Emergent Pediatric Ultrasound. Katharine Dennis, RDMS/RVT Tiffany Schultz, RDMS UNC Health Care Dept of General Ultrasound

Transcription

1 Emergent Pediatric Ultrasound Katharine Dennis, RDMS/RVT Tiffany Schultz, RDMS UNC Health Care Dept of General Ultrasound

2 Introduction

3 Learning Objectives Review common pediatric emergent ultrasound exams Summarizes conditions associated with exams comparing normal and abnormal anatomy Understand the role of ultrasound Understand the importance of its accessibility, cost effectiveness and lack of exposure to radiation Identify pitfalls Review cases of exams

4 Common Pediatric Emergent Exams in U/S Appendicitis Intussusception Midgut Volvulos Hip effusions Pyloric Stenosis Ovarian torsion Testicular Torsion

5 Why Ultrasound? Decreases exposure to radiation Advantages of Ultrasound Relatively inexpensive Does not typically require sedation Peds limited in communication Peds are smaller Peds can decompensate faster

6 Appendix Tube-shaped structure typically located 1-2 cm below ileal-cecal valve posteriomedially Normally measures 6 mm in diameter Three important landmarks Psoas Muscle Illiac Vessels Cecum (Terminal Illeum if possible)

7 Appendicitis Lumen becomes inflamed and ischemic eventually leading to infection and possibly rupture Most common condition requiring surgery in pediatrics Peak age of incidence 5-15 yo Symptoms and Presentation Differentials Pitfalls

8 Location of Appendix

9 Location of Appendix

10 Early Appendicitis

11 Early Appendicitis

12 Early Appendicitis

13 Appendicolith

14 Appendicitis/ Appendicolith

15 Appendicolith

16 Appendicolith

17 Intussusception Small bowel prolapses or telescopes into adjacent segment Most common form of small bowel obstruction in children Highest occurrence between ages 6 months to 4 years Peak incidence 5-9 months More common in males 2/1 Pt with Cystic Fibrosis may be at higher risk

18 Intussusception Ileocolic most common type followed by ileoileal and colocolic Early detection important to avoid injury to bowel 2/2 ischemia and necroses necessitating surgical removal of bowel and risk of sepsis Can be corrected/reduced in most cases utilizing air enema and floroscopy avoiding surgery Fatal if left untreated Paradoxically spontaneous reduction is not uncommon (especially in pts with hyperperistalsis)

19 Necrotic Intussusception

20 Necrotic Intussusception

21 Necrotic Intussusception

22 Necrotic Intussusception

23 Necrotic Intussusception

24 Necrotic Intussusception

25 Midgut Volvulus Most severe type of malrotation of the intestines Seen in infants less than 1yo Ultrasound is not the primary modality may been noted incidentally, esp in abd u/s ordered to assess pyloris Infants can present with similar appearance as pts with pyloric stenosis Important indicator on ultrasound would be reversal of position of SMA and SMV

26 Midgut Volvulus

27 Midgut Volvulus

28 Midgut Volvulus Positive Negative

29 Normal Vessel Orientaion

30 Midgut Volvulus

31 Midgut Volvulus

32 Hip Effusions Excessive fluid in the hip joint If septic may lead to permanent damage that can limit mobility Can be drained under ultrasound guidance

33 Hip Effusions Septic joint more often seen in pts under the age of three Symptoms of Fever Elevated WBC Unable to bare weight

34 Hip Effusions Scanning Technique Measurements

35 Hip Effusions Cases

36 Pyloric Stenosis The pylorus is the opening from the stomach into the small intestine; therefore, this condition is also known as gastric outlet obstruction In case of pyloric stenosis, the muscles of the pylorus become thickened due to hypertrophy thus preventing stomach contents to empty into the small intestine. The causes of this condition are unknown; however, some correlation to genetics have been noted. Babies of parents who had P.S. are more likely to have the condition as well Pyloric stenosis is a very common condition

