as well.

Here with us today we have Dr. Marla Levine.

Dr. Levine is the director of Point-of-Care Ultrasound

at Monroe Carrel Jr. Children's Hospital at Vanderbilt.

She's also an associate professor of pediatrics

at Vanderbilt University.

Dr. Levine is boarded in pediatrics

and pediatric emergency medicine,

and she completed an emergency ultrasound fellowship

following her PEM training.

Dr. Levine has been an educator in Point-of-Care Ultrasound

or POCUS for the last 10 years,

having lectured locally, nationally and internationally

on POCUS in the care of children.

Her academic interests include POCUS education,

medical education, and gender equity issues.

She recently published an expert panel curriculum tool

for PEM POCUS Fellowship,

and has recently published a PEM POCUS Competency Checklist

for POCUS within PEM Fellowship.

Dr. Levine, we're super excited to have you here with us,

so I'll go ahead and turn it on over to you.

- Thank you so much for having me.

I want to thank you all for being here,

and I want to thank Sonosite for inviting me to speak.

So today we're going to be talking about

Point-of-Care Ultrasound

for diagnosing pediatric appendicitis.

And for those of us who do Point-of-Care Ultrasound,

this is an application that is a favorite.

It is a challenging application to do,

but once you become good at it,

it is incredible how it can change your practice.

So with that, we will begin.

The only disclosure that I need to make

is that I'm speaking on behalf of myself,

and I am not speaking on behalf of Vanderbilt University

or Vanderbilt University Medical Center, or Monroe Carrel.

And the contents of this lecture

are not proprietary of Vanderbilt.

The objectives of this talk,

we're going to discuss appendicitis

and its clinical significance.

We're going to discuss the history of appendicitis imaging.

We're going to review relevant literature

that describes Point-of-Care Ultrasound for appendicitis.

And then hopefully through a case-based approach,

you're going to understand how to use Point of Care Ultrasound

in the diagnosis of appendicitis.

To start us off, we'll go through a case.

So this was a previously healthy seven-year-old male,

whose immunizations were up to date,

and he presented to the emergency department

with abdominal pain

that started approximately 36 hours prior to presentation.

Mother reports the child had three episodes,

of non bilious, non bloody vomiting over the last day.

He also had a single episode of diarrhea.

Mother denies a history of cough or congestion or fever,

and she does note that he's had

a slight decrease in oral intake.

His past medical history is notable for constipation,

he has no history of any surgeries,

and family history is non-contributory.

So on a review of systems,

we have a child who's reporting abdominal pain

that's localized to the periumbilical region.

Three episodes of non bilious, non bloody vomiting,

so mild decrease in oral intake, normal urine output,

diarrhea, and somewhat decrease in activity level.

On physical exam, his vital signs are fairly normal,

his general assessment is he looks tired, non-toxic,

and no signs of dehydration, but he is lying still in bed.

His ENT exam is normal.

Lungs are cleared auscultation,

his cardiac exam notes regular rate and rhythm.

On abdomen exam, you note that his belly is soft,

but he does have tenderness all along the right side,

so both the right upper and right lower quadrant

with point of maximal tenderness

at the periumbilical region.

His genital urinary exam is normal,

non-tender testicles bilaterally,

and he has normal strength, and distal pulses are normal.

On our workup, we order an IV, and order some labs.

He receives some Zofran and a normal saline bolus,

and we give him some morphine, and imaging is ordered,

so a radiology ultrasound is ordered.

But we have ultrasound skills.

And when I saw this patient, I had already had

almost a complete year of my ultrasound fellowship,

so I already felt fairly confident

in doing Point-of-Care Ultrasound on my patients.

So I decided, you know what, let's bring the ultrasound

to the child's bedside, and see what we could find

before the child was called for radiology ultrasound.

And lo and behold, on imaging,

we found a circular structure in the right lower quadrant

that had fairly defined wall.

There's some fat stranding surrounding the structure,

and this was in fact his appendicitis,

the cause of his pain was identified.

We measured the structure, and it measured 0.94 centimeters.

