Chapter 2

### INTRODUCTION

Bedside ultrasound has revolutionized the practice of emergency medicine. It has allowed physicians to diagnose and treat patients more efficiently and safely. One of the main benefits of ultrasound is that it does not expose the patient to ionizing radiation. This is especially important for pediatric patients, who are the most vulnerable individuals to radiation risk. The number of computed tomography (CT) scans in the United States has increased from 2 million in 1980 to 72 million in 2007. This is despite the fact that radiation from two to three abdominal scans gives the same amount of radiation exposure that survivors of the Hiroshima nuclear bombing received, and 1–2% of all cancers in the United States may be attributable to the radiation from CT examinations.

One of the limitations of ultrasound is that as the ultrasound beam penetrates further into the body, resolution is diminished, making diagnosis more difficult. However, children are on average smaller than adults, making this less of a problem.

These two factors, that children are small with less soft tissue to penetrate, and that they are the individuals with the most to gain from decreased radiation make them an ideal population for this modality.

Bedside ultrasound applications useful in a pediatric population include the following: EFAST for trauma, nerve blocks, lung, cardiac, soft tissue, appendicitis, testicular, rapid ultrasound in shock and hypotension (RUSH), heart, gallbladder, pyloric stenosis, intussussception, vascular access, MSK, and ocular.

There are a number of additional applications for bedside ultrasound, but these are the ones that we will focus on.

### EXTENDED FOCUSED ASSESSMENT WITH SONOGRAPHY FOR TRAUMA (EFAST)

One of the most well-known uses of bedside ultrasound is in the evaluation of trauma with multiple studies over the last 30 years showing the great utility of this examination. The majority of the studies are in adults, and the pediatric literature had historically been less promising. Recent studies had sensitivities of 81% and 92.5%, specificities of 100% and 97.2%, and accuracies of 97% and 95.5%. The acronym FAST stands for Focused Assessment with Sonography for Trauma and comprises four windows. However, the term may be outdated as now the pleural window is routinely added looking for pneumothorax. This is now referred to as EFAST with the E standing for Extended Ultrasound. The pleural window has been shown to be much more sensitive than chest radiography for pneumothorax in the supine patient. In one study the sensitivity was 76% for radiography compared with 98% for sonography. Ultrasound for pneumothorax in children has been reported.

The EFAST windows are the RUQ, LUQ, cardiac, pelvic, and pleural windows. The goals of the EFAST are to identify hemodynamically significant intraperitoneal bleeding, pericardial tamponade, hemothorax, and pneumothorax.

The probes used are quite variable. Some practitioners prefer the phased array probe, while others prefer the curvilinear probe. ...

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