Ultraspund in Pediatric Emergency

9/14/14
www.medscape.com/viewarticle/830536_print
www.medscape.com
Ultrasound in Pediatric Emergencies

Gaurav Saigal, MD, Jennifer Runco Therrien, MD, and Frank Kuo, BS
Appl Radiol. 2014;43(8)
Abstract and Introduction

Introduction
Ultrasound (US) imaging has several advantages over other radiologic imaging modalities, particularly in the emergency
department (ED). It is a low cost, non-invasive, easily accessible and painless imaging modality that can be quickly performed
at the bedside of an unstable or very ill patient. It is easily reproducible and can be repeated multiple times without any risk.
However, the greatest advantage of US over other imaging modalities, such as computed tomography (CT), is the absence of
ionizing radiation. As evidence of harmful effects of radiation due to CT continues to increase, US is gaining greater acceptance
as the imaging modality of choice in the pediatric emergency setting. The main disadvantage of US is operator dependence.
This review article highlights the use of US in evaluating common emergency conditions in children presenting to the ED.
Traumatic Pathology
Focused assessment with sonography for trauma (FAST) is a rapidly performed bedside study to identify ectopic abdominal
fluid. The four locations typically examined for free fluid include the right upper quadrant (perihepatic space or the Morison's
pouch), the left upper quadrant (perisplenic space), the pericardium and the pelvis. A positive FAST is defined as the presence
of fluid, seen as an anechoic volume in dependent regions of the peritoneal cavity (Figure 1). For an unstable patient with blunt
trauma, the speed and cost of ultrasound (US) are significantly better than either diagnostic peritoneal lavage or CT. In addition,
including US for trauma in the ED results in decreased time to operative care and more efficient utilization of ED resources.[1]
1/22
9/14/14
Figure 1.
A 3-year-old, status post MVA. FAST ultrasound demonstrates the presence of free fluid (white arrows) in the pelvis (A) and the
2/22
9/14/14
left upper quadrant, surrounding the spleen (B). Axial CT scan of the abdomen (C) demonstrates a splenic laceration (black
arrow).
Abdominal Pathology
Malrotation and Volvulus
Intestinal malrotation is a developmental abnormality leading to a decrease in the length of the mesenteric root, predisposing
the midgut to rotation. One of the most dangerous sequelae of malrotation is volvulus, a medical emergency that causes bowel
obstruction, ischemia of and necrosis of the affected intestine. Patients can present with bilious vomiting, failure to thrive,
abdominal pain and other nonspecific symptoms. Although an upper gastrointestinal (UGI) contrast study is the gold standard
of diagnosis, US can also be useful, particularly when results of the UGI study are equivocal. On US, the anatomical
relationship of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) may be reversed (Figure 2A).
Normally, the SMV is to the right of the SMA. With midgut volvulus, the SMV may occupy a position directly anterior or to the
left of the SMA. It is important to note, however, that a normal SMA/SMV relationship does not exclude volvulus and the UGI
study remains the imaging gold standard. Conversely, some children without volvulus may have a vertical or inverted SMA/SMV
relationship.[2]
3/22
9/14/14
Figure 2.
An 8-month-old presented to the ED with bilious vomiting. Gray-scale (A) and color Doppler (B) images demonstrate the SMV
(long white arrow) curving anterior and to the left of the SMA (black arrow). On the color Doppler image, there is twisting of the
mesenteric vessels (short white arrows) around the SMA (black arrow), also known as the "whirlpool" sign of volvulus.
On US, twisting of the mesenteric vessels and superior mesenteric veins (SMV) around the superior mesenteric artery (SMA)
can produce a "whirlpool sign" on color Doppler US (Figure 2B).[3] Other US signs of volvulus include the "hyperdynamic
pulsating SMA" or the "truncated SMA" sign.[4,5]
Pyloric Stenosis
Although not a true emergency, pyloric stenosis is common in the ED. Pyloric stenosis occurs when hypertrophy of the pyloric
muscle causes narrowing, resulting in projectile non-bilious vomiting. The physical exam may reveal an olive-shaped mass in
the right upper quadrant of the abdomen. US is the modality of choice when suspecting pyloric stenosis.[6] The main diagnostic
4/22
9/14/14
criterion is a measurement of greater than 3mm in the thickness of the muscular layer of a single wall of the pylorus (Figure 3).
Elongation of the canal greater than 12mm has also been reported as an abnormal finding, but is less reliable due to the
difficulty in achieving reproducible measurements.[7] Other findings include hypertrophy of the mucosa, gastric distension with
active peristalsis and redundant mucosa protruding through the antrum. Some technical maneuvers which might be useful while
