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SAEM Clinical Images Series: Strawberry Tongue

A 7-year-old male with no significant past medical history presented to the Emergency Department complaining of a sore throat. The parents stated that he had been running fevers for two days along with a worsening sore throat. The patient had been able to swallow, but had decreased oral intake secondary to pain. There are no other complaints at the time.

 

strawberry tongue

Vitals: BP 110/70; HR 111; R 17; T 101°F; O2 sat: 99% on room air.

General: Well appearing, no acute distress, normal voice.

HEENT: There is no sign of conjunctivitis. Oropharyngeal exam is remarkable for exudative pharyngitis with tonsillar swelling. There is no sign of peritonsillar abscess or airway compromise. Uvula midline and normal. Tongue as shown. Anterior cervical lymphadenopathy is present.

Respiratory: Clear to auscultation bilaterally.

Cardiovascular: Tachycardia without murmur.

Abdomen: Non-tender, no organomegaly.

Skin: Relevant findings as shown.

Non-contributory

Strawberry tongue and sandpaper rash.

Scarlet fever

Scarlet fever is caused by Group A Streptococcus (S. pyogenes), and most commonly occurs in children aged 5-15 years. The illness typically begins with a prodrome of fever, sore throat, headache, and abdominal pain, followed 1-2 days later by a distinctive coarse rash with a texture that resembles sandpaper. Exudative pharyngitis is usually present. The tongue may initially have a white coating which fades by day 4-5, revealing a bright red, “strawberry tongue” as seen in this case. The rash usually starts on the neck, axillae, and groin, and then spreads to the trunk and extremities. Pastia lines, which are linear petechial eruptions, may be present in the antecubital and axillary folds. Facial flushing with a pale area around the mouth is also common. Desquamation of the skin may occur about two weeks after the rash appears. A rapid strep test can quickly confirm the diagnosis. If scarlet fever is left untreated, it can lead to serious complications such as rheumatic fever or post-streptococcal glomerulonephritis. Early diagnosis and treatment with antibiotics, usually penicillin or amoxicillin, are effective in preventing sequelae.

Take-Home Points

  • Scarlet fever is characterized by strawberry tongue, sandpaper rash, and exudative pharyngitis. The cause is Group A Streptococcus.

  • Early diagnosis and antibiotic treatment are crucial to prevent the serious potential complications of untreated scarlet fever, such as rheumatic fever and post-streptococcal glomerulonephritis.

  • The Sanford Guide to Antimicrobial Therapy. Dallas, TX :Antimicrobial Therapy, Inc., 1995.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.



By |2025-11-09T21:20:57-08:00Nov 14, 2025|Infectious Disease, Pediatrics, SAEM Clinical Images|
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PEM POCUS Series: Pediatric Cardiac

PEM POCUS pediatric cardiac

Read this tutorial on the use of point of care ultrasonography (POCUS) for pediatric cardiac evaluation. 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 and limitations of pediatric cardiac point-of-care ultrasound (POCUS)
  2. Describe the technique for performing cardiac POCUS
  3. Identify anatomical landmarks accurately on cardiac POCUS
  4. Interpret abnormal findings on cardiac POCUS
  5. Describe the basic literature behind pediatric cardiac POCUS

Case Introduction: Child with respiratory distress

You are in the emergency department evaluating a 2-month-old full-term male infant presenting with worsening respiratory distress over the past few days. He has had no fever, rhinorrhea, congestion, or cough. He is feeding poorly and has only had two wet diapers in the past 24 hours.
On arrival, his vital signs are:

Vital SignFinding
Temperature36.4 C
Heart rate190 bpm
Blood pressure97/63
Respiratory pate62
Oxygen saturation (room air)95%

Exam

He is ill-appearing. The cardiac exam is notable for tachycardia and 2+ femoral pulses. There is no appreciable murmur. Pulmonary exam shows tachypnea, clear lungs, and mildly increased work of breathing. The abdomen is mildly distended with a liver palpable 2 cm below the costal margin. Capillary refill is 2 seconds.

Diagnostics and Management

You order a chest x-ray and labs, and order blood and urine cultures. You start a fluid bolus and empiric antibiotics. While waiting for your initial work-up, you perform a cardiac POCUS.

Cardiac POCUS can help providers rapidly identify significant cardiac pathology and drastically change management. The major POCUS questions are qualitative evaluation of:

  1. Ventricular function
  2. Pericardial effusion
  3. Relative chamber sizes
  4. Fluid tolerance (or volume status)

In the context of cardiac arrest, POCUS can assess the presence of cardiac activity. Additionally, performing repeat cardiac POCUS exams can help providers gauge response to interventions.

Limitations

Cardiac POCUS is NOT a replacement for comprehensive echocardiography. A number of applications are beyond the scope of cardiac POCUS and should be evaluated by comprehensive echocardiography, including:

  • Valvular pathology
  • Structural abnormalities
  • Congenital heart defects
  • Quantitative measurements (i.e., quantitative ventricular function, flow measurements)

Like other POCUS applications, sonographer skill and experience can influence the sensitivity/specificity of the exam to detect abnormalities.

 

  • Supine positioning as tolerated. Raise head of bed if needed for comfort.
    • Left lateral decubitus position can improve the A4CH and parasternal views.

Figure 1. Phased array ultrasound probe

  • Phased array probe: Smaller footprint for intercostal windows and useful for moving objects.
  • Cardiac setting on the machine (if available). Can improve temporal resolution of the images.
  • Tips for young children:
    • If fearful of staff, consider seating the child in the guardian’s lap.
    • Distract the child with a video or toy.
    • Obtain the subxiphoid view last (as this sometimes requires pressure).
    • Warmed gel can be very helpful!

A cardiac POCUS includes five standard views of the heart and inferior vena cava (below). Sonographers should recognize each of the ideal views and limitations of suboptimal views.

  • Parasternal long axis (PSLA or PLAX)
  • Parasternal short axis (PSSA or PSAX)
  • Apical four chamber view (A4CH)
  • Subxiphoid view (SUBX)
  • Inferior vena cava (IVC)

A note on probe marker orientation:

Probe marker orientation varies across pediatric disciplines, including cardiology, pediatric emergency medicine, critical care, and neonatology. This especially differs for the parasternal long axis view (discussed in more detail below). This may result in an image that appears “flipped,” or rotated 180 degrees, on the screen. Practice obtaining the views in your local environment, but also gain comfort interpreting a flipped image.

(Although all views can be used to evaluate gross ventricular function and for pericardial effusion, highlights of each view are listed below.)

