[1] Contents: Letter from the Editors.....................1 Ultrasound Training - Lorraine Ng, David Kessler.....................................2 Pearls and Pitfalls of Ultrasonography......4 Board Review - Imaging in PEM...............5 Case Highlight - Intussusception............7 Highlights from the SOEM Meeting............8 Top 10 Articles in Pediatric Emergency Medicine, 2011-2012.........................9 Image Feature: Bedside Ultrasound in a Baby with Respiratory Distress..................10 Case Highlight: Baby with a Neck Mass.....11 PEMNetwork Fellowship Section Update.......12 For Authors................................13 FOCUS ON ULTRASOUND From the Editors: Ultrasound is becoming an increasingly useful and vital part of the practice of pediatric emergency medicine. PEM Ultrasound fellowships are emerging, and new uses for ultrasound in our daily practice are being described in the literature on a constant basis. For those of us with interest in ultrasound, we cannot learn fast enough. For those of us without solid ultrasound skills, the learning process is intimidating and it can be hard to know where to start. With this in mind, we present our Winter Newsletter with a focus on ultrasound, featuring established experts in the field, and cases demonstrating the varied use of ultrasound in practice. All cases presented were performed by novice ultrasonographers. We hope this will encourage our readers to pick up that probe! January 2013
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Transcript
[1]
Contents:
Letter from the Editors.....................1Ultrasound Training - Lorraine Ng, David Kessler.....................................2Pearls and Pitfalls of Ultrasonography......4Board Review - Imaging in PEM...............5Case Highlight - Intussusception............7Highlights from the SOEM Meeting............8Top 10 Articles in Pediatric Emergency Medicine, 2011-2012.........................9Image Feature: Bedside Ultrasound in a Baby with Respiratory Distress..................10Case Highlight: Baby with a Neck Mass.....11PEMNetwork Fellowship Section Update.......12For Authors................................13
FOCUS ON ULTRASOUND
From the Editors:Ultrasound is becoming an increasingly useful and vital part of the
practice of pediatric emergency medicine. PEM Ultrasound
fellowships are emerging, and new uses for ultrasound in our
daily practice are being described in the literature on a constant
basis. For those of us with interest in ultrasound, we cannot learn
fast enough. For those of us without solid ultrasound skills, the
learning process is intimidating and it can be hard to know where
to start. With this in mind, we present our Winter Newsletter with
a focus on ultrasound, featuring established experts in the field,
and cases demonstrating the varied use of ultrasound in practice.
All cases presented were performed by novice ultrasonographers.
We hope this will encourage our readers to pick up that probe!
January 2013
[2]
Lorraine Ng, MD, David O. Kessler, MD, MSc, RDMS
Columbia University Medical Center
Emergency ultrasound (EUS) has been deemed a core
competency for emergency medicine residents by the American
College of Physicians (ACEP) since 2002.1 The past two
decades have seen a transformation in the role of EUS from a
novel toy to standard practice and full integration of a wide
variety of applications in the emergency department. This role
has been accompanied by a robust growing body of literature to
support the use of EUS in clinical decision-making, guiding
resuscitative care, and improving procedural safety and
success.
Pediatric emergency medicine (PEM) training programs
have not yet adopted ultrasound as a core competency,
however ultrasound use in the pediatric emergency department
and training opportunities have also been on the rise.2 Despite
the increase in training and exposure to EUS within PEM
fellowships, very few programs (~25%) have a formal curriculum
leading many to pursue further training. We spoke with several
leaders in the field to learn more about their paths to expertise
and where they see the future of this exciting new field.
“Scan as much as possible - even
if you don't know what you are
looking at!” says Dr. Alex Arroyo,
Director of Pediatric Emergency
Medicine Ultrasound Research at
Maimonides Medical Center. But warns, “there are some things
you just can’t get from self-teaching and an informal "mini"
fellowship,” says Dr. Arroyo.
