PEM Network Jan'13 Newsletter


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PEM Network Jan'13 Newsletter

  1. 1. January 2013 FOCUS ON ULTRASOUND Contents: Letter from the Editors.....................1 Ultrasound Training - Lorraine Ng, David Kessler.....................................2 Pearls and Pitfalls of Ultrasonography......4 Board Review - Imaging in PEM...............5 Case Highlight - Intussusception............7 Highlights from the SOEM Meeting............8 Top 10 Articles in Pediatric Emergency Medicine, 2011-2012.........................9 Image Feature: Bedside Ultrasound in a Baby with Respiratory Distress..................10 Case Highlight: Baby with a Neck Mass.....11 PEMNetwork Fellowship Section Update.......12 For Authors................................13 From the Editors: Ultrasound is becoming an increasingly useful and vital part of the practice of pediatric emergency medicine. PEM Ultrasound fellowships are emerging, and new uses for ultrasound in our daily practice are being described in the literature on a constant basis. For those of us with interest in ultrasound, we cannot learn fast enough. For those of us without solid ultrasound skills, the learning process is intimidating and it can be hard to know where to start. With this in mind, we present our Winter Newsletter with a focus on ultrasound, featuring established experts in the field, and cases demonstrating the varied use of ultrasound in practice. All cases presented were performed by novice ultrasonographers. We hope this will encourage our readers to pick up that probe! [1]
  2. 2. Formal pediatric emergency ultrasound training programs are on the rise! Lorraine Ng, MD, David O. Kessler, MD, MSc, RDMS Columbia University Medical Center Emergency ultrasound (EUS) has been deemed a core competency for emergency medicine residents by the American College of Physicians (ACEP) since 2002.1 The past two decades have seen a transformation in the role of EUS from a novel toy to standard practice and full integration of a wide variety of applications in the emergency department. This role has been accompanied by a robust growing body of literature to support the use of EUS in clinical decision-making, guiding resuscitative care, and improving procedural safety and success. Pediatric emergency medicine (PEM) training programs have not yet adopted ultrasound as a core competency, however ultrasound use in the pediatric emergency department and training opportunities have also been on the rise.2 Despite the increase in training and exposure to EUS within PEM fellowships, very few programs (~25%) have a formal curriculum becoming a local “champion,” he also adds for those seeking to hone their ultrasound skills during fellowship, “If you have an ultrasound fellowship already at your institution, you could potentially gain competency through regular use and attendance at lectures, similar to EM residents.” That’s exactly the strategy that Dr. Jennifer Marin started out with, now director of Pediatric Emergency Ultrasound at the Children’s Hospital of Pittsburgh. "I began my ultrasound experience when I was a first year fellow, being introduced to the FAST exam during my trauma rotation. From there, I developed a research interest using bedside ultrasound and then decided to improve my skills even further by creating a training program for myself during an extra year of fellowship."   By obtaining a grant through the NIH to fund an additional year of research, she was also able to design her own EUS experience that mirrored the EUS fellowship at the neighboring, general emergency department in which she attended weekly video clip reviews, had mentored scanning shifts, and pursued further ultrasound teaching responsibilities.   leading many to pursue further training. We spoke with several leaders in the field to learn more about their paths to expertise Wait, fellowships do exist? and where they see the future of this exciting new field. Have no fear, formal training opportunities for PEM trainees are rapidly on the rise. Many have already “Scan as much as possible - even What is the best way to learn during my PEM fellowship? if you don't know what you are looking at!” says Dr. Alex Arroyo, Director of Pediatric Emergency Medicine Ultrasound Research at Maimonides Medical Center. But warns, “there are some things you just can’t get from self-teaching and an informal "mini" fellowship,” says Dr. Arroyo. “Scan, scan, scan, there is no substitute for actually using ultrasound on a regular basis and getting hands-on instruction by knowledgeable attending staff,” agrees Dr. Adam Sivitz, the Director of Pediatric Emergency Medicine at the Children's Hospital of New Jersey at Newark Beth Israel Medical, where they currently have a 2-day bootcamp and 2-week elective for their PEM fellows, along with regular education and hands-on use throughout fellowship. While Dr. Sivitz recommends fellowship for those interested in pursuing an US career or taken advantage of formal specialization in