PEM POCUS Series: Pediatric Renal and Bladder Ultrasound

PEM POCUS fascia iliaca block

Read this tutorial on the use of point of care ultrasonography (POCUS) for pediatric renal and bladder ultrasonography. Then test your skills on the ALiEMU course page to receive your PEM POCUS badge worth 2 hours of ALiEMU course credit.

Module Goals

  1. List the indications for performing a pediatric renal/bladder point-of-care ultrasound (POCUS)
  2. Describe the technique for performing renal/bladder POCUS
  3. Identify hydronephrosis and its appearance at different severities
  4. List the limitations of renal/bladder POCUS
  5. Advanced: Recognize direct and other indirect signs of nephrolithiasis as well as gross renal/bladder structural anomalies such as cysts and masses

Case Introduction: Child with abdominal pain

Serena is a 9-year-old girl who comes into the emergency department complaining of one day of left flank and left lower quadrant pain (LLQ). The pain is intermittent, sharp, severe, and associated with 2 episodes of nonbloody, nonbilious emesis. Her mother denies any fevers, upper respiratory symptoms, sore throat, or diarrhea. She adds that her daughter has complained of 2-3 episodes of dysuria and gross hematuria over the last few days.

On arrival, her vital signs are:

Vital SignFinding
Temperature99 F
Heart Rate115 bpm
Blood Pressure97/50
Respiratory Rate19
Oxygen Saturation (room air)100%

You find her lying on the gurney, uncomfortable appearing, and intermittently crying. She has a normal HEENT, neck, cardiac, respiratory, and back examination. She has no flank tenderness, but she does cry out with palpation of the LLQ and suprapubic areas.

Given her pain with a history of intermittent hematuria and dysuria, you perform a renal and bladder point of care ultrasound (POCUS) examination.

Pediatric Renal and Bladder POCUS

  • Hematuria
  • Flank pain
  • Abdominal distension or palpable mass
  • Anuria, oliguria, or urinary retention
  • Concern for nephrolithiasis
  • Bladder volume assessment prior to urinary catheterization

Probe choice [1]

  • Typically based on the size of the child (Figure 1)
  • If unsure, perform test scans and choose the probe that most effectively provides the desired views and level of detail
ultrasound probe transducers

Figure 1. Ultrasound probes from left to right: linear (nenoates), phased array (infants/younger children), and curvilinear (older children/adolescents)

Pro tips for performing renal/bladder POCUS on a child [1]

  • Addressing potential anxiety leads to a more efficient and comfortable examination.
  • Explain to the parent (and child if old enough), the areas you need to examine.
  • Set up distractions such as toys or videos on a tablet or smartphone
  • When appropriate, demonstrate the probe(s) to the child and apply some ultrasound gel to the back of their hand so they understand it will not be painful.
  • Pre-warmed ultrasound gel is helpful when available.
  • Examine the patient in a position that maximizes comfort and minimizes anxiety.
    • Lay the patient supine when possible. They can lay on the stretcher, or in the parent’s lap if it calms them (Figure 2, left). This is also an optimal position in which the parent can hold a tablet or smart device above the patient’s face as a distractor.
    • If supine positioning is unsuccessful, the patient can be placed upright in their parent’s lap facing away from the sonographer (Figure 2, right). In this position, the parent can hug and hold the patient if needed.
pediatric ultrasound positioning

Figure 2: Patient positioning options: Left (supine) – Patient playing with the distractors during bladder POCUS; Right (upright) – Toddler facing away from sonographer during renal POCUS. Note: Blue dot represents the probe indicator.

Right Kidney (Longitudinal View)

  • Begin in the mid-axillary line around the 10th or 11th intercostal space with the probe marker pointed toward the patient’s head and identify the renal structures (Figure 3).
  • While maintaining probe contact on the skin, tilt it perpendicular to its long axis in each direction (also known as fanning) to assess the entire kidney (Video 1).
Longitudinal view ultrasound right kidney

Figure 3. Longitudinal view of the right kidney: Left – Probe placement in right mid-axillary line; Right – Unlabeled and labeled ultrasound view

Video 1. Longitudinal view of the right kidney

Right Kidney (Transverse View)

  • From the longitudinal view, rotate the probe 90 degrees and fan the probe to assess the entire kidney in the transverse plane (Video 2).
  • Identify the medullary pyramids, calyces, renal cortex, and renal pelvis (Figure 4).
Video 2. Transverse view of the right kidney
right kidney ultrasound transverse view

Figure 4. Transverse ultrasound view of the right kidney with anatomical labels

Left Kidney (Longitudinal View)

  • Place the probe in the left posterior axillary line (the left kidney is slightly more superior and posterior than the right) around the 8th to 10th intercostal space (Figure 5).
  • As performed on the right kidney, identify the relevant structures and fully assess the left kidney by fanning through (Video 3).
left kidney longitudinal ultrasound probe position

Figure 5. Longitudinal view of the left kidney with probe placement in posterior axillary line

Video 3. Longitudinal view of the left kidney

Left Kidney (Transverse View)

  • From the left longitudinal view, rotate the probe 90 degrees. Identify the relevant structures and fully assess the left kidney by fanning through (Video 4).
Video 4. Transverse view of the left kidney

Bladder (Transverse View)

  • With the indicator towards the patient’s right, place the probe on the patient’s midline just above the pubic symphysis and fan the probe downward into the pelvis (Figure 6). The pelvis, the bladder, uterus, prostate, and rectum can be seen in this view (Figure 7).
    • Pro Tip: The bladder is always directly behind the pubic symphysis, so if you cannot locate it, the probe may be too superior. 2
  • Fan through the entire bladder from superior to inferior borders (Video 5).

Figure 6. Probe positioning for transverse view of the bladder

Figure 7. Transvere ultrasound views of the bladder: Left – Uterus identified posteriorly in girl; Right – Prostate identified posteriorly in boy (Images courtesy of Dinh et al.)

Video 5. Transverse view of the bladder

Bladder (Longitudinal/Sagittal View)

  • From the transverse view, rotate the probe 90 degrees clockwise so the indicator is now pointing to the patient’s head.
  • Identify the bladder, bowel gas, uterus or prostate, and rectum (Figure 8). Then fan to scan from one lateral border of the bladder to the other (Video 6).
bladder longitudinal sagittal view

Figure 8. Sagittal view of bladder: Left – Uterus identified posteriorly in girl; Right – Prostate identified posteriorly in boy (Images courtesy of Dinh et al.)

Video 6. Sagittal view of bladder

Formula

Figure 9. Bladder volume calculation per dimension

The bladder’s shape may appear more rounded when it is full or distended. Bladder volume may be assessed prior to urinary catheterization to avoid an unsuccessful catheterization. Many ultrasound machines also have software which can calculate estimated bladder volume based on the above measurements.

Manual Measurement (Figure 10)

  • In the transverse view, measure the width and depth.
  • In the sagittal view, measure the height from the apex to the base.

