Chapter 15: Pediatric Point-of-Care Ultrasound (P-POCUS)

High-Yield Facts

• Focused assessment with sonography in trauma (FAST) in the hypotensive child allows for rapid identification of life-threatening intra-abdominal hemorrhage. In the stable traumatized child, serial FAST improves the identification of occult intra-abdominal injuries and may prove to be a useful screening tool aimed at reducing the number of computed tomography scans obtained.

• Pediatric point-of-care ultrasound (P-POCUS) allows for the more accurate identification of skin and soft-tissue infections requiring incision and drainage.

• P-POCUS improves the safety and efficiency with which central venous access is obtained in children and may improve the first-time success rate and efficiency of peripheral vascular access in children with difficult peripheral vascular access.

Introduction

Pediatric point-of-care ultrasound (P-POCUS) is a skill that is enabling physicians to use ultrasound technology as an extension of the physical examination to more accurately, efficiently, and safely manage children with acute medical, surgical, and trauma-related conditions. In this chapter, an introduction to three common indications for P-POCUS will be briefly reviewed—abdominal and torso trauma, skin and soft-tissue infections, and vascular access.

Torso Trauma

The focused assessment with sonography in trauma (FAST) scan was shown to reduce time to operative care, hospital length of stay, use of computed tomography (CT) and hospital costs, as well as improved morbidity in adult trauma patients.¹ In the persistently unstable child with torso trauma, FAST similarly allows for the rapid identification and management of intra-abdominal hemorrhage². On the other hand, most children with intra-abdominal injuries do not require surgery and therefore FAST may serve a different goal. Some have studied the utility of pediatric FAST scanning in diagnosing intra-abdominal hemorrhage versus diagnosing any injury versus clinically important injuries. The difficulty is in the consistent finding that approximately 15% of patients with torso trauma, for whom trauma code activation criteria were met, and likely some of those in whom it was not, have significant occult injuries. The current gold standard is still CT scanning. When FAST is used in the stable pediatric trauma patient,³ in conjunction with other diagnostic examinations, such as physical examination,⁴ liver function test,⁵ and/or serial FAST,⁶ its performance at identifying clinically important intra-abdominal injuries improves significantly. Most likely, a clinical decision rule incorporating serial FAST will improve the sensitivity and specificity of algorithms such as that proposed by Holmes et al.⁷ thereby assuring the appropriate group of injured children have diagnostic imaging, while not missing clinically important injuries with the goal of minimizing unnecessary radiation exposure.

The FAST technique using a low-frequency curvilinear probe in pediatrics is often easier to perform compared with adults given their smaller size and more echogenic tissue. One begins by looking at the hepatorenal space (Morison's pouch) in the right upper quadrant, which is the second most dependent part of the supine abdomen and where blood from the pelvis (the most dependent part but very ...