Highlights of View

  • Excellent overall assessment
  • Gross LV function
  • Pericardial effusion
  • General chamber sizes

Probe Placement

Figure 2 PSLA probe placement

Figure 2. PSLA probe placement with phased array probe. (Image from Dr. Margaret Lin-Martore)

  1. Place the probe to the left of the sternum, near the 3rd-4th intercostal space.
  2. Point the probe marker towards the patient’s left hip.
  3. Slide the probe up and down intercostal spaces to obtain an ideal window.
  4. Make subtle adjustments to optimize the view.

In this image and the ones below, note that the probe is larger than a typical phased-array probe (Figure 1).

Note: The direction of the probe marker, especially for the parasternal long axis, may vary across specialties and institutions. Some specialties point the probe marker towards the left hip and others towards the right shoulder. This may result in an image that appears “flipped” (or rotated 180 degrees) on the screen.

Normal View and Landmarks

normal pediatric cardiac POCUS PSLA view

Video 1: Normal PSLA cardiac view (Image from thepocusatlas.com. Images: Dr. Lindsay Davis, Dr. Hanna Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti)

Color labels in video:

  • Right ventricle (green)
  • Left ventricle (violet)
  • Left atrium (teal)
  • Mitral valve (yellow-brown), visualize both leaflets with the anterior leaflet centered and hitting or nearly hitting the septum
  • Aortic valve (pink)
  • Descending aorta (black circle behind pericardium)
  • Pericardium (pink), note tapering anterior to the descending aorta

Troubleshooting and Tips

  • If the left ventricle is oblique (and not horizontal across the screen), slide up a rib space.
  • The patient can hold breath in exhalation to decrease lung artifact.
  • Ensure adequate depth to see the descending aorta.
  • Try subtle micro-adjustments (fan and rotate the probe until you obtain the ideal image).
  • If the lung is obscuring the view, try rolling the patient into the left lateral decubitus position.

Normal Ultrasound Video (PSLA)

Video 2. Normal PSLA view

Highlights of View

  • Gross LV function
  • Interventricular septum position

Probe Placement

PSSA probe placement

Figure 3. Probe placement for PSSA. From the PLSA view, center the left ventricle (LV) on the screen then rotate the probe 90° clockwise towards the right hip.

 

Normal View and Landmarks

video normal PSSA view

Video 3: Normal PSSA view (Image from thepocusatlas.com – Dr. Lindsay Davis, Dr. Hanna Kopinski. Image editing: Michael Amador and Dr. Matthew Riscinti.)

 

Color labels in video:

  • Left ventricle (red)
  • Mitral valve (blue)
  • Right ventricle (top of the screen)

The ideal view is at the mid-papillary level, meaning both papillary muscles are visible in the LV at approximately 4 and 8 o’clock.  Note that this video starts with the “fish mouth” view of the mitral valve and ends with the mid-papillary view.

Additional views: Fanning through the PSSA view, starting at the apex → mid-papillary view → “fish mouth” view of the mitral valve → “Mercedes-Benz” view of the aortic valve (video 3A).

 Video 3a. Troubleshooting the PSSA view with the “PSSA sweep”

 

Troubleshooting and Tips

  • If you see the “fish mouth” view of the mitral valve, fan the probe towards the apex to visualize the papillary muscles.
  • If you only see one papillary muscle, anchor that side of the probe and move the other side of the probe back-and-forth (like a windshield wiper) until you find the second papillary muscle.
Video 3b. Troubleshooting the PSSA View -The Windshield Wiper:
If you cannot find the view, try sliding the probe towards the apex. Alternatively, you can return to the PSLA view and rotate from there. Rock the probe to center the LV on the screen.

 

Video 3c. Troubleshooting the PSSA view: Rocking the probe

Normal Ultrasound Video (PSSA)

Video 4. Normal PSSA view

Highlights of View

  • Gross chamber sizes
  • Interventricular septum position

Additional Uses:

  • Global assessment of function
  • Another view for pericardial effusion
  • Can be useful in cardiac arrest during active compressions (though SUBX most commonly used)
  • Pro tip: often helpful for advanced applications (calculations and evaluation for valvular dysfunction)

Probe Placement

Probe placement for apical 4-chamber view (A4CH)

Figure 4. Probe placement for apical 4-chamber view (A4CH). Image from Dr. Margaret Lin-Martore.

  1. From the PSSA view, slide the probe towards the apex of the heart, keeping the probe marker towards the patient’s right hip.
  2. Flatten the probe to point it towards the right shoulder.
  3. For patients with breast tissue, place the probe near the inframammary line.

Normal View and Landmarks

Normal A4CH view

Video 5: Normal A4CH view (Image from thepocusatlas.com. Images: Dr. Lindsay Davis, Dr. Hanna Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti.)

Color labels in video:

  • Left ventricle, left atrium, mitral valve (blue, screen right)
  • Right ventricle, right atrium, tricuspid valve (red, screen left)
  • A5CH view includes the aortic outflow tract (video 5 above initially shows the A5CH view before becoming the A4CH view)
Normal A4CH view with labels

Figure 5. Normal A4CH view with labels

Troubleshooting and Tips

Ventricle differentiation: Regardless of probe marker orientation, you can still differentiate the 2 ventricles in a number of ways:

  1. The tricuspid valve inserts more apically (towards the top of the screen) than the mitral valve.
  2. The LV connects to the aortic outflow tract.
  3. The LV occupies the most apical point of the heart.
  4. The RV contains the moderator band near the apex.
Figure 5 Probe placement A4CH left lateral decub

Figure 6. Left lateral decubitus positioning for A4CH probe positioning

Optimize views:

  1. Roll the patient onto their left side (left lateral decubitus) to bring the heart towards the chest wall and decrease lung artifact (figure 5). This maneuver improves PSLA and PSSA views too, but can be essential to acquire the A4CH view.
  2. If the heart appears oblique, you are likely too medial.
    1. Slide laterally.
    2. Flatten the probe.
    3. Point the probe towards the right shoulder.

Normal Ultrasound Video

Video 6. Normal apical 4-chamber (A4CH) views

Highlights of View

  • Pericardial effusion (most sensitive view)
  • Cardiac arrest (most commonly used)

Probe Placement

Figure 6 subxiphoid view probe

Figure 7. Subxiphoid view probe placement (Image from Dr. Margaret Lin-Martore)

  1. With the probe marker pointing to the patient’s right, place the probe inferior to the xiphoid process.
  2. Switch to an overhand grip, flatten the probe, apply adequate pressure, and point towards the patient’s left shoulder.