So size parameter,

and we'll discuss this later in the lecture,

but by size criteria,

a structure greater than six millimeters or 0.6 centimeters

is consistent with appendicitis.

So we had our size parameter.

Then we rotated the probe,

and found the long axis of this structure,

and noted that it had a blind end.

So we had made the diagnosis of appendicitis

even before this child was called to go to radiology

for his ultrasound.

So we made the diagnosis,

and we were able to cancel a radiology ultrasound.

And I contacted the surgeon,

who at that point I had been working with,

and he had seen the skills that I had acquired

in Point-of-Care Ultrasound for appendicitis,

and he booked the child for an appendectomy.

And so child was taken to the operating room,

only with our bedside ultrasound

as the single imaging modality.

What was really interesting is,

the image on the left was the image that I sent the surgeon,

and approximately an hour

after the child left our emergency department,

he sent me a text message with the image on the right,

so that was his appendicitis.

So this is a really beautiful example

of how bedside ultrasound can really change,

or rather positively influence

your medical management of patient.

And this allowed for a fairly expeditious

movement of the child from the emergency department

to the operating room.

So let's talk a little bit about appendicitis.

Abdominal pain is a very common presenting chief complaint

to emergency departments amongst children.

In 2013, the National Hospital

Ambulatory Medical Care Survey

estimated approximately 800,000 annual abdominal pain visits

in children under the age of 15.

Also, appendicitis is the most common surgical cause

of abdominal pain in children.

But here's the rub,

appendicitis can have very variable symptomatology,

and this is what presents the challenge for us

in pediatric emergency medicine,

or pediatrics, or emergency medicine.

Additionally, missed appendicitis

is one of the most successful malpractice claims

brought against emergency physicians and pediatricians.

So a little history lesson, so how did we get to today?

Well, once upon a time,

we actually didn't know what appendicitis was.

In fact, Boerhaave described in 1709,

this discomfort that people had reported

in the right lower quadrant as, and I quote "iliac passion."

The treatment at the time was bloodletting, enemas,

and various tinctures.

In 1735, Claudius Amyand was actually the first person

to perform an appendectomy.

It was fairly accidental,

he was doing a hernia correction on an 11-year-old

who had developed a fistula connection,

probably from prior appendicitis.

And at surgery, he removed the appendix.

In 1886, Reginald Fitz, who was actually a pathologist,

published a study on appendicitis,

and actually named the procedure for removing the appendix,

the appendectomy, and his research came from

studying autopsies of patients who had died of appendicitis.

And then 100 years later, Pyelert, in 1986,

was the first to describe how we could use ultrasound

to actually see the appendix.

This was a landmark study,

nobody had ever used ultrasound prior to this time,

and he described that in order to see the appendix,

you actually have to displace bowel gas,

and see the anatomy, which means you have to apply

a graded compression approach,

and we're going to discuss this a little bit more

throughout this lecture.

Prior to the 2000s, appendicitis was really a diagnosis

that was made clinically.

The provider would palpate the abdomen and based on history

and the physical exam, children would be taken,

actually not just children, all patients with appendicitis

would be taken to the OR.

And then in around the 2000s, it began to be understood

that maybe this 20% to 25% negative appendectomy rate,

or negative appendectomy rate,

meaning that 20% to 25% of normal appendixes

were being removed,

maybe we should change things a little bit,

maybe we should get some sort of confirmation

before taking patients to the operating room

to confirm that in fact they had appendicitis.

And in the 2000s, CT scans became fairly standard.

Most patients who were being evaluated for appendicitis

got an CT scan.

So we were able to decrease the negative appendectomy rate,

but we were now exposing many more patients

to ionizing radiation.

And in around the 2000s, we began to really appreciate

that maybe this wasn't the best idea.

That subjecting children and young adults

to high doses of radiation for valuation of appendicitis

may not be best for the patient.

And this concept of as low as reasonably achievable

became part of our understanding.

And so in the last 10, eight years, a lot of institutions

have been moving more towards clinical practice guidelines

and using things like the Pediatric Appendicitis Score,

or the Alvarado Score to use clinical markers

as well as physical exam findings to decide which children,

which patients need to have further imaging

to diagnose their appendicitis.

