Transcript
- Hi everybody.
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Hi everybody, my name is Chris Pennell
and I'll be moderating today's webinar.
Welcome to the behind the scan webinar titled PUD Pediatric
POCUS into Practice.
Before we begin, I just have a few things to cover.
All webinar attendees are muted due to previous commitments.
We will not have a live q and a as usual.
However, we will still be taking questions.
If you're on the main zoom stream,
you can type your questions into the q
and a box in the toolbar located at the
bottom or the side of your screen.
And feel free to enter them throughout the presentation
and they'll be passed on to be answered.
For those not on the zoom stream,
you may send your questions
to Paul Bosky at paul dot bosky@fujifilm.com.
Paul will then forward your questions along
This webinar will be recorded in Archive
for future reference on our webinars page.
Here with us today we have Dr. Marlo Levine.
Dr. Levine is an associate professor
of pediatrics in the division
of emergency medicine at Monroe Carol Jr.
Children's Hospital at Vanderbilt
and the director of point-of-care ultrasound within their
pediatric emergency department.
She's been recognized as a leader in PEM pocus, particularly
as an educator in emergency ultrasound regionally,
nationally and internationally.
She has authored numerous papers on the utility of POCUS
and the care of pediatric patients as well
as helped create educational guidelines for how
to incorporate POCUS into educational curricula.
Dr. Levine currently serves on the executive committee
for the P two network,
the International PM POCUS Collaborative
as the chair of Global Health.
Dr. Levine, thanks so much for being here.
I'll go ahead and turn it on over to you.
- Well thank you so much Chris, and thank you so much
to Sona site for inviting me to today to speak
and given me the opportunity to share
with you all about why I love ultrasound so much
and how ultrasound has been really critical
and invaluable
for me in my journey in pediatric emergency medicine
and in the care of my patients.
And so I hope throughout this lecture you're really gonna
get an understanding for how we can use point
of care ultrasound in pediatric emergency medicine.
And I would argue just in terms of of whoever's visiting
with us today, pediatrics in general in terms of
how we can use point of care ultrasound in the care
of children because this technology is really,
really helpful throughout the whole clinical landscape
of the care of children.
This talk is gonna be a case-based lecture.
So we're gonna go through various applications in
point-of-care ultrasound using cases to demonstrate
how we can use this technology in the,
in the care of our patients.
So starting out, chapter one is skin soft tissue ultrasound.
And for those of us who have been using ultrasound
in clinical care, we understand
that skin soft tissue ultrasound was really how we began
to understand that this could really change
how we cared for patients.
The earliest prospective studies in point
of care ultrasound looked at skin soft tissue ultrasound
and this really
helped us understand
that this could have clinical significance at the bedside
and allow us to take better care of our patients
by understanding at the bedside
how we should be managing our patients.
So with that, let's start.
So this was a case of a 2-year-old male who presented
to the emergency department with left hand swelling
after being bitten by a spider on the night prior
to presentation, he had been afebrile, he had full range
of motion at his hand and
what you can see in this picture is that he had really,
really very,
very impressive swelling of his hand.
He had bright cellulitis appearing redness to his hand.
He was had circumferential swelling.
We demarcated that area of redness.
And then if you can see right at about his wrist right over
here, you can see this was the
area where he had been bitten.
But with the aggressiveness of the spread of redness
and the degree of swelling, it was actually pretty hard
to sense as to whether
or not there was an underlying abscess in there.
And this is where we were able to use ultrasound
to help guide our, our management.
So grab the ultrasound machine and did a bedside ultrasound.
And what we were able to see is
that when we put the ultrasound on this child's hand,
we were able to see the signs,
the sonographic signs of cellulitis.
What we can see is this cobble stoning appearance
of the subcutaneous tissue.
You can see those, those lakes, those koic, those
black lakes of fluid that are coursing
through the subcutaneous tissue.
And that is consistent with edema swelling
and that appearance, that kind of cobble stoning
or cottage cheese looking appearance
of skin is consistent with cellulitis.
And we were effectively able to rule out
an abscess in this child
and we were able to initiate the appropriate
management for this little guy.
This next case is a case of a 15-year-old male who presented
to the ED with a painful mast who his left arm.
He stated that this MAs started
as a small lesion three days prior to presentation.
He's been afebrile, he's been freely able to use his arm,
he's been raging the arm appropriately.
We can see on exam that this looks consistent
with an abscess so we can see
that it looked quite fluctuate.
It had that boggy appearance.
So we knew, I mean you can see that this looks consistent
with an abscess, but what's nice is when you use ultrasound
and here's what the ultrasound looked like when you put the
ultrasound on the arm, you can see that we have this kind
of swirling presentation of the
contents within the abscess.
It looks ugly,
which abscesses typically look kind of ugly.
You can see this kind of rim of of kind of
the abscess collection.
But what's nice with an, with doing an an ultrasound
before you, you do any interventions
with an abscess is in addition to confirming the presence
of an abscess, you can also ensure that
before you do any interventions
that you're not gonna cut into any
important other anatomy.
