Publications by authors named "Aaron E Chen"

20 Publications

  • Page 1 of 1

Contrast-enhanced ultrasound of blunt abdominal trauma in children.

Pediatr Radiol 2021 May 12. Epub 2021 May 12.

Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Trauma is the leading cause of morbidity and mortality in children, and rapid identification of organ injury is essential for successful treatment. Contrast-enhanced ultrasound (CEUS) is an appealing alternative to contrast-enhanced CT in the evaluation of children with blunt abdominal trauma, mainly with respect to the potential reduction of population-level exposure to ionizing radiation. This is particularly important in children, who are more vulnerable to the hazards of ionizing radiation than adults. CEUS is useful in hemodynamically stable children with isolated blunt low- to moderate-energy abdominal trauma to rule out solid organ injuries. It can also be used to further evaluate uncertain contrast-enhanced CT findings, as well as in the follow-up of conservatively managed traumatic injuries. CEUS can be used to detect abnormalities that are not apparent by conventional US, including infarcts, pseudoaneurysms and active bleeding. In this article we present the current experience from the use of CEUS for the evaluation of pediatric blunt abdominal trauma, emphasizing the examination technique and interpretation of major abnormalities associated with injuries in the liver, spleen, kidneys, adrenal glands, pancreas and testes. We also discuss the limitations of the technique and offer a review of the major literature on this topic in children, including an extrapolation of experience from adults.
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http://dx.doi.org/10.1007/s00247-020-04869-wDOI Listing
May 2021

Impact of Emergency Medicine Point-of-Care Ultrasound on Radiology Ultrasound Volumes in a Single Pediatric Emergency Department.

J Am Coll Radiol 2020 Dec 29;17(12):1555-1562. Epub 2020 Jul 29.

Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Director of Off-Site Imaging, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

Purpose: Point-of-care ultrasound (POCUS) is growing, but few data exist regarding its effects on radiology ultrasound (Rad US) volumes. The authors studied changes in Rad US ordered by emergency medicine (EM) as POCUS began and grew at their pediatric hospital.

Methods: This retrospective study included EM POCUS and EM-ordered Rad US volumes between 2011 and 2017, during three 2-year intervals: before POCUS, early POCUS, and expanded POCUS. Changes in overall Rad US and POCUS volumes per visit during these intervals were studied. Changes in skin and soft tissue infection (SSTI) US per SSTI visit, an examination performed diagnostically by both radiology and EM, were also assessed. Volume differences were examined using the Mann-Whitney U test (significance threshold, P < .05), and process control charts were used to identify nonrandom variations.

Results: The study included 49,908 Rad US and 2,772 POCUS examinations during 647,890 emergency department visits. Rad US volumes per visit remained unchanged during early POCUS (P = .858) but increased with expanded POCUS (P < .005). A transient nonrandom increase in Rad US occurred as POCUS began. SSTI Rad US per SSTI visit significantly increased (P < .001) during early POCUS but did not change with expanded POCUS (P = .143). An SSTI management pathway in the emergency department before expanded POCUS may have affected ordering. Other variation occurred in proximity to practice changes and seasonal patterns.

Conclusions: Rad US overall and specifically for SSTI increased or remained stable during the introduction and growth of EM POCUS. Rather than decreasing Rad US, EM POCUS had a complementary role.
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http://dx.doi.org/10.1016/j.jacr.2020.07.005DOI Listing
December 2020

Point-of-care ultrasound of optic nerve sheath diameter to detect intracranial pressure in neurocritically ill children - A narrative review.

Biomed J 2020 06 23;43(3):231-239. Epub 2020 Apr 23.

Division of Pediatric Neurology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan. Electronic address:

The rapid diagnosis of increased intracranial pressure is urgently needed for therapeutic reasons in neurocritically ill children, however this can rarely be achieved without invasive procedures. Point-of-care ultrasound of the optic nerve sheath diameter has been proposed as a non-invasive and reliable means to detect increased intracranial pressure in adults. Accordingly, clinicians may be able to use this technique to initiate early treatment and monitor the effectiveness of treatment in conjunction with other clinical examination and diagnostic modalities. Two meta-analyses and a systematic review have been published on this topic in adults. However, data on the correlation between optic nerve sheath diameter and intracranial pressure in neurocritically ill children are scarce. The aim of this review was to briefly describe what is being measured with point-of-care ultrasound of the optic nerve sheath diameter, summarize the most recent findings from adult literature, and provide an update of current work in children.
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http://dx.doi.org/10.1016/j.bj.2020.04.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7424084PMC
June 2020

Moving Beyond the Stethoscope: Diagnostic Point-of-Care Ultrasound in Pediatric Practice.