Normal View and Landmarks

Video 7 SUBX view normal

Video 7. Normal subxiphoid view (Image from thepocusatlas.com by Dr. Lindsay Davis, Dr. Hanna Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti)

Anatomy in video:

  • Liver (top of the screen)
  • Left ventricle and atrium (red)
  • Right ventricle and atrium (blue) (RV = most anterior chamber)

Troubleshooting and Tips

  • Position the patient supine if possible.
  • Have the patient bend knees to relax abdominal muscles.
  • Have the patient hold breath in inhalation to move the heart inferiorly.
  • Slowly apply moderate pressure to displace bowel gas. Sometimes children cannot tolerate the pressure needed for an adequate view.
  • Using the liver as an acoustic window, try sliding the probe to the patient’s right and pointing the probe towards the patient’s heart through the liver.

Pro tip: Sweeping through this view can allow further assessment for pericardial effusions

Normal Ultrasound Video

 Video 8. Normal subxiphoid view

Highlights of View

  • Rough estimate of fluid tolerance / volume status
  • Adjunct to overall hemodynamic assessment

Probe Placement

Figure 7. Probe placement for IVC transverse view

Figure 8. Probe placement for IVC transverse view. Tilt the probe perpendicular to the patient in a similar location as the subxiphoid view with probe marker to patient’s right. (Image from Dr. Margaret Lin-Martore)

Figure 8. Probe placement IVC sagittal

Figure 9. Probe placement for IVC sagittal view. Center the IVC on the screen, then rotate the probe 90 degrees with probe marker to patient’s head. Slide the probe cephalic until you see the IVC entering the right atrium.  (Image from Dr. Margaret Lin-Martore)

Notes:

  • It is important to evaluate the IVC at its maximum diameter. If you are off-axis in this view, the IVC may appear artificially narrower.
  • Practice obtaining both views, as occasionally it can be difficult to obtain one of the two views depending on patient comfort and the presence of bowel gas.

Normal View and Landmarks

Figure 9. IVC transvere view with anatomy labels

Figure 10. IVC transverse view with anatomy labels. Locate the spinal column (shadowing posteriorly). This shadowing can be seen even in a patient with a larger body habitus. Just anterior to the spinal column, locate the IVC (screen left, patient right) and abdominal aorta (screen right, patient left).

Figure 10 IVC sagittal view labelled

Figure 11. IVC sagittal view with anatomy labels. Visualize the IVC entering into the right atrium (note the hepatic vein draining into the IVC). Examine for collapsibility just distal to the hepatic vein.

Measurements

Various IVC measurements exist, including IVC collapsibility index and IVC-aorta ratio.

1. IVC Collapsibility Index

In the sagittal plane at the level of the IVC just distal to the entry of the hepatic vein, measure the maximum and minimum IVC diameters. A collapsibility index of >50% may represent volume responsiveness.

  • IVC collapsibility index = [Max IVC diameter – Min IVC diameter] / Max IVC diameter

2. IVC-Aorta Ratio

In the transverse plane near the entry of the renal vein, measure the maximum IVC and aorta diameters. Numerous cutoffs for IVC/Ao ratio exist, and can vary by patient age. An IVC/Ao ratio < 0.8 may be suggestive of dehydration.

  • IVC/Ao ratios vary by age, ranging from 0.83 (young infants) to 1.22 (older children) [1].

Please see Facts and Literature Review section for more information on IVC and volume status.

Troubleshooting and Tips

Transverse

  • Many structures can be mistaken for the IVC, including the aorta, portal vessels, and gallbladder. Locate the IVC using the spinal column (shadowing deep on the screen). In a patient without situs inversus, the IVC will be located on screen left (patient right), and the aorta is located on the other side. Both vessels may appear pulsatile, and the IVC shape can change depending on a variety of hemodynamic factors.

Sagittal

  • A common mistake is misidentifying the aorta as the IVC. The aorta is located more to the patient’s left and dives more posteriorly as it crosses the diaphragm. “Prove” that the vessel is the IVC by showing:
    1. The IVC entering the right atrium
    2. The hepatic vein draining into the IVC
  • Because the IVC is a cylindrical structure, it can look like it is completely collapsing if you are located on the edge of the vessel.

Serial IVC Exams:

  • Repeating the IVC exam after interventions (like giving a fluid bolus) can be more helpful than evaluating the IVC at a single point in time.

Normal Ultrasound Video

Video 9: Inferior vena cava (transverse view)
Video 10. Inferior vena cava (sagittal view)

Cardiac POCUS is used primarily to detect significant abnormalities, including:

  1. Gross ventricular dysfunction
  2. Pericardial effusion +/- cardiac tamponade
  3. Gross chamber dilation
  4. Completely collapsed or plethoric IVC

Left Ventricular Systolic Dysfunction

  •     Goal is to identify clinically significant moderate/severe dysfunction.
  •     Qualitative assessment is sufficient, and pattern recognition is important!
  •     As with any diagnostic test, clinical correlation is key
  •     Views: Best assessed on PSLA and PSSA
  •     PSLA:
    • Qualitative assessment of overall “squeeze,” including wall thickening and decrease in chamber size
    • Anterior leaflet of mitral valve excursion: The anterior leaflet should touch or nearly touch the interventricular septum during diastole. Adult POCUS commonly measures this distance, known as EPSS (E-point septal separation); however, age-specific norms are not yet defined in children.
      • Pitfall – An oblique view can underestimate mitral valve movement.
  •     PSSA: 
    • Qualitative assessment of overall “squeeze.”
    • The LV chamber diameter should shorten by ~1/3 and have uniform concentric contraction.

Note: Lung POCUS views may show diffuse B-lines. These vertical white lines originating from the pleura can suggest pulmonary edema in the presence of heart failure. Please see ALiEM PEM POCUS Series: Pediatric Lung Ultrasound for more information.

Ultrasound videos of severe LV dysfunction

Video 11. PSLA view – Severe LV dysfunction in a teenager with new diagnosis of cardiomyopathy. Note the poor overall squeeze, poor excursion of the anterior leaflet of the mitral valve, and lack of thickening of the LV free wall.

 

Video 12. PSSA view in the same patient – note the poor concentric squeeze of the left ventricle

 

Video 13. PSLA view – Severe LV dysfunction in a young infant presenting with failure to thrive and ALCAPA (anomalous left coronary artery from the pulmonary artery). Again note the poor overall squeeze, poor excursion of the anterior leaflet of the mitral valve, lack of thickening of the LV free wall, and dilation of the LV.

 

Video 14. PSSA view – Again note the poor concentric squeeze of the LV and the LV dilation.

  • Views: An effusion should be visible on multiple views.
  • SUBX view:
    • Most sensitive view
    • Pericardial effusion is located between the liver and the right ventricle.
  • PSLA view:
    • Both pericardial and pleural effusions can be seen posterior to the heart.
    • Pericardial effusions track anterior to the descending aorta.
    • Pleural effusions stop posterolateral to the descending aorta and do not cross anteriorly.

