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244 Diagnostic ultrasound Pediatric ultrasound
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on clinical history, laboratory values, and pain severity. While the absence of effusion effectively rules out septic arthritis, osteomyelitis is not well evaluated with ultrasound and may require further diagnostic imaging when indicated. Placing the hip in the extended and abducted position and scanning along the femoral neck seems to be the most efficacious scanning protocol [ 11 ]. There is also evidence that emergency physician practitioners have comparable accuracy when looking for effusions using radiology- performed studies as the gold standard, with a sensitivity of 0.8 (95% CI 0.51–0.95) and a specificity of 0.98 (95% CI 0.85–0.99) [ 12 ]. IVC evaluation for dehydration Evaluating the collapsibility of the inferior vena cava (IVC) as a proxy for dehydration and central venous pressures will be discussed further in Chap- ter 14 . While most of the research looking at this application has been done in adults, there is some literature to support its relevance in the evaluation of the dehydrated pediatric patient. Indeed, the ability of ultrasound to reliably diagnose moderate to severe dehydration across users and to monitor the response to fluid challenges may be one of the more efficacious applications in pediatric ultrasound. There are two standard imaging protocols: the longi- tudinal scan just distal to the right atrial junction and an IVC/aorta ratio protocol ( Figure 13.5 ). The obvious benefit of the ratio in pediatrics is that the size of the aorta acts as a control for the age of the patient, and thus age-based IVC diameter sizes do not need to be memorized. IVC/aorta ratios have been shown to be significantly lower in patients before intravenous hydration (mean of 0.75 vs. 1.09 in hydrated patients) [ 13 ], and studies are ongoing to correlate this ratio with accepted clinical dehydration scores. One such study showed that the aorta/IVC ratio had a sensitivity of 93% and specificity of Figure 13.4 Fracture. Note the break in the otherwise smooth cortex. Diagnostic ultrasound 245 Pediatric ultrasound
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59% when compared to a reference standard of percent weight change. The World Health Organization dehydration scale had a sensitivity of 73% and a specificity of 43% when compared to this same standard [14]. Focused questions for pediatric ultrasound The questions for pediatric abdominal ultrasound are as follows: 1. Is there a dilated ( > 6 mm) appendix visualized and is it compressible? 2. Is there a large ( > 5 cm) folded layer of bowel visualized? 3. Is there a dilated ( > 4 mm) pylorus? (A) I (B) Figure 13.5 ( A ) Longitudinal and ( B ) transverse views of the inferior vena cava (I) just superior to the vertebral body shadow (V) and next to the aorta (A). 246 Diagnostic ultrasound Pediatric ultrasound
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The questions for pediatric musculoskeletal ultrasound are as follows: 1. Is the long bone defect improved with reduction?
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