Pediatrics 2019 10 3;144(4). Epub 2019 Sep 3.

Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Diagnostic point-of-care ultrasound (POCUS) is a growing field across all disciplines of pediatric practice. Machine accessibility and portability will only continue to grow, thus increasing exposure to this technology for both providers and patients. Individuals seeking training in POCUS should first identify their scope of practice to determine appropriate applications within their clinical setting, a few of which are discussed within this article. Efforts to build standardized POCUS infrastructure within specialties and institutions are ongoing with the goal of improving patient care and outcomes.
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http://dx.doi.org/10.1542/peds.2019-1402DOI Listing
October 2019

Ultrasonographic Guidance to Improve First-Attempt Success in Children With Predicted Difficult Intravenous Access in the Emergency Department: A Randomized Controlled Trial.

Ann Emerg Med 2019 07 22;74(1):19-27. Epub 2019 May 22.

Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

Study Objective: We determine whether ultrasonographically guided intravenous line placement improves the rate of first-attempt success by 20% for children with predicted difficult intravenous access. Secondary objectives included determining whether ultrasonographically guided intravenous line placement reduces the attempt number, improves time to access or parental satisfaction, or affects intravenous line survival and complications.

Methods: This was a prospective, randomized controlled trial conducted in an urban tertiary care pediatric emergency department that enrolled a convenience sample of children requiring an intravenous line and who were predicted to have difficult intravenous access according to a previously validated score. Participants were randomized to traditional or ultrasonographically guided intravenous line placement on first attempt and stratified by aged 0 to 3 versus older than 3 years.

Results: One hundred sixty-seven patients were enrolled and randomized to traditional intravenous line or to a care bundle with a multidisciplinary team trained to place ultrasonographically guided intravenous lines. First-attempt success was increased in the ultrasonographically guided intravenous line placement arm (n=83) compared with the traditional intravenous line arm (n=84) (85.4% versus 45.8%; relative risk 1.9; 95% confidence interval [CI] 1.5 to 2.4). There were fewer attempts in the ultrasonographically guided intravenous line placement arm than in the traditional intravenous line arm (median 1 versus 2; median difference 1; 95% CI 0.8 to 1.2) and a shorter time from randomization to intravenous line flush (median 14 minutes [interquartile range 11 to 20] versus 28 minutes [interquartile range 16 to 42]). A Kaplan-Meier survival analysis demonstrated that ultrasonographically guided intravenous lines survived longer than traditional ones (median 7.3 days [95% CI 3.7 to 9.5] versus 2.3 days [95% CI 1.8 to 3.3]). There was no difference in complications between the groups. Parents were more satisfied with ultrasonographically guided intravenous line placement.

Conclusion: Ultrasonographically guided intravenous line placement in children with predicted difficult intravenous access improved first-attempt success and intravenous line longevity when conducted by a team of trained providers.
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http://dx.doi.org/10.1016/j.annemergmed.2019.02.019DOI Listing
July 2019

Identifying infant hydrocephalus in the emergency department with transfontanellar POCUS.

Am J Emerg Med 2019 01 11;37(1):127-132. Epub 2018 Oct 11.

Emergency Department, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States of America. Electronic address:

Hydrocephalus carries significant morbidity in the infant population. Although clinical symptoms are often nonspecific, hydrocephalus is easily identified using transfontanellar sonography. In this review, we provide the emergency physician with a succinct overview of infant hydrocephalus and the point-of-care ultrasound (POCUS) technique for identification of this pathology.
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http://dx.doi.org/10.1016/j.ajem.2018.10.012DOI Listing
January 2019

Point-of-care lung ultrasonography for pneumonia in children: does size really matter?

Authors:
Aaron E Chen

Arch Dis Child 2019 01 4;104(1):2-3. Epub 2018 Jul 4.

Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.

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http://dx.doi.org/10.1136/archdischild-2018-315196DOI Listing
January 2019

Ultrasound features of purulent skin and soft tissue infection without abscess.

Emerg Radiol 2018 Oct 6;25(5):505-511. Epub 2018 Jun 6.

Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Purpose: Ultrasound (US) aids clinical management of skin and soft tissue infection (SSTI) by differentiating non-purulent cellulitis from abscess. However, purulent SSTI may be present without abscess. Guidelines recommend incision and drainage (I & D) for purulent SSTI, but US descriptions of purulent SSTI without abscess are lacking.

Methods: We retrospectively reviewed pediatric emergency department patients with US of the buttock read as negative for abscess. We identified US features of SSTI with adequate interobserver agreement (kappa > 0.45). Six independent observers then ranked presence or absence of these features on US exams. We studied association between US features and positive wound culture using logistic regression models (significance at p < 0.05).

Results: Of 217 children, 35 patients (16%) had cultures positive for pathogens by 8 h after US and 61 patients (32%) had cultures positive by 48 h after US. We found kappa > 0.45 for focal collection > 1.0 cm (κ = 0.57), hyperemia (κ = 0.57), swirling with compression (κ = 0.52), posterior acoustic enhancement (κ = 0.47), and cobblestoning or branching interstitial fluid (κ = 0.45). Only cobblestoning or interstitial fluid was associated with positive wound cultures in logistic regression models at 8 and 48 h.

Conclusions: Cobblestoning or interstitial fluid on US may indicate presence of culture-positive, purulent SSTI in patients without US appearance of abscess. Although our study has limitations due to its retrospective design, this US appearance should alert imagers that the patient may benefit from early I & D.
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http://dx.doi.org/10.1007/s10140-018-1612-0DOI Listing
October 2018

Sonographically Occult Abscesses of the Buttock and Perineum in Children.

Pediatr Emerg Care 2017 Sep 25. Epub 2017 Sep 25.

From the *Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE; †Department of Radiology, and ‡Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.

Background: Ultrasound (US) is used to differentiate abscess from cellulitis. At our institution, we observed children who had purulent fluid obtained after a negative abscess US. We sought to determine the incidence of sonographically occult abscess (SOA) of the buttock and perineum, and identify associated clinical and demographic characteristics.

Methods: Retrospective chart review including children younger than 18 years old presenting to pediatric emergency department with soft tissue infection of the buttock or perineum and diagnostic radiology US read as negative for abscess. We defined SOA as wound culture growing pathogenic organism obtained within 48 hours of the US. Clinical and demographic characteristics included age, sex, race, ethnicity, fever, history of spontaneous drainage, duration of symptoms, previous methicillin resistant Staphylococcus aureus (MRSA) infection, or previous abscess. We used univariate and multivariate logistic regression to assess correlation between these characteristics and SOA.

Results: A total of 217 children were included. Sixty-one (28%) children had SOA; 33 of 61 (54%) had incision and drainage within 4 hours of the US. Of children with SOA, 49 (80%) grew MRSA and 12 (20%) grew methicillin-sensitive S. aureus. In univariate analysis, a history of MRSA, symptom duration 4 days or less, age of younger than 4 years, and Hispanic ethnicity increased the odds of having SOA. In multivariate analysis, history of MRSA and duration of 4 days or less were associated with SOA.

Conclusions: Twenty-eight percent of children in our institution with US of the buttock and perineum negative for abscess had clinical abscess within 48 hours, most within 4 hours. History of MRSA and shorter symptom duration increased the odds of SOA.
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http://dx.doi.org/10.1097/PEC.0000000000001294DOI Listing
September 2017

First-Attempt Success, Longevity, and Complication Rates of Ultrasound-Guided Peripheral Intravenous Catheters in Children.

Pediatr Emerg Care 2018 Jun;34(6):376-380

Division of Emergency Ultrasonography, Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.

Objective: The aim of this study was to examine the success rates, longevity, and complications of ultrasound-guided peripheral intravenous lines (USgPIVs) placed in a pediatric emergency department.

Methods: The study analyzed 300 USgPIV attempts in an urban tertiary-care pediatric emergency department. Data regarding USgPIV placement were collected from a 1-page form completed by the clinician placing the USgPIV. The time and reason for USgPIV removal were extracted from the medical record for patients with USgPIVs admitted to the hospital. A Kaplan-Meier survival analysis was performed.

Results: This study demonstrated a success rate of 68% and 87% for the first and second attempts with USgPIV. Fifty-five percent of patients had 1 or more prior traditional intravenous access attempt. Most USgPIVs placed on patients admitted to the hospital were removed because they were no longer needed (101/160). We calculated a Kaplan-Meier median survival of 143 hours (6 days; interquartile range, 68-246 hours). The failure rate at 48 hours was 25%.

Conclusion: Ultrasound-guided intravenous access is a feasible alternative to traditional peripheral intravenous access in the pediatric emergency setting. We observed a high first-stick success rate even in patients who had failed traditional peripheral intravenous access attempts, few complications, and a long intravenous survival time.
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http://dx.doi.org/10.1097/PEC.0000000000001063DOI Listing
June 2018

Identification of Optic Nerve Swelling Using Point-of-Care Ocular Ultrasound in Children.

Pediatr Emerg Care 2018 Aug;34(8):531-536

Neuro-ophthalmology, Children's Hospital of Philadelphia, Philadelphia, PA.

Objective: The aim of this study was to determine the feasibility and accuracy of point-of-care (POC) ocular ultrasound (US) when performed by a pediatric emergency medicine (PEM) physician to detect optic nerve abnormalities concerning for swelling, as compared with the fundus examination performed by an ophthalmologist.

Methods: This was a single-center, prospective cohort pilot study of children aged 12 months to 18 years who required optic disc evaluation by an ophthalmologist. Eligible subjects were enrolled from the emergency department, inpatient wards, and neuro-ophthalmology outpatient clinic of an urban, tertiary care children's hospital. Point-of-care ocular US, specifically assessing optic nerve sheath diameter and optic disc elevation, was performed. Findings on US were compared with findings identified by an ophthalmologist on dilated fundus examination.

Results: Seventy-six subjects were enrolled; 20 (26%) of 76 had findings concerning for optic nerve swelling diagnosed by an ophthalmologist on fundus examination. Using a sonographic definition for optic nerve swelling of optic nerve sheath diameter greater than 4.5 mm or the presence of optic disc elevation, the sensitivity and specificity were 90% and 55%, respectively. The success rate of POC ocular US was 100%, and the mean time to completion was 8 minutes. For emergency department subjects in whom direct fundus examination was attempted, the PEM physician could visualize the optic disc and assess for swelling in only 40% (14/35) of examinations.

Conclusions: The results of our study suggest that POC ocular US performed by PEM physicians was feasible and determined to be sensitive but nonspecific in the detection of optic nerve swelling. Additional larger studies may determine generalizability to other nonophthalmologist physicians performing POC ocular US.
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http://dx.doi.org/10.1097/PEC.0000000000001046DOI Listing
August 2018

The Effect of Bedside Ultrasonographic Skin Marking on Infant Lumbar Puncture Success: A Randomized Controlled Trial.

Ann Emerg Med 2017 May 14;69(5):610-619.e1. Epub 2016 Nov 14.

Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.

Study Objective: Lumbar puncture is a commonly performed procedure, although previous studies have documented low rates of successful completion in infants. Ultrasonography can visualize the anatomic landmarks for lumbar puncture and has been shown in some studies to reduce the failure rate of lumbar puncture in adults. We seek to determine whether ultrasonography-assisted site marking increases success for infant lumbar punctures.

Methods: This was a prospective, randomized, controlled trial in an academic pediatric emergency department (ED). We enrolled a convenience sample of infants younger than 6 months between June 2014 and February 2016 and randomized them to either a traditional lumbar puncture arm or an ultrasonography-assisted lumbar puncture arm. Infants in the ultrasonography arm received bedside ultrasonography of the spine by one of 3 study sonographers before lumbar puncture, during which the conus medullaris and most appropriate intervertebral space were identified and marked. The lumbar puncture was then performed by the predetermined ED provider. Our primary outcome was successful first-attempt lumbar puncture. Subjects were considered to have a successful lumbar puncture if cerebrospinal fluid was obtained and RBC counts were less than 1,000/mm. All outcomes were assessed by intention-to-treat analysis.

