Pediatric Emergency Medicine

Point of care ultrasound (POCUS)

- Beyond FAST

Dr Vigil James,
MBBS, MD, MRCPCH (UK),
Fellowship Pediatric Emergency (SickKids, Toronto)
Pediatric Emergency Physician,
Children’s Emergency,
KK Women’s and Children’s Hospital, Singapore
 Focused Assessment with Sonography in Trauma (FAST)

Can POCUS be integrated into Pediatric medical resuscitations in the emergency department?
 [1] Understand the sono-physiology of shock in children

[2] Assessment of the cardiac function in a child with shock

[3] Assessment of IVC contractility in a child with shock

Objectives [4] Assessment for free fluid in abdomen – FAST

[5] Assessment of lung status in a child with shock

[6] Assessment of response and complications of fluid

replacement

[7] Integrated POCUS application in management of shock in

children
 Case scenarios
4 years old boy presented to the
emergency department with fever for 5
days with poor oral intake, intermittent
episodes of vomiting and decreased urine
output.
On examination, the child was irritable
with cold peripheries. Blood pressure was
70/40 mmHg, HR 172/min and central
CRT was 4 secs. Auscultation revealed
clear lung fields, soft first & second heart
sound, liver palpable 4 cm below costal
margin.
2 years old boy was brought into the
emergency department by his dad with
severe irritability and refusal to feed.
On examination, the child was pale and
lethargic. Blood pressure was 74/46
mmHg, HR 160/min and central CRT was
3 secs. Auscultation revealed clear lung
fields, normal first & second heart sound.
Abdominal distension +
SHOCK
10 years old girl presented with
underlying autism was brought in to the
emergency department with fever for 6
days with poor oral intake and a rash
noticed for the past 24 hours.
On examination, the child was drowsy
with cold peripheries. Blood pressure was
76/40 mmHg and HR 152/min. There was
a non -blanchable rash on the abdominal
wall. Auscultation revealed clear lung
fields, normal heart sound, liver was not
palpable below costal margin.
 Shock pathophysiology is traditionally divided into 4 categories:

Volume loss Distributive

Bleeding, vomiting, Sepsis, anaphylaxis,
diarrhea, poor oral neurogenic causes
intake

Obstructive
Cardiogenic Cardiac tamponade,
Myocarditis, arrhythmia pneumothorax,
pulmonary embolism

The common limitations in history and physical examination may lead to delay in care or ineffective treatment.
Hemodynamics
• Shock: “Life threatening organ dysfunction caused by a dysregulated host response to infection”. (JAMA 2016)
• In shock - there is a lack of effective circulatory volume.
4 areas to determine the cause of the patient's hypotension with POCUS

Heart IVC / Aorta Intraperitoneal cavity Lungs and pleura

By evaluating the 4 areas, the clinician can get an overview of the preload, myocardial contractility and afterload
Heart
 Heart
• Assess LV function and filling
• Pericardial collection
• Assess pulseless electrical
activity

Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American
Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010;23:1225–1230.
 Para sternal long axis view (PLAX)

Ultrasound at U of SC School of Medicine

LV function and filling

• Adequacy of LV contractility

• E-point septal separation (EPSS):

distance from septal wall and
anterior mitral leaflet - < 1cm:
corresponds to a EF of >50%

• Uniform and circumferential

contracting endocardium: moving
significantly from diastole to
systole: “Visual squeeze”
 Cardiac contractility

• Single cardiac view parasternal

long axis view or subxiphoid
allow rapid identification of LV
dysfunction and cardiac
tamponade.

Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American
College of Emergency Physicians. J Am Soc Echocardiogr. 2010;23:1225–1230.
 Pericardial collection
• Anechoic or dark strip surrounding the
heart
• Early effusion: posterior pericardium
• Eventually spread anterior and
circumferential
• Tamponade: diastolic right atrial and right
ventricular collapse
 Asystole vs PEA
• Pulse palpation is very unreliable in
pediatric cardiac arrest (accuracy only
78%)

• Bedside ultrasound can reliably

distinguish cardiac activity from
standstill
• For PEA seen on ECHO: identify
potentially correctable causes

Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. Tibballs J1, Russell P. Resuscitation. 2009 Jan;80(1):61-4. doi: 10.1016/j.resuscitation.2008.
Is there evidence for use of cardiac POCUS by emergency
physician to be effective?
• Comparable results between
non-cardiologist sonographers
and formal echocardiograms on
pediatric patients with regard to
the identification of:

• Pericardial effusion
• LV size
• LV systolic function
Inferior vena cava
Inferior vena cava
• Ultrasonic evaluation of the IVC -
surrogate for central venous pressure
and relative intravascular volume

• Assess amount of collapse of the IVC

when the patient creates negative
intrathoracic pressure during inspiration
 Assessment of Inferior vena cava

Ultrasound at U of SC School of Medicine

 IVC physiology
• IVC is very large and collapses only a
small amount - likely elevated central
venous pressure
Assess the IVC for
collapsibility 2 to 3
• IVC is very thin and collapses with cm distal to the RA-
IVC junction
inspiration – likely low CVP

• Alternative - ratio of IVC to aorta:

volume depletion IVC-to-aorta ratio of
less than 0.8

Early diagnosis of hypovolemic shock by sonographic measurement of inferior vena cava in trauma patients.
Yanagawa Y1, Nishi K, Sakamoto T, Okada Y. J Trauma. 2005 Apr;58(4):825-9.
 Does bedside sonographic measurement of the IVC diameter correlate with central
venous pressure (CVP) in the assessment of intravascular volume in children?

• IVC has been extensively studied and is

considered a reasonable predictor of
intravascular volume.

• IVC sonographic indices provide a useful guide for

noninvasive intravascular volume status assessment
in children.
 Abdomen for
Intraperitoneal Free
Fluid
 Abdomen for Intraperitoneal Free Fluid

• 2 areas providing the greatest yield are: the RUQ

and the pelvic or suprapubic space

• Fluid needed to elicit a positive FAST: 200 to 600 mL

• Most commonly injured structures in the pediatric

patient are the liver and the spleen

Gaines BA. Intra-abdominal solid organ injury in children: diagnosis and treatment. J Trauma. 2009;67(suppl 2):S135–S139
The RUQ: Technique

Normal RUQ view

Free fluid Morison pouch

RUQ view

• Structures visualized

➢Pleural space
➢Subphrenic space
➢Morison pouch
➢Inferior pole of the kidney
The Pelvic view

Normal suprapubic view Fluid in pouch of Douglas

Suprapubic View (Pelvis) “Bow-tie” appearance

Fluid in the rectouterine pouch (pouch of Douglas) in girls and the rectovesical pouch in boys
Evidence for benefit of FAST in Pediatric population

• A positive FAST in hypotensive

trauma patient confirms an
intraperitoneal source of blood
loss

• FAST examination was useful in

detecting free fluid but is
inadequate as a screening tool
for abdominal injury
Evaluating the
Lungs
Evaluating the Lungs
• Pneumothorax
• Pulmonary Edema
• Pleural Effusions
 Pneumothorax
Ultrasound to detect pneumothorax has been shown to be superior “Shimmering” appearance
to chest radiography

• Lung sliding (pleural sliding)

• Absence of lung sliding may be
due to
❑Pneumothorax
❑Apnoea
❑Pleural adhesions
❑Bullae
❑Right endobronchial intubation

Test characteristics of ultrasonography for the detection of pneumothorax: a systematic review and meta-analysis. Alrajhi K, Woo MY, Vaillancourt C. Chest. 2012;141:703–708.
 Pneumothorax lung ultrasound

• Lung point
• Transition between intermittent
presence and absence of lung
sliding

The "lung point" has an overall sensitivity of 66 % and a

specificity of 100% for the “positive” diagnosis of pneumothorax
Pneumothorax – M mode
 Lung ultrasound features (artifacts)

