Chapter 15: Pediatric Applications

INTRODUCTION

The role of point-of-care ultrasound (POCUS) in the emergent care of ill and injured pediatric patients continues to evolve and mature. Ultrasound technology is ideally suited for infants and children as it allows real-time visualization of anatomic structures without causing pain, requiring sedation, or exposing developing tissues to ionizing radiation.

There are numerous indications for POCUS common to both adult and pediatric emergency care. In addition, the functionality of POCUS has been further expanded by recent innovation and the development of several pediatric-specific applications.

TRAUMA

Trauma remains one of the leading causes of morbidity and mortality in children. Motor vehicle crashes are currently the leading cause of death for children and adolescents, representing 20% of all deaths; firearm-related injuries are the second leading cause of death, responsible for 15% of deaths.¹ In the pediatric age group, blunt trauma is more prevalent than penetrating trauma, and 20–30% of pediatric trauma cases involve the abdomen.²

The history and physical examination form the foundation of the patient evaluation; however, they may be difficult to obtain in children who have altered mental status, central nervous system (CNS) trauma, or distracting injuries. In one study of children with blunt abdominal trauma, an initial physical examination was considered reliable in only 41% of cases.³ Furthermore, the examination may be misleading in up to 45% of injured children.^4,5

The use of the focused assessment with sonography for trauma (FAST) examination in pediatrics has increased over the past decade, but it has not been as well accepted or widely used as it has for adult trauma care. In a survey of general emergency physicians (EPs), pediatric EPs, and trauma surgeons, 91% of the respondents considered abdominal ultrasound to be “somewhat to extremely useful.”⁶ However, with regard to pediatric trauma patients, 73% of all respondents considered abdominal ultrasound to be useful, while only 57% of pediatric EPs considered it so. Furthermore, only 14% of pediatric EPs routinely use abdominal ultrasound for evaluation of their trauma patients.⁶

Numerous advantages exist for using ultrasound in pediatric trauma, mirroring its benefits in adult trauma (see Chapter 9, “Trauma”). In pediatrics, limiting the exposure of ionizing radiation is especially appealing.⁷ In 2012, the results of a large prospective multicenter trial showed that pediatric trauma patients with a low-to-moderate clinical suspicion for intra-abdominal injury were significantly less likely to undergo abdominal computed tomography (CT) scanning if they underwent a FAST examination.⁸ However, in a randomized control trial of nearly 1000 hemodynamically stable pediatric patients who suffered blunt abdominal trauma, the FAST examination did not improve clinical care.⁹ A meta-analysis of the FAST with respect to blunt abdominal trauma reported the following conclusion: