1
|
Snelling PJ, Jones P, Bade D, Gillespie A, Keijzers G, Ware RS. Ultrasound Secondary Signs for the Diagnosis of Pediatric Distal Forearm Fractures: A Diagnostic Study. Ultrasound Med Biol 2024; 50:898-907. [PMID: 38519361 DOI: 10.1016/j.ultrasmedbio.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/13/2024] [Accepted: 02/22/2024] [Indexed: 03/24/2024]
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of ultrasound secondary signs of fractures in pediatric patients aged 5-15 y presenting to the emergency department with a clinically non-deformed distal forearm injury. METHODS This diagnostic study was conducted in South East Queensland, Australia. Emergency clinicians performed point-of-care ultrasound on eligible patients and recorded secondary signs of fractures (pronator quadratus hematoma [PQH] sign, periosteal hematoma, visible angulation) or physeal fractures (fracture-to-physis distance [FPD], physis alteration). The reference standard was the final fracture diagnosis determined by expert panel. The primary outcome was the diagnostic accuracy of secondary signs for cortical breach and physeal fractures. Diagnostic statistics were reported for each relevant secondary sign. RESULTS A total of 135 participants were enrolled. The expert panel diagnosed 48 "no" fracture, 52 "buckle" fracture and 35 "other" fracture. All "other" fractures were cortical breach fractures and included 15 Salter-Harris II fractures. The PQH sign demonstrated high sensitivity and moderate specificity to diagnose cortical breach fractures (91%, 95% Confidence Interval [CI] 78%-97% and 82%, 73%-88%). Poor sensitivity but high specificity was observed for the visible angulation and periosteal hematoma secondary signs. FPD <1cm showed perfect sensitivity and moderate specificity (100%, 80%-100% and 85%, 78%-90%) for diagnosis of Salter-Harris II fracture. Conversely, physis alteration showed poor sensitivity but excellent specificity (40%, 20%-64% and 99%, 95%-100%) for the diagnosis of Salter-Harris II fractures. CONCLUSION Ultrasound secondary signs showed good diagnostic accuracy for both cortical breach fractures and Salter-Harris II fractures. Future research should consider optimal use of secondary signs to improve diagnostic accuracy.
Collapse
Affiliation(s)
- Peter J Snelling
- School of Medicine and Dentistry, Griffith University, Southport, Queensland, Australia; Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia; Sonography Innovation and Research (Sonar) Group, Queensland, Australia; Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia.
| | - Philip Jones
- School of Medicine and Dentistry, Griffith University, Southport, Queensland, Australia; Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia; Sonography Innovation and Research (Sonar) Group, Queensland, Australia; Department of Emergency Medicine, Logan Hospital, Meadowbrook, Queensland, Australia
| | - David Bade
- School of Medicine and Dentistry, Griffith University, Southport, Queensland, Australia; Department of Orthopaedics, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Alan Gillespie
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Gerben Keijzers
- School of Medicine and Dentistry, Griffith University, Southport, Queensland, Australia; Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia; Sonography Innovation and Research (Sonar) Group, Queensland, Australia; Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Robert S Ware
- School of Medicine and Dentistry, Griffith University, Southport, Queensland, Australia; Sonography Innovation and Research (Sonar) Group, Queensland, Australia
| |
Collapse
|
2
|
Schlapbach LJ, Ganesamoorthy D, Wilson C, Raman S, George S, Snelling PJ, Phillips N, Irwin A, Sharp N, Le Marsney R, Chavan A, Hempenstall A, Bialasiewicz S, MacDonald AD, Grimwood K, Kling JC, McPherson SJ, Blumenthal A, Kaforou M, Levin M, Herberg JA, Gibbons KS, Coin LJM. Host gene expression signatures to identify infection type and organ dysfunction in children evaluated for sepsis: a multicentre cohort study. Lancet Child Adolesc Health 2024; 8:325-338. [PMID: 38513681 DOI: 10.1016/s2352-4642(24)00017-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/14/2024] [Accepted: 01/15/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Sepsis is defined as dysregulated host response to infection that leads to life-threatening organ dysfunction. Biomarkers characterising the dysregulated host response in sepsis are lacking. We aimed to develop host gene expression signatures to predict organ dysfunction in children with bacterial or viral infection. METHODS This cohort study was done in emergency departments and intensive care units of four hospitals in Queensland, Australia, and recruited children aged 1 month to 17 years who, upon admission, underwent a diagnostic test, including blood cultures, for suspected sepsis. Whole-blood RNA sequencing of blood was performed with Illumina NovaSeq (San Diego, CA, USA). Samples with completed phenotyping, monitoring, and RNA extraction by March 31, 2020, were included in the discovery cohort; samples collected or completed thereafter and by Oct 27, 2021, constituted the Rapid Paediatric Infection Diagnosis in Sepsis (RAPIDS) internal validation cohort. An external validation cohort was assembled from RNA sequencing gene expression count data from the observational European Childhood Life-threatening Infectious Disease Study (EUCLIDS), which recruited children with severe infection in nine European countries between 2012 and 2016. Feature selection approaches were applied to derive novel gene signatures for disease class (bacterial vs viral infection) and disease severity (presence vs absence of organ dysfunction 24 h post-sampling). The primary endpoint was the presence of organ dysfunction 24 h after blood sampling in the presence of confirmed bacterial versus viral infection. Gene signature performance is reported as area under the receiver operating characteristic curves (AUCs) and 95% CI. FINDINGS Between Sept 25, 2017, and Oct 27, 2021, 907 patients were enrolled. Blood samples from 595 patients were included in the discovery cohort, and samples from 312 children were included in the RAPIDS validation cohort. We derived a ten-gene disease class signature that achieved an AUC of 94·1% (95% CI 90·6-97·7) in distinguishing bacterial from viral infections in the RAPIDS validation cohort. A ten-gene disease severity signature achieved an AUC of 82·2% (95% CI 76·3-88·1) in predicting organ dysfunction within 24 h of sampling in the RAPIDS validation cohort. Used in tandem, the disease class and disease severity signatures predicted organ dysfunction within 24 h of sampling with an AUC of 90·5% (95% CI 83·3-97·6) for patients with predicted bacterial infection and 94·7% (87·8-100·0) for patients with predicted viral infection. In the external EUCLIDS validation dataset (n=362), the disease class and disease severity predicted organ dysfunction at time of sampling with an AUC of 70·1% (95% CI 44·1-96·2) for patients with predicted bacterial infection and 69·6% (53·1-86·0) for patients with predicted viral infection. INTERPRETATION In children evaluated for sepsis, novel host transcriptomic signatures specific for bacterial and viral infection can identify dysregulated host response leading to organ dysfunction. FUNDING Australian Government Medical Research Future Fund Genomic Health Futures Mission, Children's Hospital Foundation Queensland, Brisbane Diamantina Health Partners, Emergency Medicine Foundation, Gold Coast Hospital Foundation, Far North Queensland Foundation, Townsville Hospital and Health Services SERTA Grant, and Australian Infectious Diseases Research Centre.
Collapse
Affiliation(s)
- Luregn J Schlapbach
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland; Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia.
| | - Devika Ganesamoorthy
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Clare Wilson
- Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Sainath Raman
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia; Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
| | - Shane George
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia; School of Medicine and Dentistry and the Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
| | - Peter J Snelling
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia; School of Medicine and Dentistry and the Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
| | - Natalie Phillips
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia; Emergency Department, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
| | - Adam Irwin
- Faculty of Medicine, UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia; Infection Management and Prevention Services, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
| | - Natalie Sharp
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia; Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
| | - Renate Le Marsney
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Arjun Chavan
- Paediatric Intensive Care Unit, Townsville University Hospital, Townsville, QLD, Australia
| | | | - Seweryn Bialasiewicz
- School of Chemistry and Molecular Biosciences, The Australian Centre for Ecogenomics, and Queensland Paediatric Infectious Diseases Laboratory, The University of Queensland, Brisbane, QLD, Australia
| | - Anna D MacDonald
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Keith Grimwood
- School of Medicine and Dentistry and the Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia; Department of Infectious Disease and Paediatrics, Gold Coast Health, Southport, QLD, Australia
| | - Jessica C Kling
- Frazer Institute, The University of Queensland, Brisbane, QLD, Australia
| | | | - Antje Blumenthal
- Frazer Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Myrsini Kaforou
- Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Michael Levin
- Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Jethro A Herberg
- Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Kristen S Gibbons
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Lachlan J M Coin
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, Australia; Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
| |
Collapse
|
3
|
Snelling PJ, Jones P, Bade D, Bindra R, Davison M, Gillespie A, McEniery J, Moore M, Keijzers G, Ware RS. Diagnostic Accuracy of Point-of-Care Ultrasound Versus Radiographic Imaging for Pediatric Distal Forearm Fractures: A Randomized Controlled Trial. Ann Emerg Med 2024; 83:198-207. [PMID: 37999655 DOI: 10.1016/j.annemergmed.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 10/05/2023] [Accepted: 10/10/2023] [Indexed: 11/25/2023]
Abstract
STUDY OBJECTIVE In patients aged 5 to 15 years with a clinically nondeformed distal forearm injury presenting to the emergency department (ED), we examined whether point-of-care ultrasound or radiographic imaging had better diagnostic accuracy, with the reference diagnosis determined by an expert panel review. METHODS This multicenter, open-label, diagnostic randomized controlled trial was conducted in South East Queensland, Australia. Eligible patients were randomized to receive initial imaging through point-of-care ultrasound performed by an ED clinician or radiograph. Images were defined as "no," "buckle," or "other" fracture by the treating clinician. The primary outcome was the diagnostic accuracy of the treating clinician's interpretation compared against the reference standard diagnosis, which was determined retrospectively by an expert panel consisting of an emergency physician, pediatric radiologist, and pediatric orthopedic surgeon, who reviewed all imaging and follow-up. RESULTS Two-hundred and seventy participants were enrolled, with 135 randomized to each initial imaging modality. There were 132 (97.8%) and 112 (83.0%) correctly diagnosed participants by ED clinicians in the point-of-care ultrasound and radiograph groups, respectively (absolute difference [AD]=14.8%; 95% confidence interval [CI] 8.0% to 21.6%; P<.001). Point-of-care ultrasound had better accuracy for participants with "buckle" fractures (AD=18.5%; 95% CI 7.1% to 29.8%) and "other" fractures (AD=17.1%; 95% CI 2.7% to 31.6%). No clinically important fractures were missed in either group. CONCLUSION In children and adolescents presenting to the ED with a clinically nondeformed distal forearm injury, clinician-performed (acquired and interpreted) point-of-care ultrasound more accurately identified the correct diagnosis than clinician-interpreted radiographic imaging.
Collapse
Affiliation(s)
- Peter J Snelling
- School of Medicine and Dentistry Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia; Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia; Sonography Innovation and Research (Sonar) Group, Queensland, Australia; Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia.
| | - Philip Jones
- School of Medicine and Dentistry Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia; Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia; Sonography Innovation and Research (Sonar) Group, Queensland, Australia
| | - David Bade
- Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia; Department of Orthopaedics, Queensland Children's Hospital, South Brisbane, Queensland, Australia; Griffith Centre of Biomedical and Rehabilitation Engineering (GCORE), Menzies Health Institute, Griffith University, Southport, Queensland, Australia
| | - Randy Bindra
- Department of Orthopaedics, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Michelle Davison
- School of Medicine and Dentistry Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia; Department of Emergency Medicine, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Alan Gillespie
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Jane McEniery
- Department of Medical Imaging and Nuclear Medicine, Queensland Children's Hospital, South Brisbane, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Mark Moore
- Department of Emergency Medicine, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Gerben Keijzers
- School of Medicine and Dentistry Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia; Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia; Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
| | - Robert S Ware
- School of Medicine and Dentistry Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
| |
Collapse
|
4
|
Joyce A, Snelling PJ, Elsayed T, Keijzers G. Point-of-care ultrasound to diagnose acute cholecystitis in the emergency department: A scoping review. Australas J Ultrasound Med 2024; 27:26-41. [PMID: 38434543 PMCID: PMC10902832 DOI: 10.1002/ajum.12371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
Introduction/Purpose Ultrasound is the first-line imaging modality for suspected acute cholecystitis. This can be radiology-performed ultrasound or point-of-care ultrasound (POCUS). POCUS can potentially streamline patient assessment in the emergency department (ED). The primary objective was to evaluate the literature for the diagnostic accuracy of POCUS performed for acute cholecystitis in the ED. Secondary objectives were to assess the effect of POCUS operator training on diagnostic accuracy for acute cholecystitis, utility of POCUS measurement of the common bile duct and POCUS impact on resource utilisation. Methods A systematic scoping review of articles was conducted using Medline, Embase, CENTRAL and CINAHL. Original studies of adults with POCUS performed for the diagnosis of acute cholecystitis in the ED were included. The study was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist (PRISMA-ScR). Results A total of 1090 publications were identified. Forty-six met the eligibility criteria. Studies were thematically grouped into categories according to specified objectives. Point-of-care ultrasound was of acceptable but variable accuracy, contributed to by the absence of a consistent reference standard and uniform training requirements. It may positively impact ED resource utilisation through reduced ED length of stay and radiology-performed imaging, whilst improving patient experience. Conclusion This review highlights the heterogeneity of existing research, emphasising the need for standardisation of training and reference standards in order to precisely define the utility of POCUS for acute cholecystitis in the ED and its benefits on ED resource utilisation.
Collapse
Affiliation(s)
- Alexander Joyce
- Department of Emergency MedicineGold Coast University HospitalSouthportQueenslandAustralia
| | - Peter J Snelling
- Department of Emergency MedicineGold Coast University HospitalSouthportQueenslandAustralia
- School of Medicine and DentistryGriffith UniversitySouthportQueenslandAustralia
- Sonography Innovation and Research GroupSouthportQueenslandAustralia
| | - Tarek Elsayed
- Department of Emergency MedicineGold Coast University HospitalSouthportQueenslandAustralia
- Faculty of Health Sciences and MedicineBond UniversityGold CoastQueenslandAustralia
| | - Gerben Keijzers
- Department of Emergency MedicineGold Coast University HospitalSouthportQueenslandAustralia
- School of Medicine and DentistryGriffith UniversitySouthportQueenslandAustralia
- Faculty of Health Sciences and MedicineBond UniversityGold CoastQueenslandAustralia
| |
Collapse
|
5
|
Furness J, Abery P, Kemp-Smith K, Bruce K, Lamond D, Taylor N, Jones P, Snelling PJ. Comparison of surf lifesaver pressure point control and a commercial arterial tourniquet for major lower limb haemorrhage: A randomised controlled crossover pilot trial. Emerg Med Australas 2023; 35:1038-1040. [PMID: 37704229 DOI: 10.1111/1742-6723.14307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/19/2023] [Accepted: 08/15/2023] [Indexed: 09/15/2023]
Abstract
OBJECTIVE This pilot study compared non-medically trained surf lifesavers' (SLS) ability, after infographic training, to occlude the femoral artery using a pressure point (PP) versus an arterial tourniquet (AT). METHODS Using a crossover design, eight SLS applied PP and AT to a participant's leg to occlude the femoral artery. Arterial flow, application time and perceived difficulty were recorded. RESULTS PP achieved 89.7% and 50.8% blood flow reduction for PP and AT, respectively. Average application time was 50.63 and 113.5 s for PP and AT, respectively. Perceived difficulty using a Likert scale from 0 to 10 (0 being no difficulty and 10 being maximal difficulty) was 2.75 and 3.50 for PP and AT, respectively. CONCLUSION Infographic-trained SLS showed superior blood flow occlusion using PP. This pilot study will inform a larger trial for untrained beachgoers.
Collapse
Affiliation(s)
- James Furness
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Philip Abery
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Kevin Kemp-Smith
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Kimberly Bruce
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - David Lamond
- ACT Government/Canberra Health Services, Canberra, Australian Capital Territory, Australia
| | - Nicholas Taylor
- ACT Government/Canberra Health Services, Canberra, Australian Capital Territory, Australia
| | - Philip Jones
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Peter J Snelling
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
| |
Collapse
|
6
|
Peters N, Williamson F, Bauer MJ, Llewellyn S, Snelling PJ, Marsh N, Harris PNA, Stewart AG, Rickard CM. Comparison of Low-Level to High-Level Disinfection in Eliminating Microorganisms From Ultrasound Transducers Used on Skin: A Noninferiority Randomized Controlled Trial. J Ultrasound Med 2023; 42:2525-2534. [PMID: 37306253 DOI: 10.1002/jum.16286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/27/2023] [Accepted: 05/29/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION There is a lack of international consensus as to whether high- or low-level disinfection (HLD or LLD) is required for ultrasound (US) transducers used during percutaneous procedures. This study compared the effectiveness of LLD to HLD on US transducers contaminated with microorganisms from skin. METHODS Two identical linear US transducers repeatedly underwent either LLD or HLD during the study. Randomization determined which of these transducers was applied to left and right forearms of each participant. Swabs taken from transducers before and after reprocessing were plated then incubated for 4-5 days, after which colony forming units (CFU) were counted and identified. The primary hypothesis was the difference in the proportion of US transducers having no CFUs remaining after LLD and HLD would be less than or equal to the noninferiority margin of -5%. RESULTS Of the 654 recruited participants 73% (n = 478) had microbial growth from both transducers applied to their left and right forearms before reprocessing. These were included in the paired noninferiority statistical analysis where, after disinfection, all CFUs were eliminated in 100% (95% CI: 99.4-100.0%) of HLD transducer samples (n = 478) and 99.0% (95% CI: 97.6-99.7%) of LLD transducer samples (n = 473). The paired difference in the proportion of transducers having all CFUs eliminated between LLD and HLD was -1.0% (95% CI: -2.4 to -0.2%, P-value <.001). CONCLUSIONS Disinfection with LLD is noninferior to HLD when microorganisms from skin have contaminated the transducer. Therefore, using LLD for US transducers involved in percutaneous procedures would present no higher infection risk compared with HLD.
Collapse
Affiliation(s)
- Nathan Peters
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Department of Surgery, University of Melbourne, Melbourne, Australia
| | - Frances Williamson
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Michelle J Bauer
- University of Queensland Centre for Clinical Research, University of Queensland, Brisbane, Australia
| | - Stacey Llewellyn
- Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Peter J Snelling
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Emergency Department, Gold Coast University Hospital, Southport, Australia
- School of Medicine and Dentistry, Griffith University, Southport, Australia
| | - Nicole Marsh
- School of Nursing and Midwifery, Griffith University, Brisbane, Australia
- Nursing and Midwifery Research Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Alliance for Vascular Access Teaching and Research Group, Griffith University, Brisbane, Australia
- School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, Australia
| | - Patrick N A Harris
- University of Queensland Centre for Clinical Research, University of Queensland, Brisbane, Australia
- Central Microbiology, Pathology Queensland, Brisbane, Australia
| | - Adam G Stewart
- University of Queensland Centre for Clinical Research, University of Queensland, Brisbane, Australia
- Central Microbiology, Pathology Queensland, Brisbane, Australia
| | - Claire M Rickard
- School of Nursing and Midwifery, Griffith University, Brisbane, Australia
- Nursing and Midwifery Research Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Alliance for Vascular Access Teaching and Research Group, Griffith University, Brisbane, Australia
- School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, Australia
- Herston Infectious Diseases Institute, Metro North Hospitals and Health Service, Brisbane, Australia
| |
Collapse
|
7
|
Snelling PJ, Keijzers G, Ware RS. Ultrasonography or Radiography for Suspected Pediatric Distal Forearm Fractures. Reply. N Engl J Med 2023; 389:673-674. [PMID: 37585644 DOI: 10.1056/nejmc2307617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
|
8
|
Lam C, Dunstan L, Sweeny A, Watkins S, George S, Snelling PJ. A survey of paediatric difficult peripheral intravenous access in the emergency department and use of point-of-care ultrasound. Australas J Ultrasound Med 2023; 26:184-190. [PMID: 37701768 PMCID: PMC10493356 DOI: 10.1002/ajum.12353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Introduction/Purpose Peripheral intravenous catheter (PIVC) insertion can be challenging in children, with point-of-care ultrasound (POCUS) known to increase success rates. The objective of this study was to survey how emergency department (ED) clinicians identify and escalate paediatric patients with difficult intravenous access (DIVA), specifically the use of POCUS. Methods This cross-sectional study was conducted in an Australian academic mixed ED that surveyed resident medical officers (RMOs), registrars, consultants and senior paediatric nurses. A 15 multiple-choice questionnaire evaluated clinicians experience with paediatric PIVC insertion, approach to identifying and managing DIVA and the use of POCUS or other adjuncts. Results Eighty clinicians (34.2% response rate) completed the survey. Poor vein palpability was rated the highest predictor of DIVA. Of the respondents, 19 consultants (86.4%), 28 registrars (90.3%) and 16 RMOs (64.0%) used POCUS as an adjunct for paediatric DIVA patients but 16 consultants (72.8%), 21 registrars (67.8%) and 20 RMOs (80.0%) would use this less than 25% of the time in clinical practice. Discussion This survey suggests more clinicians to prefer using objective factors when identifying paediatric DIVA patients, rather than subjectively using gestalt, which relies on clinician experience. Whilst clearly recognised as a useful tool in our study, POCUS was used infrequently for paediatric DIVA patients. Conclusions There is currently no consistent process for the identification and escalation of paediatric DIVA patients, including the use of adjuncts such as POCUS. Clinician awareness for these issues should be addressed, which should include the development of guidelines and clinician training in POCUS for PIVC insertion in children.
Collapse
Affiliation(s)
- Clayton Lam
- Department of Emergency MedicineGold Coast University HospitalSouthportQueenslandAustralia
- School of Medicine and DentistryGriffith UniversitySouthportQueenslandAustralia
| | - Lucy Dunstan
- Department of Emergency MedicineGold Coast University HospitalSouthportQueenslandAustralia
| | - Amy Sweeny
- Department of Emergency MedicineGold Coast University HospitalSouthportQueenslandAustralia
- School of Medicine and DentistryGriffith UniversitySouthportQueenslandAustralia
| | - Stuart Watkins
- Department of Emergency MedicineGold Coast University HospitalSouthportQueenslandAustralia
- School of Medicine and DentistryGriffith UniversitySouthportQueenslandAustralia
| | - Shane George
- Department of Emergency MedicineGold Coast University HospitalSouthportQueenslandAustralia
- School of Medicine and DentistryGriffith UniversitySouthportQueenslandAustralia
- Children's Critical Care UnitGold Coast University HospitalSouthportQueenslandAustralia
- Menzies Health Institute QueenslandGriffith UniversitySouthportQueenslandAustralia
| | - Peter J. Snelling
- Department of Emergency MedicineGold Coast University HospitalSouthportQueenslandAustralia
- School of Medicine and DentistryGriffith UniversitySouthportQueenslandAustralia
- Sonography Innovation and Research (Sonar) GroupSouthportQueenslandAustralia
- Child Health Research CentreUniversity of QueenslandSouth BrisbaneQueenslandAustralia
| |
Collapse
|
9
|
Snelling PJ, Jones P, Bade D, Bindra R, Byrnes J, Davison M, George S, Moore M, Keijzers G, Ware RS. Ultrasonography or Radiography for Suspected Pediatric Distal Forearm Fractures. N Engl J Med 2023; 388:2049-2057. [PMID: 37256975 DOI: 10.1056/nejmoa2213883] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Data on whether ultrasonography for the initial diagnostic imaging of forearm fractures in children and adolescents is noninferior to radiography for subsequent physical function of the arm are limited. METHODS In this open-label, multicenter, noninferiority, randomized trial in Australia, we recruited participants 5 to 15 years of age who presented to the emergency department with an isolated distal forearm injury, without a clinically visible deformity, in whom further evaluation with imaging was indicated. Participants were randomly assigned to initially undergo point-of-care ultrasonography or radiography, and were then followed for 8 weeks. The primary outcome was physical function of the affected arm at 4 weeks as assessed with the use of the validated Pediatric Upper Extremity Short Patient-Reported Outcomes Measurement Information System (PROMIS) score (range, 8 to 40, with higher scores indicating better function); the noninferiority margin was 5 points. RESULTS A total of 270 participants were enrolled, with outcomes for 262 participants (97%) available at 4 weeks (with a window of ±3 days) as prespecified. PROMIS scores at 4 weeks in the ultrasonography group were noninferior to those in the radiography group (mean, 36.4 and 36.3 points, respectively; mean difference, 0.1 point; 95% confidence interval [CI], -1.3 to 1.4). Intention-to-treat analyses (in 266 participants with primary outcome data recorded at any time) produced similar results (mean difference, 0.1 point; 95% CI, -1.3 to 1.4). No clinically important fractures were missed, and there were no between-group differences in the occurrence of adverse events. CONCLUSIONS In children and adolescents with a distal forearm injury, the use of ultrasonography as the initial diagnostic imaging method was noninferior to radiography with regard to the outcome of physical function of the arm at 4 weeks. (Funded by the Emergency Medicine Foundation and others; BUCKLED Australian New Zealand Clinical Trials Registry number, ACTRN12620000637943).
Collapse
Affiliation(s)
- Peter J Snelling
- From the School of Medicine and Dentistry and Menzies Health Institute Queensland (P.J.S., P.J., R.B., M.D., S.G., G.K., R.S.W.) and the Centre for Applied Health Economics, School of Medicine and Dentistry (J.B.), Griffith University, the Departments of Emergency Medicine (P.J.S., S.G., G.K.) and Orthopaedics (R.B.) and the Children's Critical Care Unit (S.G.), Gold Coast University Hospital, and the Sonography Innovation and Research (Sonar) Group (P.J.S.), Southport, the Child Health Research Centre, University of Queensland, Brisbane (P.J.S., S.G.), the Departments of Orthopaedics (D.B.) and Emergency Medicine (M.M.), Queensland Children's Hospital, South Brisbane, the Department of Emergency Medicine, Sunshine Coast University Hospital, Birtinya (M.D.), and the Faculty of Health Sciences and Medicine, Bond University, Gold Coast (G.K.) - all in Queensland, Australia
| | - Philip Jones
- From the School of Medicine and Dentistry and Menzies Health Institute Queensland (P.J.S., P.J., R.B., M.D., S.G., G.K., R.S.W.) and the Centre for Applied Health Economics, School of Medicine and Dentistry (J.B.), Griffith University, the Departments of Emergency Medicine (P.J.S., S.G., G.K.) and Orthopaedics (R.B.) and the Children's Critical Care Unit (S.G.), Gold Coast University Hospital, and the Sonography Innovation and Research (Sonar) Group (P.J.S.), Southport, the Child Health Research Centre, University of Queensland, Brisbane (P.J.S., S.G.), the Departments of Orthopaedics (D.B.) and Emergency Medicine (M.M.), Queensland Children's Hospital, South Brisbane, the Department of Emergency Medicine, Sunshine Coast University Hospital, Birtinya (M.D.), and the Faculty of Health Sciences and Medicine, Bond University, Gold Coast (G.K.) - all in Queensland, Australia
| | - David Bade
- From the School of Medicine and Dentistry and Menzies Health Institute Queensland (P.J.S., P.J., R.B., M.D., S.G., G.K., R.S.W.) and the Centre for Applied Health Economics, School of Medicine and Dentistry (J.B.), Griffith University, the Departments of Emergency Medicine (P.J.S., S.G., G.K.) and Orthopaedics (R.B.) and the Children's Critical Care Unit (S.G.), Gold Coast University Hospital, and the Sonography Innovation and Research (Sonar) Group (P.J.S.), Southport, the Child Health Research Centre, University of Queensland, Brisbane (P.J.S., S.G.), the Departments of Orthopaedics (D.B.) and Emergency Medicine (M.M.), Queensland Children's Hospital, South Brisbane, the Department of Emergency Medicine, Sunshine Coast University Hospital, Birtinya (M.D.), and the Faculty of Health Sciences and Medicine, Bond University, Gold Coast (G.K.) - all in Queensland, Australia
| | - Randy Bindra
- From the School of Medicine and Dentistry and Menzies Health Institute Queensland (P.J.S., P.J., R.B., M.D., S.G., G.K., R.S.W.) and the Centre for Applied Health Economics, School of Medicine and Dentistry (J.B.), Griffith University, the Departments of Emergency Medicine (P.J.S., S.G., G.K.) and Orthopaedics (R.B.) and the Children's Critical Care Unit (S.G.), Gold Coast University Hospital, and the Sonography Innovation and Research (Sonar) Group (P.J.S.), Southport, the Child Health Research Centre, University of Queensland, Brisbane (P.J.S., S.G.), the Departments of Orthopaedics (D.B.) and Emergency Medicine (M.M.), Queensland Children's Hospital, South Brisbane, the Department of Emergency Medicine, Sunshine Coast University Hospital, Birtinya (M.D.), and the Faculty of Health Sciences and Medicine, Bond University, Gold Coast (G.K.) - all in Queensland, Australia
| | - Joshua Byrnes
- From the School of Medicine and Dentistry and Menzies Health Institute Queensland (P.J.S., P.J., R.B., M.D., S.G., G.K., R.S.W.) and the Centre for Applied Health Economics, School of Medicine and Dentistry (J.B.), Griffith University, the Departments of Emergency Medicine (P.J.S., S.G., G.K.) and Orthopaedics (R.B.) and the Children's Critical Care Unit (S.G.), Gold Coast University Hospital, and the Sonography Innovation and Research (Sonar) Group (P.J.S.), Southport, the Child Health Research Centre, University of Queensland, Brisbane (P.J.S., S.G.), the Departments of Orthopaedics (D.B.) and Emergency Medicine (M.M.), Queensland Children's Hospital, South Brisbane, the Department of Emergency Medicine, Sunshine Coast University Hospital, Birtinya (M.D.), and the Faculty of Health Sciences and Medicine, Bond University, Gold Coast (G.K.) - all in Queensland, Australia
| | - Michelle Davison
- From the School of Medicine and Dentistry and Menzies Health Institute Queensland (P.J.S., P.J., R.B., M.D., S.G., G.K., R.S.W.) and the Centre for Applied Health Economics, School of Medicine and Dentistry (J.B.), Griffith University, the Departments of Emergency Medicine (P.J.S., S.G., G.K.) and Orthopaedics (R.B.) and the Children's Critical Care Unit (S.G.), Gold Coast University Hospital, and the Sonography Innovation and Research (Sonar) Group (P.J.S.), Southport, the Child Health Research Centre, University of Queensland, Brisbane (P.J.S., S.G.), the Departments of Orthopaedics (D.B.) and Emergency Medicine (M.M.), Queensland Children's Hospital, South Brisbane, the Department of Emergency Medicine, Sunshine Coast University Hospital, Birtinya (M.D.), and the Faculty of Health Sciences and Medicine, Bond University, Gold Coast (G.K.) - all in Queensland, Australia
| | - Shane George
- From the School of Medicine and Dentistry and Menzies Health Institute Queensland (P.J.S., P.J., R.B., M.D., S.G., G.K., R.S.W.) and the Centre for Applied Health Economics, School of Medicine and Dentistry (J.B.), Griffith University, the Departments of Emergency Medicine (P.J.S., S.G., G.K.) and Orthopaedics (R.B.) and the Children's Critical Care Unit (S.G.), Gold Coast University Hospital, and the Sonography Innovation and Research (Sonar) Group (P.J.S.), Southport, the Child Health Research Centre, University of Queensland, Brisbane (P.J.S., S.G.), the Departments of Orthopaedics (D.B.) and Emergency Medicine (M.M.), Queensland Children's Hospital, South Brisbane, the Department of Emergency Medicine, Sunshine Coast University Hospital, Birtinya (M.D.), and the Faculty of Health Sciences and Medicine, Bond University, Gold Coast (G.K.) - all in Queensland, Australia
| | - Mark Moore
- From the School of Medicine and Dentistry and Menzies Health Institute Queensland (P.J.S., P.J., R.B., M.D., S.G., G.K., R.S.W.) and the Centre for Applied Health Economics, School of Medicine and Dentistry (J.B.), Griffith University, the Departments of Emergency Medicine (P.J.S., S.G., G.K.) and Orthopaedics (R.B.) and the Children's Critical Care Unit (S.G.), Gold Coast University Hospital, and the Sonography Innovation and Research (Sonar) Group (P.J.S.), Southport, the Child Health Research Centre, University of Queensland, Brisbane (P.J.S., S.G.), the Departments of Orthopaedics (D.B.) and Emergency Medicine (M.M.), Queensland Children's Hospital, South Brisbane, the Department of Emergency Medicine, Sunshine Coast University Hospital, Birtinya (M.D.), and the Faculty of Health Sciences and Medicine, Bond University, Gold Coast (G.K.) - all in Queensland, Australia
| | - Gerben Keijzers
- From the School of Medicine and Dentistry and Menzies Health Institute Queensland (P.J.S., P.J., R.B., M.D., S.G., G.K., R.S.W.) and the Centre for Applied Health Economics, School of Medicine and Dentistry (J.B.), Griffith University, the Departments of Emergency Medicine (P.J.S., S.G., G.K.) and Orthopaedics (R.B.) and the Children's Critical Care Unit (S.G.), Gold Coast University Hospital, and the Sonography Innovation and Research (Sonar) Group (P.J.S.), Southport, the Child Health Research Centre, University of Queensland, Brisbane (P.J.S., S.G.), the Departments of Orthopaedics (D.B.) and Emergency Medicine (M.M.), Queensland Children's Hospital, South Brisbane, the Department of Emergency Medicine, Sunshine Coast University Hospital, Birtinya (M.D.), and the Faculty of Health Sciences and Medicine, Bond University, Gold Coast (G.K.) - all in Queensland, Australia
| | - Robert S Ware
- From the School of Medicine and Dentistry and Menzies Health Institute Queensland (P.J.S., P.J., R.B., M.D., S.G., G.K., R.S.W.) and the Centre for Applied Health Economics, School of Medicine and Dentistry (J.B.), Griffith University, the Departments of Emergency Medicine (P.J.S., S.G., G.K.) and Orthopaedics (R.B.) and the Children's Critical Care Unit (S.G.), Gold Coast University Hospital, and the Sonography Innovation and Research (Sonar) Group (P.J.S.), Southport, the Child Health Research Centre, University of Queensland, Brisbane (P.J.S., S.G.), the Departments of Orthopaedics (D.B.) and Emergency Medicine (M.M.), Queensland Children's Hospital, South Brisbane, the Department of Emergency Medicine, Sunshine Coast University Hospital, Birtinya (M.D.), and the Faculty of Health Sciences and Medicine, Bond University, Gold Coast (G.K.) - all in Queensland, Australia
| |
Collapse
|
10
|
Tsao H, Tang C, Trembath M, Jones P, Snelling PJ. Ultrasound-guided supraclavicular block versus Bier block for emergency reduction of upper limb injuries: a protocol for an open-label, non-inferiority, randomised controlled trial. Trials 2023; 24:366. [PMID: 37254224 DOI: 10.1186/s13063-023-07403-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/22/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Closed reduction of upper limb fractures and/or dislocations are common in the emergency department (ED), which involves physically re-aligning the injured part prior to immobilisation. As this is painful, numerous techniques are available to provide regional anaesthesia to ensure patient tolerance. A Bier block (BB) is typically performed as part of routine care. An alternative technique gaining interest in the ED is ultrasound-guided supraclavicular block (UGSCB), which involves injecting local anaesthetic around the brachial plexus at the supraclavicular fossa under ultrasound guidance. It is unclear whether UGSCB is effective and safe when performed in the ED. METHODS SUPERB (SUPraclavicular block for Emergency Reduction versus Bier block) is a prospective open-label, non-inferiority randomised controlled trial that compares the effectiveness of UGSCB versus BB for closed reduction of upper limb fractures and/or dislocations. Adult patients presenting with an upper limb fracture and/or dislocation that requires emergent closed reduction in the ED will be eligible. After screening, participants will be randomised to either UGSCB or BB. Once regional anaesthesia is obtained, closed reduction of the injured part will be performed and appropriately immobilised. The primary outcome is maximal pain experienced during closed reduction measured via a visual analogue scale (VAS). Secondary outcomes include baseline and post-reduction pain, patient satisfaction, total opioid requirement in ED, ED length of stay, adverse events and regional anaesthesia failure. DISCUSSION Existing evidence suggests UGSCB is effective when performed in the operating theatre by trained anaesthetists. SUPERB will be the first randomised controlled trial to elucidate the effectiveness and safety of UGSCB in the ED. The findings have the potential to provide an alternative safe and effective option for the management of upper extremity emergencies in the ED. TRIAL REGISTRATION This trial has been registered on 21 October 2022 with Australia and New Zealand Clinical Trials Registry (ACTRN12622001356752).