Figure 10. Bladder measurement example: Left – Transverse view with width (4.35 cm) and depth (3.65 cm); Right – Sagittal view with height (3.53 cm). Estimated volume = 39.2 mL

Estimated Bladder Capacity by Age

  • [Age of the child (yr) x 30] + 30 = bladder capacity in mL
  • In a toilet-trained child, a post-void volume of ≤20 mL is normal [1].

The scope of POCUS focuses on the detection of hydronephrosis which would necessitate further workup. Hydronephrosis may be secondary to various obstructive etiologies such as nephrolithiasis, masses, or anatomical anomalies.

Severity Grading

Hydronephrosis severity grading begins with dilation at the renal pelvis (grade 1 or pelviectasis), which can be present in normal individuals who have not urinated in some time. The greater the degree of hydronephrosis, the more the dilation extends outwards into the calyces and the renal cortex (Figures 11-15 and Videos 7-9).

Figure 11. Hydronephrosis grading scale (courtesy of Dinh et al.)

Hydronephrosis: Hydroureter

Figure 12. Hydroureter on ultrasound of the right kidney

Hydronephrosis: Mild

Figure 13. Mild hydronephrosis on ultrasound with only pelviectasis, or dilation of the renal pelvis (Image courtesy of Dr. Jim Tsung)

Video 7. Renal ultrasound showing pelviectasis

Hydronephrosis: Moderate

Figure 14. Moderate hydronephrosis showing dilation extending into the major/minor calyces (Image courtesy of POCUS atlas)

Video 8. Moderate hydronephrosis (full video from Figure 14)

Hydronephrosis: Severe

Figure 15. Severe hydronephrosis with dilation causing cortical thinning (Image courtesy of POCUS Atlas)

Video 9. Severe hydronephrosis with “bear claw” sign (full video from Figure 15)

Direct Visualization

Stones may be located anywhere along the urogenital tract. If directly visible, stones will appear as hyperechoic structures and may have acoustic shadowing (Figure 16).

Figure 16. Left – Hyperechoic renal stone with acoustic shadowing and associated moderate hydronephrosis; Right – Bladder stone with acoustic shadowing (images courtesy of Dr. James Tsung)

Video 11. Renal stone with acoustic shadowing and moderate hydronephrosis

Indirect Visualization

Direct visualization will not always be possible since stones are most commonly located in the ureters and may be obscured by bowel gas. Indirect signs of stones include hydronephrosis, twinkling artifact, and absence of ureteral jet [1, 4].

Twinkling artifact is a color Doppler finding that can help identify a stone that may not be directly visible in B-mode. It is generated from turbulent flow around a rough-edged structure (i.e, a stone). Color Doppler interrogation will produce a multi-colored high high-intensity structure behind the stone (Figure 17). The turbulent flow depicted can be seen even if the causative hyperechoic stone is not visible [1, 3].

Figure 17. Twinkling artifact in a patient with a right ureterovesciular junction stone (Image courtesy of Dr. James Tsung)

Video 12. Twinkling artifact from a renal stone
Renal cysts are thin-walled, smooth, localized, and anechoic areas that are round or oval in shape. They can occur as solitary lesions or multiple lesions often in the periphery of the kidney (Figures 18-19). They should not be confused with dilated medullary pyramids from hydronephrosis, which appear as branching and “interlinked” hypoechoic areas resembling a cauliflower. Cysts will have a more spherical shape and will not “communicate” with one another [5].

Figure 19. Single renal cyst without (left) and with (right) color Doppler flow to differentiate from vasculature (Images courtesy of Dr. Jeffrey Tutman)

Figure 20. Multiple renal cysts without (left) and with (right) color Doppler flow differentiating from vasculature  (Images courtesy of Dr. Jeffrey Tutman)

Hyperechoic and heterogeneous lesions that distort or do not conform to typical renal architecture are concerning for renal masses. Wilms tumor is the most common renal malignancy in children with peak incidence between ages 1 and 5 years old. On ultrasound, it appears as an echogenic intrarenal mass that may have cystic areas from hemorrhage and necrosis (Figure 21) [4].

Figure 21. Wilms tumor in the right kidney without (left) and with (right) color Doppler flow (Images courtesy of Dr. Jeffrey Tutman)

Other potential neoplasms within or adjacent to the genitourinary system include but are not limited to neuroblastoma, rhabdoid tumor, rhabdomyosarcoma, renal cell carcinoma, and clear cell carcinoma [4, 6]. The most common malignant bladder mass is rhabdomyosarcoma, and the genitourinary tract is the second most common tumor site. It is usually large, nodular, well-defined, homogeneous, and slightly hypoechoic (Figure 13) [6].

Figure 22. Bladder rhabdomyosarcoma tumor without (left) and with (right) color Doppler flow (Images courtesy of Dr. Jeffrey Tutman)

  • Always scan both kidneys for comparison
  • Scan the bladder when evaluating the kidneys
  • Rib shadowing – attempt to maneuver around rib shadows by reangling the probe or moving up or down a rib space.
  • Bladder dimension calculations may be inaccurate if the calipers are not placed in the right orientations.
  • Large ovarian cysts may be mistaken for the bladder.
  • Because renal stones can be difficult to visualize directly, look for secondary signs such as hydronephrosis.
  • Because renal vasculature may be mistaken for hydronephrosis, use color Doppler to differentiate.
  • Renal cysts can be confused for hydronephrosis, and both warrant further imaging by Radiology.

Bladder volume estimation

Measuring bladder volume via POCUS in pediatric patients has been studied, demonstrating a benefit on Emergency Department workflow and length of stay (Table 1). For example, POCUS can confirm urine in the bladder, prior to catheterization in infants [7-8].

Author, Title, Journal, Publication YearStudy Type, Location, Time FrameN, AgesSummary
Milling et al., Use of ultrasonography to identify infants for whom urinary catheterization will be unsuccessful because of insufficient urine volume: validation of the urinary bladder index. Ann Emer Med, 2005 [7]Prospective, blinded, observational study performed in the pediatric ED, 3 month periodN=44, < 2 years of age
  • Created a bladder urinary index by multiplying the AP and transverse bladder diameters.
  • Determined the smallest bladder index that would result in successful urinary catheterization, which was defined as yielding at least 2 mL of urine.
  • The index achieved 100% sensitivity and 97% specificity.
Chen et al., Utility of bedside bladder ultrasound before urethral catheterization in young children. Pediatrics, 2005 [8]Prospective 2 -hase study, performed in the pediatric ED, 6 month periodN=136 for observation phase

N=112 for intervention phase

Ages 0-24 months

  • Observation Phase: The success rate of the first urethral catheterization attempt was calculated without preemptive bladder ultrasound
  • Intervention Phase: Bladder POCUS was performed, and catheterization was withheld until sufficient urine was present.
  • Successful catheterization rate during the observation phase was 72% overall, compared to 96% in the intervention phase.
Dessie et al., Point-of-Care Ultrasound Assessment of Bladder Fullness for Female Patients Awaiting Radiology-Performed Transabdominal Pelvic Ultrasound in a Pediatric Emergency Department: A Randomized Controlled Trial. Ann Emerg Med, 2018 [9]Randomized controlled trial, performed in a pediatric ED, 12 month periodN=120

8-18 years

  • To assess bladder fullness prior to transabdominal pelvic ultrasound, patients were randomized to subjective numerical scale versus bladder POCUS in addition to numerical scale.
  • Those in the bladder ultrasound arm completed their pelvic ultrasounds 51 minutes faster than the control group.
  • Success rate of pelvic ultrasound was 100% vs 84.7% in the control group.
Table 1. Pediatric bladder POCUS studies

Pediatric Hydronephrosis and Nephrolithiasis

Although adult studies (Table 2) have shown moderate diagnostic accuracy of POCUS in detecting hydronephrosis and nephrolithiasis, there is a dearth of POCUS-based renal studies in the pediatric literature . This has led to controversy whether to perform a renal ultrasound versus CT, even when the Radiology department performs the ultrasound.