performing the US include laying the patient right-side down (allowing gas to move away from the pylorus), use of sugar water
to feed (not only helps in calming the baby but also provides a good acoustic medium for the ultrasound beam) and observing
the pylorus during the study for any passage of stomach content through the pyloric channel.[8]
Figure 3.
A 4-week-old boy with non-bilious vomiting. Axial (A) image of the right upper quadrant demonstrates a hypoechoic rounded
structure (black arrow) posterior to the gallbladder (long white arrow) consistent with the pylorus. Longitudinal image (B)
demonstrates the elongated and thickened pylorus, with each muscular wall measuring 5 mm and the length as 21.5 mm,
consistent with hypertrophic pyloric stenosis. The centrally seen echogenic linear bands (short white arrows) represent the
mucosa and should not be included in the measurements.
Intussusception
Intussusception occurs when part of the intestine invaginates or telescopes into a distal portion of bowel, causing obstruction.
Symptoms include nausea, vomiting, crampy abdominal pain, and rectal bleeding classically described as "red currant jelly."
Most patients are between the ages of 6 months and 2 years. Prognosis is improved by early diagnosis. US has a high
sensitivity of 98-100% and specificity of 88100%.[9] US findings include a soft-tissue abdominal mass corresponding to the
intussusception. The intussusception appears as a "target" or "donut" sign (Figure 4) created by the receiving bowel loopintussuscipiens, and the proximal prolapsing bowel loop- intussusceptum, with echogenic intervening mesenteric fat. Another
US appearance described is the "pseudokidney" sign, when mesentery containing fat and vessels are dragged into the
intussusception, suggesting the US appearance of the renal hilum, with the apparent renal parenchyma formed by the
surrounding edematous bowel.[10] Ultrasound can also be useful in detecting a lead point, such as lymph nodes, polyps,
duplication cysts (Figure 5) and Meckel's diverticulum, among others. Trapped fluid within the intussusception (Figure 5) and
absence of blood flow to the bowel on Doppler imaging have been described as signs of ischemia and decreased reducibility .[9]
Recently, successful reduction with ultrasound-guided hydrostatic pressure has been performed in some institutions.[11]
5/22
9/14/14
Figure 4.
Ultrasound of the mid abdomen of a 1-year-old with abdominal distension and bloody stools. A rounded mass having a 'targetlike' appearance consistent with an intussusception is noted in the upper abdomen (A). Longitudinal image (B) of the mass
nicely depicts the intussusceptum (short white arrow) protruding into the intussuscipiens (short black arrows). The echogenic
structure between the bowel loops (long white arrow) represents the mesenteric fat caught in the intussusception. Doppler
image (C) demonstrates preserved vascularity in the intussuscepted bowel. Image (D) demonstrates multiple enlarged
mesenteric lymph nodes (long black arrows) in the vicinity, felt to be the leading point for the intussusception.
6/22
9/14/14
Figure 5.
A 9-month-old child with increased fussiness and blood-tinged stool. Ultrasound images of the right lower quadrant (A-C)
demonstrate a rounded mass consistent with an intussusception. A rounded cystic structure demonstrating "gut" signature
(white arrow) was noted within the intussusception (white arrow), suggesting a duplication cyst. A small amount of free fluid
was noted within the loops of the intussusceptum (black arrow), considered to be a sign of decreased reducibility and
ischemia.
Appendicitis
Appendicitis is the most common childhood surgical emergency. The diagnosis is challenging, particularly in younger children,
potentially leading to a false negative diagnosis with potential for perforation and other complications. Although primarily a
clinical diagnosis, imaging studies can aid in confirmation and reducing the number of negative appendectomies. US has a
sensitivity of 88% and specificity of 94% according to a meta-analysis of studies from 1986 to 2004.[12] US evaluation is
performed using a high frequency linear transducer and graded compression technique. Gentle pressure is applied to the right
lower quadrant to displace normal bowel loops and ascertain the position of the nonperistaltic cecum. The appendix usually lies
just lateral to the cecum and anterior to the iliac vessels. Positive findings of appendicitis include an outer diameter greater than
6 mm, a noncompressible lumen arising from the base of the cecum, echogenic periappendiceal inflammatory fat changes, an
appendicolith or a periappendiceal fluid collection (Figures 6 and 7). Enlarged mesenteric lymph nodes or signs of a perforated
appendix such as an abscess can also be seen.
7/22
9/14/14
Figure 6.
Ultrasound images of the abdomen in a 5-year-old child presenting with right lower quadrant pain (A, B). A dilated fluid-filled