Collapse
Affiliation(s)
- Henry Tsao
- Emergency Department, Redland Hospital, Cleveland, QLD, Australia.
- School of Medicine, The University of Queensland, Herston, QLD, Australia.
| | - Christopher Tang
- Emergency Department, Redland Hospital, Cleveland, QLD, Australia
- School of Medicine, The University of Queensland, Herston, QLD, Australia
| | - Mark Trembath
- School of Medicine, The University of Queensland, Herston, QLD, Australia
- Department of Anaesthetics, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Philip Jones
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia
| | - Peter J Snelling
- School of Medicine, The University of Queensland, Herston, QLD, Australia
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia
- School of Medicine and Dentistry, Griffith University, Southport, QLD, Australia
- Sonography Innovation and Research Group (Sonar Group), Southport, QLD, Australia
| |
Collapse
|
11
|
Yasuda K, Snelling PJ, Ng J, Manley R, Watkins S. Point-of-care ultrasound-assisted diagnosis of gastric vessel rupture in a young man presenting with chest pain: A cautionary tale. Australas J Ultrasound Med 2023; 26:115-117. [PMID: 37252628 PMCID: PMC10225006 DOI: 10.1002/ajum.12338] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024] Open
Abstract
We report a young male patient who presented with chest and shoulder tip pain with spontaneous intraperitoneal haemorrhage (haemoperitoneum) due to gastric vessel rupture. Point-of-care ultrasound detected abdominal free fluid, which led to a CT scan of the abdomen and reached the diagnosis. Intra-abdominal bleeding can present as referred chest or shoulder tip pain, as more commonly seen in females with pelvic pathologies. Point-of-care ultrasound may add diagnostic value with the detection of a haemoperitoneum in this context.
Collapse
Affiliation(s)
- Koichi Yasuda
- Emergency DepartmentGold Coast University HospitalSouthportQueenslandAustralia
| | - Peter J. Snelling
- Emergency DepartmentGold Coast University HospitalSouthportQueenslandAustralia
- School of Medicine and DentistryGriffith UniversitySouthportQueenslandAustralia
| | - Justin Ng
- Department of General SurgeryGold Coast University HospitalSouthportQueenslandAustralia
| | - Russell Manley
- Department of General SurgeryGold Coast University HospitalSouthportQueenslandAustralia
| | - Stuart Watkins
- Emergency DepartmentGold Coast University HospitalSouthportQueenslandAustralia
| |
Collapse
|
12
|
Snelling PJ, Aruljoe Thanasingam A, Jones P, Connors J. Response to Re: Comparison of abusive head trauma versus non-inflicted subdural haematoma in infants: A retrospective cohort study. Emerg Med Australas 2023; 35:531-532. [PMID: 36958301 DOI: 10.1111/1742-6723.14204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/16/2023] [Indexed: 03/25/2023]
Affiliation(s)
- Peter J Snelling
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Child Protection Unit, Mater Children's Hospital, Brisbane, Queensland, Australia
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | | | - Philip Jones
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jan Connors
- Child Protection Unit, Mater Children's Hospital, Brisbane, Queensland, Australia
- Child Protection and Forensic Medical Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| |
Collapse
|
13
|
Snelling PJ, Jones P, Gillespie A, Bade D, Keijzers G, Ware RS. Point-of-Care Ultrasound Fracture-Physis Distance Association with Salter-Harris II Fractures of the Distal Radius in Children: The "POCUS 1-cm Rule". Ultrasound Med Biol 2023; 49:520-526. [PMID: 36333153 DOI: 10.1016/j.ultrasmedbio.2022.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 09/21/2022] [Accepted: 10/03/2022] [Indexed: 06/16/2023]
Abstract
Salter-Harris II fractures of the distal radius can result in serious complications. The aim of this study was to measure the fracture-physis distance using point-of-care ultrasound (POCUS) to determine whether a certain distance is associated with Salter-Harris II fractures, compared with other fracture types, in a cohort of children with X-ray-identified distal radius fractures. Participants were from a parent diagnostic study conducted in an Australian tertiary pediatric emergency department, which prospectively evaluated the diagnosis of pediatric distal forearm fractures using POCUS compared against X-ray. Nurse practitioners, who underwent 2 h of training, administered a six-view POCUS protocol in clinically non-angulated pediatric forearm injuries prior to X-ray. This was a secondary analysis of data from the parent study. The 122 participants with X-ray-identified distal radius fractures from the parent study had their POCUS images interpreted by two emergency physician sonologists, who measured the fracture-physis distance. The median and maximum fracture-physis distances for Salter-Harris II fractures (n = 19) were 8.00 and 9.85 mm, whereas minimum and median distances for incomplete fractures (n = 22) were 10.20 and 15.98 mm, and those for complete fractures (n = 9) were 10.85 and 12.85 mm. Buckle fracture (n = 72) distances ranged from 4.35 to 26.55 mm, with a median of 13.65 mm. In children diagnosed with a distal radius fracture on X-ray, a fracture-physis distance cutoff of 1 cm differentiated Salter-Harris II fractures from other cortical breach fracture types, but not buckle fractures. Although this exploratory study suggests the "POCUS 1-cm rule" could be used as a secondary sign to augment the diagnosis of Salter-Harris II distal radius fractures using POCUS, further research is required to validate this measurement prospectively.
Collapse
Affiliation(s)
- Peter J Snelling
- School of Medicine and Dentistry and Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia; Emergency Department, Gold Coast University Hospital, Southport, Queensland, Australia; Sonography Innovation and Research (Sonar) Group, Queensland, Australia; Child Health Research Centre, University of Queensland, South Brisbane, Queensland, Australia; Queensland Children's Hospital, South Brisbane, Queensland, Australia.
| | - Philip Jones
- School of Medicine and Dentistry and Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia; Emergency Department, Gold Coast University Hospital, Southport, Queensland, Australia; Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Alan Gillespie
- Emergency Department, Gold Coast University Hospital, Southport, Queensland, Australia
| | - David Bade
- Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Gerben Keijzers
- School of Medicine and Dentistry and Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia; Emergency Department, Gold Coast University Hospital, Southport, Queensland, Australia; Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Robert S Ware
- School of Medicine and Dentistry and Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
| |
Collapse
|
14
|
Snelling PJ, Aruljoe Thanasingam A, Jones P, Connors J. Comparison of abusive head trauma versus non-inflicted subdural haematoma in infants: A retrospective cohort study. Emerg Med Australas 2022; 34:968-975. [PMID: 35661408 PMCID: PMC9796578 DOI: 10.1111/1742-6723.14028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/11/2022] [Accepted: 05/14/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To compare the characteristics of subdural haematoma (SDH) in children under the age of 2 years, between inflicted, otherwise known as abusive head trauma (AHT), and non-inflicted aetiologies. METHODS This was a retrospective cohort study of 37 cases of SDH in children under the age of 2 years presenting to the ED at an Australian tertiary children's hospital between January 2009 and December 2012 and been assessed by the Child Protection Unit. SDH aetiology was classified into AHT and non-inflicted groups, based on child protection interagency outcome. These groups were compared to determine clinical associations with AHT. RESULTS Of the 37 infants with SDH, 20 cases were deemed due to AHT, whereas 17 cases were determined to be non-inflicted SDH (15 cases due to accidental trauma and two cases due to congenital benign enlargement of the subarachnoid space). SDH due to AHT was associated with antenatal maternal drug use, previous Department of Child Safety involvement, delayed presentation, history of seizures, floppiness or altered level of consciousness; extracranial findings of fractures, bruising or retinal haemorrhages; radiological findings of >5 mm depth, bilateral, inter-hemispheric blood, posterior fossa blood and diffusion restriction; and outcomes of death or permanent disability. Non-inflicted SDH was associated with witnessed injury, falls and scalp haematoma on imaging. CONCLUSIONS Infant SDH due to AHT accounts for high mortality and morbidity. Early identification of these patients in the ED with referral to specialised units that investigate for potential child abuse is essential.