Figure 12. Pericardial and pleural effusion on PSLA view

Beware of 2 potential false positives when evaluating for pericardial effusion.

1. Pericardial fat pad

In the PSLA view, this looks like a hypoechoic rim anterior to the heart (closest to probe marker) but NOT posterior to the heart. Typically a fat pad will move in sync with the heart while an effusion does not.

Video 15. Pericardial fat pad and effusion (From thepocusatlas.com by Dr. Dimitri Livshits; Dr. Jane Belyavskaya; Dr. Chris Hanuscin)

2. “Myocardial dropout”

Myocardial dropout occurs when ultrasound waves strike cardiac muscle fibers at specific angles, causing alterations in echogenicity. This acoustic phenomenon can result in the myocardium appearing as a hypoechoic rim. It’s important to note that this rim represents actual myocardial tissue rather than an external collection such as a pericardial effusion. By adjusting the probe angle during the examination, the echogenicity of the myocardium will correspondingly shift, confirming that the hypoechoic area is indeed myocardial tissue rather than a fluid collection (e.g., pericardial effusion).

Figure 13. “Myocardial dropout” effect with asterisks marking drop out area – Changes in echogenicity of the myocardium can sometimes look like a hypoechoic rim. This rim is within the myocardium and not external to the heart as expected for a pericardial effusion. (Image: Dr. Margaret Lin-Martore)

Ultrasound videos of pericardial effusion

Video 16. Pericardial effusion (PSLA view) – The anechoic pericardial effusion is anterior to the heart and also posterior to the heart, tapering just in front of the descending aorta.
Video 17. Pericardial effusion (PSSA view) – Note the circumferential pericardial effusion. A pathologic pericardial effusion should be visualized in multiple views.
Video 18. Pericardial effusion (A4CH view) – Note the pericardial effusion at the apex, right, and left sides of the heart.
Video 19. Pericardial effusion (SUBX view) – Note the pericardial effusion between the liver and the heart. This effusion also surrounds the apex of the heart. Remember that the subxiphoid view is the most sensitive view for detecting pericardial effusion.
Video 20. Trace pericardial effusion (PSLA view) – There is a trace pericardial effusion between the LV free wall and the pericardium. A trace effusion will disappear during part of the cardiac cycle.
Video 21. Pericardial and plerual effusions (PSLA view) – Note both the pericardial and pleural effusions. The pericardial effusion tapers anteriorly to the descending aorta. The pleural effusion stops laterally / posteriorly to the descending aorta.

Definitive diagnosis of cardiac tamponade is beyond the scope of this module, and immediate specialist consultation is recommended if there is clinical concern. However, some concerning ultrasound features would include:

Features:

  1. Circumferential pericardial effusion
  2. Right atrial systolic collapse (earliest sign)
  3. Right ventricular diastolic collapse (*most specific*)
  4. Plethoric IVC

Views:

  • Any view can be used, but the A4CH view shows right-sided structures best.
Video 22. Cardiac tamponade (A4CH view)

Right ventricular function assessment is beyond the scope of this module and typically cardiac POCUS is used as a general assessment. If there is clinical concern for this, specialist consultation is recommended.

Etiologies include pulmonary hypertension, pulmonary embolism, and right heart failure.

  • Increased RV size can suggest increased right heart pressures.
  • Views: Best assessed on A4CH and PSSA.
  • A4CH:
    • A dilated RV will be equal to or larger than the LV
    • Increased RV pressures cause flattening or bowing of the interventricular septum.
  • PSSA view:
    • Increased RV pressures cause flattening of the interventricular septum.
    • “D-sign” = The LV looks like the letter “D” from septal flattening

Figure 13. The D-sign (Image from thepocusatlas.com by Drs. Ronald Rivera, Elizabeth Hanson, Melanie Malloy, Kelly Maurelius, Kings County/SUNY Downstate Emergency Medicine.)

Pitfall:

Beware the “Pseudo D-Sign”. If only one papillary muscle is in view due to probe rotation, the interventricular septum may appear artificially flattened.

Figure 14. Pseudo D-Sign

Video 23. Pseudo D-Sign mimicking right ventricular dilation
Video 24. Right ventricular dilation (PSSA view) – Note the dilation of the right ventricle and flattening of the interventricular septum (D-sign).
Video 25. Right ventricular dilation (A4CH view) – Although this video is intermittently off axis, you can still appreciate right ventricular (RV) dilation. Note the enlarged right ventricle and bowing of the inter ventricular septum into the left ventricle. In a normal heart, the RV should be approximately 2/3 the size of the LV in the apical four chamber view. In infants, the RV can be equal to the size of the LV.
Video 26 RV dilation PSLA

Video 26. RV dilation (PSLA view) – Note the enlarged right ventricle at the top of the screen.

Video 27 McConnells sign PE

Video 27. McConnell’s sign in acute massive pulmonary embolism, showing akinesia of the lateral wall of the right ventricle and hypercontractility of the apical wall. (Image from thepocusatlas.com by Dr. Kelly Maurelus, Matthew Riscinti – Kings County Emergency Medicine)

In general, IVC assessment is most useful at the extremes:

  • Completely collapsed: Walls touch with inhalation.
    • Suggests the patient may benefit from fluid resuscitation.
    • Could be consistent with hypovolemia or distributive shock.
  • Completely plethoric (full): Minimal respiratory variation.
    • Suggests the patient may not need or tolerate significant fluid resuscitation.
    • May consider other medications or treatment.
    • Could be consistent with cardiogenic or obstructive shock.

When evaluating the IVC, it is important to interpret in the overall context of the patient’s presentation. For example, a plethoric IVC with minimal XXX

Video 28. Plethoric IVC – The IVC is very large and does not change in size with respiration.
Video 29. Flattened IVC – The IVC is flat and the walls completely collapse during inspiration.

Cardiac POCUS Literature

Much of the foundation for pediatric cardiac POCUS use is extrapolated from adult studies. Marbach et al. provide an excellent summary of the adult literature and highlights that cardiac POCUS improves clinicians’ bedside diagnostic accuracy, which influences management decisions, expedites time to diagnosis, and decreases resource use [2].

Pediatric-specific studies are summarized below. In general, cardiac POCUS demonstrates adequate sensitivity and specificity in evaluating for pericardial effusion and left ventricular systolic dysfunction [3]. POCUS may even be a promising adjunct to cardiology consultation for children with a variety of preexisting cardiac conditions [4]. These studies are primarily retrospective and warrant further future study.