tubular structure demonstrating increased vascularity is noted in the right lower quadrant (short white arrows). Transverse
images of the dilated structure demonstrate a diameter of 1.4 cm, as well as non-compressibility, findings consistent with
appendicitis.
8/22
9/14/14
Figure 7.
Ultrasound of the abdomen in a child presenting with pain for the past two days demonstrates a collection in the right lower
quadrant with an underlying tubular structure (short white arrows), felt to represent a ruptured appendicitis, which was confirmed
at surgery.
9/22
9/14/14
Scrotal Pathology
US is the primary imaging modality for evaluating the acute scrotum in children. Common pediatric scrotal diseases seen in the
ED include testicular torsion, testicular appendage torsion, epididymitis, orchitis, hernia, hematocele and abscess. Familiarity
with ultrasound technique, characteristics and common pitfalls is essential to differentiate these conditions, establish an
accurate diagnosis, and initiate treatment.
Testicular Torsion
The principle objective in imaging the child with acute scrotal pain is to promptly detect testicular torsion. Testicular torsion
results when an abnormally mobile testis twists on the spermatic cord, obstructing its blood supply. Testicular torsion is a
surgical emergency since ischemia can lead to testicular necrosis and nonviability if not corrected within 6 hours of onset of
symptoms.[13] Severe testicular pain is the most common presenting symptom.
On color Doppler, complete absence of intratesticular blood flow and normal extratesticular blood flow is diagnostic (Figure
8).[13,14] The presence of flow within the testis does not exclude torsion, since incomplete vascular obstruction can sometimes
occur from intermittent torsion. Using a linear-array high-frequency (714 MHz) transducer, the asymptomatic testis is scanned
to optimize settings for low flow, resistance and velocity. Once a satisfactory image of the asymptomatic side is obtained, the
painful symptomatic side is studied without changing machine settings.[15]
Figure 8.
A 9-year-old boy presenting with right testicular pain for the past 12 hours. Gray-scale (A) and color Doppler (B) ultrasound
images of both testes demonstrate an altered echogenicity of the right testicle compared to the left. Doppler image of both
testes side to side demonstrates absence of flow in the right testicle with preserved flow in the left, using the same ultrasound
settings. Right-sided testicular torsion was noted at surgery and right sided orchiectomy was performed.
Gray-scale sonography has no role in diagnosing torsion, but can effectively display the sequelae of testicular ischemia and
predict viability.[13] During the first 6 hours after symptom onset, when the testis is salvageable, normal architecture and
echogenicity is typically preserved. Over the next 24 hours, the testis becomes enlarged, susually hypoechoic or
inhomogeneous, associated with edema of the epididymis and scrotal wall. These alterations indicate decreased likelihood of
viability. Imaging both testes simultaneously in transverse orientation is the optimal technique to identify subtle sonographic
differences (Figure 8).[16]
Testicular torsion can be a diagnostic challenge because blood flow is often difficult to detect in normal small prepubertal
10/22
9/14/14
testes. Torsion may be partial or intermittent so arterial flow is not necessarily absent. The testis can also undergo
spontaneous detorsion and ischemia may be secondary to other conditions (vasculitis, trauma, epididymitis-ochitis).[13,16]
Hydrocele and scrotal skin thickening are common findings in the majority of these conditions and thus nonspecific.
Torsion of Testicular Appendage
In a child with an acute scrotum, torsion of a testicular appendage represents the most common cause of scrotal pain.[17]
Testicular appendages are remnants of the paramesonephric duct and are usually located at the superior testicular or
epididymal head.[18] Patients are typically under 13 yrs. of age and the onset of pain is more gradual than that seen with
testicular torsion; thus, patients often present days after symptoms develop. An avascular structure in an area of increased
vascularity, separate from the typically enlarged testis and epididymis is the characteristic appearance of testicular appendage
torsion (Figure 9).[17] Torsion can lead to increased vascularity in the epididymis and testis and thus may mimic epididymitis
and/or orchitis. The torsed appendage becomes more echogenic with time and can eventually calcify or slough off as a calcified
loose body between the layers of the tunica vaginalis; referred to as a "scrotal pearl."
Figure 9.
A 10-year-old with right scrotal pain. US of the scrotum-transverse (A) and longitudinal (B) images demonstrate enlargement of
the right scrotum with underlying heterogeneously enlarged and hypervascular epididymis (white arrows). There is increased
flow in the right epididymis and the testis compared to the contralateral side. A heterogeneous, centrally hyperechoic avascular