So for example, you are not in a that you can confirm
that you're not in any close proximity
to any important blood vessels,
that you are not in close proximity to any nerves.
You have essentially confirmed that it's safe
to actually do a drainage.
And so in addition to confirming the presence of an abscess,
you are also confirming that it's safe
to actually do the intervention that you need to
properly manage this condition.
This was a great case. This was a colleague's case.
This is a 7-year-old male with a foreign body sensation
to the plantar aspect of his right foot.
The child stated that his sibling had dropped
a glass in the kitchen floor, it shattered, family tried
to clean up the the glass,
but this child walked in the kitchen
and subsequently had the
sensation of foreign body in his foot.
There was no outward appearance
of any foreign body on the plantar aspect of the foot,
but the child had that sensation
of the foot of the foreign body in the foot.
Now my colleague put the ultrasound on the child's foot
and lo and behold what we see is the image on the left
looks exactly consistent with the image on the right.
This was the foreign body that the child had stated he felt.
And following the foreign body removal, we can see
that exactly what the child felt
and what we see on ultrasound
that my colleague had identified he was able
to physically remove from the child's foot.
Okay, so ultrasound is fantastic
for foreign body removal.
We love it. Now you might be thinking yes,
but Marla x-ray could identify this
and we could have also proven
that this child had this glass in the child's foot
and I would say a hundred percent glass
and metal will appear on x-ray.
And I agree with you. Where ultrasound wins over x-ray is
that ultrasound can also,
I identify radio loosen form bodies.
So let's say this child had a splinter in his foot,
ultrasound would've seen that splinter
because the splinter would've also appeared brightly.
Hyper coic like this glass is hyper coic.
It's very, very bright.
Splinter or wood
or plastic would've also appeared brightly,
echogenic or bright.
And so where ultrasound winds is that in addition
to picking up structures or
or foreign body material like plant, sorry, like metallic
and glass foreign bodies that x-ray also would pick up,
it also will pick up the radiolucent foreign bodies.
And then as an additional step, as you can see,
this foreign body, my colleague was able
to identify the presence of the foreign body
and then he was also able
to identify exactly the depth of the foreign body.
And just like with abscess rated, she was able to confirm
that it was not in close proximity
to any other important structures.
So he could use this for for planning
of the foreign body removal.
So you can use this as for procedural guidance as well.
And so this was really, really a wonderful example of
how we can use ultrasound not only for confirmation
of warm body removal but for procedural guidance.
This is a case of a three-year-old female who presented
to her pediatrician's office with right sided neck swelling.
She had had some nasal congestion
and cough for the last seven days
and then began having this neck swelling.
She had full range of motion of her neck.
There was no concern for for meningitis,
she had no meningism, she was non-toxic appearing
but she had this neck mass and so she,
and she did have some tenderness
to palpation along the neck.
So when we put the ultrasound on her neck, I apologize,
the clip is a little bit stop and start,
but you can see what comes into view are these
kidney bean like structures that are coming into view
and those are our lymph nodes.
So what this child had was a conglomeration of lymph nodes
that was the neck mass and
because she had tenderness over that area,
this would be consistent with more of a lymphadenitis.
She was treated with antibiotics
and like in all situations, you know things can develop.
So she was, you know, the recommendation was
to come back in case there was any concern
that this was not improving.
And obviously we did not see any abscess on our original
past with the ultrasound.
But obviously if there was any kind of concern
that this was not improving with antibiotics then we
would've again scanned her neck with the ultrasound
and then further explored if there was any concern
that this was not improving with antibiotics.
But this was a hundred percent consistent
with normal appearing lymph nodes at that time.
Unfortunately I don't have a clip of color flow doppler.
That would've been another way to show
that these were healthy lymph nodes
because with he healthy lymph nodes you can see the color
flow doppler at the central high limb at the inner aspect
of the lymph nodes where they get their nutrition.
You will see the blood vessels come into the lymph nodes.
Unfortunately you don't see it in this clip.
That's another kind of proof
that these are healthy lymph, no lymph nodes.
And so at this past though,
however, these were consistent with healthy lymph nodes,
just inflamed lymph nodes consistent
with a lymphadenitis picture.
This next case was a case of a 25 month old female
with complex medical history including liver transplant
secondary to biliary atresia.
She presented to the ed CTIC and dehydrated
and unfortunately given her degree of toxicity,
she actually the team was the nursing team was unable
to establish IV access using landmark technique.
Now in our shop we have formidable nurses who've become
ultrasound IV champions
and one of our fantastic nurses, he was able
to secure an ultrasound guided IV on this little girl
who had very cha challenging anatomy.
And here is an example of a very, very small vein
that he was able to cannulate this little guy over here.
This is in in live cannulation
and here is in, so this is in the short axis.
We can see the, the cannula going into the IV
and then this is the long axis.
We can see the, the catheter going through the vein
after he secured axis.
And what's wonderful is that in many,
many children's hospitals now this has become a nursing
directed intervention
where nurses are leading the charge in
ultrasound guided IVs.