  • Only 2 case series and 1 case report for POCUS-identified nephrolithiasis in children (Table 3)
  • No studies have aimed to determine sensitivity and specificity of POCUS for hydronephrosis in children in the context of renal colic.
Author, Title, Journal, Publication YearStudy Type, Location, Time FrameN, AgesSummary
Pathan et al., Emergency Physician Interpretation of Point-of-care Ultrasound for Identifying and Grading of Hydronephrosis in Renal Colic Compared With Consensus Interpretation by Emergency Radiologists, Acad Emerg Med, 2018 [10]Secondary analysis of images, obtained 2014-2015 from a large volume ED.N=651, Adults
  • Secondary analysis of ED physician POCUS images diagnosing hydronephrosis
  • Images were re-interpreted by radiologists to determine accuracy.
  • Sensitivity=85.7%, specificity=65.9%
  • CT was used as a reference standard when possible, yielding sensitivity=81.1% and specificity=59.4%.
Wong et al., The Accuracy and Prognostic Value of Point-of-care Ultrasound for Nephrolithiasis in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med, 2018 [11]Systematic review & Meta-analysis, Multicenter, 2005 Through April 2016N=1,773, Adults
  • POCUS has modest diagnostic accuracy in adults for nephrolithiasis.
  • Moderate or greater hydronephrosis was highly specific for stones.
  • Detection of any hydronephrosis was suggestive of a stone >5 mm in size.
Kim et al., Usefulness of Protocolized Point-of-Care Ultrasonography for Patients with Acute Renal Colic Who Visited Emergency Department: A Randomized Controlled Study. Medicina, 2019 [12]Prospective randomized control trial in a tertiary care ED, March 2019-July 2019N=164, Adults
  • Evaluated POCUS protocol in managing patients with renal colic in the ED.
  • Patients were assigned to CT vs ultrasound group.
  • Length of stay was 62 min shorter and medical cost was lower in the ultrasound group with no difference in complications within 30 days.
Sibley et al., Point-of-care ultrasound for the detection of hydronephrosis in emergency department patients with suspected renal colic. Ultrasound J, 2020 [13]Prospective observational study in 2 Canadian academic EDs, April 2011 – July 2013N=413, Adults
  • Patients presenting with renal colic had an ED-performed POCUS.
  • The patients also had a CT or an ultrasound by Radiology as a reference standard.
  • For detecting hydronephrosis via POCUS, sensitivity=77.1% and specificity=71.8%.
Table 2. Adult POCUS studies on hydronephrosis and nephrolithiasis
Author, Title, Journal, Publication YearStudy Type, Location, Time FrameN, AgesSummary
Chandra et al., Point-of-care ultrasound in pediatric urolithiasis: an ED case series. Am J Emerg Med. 2015 [14]Case series in a pediatric ED, over a 2-year periodN=8

5-17 years

  • 8 cases of nephrolithiasis were identified with POCUS in patients presenting with renal colic.
  • All patients had confirmatory imaging in radiology.
  • Stones of 2 patients were visualized directly; others were identified by hydronephrosis, twinkling artifact, unilateral absence of ureteral jet, and/or a bladder bulge
Ng et al., Avoiding Computed Tomography Scans By Using Point-Of-Care Ultrasound When Evaluating Suspected Pediatric Renal Colic. Ultrasound in EM, 2015 [15]Retrospective case series in a pediatric ED, time frame not specifiedN=5

3-21 years

  • Hydronephrosis, ureteral jets, twinkling artifact, and the visualization of urinary tract stones were identified in patients with renal colic.
  • CT was avoided in all 5 patients.
Gillon et al., Diagnosis of Posterior Urethral Valves in an Infant Using Point-of-Care Ultrasound. Ped Emerg Care, 2021 [16]Case report in a tertiary pediatric ED, date not specified1, infant
  • Case report of 7-week old boy diagnosed with posterior urethral valves when the ED POCUS identified signs of bladder outlet obstruction. This included a thickened and distended bladder with bilateral hydroureter, severe bilateral hydronephrosis, and small perinephric fluid collections consistent with calyceal rupture.
Table 3. Pediatric POCUS studies on hydronephrosis and nephrolithiasis

Case POCUS

Using the curvilinear probe, you perform a POCUS on the bladder and both kidneys (Video 12).

Video 12. Bilateral renal ultrasound demonstrating twinkling artifact in the bladder and left-sided moderate hydronephrosis, indicative of a distal left ureteral stone (Video courtesy of Dr. Jim Tsung)

Case Resolution

Labs showed a slight leukocytosis with a serum WBC of 13 x109/L but no left shift and a normal creatinine. Urinalysis was positive for blood, RBC’s, and crystals but negative for glucose, ketones, leukocyte esterase, nitrites, WBC’s, squamous cells, and bacteria. The pain and vomiting were well-controlled with ketorolac and ondansetron, respectively. Urology was consulted and recommended medical management. The patient was discharged on tamsulosin and given urine-straining instructions.

Pediatrician Clinic Follow-Up

At her pediatrician clinic visit 2 weeks later, the patient had passed the stone and was asymptomatic.