“Scan, scan, scan, there is no substitute for actually using
ultrasound on a regular basis and getting hands-on instruction
by knowledgeable attending staff,” agrees Dr. Adam Sivitz, the
Director of Pediatric Emergency Medicine at the Children's
Hospital of New Jersey at Newark Beth Israel Medical, where
they currently have a 2-day bootcamp and 2-week elective for
their PEM fellows, along with regular education and hands-on
use throughout fellowship. While Dr. Sivitz recommends
fellowship for those interested in pursuing an US career or
becoming a local “champion,” he also adds for those seeking to
hone their ultrasound skills during fellowship, “If you have an
ultrasound fellowship already at your institution, you could
potentially gain competency through regular use and attendance
at lectures, similar to EM residents.”
That’s exactly the strategy that Dr. Jennifer Marin started
out with, now director of Pediatric Emergency Ultrasound at the
Children’s Hospital of Pittsburgh. "I began my ultrasound
experience when I was a first year fellow, being introduced to
the FAST exam during my trauma rotation. From there, I
developed a research interest using bedside ultrasound and
then decided to improve my skills even further by creating a
training program for myself during an extra year of fellowship."
By obtaining a grant through the NIH to fund an additional year
of research, she was also able to design her own EUS
experience that mirrored the EUS fellowship at the neighboring,
general emergency department in which she attended weekly
video clip reviews, had mentored scanning shifts, and pursued
further ultrasound teaching responsibilities.
Have no fear, formal training
opportunities for PEM trainees are
rapidly on the rise. Many have already
taken advantage of formal specialization in EUS
through tailor-made curriculums at one of the many non-ACGME
accredited 1 or 2 year fellowships (www.eusfellowships.com).
There are currently 86 EUS fellowships nationwide, with an
increasing number of pediatric EUS fellowships offering US
expertise tailored to PEM. Directors of EUS programs around
the country, such as Dr. J. Christian Fox from University of
California, Irvine School of Medicine, Dr. Arun Nagdev from
Highland General Hospital, Dr. John Bailitz from Cook County
Emergency Medicine in Chicago, Dr. Resa E. Lewiss from St.
Luke’s Roosevelt Hospital Center in New York City, Dr. John
Kendall from Denver Health Medical Center, and Dr. Gregory
Press from University of Texas at Houston, to name a few, have
begun to train PEM fellows in their fellowships as well because
they “realize PEM is in need of ultrasound leaders.”
Recently, several pediatric emergency medicine divisions
have also created additional fellowship training programs in
Formal pediatric emergency ultrasound training programs are on the rise!
Can you tell me a bit about when/how ultrasound became a commonly-used modality in Emergency medicine?
In the late 90's European trauma surgeons started using ultrasound to diagnose intra-abdominal
injuries. With the rapid technological breakthroughs of miniaturization portable US became a reality.
How much time and training does it take to become proficient with the ultrasound machine? What are some easy-
to-learn diagnoses/applications?
I think the FAST scan is the one that novice should start with. Not because it's the easiest but
because it helps illustrate several salient features of ultrasound: different tissues, different
orientations, dynamic imaging, etc. etc. It's hard to say how many scans. ACEP has a consensus
statement on training for a variety of modalities and is a good reference.
Procedural applications are often easier to learn. These include vascular access, abscess I&D,
nerve blocks, etc. The success and failure of the procedures give you immediate feedback on your
study.
There are few faculty in my ED who use the ultrasound machine - how do I get existing faculty on-board with
bedside ultrasound?
There was one patient in our PICU where no one could obtain vascular access except for the EM
resident with a borrowed ultrasound machine. The next week a machine was delivered.
Ultrasound is becoming very popular and the PEM community has embraced it as a skill we need, but what are
some caveats and pitfalls to PEM physicians using ultrasound?
In general for diagnostic studies specificity is higher than sensitivities. Therefore bedside ultrasound
is not good, in general, to rule OUT diagnosis. So for conditions with high potential morbidities such
as ovarian / testicular torsion, appendicitis, etc. I would be very careful in using a negative bedside
ultrasound to discharge the patient.
What are the medico-legal implications of adding ultrasound to our skill set and credentialing? Our malpractice
rates are already pretty high...How can we ensure an appropriate review process and quality assurance?