And this has really changed management, improving the care
of patients and it is a wonderful intervention that has led
to really improvement of care.
Quicker access to IV placement and,
and is is a real wonderful intervention since the advent
of of point of care.
Ultrasound chapter two is the fast exam.
The fast exam really revolutionized trauma management.
So it used to be that part
of the trauma algorithm in the acute trauma life support
algorithm in yesteryear there used
to be something called the diagnostic peritoneal
and this is how we used to interrogate the
trauma patient for any kind of bleeding within the abdomen.
It was an invasive procedure where you would actually have
to instill some fluid inside of of your patient
and then essentially withdraw fluid from your patient.
You would basically put a a needle inside your patient,
then withdraw that fluid to see if there was any bleeding
within their abdomen following a TMA traumatic
injury that was invasive.
And thankfully we don't do that anymore.
That was actually replaced in the trauma management
algorithm with the fast exam.
The fast exam stands for the focused assessment
with sonography and trauma
and this was a real kind of game changer with
with the trauma algorithm protocol for our, in our trauma
algorithm in in all emergency department management.
This is a case of a five-year-old female who presented
to the emergency department following a motor
vehicle a accident.
Just prior to presentation she the, the front
to the car was impacted at the speed
of approximately 45 miles per hour.
There was positive airbag deployment,
good news for the child.
She was properly restrained in the back seat in a toddler
seat and she denied any pain
or discomfort following the the accident.
She had no signs of injury on trauma evaluation
and as part of the protocol after the primary
and secondary survey,
she actually had some trauma labs done.
We did a fast exam
and so in the fast exam we interrogate all the dependent
regions of the body looking for sources of bleeding.
So the first location
that we interrogate is the pericardial sac, which
is essentially we're looking at the heart, we're looking
for any bleeding that could have happened from an injury
to the heart, looking at the dependent area of the heart.
So there was no bleeding to her heart
or no injury to her heart as evidenced by a lack
of any pericardial effusion.
We then moved to her right upper quadrant in Morrison's
pouch looking at the
the HEPA renal recess looking between the liver
and kidney to see if there was any bleeding in this space.
It's always a good idea off always to extend
and just make sure you don't see any bleeding
in the base of the lungs.
We're gonna go through that in the next section,
which is gonna focus specifically on the lungs
but making sure that there's no bleeding at the base
of the lungs, which would be just over the diaphragm.
We then go to the left side of the child's body.
This would be the same protocol for adults as well.
We're looking at the lenna renal recess here, looking
for any fluid that could have collected between the spleen
and the kidney.
Also trying to look under the diaphragm
between the spleen and the diaphragm.
We also wanna make sure that we're always looking near the
tip of the kidney as well, just making sure
that fluid is not hiding
and then again looking at the base of the lungs as well
to make sure that there's no hemothorax
and then we move to the pelvis.
Looking at below the bladder we usually
will scan in two orthogonal planes, both in a transverse
and in a sagittal plane.
That means we look both
with the probe marker pointing towards the patient's right
and towards the patient's head.
Again, just making sure that we have done our due diligence
to ensure that there's no free fluid
or bleeding within this child.
Now just as a point of of of information
in your pediatric patient, the most sensitive location
for free fluid or bleeding injury in a child will be this
pelvis location.
This was an amazing case of a 15-year-old male that we saw.
He was a victim of a gunshot wound.
He had actually been struck in the right upper abdomen.
He had no exit wound on his ballistic survey.
Amazingly he had a chest x-ray that was negative
and he had normal vital signs.
He was looked great, he was deceivingly stable,
it was jarring how stable he looked.
But given the location
of the entry wound colleague called, called me over
to do a fast exam.
And on the fast exam we actually realized
that this was actually, he was a ticking time bomb
because he actually had a very large pericardial effusion.
He was actually in impending pericardial
pericardial tamponade physiology.
It was based on the fast exam that
everything got kicked into high gear
because we realized he actually was not stable at all.
He actually needed to go to the OR very expeditiously.
The CT surgeon was called in, the child went emergently
to the CT scanner the OR was booked
and it everything went was done very, very quickly
after we saw what was truly going on with this child.
And this was lifesaving.
This is a case of a 6-year-old male who presented
to the ED following a motor vehicle accident, presented
with a normal neurologic exam, had a positive seatbelt sign.
So clearly he had a an injury to his abdomen.
He did complain about belly pain on exam
we do do trauma labs as part of all
of our trauma evaluation.
And given the fact that he had complaints of abdominal pain,
he had signs of injury, he was going to be going
to a CT scan to be further evaluated.
So on the initial fast exam he did have evidence
of intraabdominal trauma so there was a positive fast.
You can see that there is as opposed
to the previous examples
where we saw no free fluid in the HEPA renal
recess, meaning in the previous example the kidney liver
interface was tight.
In this example you can see that there is an an coic amount
of fluid that's tracking between the two organs
that is blood.
So that that means that there is bleeding.