Results: One hundred twenty-eight patients were enrolled, with 64 in each arm. No differences between the 2 arms were found in the baseline characteristics of the study subjects and providers, except for sex and first-attempt position. The first-attempt success rate was higher for the ultrasonography arm (58%) versus the traditional arm (31%) (absolute risk difference 27% [95% CI 10% to 43%]). Success within 3 attempts was also higher for the ultrasonography arm (75%) versus the traditional arm (44%) (absolute risk difference 31% [95% CI 15% to 47%]). On average, performing bedside ultrasonography on 4 patients (95% CI 2.1 to 6.6) resulted in 1 additional successful lumbar puncture.

Conclusion: Ultrasonography-assisted site marking improved infant lumbar puncture success in a tertiary care pediatric teaching hospital. This method has the potential to reduce unnecessary hospitalizations and exposures to antibiotics in this vulnerable population.
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http://dx.doi.org/10.1016/j.annemergmed.2016.09.014DOI Listing
May 2017

Effect of Inhalational Anesthetics and Positive-pressure Ventilation on Ultrasound Assessment of the Great Vessels: A Prospective Study at a Children's Hospital.

Anesthesiology 2016 Apr;124(4):870-7

From the Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (E.E.L., T.C., J.K., A.N.); Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania (E.E.L., A.E.C., N.P., T.C., D.C., A.N.); Department of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (A.E.C.); and Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania (N.P., N.R.J.).

Background: Bedside ultrasound has emerged as a rapid, noninvasive tool for assessment and monitoring of fluid status in children. The inferior vena cava (IVC) varies in size with changes in blood volume and intrathoracic pressure, but the magnitude of change to the IVC with inhalational anesthetic and positive-pressure ventilation (PPV) is unknown.

Methods: Prospective observational study of 24 healthy children aged 1 to 12 yr scheduled for elective surgery. Ultrasound images of the IVC and aorta were recorded at five time points: awake; spontaneous ventilation with sevoflurane by mask; intubated with peak inspiratory pressure/positive end-expiratory pressure of 15/0, 20/5, and 25/10 cm H2O. A blinded investigator measured IVC/aorta ratios (IVC/Ao) and changes in IVC diameter due to respiratory variation (IVC-RV) from the recorded videos.

Results: Inhalational anesthetic decreased IVC/Ao (1.1 ± 0.3 vs. 0.6 ± 0.2; P < 0.001) but did not change IVC-RV (median, 43%; interquartile range [IQR], 36 to 58% vs. 46%; IQR, 36 to 66%; P > 0.99). The initiation of PPV increased IVC/Ao (0.64 ± 0.21 vs. 1.16 ± 0.27; P < 0.001) and decreased IVC-RV (median, 46%; IQR, 36 to 66% vs. 9%; IQR, 4 to 14%; P < 0.001). There was no change in either IVC/Ao or IVC-RV with subsequent incremental increases in peak inspiratory pressure/positive end-expiratory pressure (P > 0.99 for both).

Conclusions: Addition of inhalational anesthetic affects IVC/Ao but not IVC-RV, and significant changes in IVC/Ao and IVC-RV occur with initiation of PPV in healthy children. Clinicians should be aware of these expected vascular changes when managing patients. Establishing these IVC parameters will enable future studies to better evaluate these measurements as tools for diagnosing hypovolemia or predicting fluid responsiveness.
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http://dx.doi.org/10.1097/ALN.0000000000001032DOI Listing
April 2016

An Uncommon Complication of Sinusitis in a Young Adolescent.

Pediatr Emerg Care 2015 Jul;31(7):531-2

From the *Department of Emergency Medicine, Hospital of the University of Pennsylvania; and †Department of Pediatric Emergency Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

A young adolescent patient presented to the emergency department with forehead and eyelid swelling after a week of nasal discharge that was suspicious for Pott's puffy tumor. Point-of-care ultrasound facilitated rapid diagnosis and initiation of treatment for a concerning and rare complication of sinusitis, confirmed by computed tomography scan.
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http://dx.doi.org/10.1097/PEC.0000000000000491DOI Listing
July 2015

Identification of optic disc elevation and the crescent sign using point-of-care ocular ultrasound in children.

Pediatr Emerg Care 2015 Apr;31(4):304-7

From the *Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; and †Division of Emergency Medicine, Children's Hospital Colorado, Colorado, Aurora, CO.

