pediatric emergency ultrasound - north carolina ultrasound ...learning objectives review common...

Emergent Pediatric Ultrasound

Katharine Dennis, RDMS/RVT

Tiffany Schultz, RDMS

UNC Health Care

Dept of General Ultrasound

Introduction

Learning Objectives

Review common pediatric emergent ultrasound exams

Summarizes conditions associated with exams comparing normal and abnormal anatomy

Understand the role of ultrasound

Understand the importance of its’ accessibility, cost effectiveness and lack of exposure to radiation

Identify pitfalls

Review cases of exams

Common Pediatric Emergent Exams in U/S

Appendicitis

Intussusception

Midgut Volvulos

Hip effusions

Pyloric Stenosis

Ovarian torsion

Testicular Torsion

Why Ultrasound?

Decreases exposure to radiation

Advantages of Ultrasound

Relatively inexpensive

Does not typically require sedation

Peds limited in communication

Peds are smaller

Peds can decompensate faster

Appendix

Tube-shaped structure typically located

1-2 cm below ileal-cecal valve

posteriomedially

Normally measures 6 mm in diameter

Three important landmarks

Psoas Muscle

Illiac Vessels

Cecum (Terminal Illeum if possible)

Appendicitis

Lumen becomes inflamed and ischemic eventually leading to infection and possibly rupture

Most common condition requiring surgery in pediatrics

Peak age of incidence 5-15 yo

Symptoms and Presentation

Differentials

Pitfalls

Location of Appendix

Location of Appendix

Early Appendicitis

Early Appendicitis

Early Appendicitis

Appendicolith

Appendicitis/ Appendicolith

Appendicolith

Appendicolith

Intussusception

Small bowel prolapses or telescopes into

adjacent segment

Most common form of small bowel

obstruction in children

Highest occurrence between ages 6

months to 4 years

Peak incidence 5-9 months

More common in males 2/1

Pt with Cystic Fibrosis may be at higher

risk

Intussusception

Ileocolic most common type followed by ileoileal and colocolic

Early detection important to avoid injury to bowel 2/2 ischemia and necroses necessitating surgical removal of bowel and risk of sepsis

Can be corrected/reduced in most cases utilizing air enema and floroscopy avoiding surgery

Fatal if left untreated

Paradoxically spontaneous reduction is not uncommon (especially in pts with hyperperistalsis)

Necrotic Intussusception

Necrotic Intussusception

Necrotic Intussusception

Necrotic Intussusception

Necrotic Intussusception

Necrotic Intussusception

Midgut Volvulus

Most severe type of malrotation of the intestines

Seen in infants less than 1yo

Ultrasound is not the primary modality may been noted incidentally, esp in abd u/s ordered to assess pyloris

Infants can present with similar appearance as pts with pyloric stenosis

Important indicator on ultrasound would be reversal of position of SMA and SMV

Midgut Volvulus

Midgut Volvulus

Midgut Volvulus

Positive Negative

Normal Vessel Orientaion

Midgut Volvulus

Midgut Volvulus

Hip Effusions

Excessive fluid in the hip joint

If septic may lead to permanent

damage that can limit mobility

Can be drained under ultrasound

guidance

Hip Effusions

Septic joint more often seen in pts

under the age of three

Symptoms of

Fever

Elevated WBC

Unable to bare weight

Hip Effusions

Scanning Technique

Measurements

Hip Effusions

Cases

Pyloric Stenosis

The pylorus is the opening from the stomach into the

small intestine; therefore, this condition is also known

as gastric outlet obstruction

In case of pyloric stenosis, the muscles of the pylorus

become thickened due to hypertrophy thus preventing

stomach contents to empty into the small intestine.