Now what's amazing that we can do with with a,
with the ultrasound that you would not wanna do
with any other imaging modality
because of the risk of ionizing radiation
and you would not wanna do unnecessary repeat imaging
because ultrasound exposes your child, your patient
to no risks.
I mean this is the safest imaging modality that we have.
You can repeat the ultrasounds as much as you want.
So when this child came back to the department
after a little while we were able to repeat the ultrasound
and see that there was actually expansion of the bleeding.
And you will see over time if there is bleeding,
you will see worsening signs on the fast exam, worsening,
bleeding, worsening collection of free fluid.
Then ultimately this child went,
this was actually a liver lax.
So the child actually did not go to the,
or just went to the PICU for management.
Okay, chapter three, the lung ultrasound For many of us who
do ultrasound medicine, lung ultrasound is one
of those like favorite applications largely
because it's always nice when you can have
an application where ultrasound is better than other
imaging modalities.
And that's one of the areas where really ultrasound shines
in when we talk about lung
because where ultrasound
and CT scan are are comparable in their test
characteristics, ultrasound is often more sensitive
than than x-ray.
And obviously we don't wanna do CT scans on most
of our patients and X-ray tends to be that imaging modality
that we get more than any other imaging modality when
we're interrogating the lungs.
It's nice that we can look at x-ray as compared
to ultrasound and know that in most situations ultrasound is
gonna be even better than x-ray.
This is a case of a 14-year-old male who presented to the ED
with acute onset of left sided chest pain
after bed in practice he placed the trombone, he arrived
to the ed, he wasn't in respiratory distress
but he had that chest discomfort.
And on the right side what we can see is this is,
so this is what the ultrasound of the chest looks like.
So when we talk about lung ultrasound,
the lung looks different sono graphically than other organs
'cause you're not gonna see something
that looks like the lung
unless there's, there's a lot of fluid there.
So unless there's a disease in the lung,
you're not gonna see lung tissue.
But what you see over here is what,
because the lung is a dynamic organ,
you're gonna see movement
because as you're breathing there's gonna be
signs of movement.
And this is what the pleura looks like
as it's moving, you're breathing.
And so the visceral and parietal pleura are
gonna move against each other.
So this is a rib over here, a rib over here
and the pleura that's moving now on the left side
of his chest, there was no movement of pleura, right?
This is what we can see over here.
The absence of lung sliding is highly
suggestive of a pneumothorax.
Now it's not a hundred percent specific
but it's highly suggestive.
Now there is a differential, obviously
it could be a right main st stem intubation if your patient
is intubated, maybe your patient's already had a pleurodesis
and it could mean that this child has already
had a pneumothorax.
But in this clinical context it would obviously be highly,
highly suggestive of a pneumothorax.
So as we continue the case, I was scanning
and I started, so with,
with pneumothorax is obviously it's gonna go from the point
of least dependent to the point of most dependent.
So when you start off,
you're gonna see it most likely is you're gonna see it
apically and then you're gonna scan down.
So as I was scanning, I saw lack
of lung sliding the higher I was.
And as I scanned down, I started to see the interface
of the lack of lung sliding the,
and the presence of lung sliding.
So over here was actually that interface
where we found the point where it popped
where the bleb was located and that's right over here.
And then on x-ray you can see, you can see that
it was right over here was the pneumothorax.
And and so it consisted
that the x-ray was completely corresponded.
I mean I had the ultrasound way
before we had the chest x-ray, which was nice
'cause I, I was able to already tell mom what the plan was
and we were just now waiting on kind of the,
the next steps which were to get the chest x-ray
and then get surgery but put him on some a hundred percent
oxygen, got him comfortable and,
and then we were able to take it from there.
So the nice thing with ultrasound is that if you know how
to use it and you know how to interpret it,
then you are relying on yourself to,
to get, capture the imaging.
To interpret the imaging and then,
and you know, you're not waiting on radiology
or you know, whether it's chest x-ray to come to the bedside
or radiology to interpret you're, you're kind
of doing it all on your own, which is really the, the nice
and empowering thing about the use
of point-of-care ultrasound in your practice.
This is a case of an eight-year-old male
with a history of nephrotic syndrome.
He presented to the ED with report of shortness of breath.
He had an oxygen saturation of 92%
and a respiratory rate of 32.
So this child was clearly in like he was showing signs
that he was in respiratory distress.
He, he was breathing fast.
I had a suspicion that he was gonna be fluid overloaded
and lo and behold, when we looked at his chest we could
see something was wrong.
So as I mentioned earlier,
you should never see anything within
the thoracic cavity because it is filled with air.
I didn't say that a second ago
but I just said that you, you, you won't see the lung
because it's gonna behave differently than other organs.
So now as I kind of go into it,
because most of medical imaging, you're looking at tissue
and most tissue has some degree of fluid in in the tissue,
which allows us to actually see that Tim, that tissue
with ultrasound we can interpret it, right?
So we see over here liver
and kidney, these have varying degrees of
liquid density, right?