EUS through tailor-made curriculums at one of the many non-ACGME accredited 1 or 2 year fellowships ( There are currently 86 EUS fellowships nationwide, with an increasing number of pediatric EUS fellowships offering US expertise tailored to PEM. Directors of EUS programs around the country, such as Dr. J. Christian Fox from University of California, Irvine School of Medicine, Dr. Arun Nagdev from Highland General Hospital, Dr. John Bailitz from Cook County Emergency Medicine in Chicago, Dr. Resa E. Lewiss from St. Luke’s Roosevelt Hospital Center in New York City, Dr. John Kendall from Denver Health Medical Center, and Dr. Gregory Press from University of Texas at Houston, to name a few, have begun to train PEM fellows in their fellowships as well because they “realize PEM is in need of ultrasound leaders.” Recently, several pediatric emergency medicine divisions have also created additional fellowship training programs in [2]
  3. 3. pediatric EUS (e.g. Boston Children’s Hospital, Columbia Dr. Arroyo adamantly agreed that the extra year was University, Maimonides Medical Center, and Oakland Children’s worthwhile, “If you took my ultrasound skills away I would rather Hospital). not practice medicine - that’s how much I depend on it on a daily Fellowships provide time for intensive hands-on scanning with basis.” direct feedback on performance to allow for rapid improvement and expertise in ultrasound scanning and interpretation. Additional “I think any good PEM fellowship will have an focus on relevant literature, scholarly projects, teaching ultrasound component, and most responsibilities, and administrative topics round out a fellow’s As training becomes more pervasive, will fellowships become obsolete one day? experience to help nurture them as true experts in the field. When training pediatric EUS fellows, the fellowship should have “access to a busy pediatric ED with extensive opportunities to scan kids, [since the pediatric US] applications fellows will be looking to have this built into their curriculum” says Dr. Nagdev.  And Dr. Fox suggests that “It will only [become obsolete] when all medical are so unique [they] can't be reproduced in an adult population,” schools have fully integrated ultrasound into states Dr. John Kendall, the Director of Emergency Ultrasound at their curricula.” Denver Health Medical Center, where they have had an EUS But as the field of pediatric EUS develops, there will still fellowship since 2005 and incorporated pediatric US fellowship always be a demand for pediatric EUS-trained leaders to train our training into the standard EUS curriculum. PEM colleagues and to conduct cutting-edge research to support the integration of EUS into routine PEM practice. At the end of the day, regardless of how you choose to tailor your pediatric EUS According to Dr. Stephanie Doniger, who is Is it worth the extra year? training, whether it is supplementing your PEM fellowship with now Director of Ultrasound at the Children’s independent scanning or pursuing a pediatric EUS fellowship, the Hospital and Research Center in Oakland most important thing to do is follow Dr. Sivitz’s advice and “Scan, and runs a PEM EUS fellowship, it was “the scan, scan!” absolute best decision I ever made.” As the first PEM trainee to ever do a formal fellowship at St Luke’s Roosevelt Hospital Center in New York City, she learned the skills necessary to become an internationally renowned educator, develop her own training curriculum, and oversee faculty development at her next job. “A one month rotation just didn’t seem enough to [learn] to ULTRASOUND BLOG/PODCAST http:// ULTRASOUND LISTSERVE  Email and ask to be added to receive weekly updates of articles published on emergency ultrasound topics 1. Akhtar S, Theodoro D, Gaspari R, Tayal V, Sierzenski P, LaMantia J, Stahmer S, Raio C. Resident Training in Emergency Ultrasound: Consensus Recommendations from the 2008 Council of Emergency Medicine Residency Directors Conference. Academic Emergency Medicine. 2009; 16:S32-36. 2. Marin JR, Zuckerbraun NS, Kahn JM. Use of emergency ultrasound in United States Pediatric Emergency Medicine Fellowship programs in 2011. J Ultrasound Med. 2012;31:1357-63. effectively teach other people.” Useful Ultrasound Links References: ULTRASOUND SOCIETIES OR SECTIONS: soundbytes echo_atlas/views/index.html emergency-ultrasound ULTRASOUND app: ULTRASOUND LEARNING/ SHARING WEBSITES: 2012/10/emultrasound-app- iphone/ [3] These links will also be available on the ultrasound sub-site of