• A lines (A profile) - normal

• Horizontal, regularly spaced hyper-
echogenic lines: reverberations of the
pleural line

• B lines (B profile)
• Vertical narrow based lines arising from
the pleural line to the edge of the
ultrasound screen

• Ultrasound signal bounce back and forth

between air bubbles suspended in fluid

• More than 3 B-lines in a single view is

abnormal
Pulmonary Edema B-lines can also be seen:
➢ Pneumonia
➢ Pulmonary contusion
➢ Acute respiratory distress syndrome

Multiple confluent B lines “Alien light pattern”

 Pleural Effusions
When compared with supine chest x-ray, ultrasound has
higher sensitivity for diagnosing pleural effusions
“Dove sign”

Pleural effusion

Anechoic collection RUQ view above the diaphragm

Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED. Zanobetti M, Poggioni C, Pini R. Chest. 2011;139
Is there evidence for use of lung POCUS by emergency physician to be effective?

Comparative diagnostic performances of auscultation, chest

radiography, and lung ultrasonography in acute respiratory distress
syndrome. Lichtenstein D1, Goldstein I, Mourgeon E, Cluzel P, Grenier P,
Rouby JJ. Anesthesiology. 2004 Jan;100(1):9-15.
 Response and
complications of
therapy
Response and complications of therapy
• Response to fluid therapy
• IVC diameter
• Cardiac contractility
• Bladder filling Dynamic
Response and complications of therapy
• Complications during fluid administration

RUQ

Lung
Arrhythmias
resulting in
poor cardiac
contractility
Is there evidence for use
of “Shock Protocol” in
Pediatric shock?
• Some of the evidence is extrapolated from
adult literature

• This meta-analysis suggested that RUSH

protocol has good role to distinguish the
states of shock in patients with
undifferentiated shock
Evidence of POCUS in shock

• The rapid ultrasound for shock and hypotension performs better

when used to rule in causes of shock, rather than to definitively
exclude specific etiologies

• The negative likelihood ratios of the exam by subtype suggest

that it most accurately rules out obstructive shock
Evidence of POCUS in shock

• The authors did not find any benefits for survival, length of stay, rates
of CT scanning or inotrope use.
• The addition of a point-of-care ultrasonography protocol to standard
care may not translate into a survival benefit in this group.
Is POCUS a game changer in undifferentiated pediatric shock?

• POCUS is just one part of the

“clinical puzzle”.

• POCUS must be integrated with

history, vital signs and physical
examination to explore the
cause of shock.
 Case scenarios

4 years old boy presented to the

emergency department with fever for 5
days with poor oral intake, intermittent
episodes of vomiting and decreased urine
output.

On examination, the child was irritable

with cold peripheries. Blood pressure was
70/40 mmHg, HR 172/min and central
CRT was 4 secs. Auscultation revealed
clear lung fields, soft first & second heart
sound, liver palpable 4 cm below costal
margin.

• Myocarditis
• Hypo-contractile heart
• Judicious IV fluids • Distended IVC
• Early ECMO • Lung rockets (B lines)
Case scenarios

2 years old boy was brought into the

emergency department by his dad with
severe irritability and refusal to feed. No history of
trauma
On examination, the child was pale and
lethargic. Blood pressure was 74/46
mmHg, HR 160/min and central CRT was
3 secs. Auscultation revealed clear lung • Hypovolemic shock – Child abuse / NAI
fields, normal first & second heart sound.
Abdominal distension +
• Flat IVC
• Peritoneal fluid
• Hypercontractile heart

• Etiology of shock
Case scenarios

10 years old girl presented with

underlying autism was brought in to the
emergency department with fever for 6
days with poor oral intake and a rash
noticed for the past 24 hours.