So it was once a clinical diagnosis,

now, really does require some form of imaging

to make the diagnosis.

Now here's the clinical conundrum.

With appendicitis, you can have fever,

abdominal pain, vomiting, diarrhea, or anorexia.

But all of these could also be present with viral illnesses.

So the differential diagnosis is quite large.

I would argue migration of abdominal pain

is a fairly specific marker for appendicitis.

So if you have a patient reporting that they had

non-specific abdominal pain

that migrated to the right lower quadrant,

that's pretty suggestive of appendicitis.

Additionally, your physical exam could be very nonspecific.

Patients with appendicitis can present

with lower quadrant abdominal pain,

periumbilical abdominal pain, epigastric abdominal pain,

Suprapubic abdominal pain, even groin or hip pain.

And no specific location of the pain

is particularly sensitive, or specific for appendicitis.

Again, if your patient has hop tenderness,

meaning if they jump and they endorse pain

in the right lower quadrant,

that is a finding, a physical exam finding

that is quite suggestive of appendicitis.

Okay, adding to the clinical conundrum

is, younger children are not able

to really express the experience that they're having,

and so often, they go undiagnosed when symptoms first start,

and once they present to you in the emergency department,

they often already have rupture and peritonitis.

They may present with respiratory symptoms

secondary to sepsis, they may have abdominal pain,

they may refuse to ambulate.

They often look a lot sicker

than had they come in when symptoms started.

Often the initial symptoms of fever, abdominal pain,

vomiting, and diarrhea go misdiagnosed as a gastroenteritis,

or a viral illness, 'cause we're not always expecting

this younger subset of patients to have appendicitis,

and so they're often missed.

So how do we mitigate the conundrum?

Well, we use objective findings.

So history and physical exam.

In the younger children,

you'll get the history from parents obviously,

and then the physical exam.

We have also started to use labs more regularly.

So getting a CBC and a CRP.

And the scoring systems,

either the Pediatric Appendicitis Score in children,

or the Alvarado Score in adults, are quite helpful

in scoring the likelihood of appendicitis,

or those patients who should get some form of imaging

to confirm the diagnosis is quite helpful.

And then you have a choice in imaging,

there's ultrasound, CT, or MRI.

So the options are available to you as the provider,

obviously we're here to discuss ultrasound,

and ultrasound is for most of us the preferred

method of diagnosing appendicitis.

But unfortunately, while it is the safest imaging modality,

it is at risk of operator dependence,

it's operator dependent.

So if you have an excellent sonographer

who is very, very skilled at finding appendixes

on ultrasound,

then you're in great shape.

You'll have very, very positive and strong

test characteristics.

However, if you have a novice sonographer who is not great,

then you may be in a situation

where you're going to have to get

some other form of imaging to confirm your diagnosis.

And the traditional other imaging modalities,

for most places it is a CT scan that is readily available.

Unfortunately, this does expose your patient

to ionizing radiation.

And if you're seeing patients

at a general emergency department,

your child, patient, who you're evaluating,

is going to be sent into the scanner,

and exposed to very similar doses of radiation

as your fully grown adults.

There isn't the process of calibrating the radiation

to the size of the patient.

And so while the test characteristics are very, very good,

anywhere between sensitivity of 94% to 100%,

specificity of 93% to 100%,

it's at the risk of having subjected your patients

to ionizing radiation.

That is not true at children's hospitals,

we do tend to calibrate the amount of radiation

to the size of our patients,

and that's one of the benefits for children

when they are seen in children's hospitals

and require a CT scan,

we can dose adjust the radiation exposure.

The last imaging modality is MRIs.

And while there's no exposure to ionizing radiation,

for most institutions,

MRI is not one of the options available

for evaluation of appendicitis.

So while the test characteristics are excellent,

it's not readily available at most institutions.

Over the last 20 plus years,

there's been this really incredible evolution

of the use of ultrasound by emergency providers.

