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et al A randomized clinical trial of jetinjected lidocaine to reduce venipuncture pain for young children Ann Emerg Med 2015;66:466–474 Spanos S, Booth R, Koenig H, et al Jet injection of 1% buffered lidocaine versus topical ela-max for anesthesia before peripheral intravenous catheterization in children Pediatr Emerg Care 2008;24:511–515 Reduction of Nursemaid’s Elbow Gottlieb M, Suleiman L Current approach to the management of forearm and elbow dislocations in children Pediatr Emerg Care 2019;35:293–298 Green DA, Linares MY, Garcia Peña BM, et al Randomized comparison of pain perception during radial head subluxation reduction using supination-flexion or forced pronation Pediatr Emerg Care 2006;22:235–238 CHAPTER 131 ■ ULTRASOUND JASON LEVY, JOANNA S COHEN, ALYSSA ABO, RACHEL G REMPELL, J KATE DEANEHAN INTRODUCTION Point-of-care ultrasound (POCUS) has been used in the emergency department (ED) for nearly four decades Its beginnings are rooted in the adult population, which has well-established, evidence-based applications such as the focused assessment with sonography in trauma (FAST) and evaluation for abdominal aortic aneurysm It is now a required component of emergency medicine residencies and is considered core content by the American Board of Emergency Medicine and the American College of Emergency Physicians (ACEP) Traditionally, ultrasound performed by imaging specialists involves comprehensive examinations in which entire anatomic areas are evaluated In contrast, emergency POCUS is intended to answer a more focused, limited clinical question (e.g., “Is there cardiac activity or not?”) or assist with a specific procedure Consequently, the approach to both training and patient evaluation is different Pediatric emergency medicine has been slower to adopt bedside ultrasound into clinical practice In recent years, however, it has gained widespread acceptance as the body of literature has expanded and training has become more accessible There are now consensus educational guidelines for POCUS training in pediatric emergency medicine fellowship and its inclusion in pediatric emergency medicine practice is endorsed by the American Academy of Pediatrics (AAP) Besides the obvious advantage of being done directly at the patient’s bedside, emergency POCUS offers several other benefits to the pediatric patient It is painless, readily available, does not require sedation, and does not expose the patient to ionizing radiation Furthermore, published data supports its use with respect to better patient care, improved patient satisfaction, and decreased wait times Although a substantial amount of pediatric-specific research exists, its growing use will necessitate further investigation to determine which adult applications can be generalized to children and to develop and implement bedside ultrasound examinations specific to the pediatric patient ADMINISTRATIVE ASPECTS Starting a Point-of-Care Ultrasound Program Before implementing a POCUS program, several administrative requirements should be addressed First, a point person should be identified who either is already well trained in POCUS, or is prepared to undertake additional ultrasound training This person will ultimately be responsible for the training of staff, residents, and fellows, as well as assume responsibility for quality assurance and interdepartmental communication Second, an ultrasound system should be purchased designed for the purposes of ED use Staff and trainees must be able to put what they have learned into use and only those who perform ultrasound scans routinely will gain sufficient facility to incorporate it into their practice There are now many companies that recognize the need for ED-specific machines and have products that cater to this niche Third, starting a program is best done in concert with hospital leadership and credentialing committees A collaborative relationship with Radiology is important Whenever possible, data should be employed to justify evidence-based implementation of specific POCUS examinations with the ultimate goal of improving patient care Once the lead person has been identified, teaching of the staff and trainees can commence Although there are some published standards for training in ultrasound, there is still debate among different governing bodies as to minimal requirements to achieve competency Guidelines from the American College of Radiology and the American Institute of Ultrasound in Medicine are geared toward comprehensive, diagnostic examinations and are not applicable to POCUS The AAP and ACEP have published consensus guidelines based on expert opinion and previously published data which have now become the current standard for pediatric emergency medicine In general, programs should establish a minimum number of didactic hours, a minimum number of overall ultrasound examinations, and a minimum number of examinations to look for a specific finding These requirements will form the basis of the credentialing process for staff physicians Despite these baseline requirements, literature would suggest that there continues to be an ongoing learning curve that plateaus at a significantly higher number of scans per application Equipment Considerations The ideal equipment for POCUS should have durability, mobility, good image quality, good battery life, and rapid boot-up time Most importantly, the anticipated type of ultrasound scans should guide the purchasing of equipment If a machine is being purchased for vascular access only, then one with a highquality cardiac application would not be justified There are numerous ultrasound systems that are tailored to the practice of emergency medicine and the technology is constantly advancing All machines should be portable and maneuverable enough to fit into the cramped spaces of an ED A cart-based system is ideal for ease of movement, changing of probes, storage space, and housing considerations Furthermore, one must consider a device’s ease of use, as the more complicated systems may intimidate novice users and be a roadblock to gaining experience Other factors to consider are initial cost and the ongoing costs of service plans There are numerous types of transducers (probes) from which to choose Transducers are generally classified based on frequency, with low-frequency probes for improved penetration (but poorer image quality) and high-frequency probes for better image resolution (but weaker penetration into deep tissue) Transducers should be purchased based on the anticipated type of ultrasound examinations For example, if a significant percentage of patients present with pregnancy-related complaints, an endocavitary probe may be warranted The footprint of the probe should also be considered The footprint is that portion of the probe that comes into contact with the skin and sends out the ultrasonic waves Probes with a large footprint can give a wider field of view but are difficult to fit into the small intercostal spaces of infants and children Generally speaking, at least two probes should be considered essential when purchasing an ultrasound machine, a low-frequency probe that can be used for abdominal and cardiac examinations, and a high-frequency linear probe which can be used for procedural applications and ultrasound of superficial soft tissues (Fig 131.1 ) ... guidelines for POCUS training in pediatric emergency medicine fellowship and its inclusion in pediatric emergency medicine practice is endorsed by the American Academy of Pediatrics (AAP) Besides the... now a required component of emergency medicine residencies and is considered core content by the American Board of Emergency Medicine and the American College of Emergency Physicians (ACEP) Traditionally,... procedure Consequently, the approach to both training and patient evaluation is different Pediatric emergency medicine has been slower to adopt bedside ultrasound into clinical practice In recent