structure is noted within the area of the increased vascularity (black arrows), consistent with a torsed testicular appendage.
Epididymitis
Epididymitis is more common in young adults secondary to sexually transmitted pathogens. However, it also occurs in children
and is usually idiopathic, due to retrograde urinary tract infection or may be related to an underlying urogenital anomaly.[18] In
the acute setting, the epididymis appears enlarged and heterogeneous on gray-scale US and demonstrates increased flow on
color Doppler (Figure 10).[14,16] The adjacent testis is concurrently involved in 20% of cases, occurring more commonly in
adults.[14,18] A heterogeneous, enlarged and hyperemic testis is characteristic of orchitis. Orchitis without epididymitis is
typical of infection by the paramyxovirus, which causes mumps.[15] Complications include abscess and infarction, both of
which can be easily mistaken for torsion.[19]
11/22
9/14/14
Figure 10.
A 14-year-old boy presenting with right scrotal pain. Longitudinal (A) Color Doppler image of the right scrotum demonstrates
marked increased vascularity (white arrows) in an enlarged and heterogeneous-appearing right epididymis, consistent with
epididymitis. Transverse image (B) with the left side for comparison shows normal minimal flow (black arrow) in the left
epididymis.
Testicular Trauma
In the setting of trauma, accurately diagnosing testicular rupture is important, since treatment involves urgent surgical repair.
On gray-scale US, the testicle appears heterogeneous with irregular contours and the tunica albuginea is disrupted (Figure
11A, B).[18,20] Hematocele is the most common finding following trauma, which initially appears echogenic becoming
hypoechoic as it evolves. The hematocele is avascular on color Doppler.[19]
12/22
9/14/14
Figure 11.
A young adult male presented with trauma to his scrotum and scrotal pain following a motorcycle accident. Testicular
ultrasound (a, b) demonstrates a heterogeneous, predominantly echogenic left testis (solid white arrow) with markedly irregular
and lobulated contours and no color flow compared to the normal right testis (red arrow). A large left scrotal hematoma was
also present with scrotal edema (dotted white arrow). At surgery, tunica albuginea lacerations and a large scrotal hematoma
were found.
Hernia
Intrascrotal inguinal hernia occurs through the patent processus vaginalis. Imaging should begin with the patient supine and
then standing. The bowel or omentum is visualized separately from the normal testis and epididymis. Absence of peristalsis on
real-time scanning is worrisome for incarceration, another cause of acute scrotal pain.
Pelvic Pathology
Ovarian
US is the imaging modality of choice for evaluating the pediatric female pelvis to exclude or diagnose emergency surgical
conditions, including ovarian torsion, ectopic pregnancy and abscess. Functional ovarian (follicular) cysts result from failure of
involution during the normal menstrual cycle. Bleeding into or rupture of a functional ovarian cyst is a cause of pain and may
mimic acute appendicitis.[21] Non-hemorrhagic ovarian cysts appear as avascular, anechoic, thin-walled masses with posterior
acoustic enhancement. Most cysts are small and resolve without treatment, but some may be large (up to 6 cm), in which
case follow-up is recommended to ensure resolution. The US appearance of hemorrhagic cysts depends on the age of the
blood, but typically they appear as avascular complex adnexal masses with septations and internal echoes in a "lace-like
pattern" with some degree of through transmission.[22,23]
Congenital Anomalies
Congenital anomalies are not infrequently encountered in the ED as a cause of pain in the female child or adolescent.
Hydrocolpos, hydrometrocolpos and hematametrocolpos in adolescents are typically caused by an imperforate hymen, leading
to filling of the uterus and/or vagina with fluid and blood. US demonstrates a pelvic cystic mass with a fluid-debris level (Figure
12A-C).[21,22] Many cases of hydrometrocolpos in the neonate are associated with a urogenital sinus or cloacal
malformation.[21, 23] Failure of the Mullerian or para-mesonephric ducts to reach the urogenital sinus causes accumulation of
uterine secretions proximal to the vaginal occlusion. This anomaly may present as a bulging mass between the labia in
neonates or with primary amenorrhea and cyclical lower abdominal pain in adolescents.[22]
13/22
9/14/14
Figure 12.
An 11-year-old girl presented with pelvic pain. Relevant history was that the patient had never previously menstruated. On
sagittal and transverse (A, B) gray-scale sonographic images of the pelvis, the vagina (solid white arrow) is markedly distended
with echogenic material compatible with fluid and blood. The uterus (dotted white arrow) is visualized superior to the vagina on
sagittal ultrasound and CT images (A, C) and the endometrial cavity is also distended but to a lesser extent with fluid and blood