And it'll interact with the ultrasound beam
and you can interpret that the lung is filled with air,
air and ultrasound don't interact the same way.
And because they don't interact the same way, what happens
is, is in a normal situation like the image on the right,
what should happen is that you should have complete darkness
in the chest cavity because the air
and ultrasound beams don't interact.
It results in this kind of fraction picture
with the ultrasound air interface of the molecule, the al,
the ultrasound beam and the molecule such
that you don't get any kind of meaningful information back.
In fact, for a very long time it was believed
that air is the enemy of ultrasound
that you can never image through air.
We now understand that we can, we just had
to interpret it differently.
But so in this example you can see in the thoracic cavity,
right, you have a complete absence,
darkness above the diaphragm.
This is the diaphragm that meets the spine
and you have darkness in this situation.
Actually darkness is good.
Darkness means you don't have pathology,
you don't wanna see anything north of the diaphragm.
This is good. You should not see anything in this example.
However, what you can see is you have the liver,
you have kidney, you have diaphragm, you have spine.
And you see that spine go north
and you see darkness that looks different.
This is fluid darkness, this is actually liquid darkness.
And this has actually created an acoustic window
through which that sound beam,
that sound energy can now travel throughout
through the thoracic cavity
and actually propagate those sound waves to the spine
and allow now the spine to light up.
And now you can actually see within the thoracic cavity you
can actually see information.
Unfortunately if you can see things within the thoracic
cavity, it means that there's pathology there.
And in this case you have all
that liquid within the thoracic cavity
here it's pleural effusion, lighting up the spine.
You even can see a bit of the lung
that's flapping around in there.
That's atelectatic lung.
So this is a case of pleural effusion.
So this is an example of what we call spine
sign pleural effusion.
In new Seattle LAC lung,
this is a case of a 7-year-old male four month status post
cardiac transplantation.
He was presenting to the ED with respiratory distress.
The child's not to have a respiratory rate of 40
and an oxygen saturation of 91%.
So we're gonna do a side by side again.
So with this little guy, we see something over here
that's a bit hard to interpret if you've never
seen lung ultrasound.
But I'm gonna go back there.
This is what we call pulmonary edema. It's B lines.
You know what pulmonary edema is?
It's fluid overload, it's interstitial edema.
But this is what pulmonary edema looks like.
So graphically and it's
because you have a bunch of beelines which is,
it's a manifestation what we call reverberation artifact.
And all of these beelines have have coalesced
and you basically just see basically a whiteout
picture as you're scanning.
And that's because there's so much interstitial fluid
that from the pleura which starts over here,
all you see are now all these beam like beelines have
coalesced and all you see is basically fluid.
This is a manifestation of fluid.
Now by comparison, this is what a normal lung looks like.
If you're looking at the pleural line,
you can get one beeline here, one beeline.
So two beelines in any region is non pathologic.
Here's the pleural line, here's a B line coming into view
and then another P line coming into view.
But what you should see is these kind of horizontal lines.
Those are a lines, you should see those actually
that's another example of an artifact.
But you should see this kind of picture,
the occasional horizontal line,
maybe the occasional vertical line
and then just the pleura if you can't see anything
but these strobe lighty, conglomeration of beelines,
this picture is in a lot
of interstitial fluid consistent with pulmonary edema.
And that's what this kid had, this is a case
of a two-year-old male with one week history
of cough and congestion.
And he had had a diagnosis as a diagnosis
of RSV at the onset of illness.
Now he's presenting to the ED with a temperature of 103.2,
a respiratory rate of 46 and saturating 93%.
So now that you've had an explanation of
normal versus abnormal thoracic cavity appearance already,
you should see that this doesn't look normal.
'cause right over here is the liver.
The diaphragm is coming into view over here,
this is the spine and it's going north of the diaphragm.
And what it looks like is you have liver
and then it looks like liver's on top of liver.
And we know that that happen.
So this liver like consistency organ that's sitting
above the liver is actually what the lung looks like.
If there's pneumonia in the lung,
we call this HEPA of the lung.
And this is what the sonographic appearance
of pneumonia looks like.
And you can also see that there is the extension
of the spine because there's now fluid in, we have fluid
inside the lung you can, it'll light up the spine.
And this is, this is pneumonia.
Now again for comparison's sake, so looking at it side
by side, you can see this is again healthy lung.
You have the liver, you have the diaphragm,
you have spine and you see nothing.
So side by side it should really be quite convincing
that this represents pathology and this is healthy.
Okay, chapter
four is pediatric abdominal ultrasound.
So while those other applications were, for those
of us who've been doing point of care ultrasound,
those were brought over to us
by our adult emergency ultrasound counterparts.
Whereas the pediatric abdominal ultrasound, this is unique
to us, our adult counterparts may do this on children if
they're working in general emergency departments.
But for those of us who work in peds, this is
what if we are in centers that will, you know, sometimes
depending on where we practice, we may be using a lot
of this and working with our surgeons
to help in in really expediting care of our, our patients
who may be coming in with with clinical con clinically
concerning pediatric abdominal pathology, this is a case
of an 18 month old female who presented
to the emergency department with intermittent crying spells
and vomiting and periods of lethargy.