37 Pyloric Stenosis Age less than 6 months of age Symptoms: Projectile vomiting =j&sa=x&ei=pqtqupbyn4sq8asv8idodq&ved=0cesquaiwbg&q=newborn+projectile+vo miting+video&usg=afqjcnhhtz89vdsaejonvasd7k78cldn8g Weight loss Constant hunger Dehydration and lethargy Clinical findings/symptoms: Wave-like motion of abdomen after feeding and just prior to vomiting The pyloric olive

38 Pyloric Stenosis The pyloric channel is considered stenosed when it measures larger than 17mm in length and 3mm in thickness Is the test a STAT exam?

39 Pyloric Stenosis How is the study performed? Baseline images obtained AVOID IMAGING ESOPHAGUS Position the infant Feed infant Image pylorus

40 Positive Exam

41 Positive Exam

42 Swirl Effect

43 Negative Exam

44 Negative Exam

45 Negative Exam

46 Pitfall Imaging the Esophagus

47 Pitfall Imaging the Esophagus

48 Ovarian Torsion Twisting of the ovary around the ligaments which support it. This may result in loss of blood supply to both the ovary and the fallopian tube. Torsion in normally precipitated by another condition or disease.

49 Ovarian Torsion Unilateral Age - Early reproductive yearsmid 20 s Predisposing conditions Developmental abnormalities Cysts or other masses (i.e teratomas) Malignant = Greater risk Larger size = Larger risk

50 Ovarian Torsion Symptoms Sudden onset of worsening severe, unilateral lower abdominal pain Nausea and vomiting Fever (later stages) Previous episodes of pain

51 Ovarian Torsion TRUE STAT EXAM Early detection = Ovarian salvage Early detection = Reduced risk of complications Laproscopy is the gold standard of diagnosis Postive = dusky, blue-black appearance

52 Ovarian Torsion and the Sonographer Color Doppler imaging is essential Where color Doppler fails, power Doppler may be beneficial Detection of flow is more important that direction of flow in this case Spectral waveform must be documented to rule out torsion Arterial and venous flow

53

54 Laproscopic Diagnosis

55 Positive for Torsion 5 year old

56 Positive for Torsion Doppler

57 Positive for Torsion

58 Positive for Torsion 16 year old - Adnexal Mass

59 Positive for Torsion

60 Testicular Torsion Twisting of the spermatic cord, which cuts off the blood supply to the testicle and surrounding scrotal structures This condition results in ischemic injury to the testis and infarction. The condition may also result in loss of the testis.

61 Testicular Torsion Causes Trauma to the scrotum Strenuous exercise Puberty May not have an obvious cause Cryptorchidism Symptoms Acute onset of severe scrotal pain Redness Unilateral scrotal swelling Nausea and vomiting

62 Testicular Torsion Role of the Sonographer True STAT exam 6 hours to save the testicle DOPPLER, DOPPLER, DOPPLER Absence of blood flow is a key indicator in diagnosing testicular torsion DON T GET DISCOURAGED!

63 Testicular Torsion Treatments Manual Detorsion Surgery Detorsion Orchiopexy Possible orchiectomy

64 Surgical Examination Within the Scrotum Undescended Testicle

65 Positive for Testicular Torsion 10 year old

66 Positive for Testicular Torsion 10 year old

67 Positive for Testicular Torsion 14 year old Normal Appearing Testicles

68 Positive for Testicular Torsion 14 year old

69 Positive for Testicular Torsion 14 year old

70 Positive for Testicular Torsion 15 year old

71 Positive for Testicular Torsion 15 year old Testicle and Epididymal Torsion

72 Positive for Testicular Torsion 15 year old

73 Positive for Testicular Torsion 17 year old

74 Positive for Testicular Torsion 17 year old

75 Positive for Testicular Torsion 15 year old

76 Positive for Testicular Torsion 15 year old