You need to work with your hospital / institution credentialing body which have their own rules. For
procedural studies there is general consensus that ultrasound
improves success rates and decreases complications. For
diagnostic tests it gets much trickier. Again I would avoid those
conditions mentioned previously, or at least not rely on the
bedside reading exclusively, without confirmatory testing.
Pearls and Pitfalls of Bedside Ultrasound - an Interview with Lei Chen
- Michelle Alletag
Q
Q
Q
Q
A
A
A
A
A
Q
Dr. Chen is an Associate Professor of Pediatric Emergency Medicine at Yale University and has contributed extensively to the study and development of ultrasound in PEM.
[5]
1. The amount of experience and training required by a
non-radiologist to perform a focused exam is:a. Not definitively established
b. 300 completed studies
c. 150 completed studies
d. 8 hours of hands-on training
2. Which of the following is NOT true?a. Ultrasound is defined as frequency greater than 20,000 hertz.
b. Hypoechoic objects appear dark on the ultrasound screen.
c. High-frequency ultrasound penetrates deeper into tissues than
low-frequency ultrasound.
d. Urine in the bladder will appear black because it does not reflect
ultrasound waves well.
3. With respect to FAST scans, which of these
statements are true?a. The most common practice uses four ultrasound views, but
additional views are sometimes obtained.
b. FAST scans are useful for identifying free fluid in the abdomen
and somewhat less so for solid organ injury.
c. A normal FAST scan may occur if there is not enough free
intraperitoneal fluid.
d. All of the above.
4. Choose the best statement.a. For soft tissue ultrasound, use of a curved ultrasound probe
allows for better contact with the skin.
b. A spacer or stand-off may help place the are of interest within the
optimal focal zone of the ultrasound probe.
c. A low-frequency probe is most appropriate for evaluation of the
superficial soft tissues.
d. Ultrasound is of no value in evaluating simple cellulitis.
5. Which of the following is true? a. A-mode ultrasound is the most frequently used today
b. M-mode is a form of Doppler ultrasound
c. Color Doppler gives a quantitative measurement of flow
d. Doppler ultrasound is dependent on how the probe is held relative
to the direction of the moving object.
6. An intrauterine pregnancy can be confirmed earliest
by:a. Quantitative human chorionic gonadotropin (HCG)
b. Endovaginal sonography (EVS)
c. Transabdominal sonography (TAS)
d. Doppler
7. The indirect method of venous cannulation using
8. The most common ultrasound probe placement for a
rapid cardiac exam is:a. Transesophageal
b. Parasternal
c. Apical
d. Subxiphoid
Questions used with permission by Jennifer Pai, MD, editor of Pediatric Emergency Medicine Practice.
For full text and more review topics, visit EBMedicine.net/topics.php. All reviews published >36 months ago are free for viewing.
Answers and discussion, next
page
BOARD REVIEW:IMAGING IN PEDIATRIC EMERGENCY MEDICINE
[6]
1. a. Not definitively established
Though all of the above choices have been issued in consensus
statements, studies have shown that ED physicians can accomplish a
high degree of accuracy in as little as 4 hours of training. More important
than following consensus statements is implementing a process for
continued experience and quality review.
2. c. High-frequency ultrasound penetrates deeper into
tissues than low-frequency. High-frequency transducers (such as the linear probe commonly
used in bedside ultrasound) have beams that are more unidirectional and
focused with shorter wavelengths, so images are high resolution but
attenuate quickly. Attenuation is the process of “losing power” as the
ultrasound beam travels through tissue. Lower frequency transducers,
such as the curvilinear probe, have longer wavelengths, are more
multidirectional, and penetrate deeper into tissues, providing a lower-
resolution but deeper picture.
3. d. All of the above The FAST exam is designed primarily to detect free fluid in the
abdominal cavity, which translates to blood in the setting of abdominal
trauma. The classic FAST method is a four-view scan, beginning with the
RUQ and Morrison’s pouch, followed by the LUQ, subxiphoid region (to
assess for pericardial effusion), and the suprapubic region. If free fluid is
found, the adjacent organ may be assessed to evaluate for injury, thought
the FAST is less sensitive for this. While FAST is highly sensitive and
specific in adult trauma, its sensitivity decreases in the pediatric setting.