So just by the clinical
scenario, this sounds very concerning for intussusception
and on ultrasound in scanning her belly.
Lo and behold what we saw was this OID lesion
that did pop up right under her liver.
So when you do an intussusception ultrasound,
you're basically tracking from the right lower quadrant all
the way to the left lower quadrant,
you're basically lawnmowing
with your linear probe tracking the large bowel looking
for this toy lesion.
And it's gonna have, if it comes into view,
it's gonna be greater than two centimeters in
cross-sectional DI diameter.
And it will, if you do a second pass, it'll still be there.
It's not gonna self reduce.
And if it's present it needs to be reduced.
So if it's there, you're gonna have to be working in concert
with your, with your
pediatric radiologist,
sub sub pediatric radiology subspecialist to,
to have the child undergo appropriate either air
or barium reduction.
This was a case that I had of an 8-year-old male
who presented to the ED with 36 hours of abdominal pain
that migrated to the right lower quadrant.
He had had episodes of vomiting and low grade fever.
What was so nice with this case is that yes, this child had
signs and symptoms that were a hundred percent
consistent with appendicitis.
He, we brought him into the room and even
before he had been registered, I was able
to capture the image on the left.
And you know,
and in certain times there was a time
where surgeons would take children to the, OR just by
clinical exam alone.
And I would argue this kid had a history
and an exam that was very consistent with appendicitis.
But I, I would say that we're now working in, in an era
where most people require some form of imaging
to take a child to the or.
And what was nice is that I was able to capture the imaging
that confirmed the presence of appendicitis.
And then even before the child was registered as a patient,
I was working in a shop.
This was in a previous job where I worked with my surgeons.
I was able to send the surgeon a
screenshot of the image that I captured
with obviously a little bit of information about the child.
He saw this booked the or
and then an hour and a half later shot me the
image on the right.
And so this was this kind of beautiful example of how
with the right understanding of how to use this technology,
not only is this going to help in clinical care
and it's obviously a huge satisfier to to families,
but it also really helps in patient throughput and,
and the, the benefits down the line in terms of everyone
who is helped by point of care ultrasound
from a hospital level as well.
It, it, it, it doesn't end just with you
and the patient, it really is a systems benefiter.
And so this, I just love this
because it's not every day
that a surgeon will send you a picture
of the inflamed appendix and,
and it just looked so beautiful side by side.
So I I really love this case.
This was the case of a six year week old infant male infant
who presented to the ED with a report of three days
of projectile vomiting.
The infant was otherwise well appearing, no fever,
no viral symptoms.
He appeared hungry and interested in feeding.
And for those of you
who remember the hungry Vomiter is very, very classic story
for pric stenosis.
Often with these little ones, they're vomiting so much that
with an empty stomach often you can't see the pylori very
clearly because it's usually deflated
and they often will cry and swallow air
and it can sometimes be very challenging to see the pori.
But for some reason we were able to capture these beautiful,
beautiful images of this pylori.
And what you can see is here is the stomach that's quite
empty, but we can see this very hypertrophied pylos.
And what you can I hope appreciate is
that there's actually no, the lumen is so hyper,
like the whole pilar is so hypertrophy
that there actually is no lumen in here.
You can appreciate that there will be no ability for outflow
of contents from this pylos.
You may or may not remember
that there's certain size parameters for the diagnosis
of pyloric stenosis.
So you need to have a channel length greater than 14
millimeters and a wall thickness greater
than three millimeters.
And that was what we were able
to confirm when we actually measured
that the pori on this child,
Chapter five pocus in global health.
So I, I am very understanding
that in the western world we have many options
for imaging and while I'm obviously a great believer in
point-of-care ultrasound, we have a lot of resources.
And so while we can use point-of-care ultrasound,
we have many, many ways
of making the diagnosis with our patients.
Where I have been so incredibly humbled
is when I have been able to use point of care ultrasound
in the global health setting where I really appreciate that
sometimes this is the only imaging modality that we have.
And this is where this could be the,
the difference between life and death.
And I think for anybody
who is exploring the potential of working in the,
in a global health setting or in in in austere environments,
this is invaluable to your practice.
Obviously I'm a believer in using point
of care ultrasound regardless of where you practice,
but I have really been so, so grateful
for this, this training in order to help patients
in settings where this is really all you
have to help your patient.
So on a medical mission, the last time I was in Haiti,
unfortunately was years ago and,
and obviously I have, I have not been able to get back,
but this was back in 2016, we did a medical mission
that actually purpose of the medical mission was an
educational mission to teach providers at a children's
hospital how to use point-of-care ultrasound
to take care of their patients.
But in the process, we actually went to do a home visit
to a woman who one of the members
of our team had met on a prior visit.
She had been a woman, a 29-year-old female with a complaints
of several months history of
fatigue and shortness of breath.
Actually this all started after a few months
after the birth of,
or within weeks of the birth of her last child.