In 2008, ASEP did publish a policy statement

that essentially spoke to the importance that EM providers

have ultrasound as a skillset

so that they can improve the care of their patients.

In 2011, ASEP endorsed

the Emergency Ultrasound Fellowship Guidelines.

So the fellowship,

the Emergency Ultrasound Fellowship became

an accepted ultrasound, became an accepted fellowship,

and these were the guidelines that all ultrasound grads

were supposed to have by the completion of their fellowship.

And then in 2015, was a really pivotal time

for us in peds emergency medicine,

because this was the year

that there was the policy statement that was put out

that advocated the use of Point-of-Care Ultrasound

by pediatric emergency medicine providers.

This was really the dawn of a brand new day.

This was the moment in our recent history

where there was a collective acceptance that,

not only should EM providers have ultrasound

available to them as they take care of children,

but we as pediatric emergency providers

need to have ultrasound as well as one of the skills

that we acquire during our training,

and that we use to improve the care of our patients.

So with that, I'm going to go through a little clip

of how to do an ultrasound,

looking for the appendix in a small child.

All right, with the probe marker,

pointing towards the patient's right,

we're going to put the probe down on child's belly.

This will correspond to the right lower quadrant.

On the screen, we can see, looking down,

we can see the cross section of the psoas muscle,

and the iliac vessels.

Iliac vessels show color flow doppler.

It's in this location that we're going to start scanning

using a graded compression approach

to try to find the appendix.

It is not uncommon to see a few lymph nodes in proximity

to the organs of interest,

the psoas muscle, the iliac vessels, and bowel.

As you can see,

my probe is always in the right lower quadrant,

and I'm just putting gentle pressure

to try to displace bowel gas and see the anatomy.

And that is the approach to the appendix ultrasound.

- So we're going to go through

you'll see in subsequent clips

that you also see a lot of bowel within the region

that you're going to be scanning in the right lower quadrant.

So large bowel has a very large caliber,

it tends to have air or stool within,

and often the posterior wall of the large bowel is obscured,

so you often just see gas

or dirty shadowing coming from large bowel.

And then you'll also see potentially haustral folds.

The large bowel doesn't peristal,

so when you do see peristalsing bowel, that small bowel.

It has a smaller lumen,

you may appreciate the valvulae conniventes,

which are the grooves, it kind of looks like a CNM and E,

as it's peristalsing through the bowel, through the abdomen.

It is often liquid filled, and then again you'll see

the peristalsis when you put the probe down on the belly.

There's a typical gut signature

of all the contents of the abdomen through the GI tract.

So from the stomach to the large bowel,

you'll note that the wall

has a very characteristic appearance.

It'll look like alter,

you'll appreciate alternating echogenicity,

where it will alternate between hyperechoic

and hypoechoic layers.

And this corresponds to the mucosa, the submucosa,

the muscularis propria, and the sirosa.

So here's an example of the psoas muscle,

you can see this very large muscle, and the iliac vessels.

So our psoas muscle,

and our iliac vessels.

And this is really the starting point

when you start to scan, you're going to go super, super low

in the right lower quadrant, often seeing the pelvic brim,

but you really want to get in low so you really appreciate

the psoas muscle and the iliacs.

Looking for the appendix in the abdomen

is truly looking for a needle in the haystack.

If you look at your thumbnail,

my thumbnail is about six millimeters.

Doing appendix ultrasound is like looking for a thumbnail

in the very active abdomen.

And so it takes a lot of practice.

It is something that the more you practice,

the better you will get.

And it's also incredibly humbling,

because the appendix is so small

within this very, very active cavity,

often you don't find a normal appendix,

but it's always a good idea to try, and just be reminded

that the structure that you're looking for

is exceptionally hard to find.

So we're going to look at this clip right now.

And what you can see, we started low,

over here is the psoas muscle.

You have the iliac vessels

that are coming into view over here.

And over the psoas muscle, and over the Iliacs you can see

small bowel that's peristalsing away.

Where your eye should go,

is to this little structure right over here.

Because you can see that it maintains its shape,

it doesn't collapse, it's non peristalsing.