  4. 4. Pearls and Pitfalls of Bedside Ultrasound - an Interview with Lei Chen - Michelle Alletag Q Can you tell me a bit about when/how ultrasound became a commonly-used modality in Emergency medicine? A Q In the late 90's European trauma surgeons started using ultrasound to diagnose intra-abdominal injuries.  With the rapid technological breakthroughs of miniaturization portable US became a reality.  How much time and training does it take to become proficient with the ultrasound machine?  What are some easyto-learn diagnoses/applications? A I think the FAST scan is the one that novice should start with.  Not because it's the easiest but because it helps illustrate several salient features of ultrasound: different tissues, different orientations, dynamic imaging, etc. etc.  It's hard to say how many scans. ACEP has a consensus statement on training for a variety of modalities and is a good reference.  Procedural applications are often easier to learn.  These include vascular access, abscess I&D, nerve blocks, etc.  The success and failure of the procedures give you immediate feedback on your study. Q There are few faculty in my ED who use the ultrasound machine - how do I get existing faculty on-board with bedside ultrasound? A Q There was one patient in our PICU where no one could obtain vascular access except for the EM resident with a borrowed ultrasound machine.  The next week a machine was delivered.  Ultrasound is becoming very popular and the PEM community has embraced it as a skill we need, but what are some caveats and pitfalls to PEM physicians using ultrasound? A In general for diagnostic studies specificity is higher than sensitivities.  Therefore bedside ultrasound is not good, in general, to rule OUT diagnosis.  So for conditions with high potential morbidities such as ovarian / testicular torsion, appendicitis, etc. I would be very careful in using a negative bedside ultrasound to discharge the patient. Q What are the medico-legal implications of adding ultrasound to our skill set and credentialing?  Our malpractice rates are already pretty high...How can we ensure an appropriate review process and quality assurance? A You need to work with your hospital / institution credentialing body which have their own rules.  For procedural studies there is general consensus that ultrasound improves success rates and decreases complications.  For diagnostic tests it gets much trickier.  Again I would avoid those conditions mentioned previously, or at least not rely on the bedside reading exclusively, without confirmatory testing.  [4] Dr. Chen is an Associate Professor of Pediatric Emergency Medicine at Yale University and has contributed extensively to the study and development of ultrasound in PEM.
  5. 5. BOARD REVIEW: IMAGING IN PEDIATRIC EMERGENCY MEDICINE Questions used with permission by Jennifer Pai, MD, editor of Pediatric Emergency Medicine Practice. For full text and more review topics, visit topics.php. All reviews published >36 months ago are free for viewing. 1. The amount of experience and training required by a non-radiologist to perform a focused exam is: c. A low-frequency probe is most appropriate for evaluation of the superficial soft tissues. d. Ultrasound is of no value in evaluating simple cellulitis. a. Not definitively established b. 300 completed studies 5. Which of the following is true? c. 150 completed studies a. A-mode ultrasound is the most frequently used today d. 8 hours of hands-on training b. M-mode is a form of Doppler ultrasound c. Color Doppler gives a quantitative measurement of flow 2. Which of the following is NOT true? d. Doppler ultrasound is dependent on how the probe is held relative a. Ultrasound is defined as frequency greater than 20,000 hertz. to the direction of the moving object. b. Hypoechoic objects appear dark on the ultrasound screen. c. High-frequency ultrasound penetrates deeper into tissues than 6. An intrauterine pregnancy can be confirmed earliest low-frequency ultrasound. by: d. Urine in the bladder will appear black because it does not reflect ultrasound waves well. a. Quantitative human chorionic gonadotropin (HCG) b. Endovaginal sonography (EVS) 3. With respect to FAST scans, which of these statements are true? c. Transabdominal sonography (TAS) d. Doppler a. The most common practice uses four ultrasound views, but 7. The indirect method of venous cannulation using ultrasound guidance requires: additional views are sometimes obtained. b. FAST scans are useful for identifying free fluid in the abdomen and somewhat less so for solid organ injury. a. Sterile transducer sleeve c. A normal FAST scan may occur if there is not enough free b. At least 2 people to perform intraperitoneal fluid. c. Sterile gel d. All of the above. d. One person without special preparations 4. Choose the best statement. 8. The most common ultrasound probe placement for a rapid cardiac exam is: a. For soft tissue ultrasound, use of a curved ultrasound probe allows for better contact with the skin. a. Transesophageal b. A spacer or stand-off may help place the are of interest within the optimal focal zone of the ultrasound probe. b. Parasternal c. Apical d. Subxiphoid [5] Answers and discussion, next page