Learn More…

References

  1. Paliwalla M, Park K. A practical guide to urinary tract ultrasound in a child: Pearls and pitfalls. Ultrasound. 2014 Nov;22(4):213-22. doi: 10.1177/1742271X14549795. Epub 2014 Nov 10. PMID: 27433222; PMCID: PMC4760558.
  2. Deschamps J, Dinh V, Ahn J, et al. Renal Ultrasound Made Easy: Step-By-Step Guide. POCUS101.com. [cited 2023 July 4].
  3. Sethi SK, Raina R, Koratala A, Rad AH, Vadhera A, Badeli H. Point-of-care ultrasound in pediatric nephrology. Pediatr Nephrol. 2023 Jun;38(6):1733-1751. doi: 10.1007/s00467-022-05729-5. Epub 2022 Sep 26. PMID: 36161524; PMCID: PMC9510186.
  4. Milla, Sarah; Lee, Edward; Buonomo, Carlo; Bramson, Robert T. Ultrasound Evaluation of Pediatric Abdominal Masses, Ultrasound Clinics, Volume 2, Issue 3, 2007, Pages 541-559.
  5. Koratala A, Alquadan KF. Parapelvic cysts mimicking hydronephrosis. Clin Case Rep. 2018 Feb 21;6(4):760-761. doi: 10.1002/ccr3.1431. PMID: 29636957; PMCID: PMC5889270.
  6. Shelmerdine SC, Lorenzo AJ, Gupta AA, Chavhan GB. Pearls and Pitfalls in Diagnosing Pediatric Urinary Bladder Masses. Radiographics. 2017 Oct;37(6):1872-1891. doi: 10.1148/rg.2017170031. PMID: 29019749.
  7. Milling TJ Jr, Van Amerongen R, Melville L, et al. Use of ultrasonography to identify infants for whom urinary catheterization will be unsuccessful because of insufficient urine volume: validation of the urinary bladder index. Ann Emerg Med. 2005;45(5):510-513. doi:10.1016/j.annemergmed.2004.11.010
  8. Chen L, Hsiao AL, Moore CL, Dziura JD, Santucci KA. Utility of bedside bladder ultrasound before urethral catheterization in young children. Pediatrics. 2005 Jan;115(1):108-11. doi: 10.1542/peds.2004-0738. PMID: 15629989.
  9. Dessie A, Steele D, Liu AR, Amanullah S, Constantine E. Point-of-Care Ultrasound Assessment of Bladder Fullness for Female Patients Awaiting Radiology-Performed Transabdominal Pelvic Ultrasound in a Pediatric Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2018 Nov;72(5):571-580. doi: 10.1016/j.annemergmed.2018.04.010. Epub 2018 Jul 3. PMID: 29980460.
  10. Pathan SA, Mitra B, Mirza S, Momin U, Ahmed Z, Andraous LG, Shukla D, Shariff MY, Makki MM, George TT, Khan SS, Thomas SH, Cameron PA. Emergency Physician Interpretation of Point-of-care Ultrasound for Identifying and Grading of Hydronephrosis in Renal Colic Compared With Consensus Interpretation by Emergency Radiologists. Acad Emerg Med. 2018 Oct;25(10):1129-1137. doi: 10.1111/acem.13432. Epub 2018 May 28. PMID: 29663580.
  11. Wong C, Teitge B, Ross M, Young P, Robertson HL, Lang E. The Accuracy and Prognostic Value of Point-of-care Ultrasound for Nephrolithiasis in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med. 2018 Jun;25(6):684-698. doi: 10.1111/acem.13388. Epub 2018 Mar 25. PMID: 29427476.
  12. Kim SG, Jo IJ, Kim T, et al. Usefulness of Protocolized Point-of-Care Ultrasonography for Patients with Acute Renal Colic Who Visited Emergency Department: A Randomized Controlled Study. Medicina (Kaunas). 2019 Oct 28;55(11):717. doi: 10.3390/medicina55110717. PMID: 31661942; PMCID: PMC6915595.
  13. Sibley S, Roth N, Scott C, et al. Point-of-care ultrasound for the detection of hydronephrosis in emergency department patients with suspected renal colic. Ultrasound J. 2020 Jun 8;12(1):31. doi: 10.1186/s13089-020-00178-3. PMID: 32507905; PMCID: PMC7276462.
  14. Chandra A, Zerzan J, Arroyo A, Levine M, Dickman E, Tessaro M. Point-of-care ultrasound in pediatric urolithiasis: an ED case series. Am J Emerg Med. 2015 Oct;33(10):1531-4. doi: 10.1016/j.ajem.2015.05.048. Epub 2015 Jun 23. PMID: 26321169.
  15. Ng C, Tsung JW. Avoiding Computed Tomography Scans By Using Point-Of-Care Ultrasound When Evaluating Suspected Pediatric Renal Colic. J Emerg Med. 2015 Aug;49(2):165-71. doi: 10.1016/j.jemermed.2015.01.017. Epub 2015 Apr 29. PMID: 25934378.
  16. Gillon JT, Cohen SG. Diagnosis of Posterior Urethral Valves in an Infant Using Point-of-Care Ultrasound. Pediatr Emerg Care. 2021 Aug 1;37(8):435-436. doi: 10.1097/PEC.0000000000002393. PMID: 34397679

SAEM Clinical Images Series: Neonatal Rash

An 18-day-old male presented for a rash on his face for two days. The patient was born via spontaneous vaginal delivery full term without complications to a mom who has a history of genital HSV but without active lesions at delivery and on acyclovir. The patient presented with a vesicular rash on his face including around his eyes. He had conjunctival discharge noted by mom. Otherwise, he was well-appearing, acting normally, and eating/voiding/stooling normally.

General: Well appearing, acting appropriately for age

HEENT: Scalp normal. Anterior fontanelle soft and flat. Vesicular appearing rash with erythematous base in clusters noted around eyes, cheek, and chin. Fluorescein staining with corneal abrasion noted at 4 o’clock region on right eye, no dendritic pattern. Scant yellow discharge noted from left eye. TM normal bilaterally. Oropharynx clear.

Neuro: Normal tone, moving all extremities

Skin: Flaky skin, no rash noted elsewhere except as listed above (Photos taken after fluorescein)

CBC: Normal

LFTs: Normal

BMP: Unremarkable

CRP: Negative

Lab results for HSV were negative:

HSV 1 and 2 (chin): negative

HSV 1 and 2 (near eye): negative

HSV 1 and 2 (nose, mouth, rectum): negative

HSV 1 blood Igg: negative

HSV 2 blood Igg: positive (reflective of maternal antibody status)

What was once called “neonatal acne” now known as neonatal cephalic pustulosis is usually seen in the first three weeks of life. Usually, it appears as pustulo-papules on the face, around the eyes, on the cheeks, and chin. Some studies have suggested that neonatal cephalic pustulosis is caused by Malassezia species. As the rash is self-limiting, treatment is not necessary.

Take-Home Points

  • When a vesicular rash is in a neonate < 1 month and all over the face, consider benign neonatal pustular lesions such as neonatal cephalic pustulosis.

  • Antoniou C, Dessinioti C, Stratigos AJ, Katsambas AD. Clinical and therapeutic approach to childhood acne: an update. Pediatr Dermatol. 2009 Jul-Aug;26(4):373-80. doi: 10.1111/j.1525-1470.2009.00932.x. PMID: 19689511.
  • Ghosh S. Neonatal pustular dermatosis: an overview. Indian J Dermatol. 2015 Mar-Apr;60(2):211. doi: 10.4103/0019-5154.152558. PMID: 25814724; PMCID: PMC4372928.