So this is in fact your normal appendix,

and you can see how subtle it is,

and how easy it would be to just scan right past it.

It is a very, very small structure, it is often very subtle,

and you really have to displace gas,

big bowel gas in order to see it.

Sometimes you find appendixes in locations

you never expect to find them.

This was an example of an appendix that I found

that I started scanning really high up.

I was already in the territory of the kidney,

and I found this retrocecal appendix.

Case number two,

We have a previously healthy obese male

who's presenting to the emergency department

with abdominal pain that started two days prior to arrival.

Mother reports the child has had three episodes

of non-bilious, non-bloody diarrhea

and hasn't wanted to eat.

He's had no fever or vomiting, no cough or congestion,

he does endure some mild Dysuria,

and he denies a history of sexual activity.

His medical history is pertinent for obesity.

He actually has had a cholecystectomy,

his family history is non-contributory.

So his review of systems, notable for abdominal pain,

localized to the suprapubic region.

Three episodes of non-blood diarrhea,

otherwise fairly negative review of systems

other than reported decreased oral intake.

On physical exam, his vital signs are significant

for tachycardia as well as a little bit of hypertension,

and a slightly increased respiratory rate.

On appearance, his general appearance,

he looks tired, non-toxic,

but he does really look like he doesn't feel well.

His mucus membranes are moist, his lungs are clear.

On cardiac exam, you do appreciate the tachycardia.

On exam of his abdomen, his belly is soft.

There is tenderness to palpation in the suprapubic region.

On GU exam, you note normal,

non-tender testicles bilaterally, and his extremities show

brisk cap refill with normal pulses.

So we placed an IV, and sent some labs,

gave him a normal saline bolus.

We ordered a urinalysis, as well as a radiology ultrasound,

and then sent a viral pathogen panel.

But again, we are folks who use ultrasound in our practice,

and so I brought the ultrasound to the bedside,

and started to scan.

And the first thing that popped out

was this echogenic structure

within what looked like a walled lumen.

And this was in fact the appendix.

So what you can see is, he is the appendical width,

and surrounding it, is the wall of an inflamed appendix.

In long axis we appreciate it a blind end,

and by size parameter it was greater than,

it's 0.87, so greater than 0.6 centimeters.

So surgery was consulted, child was started on Zosyn

and booked for operative management.

What are the sonographic features of appendicitis?

Well, as we discussed before,

this is a very, very small structure.

So in order to see the appendix,

you're going to have use the linear probe.

You need a high frequency probe

to really see the image detail

in the right lower quadrant.

And what you're looking for is a targetoid

or a bullseye appearing structure.

It has a blind end and it looks like a tube.

It's non-compressible, it lacks peristalsis.

So the non compressibility

and the lacking peristalsis are features of the appendix,

not just features of appendicitis.

Often you're going to note transducer tenderness.

An inflamed or infected appendix

is going to measure greater than six millimeters

or 0.6 centimeters and you may

or may not see an appendicular lift.

This was an example of an appendix with two appendic

and it's just a great image.

So with that we're going to go through again

in a little bit more depth, we're going to show you

how to do an appendix ultrasound on a child

and we will begin now.

- [Speaker] Ad we do our pediatric appendicitis study,

one thing to keep in mind is those patients

that we're going to be evaluating

for appendicitis probably have substantial abdominal pain.

I highly encourage you to give them pain medicine

before trying to attempt to do an appendicitis study.

Also keep in mind that the gel can be a little bit cold

and so just being mindful

and letting the child know

that it might feel a little bit cold

going on to their belly.

For pediatric abdomen,

we're going to always be using our linear probe.

So I have a 50 megahertz probe, I'm going to be using this.

It has a benefit of having a fairly large footprint,

which I quite like,

but if you have a smaller footprint probe, that's fine,

you just may have to scan a little bit more of the region

to see everything you're looking for.

Also, keep in mind

that with the linear probe presets on our machines,

there isn't an abdominal pediatric abdomen preset

on our linear probe.

So I usually use a superficial or small part setting.

So to do our appendicitis study,

we're going to go probe marker towards the patient's right.