in this patient with hematometrocolpos.
Ovarian Torsion
Ovarian torsion is more common in patients with predisposing lesions, such as ovarian cysts or masses (teratomas), and is
due to excessive mobility of the ovary.[22,24] Presentation is often confusing clinically and includes abrupt onset of severe lower
abdominal pain usually preceded by intermittent pain or palpation of a pelvic mass.[23] Torsion initially occludes the venous
circulation and, if untreated, progresses to occlude the arterial circulation. On US, the ovary appears diffusely enlarged with
multiple peripheral follicles. (Figure 13A-B).[25] Additional findings include a complex pelvic mass, free fluid in the pouch of
Douglas and absence of flow on color Doppler. However, lack of flow on color Doppler is not a reliable diagnostic criterion, as
arterial flow has been seen in surgically proven ovarian torsion likely due to a dual arterial supply or preceding venous
thrombosis.[21,24,25]
14/22
9/14/14
Figure 13.
A 13-year-old girl with right-sided pelvic pain. (A) Ultrasound demonstrates an enlarged and heterogeneous-appearing right
ovary demonstrating multiple cysts. A dominant large cyst measuring up to 4.7cm (white arrow) was noted. (B) No vascularity
was detected on color Doppler. At surgery, the right ovary was torsed and nonviable with omentum caked to it.
Pancreaticobiliary Pathology
The pancreas and biliary system are well evaluated with US in the acute setting. Imaging findings in pancreatitis are similar to
adults and include diffuse or focal, often hypoechoic, pancreatic enlargement and dilatation of the pancreatic duct.[2628]
Pseudocyst, pancreatic abscess, necrosis and hemorrhage are the main complications. However, the causes differ in the
pediatric setting and are usually idiopathic or related to trauma or congenital structural anomalies such as pancreatic divisum
and choledochal cysts. Choledochal cysts are congenital cystic malformations of the biliary tree. Patients typically present
with episodic pain, jaundice, a right upper quadrant mass or clinical pancreatitis.[26] US can easily localize and measure the
degree of biliary dilatation and differentiate among the five types of biliary congenital choledochal cysts (Figures 14 and 15).
15/22
9/14/14
Figure 14.
A 2-year-old presented with severe colicky abdominal pain lasting a few minutes then resolving without treatment.
Intussusception was suspected clinically. Gray-scale sonographic image of the right upper quadrant (A) demonstrates tortuous
and fusiform dilation of the common bile duct (solid white arrow. Subsequent MRCP (B) nicely illustrates the fusiform common
bile duct dilation without intrahepatic or extrahepatic dilatation or obstruction. Findings were consistent with a choledochal cyst
type 1.
Figure 15.
A 12-year-old with severe abdominal pain and elevated amylase. Gray-scale ultrasound (A) demonstrates a markedly and
16/22
9/14/14
diffusely enlarged common bile duct (solid white arrow). Gallbladder appeared normal (dashed white arrow). Image through the
left hepatic lobe (B) demonstrates a cystic structure with posterior acoustic enhancement (solid red arrow). Subsequent MRCP
(C) nicely illustrates the diffuse marked dilatation of the common bile duct and cystic structure in the left hepatic lobe. At
surgery, this was as a confirmed type 4a choledochal cyst.
Renal Pathology
Pediatric renal disease, including pyelonephritis, ureteropelvic junction (UPJ) obstruction and rarely nephrolithiasis, is a
frequent cause of abdominal pain. Although the sensitivity of US in detecting acute pyelonephritis is low, the sensitivity for
complications, including abscess and pyonephrosis, is quite high.[29] On US, the infected kidney appears enlarged with focal or
diffuse areas of abnormal echogenicity and loss of corticomedullary differentiation. Power Doppler increases sensitivity by
detecting decreased perfusion in the affected area of the kidney.[30,31]
UPJ obstruction can be secondary to intrinsic causes or extrinsic compression secondary to bands, kinks or aberrant vessels.
Patients may present with a palpable mass, urinary tract infection or hematuria. US can detect a dilated renal pelvis
communicating with dilated calyces, however, the renal pelvis is dilated out of proportion to the calyces and the distal ureter is
not seen. It is essential to differentiate UPJ obstruction from a multicystic dysplastic kidney, which very often occurs in the
contralateral kidney and appears as multiple non-communicating cysts of varying sizes.[3133]
Cranial Pathology
In a young infant (with an open anterior fontanelle), presenting to the ER with an enlarging head circumference, cranial US can
be used not only to rule out a parenchymal abnormality (hemorrhage, hydrocephalus, tumor, etc.) but also to differentiate
benign enlargement of subarachnoid spaces (BESS) from subdural collections, particularly hematomas. BESS refers to