Collapse
Affiliation(s)
- Peter J Snelling
- Emergency DepartmentGold Coast University HospitalGold CoastQueenslandAustralia,Child Protection UnitMater Children's HospitalBrisbaneQueenslandAustralia,School of Medicine and DentistryGriffith UniversityGold CoastQueenslandAustralia,Child Health Research CentreThe University of QueenslandBrisbaneQueenslandAustralia
| | | | - Philip Jones
- Emergency DepartmentGold Coast University HospitalGold CoastQueenslandAustralia,School of Medicine and DentistryGriffith UniversityGold CoastQueenslandAustralia,Emergency and Trauma CentreRoyal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
| | - Jan Connors
- Child Protection UnitMater Children's HospitalBrisbaneQueenslandAustralia,Child Protection and Forensic Medical ServiceQueensland Children's HospitalBrisbaneQueenslandAustralia
| |
Collapse
|
15
|
Fahey A, Cripps E, Ng A, Sweeny A, Snelling PJ. Pericapsular nerve group block for hip fracture is feasible, safe and effective in the emergency department: A prospective observational comparative cohort study. Emerg Med Australas 2022; 34:884-891. [PMID: 35701386 PMCID: PMC9796647 DOI: 10.1111/1742-6723.14013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 04/01/2022] [Accepted: 04/18/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVES The pericapsular nerve group (PENG) block was first described for analgesia of hip fracture in 2018. We hypothesised that the PENG block is safe and effective for patients with hip fracture when provided by emergency physicians and trainees in the ED. METHODS This was an observational study of routine care. Consecutive patients receiving regional anaesthesia for hip fracture at a single ED were prospectively enrolled. Pain scores were assessed prior to regional anaesthesia then at 15, 30 and 60 min after administration. Maximal reduction in pain scores within 60 min were assessed using the Visual Analogue Scale (at rest and on movement) or the Pain Assessment IN Advanced Dementia tool (at rest). Patients were followed for opioid use for 12 h after regional anaesthesia and adverse events over the duration of admission. RESULTS There were 67 eligible patients during the enrolment period, with 52 (78%) prospectively enrolled. Thirty-three received femoral blocks (19 fascia iliaca compartment blocks, 14 femoral nerve blocks) and 19 received a PENG block. Inexperienced providers were able to successfully perform the PENG block. There was no difference in maximum pain score reduction between the groups. There was no difference in adverse effects between groups. Opioid use was similar between the groups. More patients were opioid-free after a PENG block. CONCLUSIONS The present study demonstrated that the PENG block can be provided safely and effectively to patients with hip fracture in the ED. On the basis of this pilot study, a larger randomised controlled study should now be designed.
Collapse
Affiliation(s)
- Alan Fahey
- Department of Emergency MedicineGold Coast University HospitalGold CoastQueenslandAustralia
| | - Elinor Cripps
- Department of AnaesthesiaLismore Base HospitalLismoreNew South WalesAustralia
| | - Aloysius Ng
- Department of Acute Care MedicineFiona Stanley HospitalPerthWestern AustraliaAustralia
| | - Amy Sweeny
- Department of Emergency MedicineGold Coast University HospitalGold CoastQueenslandAustralia,School of Medicine and DentistryGriffith UniversityGold CoastQueenslandAustralia,Faculty of Health Sciences and Medicine, Bond UniversityGold CoastQueenslandAustralia
| | - Peter J Snelling
- Department of Emergency MedicineGold Coast University HospitalGold CoastQueenslandAustralia,School of Medicine and DentistryGriffith UniversityGold CoastQueenslandAustralia,Sonography Innovation and Research GroupGold CoastQueenslandAustralia,Child Health Research CentreThe University of QueenslandBrisbaneQueenslandAustralia
| |
Collapse
|
16
|
Elsayed T, Snelling PJ, Stirling EJ, Watkins S. Emergency medicine trainees' perceived barriers to training and credentialing in point-of-care ultrasound: A cross-sectional study. Australas J Ultrasound Med 2022; 25:160-165. [PMID: 36405796 PMCID: PMC9644443 DOI: 10.1002/ajum.12317] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Introduction Point-of-care ultrasound (POCUS) is an important tool in emergency medicine (EM), with the Australasian College for Emergency Medicine (ACEM) recommending core modalities as part of fellowship training. In Australia, acquisition of these skills is certified via credentialing but is currently poorly undertaken by EM trainees. Methods We performed a cross-sectional survey of EM trainees across two academic teaching hospitals in Gold Coast, Queensland, between December 2018 and January 2019, to determine the current state of training and perceived barriers to credentialing in POCUS. Results Fifty-two (59%) eligible EM trainees participated. Although credentialing rates (15%) were low amongst respondents, the majority agreed that it was necessary (69%) and should form part of ACEM training (88%). Amongst these trainees, we identified the desire for increased POCUS training and several barriers including time constraints and the credentialing process itself. Conclusion Although there is general agreement amongst EM trainees for POCUS credentialing, barriers such as time limitations and technical difficulties were prohibitive for many. We propose the development of an internal structured POCUS training programme within mandatory training time to address these issues.
Collapse
Affiliation(s)
- Tarek Elsayed
- Emergency DepartmentGold Coast Hospital and Health ServiceSouthport4215QueenslandAustralia
- School of Medicine and DentistryGriffith UniversitySouthportQueenslandAustralia
- Faculty of Health Sciences & MedicineBond UniversityRobinaQueenslandAustralia
| | - Peter J. Snelling
- Emergency DepartmentGold Coast Hospital and Health ServiceSouthport4215QueenslandAustralia
- School of Medicine and DentistryGriffith UniversitySouthportQueenslandAustralia
- Faculty of Health Sciences & MedicineBond UniversityRobinaQueenslandAustralia
- Child Health Research CentreUniversity of QueenslandQueenslandAustralia
- Sonography Innovation and Research (Sonar) GroupGold CoastQueenslandAustralia
| | - Erin J. Stirling
- Emergency DepartmentGold Coast Hospital and Health ServiceSouthport4215QueenslandAustralia
| | - Stuart Watkins
- Emergency DepartmentGold Coast Hospital and Health ServiceSouthport4215QueenslandAustralia
- School of Medicine and DentistryGriffith UniversitySouthportQueenslandAustralia
| |
Collapse
|
17
|
Snelling PJ, Shefrin AE, Moake MM, Bergmann KR, Constantine E, Deanehan JK, Dessie AS, Elkhunovich MA, Gold DL, Kornblith AE, Lin‐Martore M, Nti B, Pade KH, Parri N, Sivitz A, Lam SHF. Establishing the international research priorities for pediatric emergency medicine point-of-care ultrasound: A modified Delphi study. Acad Emerg Med 2022; 29:1338-1346. [PMID: 36043227 PMCID: PMC9826219 DOI: 10.1111/acem.14588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/23/2022] [Accepted: 08/26/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The Pediatric Emergency Medicine (PEM) Point-of-care Ultrasound (POCUS) Network (P2Network) was established in 2014 to provide a platform for international collaboration among experts, including multicenter research. The objective of this study was to use expert consensus to identify and prioritize PEM POCUS topics, to inform future collaborative multicenter research. METHODS Online surveys were administered in a two-stage, modified Delphi study. A steering committee of 16 PEM POCUS experts was identified within the P2Network, with representation from the United States, Canada, Italy, and Australia. We solicited the participation of international PEM POCUS experts through professional society mailing lists, research networks, social media, and "word of mouth." After each round, responses were refined by the steering committee before being reissued to participants to determine the ranking of all the research questions based on means and to identify the high-level consensus topics. The final stage was a modified Hanlon process of prioritization round (HPP), which emphasized relevance, impact, and feasibility. RESULTS Fifty-four eligible participants (16.6%) provided 191 items to Survey 1 (Round 1). These were refined and consolidated into 52 research questions by the steering committee. These were issued for rating in Survey 2 (Round 2), which had 45 participants. At the completion of Round 2, all questions were ranked with six research questions reaching high-level consensus. Thirty-one research questions with mean ratings above neutral were selected for the HPP round. Highly ranked topics included clinical applications of POCUS to evaluate and manage children with shock, cardiac arrest, thoracoabdominal trauma, suspected cardiac failure, atraumatic limp, and intussusception. CONCLUSIONS This consensus study has established a research agenda to inform future international multicenter PEM POCUS trials. This study has highlighted the ongoing need for high-quality evidence for PEM POCUS applications to guide clinical practice.
Collapse
Affiliation(s)
- Peter J. Snelling
- Department of Emergency MedicineGold Coast University Hospital and Griffith UniversitySouthportQueenslandAustralia
| | - Allan E. Shefrin
- Department of PediatricsChildren's Hospital of Eastern OntarioOttawaOntarioCanada
| | - Matthew M. Moake
- Department of Pediatric Emergency MedicineMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Kelly R. Bergmann
- Department of Pediatric Emergency MedicineChildren's MinnesotaMinneapolisMinnesotaUSA
| | - Erika Constantine
- Division of Pediatric Emergency MedicineHasbro Children's Hospital/Rhode Island Hospital and Brown UniversityProvidenceRhode IslandUSA
| | - J. Kate Deanehan
- Division of Pediatric Emergency MedicineJohns Hopkins Children's Center BaltimoreBaltimoreMarylandUSA
| | - Almaz S. Dessie
- Department of Emergency MedicineColumbia University Vagelos College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Marsha A. Elkhunovich
- Division of Emergency and Transport MedicineChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
| | - Delia L. Gold
- Division of Emergency MedicineNationwide Children's Hospital and Ohio State UniversityColumbusOhioUSA
| | - Aaron E. Kornblith
- Department of Emergency MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Margaret Lin‐Martore
- Department of PediatricsUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Benjamin Nti
- Riley Hospital for Children at Indiana University HealthIndianapolisIndianaUSA
| | - Kathryn H. Pade
- Division of Pediatric Emergency MedicineRady Children's Hospital San Diego and University of California at San DiegoSan DiegoCaliforniaUSA
| | - Niccolò Parri
- Department of Emergency MedicineMeyer University Children's HospitalFlorenceItaly
| | - Adam Sivitz
- Children's Hospital of New JerseyNewark Beth Israel Medical CenterNewarkNew JerseyUSA
| | | |
Collapse
|
18
|
Libbis E, Sweeny AL, Holmes T, Aggarwal N, Snelling PJ, Slaughter E, Poncia H, Watkins SC. Forearmed is forewarned: A prospective intervention observational time-series study of patient empowerment for ultrasound-guided peripheral intravenous access. Emerg Med Australas 2022; 34:779-785. [PMID: 35578995 PMCID: PMC9790456 DOI: 10.1111/1742-6723.13981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 02/28/2022] [Accepted: 03/18/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Ultrasound (US) is a valuable adjunct to improve the success rates of difficult peripheral intravenous cannula (PIVC) insertions but is usually clinician initiated. The present study assessed for any change in clinician practice resulting from interventions aimed at empowering patients to advocate for early use of US if they self-identified as having difficult PIVC access. METHODS This was a prospective observational time-series study using a rapid quality improvement (RQI) framework. Three ED waiting room intervention strategies (printed media, video and wristband) were tested over three 2-week periods at a large teaching hospital. The impact of each intervention was assessed at eight time points during each intervention and compared to a pre-intervention baseline period using trend and time-series analysis. RESULTS A total of 1611 PIVC insertions were surveyed over 42 time points. The proportion of US-guided PIVC insertions was highest during Intervention 3 (wristbands; 5.5%) but all proportions remained below baseline (6.5%). Trend analysis identified an increasing frequency of US use during Intervention 1 (printed media, P = 0.01). However, no statistically significant trends were observed within the periods. CONCLUSIONS This is the first prospective study to assess the effect of various interventions to empower patients to self-identify as having difficult PIVC access and advocate for the use of US-guidance. The present study was indeterminate: no intervention tested in the present study noticeably influenced clinical practice, potentially attributable to the study design and confounding factors. This innovative study serves as a pilot for future research into patient empowerment, which is currently lacking in the literature.
