Emergency Ultrasound (EUS)(12)

Clinical application
Trauma
Intussusception
Appendicitis
Hypertrophic stenosis
Procedure
Acute abdomen
Pediatric trauma management algorithm
Dependent compartment
FAST transducer placement
 FAST
Normal RUQ View Normal LUQ View
 FAST
Normal Subxiphoid View Normal Pelvic View
 E-FAST
Doppler lung sliding M mode - seashore sign
RUQ hemoperitoneum
Hemoperitoneum
Pericardial fluid
Hemo-Pneumothorax
Pediatric FAST & elevated liver transaminases:
an effective screening tool in BAT

Journal of Surgical Research 2009;157: 103107

 IVC/Ao ratio as an objective tool in
assessment for dehydrated children

Acad Emerg Med 2007; 14:841845

 IVC/Ao ratio as an objective tool in
assessment for dehydrated children

AUC: 0.91

Acad Emerg Med 2007; 14:841845

 Sonographic inferior vena cava/aorta diameter index:
a new approach to the body fluid status assessment

IVC/Ao = 0.59

IVC/Ao = 1.02
Reference value for 20-30 years
IVC/Ao index: 1.2 2 SD for SD = 0.17
AJEM2008;26:320325
Sonographic inferior vena cava/aorta diameter index:
a new approach to the body fluid status assessment
Normal appendix
 Graded-compression US
Nocompressible
Diameter > 6mm

Appendicolith
Pericecal or
periappendiceal fluid
Enlarged mesenteric
LN
Appendicitis
Appendicitis
 Intussuception
Pseudokidney sign Donut sign
 Intussusception
Peak: 5-10 months, up to 3 years
s/s:
Cramping abdominal pain
Irritability
Vomiting
Bloody stool
Intussusception
Intussusception
 Doughnut sign
Ileoileal intussuscuption (6 m/o infant)

SBI
2-3-cm sized, short,
doughnut-like lesion
Left abdomen or
paraumbilical region

Tiao MM, et al. AEM 2001;8:368-373

 Crescent-in-doughnut sign
Ileoileal intussuscuption (7 y/o boy)

mesentery

Tiao MM, et al. AEM 2001;8:368-373

 Multiple-concentric-rings sign
ideopathic jejunojejunal intussuscuption (4 y/o boy)

Tiao MM, et al. AEM 2001;8:368-373

 Ileocolic intussusception
Crescent-in-doughnut sign Target (multiple concentric rings) sign

Sandwich (pseudokidney sign) Hay-fork sign

 Small-bowel intussusception

Double target sign Pseudokidney sign Double target sign

US-guided hydrostatic reduction
Post-reduction-doughnut sign
Edematous ileocecal valve

Ko HS, et al. European Radiology (2007)

Triple-circle appearance
(Double intussusception)
 Bladder Imaging

Bladder diameter 2cm urine 2.5 cm3

US can improve urine collection

AJEM 2008; 26:1823

Mimickers of appendicitis
 Mesenteric adenitis

8-year-old girl
RLQ pain
Fever
 Crohns disease

13-year-old boy
RLQ pain
Fever

Thickened terminal ileum

 Sonography of the acute
abdomen in the pediatirc patient
Necrotizing enterocolitis
Small bowel obstruction
Malrotation
Midgut Volvulus
Whirlpool Sign
Inguinal hernia

Normal testes with hydrocele

Acalculous cholecystitis
Gallstones
 Point-of-care ultrasound diagnosis of
pediatric cholecystitis in the ED

Wall: 3mm; CBD: 3mm AJEM 2010;28: 338342

Pyelonephrosis
Acute pancreatitis
Mesenteric adenitis
Hemorrhagic ovarian cyst
Ovarian torsion
Constipation
Pylorus
Hypertrophic pyloric stenosis

Antral nipple sign

MWT > 3mm

Muscle Wall Thickeness
Referred pain
New applications
 Bedside Limited Echocardiography by the EP Is
Accurate During Evaluation of the Critically Ill Patient

Pediatrics 2004;114:e667e671.
Positioning for Lumbar Puncture in Children
Evaluated by Bedside Ultrasound

Pediatrics 2010;125:e1149e1153
Use of bedside ultrasonography for endotracheal
tube placement in pediatric patients

Pediatrics 2007;120;1297-1303
Bedside ultrasonography to identify
hip effusions in pediatric patients

Ann Emerg Med. 2010;55:284-289

 The Utility of Bedside Ultrasonography in Identifying
Fractures and Guiding Fracture Reduction in Children

Pediatr Emer Care 2009;25: 221Y225

 The Utility of Bedside Ultrasonography in Identifying
Fractures and Guiding Fracture Reduction in Children

Pediatr Emer Care 2009;25: 221Y225

 Bedside US changed management of
pediatric soft tissue infection

Management changed: 11/50 The Journal of Emergency Medicine, 2009

Optic nerve sheath diameter
ONSD
3mm behind the globe
Adult: 5mm
Child
> 1 y/o : 4.5mm
< 1 y/o 4.0mm

Br. J. Ophthalmol. 2002;86;1109-1113

The sensitivity and specificity of bedside sonographic
measurement of ONSD is inadequate children with
suspected IICP

Ann Emerg Med. 2009;53:785-791

 Ultrasound allows physicians to
visualize peripheral veins of young
children in the ED

WestJEM. 2008;9:219-224