excessive CSF accumulation in the subarachnoid spaces (particularly in the frontal regions) in infants.[34] The exact cause is
unknown, but arachnoid villi immaturity has been hypothesized as one of the probable causes.[35] Identifying subdural
hematomas as the cause of extra-axial collections is particularly important in the setting of non-accidental trauma. Doppler
imaging is extremely useful in differentiating BESS from subdural hematoma (Figure 16).[36] In BESS, multiple vessels can be
seen traversing the extra-axial collections, which helps in localizing collections to the subarachnoid space. Collections in the
subdural space, on the other hand, displace vessels towards the surface of the brain.
17/22
9/14/14
Figure 16.
Child presenting with enlarging head circumference. Coronal US image (A) demonstrates isoechoic prominence of the extraaxial spaces bilaterally (short white arrows). Oblique color Doppler images towards the prominent spaces (B, C) demonstrate
the vessels (long white arrows) displaced towards the cortical surface bilaterally, suggesting that the collections are not benign
extra-axial fluid (subarachnoid spaces), but are subdural in location. A CT scan (not shown) demonstrated chronic subdural
hematomas bilaterally. Coronal image (D) in a different patient with prominent CSF spaces demonstrates vessels traversing the
spaces (black arrows), suggesting subarachnoid CSF accumulation as a cause of the widening of the CSF spaces.
Musculoskeletal Pathology
US applications in MSK pathology include evaluation of joint effusions (particularly of the hip), guidance for percutaneous
drainage and localization of non-radiopaque foreign bodies.
Hip Effusion
Hip effusions have various etiologies. However, when a pediatric patient presents with fever, pain, and refusal to bear weight on
one limb, septic arthritis or transient synovitis are the most likely diagnoses. Transient or toxic synovitis is a self-limiting
inflammation of the joint space precipitated by a prior infection (classically an upper respiratory infection) or allergy.[36] A hip
effusion may or may not always be present in transient synovitis (Figure 17). In septic arthritis, it is extremely important to
diagnose and treat quickly due to the potential devastating consequence of joint destruction.[37] Usually, joint effusions are
18/22
9/14/14
clear in transient synovitis and contain debris (due to purulent fluid) in cases of septic arthritis.[38] However, this may not
always be the case and the currently accepted mode of practice is US- guided aspiration of fluid, even if clear, to exclude the
possibility of septic arthritis.[39,40] If no fluid is seen on the US, the cause is presumed to be due to transient synovitis,
particularly if other clinical signs and symptoms favor the diagnosis and no invasive procedure is necessary.
Figure 17.
Male child presenting at 1 yr refusing to walk on the left lower extremity following history of a viral infection a few days before.
Longitudinal US views of the hips side-by-side for comparison demonstrate a left-sided hip effusion (white arrows). Note that the
effusion usually collects just anterior to the neck of the femur in a dependent portion of the joint. No effusion is noted in the
contralateral joint space.
Foreign Bodies
A high-frequency linear transducer is used for the localization of foreign bodies.[41] Usually, a "stand-off pad" is used for better
sound transmission and an improved view of the underlying soft tissues. Foreign bodies usually appear hyperechoic in relation
to the surrounding soft tissues.[41] Material such as wood or plastic tends to produce shadowing, whereas metallic objects
produce reverberation or a "comet-tail" artifact.[42,43] Color Doppler can be utilized to ensure that there are no vascular
structures adjacent to the foreign body.[43]
Conclusion
Ultrasonography has many applications in the evaluation of pediatric patients presenting to the ED with both traumatic and nontraumatic emergencies. Because of its rapidity, ease of use and absence of ionizing radiation, US has not only been used to
make or exclude diagnoses, but it has also become the modality of choice in the imaging of both the stable and unstable
pediatric patient in the ED.
References
1. Melniker LA, Leibner E, McKenney MG, et al. Randomized controlled clinical trial of point-of-care, limited
ultrasonography for trauma in the emergency department: The first sonography outcomes assessment program trial.
Ann Emerg Med. 2006;48:227235.
2. Zerin JM, DiPietro MA. Superior mesenteric vascular anatomy at US in patients with surgically proved malrotation of the
midgut. Radiology. 1992;183:693694.
3. Shimanuki Y, Aihara T, Takano H, et al. Clockwise whirlpool sign at color Doppler US: An objective and definite sign of
midgut volvulus. Radiology. 1996;199:261264.
4. Smet MH, Marchal G, Ceulemans R, Eggermont E. The solitary hyperdynamic pulsating superior mesenteric artery: An
19/22
9/14/14
additional dynamic sonographic feature of midgut volvulus. Pediatr Radiol. 1991;21:156157.