Collapse
Affiliation(s)
- Eng Libbis
- Emergency DepartmentGold Coast Hospital and Health ServiceGold CoastQueenslandAustralia,School of Medicine and DentistryGriffith UniversityGold CoastQueenslandAustralia
| | - Amy L Sweeny
- Emergency DepartmentGold Coast Hospital and Health ServiceGold CoastQueenslandAustralia,Alliance for Vascular Access Teaching and ResearchSchools of Nursing and Midwifery, and Pharmacy and Medical Sciences, Griffith UniversityGold CoastQueenslandAustralia,Faculty of Health Sciences and MedicineBond UniversityGold CoastQueenslandAustralia
| | - Travis Holmes
- Faculty of Health Sciences and MedicineBond UniversityGold CoastQueenslandAustralia
| | - Nisha Aggarwal
- Faculty of Health Sciences and MedicineBond UniversityGold CoastQueenslandAustralia
| | - Peter J Snelling
- Emergency DepartmentGold Coast Hospital and Health ServiceGold CoastQueenslandAustralia,School of Medicine and DentistryGriffith UniversityGold CoastQueenslandAustralia,Child Health Research CentreThe University of QueenslandBrisbaneQueenslandAustralia
| | - Eugene Slaughter
- Alliance for Vascular Access Teaching and ResearchSchools of Nursing and Midwifery, and Pharmacy and Medical Sciences, Griffith UniversityGold CoastQueenslandAustralia,School of NursingMidwifery and Social Work, The University of QueenslandBrisbaneQueenslandAustralia
| | - Hugo Poncia
- Faculty of Health Sciences and MedicineBond UniversityGold CoastQueenslandAustralia,Emergency DepartmentThe Tweed HospitalTweed HeadsNew South WalesAustralia
| | - Stuart C Watkins
- Emergency DepartmentGold Coast Hospital and Health ServiceGold CoastQueenslandAustralia,School of Medicine and DentistryGriffith UniversityGold CoastQueenslandAustralia,Alliance for Vascular Access Teaching and ResearchSchools of Nursing and Midwifery, and Pharmacy and Medical Sciences, Griffith UniversityGold CoastQueenslandAustralia,Faculty of Health Sciences and MedicineBond UniversityGold CoastQueenslandAustralia
| |
Collapse
|
19
|
Bergmann KR, Khant M, Lammers S, Arroyo AC, Avendano P, Chaudoin L, Cohen SG, Deanehan JK, Kornblith AE, Lam SHF, Lin-Martore M, Malia L, Pade KH, Park DB, Sivitz A, Shahar-Nissan K, Snelling PJ, Tessaro MO, Thomas-Mohtat R, Whitcomb V, Yock-Corrales A, Walsh P, Watson D, Madhok M. Accuracy and Interrater Reliability of Point-of-Care Ultrasonography Image Interpretation for Intussusception. Pediatr Emerg Care 2022; 38:442-447. [PMID: 36040465 DOI: 10.1097/pec.0000000000002786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to determine the accuracy and interrater reliability of (1) point-of-care ultrasound (POCUS) image interpretation for identification of intussusception and (2) reliability of secondary signs associated with intussusception among experts compared with novice POCUS reviewers. METHODS We conducted a planned secondary analysis of a prospective, convenience sample of children aged 3 months to 6 years who were evaluated with POCUS for intussusception across 17 international pediatric emergency departments between October 2018 and December 2020. A random sample of 100 POCUS examinations was reviewed by novice and expert POCUS reviewers. The primary outcome was identification of the presence or absence of intussusception. Secondary outcomes included intussusception size and the presence of trapped free fluid or echogenic foci. Accuracy was summarized using sensitivity and specificity, which were estimated via generalized mixed effects logistic regression. Interrater reliability was summarized via Light's κ statistics with bootstrapped standard errors (SEs). Accuracy and reliability of expert and novice POCUS reviewers were compared. RESULTS Eighteen expert and 16 novice POCUS reviewers completed the reviews. The average expert sensitivity was 94.5% (95% confidence interval [CI], 88.6-97.5), and the specificity was 94.3% (95% CI, 90.3-96.7), significantly higher than the average novice sensitivity of 84.7% (95% CI, 74.3-91.4) and specificity of 80.4% (95% CI, 72.4, 86.7). κ was significantly greater for expert (0.679, SE 0.039) compared with novice POCUS reviewers (0.424, SE 0.044; difference 0.256, SE 0.033). For our secondary outcome measure of intussusception size, κ was significantly greater for experts (0.661, SE 0.038) compared with novices (0.397, SE 0.041; difference 0.264, SE 0.029). Interrater reliability was weak for expert and minimal for novice reviewers regarding the detection of trapped free fluid and echogenic foci. CONCLUSIONS Expert POCUS reviewers demonstrate high accuracy and moderate interrater reliability when identifying intussusception via image interpretation and perform better than novice reviewers.
Collapse
Affiliation(s)
- Kelly R Bergmann
- From the Department of Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Marshal Khant
- From the Department of Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Shea Lammers
- From the Department of Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Alexander C Arroyo
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - Pablo Avendano
- Division of Pediatric Emergency Medicine, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Lindsey Chaudoin
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, NC
| | - Stephanie G Cohen
- Department of Pediatrics and Emergency Medicine, Children's Healthcare Atlanta and Emory University, Atlanta, GA
| | - J Kate Deanehan
- Department of Pediatric Emergency Medicine, Johns Hopkins Children's Center, Baltimore, MD
| | - Aaron E Kornblith
- Departments of Emergency Medicine and Pediatrics, University of California, San Francisco, San Francisco
| | - Samuel H F Lam
- Department of Emergency Medicine, Sutter Medical Center Sacramento, Sacramento, CA
| | - Margaret Lin-Martore
- Departments of Emergency Medicine and Pediatrics, University of California, San Francisco, San Francisco
| | - Laurie Malia
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York Presbyterian-Morgan Stanley Children's Hospital, New York, NY
| | - Kathryn H Pade
- Department of Pediatrics, University of California, San Diego, CA
| | - Daniel B Park
- Department of Pediatrics and Emergency Medicine, University of North Carolina, Chapel Hill, NC
| | - Adam Sivitz
- Department of Emergency Medicine, Newark Beth Israel Medical Center, Newark, NJ
| | - Keren Shahar-Nissan
- Department of Emergency Medicine, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Peter J Snelling
- Department of Pediatric Emergency Medicine, Gold Coast University Hospital and Griffith University, Southport, Queensland, Australia
| | - Mark O Tessaro
- Division of Pediatric Emergency Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rosemary Thomas-Mohtat
- Department of Pediatric Emergency Medicine, Children's National Hospital, Washington, DC
| | - Valerie Whitcomb
- From the Department of Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Adriana Yock-Corrales
- Department of Emergency Medicine, Hospital Nacional de Niños "Dr. Carlos Sáenz Herrera," CCSS, San José, Costa Rica
| | - Paige Walsh
- Department of Research and Sponsored Programs, Children's Minnesota, Minneapolis, MN
| | - Dave Watson
- Department of Research and Sponsored Programs, Children's Minnesota, Minneapolis, MN
| | - Manu Madhok
- From the Department of Emergency Medicine, Children's Minnesota, Minneapolis, MN
| |
Collapse
|
20
|
Samy L, Snelling PJ. You are what you eat: The diagnosis of recurrent intussusception in the emergency department. J Paediatr Child Health 2022; 58:1079-1080. [PMID: 34528322 DOI: 10.1111/jpc.15750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Lydia Samy
- Children's Emergency, Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Peter J Snelling
- Children's Emergency, Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia.,Emergency Department, Sonography Innovation and Research (Sonar) Group, Gold Coast, Queensland, Australia.,Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia
| |
Collapse
|
21
|
Snelling PJ, Jones P, Moore M, Gimpel P, Rogers R, Liew K, Ware RS, Keijzers G. Describing the learning curve of novices for the diagnosis of paediatric distal forearm fractures using point-of-care ultrasound. Australas J Ultrasound Med 2022; 25:66-73. [PMID: 35722050 PMCID: PMC9201201 DOI: 10.1002/ajum.12291] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Purpose The learning curve of nurse practitioners (NPs) to accurately diagnose paediatric distal forearm fractures using point-of-care ultrasound (POCUS) was investigated. Methods Each NP's learning curve was calculated as cumulative diagnostic accuracy against a number of scans performed. The curve's plateau represented the attainment of competency. Secondary outcomes were the comparisons before and after this cut-off of diagnostic accuracy, classification of diagnostic errors, pain scores, duration and preference. Results Five NPs performed 201 POCUS studies with diagnostic accuracy plateauing at 90%, providing a 'cut-off' point at scan 15. Accuracy of POCUS scanning before and after the fifteenth scan was 81% (95% CI 70%-89%) and 90% (95% CI 84%-94%), respectively, demonstrating 9% improvement (P = 0.07). There was a 10% reduction in image interpretation errors. After fifteen scans, POCUS became faster (mean difference (MD) 2.6 min [95% CI 2.0-3.3], P < 0.001), less painful (MD 0.61 points FPSR scale [95% CI 0.04-1.18], P = 0.04) and more preferred by NPs (63% vs 77%, P = 0.03). Discussion The learning curve of POCUS-novice NPs independently scanning paediatric distal forearm injuries plateaued with mean diagnostic accuracy of 90% after 15 scans, suggesting competency was attained at this cut-off, supported by higher accuracy, being faster, less painful and more preferred by NPs. Future training packages in forearm POCUS should further address image interpretation and provide ongoing expert feedback. Conclusions The findings from this study suggest that competency in paediatric distal forearm POCUS can be attained by novices after a short training course and approximately 15 scans.
Collapse
Affiliation(s)
- Peter J Snelling
- School of Medicine and Dentistry and Menzies Health Institute Queensland Griffith University Southport Queensland Australia.,Emergency Department Gold Coast University Hospital Southport Queensland Australia.,Sonography Innovation and Research (Sonar) Group Southport Queensland Australia.,Child Health Research Centre University of Queensland Southport Queensland Australia.,Emergency Department Queensland Children's Hospital South Brisbane Queensland Australia
| | - Philip Jones
- School of Medicine and Dentistry and Menzies Health Institute Queensland Griffith University Southport Queensland Australia.,Emergency Department Gold Coast University Hospital Southport Queensland Australia.,Emergency and Trauma Centre Royal Brisbane and Women's Hospital Herston Queensland Australia
| | - Mark Moore
- Emergency Department Queensland Children's Hospital South Brisbane Queensland Australia
| | - Peta Gimpel
- Emergency Department Queensland Children's Hospital South Brisbane Queensland Australia
| | - Rosemary Rogers
- Emergency Department Queensland Children's Hospital South Brisbane Queensland Australia
| | - Kong Liew
- Emergency Department Queensland Children's Hospital South Brisbane Queensland Australia
| | - Robert S Ware
- School of Medicine and Dentistry and Menzies Health Institute Queensland Griffith University Southport Queensland Australia
| | - Gerben Keijzers
- School of Medicine and Dentistry and Menzies Health Institute Queensland Griffith University Southport Queensland Australia.,Emergency Department Gold Coast University Hospital Southport Queensland Australia.,Faculty of Health Sciences and Medicine Bond University Gold Coast Queensland Australia
| |
Collapse
|
22
|
Mitchell EO, Jones P, Snelling PJ. Ultrasound for Pediatric Peripheral Intravenous Catheter Insertion: A Systematic Review. Pediatrics 2022; 149:186816. [PMID: 35445257 DOI: 10.1542/peds.2021-055523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Establishing peripheral intravenous catheter (PIVC) access in infants and children is a common procedure but can be technically difficult. The primary objective was to determine the effect ultrasound had on first attempt PIVC insertion success rates in the pediatric population. Secondary objectives included overall success rates and subgroups analyses. METHODS A systematic review of articles using Medline, Embase, CENTRAL, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. Randomized trials evaluating ultrasound-guided PIVC insertion against the landmark approach in pediatric patients who reported at least 1 outcome of success rate (first attempt or overall) were included. Methodological quality of the literature was assessed using the Revised Cochrane risk-of-bias tool for randomized trials. A meta-analysis using a random-effects model was performed. RESULTS Nine studies with 1350 patients, from a total of 1033 studies, were included for analysis. Ultrasound showed a statistically significant improvement in PIVC insertion success on first attempt in 5 of 8 studies, with an overall success rate of 78% in the ultrasound group and 66% in the control group. The secondary outcome of overall success was improved by ultrasound in studies that allowed ≥3 attempts (pooled OR 3.57, 95% CI 2.05 to 6.21, P < .001, I2 = 0.0%). CONCLUSIONS This systematic review suggested that ultrasound improves pediatric PIVC first pass and overall success rates. Subgroup analysis showed improvement in PIVC success rates for patients with difficult intravenous access and a single operator, dynamic, short-axis ultrasound technique.