This is due to many factors, but primarily because children are more likely
to have organ injury without corresponding major blood loss, and are less
likely to bleed with a volume sufficient to produce the anechoic strip that
indicates free fluid. Specificity of FAST, however, remains high for children
as well as adults.
4. b. A spacer or stand-off may help place the are of interest
within the optimal focal zone of the ultrasound probe. High-frequency linear transducers produce the best quality
images of superficial soft tissue structures and can be useful in evaluating
cellulitis and presence/absence of drainable abscesses. A spacer or
stand-off can be useful in cases of very superficial skin and soft tissue
structures that are closer to the probe than the usual focus zone -
commercial products are available, but the use of a glove filled with water
is an excellent and inexpensive alternative. For foreign body evaluation, a
stand-off, made by placing the extremity in a basin of water and then
placing the probe on the water’s surface, is also useful.
5. d. Doppler ultrasound is dependent on how the probe is
held relative to the direction of the moving object.
The most commonly used mode of ultrasound is B-mode (or
“bright”), with object intensity corresponding to echogenicity. M-mode is
a time-motion mode that shows both the traditional B-mode image and a
tracing of tissue motion (e.g. fetal heartbeat). Doppler ultrasound utilizes
the fact that ultrasound (or any sound wave, to be exact) beam frequency
increases if an object moves toward it, and decreases as it moves away.
Color doppler provides a visual interpretation of directionality and velocity
of flow.
6. b. Transvaginal ultrasoundWhile quantitative HCG can confirm a pregnancy earlier that ultrasound, it
is not specific for intrauterine pregnancy (IUP). At 5-6 weeks gestation, TV
ultrasound can confirm the presence of a gestational sac, with
transabdominal able to confirm slightly later. At 6-7 weeks, a fetal pole
and, at 7-8 weeks, a cardiac flicker may be then visible by either modality,
though TV provides higher quality images and can detect each
approximately one week earlier than TAS. Confirming an IUP in the female
patient with abdominal pain or bleeding can effectively rule out ectopic
pregnancy (though the risk of a second ectopic pregnancy may be as high
as 1:4000, or greater if fertility agents are used)
7. d. One person without special preparation The indirect method provides less guidance than the direct
method of cannulation, and simply uses the ultrasound probe to locate
and mark the site of a vessel prior to attempted cannulation. Light
pressure on the vessel to flatten and thus confirm that it is a vein is
performed prior to attempted cannulation. This method can be performed
by a single provider without any special preparation. The direct method
requires more preparation and is best performed with 2 operators, and
uses ultrasound to directly visualize the needle as it is being cannulated.
A linear high-frequency probe should be used for this method, as
curvilinear will distort the image. Ultrasound-guided central line
placement is currently considered standard of care in the adult emergency
setting, though formal guidelines in the pediatric setting have not yet been
established.
8. d. Subxiphoid
A single subcostal (subxyphoid) view is the most useful for
evaluating pericardial effusions and cardiac standstill, and is the view
included in ATLS and PALS teaching. The parasternal views may provide
additional information about cardiac function. The subcostal view is
obtained by placing the transducer just below the xiphoid and aiming
toward the patient’s left shoulder. This places the right ventricle at the top
of the screen, and provides a “reverse” image of standard
echocardiography images.
Imaging in PEM: Answers
[7]
The Patient:
A 3yo afebrile female presented to the
emergency department (ED) with 1 day of
abdominal pain in “waves” with emesis and
negative hemoccult. She had a negative
laboratory evaluation and had an abdominal
ultrasound (US) that demonstrated
intussusception. [Figure 1] She was taken for
an air enema during which the
intussusception was no longer visualized.