She had no electricity in her home.
The nice thing is that the earliest iterations
of the sono site product, the M turbo who if you're familiar
with the sono site fleet of of ultrasounds, the m turbo
in spite of its age, is still a,
an incredibly durable machine.
It is been, it's still a great, great machine,
it travels well and it has a great battery life.
So they were very generous in, in lending me a machine
for this medical mission.
And so in spite of the fact
that this woman had no electricity in her home, we were able
to work off of the battery of this m turbo
and we started scanning.
And so the first thing I did given her complaint was I
looked at her heart and unfortunately in looking at her
heart, I had, I had the answer as soon as I looked.
So you don't have to be a cardiologist
to appreciate when you're looking at her heart
that her heart looked quite diseased.
Her heart was very boggy in its appearance.
It didn't have much of a squeeze, which you can appreciate.
And her mitral valve was not doing very much.
So here's her mi the mitral valve,
this is the anterior septal wall
and that mitral valve is not making very much
contact with the septal wall.
So when we talk about ejection fraction,
we're we're really talking about how close is
that mitral valve meeting the septal wall
and the further away it is the poor, the ejection fraction.
So this woman had a very,
very compromised ejection fraction.
So she was in quite a significant degree
of, of heart failure.
She also had a little bit of a pericardial effusion,
which you can see over here.
But I would argue her,
her main issue was her heart failure.
She also had a really dilated IVC.
So because her heart was feeling so substantially,
her IVC was quite plethoric.
So the IVC should show respiratory variation.
It should show a collapse of about 50%
with each inspiration.
And what you can see is
that this is just a big plethoric IVC.
It's not really changing with respiratory variation at all.
It's just staying large and plump.
There was a lot of hope years ago
that the IVC could be used as a marker
of intravascular fluid volume.
Unfortunately those studies didn't really pan out,
but I would argue in the extremes,
either in the very fluid overloaded
and very fluid deplete, you can use that
to get additional information on your patient.
She was, I mean her,
her fluid overloaded state given her lack of for propulsion
of blood was quite evident.
She had fluid everywhere, including, as you can see,
here's her liver diaphragm
spine going north of the diaphragm.
And you can see she had fluid, she had just a little bit
of pericardial, sorry, pleural effusion and, and ectasis
'cause she was had fluid everywhere
and she had ascites as well in her belly.
She even had like quite a little bit of a,
a belly distension because of her fullness of her abdomen.
It, this was a, a sa I know
what ultimately happened with her.
She, she did not live close to Port-au-Prince.
I don't know her ease of getting to Port-au-Prince,
obviously Port-au-Prince being the main referral center
and that, and she clearly needed a cardiologist.
And I don't know what ultimately happened.
The majority of our time
for the medical mission was spent
in the children's hospital.
And as I as mentioned, the purpose of the,
of the mission was in education, working with the nurses
and the staff at this church children's hospital
to give them the skills on how they could use ultrasound.
Because amazingly, in spite of the fact that they are,
you know, they only had radiology twice a week,
they did have an x-ray.
There was one CT scanner in the whole porter prints
that was not on their site.
It actually was down for the, for, for the month.
While, while I was there, during the time that I was there,
the CT scanner was down.
They had a great machine on site.
So really truly the limit for their use
of the machine was just education.
So I was really happy to be part of the process
of helping them use the things that they, the,
the equipment that they already had.
We had been packing up on nearing the end
of our medical mission.
I think it was two days before the end
of our medical mission when a father came in
with a three-year-old child draped over his arms.
And for those of us who work in with children,
especially in pediatric emergency medicine,
whenever a child is draped over a parent's arm, it's kind
of the international sign of potentially impending death.
It's, it's a really kind of critical and, and ominous sign.
And the father came in with this child in that, in that way.
And for those of you who work in emergency medicine,
you know that boarding is definitely a situation.
It is also a situation in the developing world.
And this was at the end of the day that we were packing up
and every bed in the whole room, I mean it,
it was not a huge emergency department
but every space had been occupied by, by a patient
and there was nowhere to put this child.
So one of my colleagues, one of the
local physicians grabbed a code cart
and wiped all of the
tools that were on the code cart off the code cart
and we put the little girl on the code cart.
Now while they were in the process
of doing medical resuscitation
and attending to her, I grabbed the machine
and started to collect information to help them.
And so I started with a fast exam.
So I first looked at her heart, I saw
that she had good squeeze, great,
this was not heart related.
Fantastic. I then did a fast exam
'cause I didn't know if she had sustained trauma.
So looked and ensured that she had no free fluid
in her right upper quadrant.
I then went to her left upper quadrant
and ensured that she had no fluid there.
I looked in her pelvis, great, nothing was there. Phew.
Okay, so I ruled out heart and I ruled out trauma.
I then looked at her IVC and something was suspicious.
So now that you've looked at the last case
where the woman had the plethoric IVC,
now you can see this looks the complete opposite.
So this child had a completely collapsed IVC.
