Emergent Pediatric Ultrasound
Katharine Dennis, RDMS/RVT
Tiffany Schultz, RDMS
UNC Health Care
Dept of General Ultrasound
Introduction
Learning Objectives
Review common pediatric emergent ultrasound exams
Summarizes conditions associated with exams comparing normal and abnormal anatomy
Understand the role of ultrasound
Understand the importance of its’ accessibility, cost effectiveness and lack of exposure to radiation
Identify pitfalls
Review cases of exams
Common Pediatric Emergent Exams in U/S
Appendicitis
Intussusception
Midgut Volvulos
Hip effusions
Pyloric Stenosis
Ovarian torsion
Testicular Torsion
Why Ultrasound?
Decreases exposure to radiation
Advantages of Ultrasound
Relatively inexpensive
Does not typically require sedation
Peds limited in communication
Peds are smaller
Peds can decompensate faster
Appendix
Tube-shaped structure typically located
1-2 cm below ileal-cecal valve
posteriomedially
Normally measures 6 mm in diameter
Three important landmarks
Psoas Muscle
Illiac Vessels
Cecum (Terminal Illeum if possible)
Appendicitis
Lumen becomes inflamed and ischemic eventually leading to infection and possibly rupture
Most common condition requiring surgery in pediatrics
Peak age of incidence 5-15 yo
Symptoms and Presentation
Differentials
Pitfalls
Location of Appendix
Location of Appendix
Early Appendicitis
Early Appendicitis
Early Appendicitis
Appendicolith
Appendicitis/ Appendicolith
Appendicolith
Appendicolith
Intussusception
Small bowel prolapses or telescopes into
adjacent segment
Most common form of small bowel
obstruction in children
Highest occurrence between ages 6
months to 4 years
Peak incidence 5-9 months
More common in males 2/1
Pt with Cystic Fibrosis may be at higher
risk
Intussusception
Ileocolic most common type followed by ileoileal and colocolic
Early detection important to avoid injury to bowel 2/2 ischemia and necroses necessitating surgical removal of bowel and risk of sepsis
Can be corrected/reduced in most cases utilizing air enema and floroscopy avoiding surgery
Fatal if left untreated
Paradoxically spontaneous reduction is not uncommon (especially in pts with hyperperistalsis)
Necrotic Intussusception
Necrotic Intussusception
Necrotic Intussusception
Necrotic Intussusception
Necrotic Intussusception
Necrotic Intussusception
Midgut Volvulus
Most severe type of malrotation of the intestines
Seen in infants less than 1yo
Ultrasound is not the primary modality may been noted incidentally, esp in abd u/s ordered to assess pyloris
Infants can present with similar appearance as pts with pyloric stenosis
Important indicator on ultrasound would be reversal of position of SMA and SMV
Midgut Volvulus
Midgut Volvulus
Midgut Volvulus
Positive Negative
Normal Vessel Orientaion
Midgut Volvulus
Midgut Volvulus
Hip Effusions
Excessive fluid in the hip joint
If septic may lead to permanent
damage that can limit mobility
Can be drained under ultrasound
guidance
Hip Effusions
Septic joint more often seen in pts
under the age of three
Symptoms of
Fever
Elevated WBC
Unable to bare weight
Hip Effusions
Scanning Technique
Measurements
Hip Effusions
Cases
Pyloric Stenosis
The pylorus is the opening from the stomach into the
small intestine; therefore, this condition is also known
as gastric outlet obstruction
In case of pyloric stenosis, the muscles of the pylorus
become thickened due to hypertrophy thus preventing
stomach contents to empty into the small intestine.