Collapse
Affiliation(s)
- Evan O Mitchell
- School of Medicine and Dentistry, Griffith University, Southport, Queensland, Australia.,Departments of Pediatrics
| | - Philip Jones
- School of Medicine and Dentistry, Griffith University, Southport, Queensland, Australia.,Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia.,Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Peter J Snelling
- School of Medicine and Dentistry, Griffith University, Southport, Queensland, Australia.,Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia.,Sonography Innovation and Research (Sonar) Group, Queensland, Australia.,Child Health Research Centre, University of Queensland, Queensland, Australia
| |
Collapse
|
23
|
Snelling PJ, Keijzers G, Ware RS. Reply to Addition of Long-Axis Ultrasound Imaging for the Pronator Quadratus Muscle for the Diagnosis of Pediatric Distal Forearm Fracture. J Ultrasound Med 2022; 41:795. [PMID: 33978964 DOI: 10.1002/jum.15743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 06/12/2023]
Affiliation(s)
- Peter J Snelling
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
- Sonography Innovation and Research Group (Sonar Group), Queensland, Australia
- Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia
| | - Gerben Keijzers
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Robert S Ware
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
| |
Collapse
|
24
|
Kornblith AE, Addo N, Plasencia M, Shaahinfar A, Lin-Martore M, Sabbineni N, Gold D, Bellman L, Berant R, Bergmann KR, Brenkert TE, Chen A, Constantine E, Deanehan JK, Dessie A, Elkhunovich M, Fischer J, Gravel CA, Kharasch S, Kwan CW, Lam SHF, Neal JT, Pade KH, Rempell R, Shefrin AE, Sivitz A, Snelling PJ, Tessaro MO, White W. Development of a Consensus-Based Definition of Focused Assessment With Sonography for Trauma in Children. JAMA Netw Open 2022; 5:e222922. [PMID: 35302632 PMCID: PMC8933745 DOI: 10.1001/jamanetworkopen.2022.2922] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 01/30/2022] [Indexed: 11/14/2022] Open
Abstract
Importance The wide variation in the accuracy and reliability of the Focused Assessment With Sonography for Trauma (FAST) and the extended FAST (E-FAST) for children after blunt abdominal trauma reflects user expertise. FAST and E-FAST that are performed by experts tend to be more complete, better quality, and more often clinically valuable. Objective To develop definitions of a complete, high-quality, and accurate interpretation for the FAST and E-FAST in children with injury using an expert, consensus-based modified Delphi technique. Design, Setting, and Participants This consensus-based qualitative study was conducted between May 1 to June 30, 2021. It used a scoping review and iterative Delphi technique and involved 2 rounds of online surveys and a live webinar to achieve consensus among a 26-member panel. This panel consisted of international experts in pediatric emergency point-of-care ultrasonography. Main Outcomes and Measures Definitions of complete, high-quality, and accurate FAST and E-FAST studies for children after injury. Results Of the 29 invited pediatric FAST experts, 26 (15 men [58%]) agreed to participate in the panel. All 26 panelists completed the 2 rounds of surveys, and 24 (92%) participated in the live and asynchronous online discussions. Consensus was reached on FAST and E-FAST study definitions, and the panelists rated these 5 anatomic views as important and appropriate for a complete FAST: right upper-quadrant abdominal view, left upper-quadrant abdominal view, suprapubic views (transverse and sagittal), and subxiphoid cardiac view. For E-FAST, the same FAST anatomic views with the addition of the lung or pneumothorax view were deemed appropriate and important. In addition, the panelists rated a total of 32 landmarks as important for assessing completeness. Similarly, the panelists rated 14 statements on quality and 20 statements on accurate interpretation as appropriate. Conclusions and Relevance This qualitative study generated definitions for complete FAST and E-FAST studies with high image quality and accurate interpretation in children with injury. These definitions are similar to those in adults with injury and may be used for future education, quality assurance, and research. Future research may focus on interpretation of trace volumes of abdominal free fluid and the use of serial FAST.
Collapse
Affiliation(s)
- Aaron E. Kornblith
- Department of Pediatrics, University of California, San Francisco, San Francisco
- Department of Emergency Medicine, University of California, San Francisco, San Francisco
| | - Newton Addo
- Department of Emergency Medicine, University of California, San Francisco, San Francisco
- Department of Medicine, University of California, San Francisco, San Francisco
| | - Monica Plasencia
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco
- Department of Bioengineering, University of California, Berkeley, Berkeley
| | - Ashkon Shaahinfar
- Department of Pediatrics, University of California, San Francisco, San Francisco
- Department of Emergency Medicine, University of California, San Francisco, San Francisco
| | - Margaret Lin-Martore
- Department of Pediatrics, University of California, San Francisco, San Francisco
- Department of Emergency Medicine, University of California, San Francisco, San Francisco
| | - Naina Sabbineni
- Department of Emergency Medicine, University of California, San Francisco, San Francisco
| | - Delia Gold
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Lily Bellman
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency Medicine, Harbor-UCLA (University of California, Los Angeles) Medical Center, California Pacific Medical Center, Los Angeles
| | - Ron Berant
- Department of Emergency Medicine, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel
| | - Kelly R. Bergmann
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | - Timothy E. Brenkert
- Division of Pediatric Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Aaron Chen
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Erika Constantine
- Division of Pediatric Emergency Medicine, Hasbro Children’s Hospital, Rhode Island Hospital, Providence
| | - J. Kate Deanehan
- Division of Pediatric Emergency Medicine, Johns Hopkins Children’s Center, Baltimore, Maryland
| | - Almaz Dessie
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Marsha Elkhunovich
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
| | - Jason Fischer
- Division of Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia A. Gravel
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Sig Kharasch
- Department of Pediatrics, Massachusetts General Hospital, Boston
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | - Charisse W. Kwan
- Department of Pediatric Emergency Medicine, London Health Sciences Centre Children's Hospital, Western University, London, Ontario, Canada
| | - Samuel H. F. Lam
- Department of Emergency Medicine, Sutter Medical Center Sacramento, Sacramento, California
| | - Jeffrey T. Neal
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Kathyrn H. Pade
- Department of Emergency Medicine, Rady Children’s Hospital, University of California, San Diego, San Diego
| | - Rachel Rempell
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Allan E. Shefrin
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Adam Sivitz
- Department of Pediatric Emergency Medicine, Children’s Hospital of New Jersey, Newark Beth Israel Medical Center, Newark
| | - Peter J. Snelling
- Department of Pediatric Emergency Medicine, Gold Coast University Hospital, Griffith University, Brisbane, Queensland, Australia
| | - Mark O. Tessaro
- Division of Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - William White
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency Medicine, Harbor-UCLA (University of California, Los Angeles) Medical Center, California Pacific Medical Center, Los Angeles
| |
Collapse
|
25
|
Snelling PJ, Keijzers G, Ware RS. Point-of-Care Ultrasound Pronator Quadratus Hematoma Sign for Detection of Clinically Non-Angulated Pediatric Distal Forearm Fractures: A Prospective Cohort Study. J Ultrasound Med 2022; 41:193-205. [PMID: 33749859 DOI: 10.1002/jum.15695] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/22/2021] [Accepted: 03/01/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Point-of-care ultrasound (POCUS) diagnosis of distal forearm fractures relies on the identification of buckling or breach of hyperechoic bone cortex. We describe the pronator quadratus hematoma (PQH) formation visualized on POCUS, the PQH sign, as it may aid diagnosis of pediatric distal forearm cortical breach fractures. METHODS A prospective cohort of children presenting to an emergency department with isolated, clinically non-angulated distal forearm injuries received POCUS by an expert emergency physician sonologist who identified the presence or absence of the PQH sign. They secondarily recorded the difference between the size of the pronator quadratus (PQ) muscle on both the affected and non-affected forearms (PQ delta thickness). Children received an x-ray subsequent to POCUS and were diagnosed based on an x-ray reported by a radiologist masked to POCUS findings. RESULTS Thirty-eight children were recruited. All 22 patients with cortical breach fracture had PQH sign present (100%; 95%CI: 85-100%), while all 16 patients without cortical breach fracture had PQH sign absent (100%; 95%CI: 79-100%). PQ delta thickness ranged from 2.1 to 10.2 mm in cortical breach fractures, 0.0 to 1.1 mm in buckle fractures, and 0.2 to 0.8 mm in patients without fracture. CONCLUSIONS The PQH sign correctly distinguished all children with, and without, cortical breach fractures. All PQ delta thicknesses were ≧2.1 mm when cortical breach fracture was present and ≦1.1 mm when cortical breach fracture was absent. The PQH sign and PQ delta thickness are promising measurements to identify pediatric distal forearm cortical breach fractures, and their utility should be confirmed in larger studies with sonologists of different abilities.
Collapse
Affiliation(s)
- Peter J Snelling
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
- Sonography Innovation and Research Group (Sonar Group), Queensland, Australia
- Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia
| | - Gerben Keijzers
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Robert S Ware
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
| |
Collapse
|
26
|
Bergmann KR, Arroyo AC, Tessaro MO, Nielson J, Whitcomb V, Madhok M, Yock-Corrales A, Guerrero-Quesada G, Chaudoin L, Berant R, Shahar-Nissan K, Deanehan JK, Lam SHF, Snelling PJ, Avendano P, Cohen SG, Friedman N, Ekpenyong A, Pade KH, Park DB, Lin-Martore M, Kornblith AE, Montes-Amaya G, Thomas-Mohtat R, Jin J, Watson D, Sivitz A. Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception: A Multicenter, Noninferiority Study of Paired Diagnostic Tests. Ann Emerg Med 2021; 78:606-615. [PMID: 34226072 DOI: 10.1016/j.annemergmed.2021.04.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/13/2021] [Accepted: 04/27/2021] [Indexed: 01/09/2023]
Abstract
STUDY OBJECTIVE To determine the diagnostic accuracy of point-of-care ultrasound (POCUS) performed by experienced clinician sonologists compared to radiology-performed ultrasound (RADUS) for detection of clinically important intussusception, defined as intussusception requiring radiographic or surgical reduction. METHODS We conducted a multicenter, noninferiority, observational study among a convenience sample of children aged 3 months to 6 years treated in tertiary care emergency departments across North and Central America, Europe, and Australia. The primary outcome was diagnostic accuracy of POCUS and RADUS with respect to clinically important intussusception. Sample size was determined using a 4-percentage-point noninferiority margin for the absolute difference in accuracy. Secondary outcomes included agreement between POCUS and RADUS for identification of secondary sonographic findings. RESULTS The analysis included 256 children across 17 sites (35 sonologists). Of the 256 children, 58 (22.7%) had clinically important intussusception. POCUS identified 60 (23.4%) children with clinically important intussusception. The diagnostic accuracy of POCUS was 97.7% (95% confidence interval [CI] 94.9% to 99.0%), compared to 99.3% (95% CI 96.8% to 99.9%) for RADUS. The absolute difference between the accuracy of RADUS and that of POCUS was 1.5 percentage points (95% CI -0.6 to 3.6). Sensitivity for POCUS was 96.6% (95% CI 87.2% to 99.1%), and specificity was 98.0% (95% CI 94.7% to 99.2%). Agreement was high between POCUS and RADUS for identification of trapped free fluid (83.3%, n=40/48) and decreased color Doppler signal (95.7%, n=22/23). CONCLUSION Our findings suggest that the diagnostic accuracy of POCUS performed by experienced clinician sonologists may be noninferior to that of RADUS for detection of clinically important intussusception. Given the limitations of convenience sampling and spectrum bias, a larger randomized controlled trial is warranted.