By |2024-02-25T20:47:08-08:00Feb 26, 2024|Dermatology, Pediatrics, SAEM Clinical Images|

SAEM Clinical Images Series: Pediatric Genitourinary Bleeding

A 4-year-old female with no significant past medical history is brought to the Emergency Department by her grandmother for concern for two days of progressive vaginal bleeding. The grandmother first noted blood in the patient’s underwear the previous morning when she was helping the patient wipe and she noticed it again prior to arrival, this time saturating the patient’s underwear. There is no history of any recent falls or trauma, abdominal pain, pain to the vagina, dysuria, prior incidents of vaginal bleeding, or any noticeable behavioral changes per the grandmother. The patient lives at home with her mother but has been at her grandmother’s house for the past four days (the household consists of female cousins, grandmother, and grandfather). Of note, the patient’s father took her to a trampoline park with her younger sister two days ago.

Vitals: BP 95/68; HR 96; RR 24; 98% on room air; Temp 36.2°C; Wt 18.2 kg

General: Well-appearing 4-year-old female acting appropriately with grandmother and mother at the bedside.

Abdomen: Soft, nontender, nondistended.

Genitourinary: Normal appearing external genitalia without any skin tears/lacerations. Vaginal exam: Slow oozing bleed noted with round “doughnut” shaped tissue protruding at the vaginal opening.

Hemoglobin: 12.2 g/dL

Urinalysis (clean catch): Blood: Large; >200 RBCs, Ketones: 20, Nitrite: Negative, Leukocytes: Moderate, 19 WBCs

FSH/LH/Testosterone: Within normal limits

Urethral prolapse is a rare condition occurring in prepubertal female pediatric patients. It often presents to the emergency department with complaints of vaginal bleeding, difficulty urinating, or dysuria. The most common predisposing factors to this condition include obesity, cough, trauma, constipation, or a history of any activity that causes a sudden recurrent increase in pelvic pressure, such as a trip to the trampoline park as was the case in this patient [1]. On physical examination, urethral prolapse appears as an annular-like mucosal mass with a central dimple located between the labia majora on examination [1]. Initial treatment is medical management with topical estrogen cream in conjunction with Sitz baths and outpatient follow-up with pediatric urology or gynecology. However, persistence of the prolapse or necrosis of the distal urethra often warrants emergent pediatric urology consultation [2,3]. Recurrent cases or cases refractory to medical management will often require surgery. The patient in this case was treated with a 4-week estrogen cream taper. The patient followed up with pediatric gynecology without further complication or need for further intervention.

Child Abuse, Vaginal Trauma, Malignancies (ie: sarcoma botryoides), Infection, Vaginal foreign body, Urethral Prolapse, Precocious puberty, Hypothyroidism, and Exogenous hormone

Take-Home Points

  • Consider urethral prolapse in any prepubertal female who presents to the Emergency Department with a triage complaint of vaginal bleeding.
  • Treatment for urethral prolapse is typically conservative with topical estrogen cream and prompt follow up with pediatric urology or gynecology.
  • Always keep a broad differential for prepubertal pediatric patients with genitourinary and vaginal bleeding complaints
  • HHillyer S, Mooppan U, Kim H, Gulmi F. Diagnosis and treatment of urethral prolapse in children: experience with 34 cases. Urology. 2009 May;73(5):1008-11. doi: 10.1016/j.urology.2008.10.063. Epub 2009 Mar 13. PMID: 19285715.
  • Laufer M, Emans S. Overview of vulvovaginal conditions in the prepubertal child. Uptodate.com. https://www.uptodate.com/contents/overview-of-vulvovaginal-conditions-in-the-prepubertal-child. Published 2021. Accessed January 5, 2022.
  • Teach S. Evaluation of vulvovaginal bleeding in children and adolescents. Uptodate.com. https://www.uptodate.com/contents/evaluation-of-vulvovaginal-bleeding-in-children-and-adolescents#H11716993. Published 2021. Accessed January 5, 2022.

By |2023-11-12T14:19:13-08:00Nov 17, 2023|Ob/Gyn, Pediatrics, SAEM Clinical Images|

SAEM Clinical Images Series: Unusual Scalp Lesions

scalp

A 6-year-old male presented to the pediatric emergency department (PED) for scalp lesions. He was seen by his pediatrician 2 weeks prior and prescribed antibiotics and a delousing shampoo for suspected cellulitis versus lice infestation. Symptoms did not improve despite completion of treatment. An outpatient ultrasound was performed showing “multiple scalp echogenic nodular lesions measuring from 0.5 cm to 1.2 cm in the long axis diameter.” The following differential diagnosis was entertained: lymphadenitis, benign avascular mass, epidermal inclusion cyst, or pilomatricoma, and the patient was started on clindamycin. Due to concern for an oncologic process, a surgery consultation was placed to arrange for a biopsy. Four days after the ultrasound and before the biopsy could be performed, the patient and his mother presented to the PED due to worsening symptoms. Multiple new lesions developed across the patient’s scalp which bled when pressure was applied. The patient denied fever and reported intermittent pruritus and pain over the lesion sites. The mother reported a history of travel to Ecuador one month prior to symptom onset.

Vitals: BP 98/61; Pulse 73; Temp 36.3°C (97.3°F) temporal; Resp 18; SpO2 99%, RA

Skin: Large, 3 x 3cm indurated, erythematous lesion located over the patient’s right temporal scalp (Image 1). Five additional lesions noted across the entirety of the scalp. No lesions identified below the neck. Lesions are mildly tender to palpation; no fluid able to be expressed. A small centrally located pore is noted on each lesion with appearance of pulsatile fluid level. No associated lymphadenopathy. A point-of-care ultrasound (POCUS) using a high-frequency, linear transducer was performed during the PED visit (Image 2).

Non-contributory

In short axis, there is an echogenic lesion with surrounding fluid (halo sign) suggesting a foreign body that also exhibits posterior acoustic shadowing. With the transducer held still, independent movement is visualized within the center of the lesion (Image 3).

Cutaneous furuncular myiasis due to Dermatobia hominis (botfly infestation).

Take-Home Points

  • Native to Central and South America, botfly infestation is facilitated through an infected female mosquito which deposits its eggs on the skin of a mammal on which it feeds.
  • Cutaneous furuncular myiasis is important to consider for unexplained head, neck, and extremity lesions when there is suspected travel to endemic areas and is unlikely to be recognized in the continental United States due to low prevalence.
  • Consider pertinent physical exam findings and utility of POCUS in confirming the diagnosis.
  • Harris AT, Bhatti I, Bajaj Y, Smelt GJ. An unusual cause of pre-auricular swelling. J Laryngol Otol. 2010 Mar;124(3):339-40. doi: 10.1017/S002221510999082X. Epub 2009 Aug 11. PMID: 19664319.
  • Minakova E, Doniger SJ. Botfly larva masquerading as periorbital cellulitis: identification by point-of-care ultrasonography. Pediatr Emerg Care. 2014 Jun;30(6):437-9. doi: 10.1097/PEC.0000000000000156. PMID: 24892687.

PEM POCUS Series: Pediatric Lung Ultrasound

PEM POCUS fascia iliaca block

Read this tutorial on the use of point of care ultrasonography (POCUS) for pediatric lung ultrasound. Then test your skills on the ALiEMU course page to receive your PEM POCUS badge worth 2 hours of ALiEMU course credit.