  6. 6. Imaging in PEM: Answers 1. a. Not definitively established 5. d. Doppler ultrasound is dependent on how the probe is held relative to the direction of the moving object. Though all of the above choices have been issued in consensus statements, studies have shown that ED physicians can accomplish a high degree of accuracy in as little as 4 hours of training. More important “bright”), with object intensity corresponding to echogenicity. M-mode is than following consensus statements is implementing a process for a time-motion mode that shows both the traditional B-mode image and a continued experience and quality review. tracing of tissue motion (e.g. fetal heartbeat). Doppler ultrasound utilizes The most commonly used mode of ultrasound is B-mode (or the fact that ultrasound (or any sound wave, to be exact) beam frequency 2. c. High-frequency ultrasound penetrates deeper into increases if an object moves toward it, and decreases as it moves away. tissues than low-frequency. Color doppler provides a visual interpretation of directionality and velocity High-frequency transducers (such as the linear probe commonly of flow. used in bedside ultrasound) have beams that are more unidirectional and focused with shorter wavelengths, so images are high resolution but 6. b. Transvaginal ultrasound attenuate quickly. Attenuation is the process of “losing power” as the While quantitative HCG can confirm a pregnancy earlier that ultrasound, it ultrasound beam travels through tissue. Lower frequency transducers, is not specific for intrauterine pregnancy (IUP). At 5-6 weeks gestation, TV such as the curvilinear probe, have longer wavelengths, are more ultrasound can confirm the presence of a gestational sac, with multidirectional, and penetrate deeper into tissues, providing a lower- transabdominal able to confirm slightly later. At 6-7 weeks, a fetal pole resolution but deeper picture. and, at 7-8 weeks, a cardiac flicker may be then visible by either modality, though TV provides higher quality images and can detect each 3. d. All of the above approximately one week earlier than TAS. Confirming an IUP in the female patient with abdominal pain or bleeding can effectively rule out ectopic The FAST exam is designed primarily to detect free fluid in the abdominal cavity, which translates to blood in the setting of abdominal pregnancy (though the risk of a second ectopic pregnancy may be as high trauma. The classic FAST method is a four-view scan, beginning with the as 1:4000, or greater if fertility agents are used) RUQ and Morrison’s pouch, followed by the LUQ, subxiphoid region (to assess for pericardial effusion), and the suprapubic region. If free fluid is 7. d. One person without special preparation found, the adjacent organ may be assessed to evaluate for injury, thought the FAST is less sensitive for this. While FAST is highly sensitive and method of cannulation, and simply uses the ultrasound probe to locate specific in adult trauma, its sensitivity decreases in the pediatric setting. and mark the site of a vessel prior to attempted cannulation. Light This is due to many factors, but primarily because children are more likely pressure on the vessel to flatten and thus confirm that it is a vein is to have organ injury without corresponding major blood loss, and are less performed prior to attempted cannulation. This method can be performed likely to bleed with a volume sufficient to produce the anechoic strip that by a single provider without any special preparation. The direct method indicates free fluid. Specificity of FAST, however, remains high for children requires more preparation and is best performed with 2 operators, and as well as adults. uses ultrasound to directly visualize the needle as it is being cannulated. The indirect method provides less guidance than the direct A linear high-frequency probe should be used for this method, as 4. b. A spacer or stand-off may help place the are of interest curvilinear will distort the image. Ultrasound-guided central line placement is currently considered standard of care in the adult emergency within the optimal focal zone of the ultrasound probe. setting, though formal guidelines in the pediatric setting have not yet been High-frequency linear transducers produce the best quality images of superficial soft tissue structures and can be useful in evaluating established. cellulitis and presence/absence of drainable abscesses. A spacer or stand-off can be useful in cases of very superficial skin and soft tissue 8. d. Subxiphoid structures that are closer to the probe than the usual focus zone - commercial products are available, but the use of a glove filled with water evaluating pericardial effusions and cardiac standstill, and is the view is an excellent and inexpensive alternative. For foreign body evaluation, a included in ATLS and PALS teaching. The parasternal views may provide stand-off, made by placing the extremity in a basin of water and then additional information about cardiac function. The subcostal view is placing the probe on the water’s surface, is also useful. obtained by placing the transducer just below the xiphoid and aiming A single subcostal (subxyphoid) view is the most useful for toward the patient’s left shoulder. This places the right ventricle at the top of the screen, and provides a “reverse” image of standard echocardiography images. [6]
