[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!

What is the best way to learn during my PEM

fellowship?

Wait, fellowships do exist?

[3]

pediatric EUS (e.g. Boston Children’s Hospital, Columbia

University, Maimonides Medical Center, and Oakland Children’s

Hospital).

Fellowships provide time for intensive hands-on scanning with

direct feedback on performance to allow for rapid improvement

and expertise in ultrasound scanning and interpretation. Additional

focus on relevant literature, scholarly projects, teaching

responsibilities, and administrative topics round out a fellow’s

experience to help nurture them as true experts in the field.

When training pediatric EUS fellows, the fellowship

should have “access to a busy pediatric ED with extensive

opportunities to scan kids, [since the pediatric US] applications

are so unique [they] can't be reproduced in an adult population,”

states Dr. John Kendall, the Director of Emergency Ultrasound at

Denver Health Medical Center, where they have had an EUS

fellowship since 2005 and incorporated pediatric US fellowship

training into the standard EUS curriculum.

According to Dr. Stephanie Doniger, who is

now Director of Ultrasound at the Children’s

Hospital and Research Center in Oakland

and runs a PEM EUS fellowship, it was “the

absolute best decision I ever made.” As the first

PEM trainee to ever do a formal fellowship at St Luke’s Roosevelt

Hospital Center in New York City, she learned the skills necessary

to become an internationally renowned educator, develop her own

training curriculum, and oversee faculty development at her next

job. “A one month rotation just didn’t seem enough to [learn] to

effectively teach other people.”

Dr. Arroyo adamantly agreed that the extra year was

worthwhile, “If you took my ultrasound skills away I would rather

not practice medicine - that’s how much I depend on it on a daily

basis.”

“I think any good PEM fellowship will have an

ultrasound component, and most

fellows will be looking to have

this built into their curriculum”

says Dr. Nagdev.  And Dr. Fox

suggests that “It will only

[become obsolete] when all medical

schools have fully integrated ultrasound into

their curricula.”

But as the field of pediatric EUS develops, there will still

always be a demand for pediatric EUS-trained leaders to train our

PEM colleagues and to conduct cutting-edge research to support

the integration of EUS into routine PEM practice. At the end of the

day, regardless of how you choose to tailor your pediatric EUS

training, whether it is supplementing your PEM fellowship with

independent scanning or pursuing a pediatric EUS fellowship, the

most important thing to do is follow Dr. Sivitz’s advice and “Scan,

scan, scan!”

References:

1. Akhtar S, Theodoro D, Gaspari R, Tayal V, Sierzenski P, LaMantia J, Stahmer S, Raio C. Resident Training in Emergency Ultrasound: Consensus Recommendations

from the 2008 Council of Emergency Medicine Residency Directors Conference. Academic Emergency Medicine. 2009; 16:S32-36.

2. Marin JR, Zuckerbraun NS, Kahn JM. Use of emergency ultrasound in United

States Pediatric Emergency Medicine Fellowship programs in 2011. J Ultrasound Med. 2012;31:1357-63.

Is it worth the extra year?

As training becomes more pervasive, will fellowships become

obsolete one day?

Useful Ultrasound Links

ULTRASOUND BLOG/PODCAST

http://

www.ultrasoundpodcast.com

http://pointofcare.blogspot.com

ULTRASOUND LISTSERVE 

Email saguarochip@gmail.com and

ask to be added to receive weekly

updates of articles published on

emergency ultrasound topics

ULTRASOUND SOCIETIES OR

SECTIONS:

http://www.susme.org

http://www.aium.org/

http://www.winfocus.org

http://www.saem.org/academy-

emergency-ultrasound

http://www.acep.org/ultrasound/

ULTRASOUND LEARNING/

SHARING WEBSITES:

www.sonoguide.com

www.sonocloud.org

http://sinaiem.us

http://cmedownload.com/courses/

soundbytes

http://www.saem.org/narrated-

lectures

http://www.yale.edu/imaging/

echo_atlas/views/index.html

ULTRASOUND app:

http://www.imedicalapps.com/

2012/10/em-

ultrasound-app-

iphone/These links will also be available on the

ultrasound sub-site of PEMNetwork.org

[4]

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

ultrasound guidance requires:a. Sterile transducer sleeve

b. At least 2 people to perform

c. Sterile gel

d. One person without special preparations

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

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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

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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

see every week? Send it to us at pemfellows.com@gmail.com!

Recommended Newsletter Submission Formats:

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 pemfellows.com@gmail.com.