In pediatric septic shock, cardiac POCUS can help clinicians characterize hemodynamics and often changes clinical management [5].

When it comes to interpretation errors, learners struggle more with evaluation for cardiac dysfunction and ventricle abnormalities than for pericardial effusion [6]. Additionally, novice trainees are more likely to make interpretation errors in real-time at the bedside than when reviewing images remotely [7]. These studies may inform future educational curricula surrounding pediatric cardiac POCUS.

YearAuthorsStudy Type, N, AgesFindings
2021Hamad et al. [9]Case series

  • 10 cases
  • Age 0-21 years
Examples of acute heart failure in children
2022Miller et al. [3]Retrospective review, single center (2015-2017)

  • 456 scans
  • Median age 14.7 years (IQR 9.1-17.5)
Test characteristics for cardiac POCUS interpretation by pediatric emergency medicine (PEM) physicians for detection of pericardial effusion (16 cases) and LV systolic dysfunction (18 cases)

PEM physicians compared to POCUS experts:

  • Pericardial effusion: Sn 100% / Sp 99.5%
  • LV dysfunction: Sn 100% / Sp 99.5%

PEM physicians compared to echocardiography done within 96 hours:

  • Pericardial effusion: Sn 88% / Sp 89%
  • LV systolic dysfunction: Sn 79% / Sp 96%
2024Hoffman et al. [4]Retrospective review,
single center (2015-2017)

  • 104 scans
  • Median age 16.3 years (IQR 8.6-20.1)
Test characteristics for cardiac POCUS interpretation by (PEM physicians for detection of pericardial effusion and LV systolic dysfunction in children with preexisting cardiac disease, including:

  • Congenital heart disease
  • Acquired cardiac disease
  • Arrhythmias

PEM physicians compared to POCUS experts:

  • Pericardial effusion: Sn 100% / Sp 98%
  • LV dysfunction: Sn 100% / Sp 99%

PEM physicians compared to echocardiography done within 96 hours:

  • Pericardial effusion: Sn 88% / Sp 87%
  • LV systolic dysfunction: Sn 100% / Sp 96%

Test characteristics were lower when including technically limited studies (5/104 studies).

Limitations:

  • Possible selection bias: POCUS may have been avoided in more complex cardiac patients
  • Exams with uninterpretable images were excluded (though were not common)
  • Only 1 patient with single ventricle included
2024Scott et al. [9]Retrospective review (pilot study)

  • 21 cases (9 POCUS)
  • Median age 11.8 years (IQR 4.9-16.8)
Examined time-based metrics if POCUS used in ED for pediatric heart failure.

  • Trend towards faster time to 1st IV heart failure medication (p<0.1).
  • No difference in ED or CICU length of stay.
Table 4. Key published studies on pediatric cardiac POCUS

IVC Literature

The evidence is highly variable for using IVC measurements (size, collapsibility index, IVC/Ao ratio) in isolation for predicting fluid responsiveness or central venous pressure [11-13]. A systematic review and meta analysis suggested IVC respiratory variation did not seem to reliably predict fluid responsiveness (AUC 0.71, Sn 71%, Sp 75%) [14]; however, this review also acknowledged high study heterogeneity.

Below are a few best practices when using the IVC assessment in your clinical care:

  • Avoid using the IVC in isolation. It is a data point in the overall clinical picture of your patient.
  • IVC size is most likely helpful at the extremes (completely plethoric or completely collapsing).
  • Serial (repeated) IVC assessments can help evaluate the patient’s response to your interventions.

Case Resolution

Your cardiac POCUS (5 videos below) shows severe left ventricular dysfunction and dilation.


PSLA view

PSSA view

A4CH view

SUBX view

IVC view

The chest X-ray shows cardiomegaly with pulmonary edema. Labs are notable for severe hypocalcemia to 4.2 mg/dL (thought to be secondary to congenital hypoparathyroidism in the setting of 22q11 syndrome). The labs are otherwise unremarkable.

You suspect his cardiac dysfunction is secondary to severe hypocalcemia, give him calcium gluconate, and emergently transfer him to the nearest pediatric center with cardiac intensive care.

Note: The IVC view does have some respiratory variation, although we more commonly see a plethoric IVC in the setting of heart failure. This is a reminder to avoid making decisions based solely on the IVC view. It’s an extra data point in the overall context of the other POCUS views.

Learn More…

References

  1. Mannarino S, Bulzomì P, Codazzi AC, et al. Inferior vena cava, abdominal aorta, and IVC-to-aorta ratio in healthy Caucasian children: Ultrasound Z-scores according to BSA and age. J Cardiol. 2019;74(4):388-393. https://doi.org/10.1016/j.jjcc.2019.02.021
  2. Marbach JA, Almufleh A, Di Santo P, et al. A Shifting Paradigm: The Role of Focused Cardiac Ultrasound in Bedside Patient Assessment. Chest. 2020;158(5):2107-2118. PMID: 32707179 DOI: 10.1016/j.chest.2020.07.021
  3. Miller AF, Arichai P, Gravel CA, et al. Use of Cardiac Point-of-Care Ultrasound in the Pediatric Emergency Department. Pediatr Emerg Care. 2022;38(1):e300-e305. doi:10.1097/PEC.0000000000002271
  4. Hoffmann RM, Neal JT, Arichai P, et al. Test Characteristics of Cardiac Point-of-Care Ultrasound in Children With Preexisting Cardiac Conditions. Pediatr Emerg Care. 2024;40(4):307-310. doi:10.1097/PEC.0000000000003050
  5. Arnoldi S, Glau CL, Walker SB, et al. Integrating Focused Cardiac Ultrasound Into Pediatric Septic Shock Assessment. Pediatr Crit Care Med. 2021;22(3):262-274. doi:10.1097/PCC.0000000000002658
  6. Kwan C, Weerdenburg K, Pusic M, et al. Learning Pediatric Point-of-Care Ultrasound: How Many Cases Does Mastery of Image Interpretation Take?. Pediatr Emerg Care. 2022;38(2):e849-e855. doi:10.1097/PEC.0000000000002396
  7. Thomas-Mohtat R, Sable C, Breslin K, et al. Interpretation errors in focused cardiac ultrasound by novice pediatric emergency medicine fellow sonologists. Crit Ultrasound J. 2018;10(1):33. Published 2018 Dec 9. doi:10.1186/s13089-018-0113-4
  8. Hamad A, Ng C, Alade K, D’Amico B, et al. Diagnosing Acute Heart Failure in the Pediatric Emergency Department Using Point-of-Care Ultrasound. J Emerg Med. 2021 Sep;61(3):e18-e25. doi: 10.1016/j.jemermed.2021.03.015. Epub 2021 Jun 4. PMID: 34092442.
  9. Scott C, Alade K, Leung SK, Vaughan RM, Riley AF. Cardiac Point-of-Care Ultrasound and Multi-Disciplinary Improvement Opportunities in Acute Systolic Heart Failure Management in a Pediatric Emergency Center. Pediatr Cardiol. 2024;45(6):1353-1358. doi:10.1007/s00246-023-03125-w
  10. Ng L, Khine H, Taragin BH, Avner JR, Ushay M, Nunez D. Does bedside sonographic measurement of the inferior vena cava diameter correlate with central venous pressure in the assessment of intravascular volume in children?. Pediatr Emerg Care. 2013;29(3):337-341. doi:10.1097/PEC.0b013e31828512a5
  11. Modi P, Glavis-Bloom J, Nasrin S, et al. Accuracy of Inferior Vena Cava Ultrasound for Predicting Dehydration in Children with Acute Diarrhea in Resource-Limited Settings. PLoS One. 2016;11(1):e0146859. Published 2016 Jan 14. doi:10.1371/journal.pone.0146859
  12. Via G, Tavazzi G, Price S. Ten situations where inferior vena cava ultrasound may fail to accurately predict fluid responsiveness: a physiologically based point of view. Intensive Care Med. 2016;42(7):1164-1167. https://doi.org/10.1007/S00134-016-4357-9
  13. Orso D, Paoli I, Piani T, Cilenti FL, Cristiani L, Guglielmo N. Accuracy of Ultrasonographic Measurements of Inferior Vena Cava to Determine Fluid Responsiveness: A Systematic Review and Meta-Analysis. J Intensive Care Med. 2020;35(4):354-363. https://doi.org/10.1177/0885066617752308