We're going to go down very, very low

in the right lower quadrant

and I usually tell my learners that you really want to see

that pelvic brim in your screen.

And so we put the probe down and we are right over.

We can see that pelvic brim, that brightly echogenic bone

that pops into view in the right lower quadrant,

I've given myself five centimeters of usable depth.

I think that's generally a good amount of depth,

somewhere around four to six centimeters is adequate

for doing your studies.

So here I see my pelvic brim.

I'm just going to go a little bit medial

and then I'm going to see my beautiful psoas muscle

that comes into view.

Medial to my psoas muscle,

I see my two iliac vessels, if you need clarification

to ensure that they are in fact vessels,

you can always put your color flow doppler over your vessels

to confirm that you're looking at vasculature.

And there's my confirmation.

If you go further medial,

you'll hit the region of the bladder, that's fine.

You don't need to be quite that medial for your API study.

So if you see your bladder, just move more lateral.

So now as I scan,

what's amazing with my little patient over here

is I actually found a normal appendix that came into view.

It normally doesn't happen this easily,

but as you can see right overly the psoas muscle,

there's a circular structure with several layers of wall.

And let me follow it out

now that hair stalls away.

So hold on one second, let's see if I can get that back.

Yep, it's that little guy right there.

So I'm going to freeze right there.

Right over here

I have found

my normal appendix.

So with my patient's normal appendix,

I found a circular structure with a echogenic center.

That's usually because the innermost aspect

of the lumen is basically collapsed on itself

because there's nothing inside the appendix

and her appendix is measuring 0.42 centimeters,

which is normal.

When you find an appendix,

it's wonderful if you can follow it out

and see it in its long axis

in addition to its cross section.

I will try to do that right now as I turn my probe

to face northbound in a satchel plane.

And there it is again, but it seemed to still have

more of a cross-sectional orientation.

As you do your appendicitis studies,

it's important to know other anatomy

that's going to come into view

and most notably in children

is you're going to often see lymph nodes.

So right over here we have a beautiful lymph node

that comes into view.

We have another lymph node right over here,

two lymph nodes such as came into view over here,

over here and over here.

The challenge with your API study

with your patients is going to be this bowel gas.

So what I encourage you to do is as your step scanning,

you're one going to want

to do a graded compression approach,

which is where you're putting gentle pressure

and pushing on the bowel to move it out of the way.

So you can really see that area just overlying

the psoas muscle at the area, the iliac vessels,

and that's how we found our model's appendix so easily.

As you note from the lecture,

an inflamed appendix will be quite large,

usually more than 0.6 centimeters.

There will be wall thickening,

there might be fat stranding

and usually there's significant transducer tenderness

as you're scanning the patient.

And that is our appe study.

- So with the understanding that we as emergency physicians

or Pedes emergency physicians can do ultrasound

to diagnose appendicitis, there's been several studies

that have been published and Dr. Lee

and colleagues did a meta-analysis

on the 17 international studies

that have looked

at emergency provider performed ultrasound for appendicitis.

And we're not going to go through this whole meta-analysis,

but really, the main takeaway

is in this table.

If you look at emergency provider performed ultrasound

for appendicitis

versus radiology ultrasound for appendicitis,

there is no statistically significant difference

in the sensitivity.

There's no statistically significant difference

in specificity.

There is additionally no difference in the positive

and negative likelihood ratios.

So this was really an excellent way of kind of,

of relaying the fact

that emergency providers can become just as good

as radiology ultrasound providers

in the diagnosis of appendicitis.

In this study, which was focusing on children specifically,

and this was a great study for those

who want to brush up on their understanding

of appendicitis in the workup,

this was really an excellently written meta-analysis

and in this study they did include Point-of-Care Ultrasound

as one of the ways that providers can better understand

how to make a diagnosis of appendicitis.

So they look specifically at the five

of the six published pediatric emergency medicine

point of care ultrasound studies on appendicitis,

only those studies that had a prospective design

and what they did

is because there was a variable, there's some degree

of variability in the number of patients within each study,

they ended up doing a pooled analysis,

basically combining all of the patients

from these five studies

to evaluate the test characteristics.