Point-of-care ocular ultrasound has been used to detect papilledema. In previous studies, investigators have evaluated only optic nerve sheath diameter as a screen for increased intracranial pressure. In this series of 4 children, we demonstrate 2 additional optic nerve abnormalities using point-of-care ocular ultrasound: optic disc elevation and the crescent sign. Assessing the optic nerve for each of these 3 findings may assist the examiner in detecting papilledema.
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http://dx.doi.org/10.1097/PEC.0000000000000408DOI Listing
April 2015

Implementation of a pediatric critical care focused bedside ultrasound training program in a large academic PICU.

Pediatr Crit Care Med 2015 Mar;16(3):219-26

1Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA. 2Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. 3Department of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA. 4Department of Emergency Medicine, The Hospital of The University of Pennsylvania, Philadelphia, PA. 5Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA. 6Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA.

Objectives: To determine the feasibility and describe the process of implementing a pediatric critical care bedside ultrasound program in a large academic PICU and to evaluate the impact of bedside ultrasound on clinical management.

Design: Retrospective case series, description of program implementation.

Setting: Single-center quaternary noncardiac PICU in a children's hospital.

Patients: Consecutive patients from January 22, 2012, to July 22, 2012, with bedside ultrasounds performed and interpreted by pediatric critical care practitioners.

Interventions: A pediatric critical care bedside ultrasound program consisting of a 2-day immersive course followed by clinical performance with internal quality assurance review was implemented. Studies performed in the PICU following training were documented and reviewed against reference standards including subspecialist-performed ultrasound or clinical response.

Measurements And Main Results: Seventeen critical care faculties and eight fellows recorded 201 bedside ultrasound studies over 6 months in defined core applications: 57 procedural (28%), 76 hemodynamic (38%), 35 thoracic (17%), and 33 abdominal (16%). A quality assurance review identified 23 studies (16% of all nonprocedural studies) as critical (affected clinical management or gave valuable information). Forty-eight percent of those studies (11/23) were within the hemodynamic core. The proportion of critical studies were not significantly different across the applications (hemodynamic, 11/76 [15%] vs thoracic and abdominal, 12/68 [18%]; p = 0.65). Examples of critical studies include evidence of tamponade secondary to pleural effusions, identification of pulmonary hypertension, hemodynamic assessment before tracheal intubation, recognition of hypovolemia and systemic vascular resistance abnormalities, determination of pneumothorax, location of chest tube and urinary catheter, and differentiation of pleural fluid from pulmonary consolidation.

Conclusions: Implementation of a critical care bedside ultrasound program for critical care providers in a large academic PICU is feasible. Bedside ultrasound evaluation and interpretation by intensivists affected the management of critically ill children.
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http://dx.doi.org/10.1097/PCC.0000000000000340DOI Listing
March 2015

Pulmonary emboli associated with isolated lower-extremity venous malformation: a case report.

Pediatr Emerg Care 2013 Mar;29(3):371-3

Department of Pediatrics, The Children's Hospital of Philadelphia, PA 19104, USA.

Pulmonary thromboembolism is a relatively rare entity in the pediatric population; however, it should always be part of the differential diagnosis in patients with the appropriate clinical presentation. We report the case of a 13-year-old girl with a history of a lower-extremity venous malformation status post sclerotherapy 2 years prior but otherwise healthy who presented with painless hemoptysis. She was found to have multiple bilateral pulmonary emboli on computed tomographic angiography of the chest. Magnetic resonance venography of the lower extremities showed stable venous changes from prior studies and no obvious source of emboli. She was started on anticoagulation and was discharged home.
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http://dx.doi.org/10.1097/PEC.0b013e31828547a9DOI Listing
March 2013

Randomized controlled trial of cephalexin versus clindamycin for uncomplicated pediatric skin infections.

Pediatrics 2011 Mar 21;127(3):e573-80. Epub 2011 Feb 21.

Johns Hopkins University, Department of Pediatrics, Division of Pediatric Emergency Medicine, CMSC 144, 600 N Wolfe St, Baltimore, MD 21287, USA.

Objective: To compare clindamycin and cephalexin for treatment of uncomplicated skin and soft tissue infections (SSTIs) caused predominantly by community-associated (CA) methicillin-resistant Staphylococcus aureus (MRSA). We hypothesized that clindamycin would be superior to cephalexin (an antibiotic without MRSA activity) for treatment of these infections.

