Emergency Ultrasound‐assisted Examination of Skin and Soft Tissue Infections in the Pediatric Emergency Department

Abstract

Objectives To evaluate the test characteristics of clinical examination (CE) with the addition of bedside emergency ultrasound (CE+EUS) compared to CE alone in determining skin and soft tissue infections (SSTIs) that require drainage in pediatric patients. Methods This was a prospective study of CE+EUS as a diagnostic test for the evaluation of patients 2 months to 19 years of age evaluated for SSTIs in a pediatric emergency department (ED). Two physicians clinically and independently evaluated each lesion, and the reliability of the CE for diagnosing lesions requiring drainage was calculated. Trained pediatric emergency physicians (EPs) performed US following their CEs. The authors determined and compared the test characteristics for evaluating a SSTI requiring drainage for CE alone and for CE+EUS for those lesions in which the two EPs agreed and were certain regarding their CE diagnosis (clinically evident). The performance of CE+EUS was evaluated in those lesions in which the two EPs either disagreed or were uncertain of their diagnosis (not clinically evident). The reference standard for determining if a lesion required drainage was defined as pus expressed at the time of the ED visit, or within two days by follow-up assessment. Results Three hundred and eighty-seven lesions underwent CE+EUS and were analyzed. CE agreement between physicians was fair (K = 0.38). For the 228 lesions for which physicians agreed and were certain of their diagnoses, sensitivity was 94.7% for CE and 93.1% for CE+EUS (difference −1.7%, 95% CI = −3.4% to 0%). The specificity of CE was 84.2% compared to 81.4% for CE+EUS (difference −2.8%, 95% CI = −9.7% to 4.1%). For lesions not clinically evident based on CE, the sensitivity of CE was 43.7%, compared with 77.6% for CE+EUS (difference 33.9%, 95% CI = 1.2% to 66.6%). The specificity of CE for this group was 42.0%, compared with 61.3% for CE+EUS (difference 19.3%, 95% CI = −13.8% to 52.4%). Conclusions For clinically evident lesions, the addition of US did not significantly improve the already highly accurate CE for diagnosing lesions requiring drainage in this study population. However, there were many lesions that were not clinically evident, and in these cases, US may improve the accuracy of the CE.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

“…A third study demonstrated that POCUS did not improve upon the already optimal test characteristics of clinical examination alone when physicians were certain of their diagnosis; however, POCUS may be of use in cases of clinical uncertainty [310]. …”

“…Both radiopaque and radiolucent foreign bodies appear hyperechoic on ultrasound, often with posterior acoustic shadowing which may assist in the detection of the foreign body [306–310]. Other sonographic findings include reverberation (or “comet tails”) artifact, and a hypoechoic halo.…”

Point-of-Care Ultrasonography by Pediatric Emergency Medicine Physicians

“…20,26,[46][47][48] Point-of-care US in pediatric patients by PEM providers has recently been adopted into practice, and the literature is still evolving. Nonetheless, there are numerous studies demonstrating the accuracy of point-of-care US by PEM physicians [49][50][51][52][53][54][55][56][57][58] and the ability of PEM physicians to become proficient in point-of-care US after adequate training. 55,56,59 Although the point-ofcare US examinations performed should be specific to the needs of the department, the most common indications for which point-of-care US is being used in PEM are for focused assessment with sonography in trauma, soft tissue evaluation, and vascular access.…”

Premier niveau de compétence pour l’échographie clinique en médecine d’urgence. Recommandations de la Société française de médecine d’urgence par consensus formalisé

“…L'échographie a modifié la prise en charge de 13 à 22 % des patients. La faisabilité, après une formation courte, par des pédiatres urgentistes a été démon-trée [36].…”