  7. 7. CASE HIGHLIGHT: A NASTY CASE OF INTUSSUSCEPTION Carrie Busch MD, William S Russell MD, Jeanne Hill MD, Christian Streck MD Medical University of South Carolina The Patient: A 3yo afebrile female presented to the received 60cc/kg of NS with improvement in her vital signs. Bedside emergency department (ED) with 1 day of ultrasound was performed and there abdominal pain in “waves” with emesis and was evidence of fluid filled loops of negative hemoccult. She had a negative bowel, abnormal thick-walled bowel without laboratory evaluation and had an abdominal blood flow on color doppler and extensive ultrasound (US) that demonstrated complicated fluid. [Figures 2, 3 & 4] The intussusception. [Figure 1] She was taken for patient was taken to the operating room for an air enema during which the exploratory laparotomy and was found to intussusception was no longer visualized. have 40cm of necrotic bowel. [Figure 5] Intra- This was confirmed with repeat US operatively, she was coagulopathic and septic immediately after the enema. She was then requiring resection and temporary abdominal observed in the PED where her pain resolved closure with a delayed re-anastomosis and she was discharged home after tolerating following resuscitation in the PICU. oral hydration. The family received strict discharge instructions to return to the ED with Discussion: any recurrence of symptoms. However, they Intussusception is a common cause of did not return until 2 days later despite return bowel obstruction in children and carries a of emesis, abdominal pain and fever shortly mortality of less than 1%. US is the initial after discharge. At that time, the patient imaging modality of choice and has been presented to her primary physician in reported to be 92% sensitive for uncompensated shock. She was transported intussusception. Many studies have sited to the PED with a surgical abdomen. She non-operative reduction techniques as [7] Figure 1 (Top Left) demonstrates pathognomonic target sign of intussusception. From Top, Figures 2 (fluid filled loops), 3 (absence of flow), 4 (complicated fluid collection), and 5 (necrotic bowel at time of surgery).
  8. 8. successful with minimal reported however, illustrates that necrosis can be of intussusceptions can be handled non- seen in the absence of a distinct re- operatively with maximal success rates in intussusception episode. While we the setting of <24 hours of symptoms and cannot rule out recurrence, we suspect in the typical age range of 6 months to 3 the clinical course observed is the result of years. An enema reduction using air or an ischemic segment that evolved to full water soluble contrast is recommended thickness necrosis in the 48 hours post for the most common location, ileocolic. reduction. We present this case as a rare In some centers, a short observation complication that illustrates the necessity period and discharge is routine for strict return precautions and next day management providing patients tolerate follow-up when an early discharge model oral hydration and have no return of is followed. This extreme case illustrates abdominal pain. However many that even seemingly routine cases of institutions routinely admit for a longer intussusception can have complications. observational period secondary to It also demonstrates that in the setting of concern for recurrence. This is estimated symptom return after intussusception to happen in approximately 10% of cases. reduction, a negative US for recurrent Bowel wall compromise and necrosis is a intussusception does not exclude known complication of unreduced or Case Highlight: Intussusception, cont. recurrent intussusception. Our case, complications. The overwhelming majority intussusception- related pathology. HIGHLIGHTS FROM SOEM A Note from the Head Site Administrator Angela Lumba, MD, FAAP St. Louis Childrens Hospital In October 2012, the AAP held its annual National Conference Exhibit in New Orleans. The Section on Emergency Medicine (SOEM) and its Committee for the Future opened the session with Technology in Pediatric Emergency Medicine. Through speeches and poster presentations, physicians shared ways they had innovated PEM education through advancing technology. The PEMNetwork was one of the many ideas highlighted! The SOEM continued to deliver our annual favorites: EmergiQuiz – a platform for fellows to explore the diagnosis and management of unique cases PEMPix – A collection of photo submissions of interesting to extreme presentations I first attended the SOEM NCE plenary session as a resident with hopes of PEM fellowship. To this day, I am inspired by the presentations I hear, by the camaraderie at the meeting, and by the depth and breadth of topics covered. I recommend that every trainee or junior faculty member attend this energetic and dynamic conference. Abstract sessions Top 10 PEM articles of 2012 - see next page for list [8] EmergiQuiz presentations can be viewed on Visit the AAP SOEM website to see PEMPix entries and winners.