So once pulled data, they had 461 patients

and as you can see the sensitivity

and specificity are very comparable to Dr. Lee's study

where they also showed very, very good

test characteristics for the diagnosis of appendicitis

by Point-of-Care Ultrasound.

So a sensitivity of 86%, a specificity of 91%

with a positive likelihood ratio of 9.24

and a negative likelihood ratio of 0.17.

Our next case is that

of a previously healthy three-year-old female,

her immunizations are up to date

and she's coming to the emergency department

with abdominal pain that started the night prior

to arrival to the emergency department.

Mother reports the child has had three episodes

of non bilious, non bloody vomiting

and endorsed Dysuria over the last two days.

Mom also reports the child has had some vomiting

and diarrhea that started five days ago.

She was actually seen by her pediatrician who diagnosed her

with gastroenteritis and prescribed her Zofran.

Child has had no cough or congestion.

She does attend daycare

and several other children have been out

with viral illnesses.

Child's past medical history is non-contributory.

She does have a history of an adenoidectomy.

Her family history is non-contributory.

On review systems,

her expressed abdominal pain was non-focal

although she did endorse some Suprapubic abdominal pain

and she had this three episodes

of non-bilious, non bloody vomiting.

She's had some decreased oral intake,

she endorses some dysuria

and mom denies any history of cough or congestion.

On physical exam once arrival, once she arrived

to the emergency department,

she did spike a low fever of 100.5.

She was noted to be tachycardic.

Her respiratory rate was ever so slightly above normal.

Her blood pressure was a little bit above normal

and she did look dehydrated.

Her mucus membranes were tacky.

Her lungs were clear.

Her cardiac exam was notable

for tachycardia, no murmurs.

And on belly exam, her belly was noted to be distended

with diffuse tenderness

to palpation including at the Suprapubic region

and she was really laying still on the stretcher.

Her extremities were notable

for a slightly delayed cap refill.

So we placed an IV

and sent off some labs,

gave this child some morphine in a normal saline bolus.

We ordered an ultrasound

and as well as a radiology ultrasound,

we ordered a urinalysis, I'm sorry,

and ordered a radiology ultrasound.

And while at the computer while putting in our orders,

the nurse comes and calls me to the bedside

because now child is showing that she is in fact hypotensive

with a blood pressure of 81 over 54

and her heart rate spiked up to 160

and now she had more significant tachypnea

with a respiratory rate of 32

and her cap refill was four seconds.

So child's clinical status had really acutely deteriorated.

We moved her to the trauma bay

and placed her on 100% non-rebreather

and we very quickly gave her three normal saline boluses

by push-pull method.

And this actually was effective in increasing,

sorry, in normalizing her blood pressure,

which improved to 100 over 78

and her heart rate decreased to 132,

as well as her respiratory decreasing to 26.

On repeat exam however, we noted that her abdomen

had now become quite distended.

In fact, it was even a little bit firm or rigid.

So we empirically started her on Zosyn and Vancomycin.

And while I put the probe in the right lower quadrant,

I really couldn't see anything because of all of her pain.

So I converted into a fast exam

and I put the probe in the right upper quadrant

and lo and behold, what I noted

was free fluid in Morrison's pouch

between the liver and the kidney.

I then moved the probe down to the pelvis

and noted free fluid in her pelvic area

just behind her bladder.

So here's a pocket of free fluid.

So I knew at that moment that we had a situation

where I had a child now with free fluid in her belly.

If this was appendicitis,

which was my clinical concern,

now we have a situation where she's a ruptured appendicitis,

so we noted that the free fluid in her pelvis

as well as in her right upper quadrant,

we consulted surgery.

We jointly had the concern for ruptured appendicitis.

We deferred radiology ultrasound

after noting the findings of free fluid

and instead opted for a CT scan.

And this confirmed the diagnosis

of a ruptured appendicitis with abscess.

Child was admitted to the PICU

with sepsis secondary to ruptured appendicitis

and she was booked for IR drainage of the abscess

that was noted and that was scheduled for the following day.