5. Sze RW, Guillerman RP, Krauter D, Evans AS. A possible new ancillary sign for diagnosing midgut volvulus: The
truncated superior mesenteric artery. J Ultrasound Med.2002;21:477480.
6. Hiorns MP. Gastrointestinal tract imaging in children: Current techniques. Pediatr Radiol. 2011;41:4254.
7. Reed AA, Michael K. Hypertrophic pyloric stenosis. J Diag Med Sonography. 2010;26:157160.
8. Costa Dias S, Swinson S, Torro H, et al. Hypertrophic pyloric stenosis: Tips and tricks for ultrasound
diagnosis.Insights Imaging. 2012;3:247250.
9. Del-Pozo G, Albillos JC, Tejedor D, et al. Intussusception in children: Current concepts in diagnosis and enema
reduction. Radiographics. 1999;19:299319.
10. Kairam N, Kaiafis C, Shih R. Diagnosis of pediatric intussusception by an emergency physician-performed bedside
ultrasound: A case report. Pediatr Emerg Care. 2009;25:177180.
11. Bahadr lger FE, Ulger A, Karakaya AE, et al. An easy, safe and effective method for the treatment of intussusception:
Ultrasound-guided hydrostatic reduction. Ulus Travma Acil Cerrahi Derg. 2014;20:12731.doi:10.5505/tjtes.2014.37898.
Turkish.
12. Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for diagnosis of appendicitis in children and adults? A metaanalysis. Radiology. 2006;241:8394.
13. Cassar S, Bhatt S, Paltiel HJ, Dogra VS. Role of spectral Doppler sonography in the evaluation of partial testicular
torsion.J Ultrasound Med. 2008;27:16291638.
14. Stengel JW Remer EM. Sonography of the scrotum: Case-based review. AJR Am J Roentgenol. 2008;190:S35-S41.
15. Dogra VS, Gottlieb RH, Oka M, Rubens RJ. Sonography of the scrotum. Radiology. 2003;227:1836.
16. Frush DP, Sheldon CA. Diagnostic imaging for pediatric scrotal disorders. Radiographics. 1998;18:969985.
17. Baldisserotto M, de Souza JCK, Pertence AP, Dora MD. Color Doppler sonography of normal and torsed testicular
appendages in children. AJR Am J Roentgenol. 2005;184:12871292.
18. Sung EK, Setty BN, Castro-Aragon I. Sonography of the pediatric scrotum: Emphasis on the Ts-torsion, trauma, and
tumors. AJR Am J Roentgenol. 2012;198: 9961003.
19. Carkaci S, Ozkan E, Lane D, Yang WT. Scrotal sonography revisited. J Clin Ultrasound. 2010;38:2137.
20. Bhatt S, Dogra VS. Role of US in testicular and scrotal trauma. Radiographics. 2008;28:16171629.
21. Servaes S, Victoria T, Lovrenski J, Epelman M. Contemporary pediatric gynecologic imaging. Semin Ultrasound CT
MRI. 2010;31:116140.
22. Stranzinger E, Strouse PJ. Ultrasound of the pediatric female pelvis. Semin Ultrasound CT MRI. 2008;29:98113.
23. Cohen HL, Bober SE, Bow SN. Imaging the pediatric pelvis: the normal and abnormal genital tract and simulators of its
diseases. Urol Radiol. 1992;14:273283.
24. Garel L, Dubois J, Grignon A, et al. US of the pediatric female pelvis: A clinical perspective. Radiographics.
2001;21:13931407.
25. Shadinger LL, Andreotti RF, Kurian RL. Preoperative sonographic and clinical characteristics as predictors of ovarian
torsion. J Ultrasound Med. 2008;27:713.
20/22
9/14/14
26. Nievelstein RAJ, Robben SGF, Blickman JG. Hepatobiliary and pancreatic imaging in children-techniques and an
overview of non-neoplastic disease entities. Pediatr Radiol. 2011;41:5575.