This was confirmed with repeat US
immediately after the enema. She was then
observed in the PED where her pain resolved
and she was discharged home after tolerating
oral hydration. The family received strict
discharge instructions to return to the ED with
any recurrence of symptoms. However, they
did not return until 2 days later despite return
of emesis, abdominal pain and fever shortly
after discharge. At that time, the patient
presented to her primary physician in
uncompensated shock. She was transported
to the PED with a surgical abdomen. She
received 60cc/kg of NS with
improvement in her vital signs. Bedside
ultrasound was performed and there
was evidence of fluid filled loops of
bowel, abnormal thick-walled bowel without
blood flow on color doppler and extensive
complicated fluid. [Figures 2, 3 & 4] The
patient was taken to the operating room for
exploratory laparotomy and was found to
have 40cm of necrotic bowel. [Figure 5] Intra-
operatively, she was coagulopathic and septic
requiring resection and temporary abdominal
closure with a delayed re-anastomosis
following resuscitation in the PICU.
Discussion:
Intussusception is a common cause of
bowel obstruction in children and carries a
mortality of less than 1%. US is the initial
imaging modality of choice and has been
reported to be 92% sensitive for
intussusception. Many studies have sited
non-operative reduction techniques as
Figure 1 (Top Left) demonstrates pathognomonic target sign of intussusception. From Top, Figures 2 (fluid filled loops), 3 (absence of flow), 4 (complicated fluid collection), and 5 (necrotic bowel at time of surgery).
CASE HIGHLIGHT: A NASTY CASE OF INTUSSUSCEPTION
Carrie Busch MD, William S Russell MD, Jeanne Hill MD, Christian Streck MD
Medical University of South Carolina
[8]
successful with minimal reported
complications. The overwhelming majority
of intussusceptions can be handled non-
operatively with maximal success rates in
the setting of <24 hours of symptoms and
in the typical age range of 6 months to 3
years. An enema reduction using air or
water soluble contrast is recommended
for the most common location, ileocolic.
In some centers, a short observation
period and discharge is routine
management providing patients tolerate
oral hydration and have no return of
abdominal pain. However many
institutions routinely admit for a longer
observational period secondary to
concern for recurrence. This is estimated
to happen in approximately 10% of cases.
Bowel wall compromise and necrosis is a
known complication of unreduced or
recurrent intussusception. Our case,
however, illustrates that necrosis can be
seen in the absence of a distinct re-
intussusception episode. While we
cannot rule out recurrence, we suspect
the clinical course observed is the result of
an ischemic segment that evolved to full
thickness necrosis in the 48 hours post
reduction. We present this case as a rare
complication that illustrates the necessity
for strict return precautions and next day
follow-up when an early discharge model
is followed. This extreme case illustrates
that even seemingly routine cases of
intussusception can have complications.
It also demonstrates that in the setting of
symptom return after intussusception
reduction, a negative US for recurrent
intussusception does not exclude
intussusception- related pathology.
Case Highlight: Intussusception, cont.
HIGHLIGHTS FROM SOEMA Note from the Head Site Administrator
Angela Lumba, MD, FAAPSt. Louis Childrens Hospital
In October 2012, the AAP held its annual National
Conference Exhibit in New Orleans. The Section on
Emergency Medicine (SOEM) and its Committee for the
Future opened the session with Technology in Pediatric
Emergency Medicine. Through speeches and poster
presentations, physicians shared ways they had
innovated PEM education through advancing technology.
The PEMNetwork was one of the many ideas highlighted!
The SOEM continued to deliver our annual favorites:
EmergiQuiz – a platform for fellows to explore the
diagnosis and management of unique cases
PEMPix – A collection of photo submissions of
interesting to extreme presentations
Abstract sessions
Top 10 PEM articles of 2012 - see next page for list
I first attended the SOEM NCE plenary session as a
resident with hopes of PEM fellowship. To this day, I am
inspired by the presentations I hear, by the camaraderie at
the meeting, and by the depth and breadth of topics
covered. I recommend that every trainee or junior faculty
member attend this energetic and
dynamic conference.EmergiQuiz
presentations can be viewed on
PEMNetwork.org. Visit the AAP SOEM website to
see PEMPix entries and winners.