Patients And Methods: Patients aged 6 months to 18 years with uncomplicated SSTIs not requiring hospitalization were enrolled September 2006 through May 2009. Eligible patients were randomly assigned to 7 days of cephalexin or clindamycin; primary and secondary outcomes were clinical improvement at 48 to 72 hours and resolution at 7 days. Cultures were obtained and tested for antimicrobial susceptibilities, pulsed-field gel electrophoresis type, and Panton-Valentine leukocidin status.

Results: Of 200 enrolled patients, 69% had MRSA cultured from wounds. Most MRSA were USA300 or subtypes, positive for Panton-Valentine leukocidin, and clindamycin susceptible, consistent with CA-MRSA. Spontaneous drainage occurred or a drainage procedure was performed in 97% of subjects. By 48 to 72 hours, 94% of subjects in the cephalexin arm and 97% in the clindamycin arm were improved (P = .50). By 7 days, all subjects were improved, with complete resolution in 97% in the cephalexin arm and 94% in the clindamycin arm (P = .33). Fevers and age less than 1 year, but not initial erythema > 5 cm, were associated with early treatment failures, regardless of antibiotic used.

Conclusions: There is no significant difference between cephalexin and clindamycin for treatment of uncomplicated pediatric SSTIs caused predominantly by CA-MRSA. Close follow-up and fastidious wound care of appropriately drained, uncomplicated SSTIs are likely more important than initial antibiotic choice.
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http://dx.doi.org/10.1542/peds.2010-2053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3387913PMC
March 2011

Discordance between Staphylococcus aureus nasal colonization and skin infections in children.

Pediatr Infect Dis J 2009 Mar;28(3):244-6

Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, MD, USA.

We examined nasal carriage of Staphylococcus aureus in otherwise healthy children presenting with skin and soft tissue infections. We found high rates of nasal colonization with S. aureus, but significant discordance between nasal and wound isolates. Recurrent skin and soft tissue infections were common but unrelated to baseline methicillin-resistant S. aureus nasal colonization status.
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http://dx.doi.org/10.1097/INF.0b013e31818cb0c4DOI Listing
March 2009

Evolving epidemiology of pediatric Staphylococcus aureus cutaneous infections in a Baltimore hospital.

Pediatr Emerg Care 2006 Oct;22(10):717-23

Department of Pediatrics, The Johns Hopkins University, Baltimore, MD, USA.

Objectives: To examine the epidemiology, antibiotic susceptibility profiles, and outcomes in pediatric Staphylococcus aureus (SA) cutaneous infections at a time when community-associated (CA) methicillin-resistant SA (CA-MRSA) infections seemed to be increasing in our community.

Methods: The hospital microbiology database was searched for unique skin and wound SA isolates among pediatric patients between November 2002 and October 2003. Demographic and clinical data were abstracted from medical records. Cases were classified as either health care-associated (HA) or CA.

Results: Among 181 pediatric SA cutaneous infections, 81 (45%) were caused by MRSA. Most (84%) of these MRSA were CA. Between the first 6 months and second 6 months of the study period, CA-MRSA increased from 15% to 45% (P < 0.001) of all SA cutaneous infections. Ninety-eight percent and 94% of CA-MRSA were susceptible to trimethoprim/sulfamethoxazole and clindamycin (confirmed by D test), respectively. Hospitalization occurred for 25% of CA-MRSA and 75% of HA-MRSA (P = 0.004). Drainage procedures were performed for 70% of CA-MRSA. No cases of CA-MRSA skin infections were accompanied by bacteremia.

Conclusions: The CA-MRSA cutaneous infections increased in children in our urban Baltimore hospital in 2003. These CA-MRSA were erythromycin resistant, clindamycin susceptible, and trimethoprim/sulfamethoxazole susceptible. The CA-MRSA cutaneous infections frequently required drainage and were not associated with bacteremia. Children with cutaneous MRSA infections were less likely to have traditional health care risk factors than children with cutaneous methicillin-sensitive SA infections--an inversion of past patterns of MRSA infections--but were equally likely to be hospitalized when other factors were considered. These CA-MRSA cutaneous infections can be managed with abscess drainage and culture, careful follow-up, and empirical clindamycin therapy when clinically indicated.
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http://dx.doi.org/10.1097/01.pec.0000236832.23947.a0DOI Listing
October 2006
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