27. Babcock DS. Sonography of the acute abdomen in the pediatric patient. J Ultrasound Med. 2002;21:887899.
28. Berrocal T, Prieto C, Pastor I, et al. Sonography of pancreatic disease in infants and children. Radiographics.
1995;15:301313.
29. Finnell SME, Carroll AE, Downs SM, Subcommittee on Urinary Tract Infection. Diagnosis and management of an initial
UTI in febrile infants and young children. Pediatrics. 2011;128: e749-e770.
30. Stogianni A, Nikolopoulos P, Oikonomou I, et al. Childhood acute pyelonephritis: comparison of power Doppler
sonography and Tc-DMSA scintigraphy. Pediatr Radiol. 2007;37:685690.
31. Brader P, Riccabona M, Schwarz T, et al. Value of comprehensive renal ultrasound in children with acute urinary tract
infection for assessment of renal involvement: comparison with DMSA scintigraphy and final diagnosis. Eur Radiol.
2008;18: 29812989.
32. Avni FE, Garel C, Cassart M, et al. Imaging and classification of congenital cystic renal diseases. AJR Am J
Roentgenol. 2012;198:10041013.
33. Wootton-Gorges SL1, Thomas KB, Harned RK, et al. Giant cystic abdominal masses in children. Pediatr Radiol.
2005;35: 12771288.
34. Hamza M, Bodensteiner JB, Noorani PA, Barnes PD. Benign extracerebral fluid collections: A cause of macrocrania in
infancy. Pediatr Neurol. 1987;3:218221.
35. Zahl SM, Egge A, Helseth E, Wester K. Benign external hydrocephalus: A review, with emphasis on management.
Neurosurg Rev. 2011;34: 417432.
Chen CY, Chou TY, Zimmerman RA, et al. Pericerebral fluid collection: Differentiation of enlarged subarachnoid spaces
from subdural collections with color Doppler US. Radiology. 1996;201:389392.
36. Nouri A, Walmsley D, Pruszczynski B, Synder M. Transient synovitis of the hip: A comprehensive review.J Pediatr
Orthop B. 2014;23:3236.
37. Eich GF, Superti-Furga A, Umbricht FS, Willi UV. The painful hip: Evaluation of criteria for clinical decision-making. Eur
J Pediatr. 1999;158:923928.
38. Zawin JK, Hoffer FA, Rand FF, Teele RL. Joint effusion in children with an irritable hip: US diagnosis and aspiration.
Radiology. 1993;187:459463.
39. Liberman B, Herman A, Schindler A, et al. The value of hip aspiration in pediatric transient synovitis. J Pediatr Orthop.
2013;33:124127.
40. Dodwell ER. Osteomyelitis and septic arthritis in children: Current concepts. Curr Opin Pediatr. 2013;25:5863.
41. Thapa M, Vo JN, Shiels WE 2nd. Ultrasound-guided musculoskeletal procedures in children. Pediatr Radiol. 2013;43
Suppl 1:S5560.
42. Shiels WE 2nd. Soft tissue foreign bodies: Sonographic diagnosis and therapeutic management. Ultrasound Clinics.
2007;2: 669681.
43. Bianchi S, Martinoli C. Ultrasound of the musculosk eletal system. Berlin: Springer, 2007.
Appl Radiol. 2014;43(8) 2014 Anderson Publishing, Ltd.
21/22
9/14/14
22/22

Ultraspund in Pediatric Emergency

Încărcat de

Informații document

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Ultraspund in Pediatric Emergency

Încărcat de

Drepturi de autor:

Formate disponibile

9/14/14

Ultrasound in Pediatric Emergencies

Abstract and Introduction

additional dynamic sonographic feature of midgut volvulus. Pediatr Radiol. 1991;21:156157.

S-ar putea să vă placă și