The causes of this condition are unknown; however,

some correlation to genetics have been noted. Babies

of parents who had P.S. are more likely to have the

condition as well

Pyloric stenosis is a very common condition

Pyloric Stenosis

Age – less than 6 months of age

Symptoms:

Projectile vomiting http://www.google.com/url?url=http://www.youtube.com/watch%3Fv%3D5VzEMr4NhgE&rct

=j&sa=X&ei=PQtqUPbYN4Sq8ASV8IDoDQ&ved=0CEsQuAIwBg&q=newborn+projectile+vo

miting+video&usg=AFQjCNHHTz89VDSaEjoNVASD7k78CLDN8g

Weight loss

Constant hunger

Dehydration and lethargy

Clinical findings/symptoms:

Wave-like motion of abdomen after

feeding and just prior to vomiting

The “pyloric olive”

Pyloric Stenosis

The pyloric channel is considered

stenosed when it measures larger

than 17mm in length and 3mm in

thickness

Is the test a STAT exam?

Pyloric Stenosis

How is the study performed?

Baseline images obtained

AVOID IMAGING ESOPHAGUS

Position the infant

Feed infant

Image pylorus

Positive Exam

Positive Exam

Swirl Effect

Negative Exam

Negative Exam

Negative Exam

Pitfall – Imaging the Esophagus

Pitfall – Imaging the Esophagus

Ovarian Torsion

Twisting of the ovary around the

ligaments which support it. This

may result in loss of blood supply

to both the ovary and the fallopian

tube.

Torsion in normally precipitated by

another condition or disease.

Unilateral

Age - Early reproductive years-

mid 20’s

Predisposing conditions

Developmental abnormalities

Cysts or other masses (i.e

teratomas)

Malignant = Greater risk

Larger size = Larger risk

Ovarian Torsion

Ovarian Torsion

Symptoms

Sudden onset of worsening

severe, unilateral lower abdominal

pain

Nausea and vomiting

Fever (later stages)

Previous episodes of pain

Ovarian Torsion

TRUE STAT EXAM

Early detection = Ovarian salvage

Early detection = Reduced risk of

complications

Laproscopy is the gold standard of

diagnosis

Postive = dusky, blue-black

appearance

Ovarian Torsion and the Sonographer

Color Doppler imaging is essential

Where color Doppler fails, power Doppler

may be beneficial

Detection of flow is more important that

direction of flow in this case

Spectral waveform must be documented

to rule out torsion

Arterial and venous flow

Laproscopic Diagnosis

Positive for Torsion

5 year old

Positive for Torsion

Doppler

Positive for Torsion

Positive for Torsion 16 year old - Adnexal Mass

Positive for Torsion

Testicular Torsion

Twisting of the spermatic cord, which

cuts off the blood supply to the testicle

and surrounding scrotal structures

This condition results in ischemic injury

to the testis and infarction. The

condition may also result in loss of the

testis.

Testicular Torsion

Causes

Trauma to the scrotum

Strenuous exercise

Puberty

May not have an obvious cause

Cryptorchidism

Symptoms

Acute onset of severe scrotal pain

Redness

Unilateral scrotal swelling

Nausea and vomiting

Testicular Torsion

Role of the Sonographer

True STAT exam

6 hours to save the testicle

DOPPLER, DOPPLER, DOPPLER

Absence of blood flow is a key

indicator in diagnosing testicular

torsion

DON’T GET DISCOURAGED!

Testicular Torsion

Treatments

Manual Detorsion

Surgery

Detorsion

Orchiopexy

Possible orchiectomy

Surgical Examination

Within the Scrotum Undescended Testicle

Positive for Testicular Torsion

10 year old

Positive for Testicular Torsion

10 year old

Positive for Testicular Torsion 14 year old

Normal Appearing Testicles

Positive for Testicular Torsion 14 year old

Positive for Testicular Torsion 14 year old

Positive for Testicular Torsion 15 year old

Positive for Testicular Torsion 15 year old

Testicle and Epididymal Torsion

Positive for Testicular Torsion 15 year old

Positive for Testicular Torsion 17 year old

Positive for Testicular Torsion 17 year old

Positive for Testicular Torsion 15 year old

Positive for Testicular Torsion 15 year old