The causes of this condition are unknown; however,
some correlation to genetics have been noted. Babies
of parents who had P.S. are more likely to have the
condition as well
Pyloric stenosis is a very common condition
Pyloric Stenosis
Age – less than 6 months of age
Symptoms:
Projectile vomiting http://www.google.com/url?url=http://www.youtube.com/watch%3Fv%3D5VzEMr4NhgE&rct
=j&sa=X&ei=PQtqUPbYN4Sq8ASV8IDoDQ&ved=0CEsQuAIwBg&q=newborn+projectile+vo
miting+video&usg=AFQjCNHHTz89VDSaEjoNVASD7k78CLDN8g
Weight loss
Constant hunger
Dehydration and lethargy
Clinical findings/symptoms:
Wave-like motion of abdomen after
feeding and just prior to vomiting
The “pyloric olive”
Pyloric Stenosis
The pyloric channel is considered
stenosed when it measures larger
than 17mm in length and 3mm in
thickness
Is the test a STAT exam?
Pyloric Stenosis
How is the study performed?
Baseline images obtained
AVOID IMAGING ESOPHAGUS
Position the infant
Feed infant
Image pylorus
Positive Exam
Positive Exam
Swirl Effect
Negative Exam
Negative Exam
Negative Exam
Pitfall – Imaging the Esophagus
Pitfall – Imaging the Esophagus
Ovarian Torsion
Twisting of the ovary around the
ligaments which support it. This
may result in loss of blood supply
to both the ovary and the fallopian
tube.
Torsion in normally precipitated by
another condition or disease.
Unilateral
Age - Early reproductive years-
mid 20’s
Predisposing conditions
Developmental abnormalities
Cysts or other masses (i.e
teratomas)
Malignant = Greater risk
Larger size = Larger risk
Ovarian Torsion
Ovarian Torsion
Symptoms
Sudden onset of worsening
severe, unilateral lower abdominal
pain
Nausea and vomiting
Fever (later stages)
Previous episodes of pain
Ovarian Torsion
TRUE STAT EXAM
Early detection = Ovarian salvage
Early detection = Reduced risk of
complications
Laproscopy is the gold standard of
diagnosis
Postive = dusky, blue-black
appearance
Ovarian Torsion and the Sonographer
Color Doppler imaging is essential
Where color Doppler fails, power Doppler
may be beneficial
Detection of flow is more important that
direction of flow in this case
Spectral waveform must be documented
to rule out torsion
Arterial and venous flow
Laproscopic Diagnosis
Positive for Torsion
5 year old
Positive for Torsion
Doppler
Positive for Torsion
Positive for Torsion 16 year old - Adnexal Mass
Positive for Torsion
Testicular Torsion
Twisting of the spermatic cord, which
cuts off the blood supply to the testicle
and surrounding scrotal structures
This condition results in ischemic injury
to the testis and infarction. The
condition may also result in loss of the
testis.
Testicular Torsion
Causes
Trauma to the scrotum
Strenuous exercise
Puberty
May not have an obvious cause
Cryptorchidism
Symptoms
Acute onset of severe scrotal pain
Redness
Unilateral scrotal swelling
Nausea and vomiting
Testicular Torsion
Role of the Sonographer
True STAT exam
6 hours to save the testicle
DOPPLER, DOPPLER, DOPPLER
Absence of blood flow is a key
indicator in diagnosing testicular
torsion
DON’T GET DISCOURAGED!
Testicular Torsion
Treatments
Manual Detorsion
Surgery
Detorsion
Orchiopexy
Possible orchiectomy
Surgical Examination
Within the Scrotum Undescended Testicle
Positive for Testicular Torsion
10 year old
Positive for Testicular Torsion
10 year old
Positive for Testicular Torsion 14 year old
Normal Appearing Testicles
Positive for Testicular Torsion 14 year old
Positive for Testicular Torsion 14 year old
Positive for Testicular Torsion 15 year old
Positive for Testicular Torsion 15 year old
Testicle and Epididymal Torsion
Positive for Testicular Torsion 15 year old
Positive for Testicular Torsion 17 year old
Positive for Testicular Torsion 17 year old
Positive for Testicular Torsion 15 year old
Positive for Testicular Torsion 15 year old