Additional Reading

  • Marbach JA, Almufleh A, Di Santo P, et al. Comparative Accuracy of Focused Cardiac Ultrasonography and Clinical Examination for Left Ventricular Dysfunction and Valvular Heart Disease: A Systematic Review and Meta-analysis. Ann Intern Med. 2019;171(4):264-272. doi:10.7326/M19-1337
By |2026-05-21T10:06:40-07:00May 21, 2025|Cardiovascular, Pediatrics, PEM POCUS|
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SAEM Clinical Images Series: Infantile Enigma

rash

A previously healthy 4-week-old born full-term presented to the emergency department with possible umbilical drainage and a new onset rash in the left lower abdominal region. The patient had an uncomplicated newborn stay with a mother with negative maternal serologies other than GBS positive, which was appropriately treated intrapartum. The patient had been gaining weight well without fevers or sick symptoms. Parents reported that their pediatrician had seen the patient earlier in the day for a routine check-up. Notably, a “cream” was applied to a small remnant of the umbilical cord that was still present. The parents noted that this abdominal rash was not present and only discovered during this evening’s diaper change. Parents had potentially accounted for this rash as a seat belt that may have been placed too tight.

General: Well-appearing neonate in no acute distress.

HEENT: Atraumatic, appropriate fontanelle. No abnormal bruising. No frenulum tears. No scalp hematomas.

Cardiac: Regular rate and rhythm. No auscultated murmur.

Pulmonary: Clear lung sounds bilaterally.

Abdomen: Soft, non-tender, non-distended. Umbilicus has homogenous darkening without evidence of fluctuance, erythema, or drainage. The left lower abdomen has a linear homogenously darkened macular rash without vesicular lesions, minimally erythematous, and no fluctuance.

Genitourinary: Phenotypic external male genitalia without rash.

Integumentary: Otherwise, no abnormal bruising or rash was noted.

None

To our knowledge, the “cream” that was applied to the umbilicus was silver nitrate, a joint compound used to cauterize umbilical granulomas. This compound is made of silver and potassium nitrate, activated when mixed with moisture. Its application may have unfavorable events if misapplied, and if applied to healthy skin, it may result in burns. We suspect this linear rash to be an accidental contact swipe of a silver nitrate stick. This patient was treated as a mild chemical burn – bacitracin applied along with a non-stick dressing and bandages with outpatient follow-up. In our evaluation of this patient, we considered early infection source or non-accidental trauma but did not pursue additional workup given this clinical history and presentation.

Take-Home Points

  • Silver nitrate sticks can be used to stop localized bleeding in the emergency department setting. It is important to be cautious when handling and applying as it may cause unwanted burns.

  • In the evaluation of the newborn rash, underlying severe infection or non-accidental trauma must be considered in the differential.

  • Sanyaolu L N, Javed M, Wilson-Jones N. A baby with a discharging umbilical lesion BMJ 2016; 355:i5587 doi:10.1136/bmj.i5587

  • Majjiga VS, Kumaresan P, Glass EJ. Silver nitrate burns following umbilical granuloma treatment. Arch Dis Child. 2005 Jul;90(7):674. doi: 10.1136/ adc.2004.067918. PMID: 15970607; PMCID: PMC1720504

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2025-03-09T22:13:27-07:00Mar 21, 2025|Pediatrics, SAEM Clinical Images|
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SAEM Clinical Images Series: Alternative Block

A 10-year-old female with a history of constipation presented with intermittent lower abdominal pain with difficulty urinating. Pain was in the suprapubic area. The patient stated she last urinated the morning of presentation and typically urinates 1-2 times a day. She reported that it is sometimes hard to initiate urination and that she has pain at the conclusion of urination. She typically takes MiraLAX daily for constipation but ran out one week ago. She denied fever, chills, nausea or vomiting.

retention

Constitutional: Awake, alert and in no acute distress.

HEENT: PERRLA. Moist mucus membranes.

Cardiovascular: Regular rate and rhythm. No murmur.

Pulmonary: Breath sounds normal. No increased work of breathing.

Abdominal: Abdomen soft. There is tenderness in the suprapubic area. There is no guarding or rebound.

Neurologic: Awake and alert. At neurologic baseline. No focal deficits.

UA: Trace ketones, 100 protein.

Post void residual: 430 cc.

X-ray of the abdomen is normal without obstruction or a significant stool burden. Ultrasound demonstrates a distended fluid-filled vagina.

Imperforate hymen. The opening of the vagina is typically surrounded by a thin membrane with an opening in the center, called the hymen. In the case of an imperforate hymen, the membrane does not have an opening and therefore blocks the vaginal canal. Symptoms of imperforate hymen vary. It can present early in life if normal mucous builds up and causes a bulge of the membrane. Imperforate hymen may not be diagnosed until adolescence when menstruation begins. Symptoms at that time include amenorrhea, back pain, lower abdominal pain, or difficulty with urinating or stooling. In an adolescent with imperforate hymen, physical exam may demonstrate a vaginal bulge with a bluish discoloration, caused by the accumulation of blood in the vagina (hematocolpos). This patient had urinary retention secondary to imperforate hymen and accumulation of blood in the vaginal canal that compressed the urethra. A genitourinary exam was later performed and confirmed the diagnosis. Imperforate hymen is treated with a minor surgical procedure to remove the extra tissue.

