Getting started in paediatric emergency medicine point‐of‐care ultrasound: Five fundamental applications

Snelling, Peter J

doi:10.1002/ajum.12191

Cited by 7 publications

(10 citation statements)

References 32 publications

(64 reference statements)

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“…An additional benefit of POCUS is the potential reduction in the number of x-rays performed by screening patients for 'buckle' or 'no' fracture diagnoses. 15 In our study, 36% of patients had no fracture and 35% had buckle fractures, demonstrating an approximate 30% yield of cortical breach fractures with routinely performed x-rays. 17 Although the radiation dose for forearm x-ray is relatively small, any avoidance of unnecessary ionising radiation in the paediatric population is desirable.…”

Section: O N F I D E N T I a L : F O R R E V I E W O N L Ysupporting

confidence: 51%

“…[8][9][10][11][12][13][14] Buckle fractures can be conservatively managed akin to soft tissue injuries. 5 If they can be reliably distinguished from other fractures using POCUS, x-rays can potentially be avoided, 15 which supports the 'as low as reasonably achievable' principle. 16,17 Furthermore, POCUS performed at the bedside at the time of clinical review may expedite the discharge of patients without a fracture or with a buckle fracture, which could lead to reduced healthcare costs.…”

Section: Introductionmentioning

confidence: 86%

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Nurse practitioner administered point-of-care ultrasound compared with X-ray for children with clinically non-angulated distal forearm fractures in the ED: a diagnostic study

Snelling¹,

Jones

Keijzers³

et al. 2020

Emerg Med J

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BackgroundPaediatric distal forearm fractures are a common ED presentation. They can be diagnosed with point-of-care ultrasound (POCUS) as an alternative to X-rays. Given that ED nurse practitioners (NPs) are relied on for the diagnosis of paediatric fractures, it is important to describe the diagnostic accuracy of NP-conducted POCUS versus X-ray.MethodsThis prospective diagnostic study was conducted in a tertiary paediatric hospital in Queensland, Australia, between February 2018 and April 2019. Participants were children aged 4–16 years with a clinically non-angulated, suspected distal forearm fracture. Diagnosis from 6-view NP-administered POCUS of the distal radius and ulna was compared against the reference standard of 2-view X-ray. Each patient received both imaging modalities. Overall forearm diagnosis was classified as ‘no’, ‘buckle’ or ‘other’ fracture for both modalities. The primary outcome was diagnostic accuracy for ‘any’ fracture (‘buckle’ and ‘other’ fractures combined). Secondary outcomes included diagnostic accuracy for ‘other’ fractures versus ‘buckle’ and ‘no’ fractures combined, and pain, imaging duration and preference for modality.ResultsOf 204 recruited patients, 129 had X-ray-diagnosed forearm fractures. The sensitivity and specificity for NP-administered POCUS were 94.6% (95% CI 89.2% to 97.3%) and 85.3% (95% CI 75.6% to 91.6%), respectively. ‘Other’ fractures (mostly cortical breach fractures), when compared with ‘buckle’/ ‘no’ fractures, had sensitivity 81.0% (95% CI 69.1% to 89.1%) and specificity 95.9% (95% CI 91.3% to 98.1%). Pain and imaging duration were clinically similar between modalities. There was a preference for POCUS by patients, parents and NPs.ConclusionsNP-administered POCUS had clinically acceptable diagnostic accuracy for paediatric patients presenting with non-angulated distal forearm injuries. This included good sensitivity for diagnosis of ‘any’ fracture and good specificity for diagnosis of cortical breach fractures alone. Given the preference for POCUS, and the lack of difference in pain and duration between modalities, future research should consider functional outcomes comparing POCUS with X-ray in this population in a randomised controlled trial.

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Section: O N F I D E N T I a L : F O R R E V I E W O N L Ysupporting

confidence: 51%

Section: Introductionmentioning

confidence: 86%

Nurse practitioner administered point-of-care ultrasound compared with X-ray for children with clinically non-angulated distal forearm fractures in the ED: a diagnostic study

Snelling¹,

Jones

Keijzers³

et al. 2020

Emerg Med J

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“…In our study, the PQH sign was present for all patients with cortical breach fractures and absent for all those with buckle fractures and without fractures. X‐rays can potentially be avoided when patients without cortical breach fractures are reliably screened with POCUS as they can then be discharged with either the application of a wrist splint (buckle fractures) or bandage 26 . X‐ray avoidance supports the ‘as low as reasonably achievable’ principle for pediatric patients 27 and potentially saves healthcare resources 28 .…”

Section: Discussionmentioning

confidence: 99%

Point‐of‐Care Ultrasound Pronator Quadratus Hematoma Sign for Detection of Clinically Non‐Angulated Pediatric Distal Forearm Fractures