So a collapsed IVC is consistent with
a depleted intravascular fluid state.
So this child was, this was a piece
of information that was not good.
I still didn't know what was going on,
but I knew that this was going to be helpful.
And then continued scanning, I would scanned her chest
and lo and behold I found the answer.
So we learned
that this child had had some respiratory distress.
The child looked to be in distress, I saw
that she was intravascularly deplete
and now we had this big, very, very impressive pneumonia.
Okay? The picture was complete,
she was in septic shock from this pneumonia
and we had our information.
So while I was collecting information,
the team was actually medically managing her
and I was just calling out information as I got it.
So they had established IV access.
What I didn't realize,
'cause I was kind of focused on scanning,
was they actually intubated this little girl.
And I thought that was really interesting
'cause it's not something that you see every day in
the developing world.
Why I say that is that in the western world we intubate
often, no question.
It's a different, it's a different setting
in the developing world.
And I'm gonna set the scene
because we're in the emergency department,
they intubated her, we're in the emergency department
and we're on the ground floor.
Radiology is also in the ground floor.
And radiology comes in twice a week.
You can get x-rays twice a week.
The pediatric ICUs on the second floor.
In order to get your patient from the ground floor
to the picu, you have to go up a ramp outside.
So they, you have to roll your patient up a ramp.
Once you get your patient up to the second floor,
then they're gonna be hooked up to a vent.
Now the vents that they have are not the vents that we have.
The vents that they have are older vents.
These are not the portable vents that we currently have.
These are the older vents that we used to have like 15,
sometimes 20 years ago.
These are the clunky old vents
that you don't move patients with.
Additionally, you ca you physically can't move your patient
because you can't move your patient in an old chunky vent
down a ramp to get down to radiology.
So what I realized after this child was intubated
and once we got her upstairs is she wasn't moving.
Once she got up to the ICU, she wasn't moving.
That's where she was going to be
until she was gonna be extubated.
And then I realized, well I had just spent the whole week
teaching them how to do ultrasound.
So we had in, we had a way
that we could actually get meaningful information
even though we couldn't move her.
We had a way that we could still image her.
So the next clip is actually the clip from the actual
machine that we did in the ICU on
in 2016.
So you're gonna see that in just one second. So here it is.
So this is how we did this.
So they, we used ultrasound, only ultrasound to image
this child throughout the course of her intubation
for her profound pneumonia with respiratory failure
until she was able to be effectively extubated.
Now I left the country two days later
and they were on their own.
They no longer had me there to, to be working with them.
But what's nice is that WhatsApp is something
that's used universally in a lot
of these developing countries.
And so I was able to still be in touch with them.
They were able to capture images
and shoot me these images via WhatsApp.
And this is one of the WhatsApp images
that they had sent me a couple days later.
And it was really, this is a really was a, a wonderful story
of how ultrasound really was instrumental in saving the
life of this child.
I don't think she would've survived without ultrasound.
I think they, the team became very empowered
to use ultrasound and the care of this child.
She ultimately was extubated.
So it was a really beautiful story of,
of the lifesaving potential of ultrasound.
And I was really, really humbled to have been part of that,
that that care team.
And as I always feel like ultrasound is really something
that I am so very much invested in.
I I really think that it is something
that can always help you in medical decision
making at the bedside.
It can help you tailor your medical workup
or your interventions obviously in,
in research limiting settings or in austere environments
or anywhere, even at, even here in the United States.
It can help you as a lifesaving imaging modality.
'cause sometimes it just gives you information that you
otherwise wouldn't have unless you put the
probe on your patient.
And so I hope I've really given you an opportunity
to see the incredible ways that ultrasound can,
can really help you better take care of your patients,
especially your little pediatric patients.
Thank you so much.
- All right, thank you so much Dr. Levine,
for an excellent presentation.
As noted in the intro, we won't have a live q
and a session today, but please feel free
to send your questions along
to Paul Bosky at paul dot bosky@fujifilm.com.
Paul will pass your questions along to Dr. Levine
and answer any questions you might have about sono
site systems as well.
Thank you all for joining us today for the today's webinar.
We'll be announcing some more webinars soon.
So keep an eye on Sonos site.com/behind the scan
webinar for more details.
And in order to get there easily, you can scan the QR code
that's on the screen right now.
Thank you Dr. Levine, for taking the time
to put together an excellent presentation for us.
As always, we appreciate you sharing your knowledge
and expertise with our audience.
And thank you to Paul Broski as well for helping out
with answering questions.
And of course, thank you to everybody else
for joining us here today.
We'll see you at the next webinar.
Point-Of-Care Ultrasound (POCUS) is a safe noninvasive tool to help you diagnose and treat pediatric patients in the Emergency Department. This case-based webinar will review how POCUS can help emergency medicine care providers better care for their patients.
What You'll Learn
After attending this webinar, viewers will be able to provide better patient care by having an improved understanding of how to:
- Incorporate POCUS exams into their practice.
- Utilize the most useful POCUS exams through a specific real-time POCUS case review.
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.
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.