Take-Home Points

  • Imperforate hymen occurs when the hymen covers the vaginal entire vaginal opening, therefore blocking it. It may present early in life or later during adolescence.

  • Consider imperforate hymen as a differential diagnosis for female patients who present with lower abdominal or back pain, amenorrhea, or difficulty with urinating or stooling.

  • Diagnosis and management of hymenal variants. ACOG. (2019, May 23). https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/06/diagnosis-and-management-of-hymenal-variants

  • Hamouie A, Dietrich JE. Imperforate Hymen: Clinical Pearls and Implications of Management. Clin Obstet Gynecol. 2022 Dec 1;65(4):699-707. doi: 10.1097/GRF.0000000000000703. Epub 2022 Mar 11. PMID: 36260009.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2025-02-26T14:55:11-08:00Feb 28, 2025|Ob/Gyn, Pediatrics, SAEM Clinical Images|
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Is Ondansetron for Nausea and Vomiting Prophylaxis Necessary with Opioids?

prophylactic ondansetron with opioids example 4+4
Ondansetron is the most documented medication given in emergency departments (ED) throughout the United States [1]. We have all heard someone ask, “Can I get an order for 4 and 4 for this patient?” in reference to 4 mg of IV morphine and 4 mg of IV ondansetron. It has become common practice in many institutions to provide a prophylactic antiemetic prior to administering an IV opioid.

Logic for giving ondansetron with opioid

This dual therapy seems to make initial sense because all opioids carry a FDA warning that nausea may occur [2]. So why not administer an antiemetic to prevent it? Opioids cause nausea and vomiting due to its interaction on the chemoreceptor trigger zone (CTZ), increased vestibular sensitivity, and hindered gastric emptying [3]. The logic is to provide these patients with a 5-HT3 antagonist (i.e., ondansetron) to inhibit the opioid from exerting emetogenic properties on 5-HT3 receptors in the CTZ and prevent nausea and/or vomiting.

How common is nausea and vomiting associated with IV opioids?

Multiple studies illustrate that morphine-induced nausea and vomiting is low, ranging from 2.0–20.2% in ED patients [4-9]. When discussing with ED nurses, nausea and vomiting are anecdotally associated with how quickly the IV opioid is administered and generally occurs within 5 minutes of administration.

So we should give IV ondansetron to prevent this, right? A common misconception with IV ondansetron is its onset of action. In fact, it can take anywhere between 27-34 minutes before there is a 50% decrease in nausea severity following the administration of ondansetron [10, 11]. This begs the question, does it really make sense to provide prophylactic antiemetics with IV opioids?

Literature Review

StudyInterventionOutcomeConclusion
Bradshaw et al. [5]

RCT- double blinded

Performed in United Kingdom

IV morphine + placebo (n=136)

IV morphine + metoclopramide 10 mg (n=123)

N/V between the 2 groups was not statistically significant (p=0.3).

Overall incidence of N/V was low in both treatment groups (3.7% in placebo and 1.6% metoclopramide)

Pre-treating patients with metoclopramide was not necessary.

Overall N/V associated with IV morphine was very low and recommended using antiemetics for patients who develop N/V.

Bhowmik et al. [8]

RCT, double blinded

Performed in India

IV morphine + placebo (n=53)

IV morphine + promethazine (n=54)

IV morphine + ramosetron (n=54)

IV morphine + metoclopramide (n=54)

Overall incidence of N/V was low in all treatment groups (9.4% ramosetron, 18.5% metoclopramide, 10.2% in promethazine and 6.2% in placebo)

Rate of N/V was not statistically significant between any of the groups.

 Patients should receive antiemetic therapy only if experience N/V and not as a prophylactic agent with IV opioids.

Patients that received (morphine + placebo) had less N/V compared to other treatment groups; however, NOT statistically significant.

Sussan et al. [9]

Randomized, double- masked multicenter trial

Performed in 9 countries

Investigated 2,574 patients that received IV opioids and randomized 520 patients that developed N/V associated with IV opioids.

Group 1: placebo (n=94)

Group 2: ondansetron 8 mg (n=214)

Group 3: ondansetron 16 mg (n=211)

Resolution of N/V was statistically more significant (p < 0.001) when comparing ondansetron therapy with placebo.

Group 1: 45.7% N/V resolved

Group 2: 62.3% N/V resolved

Group 3: 68.7% N/V resolved

The best practice seems to treat patients’ N/V after development in patients that receive IV opioids.

Trial determined the prevalence of N/V is minimal and exposing patients to medication they do not need puts them at risk for additional adverse drug reactions.

Each of the 3 trials concluded that there was no statistical significance in outcomes when adding prophylactic antiemetics with IV opioids. After these institutions analyzed their findings, the investigators at their respective institutions made it common practice for patients to only receive antiemetics AFTER a patient developed nausea or vomiting.

Prophylactic ondansetron practice

So why is ondansetron still commonly used to pre-treat patients that receive IV opioids in the ED?

The limited literature primarily focused on these anti-emetic agents: metoclopramide, promethazine, and ramosetron (5-HT3 antagonist). Literature related to specifically ondansetron is minimal.

Two randomized, placebo-controlled studies comparing ondansetron, metoclopramide, and saline in ED patients complaining of nausea showed no clinically important difference in the reduction of nausea between treatments and placebo [12, 13]. Yet in the ED, we still order ondansetron more than any other medication.

Some nerd (me!) put together a prospective multiple-site study (n=133) at 2 academic medical institutions where patients were administered IV opioids, with or without IV ondansetron [14]. Patients were observed for nausea and vomiting at baseline, 5 minutes, and 30 minutes after opioid administration, and then for a total of 2 hours. The results showed that 17.3% of patients developed nausea, with no significant difference in the rate of nausea, emesis, or the need for rescue antiemetics between the group receiving ondansetron and the group receiving opioids alone.

Of note, ondansetron is not FDA approved for the treatment or prophylaxis of acute nausea and/or vomiting (N/V) outside of chemotherapy, radiation, and postoperative use. It also, not surprisingly, has side effects!

Take Home Point

  1. Concurrent treatment with anti-emetics (including ondansetron) is unnecessary, increases costs, and adds potential for adverse drug reactions.
  2. The next time the request for “4 + 4” comes through, consider holding off on the unnecessary ondansetron with your IV opioid order.
  3. You can use this isopropyl alchohol vapor inhalation trick of the trade for those 2-20% of patients that do develop nausea.

