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

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

Introduction

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

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

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

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)

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

Location of Appendix

Early Appendicitis

Appendicolith

Appendicitis/ Appendicolith

Appendicolith

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

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)

Necrotic Intussusception

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

Midgut Volvulus

Midgut Volvulus Positive Negative

Normal Vessel Orientaion

Midgut Volvulus

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

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

Hip Effusions Scanning Technique Measurements

Hip Effusions Cases

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

Pyloric Stenosis Age less than 6 months of age Symptoms: Projectile vomiting http://www.google.com/url?url=http://www.youtube.com/watch%3fv%3d5vzemr4nhge&rct =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

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?

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

Positive Exam

Swirl Effect

Negative Exam

Pitfall Imaging the Esophagus

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.

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

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

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

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

Laproscopic Diagnosis

Positive for Torsion 5 year old

Positive for Torsion Doppler

Positive for Torsion

Positive for Torsion 16 year old - Adnexal Mass

Positive for Torsion

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.

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

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!

Testicular Torsion Treatments Manual Detorsion Surgery Detorsion Orchiopexy Possible orchiectomy

Surgical Examination Within the Scrotum Undescended Testicle

Positive for Testicular Torsion 10 year old

Positive for Testicular Torsion 14 year old Normal Appearing Testicles

Positive for Testicular Torsion 14 year old

Positive for Testicular Torsion 15 year old

Positive for Testicular Torsion 15 year old Testicle and Epididymal Torsion

Positive for Testicular Torsion 15 year old

Positive for Testicular Torsion 17 year old

Positive for Testicular Torsion 15 year old