[9]
Top 10 PEM Articles 2011-2012
Michelle D. Stevenson, MD MS FAAP
University of Louisville
#10Yield of Emergent Neuroimaging Among Children Presen:ng With a First Complex Febrile Seizure Amir A. Kimia, MD; Elana Ben-‐Joseph, MD; Sanjay Prabhu, MD, MBBS, FRCR; Tiffany Rudloe, MD; Andrew Capraro, MD; Dean Sarco, MD; David Hummel, MSc; Marvin Harper, MDPediatr Emerg Care 2012;28: 316-‐321PMID: 22453723 #9Vasopressin rescue for in-‐pediatric intensive care unit cardiopulmonary arrest refractory to ini:al epinephrine dosing:A prospec:ve feasibility pilot trialTimothy G. Carroll, MD; Vivian V. Dimas, MD; Tia Tortoriello Raymond, MDPediatr Crit Care Med 2012; 13:265–272PMID: 21926666
#8U:lity of Plain Radiographs in Detec:ng Trauma:c Injuries of the Cervical Spine in ChildrenLise E. Nigrovic, MD, MPH; Alexander J. Rogers, MD; Kathleen M. Adelgais, MD, MPH; Cody S. Olsen, MS; Jeffrey R. Leonard, MD; David M. Jaffe, MD; and Julie C. Leonard, MD, MPH; for the Pediatric Emergency Care Applied Research Network (PECARN) Cervical Spine Study Group Pediatr Emerg Care 2012;28: 426-‐432.PMID: 22531194 #7Occult Serious Bacterial Infec:on in InfantsYounger Than 60 to 90 Days With Bronchioli:sShawn Ralston, MD; Vanessa Hill, MD; Ami Waters, MDArch Pediatr Adolesc Med. 2011;165(10):951-‐956.PMID: 21969396 #6The Spectrum and Frequency of Cri:cal Procedures Performed in a Pediatric Emergency Department: Implica:ons of a Provider-‐Level ViewMaUhew R. MiVga, MD, Gary L. Geis, MD, Benjamin T. Kerrey, MD, MS, Andrea S. Rinderknecht, MDAnn Emerg Med. 2012; Jul 26. [Epub ahead of print]PMID: 22841174
#5Diagnosis of Intussuscep:on by Physician Novice Sonographers in the Emergency DepartmentAntonio Riera, MD, Allen L. Hsiao, MD, Melissa L. Langhan, MD, T. Rob Goodman, MBBChir; Lei Chen, MD, MHSAnn Emerg Med. 2012;60:264-‐268.PMID: 22424652 #4Rapid Versus Standard Intravenous Rehydra:on in Paediatric Gastroenteri:s: Pragma:c BlindedRandomised Clinical TrialStephen B. Freedman, MD; Patricia C. Parkin, MD; Andrew R. Willan, PhD; Suzanne Schuh, MDBMJ 2011;343:d6976PMID: 22094316 #3 Prevalence of Clinically Important Trauma:c Brain Injuries in Children With Minor Blunt Head Trauma and Isolated Severe Injury MechanismsLise E. Nigrovic, MD, MPH; Lois K. Lee, MD, MPH; John Hoyle, MD; Rachel M. Stanley, MD; Marc H. Gorelick, MD; Michelle Miskin, MS; Shireen M. Atabaki, MD; Peter S. Dayan, MD, MSc; James F. Holmes, MD, MPH; Nathan Kuppermann, MD, MPH; for the TraumaXc Brain Injury (TBI) Working Group of the Pediatric Emergency Care Applied Research Network (PECARN)Arch Pediatr Adolesc Med. 2012;166(4):356-‐361.PMID: 22147762 #2 Prevalence of Abusive Injuries in Siblings and Household Contacts of Physically Abused ChildrenDaniel M. Lindberg, MD; Robert A. Shapiro, MD; AntoineUe L. Laskey, MD, MPH; Daniel J. Pallin, MD, MPH; Emily A. Blood, PhD; Rachel P. Berger, MD, MPH; and for the ExSTRA InvesXgatorsPediatrics 2012;130;193-‐201.PMID: 22778300 #1 Intramuscular versus Intravenous Therapy for Prehospital Status Epilep:cusRobert Silbergleit, MD; Valerie Durkalski, PhD; Daniel Lowenstein, MD; Robin Conwit, MD; Arthur Pancioli, MD; Yuko Palesch, PhD; and William Barsan, MD; for the NETT InvesXgatorsN Engl J Med 2012;366:591-‐600.PMID: 22335744
Visit PEMNetwork.org or
the AAP SOEM site for article summaries,
description of article selection methodology,
honorable mentions and more!