  9. 9. #5 Top 10 PEM Articles 2011-2012 Diagnosis  of  Intussuscep:on  by  Physician  Novice  Sonographers   in  the  Emergency  Department Antonio  Riera,  MD,  Allen  L.  Hsiao,  MD,  Melissa  L.  Langhan,  MD,  T.  Rob   Goodman,  MBBChir;  Lei  Chen,  MD,  MHS Michelle D. Stevenson, MD MS FAAP Ann  Emerg  Med.  2012;60:264-­‐268. PMID:  22424652   University of Louisville #4 #10 Yield  of  Emergent  Neuroimaging  Among  Children  Presen:ng   With  a  First  Complex  Febrile  Seizure   Amir  A.  Kimia,  MD;  Elana  Ben-­‐Joseph,  MD;  Sanjay  Prabhu,  MD,  MBBS,   FRCR;  Tiffany  Rudloe,  MD;  Andrew  Capraro,  MD;  Dean  Sarco,  MD;  David   Hummel,  MSc;  Marvin  Harper,  MD Rapid  Versus  Standard  Intravenous  Rehydra:on  in  Paediatric   Gastroenteri:s:  Pragma:c  Blinded Randomised  Clinical  Trial Stephen  B.  Freedman,  MD;  Patricia  C.  Parkin,  MD;  Andrew  R.  Willan,   PhD;  Suzanne  Schuh,  MD Pediatr  Emerg  Care  2012;28:  316-­‐321 PMID:  22453723   BMJ  2011;343:d6976 PMID:  22094316   Vasopressin  rescue  for  in-­‐pediatric  intensive  care  unit   cardiopulmonary  arrest  refractory  to  ini:al  epinephrine  dosing: A  prospec:ve  feasibility  pilot  trial Prevalence  of  Clinically  Important  Trauma:c  Brain  Injuries  in   Children  With  Minor  Blunt  Head  Trauma  and  Isolated  Severe   Injury  Mechanisms #3   #9 Timothy  G.  Carroll,  MD;  Vivian  V.  Dimas,  MD;  Tia  Tortoriello  Raymond,   MD Pediatr  Crit  Care  Med  2012;  13:265–272 PMID:  21926666 #8 Lise  E.  Nigrovic,  MD,  MPH;  Lois  K.  Lee,  MD,  MPH;  John  Hoyle,  MD;  Rachel   M.  Stanley,  MD;  Marc  H.  Gorelick,  MD;  Michelle  Miskin,  MS;  Shireen  M.   Atabaki,  MD;  Peter  S.  Dayan,  MD,  MSc;  James  F.  Holmes,  MD,  MPH;   Nathan  Kuppermann,  MD,  MPH;  for  the  TraumaXc  Brain  Injury  (TBI)   Working  Group  of  the  Pediatric  Emergency  Care  Applied  Research   Network  (PECARN) Arch  Pediatr  Adolesc  Med.  2012;166(4):356-­‐361. PMID:  22147762     U:lity  of  Plain  Radiographs  in  Detec:ng  Trauma:c  Injuries  of   the  Cervical  Spine  in  Children Lise  E.  Nigrovic,  MD,  MPH;  Alexander  J.  Rogers,  MD;  Kathleen  M.   #2   Adelgais,  MD,  MPH;  Cody  S.  Olsen,  MS;  Jeffrey  R.  Leonard,  MD;  David  M.   Prevalence  of  Abusive  Injuries  in  Siblings  and  Household   Jaffe,  MD;  and  Julie  C.  Leonard,  MD,  MPH;  for  the  Pediatric  Emergency   Contacts  of  Physically  Abused  Children Care  Applied  Research  Network  (PECARN)  Cervical  Spine  Study  Group   Daniel  M.  Lindberg,  MD;  Robert  A.  Shapiro,  MD;  AntoineUe  L.  Laskey,   Pediatr  Emerg  Care  2012;28:  426-­‐432. MD,  MPH;  Daniel  J.  Pallin,  MD,  MPH;  Emily  A.  Blood,  PhD;  Rachel  P.   PMID:  22531194 Berger,  MD,  MPH;  and  for  the  ExSTRA  InvesXgators   Pediatrics  2012;130;193-­‐201. PMID:  22778300   #1   Intramuscular  versus  Intravenous  Therapy  for  Prehospital   Status  Epilep:cus #7 Occult  Serious  Bacterial  Infec:on  in  Infants Younger  Than  60  to  90  Days  With  Bronchioli:s Shawn  Ralston,  MD;  Vanessa  Hill,  MD;  Ami  Waters,  MD Arch  Pediatr  Adolesc  Med.  2011;165(10):951-­‐956. PMID:  21969396   Robert  Silbergleit,  MD;  Valerie  Durkalski,  PhD;  Daniel  Lowenstein,  MD;   Robin  Conwit,  MD;  Arthur  Pancioli,  MD;  Yuko  Palesch,  PhD;  and  William   Barsan,  MD;  for  the  NETT  InvesXgators #6 The  Spectrum  and  Frequency  of  Cri:cal  Procedures  Performed   in  a  Pediatric  Emergency  Department:  Implica:ons  of  a   Provider-­‐Level  View N  Engl  J  Med  2012;366:591-­‐600. PMID:  22335744 MaUhew  R.  MiVga,  MD,  Gary  L.  Geis,  MD,  Benjamin  T.  Kerrey,  MD,  MS,   Andrea  S.  Rinderknecht,  MD Ann  Emerg  Med.  2012;  Jul  26.  [Epub  ahead  of  print] PMID:  22841174   [9] Visit or the AAP SOEM site for article summaries, description of article selection methodology, honorable mentions and more!