Module Goals

  1. List indications for performing a pediatric lung point-of-care ultrasound (POCUS).
  2. Describe the technique for performing lung POCUS.
  3. Recognize anatomical landmarks and artifacts related to lung POCUS.
  4. Interpret signs of a consolidation, interstitial fluid, effusion, and pneumothorax on POCUS.
  5. Describe the limitations of lung POCUS.

Child with Cough and Fever: Case Introduction

A 6-year-old boy presents to the emergency department complaining of cough for 3 days and fever for the last day. His fever was 103°F this morning and he received ibuprofen. He has also had abdominal and back pain. He was seen at the emergency department earlier in the day where he had a chest X-ray 6 hours prior that was interpreted as negative for consolidation and bloodwork including a complete blood count and comprehensive metabolic panel that were within normal limits. He presents with persistent cough and fever and now has increased work of breathing.

On arrival, his vital signs are:

Vital SignFinding
Temperature99.7 F
Heart Rate138 bpm
Blood Pressure102/61
Respiratory Rate32
Oxygen Saturation (room air)100%

He is well appearing but has increased work of breathing. His lungs have decreased breath sounds and crackles over the left lung base. No wheezes are appreciated. He has mild subcostal retractions. His abdomen is soft, non-tender, and non-distended. His back is non-tender to palpation. He has normal HEENT, neck, and cardiac examinations, with the exception of tachycardia as above.

Given his presenting signs and symptoms in the setting of a recent chest X-ray that was interpreted as normal, you decide to perform a lung point-of-care ultrasound (POCUS) examination.

Lung POCUS can be performed for a wide range of cardiorespiratory complaints including cough, fever, difficulty breathing, chest pain, hypoxia, and chest trauma. It can also facilitate early diagnosis, allowing for appropriate management. Children are excellent candidates for lung POCUS as they have thinner chest walls and smaller thoracic widths than adults.

Background

The lungs were traditionally considered poorly accessible to ultrasound, as ultrasound waves cannot penetrate air-filled structures; however, lung POCUS relies on the interpretation of patterns of artifacts to evaluate the normal, air-filled lungs.

When there is lung pathology, the consolidation or fluid allows for direct visualization of the pathology with lung POCUS and replaces the air artifacts. Fluid in a consolidation or effusion is easily visualized with ultrasound if the fluid has direct contact with the pleural surface. As lung POCUS will only visualize the lung under the probe, it is essential to completely evaluate the lungs anteriorly, laterally, and posteriorly to avoid missing pathology.

Technique

Positioning and Probe

lung POCUS comfortable positioning child

Figure 1: Younger children can sit in their parent’s lap and give a hug for lateral and posterior lung scanning.

  • The patient should be in a position of comfort: supine, sitting, or in parent’s lap (Figure 1).
    • Warm gel helps with the child’s comfort.
    • Distractions such as a toy, book, or phone/tablet can also help ease anxiety.
  • Use a linear high frequency probe. If increased depth is needed, such as in the evaluation for effusion, a curvilinear or phased array probe may also be used.

 

Scanning Protocols

There are different protocols to scan the lung depending on the purpose of the evaluation. For example, in pneumothorax, we focus on the anterior chest where air rises in a supine patient, and for the extended Focused Assessment with Sonography (eFAST) exam, we focus on more dependent areas where pleural fluid or blood collects. Below we discuss the complete lung exam which is often used in evaluating for pneumonia.

Lung POCUS anatomy 6-zone scan area

Figure 2: The 6-zone lung scanning protocol includes anterior, lateral, and posterior lung fields bilaterally.

  • A 6-zone lung ultrasound protocol is used for a complete lung examination (Figure 2):
    • Anterior lungs bilaterally are scanned in the mid-clavicular line from the apex to the base of the lungs and diaphragm.
    • Lateral lungs bilaterally are scanned in the mid-axillary line from the apex to the base of the lungs and diaphragm.
    • Posterior lungs bilaterally are scanned medial to the scapulae and lateral to the vertebral bodies from the apex to the base of the lungs and diaphragm.
  • Place the probe longitudinally, perpendicular to the ribs, with the probe marker towards the patient’s head. Identify anatomical landmarks on ultrasound (Figure 3, Video 1).
Lung POCUS A lines normal child

Figure 3: Normal lung with A-lines in longitudinal (left) and transverse (right) orientations

 

Video 1: Normal lung POCUS in longitudinal orientation

 

Video 2: Normal lung POCUS in transverse orientation

Normal Lung Findings

  1. Ribs: Hyperechoic, curvilinear structure with posterior acoustic shadowing
  2. Pleural line: Hyperechoic line immediately deep to the ribs
    • Lung sliding sign: Visceral and parietal pleural are juxtaposed and sliding against each other with respirations, giving the pleural line a shimmering or “ants marching on a log” appearance. For additional examples, see the PEM POCUS Endotracheal Intubation Confirmation article, specifically in Section 2 – Indirect Confirmation: Visualize Bilateral Lung Sliding.
  3. Lungs filled with air: Visualized on POCUS as horizontal A-lines, which are a reverberation artifact of the pleural line. The pleural line is reflected as the ultrasound beams bounce back and forth between the probe and the highly reflective pleural line, and therefore the distance between A-lines is the same as the distance between the probe and the pleural line (Figure 4).
Lung POCUS A lines reverberation normal

Figure 4: Reverberation artifact and A-lines. The probe sends out ultrasound waves that bounce back and forth between the highly reflective pleural line and the probe (leftmost 3 arrows). The ultrasound machine then interprets these signals as A-lines equidistant from the pleural line (rightmost 3 arrows).

Lung POCUS pulmonary consolidation

Figure 5: Pneumonia with sonographic hepatization, air bronchograms, and irregular pleural line

 

Video 3: Lung POCUS showing a pneumonia

 

Consolidation will appear as a subpleural, hypoechoic, irregularly shaped area, which will move with respirations. It can have the following findings on lung POCUS:

  • Hepatization refers to the homogenous, soft tissue echotexture due to fluid in the lung.
  • Shred sign refers to the irregular borders of the non-pleural edge of a pneumonia that is not translobar and thus adjacent to normal lung.
  • Pleural line irregularities refer to the hypoechoic or fragmented pleural line at the consolidation.
  • Hyperechoic air bronchograms are air in the bronchioles (white dots or branches) surrounded by hypoechoic (dark), fluid-filled lung (Figure 5 and Video 3).
Lung POCUS B lines waterfall

Figure 6: Lung POCUS showing B-lines (A) and a confluence of B-lines, known as the waterfall sign (B)

Video 4: Lung POCUS showing a confluence of B-lines (waterfall sign)

B-lines represent interstitial fluid and may arise from viral infection, pulmonary edema, or acute respiratory distress syndrome (ARDS).