[10]
David Rodriguez, MD
UT Southwestern Medical Center
A 19 week old term male, with no
significant medical problems presents to the
Emergency Department (ED) with difficulty
breathing. He has had 1 week of congestion and
increased work of breathing but no fever. Over
the past 2-3 days he has had decreased activity,
decreased oral intake, and mildly decreased
urine output but normal stools. He was seen at
an Urgent Care Center 3 days prior and started
on amoxicillin for “infection.” Seen by PCP 2
days prior, started on albuterol and steroids for
bronchiolitis. Also seen yesterday and again
today by PCP for follow up, again given
nebulizer treatments, but sent to the ED due to
increased wob. O2 sats reportedly improved
from 90 to 94% RA after nebulizer treatments.
Presenting vital signs are as follows:
BP 110/44 | Pulse 157 | Temp(Src) 36.6 °C
(97.9 °F) (Temporal) | Resp 58 SpO2 98% (RA)
On physical exam, he was well-developed
and well-nourished, active and with a strong cry.
His anterior fontanelle was flat. Rhinorrhea and
congestion were present but mucous
membranes were moist. Oropharynx and ears
were clear. Neck was supple. Cardiac exam
was normal, with no murmur.
Tachypnea, subcostal retractions, and
accessory muscle usage present. Transmitted
upper airway sounds were present but no
wheezes, rales, or rhonchi.
Abdomen was soft with normal bowel
sounds and no organomegaly. Skin was warm
with a normal capilary refill time. No purpura,
rash, pallor or cyanosis were noted.
The patient had bulb suction and lavage,
but became dusky and cyanotic. He was taken
to the critical care room. There he was in severe
respiratory distress with a respiratory rate in the
80's, using accessory muscles. He was
intubated using atropine, fentanyl, and
rocuronium. Bedside US showed decreased
cardiac contractility. CXR showed good tube
placement and severe cardiomegaly. EKG
showed inverted T waves in the lateral leads.
Cardiology was called to perform an emergent
bedside echo prior to admission to the cardiac
ICU, with the diagnosis of myocarditis.
IMAGE HIGHLIGHT: BEDSIDE ECHO IN THE EVALUATION OF A BABY IN
RESPIRATORY FAILURE
A very abnormal subxiphoid view CXR shows severe cardiomegaly. Bedside ultrasound demonstrates no cardiac effusion, but the right ventricle is severely dilated, with poor contractility easily noted on video.
Watch the ultrasound video clip
of this heart on PEMNetwork.org
[11]
Case HighlightPeter Moyer, MD; Yale University
Michelle Alletag, MD; UT Southwestern Medical Center
The Case:An 8 day old male born via SVD presents to the ED with a left neck mass.
The mother first noted the mass three days prior, and states it has been getting
darker but not larger in size. Per mother, the patient has been feeding well, alert,
and afebrile. The patient did require forceps extraction, but birth was otherwise
uncomplicated.
On exam, the baby is alert, with normal vital signs for age. He has two
palpable masses on the left neck; one is 1x3cm over the mastoid, with a second
1x1cm mass over the angle of the mandible. Both are red and firm, with no
fluctuance or induration. The patient’s neck is supple, and a right parietal
cephalohematoma is also noted. He has a slight head tilt to the left but full
passive and active ROM. The remainder of the exam is unremarkable.
Ultrasound of the neck demonstrated two echogenic masses along the
anterior aspect of the sternocleidomastoid, with Doppler evidence of internal
vascularity and no cystic component. The diagnosis of congenital fibromatosis
coli (or psuedotumor of infancy) was made. The patient’s mother was instructed
on home care for congenital torticollis, and the patient had resolution of the
masses at his two-month well-child visit.