  10. 10. IMAGE HIGHLIGHT: BEDSIDE ECHO IN THE EVALUATION OF A BABY IN RESPIRATORY FAILURE David Rodriguez, MD His anterior fontanelle was flat. Rhinorrhea and UT Southwestern Medical Center congestion were present but mucous A 19 week old term male, with no significant medical problems presents to the Emergency Department (ED) with difficulty breathing. He has had 1 week of congestion and increased work of breathing but no fever. Over the past 2-3 days he has had decreased activity, decreased oral intake, and mildly decreased urine output but normal stools. He was seen at an Urgent Care Center 3 days prior and started on amoxicillin for “infection.” Seen by PCP 2 days prior, started on albuterol and steroids for bronchiolitis. Also seen yesterday and again today by PCP for follow up, again given nebulizer treatments, but sent to the ED due to increased wob. O2 sats reportedly improved from 90 to 94% RA after nebulizer treatments. Presenting vital signs are as follows: BP 110/44 | Pulse 157 | Temp(Src) 36.6 °C (97.9 °F) (Temporal) | Resp 58 SpO2 98% (RA)  On physical exam, he was well-developed and well-nourished, active and with a strong cry. A very abnormal subxiphoid view CXR shows severe cardiomegaly. Bedside ultrasound demonstrates no cardiac effusion, but the right ventricle is severely dilated, with poor contractility easily noted on video. Watch the ultrasound video clip of this heart on [10] membranes were moist. Oropharynx and ears were clear. Neck was supple. Cardiac exam was normal, with no murmur. Tachypnea, subcostal retractions, and accessory muscle usage present. Transmitted upper airway sounds were present but no wheezes, rales, or rhonchi. Abdomen was soft with normal bowel sounds and no organomegaly. Skin was warm with a normal capilary refill time. No purpura, rash, pallor or cyanosis were noted. The patient had bulb suction and lavage, but became dusky and cyanotic. He was taken to the critical care room. There he was in severe respiratory distress with a respiratory rate in the 80's, using accessory muscles. He was intubated using atropine, fentanyl, and rocuronium. Bedside US showed decreased cardiac contractility. CXR showed good tube placement and severe cardiomegaly. EKG showed inverted T waves in the lateral leads. Cardiology was called to perform an emergent bedside echo prior to admission to the cardiac ICU, with the diagnosis of myocarditis.