Collapse
Affiliation(s)
- Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN.
| | - Alexander C Arroyo
- Department of Pediatric Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - Mark O Tessaro
- Division of Pediatric Emergency Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jonathan Nielson
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Valerie Whitcomb
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Manu Madhok
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Adriana Yock-Corrales
- Department of Emergency Medicine, Hospital Nacional de Niños: "Dr. Carlos Sáenz Herrera," CCSS, San José, Costa Rica
| | - German Guerrero-Quesada
- Department of Surgery, Hospital Nacional de Niños: "Dr. Carlos Sáenz Herrera," CCSS, San José, Costa Rica
| | - Lindsey Chaudoin
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, NC
| | - Ron Berant
- Department of Emergency Medicine, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Keren Shahar-Nissan
- Department of Emergency Medicine, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - J Kate Deanehan
- Department of Pediatric Emergency Medicine, Johns Hopkins Children's Center, Baltimore, MD
| | - Samuel H F Lam
- Department of Emergency Medicine, Sutter Medical Center Sacramento, Sacramento, CA
| | - Peter J Snelling
- Department of Pediatric Emergency Medicine, Gold Coast University Hospital and Griffith University, Southport, Queensland, Australia
| | - Pablo Avendano
- Division of Pediatric Emergency Medicine, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Stephanie G Cohen
- Department of Pediatrics and Emergency Medicine, Children's Healthcare Atlanta and Emory University, Atlanta, GA
| | - Nir Friedman
- Department of Pediatric Emergency Medicine, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Atim Ekpenyong
- Department of Pediatrics, University of California, San Diego, CA
| | - Kathryn H Pade
- Department of Pediatrics, University of California, San Diego, CA
| | - Daniel B Park
- Department of Pediatrics and Emergency Medicine, University of North Carolina, Chapel Hill, NC
| | - Margaret Lin-Martore
- Department of Emergency Medicine and Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Aaron E Kornblith
- Department of Emergency Medicine and Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Gerardo Montes-Amaya
- Department of Pediatric Emergency Medicine, Hospital Infantil Ciudad Juárez, Chihuahua, Mexico
| | - Rosemary Thomas-Mohtat
- Department of Pediatric Emergency Medicine, Children's National Hospital, Washington, DC
| | - Jing Jin
- Department of Research and Sponsored Programs, Children's Minnesota, Minneapolis, MN
| | - Dave Watson
- Department of Research and Sponsored Programs, Children's Minnesota, Minneapolis, MN
| | - Adam Sivitz
- Department of Emergency Medicine, Newark Beth Israel Medical Center, Newark, NJ
| |
Collapse
|
27
|
Snelling PJ, Keijzers G, Byrnes J, Bade D, George S, Moore M, Jones P, Davison M, Roan R, Ware RS. Bedside Ultrasound Conducted in Kids with distal upper Limb fractures in the Emergency Department (BUCKLED): a protocol for an open-label non-inferiority diagnostic randomised controlled trial. Trials 2021; 22:282. [PMID: 33853650 PMCID: PMC8048294 DOI: 10.1186/s13063-021-05239-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 03/30/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Children frequently present to the emergency department (ED) with forearm injuries and often have x-rays to determine if there is a fracture. Bedside ultrasound, also known as point-of-care ultrasound (POCUS), is an alternative diagnostic test used to rapidly diagnose a fracture at the time of examination, without exposing children to ionising radiation. Prospective studies have demonstrated high agreement between POCUS and x-ray findings. However, whether the initial imaging modality affects the patient's medium-term physical function is unknown. METHODS This is a multicentre, open-label, non-inferiority randomised controlled trial conducted in Australian EDs. Recruitment will continue until 112 children with distal forearm injuries (including 48 buckle fractures) per trial arm have achieved the primary outcome measure. Patients aged 5-15 years presenting with an isolated, acute, clinically non-angulated, distal forearm injury with suspected fracture will have their initial diagnostic approach randomised to either POCUS, performed by a credentialled practitioner, or x-ray imaging. If a cortical breach fracture is identified on POCUS, the patient will receive x-rays and have usual care. If a buckle fracture is identified, the patient will have their forearm placed in a splint and be discharged home. Patients will be followed up at 1, 4 and 8 weeks. The primary outcome is upper limb physical function at 4 weeks, as determined by the Pediatric Upper Extremity Short Patient-Reported Outcomes Measurement Information System (PROMIS) tool. Secondary outcomes include healthcare costs, satisfaction, pain, complications, rates of imaging, ED length of stay and diagnostic accuracy. DISCUSSION If POCUS is non-inferior to x-ray in terms of patient's medium-term physical function, it may have an effect on overall health care resource use, including the number of x-ray performed and earlier ED discharge. Although prospective studies have confirmed the accuracy of POCUS, this will be the first RCT to assess non-inferiority of functional outcomes of POCUS to diagnose non-angulated paediatric distal forearm injuries, compared to x-ray. POCUS may be of particular importance in settings where access to x-ray imaging can be limited either during or after-hours, as it can aid the triaging and management of patients. TRIAL REGISTRATION Prospectively registered with the ANZCTR on 29 May 2020 ( ACTRN12620000637943 ).
Collapse
Affiliation(s)
- Peter J. Snelling
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, Queensland Australia
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland Australia
- Sonography Innovation and Research Group (Sonar Group), Southport, Queensland Australia
- Child Health Research Centre, University of Queensland, Brisbane, Queensland Australia
| | - Gerben Keijzers
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, Queensland Australia
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD Australia
| | - Joshua Byrnes
- Centre for Applied Health Economics, School of Medicine, Griffith University, Southport, Queensland Australia
| | - David Bade
- Department of Orthopaedics, Queensland Children’s Hospital, South Brisbane, Queensland Australia
| | - Shane George
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, Queensland Australia
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland Australia
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - Mark Moore
- Department of Emergency Medicine, Queensland Children’s Hospital, South Brisbane, Queensland Australia
| | - Philip Jones
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, Queensland Australia
- Emergency and Trauma Centre, Royal Brisbane and Women’s Hospital, Herston, Queensland Australia
| | - Michelle Davison
- Department of Emergency Medicine, Sunshine Coast University Hospital, Birtinya, Queensland Australia
| | - Rob Roan
- Department of Emergency Medicine, Ipswich Hospital, Ipswich, Queensland Australia
| | - Robert S. Ware
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, Queensland Australia
| |
Collapse
|
28
|
Archer-Jones A, Snelling PJ, Watkins S. Establishing a hospital-based ultrasound-guided peripheral intravenous catheter training programme: A narrative of a 5-year experience. Emerg Med Australas 2020; 32:1080-1083. [PMID: 33012110 DOI: 10.1111/1742-6723.13648] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/02/2020] [Accepted: 09/07/2020] [Indexed: 11/26/2022]
Abstract
Despite ultrasound-guided peripheral intravenous catheter insertion being a well-established method for patients with difficult intravenous access, currently there are limited hospital-based training programmes. We describe the training programme that was established in our hospital over 5 years ago and how it can be replicated in other centres.
Collapse
Affiliation(s)
- Amy Archer-Jones
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Peter J Snelling
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Sonography Innovation and Research (Sonar) Group, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Stuart Watkins
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| |
Collapse
|
29
|
Snelling PJ, Jones P, Keijzers G, Bade D, Herd DW, Ware RS. Nurse practitioner administered point-of-care ultrasound compared with X-ray for children with clinically non-angulated distal forearm fractures in the ED: a diagnostic study. Emerg Med J 2020; 38:139-145. [PMID: 32900856 DOI: 10.1136/emermed-2020-209689] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/16/2020] [Accepted: 07/21/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Paediatric distal forearm fractures are a common ED presentation. They can be diagnosed with point-of-care ultrasound (POCUS) as an alternative to X-rays. Given that ED nurse practitioners (NPs) are relied on for the diagnosis of paediatric fractures, it is important to describe the diagnostic accuracy of NP-conducted POCUS versus X-ray. METHODS This prospective diagnostic study was conducted in a tertiary paediatric hospital in Queensland, Australia, between February 2018 and April 2019. Participants were children aged 4-16 years with a clinically non-angulated, suspected distal forearm fracture. Diagnosis from 6-view NP-administered POCUS of the distal radius and ulna was compared against the reference standard of 2-view X-ray. Each patient received both imaging modalities. Overall forearm diagnosis was classified as 'no', 'buckle' or 'other' fracture for both modalities. The primary outcome was diagnostic accuracy for 'any' fracture ('buckle' and 'other' fractures combined). Secondary outcomes included diagnostic accuracy for 'other' fractures versus 'buckle' and 'no' fractures combined, and pain, imaging duration and preference for modality. RESULTS Of 204 recruited patients, 129 had X-ray-diagnosed forearm fractures. The sensitivity and specificity for NP-administered POCUS were 94.6% (95% CI 89.2% to 97.3%) and 85.3% (95% CI 75.6% to 91.6%), respectively. 'Other' fractures (mostly cortical breach fractures), when compared with 'buckle'/ 'no' fractures, had sensitivity 81.0% (95% CI 69.1% to 89.1%) and specificity 95.9% (95% CI 91.3% to 98.1%). Pain and imaging duration were clinically similar between modalities. There was a preference for POCUS by patients, parents and NPs. CONCLUSIONS NP-administered POCUS had clinically acceptable diagnostic accuracy for paediatric patients presenting with non-angulated distal forearm injuries. This included good sensitivity for diagnosis of 'any' fracture and good specificity for diagnosis of cortical breach fractures alone. Given the preference for POCUS, and the lack of difference in pain and duration between modalities, future research should consider functional outcomes comparing POCUS with X-ray in this population in a randomised controlled trial.
Collapse
Affiliation(s)
- Peter J Snelling
- School of Medicine, Griffith University Faculty of Health, Southport, Queensland, Australia .,Department of Emergency Medicine, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia.,Sonography Innovation and Research Group (Sonar Group), Southport, Queensland, Australia.,Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia
| | - Philip Jones
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Gerben Keijzers
- School of Medicine, Griffith University Faculty of Health, Southport, Queensland, Australia.,Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia.,Faculty of Health Sciences and Medicine, Bond University, Southport, Queensland, Australia
| | - David Bade
- Department of Orthopaedics, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - David W Herd
- Department of Emergency Medicine, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia
| | - Robert S Ware
- Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
| |
Collapse
|
30
|
Affiliation(s)
- Peter J Snelling
- Emergency Department, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia.,Department of Paediatrics, Greenslopes Private Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Mark Tessaro
- Emergency Department, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|