Snelling

Keijzers

Ware

2021

J of Ultrasound Medicine

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Objectives Point‐of‐care ultrasound (POCUS) diagnosis of distal forearm fractures relies on the identification of buckling or breach of hyperechoic bone cortex. We describe the pronator quadratus hematoma (PQH) formation visualized on POCUS, the PQH sign, as it may aid diagnosis of pediatric distal forearm cortical breach fractures. Methods A prospective cohort of children presenting to an emergency department with isolated, clinically non‐angulated distal forearm injuries received POCUS by an expert emergency physician sonologist who identified the presence or absence of the PQH sign. They secondarily recorded the difference between the size of the pronator quadratus (PQ) muscle on both the affected and non‐affected forearms (PQ delta thickness). Children received an x‐ray subsequent to POCUS and were diagnosed based on an x‐ray reported by a radiologist masked to POCUS findings. Results Thirty‐eight children were recruited. All 22 patients with cortical breach fracture had PQH sign present (100%; 95%CI: 85–100%), while all 16 patients without cortical breach fracture had PQH sign absent (100%; 95%CI: 79–100%). PQ delta thickness ranged from 2.1 to 10.2 mm in cortical breach fractures, 0.0 to 1.1 mm in buckle fractures, and 0.2 to 0.8 mm in patients without fracture. Conclusions The PQH sign correctly distinguished all children with, and without, cortical breach fractures. All PQ delta thicknesses were ≧2.1 mm when cortical breach fracture was present and ≦1.1 mm when cortical breach fracture was absent. The PQH sign and PQ delta thickness are promising measurements to identify pediatric distal forearm cortical breach fractures, and their utility should be confirmed in larger studies with sonologists of different abilities.

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“…4 Point-of-care ultrasound (POCUS) is an alternative imaging modality to diagnose fractures in distal forearm injuries in Correspondence to email peter.j.snelling@gmail.com doi: 10.1002/ajum.12291 children and can be conducted by a variety of users including ED physicians and nurse practitioners (NPs). 5,6 POCUS can be used to detect and differentiate clinically important fractures, which could potentially negate the requirement for Xray imaging in patients with either no fracture or a buckle fracture. 3,5 Additional benefits of POCUS are that it is well tolerated and preferred by parents.…”

Section: Introductionmentioning

confidence: 99%

Describing the learning curve of novices for the diagnosis of paediatric distal forearm fractures using point‐of‐care ultrasound

Snelling

Jones

Moore

et al. 2022

Australas J Ultrason Med

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Purpose: The learning curve of nurse practitioners (NPs) to accurately diagnose paediatric distal forearm fractures using point-ofcare ultrasound (POCUS) was investigated. Methods: Each NP's learning curve was calculated as cumulative diagnostic accuracy against a number of scans performed. The curve's plateau represented the attainment of competency. Secondary outcomes were the comparisons before and after this cutoff of diagnostic accuracy, classification of diagnostic errors, pain scores, duration and preference. Results: Five NPs performed 201 POCUS studies with diagnostic accuracy plateauing at 90%, providing a 'cut-off' point at scan 15. Accuracy of POCUS scanning before and after the fifteenth scan was 81% (95% CI 70%-89%) and 90% (95% CI 84%-94%), respectively, demonstrating 9% improvement (P = 0.07). There was a 10% reduction in image interpretation errors. After fifteen scans, POCUS became faster (mean difference (MD) 2.6 min [95% CI 2.0-3.3], P < 0.001), less painful (MD 0.61 points FPSR scale [95% CI 0.04-1.18], P = 0.04) and more preferred by NPs (63% vs 77%, P = 0.03). Discussion: The learning curve of POCUS-novice NPs independently scanning paediatric distal forearm injuries plateaued with mean diagnostic accuracy of 90% after 15 scans, suggesting competency was attained at this cut-off, supported by higher accuracy, being faster, less painful and more preferred by NPs. Future training packages in forearm POCUS should further address image interpretation and provide ongoing expert feedback. Conclusions: The findings from this study suggest that competency in paediatric distal forearm POCUS can be attained by novices after a short training course and approximately 15 scans.

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Getting started in paediatric emergency medicine point‐of‐care ultrasound: Five fundamental applications

Cited by 7 publications

References 32 publications

Nurse practitioner administered point-of-care ultrasound compared with X-ray for children with clinically non-angulated distal forearm fractures in the ED: a diagnostic study

Nurse practitioner administered point-of-care ultrasound compared with X-ray for children with clinically non-angulated distal forearm fractures in the ED: a diagnostic study

Point‐of‐Care Ultrasound Pronator Quadratus Hematoma Sign for Detection of Clinically Non‐Angulated Pediatric Distal Forearm Fractures

Describing the learning curve of novices for the diagnosis of paediatric distal forearm fractures using point‐of‐care ultrasound

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