  11. 11. Case Highlight THE BABY WITH A NECK MASS Peter Moyer, MD; Yale University Michelle Alletag, MD; UT Southwestern Medical Center The Case: An 8 day old male born via SVD presents to the ED with a left neck mass. The mother first noted the mass three days prior, and states it has been getting darker but not larger in size. Per mother, the patient has been feeding well, alert, and afebrile. The patient did require forceps extraction, but birth was otherwise uncomplicated. On exam, the baby is alert, with normal vital signs for age. He has two palpable masses on the left neck; one is 1x3cm over the mastoid, with a second 1x1cm mass over the angle of the mandible. Both are red and firm, with no fluctuance or induration. The patient’s neck is supple, and a right parietal cephalohematoma is also noted. He has a slight head tilt to the left but full passive and active ROM. The remainder of the exam is unremarkable. Ultrasound of the neck demonstrated two echogenic masses along the anterior aspect of the sternocleidomastoid, with Doppler evidence of internal vascularity and no cystic component. The diagnosis of congenital fibromatosis coli (or psuedotumor of infancy) was made. The patient’s mother was instructed on home care for congenital torticollis, and the patient had resolution of the masses at his two-month well-child visit. Discussion: Congenital fibromatosis coli is a benign condition in neonates, which may result in congenital muscular torticollis and positional plagiocephaly. It presents as a palpable, firm, nontender mass along the border of the sternocleidomastoid (SCM) muscle. It often leads to contracture and fibrosis of the underlying SCM, resulting in congenital torticollis and head tilt. It occurs equally among boys and girls, and is associated with other congenital musculoskeletal anomalies (most often hip dysplasia). The cause of fibromatosis coli is unclear, but is thought to be the result of one of two insults: fetal malpositioning in utero leading to contracture and fibrosis, or birth trauma resulting in muscular fibrosis. The forceps delivery, cephalohematoma, and visible hematoma over our patient’s masses support the latter etiology in his case. Differential diagnosis must include more pathologic conditions such as lymphadenitis, congenital cystic lesions with abscess, and oncologic processes, including sarcomas, teratomas, or lymphomas. Diagnosis is best made by ultrasound evaluation, which shows echogenicity with fusiform enlargement of the SCM, and excludes the diagnoses of lymphadenitis, congenital cysts, or abscess. While CT, MRI, and fine needle aspirate will also establish the diagnosis, ultrasonography has the advantage of lower cost, lack of radiation exposure, and avoidance of sedation. Treatment for fibromatosis coli consists of massage, heat, and passive stretching, with the majority of patients having complete resolution with home treatment alone. Those who do not resolve within the first year of life should be referred to an otolaryngologist, as they may require surgical intervention. [11] Above, the baby presents with a large erythematous region near the mastoid. Ultrasound of the affected area (Figure 2) shows hypertrophy of the SCM as compared with the contralateral normal side (Figure 3). No evidence of cellulitis, “cobblestoning”, lymphadenopathy, or fluid collections was noted.
  12. 12. From the Fellowship Corner Hello everyone, First and foremost, we would like to congratulate everyone who matched into PEM this year! It was a great match with a 143 individuals matching into PEM fellowship positions at 71 different programs around the country after completing either a Pediatrics or Emergency Medicine residency. We are very excited to have these individuals join the ranks of PEM and look forward to having them as colleagues. Congratulations again! We are also eagerly anticipating this year’s PEM Fellows’ Conference, which will be taking place from February 23rd through February 25th, 2013 in Austin, Texas. This year’s conference will be supported by the EMSC Program and Austin Children’s Hospital Medical Center. A wonderful program has been planned and we look forward to this opportunity for so many PEM fellows from around the country to come together for a weekend. We hope you all had a wonderful holiday season. Saranya Srinavasan, MD Pediatric Emergency Medicine Fellow Children's Hospital Los Angeles  [12]
  13. 13. WANT TO BE A PART OF PEMNETWORK.ORG? Now it’s easier than ever! PEMNetwork is a dynamic, ever-evolving organization and we are always looking for new ideas and input. Do you have a great case or interesting teaching point that you wish you could share with someone besides those same fellows you see every week? Send it to us at! Recommended Newsletter Submission Formats: Case Reports: May include presentation of uncommon diagnoses or of unusual presentation or complications of common diagnoses seen in the Pediatric Acute Care setting. Should consist of a brief, 1-2 paragraph description of the case, followed by a discussion of diagnosis and management of the disease process reported. Inclusion of images, either of physical exam findings or radiographic studies, are recommended. A minimum of 3 references for the discussion section is requested. EKG Submissions: Classic EKG findings of disease processes found in the acute care setting are welcome. Please include an image of the EKG, description of the EKG findings, 1-2 sentences describing the case, and a brief discussion of the disease process being shown. References are requested but not required. Image Highlights: May include an image of an interesting physical exam finding, or a radiologic image of significant teaching value. Please include a brief description of the case, followed by 1-2 paragraph discussion of the disease process being highlighted and the characteristic features of the image. References are requested but not required. Literature Review: May be in case report format, or topical only. Reviews of current or new AAP subcommittee recommendations or of specific disease processes are desired. Please limit to one page, references required. Recommended formats will be available for review at, on the newsletter page Editors: Purva Grover Michelle Alletag Angela Lumba Send Us Your Cases! We are currently accepting submissions for our spring newsletter. The focus for the spring newsletter will be on innovations in medical education. Email submissions to [13]