Fwd: We need to do this for intussusception!!!! And appendicitis!!!!​

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---------- Forwarded message ---------- From: "Jason W. Fischer" fischerjwj@mac.com Date: Sat, Apr 4, 2015 at 7:06 AM Subject: We need to do this for intussusception!!!! And appendicitis!!!! To: "Mark Tessaro" oliver.tessaro@gmail.com, "Charisse Kwan" charisse.kwan@sickkids.ca

I thought you would be interested in this article. Western Journal of Emergency Medicine 2015 Mar; 16 (2) : 250-254. Non-thrombotic Abnormalities on Lower Extremity Venous Duplex Ultrasound Examinations. Srikar Adhikari, Wes Zeger PMID: 25834665 Sent using journal reader: Read by QxMD Sent from my iPhone Twitter: @eUSMD

Gal Neuman Idea - Mediastinal Mass/Lie flat safely?

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Begin forwarded message: On Thursday, Apr 16, 2015 at 1:01 PM, Gal Neuman galn2911@gmail.com, wrote:

Hey mark.

There was an interesting discussion in radiology rounds on patients with mediastinal mass and the risk for SVC compression while lying supine in CT (which is potentially fatal because they collapse in CT and if you bag them you'll make things worse by increasing intrathoracic pressure even further).

That gave me an idea of predicting that potential risk in ED, prior to sending them to CT, by using ultrasound and doppler of the SVC while prone or supine. If a significant change in flow is demonstrated then extra precautions will have to be taken with these patients while doing the CT.

I thought you may be interested in it, and I think it may be something for a potential future research project.

Happy to hear your thoughts.


Gal Neuman, MD.

Clinical Fellow, divisions of Clinical Pharmacology & Toxicology and Pediatric Emergency Medicine.

The Hospital For Sick Children.

University of Toronto. galn2911@gmail.com gal.neuman@sickkids.ca

Ranges of ONSD in normal kids using modern technique

What if we scanned a TONNE of healthy kids of all ages presenting to the ED with complaints unrelated to eyes/optic nerve/brain? We could better describe the range of normal based on age, which I don’t think has been done on any large scale yet. We could also potentially double it up with a study on interrater reliability for new users (PEM fellows or peds residents) vs expert users. This would be separate from the VPS study.

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Re: Appendicitis in children: evaluation of the pediatric appendicitis score in younger and older children. [feedly]

Should we be doing POCUS on all kids <4y with abdo pain? How could we beat design a study to show its benefits?

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On Tue, Jan 13, 2015 at 9:06 AM, Mark Tessaro mark.tessaro@sickkids.ca wrote:

POCUS for <4y?

Appendicitis in children: evaluation of the pediatric appendicitis score in younger and older children.http://www.ncbi.nlm.nih.gov/pubmed/25574500?dopt=Abstract // pubmed: pediatric appendicit...http://www.ncbi.nlm.nih.gov/pubmed/25574500?dopt=Abstract Related Articleshttp://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=Link&LinkName=pubmed_pubmed&from_uid=25574500 Appendicitis in children: evaluation of the pediatric appendicitis score in younger and older children. Surg Res Pract. 2014;2014:438076 Authors: Salö M, Friman G, Stenström P, Ohlsson B, Arnbjörnsson E Abstract Background. This study aimed to evaluate Pediatric Appendicitis Score (PAS), diagnostic delay, and factors responsible for possible late diagnosis in children <4 years compared with older children who were operated on for suspected appendicitis. Method. 122 children, between 1 and 14 years, operated on with appendectomy for suspected appendicitis, were retrospectively analyzed. The cohort was divided into two age groups: ≥4 years (n = 102) and <4 years (n = 20). Results. The mean PAS was lower among the younger compared with the older patients (5.3 and 6.6, resp.; P = 0.005), despite the fact that younger children had more severe appendicitis (75.0% and 33.3%, resp.; P = 0.001). PAS had low sensitivity in both groups, with a significantly lower sensitivity among the younger patients. Parent and doctor delay were confirmed in children <4 years of age with appendicitis. PAS did not aid in patients with doctor delay. Parameters in patient history, symptoms, and abdominal examination were more diffuse in younger children. Conclusion. PAS should be used with caution when examining children younger than 4 years of age. Diffuse symptoms in younger children with acute appendicitis lead to delay and to later diagnosis and more complicated appendicitis.

PMID: 25574500 [PubMed]

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Tonsil visualization by submandibular approach

How do we optimize the submandibular approach for those centers that don’t have an endocavitary probe? Let’s test the quality of visualization that we get of the tonsils in all age groups via a submandibular approach, comparing -probe types (linear, phased array, maybe we can get a loaner curved probe from Zonare) -patient position (different degrees of neck extension, leaning forward, sitting straight, lying flat) -presence or absence of water held in mouth by patient to act as acoustic medium

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Viral LRI - subpleural consolidations?​

Presence of sonographic subpleural abnormalities in children with suspected viral lower respiratory tract infection

Significance of some lung POCUS findings is unclear. May represent focal atelectasis or early bacterial infiltrate.

Prospective observational study; convenience cohort

Age range

Presenting with acute cough (duration?) ?+fever;

Discharge diagnosis = viral illness (?other variants)


-?PRAISE; or do POCUS team members do this as part of their shifts?; POCUS rotators can ask treating team to bring up study

-treating team introduces the study to the family

-treating team notifies research team if they have a child with suspected viral LRTI that they are planning on discharging

Ultrasound operators

-POCUS faculty and POCUS fellows

-"have performed more than N lung ultrasounds"

-?PEM fellows if they've completed POCUS rotation

Zone Lung POCUS for presence of


-small subpleural consolidation

-multiple B-lines

Treating team notified if POCUS reveals findings considered highly suspicious for pneumonia (large subpleural consolidations with air bronchograms).


-Telephone call (7d ? 10d? 14 d?) after discharge

-Any MD visits? Admission?

-Any antibiotics prescribed?

If YES, was imaging performed prior?(can we have them prospectively consent to is getting reports?)

-Symptoms: days of fever; days of cough; overall improvement (scale? 1-10?)

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On Wed, Jan 28, 2015 at 10:00 AM, Mark Tessaro oliver.tessaro@gmail.com wrote:

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