So I hope now after we've now discussed appendicitis

and how we can use Point-of-Care Ultrasound in our practice,

I hope you understand just how challenging

making the diagnosis of appendicitis can be

given its varied clinical presentation.

Diagnosing appendicitis

by ultrasound is highly operator dependent.

So whether you as the emergency physician

or PEM physician performing the ultrasound

or if you're in radiology,

regardless of who's performing this,

it is a highly operator dependent application.

Point-of-Care Ultrasound has high sensitivity

and specificity in the right hand.

So if you become expert, if you basically commit

to making one of the skills that you have available

to you in the emergency department,

you will become the person

that can expeditiously diagnose appendicitis at the bedside.

Remember, we use a linear probe

because what we're looking for is a very subtle structure.

It's small and we're looking for all of that detail

that will help us understand

whether or not this is an infected appendix.

You want to make sure to address pain

prior to performing a port of Point-of-Care Ultrasound

because greater compression, which you're going to need to do

to displace that bowel gas is unpleasant,

especially if the child has appendicitis.

So you really want to make sure

that you've addressed pain needs

prior to performing this study.

And then remember the sonographic features of appendicitis.

You're looking for a non-compressible tubular structure

measuring greater than six millimeters.

I want to acknowledge my host of folks

who have contributed imaging

or lent me their children as models,

want to acknowledge these fantastic providers

that I have worked with at various points

in my training and my attendingship.

And with that, I want to thank you for joining me today

and if there's any questions,

I'm happy to answer any questions.

- All right.

Like Dr. Levine said, this is the time for Q&A.

So if you have any questions you can feel free to go ahead

and enter them in the Q&A box through Zoom.

- Dr. Levine, this is Laura.

I just wanted to ask how that third case went.

I mean sepsis and a ruptured appendix

sounds pretty awful.

Did that patient come out okay?

- Thankfully she did fine,

but it's obviously one of those scary situations

where you have a child acutely deteriorate

and where ultrasound can really be the guiding imaging

to help you better understand

what your next steps should be in caring for your patient.

- Right, absolutely.

That was scary, that was a scary case.

(person laughing)

- All right, looks like

there's no other questions coming in.

So Dr. Levine, thank you so much for coming in

and talking to us about this.

We really appreciate it

and there was just a whole lot to learn there.

So that was really great.

So everybody else, thank you so much for coming.

Thanks for watching.

And you can watch this recording

on the URL that's up on the screen right now.

Secure.sonosite.com/behind-the-scan-webinar

and we'll see you for the next one.

Thank you so much for coming, bye-bye.

Diagnostic imaging for appendicitis is evolving and may include a point-of-care ultrasound assessment. This is especially important for the sensitive pediatric population. Pediatric ultrasound imaging requires smaller transducer footprints and adjustable frequencies to adapt to various depths and patient sizes. This live webinar will share expert techniques for performing a bedside pediatric ultrasound exam through a presentation of actual cases. After reviewing relevant literature, you’ll have the opportunity to discuss pediatric appendicitis as it pertains to POCUS with Dr. Levine.

What You'll Learn

Upon viewing this webinar, viewers will be able to provide better patient care by having a better understanding of how to:

  • Discuss pediatric appendicitis
  • Describe the evolution of diagnostic imaging in appendicitis   
  • Review cases that demonstrate how POCUS can be used in the diagnosis of pediatric appendicitis
Marla Levine, MD
Presenter: Marla Levine, MD
Position: Associate Professor of Pediatrics, Emergency Medicine Director of Point of Care Ultrasound (POCUS) Monroe Carell Jr. Children’s Hospital at Vanderbilt Nashville, Tennessee

Dr. Marla Levine is an Associate Professor of Pediatrics in the division of Emergency Medicine at Monroe Carell Jr. Children’s Hospital at Vanderbilt and the director of Point of Care Ultrasound (POCUS) within their Pediatric Emergency Department. She completed her pediatric emergency medicine (PEM) fellowship at Children’s National Medical Center and Emergency Ultrasound fellowship at Maimonides Medical Center.

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This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.