  • POCUS appearance:
    • Ring-down artifacts that arise from the pleural line and extend to the bottom of the screen (Figure 6A). They move with lung sliding and erase A-lines at their intersection.
    • More than 3 B-lines in an intercostal space has been considered abnormal in the adult population. However it may not always be feasible to accurately count the number of B-lines.
    • The distribution of B-lines may help differentiate etiologies, with focal B-lines in pneumonia or atelectasis, and diffuse B-lines in pulmonary edema or ARDS.
  • Waterfall sign: A confluence of B-lines (Figure 6B and Video 4)
POCUS lung subpleural consolidation

Figure 7: Lung POCUS with subpleural consolidation

Video 5: Lung POCUS with subpleural consolidation

Subpleural consolidations are small hypoechoic or tissue-like structures with pleural line abnormalities and blurred margins (Figure 7 and Video 5). They measure <1 cm and are usually seen with a viral process.

Lung POCUS pleural effusion

Figure 8: Pleural effusion with linear probe (A) and phased array probe for increased depth (B).

Video 6: Lung POCUS with pleural effusion using linear probe

A pleural effusion is visualized as anechoic (black) fluid between the chest wall and lung or between the diaphragm and lung (Figure 8 and Video 6).

  • Scan the lateral chest in the posterior axillary line in the supine patient, as fluid is dependent and will accumulate posteriorly.
  • The pleural effusion can be fluid in an infectious process or blood in the setting of trauma.

Absent Lung Sliding

Video 7: Lung POCUS showing a pneumothorax with absent lung sliding

In pneumothorax, there is air between the visceral and parietal pleural, so there will be no lung sliding visualized on lung POCUS.

  • Scan for a pneumothorax in the anterior chest in the 2nd-4th intercostal space in the mid-clavicular line in a supine patient, as air will rise to the highest point in the chest.
  • The pleural line will appear as a static, hyperechoic line (Video 7).
  • There will be A-lines visualized, but no B-lines.
    • Pro Tip: The presence of B-lines is highly sensitive against the presence of a pneumothorax in that location.

 

Lung Point

Video 8: Lung POCUS with evidence of a lung point

Lung point, when seen, is the edge of the pneumothorax, where regular lung sliding occurs adjacent to absent lung sliding (Video 8).

  • Lung point is 100% specific for pneumothorax, but it may not be visualize d for a large pneumothorax with lung collapse.

 

Motion (M) Mode

Figure 9: Lung POCUS showing a normal lung with the seashore sign (A) and a pneumothorax with the barcode sign (B)

M-mode may also be used to evaluate for pneumothorax.

  • Normal lung: There will be the seashore sign, with a granular pattern representing aerated, moving lung below the pleural line (Figure 9a).
  • Pneumothorax: There will be a barcode or stratosphere sign, with no aeration or movement below the pleural line (Figure 9b).

Additional examples can be found in the PEM POCUS: Endotracheal Tube Confirmation article in Section 2 – Indirect Confirmation: Visualize Bilateral Lung Sliding.

lung abscess

Figure 10: Lung abscess with adjacent lung consolidation and pleural effusion

 

Lung abscess may also be evaluated by lung POCUS and will have a hypoechoic fluid collection (Figure 10).

  • Consolidated lung and pleural effusion are also commonly seen.
  • Lung ultrasound is more accurate than chest X-ray at evaluating lung abscess.

Lung pathology may be missed without a complete lung POCUS scanning protocol, as you will only see pathology located directly under the probe. The lung POCUS is also operator-dependent, and it has a steep learning curve.

False Negative:

  • POCUS can’t visualize a centrally located pneumonia not extending to the pleural surface. A lung consolidation needs to extend to the pleural surface to be visualized on lung POCUS.
  • However, a study in adult patients showed that 99% of lung consolidations extend to the pleura [1]. Thus, in children with smaller lung mass, most consolidations likely will be detected by lung POCUS.

False Positives:

Left Lower Chest

  • Caution is needed at the left lower chest, as the spleen and air in the stomach can be misinterpreted as consolidation (Figure 11).
  • Locate the diaphragm in the left lower chest to be sure you are evaluating lung above the diaphragm.
stomach spleen

Figure 11: The spleen and the stomach with air may be misinterpreted as consolidation.

Thymus

  • In younger children, the thymus may be misinterpreted as a consolidation.
  • The thymus will be adjacent to the heart, have regular echotexture, no air bronchograms, and regular borders (Figure 12).
thymus

Figure 12: Thymus (*) located adjacent to the heart

 

There have been multiple studies of lung POCUS identifying pneumonia in children, and several meta-analyses have been published [2-4]. Table 1 summarizes these studies, showing an overall high accuracy for lung POCUS diagnosis of pneumonia in children.

StudyNSensitivitySpecificityComments
Pereda et al., Pediatrics 20158 studies; 765 patients

96%

93%

Evidence supports lung POCUS as an alternative for diagnosis of pneumonia in children.
Balk et al., Pediatr Pulmonol 201812 studies; 1510 patients

96%

95%

Lung POCUS had significantly better sensitivity than chest X-ray, which had a sensitivity of 87%.
Tsou et al., Acad Emerg Med 201925 studies; 3353 patients

94%

92%

Significant difference in accuracy between novice and advanced sonographers.
Table 1. Meta-analyses of lung POCUS for diagnosis of pneumonia in children

1. Decreased radiation and length of stay

  • A randomized controlled trial comparing lung POCUS to chest X-ray for diagnosis of pneumonia showed a 39% reduction in chest X-ray utilization and a decreased emergency department length of stay from 180 to 132 minutes in the patients receiving only lung POCUS with no cases of missed pneumonia [5].

2. Best view for pneumonia

  • A study looking at lung consolidation locations in children with pneumonia found that 96% of pneumonias were detected by the transverse view, compared to 86% in the longitudinal view.
  • The authors concluded that the transverse orientation detects more pneumonia than the longitudinal view, and that omission of either orientation or any lung zone may miss pneumonia [6].

3. Pneumothorax: POCUS is better

  • A meta-analysis of chest X-ray vs ultrasound for diagnosis of pneumothorax showed that ultrasound had a sensitivity of 88% and specificity of 99% compared to sensitivity of 52% and specificity of 100% for chest X-ray. Furthermore, lung POCUS performed specifically by non-radiologist clinicians had a sensitivity of 89% and specificity of 99% [7].

Case Resolution

The patient’s chest X-ray from earlier in the day was interpreted by the pediatric radiologist as negative for consolidation or other pulmonary pathology. You performed a lung POCUS with a linear, high-frequency probe and observed the following:

Video 9: A lung POCUS of the case patient’s left lower lung (affected side)

Though this child with cough, fever, focal lung findings, and respiratory distress had a negative chest X-ray performed 6 hours earlier, your POCUS evaluation identified a left lower lobe pneumonia which helped you make your diagnosis and start the appropriate treatment.

ED Course

The patient received antibiotics for pneumonia. His work of breathing increased during his emergency department visit, and he was started on high flow nasal cannula at 30 L/min with improvement in his respiratory status. He was admitted to the pediatric intensive care unit. He had a repeat chest X-ray 12 hours later that was interpreted by the pediatric radiologist as having new pleural and parenchymal changes in the left hemithorax with questionable pneumonia. He continued antibiotics, and his repeat X-ray 48 hours later showed a clear left lower lobe consolidation with pleural effusion.