On examination, the child was drowsy

with cold peripheries. Blood pressure was
76/40 mmHg and HR 152/min. There was
a non -blanchable rash on the abdominal • Septic shock
wall. Auscultation revealed clear lung • Hypo-contractile heart
fields, normal heart sound, liver was not • Small IVC
palpable below costal margin.
• Peritoneal fluid

• Judicious IV fluids
• Early inotropes
Integrating the 4 domains for shock diagnosis
Shock Pump Tank

• Flat IVC
Hypovolemic • Hyper-contractile
• Peritoneal fluid
shock heart
• Pleural fluid

• Hypo-contractile heart • Distended IVC

Cardiogenic • Lung rockets
shock • Dilated heart size • Pleural effusions

Obstructive • Pericardial effusion • Distended IVC

shock • RV strain • Absent lung sliding

• Hypercontractile heart (early • Normal/small IVC

Distributive sepsis) • Pleural fluid (empyema)
shock • Hypo-contractile heart (late • Peritoneal fluid
sepsis) (peritonitis)
 • Circulatory shock in children: an overview. McKiernan CA1, Lieberman SA. Pediatr Rev. 2005
Dec;26(12):451-60.
• Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergent setting: a consensus
statement of the American Society of Echocardiography and American College of Emergency Physicians. J
Am Soc Echocardiogr. 2010;23:1225–1230.
• Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. Tibballs J1,
Russell P. Resuscitation. 2009 Jan;80(1):61-4. doi: 10.1016/j.resuscitation.2008.
• Bedside limited echocardiography by the emergency physician is accurate during evaluation of the
critically ill patient. Pershad J1, Myers S, Plouman C, Rosson C, Elam K, Wan J, Chin T. Pediatrics. 2004
Dec;114(6):e667-71.
• Inferior vena cava diameter: a useful method for estimation of fluid status in children on haemodialysis.
Krause I1, Birk E, Davidovits M, Cleper R, Blieden L, Pinhas L, Gamzo Z, Eisenstein B. Nephrol Dial
Transplant. 2001 Jun;16(6):1203-6.
• Early diagnosis of hypovolemic shock by sonographic measurement of inferior vena cava in trauma
patients. Yanagawa Y1, Nishi K, Sakamoto T, Okada Y. J Trauma. 2005 Apr;58(4):825-9.
• Gaines BA. Intra-abdominal solid organ injury in children: diagnosis and treatment. J Trauma.

References •
2009;67(suppl 2):S135–S139
Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. Holmes
JF1, Gladman A, Chang CH. J Pediatr Surg. 2007 Sep;42(9):1588-94.
• Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children With
Blunt Torso Trauma: A Randomized Clinical Trial: James F. Holmes, MD, MPH: JAMA. 2017 Jun 13;
317(22): 2290–2296.
• Test characteristics of ultrasonography for the detection of pneumothorax: a systematic review and
meta-analysis. Alrajhi K, Woo MY, Vaillancourt C. Chest. 2012;141:703–708.
• The "lung point": an ultrasound sign specific to pneumothorax. Lichtenstein D1, Mezière G, Biderman P,
Gepner A. Intensive Care Med. 2000 Oct;26(10):1434-40.
• Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED.
Zanobetti M, Poggioni C, Pini R. Chest. 2011;139
• The diagnostic accuracy of a point-of-care ultrasound protocol for shock etiology: A systematic review
and meta-analysis. Stickles SP et al. CJEM. 2019 Jan 30:1-12. doi: 10.1017/cem.2018.498.
• Does Point-of-Care Ultrasonography Improve Clinical Outcomes in Emergency Department Patients With
Undifferentiated Hypotension? An International Randomized Controlled Trial From the SHoC-ED
Investigators. Atkinson PR et al. Ann Emerg Med. 2018 Oct;72(4):478-489.
• Point-of-Care Ultrasound for Pediatric Shock. Park DB et al. Pediatr Emerg Care. 2015 Aug;31(8):591-8
Acknowledgements
• Dr Gene Ong - Senior Consultant – Children’s Emergency - KK
Women's and Children's Hospital

• Dr Arif Tyebally - Deputy Head and Senior Consultant – Children’s

Emergency - KK Women's and Children's Hospital

• Dr Lee Khai Pin - Head and Senior Consultant – Children’s

Emergency - KK Women's and Children's Hospital
Thank you!