Discussion:
Congenital fibromatosis coli is a benign condition in neonates, which may
result in congenital muscular torticollis and positional plagiocephaly. It presents
as a palpable, firm, nontender mass along the border of the sternocleidomastoid
(SCM) muscle. It often leads to contracture and fibrosis of the underlying SCM,
resulting in congenital torticollis and head tilt. It occurs equally among boys and
girls, and is associated with other congenital musculoskeletal anomalies (most
often hip dysplasia). The cause of fibromatosis coli is unclear, but is thought to be
the result of one of two insults: fetal malpositioning in utero leading to
contracture and fibrosis, or birth trauma resulting in muscular fibrosis. The
forceps delivery, cephalohematoma, and visible hematoma over our patient’s
masses support the latter etiology in his case. Differential diagnosis must include
more pathologic conditions such as lymphadenitis, congenital cystic lesions with
abscess, and oncologic processes, including sarcomas, teratomas, or
lymphomas.
Diagnosis is best made by ultrasound evaluation, which shows echogenicity
with fusiform enlargement of the SCM, and excludes the diagnoses of
lymphadenitis, congenital cysts, or abscess. While CT, MRI, and fine needle
aspirate will also establish the diagnosis, ultrasonography has the advantage of
lower cost, lack of radiation exposure, and avoidance of sedation.
Treatment for fibromatosis coli consists of massage, heat, and passive
stretching, with the majority of patients having complete resolution with home
treatment alone. Those who do not resolve within the first year of life should be
referred to an otolaryngologist, as they may require surgical intervention.
Above, the baby presents with a large erythematous region near the mastoid. Ultrasound of the affected area (Figure 2) shows hypertrophy of the SCM as compared with the contralateral normal side (Figure 3). No evidence of cellulitis, “cobblestoning”, lymphadenopathy, or fluid collections was noted.
THE BABY WITH A NECK MASS
[12]
Hello everyone,
First and foremost, we would like to congratulate everyone who matched into PEM this year! It was a great match with a 143 individuals matching into PEM fellowship positions at 71 different programs around the country after completing either a Pediatrics or Emergency Medicine residency. We are very excited to have these individuals join the ranks of PEM and look forward to having them as colleagues. Congratulations again!
We are also eagerly anticipating this year’s PEM Fellows’ Conference, which will be taking place from February 23rd through February 25th, 2013 in Austin, Texas. This year’s conference will be supported by the EMSC Program and Austin Children’s Hospital Medical Center. A wonderful program has been planned and we look forward to this opportunity for so many PEM fellows from around the country to come together for a weekend.
We hope you all had a wonderful holiday season.
Saranya Srinavasan, MDPediatric Emergency Medicine FellowChildren's Hospital Los Angeles
From the Fellowship Corner
[13]
Now it’s easier than ever! PEMNetwork is a dynamic, ever-evolving organization and we
are always looking for new ideas and input. Do you have a great case or interesting
teaching point that you wish you could share with someone besides those same fellows you
Case Reports: May include presentation of uncommon diagnoses or of unusual presentation or complications of common
diagnoses seen in the Pediatric Acute Care setting. Should consist of a brief, 1-2 paragraph description of the case, followed by a
discussion of diagnosis and management of the disease process reported. Inclusion of images, either of physical exam findings or
radiographic studies, are recommended. A minimum of 3 references for the discussion section is requested.
EKG Submissions: Classic EKG findings of disease processes found in the acute care setting are welcome. Please include an
image of the EKG, description of the EKG findings, 1-2 sentences describing the case, and a brief discussion of the disease process
being shown. References are requested but not required.
Image Highlights: May include an image of an interesting physical exam finding, or a radiologic
image of significant teaching value. Please include a brief description of the case, followed by 1-2
paragraph discussion of the disease process being highlighted and the characteristic features of the
image. References are requested but not required.
Literature Review: May be in case report format, or topical only. Reviews of current or new AAP
subcommittee recommendations or of specific disease processes are desired. Please limit to one
page, references required.
WANT TO BE A PART OF PEMNETWORK.ORG?
Recommended formats will be
available for review at PEMNetwork.org, on
the newsletter page
Editors:
Purva Grover Michelle Alletag Angela Lumba
Send Us Your Cases!
We are currently accepting submissions for our spring newsletter. The focus for the spring newsletter will be on innovations in medical education. Email submissions to [email protected].