 


Learn More…

References

  1. Lichtenstein DA, Lascols N, Mezière G, Gepner A. Ultrasound diagnosis of alveolar consolidation in the critically ill. Intensive Care Med. 2004 Feb;30(2):276-281. PMID: 14722643
  2. Pereda MA, Chavez MA, Hooper-Miele CC, et al. Lung ultrasound for the diagnosis of pneumonia in children: a meta-analysis. Pediatrics. 2015 Apr;135(4):714-22. PMID: 25780071
  3. Balk DS, Lee C, Schafer J, et al. Lung ultrasound compared to chest X-ray for diagnosis of pediatric pneumonia: A meta-analysis. Pediatr Pulmonol. 2018 Aug;53(8):1130-1139. PMID: 29696826
  4. Tsou PY, Chen KP, Wang YH, et al. Diagnostic Accuracy of Lung Ultrasound Performed by Novice Versus Advanced Sonographers for Pneumonia in Children: A Systematic Review and Meta-analysis. Acad Emerg Med. 2019 Sep;26(9):1074-1088. PMID: 31211896
  5. Jones BP, Tay ET, Elikashvili I, et al. Feasibility and Safety of Substituting Lung Ultrasonography for Chest Radiography When Diagnosing Pneumonia in Children: A Randomized Controlled Trial. Chest. 2016 Jul;150(1):131-8. PMID: 26923626
  6. Milliner BHA, Tsung JW. Lung Consolidation Locations for Optimal Lung Ultrasound Scanning in Diagnosing Pediatric Pneumonia. J Ultrasound Med. 2017 Nov;36(11):2325-2328. PMID: 28586113
  7. Ding W, Shen Y, Yang J, He X, Zhang M. Diagnosis of pneumothorax by radiography and ultrasonography: a meta-analysis. Chest. 2011 Oct;140(4):859-866. PMID: 21546439

Additional Reading

  • Rizvi MB, Rabiner JE. Pediatric Point-of-Care Lung Ultrasonography: A Narrative Review. West J Emerg Med. 2022 Jun 5;23(4):497-504. PMID: 35980421

Trick of Trade: Dual Foley catheter to control massive epistaxis

Massive epistaxis is considered a medical emergency that requires immediate attention. Symptoms of massive epistaxis include sudden and heavy bleeding from the nose, difficulty breathing, dizziness, and a rapid heartbeat. If left untreated, it can lead to significant blood loss, shock, airway obstruction, and even death. We report a case of a 50-year-old man with end stage renal disease with massive nasal bleeding from the left nostril, shortness of breath, and confusion.

Initial Management

After a rapid assessment, we inserted an anterior nasal pack, soaked in epinephrine, TXA, and an antibiotic-based lubricant. However, the bleeding continued from his nares and posterior oropharynx. We thus removed the anterior packing and instead inserted a Foley catheter into the posterior nasal space and inflated the balloon. Unfortunately, the bleeding still continued. Because he presumably had uremia-induced thrombasthenia (weak platelets), he received blood transfusions and IV TXA. And still — he continued bleeding heavily.

Trick of the Trade: Dual Catheter Technique

To provide optimal surface area coverage and tamponade effect of the posterior vessels, concurrent anterior packing is usually needed [1]. You can use commercial devices that have a dual balloon setup, but we did not have that available.

dual balloon for massive epistaxis

Illustration by Dr. Abdelhameed with patient-consented photo of dual balloon technique

Technique

  1. Insert the a 14-French Foley catheter into the nares with the patient’s mouth open (balloon 1). Stop when you see the tip of the catheter dangling in the posterior oropharynx.
  2. Inflate the balloon partially with 15-20 cc of air.
  3. Gently pull the catheter anteriorly until you feel resistance such that the balloon is snuggly positioned.
  4. If the bleeding still continues, insert a second Foley catheter until you meet resistance (balloon 2). Inflate this second balloon with 15 cc of air.

For our case, this dual catheter compression technique succeeded in halting the bleed.

Interested in Other Tricks of the Trade?

Reference

  1. Goralnick E. Posterior Epistaxis Nasal Packing. Medscape. Published Dec 9, 2020

Trick of Trade: Removal of Entrapped Metal Zipper

zipper entrapment injury

A young boy is brought to the pediatric emergency screaming at the top of his lungs by his parents. His penile skin is trapped in the zipper of his jeans. On a busy shift, you want a simple way to handle zipper injuries that minimizes pain, doesn’t require resource-intensive procedural sedation, and is quick.

Background

The 4 most common types of zippers are nylon coil zip, plastic mold zip, metal zip, and invisible zip. Most of the techniques describing solutions on zipper entrapment in the medical literature are derived from case reports and case series. All revolve around understanding zipper anatomy and obtaining adequate exposure to assess how the skin is entrapped. The penile skin often is entrapped either in the sliding mechanism (also known as the endplate) or between the teeth of the zipper.

zipper anatomy

Figure 1. Anatomy of a zipper

Penile Entrapment Injury Management Techniques in Literature

Reported techniques for releasing zippers include [1, 2]:

  • Cut the sliding mechanism (aka the endplate) using metal cutters.
  • Use a flat screwdriver placed underneath the sliding mechanism and rotate it.
  • Use mineral oil for lubrication.
  • Use lateral compression technique to relieve the tension on the trapped skin.
  • Cut the zipper and pull the teeth apart.

All these techniques are associated with variable rates of success. Some of these techniques such as using metal cutters might lead to iatrogenic injuries.

The problem is that the child’s penile skin is entrapped within a metal zipper, where many recommended methods for zipper entrapment removal won’t work.

Trick of the Trade: Removing Metal Zippers

Materials Needed

  • Lidocaine gel
  • Blade or scissors

Technique

  1. The zipper should be separated from the pants as much as possible to minimize painful stretching or pulling of the penile skin.
  2. Apply lidocaine gel on the area of entrapment for 2-3 minutes.
  3. Identify the exposed teeth closest to slider and cut off the zipper at that level (blue dots) while avoiding penile skin (Figure 2).
  4. Gently advance the zipper body forward, pulling either the tab or the body itself, to disengage it from the teeth. You may need to add more lidocaine gel or other lubrication to facilitate this sliding motion.
  5. The remaining parts of the zipper can easily be disengaged from the skin (Figure 3).

metal zipper cut trick zipper entrapment

Figure 2. Cutting off the zipper between the teeth (blue dots) and advancing the zipper body (yellow arrow)

metal zipper entrapped free

Figure 3. Freed zipper body

Interested in Other Tricks of the Trade?

References

  1. Leslie SW, Sajjad H, Taylor RS. Penile Zipper and Ring Injuries. [Updated 2023 Mar 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
  2. Tasian GE, Belfer RA. Genitourinary trauma. In: Fleisher and Ludwig’s Textbook of Pediatric Emergency Medicine, 7th ed, Shaw K, Bachur RG (Eds), Lippincott Williams & Wilkins, Philadelphia 2015.
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