References

  1. National Hospital Ambulatory Medical Care Survey: 2011 Emergency Department Summary. Accessed 19 Dec 2024.
  2. Red Book: pharmacy’s fundamental reference. Montvale, NJ: Thompson Healthcare Inc.; 2010
  3. Smith H, Smith J, Seidner P. Opioid-induced nausea and vomiting. Annals of Palliative Medicine 2012;1(2):121-129
  4. Paoloni R, Talbot-Stern J. Low incidence of nausea and vomiting with intravenous opioid analgesia in the ED. Am J Emerg Med 2002;20:604-608.
  5. Bradshaw M, A Sen. Use of prophylactic antiemetic with morphine in acute pain: randomized controlled trial. Emerg Med J 2006; 23:210-212.
  6. Talbot-Stern J, Paoloni R. Prophylactic metoclopramide is unnecessary with intravenous analgesia in the ED. Am J Emerg Med 2000;18(6):653-7.
  7. Lambie B, Chambers J, Herbison P. The role of prophylactic anti-emetic therapy in emergency department patients receiving intravenous morphine for musculoskeletal trauma. Emer Med 1990; 11(4): 240-243.
  8. Bhowmik A, Dasgupta I, Barua S, et al. Evaluation of the need of prophylactic antiemetic with injection morphine in treating acute musculoskeletal pain in the Indian population. IJAR 2014;2:53-58.
  9. Sussan G, Shurman J, Creed M, et al. Intravenous ondansetron for the control of opioid-induced nausea and vomiting. Clinical Therapeutic. 1999; 21:1216-1227.
  10. Cotton J, Rowell L, Hood R, et al. A comparative analysis of isopropyl alcohol and ondansetron in the treatment of postoperative nausea and vomiting from the hospital setting to the home. AANA J. 2007; 75(1):21-6.
  11. Winston A, Rinehart R, Riley G, et al. Comparison of inhaled isopropyl alcohol and intravenous ondansetron for treatment of postoperative nausea. AANA J. 2003; 71(2):127-32.
  12. Barrett TW, DiPersio DM, Jenkins CA, et al. A randomized, placebo-controlled trial of ondansetron, metoclopramide, and promethazine in adults. Am J Emerg Med. 2011 Mar;29(3):247-55.
  13. Egerton-Warburton D, Meek R, Mee MJ, et al. Antiemetic use for nausea and vomiting in adult emergency department patients: randomized controlled trial comparing ondansetron, metoclopramide, and placebo. Ann Emerg Med. 2014 Nov;64(5):526-532.
  14. Culver MA, Richards EC, Jarrell DH, et al. Use of Prophylactic Ondansetron With Intravenous Opioids in Emergency Department Patients: A Prospective Observational Pilot Study. J Emerg Med. 2017;53(5):629-634. PMID 28987314. DOI
By |2025-01-28T13:44:31-08:00Feb 26, 2025|Capsules, EM Pharmacy Pearls, PEM Pearls, Tox & Medications|
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SAEM Clinical Images Series: When it is Not Just a Knot

knot

A 12-year-old male with a history of hydrocephalus status post ventriculoperitoneal (VP) shunt placement presented with an abdominal “knot.” The patient’s mother noticed the knot two days ago, on the right anterolateral thorax, which has steadily been increasing in size. The patient had no known trauma to the area or had been bitten or stung by any insect. He has otherwise been complaining of a headache, generalized, without positional changes, improved with home acetaminophen, ice pack, and rest. There were otherwise no associated vision changes, nausea, vomiting, mental status changes, or fever.

Vitals: T-36.2°C; HR 74 bpm; BP 144/75 mm Hg; RR 20; O2 Sat 96% RA

General: Well-appearing teenager in NAD.

HEENT: NC/AT. PERRL approximately 2-3 mm bilaterally. EOMI.

Neck: Supple, no meningismus.

Chest Wall: Induration to the right anterolateral thorax 5 cm x 4 cm without erythema, fluctuance, or drainage, non-tender to palpation.

Neurological: Alert. No focal neurological deficit observed.

Normal

The cause of the knot is subcutaneous cerebrospinal fluid from a shunt malfunction. The ultrasound images show characteristic “cobblestoning,” indicating fluid in the subcutaneous tissue, around a linear hyperechoic object, the catheter of the VP shunt. On the plain film imaging, a disconnect was found between the thoracic and abdominal portions of the VP shunt. Up to 80% of patients with VP shunts will have experienced a shunt malfunction after 12 years, according to one study, with fractured tubing causing shunt failure in around 15% of all cases (1).

Nausea, vomiting, headache, irritability, or decreased mental status are common but nonspecific findings in shunt malfunction. Pediatric patients may present with other signs such as bulging fontanelles, increasing head circumference, or feeding and behavioral changes. An increase in the interval ventricular size can be seen in neuroimaging but can be absent in as many as 20% of patients (2). If there is a high degree of clinical suspicion for shunt malfunction, normal or unchanged neuroimaging should not preclude neurosurgical consultation.

Take-Home Points

  • In the United States, mechanical causes of VP shunt malfunction are the most common presentation, such as catheter obstruction, fracture along the clavicle or ribs, degradation of tubing, and migration of the distal catheter due to changes in height or weight.
  • Rarely, patients can develop an accumulation of CSF at the distal catheter of the VP shunt due to migration into the abdominal wall forming an abdominal pseudocyst.
  • In patients with VP shunts, abdominal complications should be considered as a sign of shunt malfunction.
  • Consider pertinent physical exam findings and POCUS to confirm the diagnosis of shunt malfunction at the distal catheter.

  • Sainte-Rose C, Piatt JH, Renier D, Pierre-Kahn A, Hirsch JF, Hoffman HJ, Humphreys RP, Hendrick EB. Mechanical complications in shunts. Pediatr Neurosurg. 1991-1992;17(1):2-9. doi: 10.1159/000120557. PMID: 1811706.

  • Reynolds RA, Ahluwalia R, Krishnan V, Kelly KA, Lee J, Waldrop RP, Guidry B, Hengartner AC, McCroskey J, Arynchyna A, Staulcup S, Chen H, Hankinson TC, Rocque BG, Shannon CN, Naftel R. Risk factors for unchanged ventricles during pediatric shunt malfunction. J Neurosurg Pediatr. 2021 Sep 24;28(6):703-709. doi: 10.3171/2021.6.PEDS2125. PMID: 34560626.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2025-02-19T12:57:12-08:00Feb 21, 2025|Neurology, Pediatrics, SAEM Clinical Images, Ultrasound|
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