1. January 2013
FOCUS ON
ULTRASOUND
Contents:
Letter from the Editors.....................1
Ultrasound Training - Lorraine Ng, David
Kessler.....................................2
Pearls and Pitfalls of Ultrasonography......4
Board Review - Imaging in PEM...............5
Case Highlight - Intussusception............7
Highlights from the SOEM Meeting............8
Top 10 Articles in Pediatric Emergency
Medicine, 2011-2012.........................9
Image Feature: Bedside Ultrasound in a Baby
with Respiratory Distress..................10
Case Highlight: Baby with a Neck Mass.....11
PEMNetwork Fellowship Section Update.......12
For Authors................................13
From the Editors:
Ultrasound is becoming an increasingly useful and vital part of the
practice of pediatric emergency medicine. PEM Ultrasound
fellowships are emerging, and new uses for ultrasound in our
daily practice are being described in the literature on a constant
basis. For those of us with interest in ultrasound, we cannot learn
fast enough. For those of us without solid ultrasound skills, the
learning process is intimidating and it can be hard to know where
to start. With this in mind, we present our Winter Newsletter with
a focus on ultrasound, featuring established experts in the field,
and cases demonstrating the varied use of ultrasound in practice.
All cases presented were performed by novice ultrasonographers.
We hope this will encourage our readers to pick up that probe!
[1]

2. Formal pediatric emergency ultrasound
training programs are on the rise!
Lorraine Ng, MD, David O. Kessler, MD, MSc, RDMS
Columbia University Medical Center
Emergency ultrasound (EUS) has been deemed a core
competency for emergency medicine residents by the American
College of Physicians (ACEP) since 2002.1 The past two
decades have seen a transformation in the role of EUS from a
novel toy to standard practice and full integration of a wide
variety of applications in the emergency department. This role
has been accompanied by a robust growing body of literature to
support the use of EUS in clinical decision-making, guiding
resuscitative care, and improving procedural safety and
success.
Pediatric emergency medicine (PEM) training programs
have not yet adopted ultrasound as a core competency,
however ultrasound use in the pediatric emergency department
and training opportunities have also been on the rise.2 Despite
the increase in training and exposure to EUS within PEM
fellowships, very few programs (~25%) have a formal curriculum
becoming a local “champion,” he also adds for those seeking to
hone their ultrasound skills during fellowship, “If you have an
ultrasound fellowship already at your institution, you could
potentially gain competency through regular use and attendance
at lectures, similar to EM residents.”
That’s exactly the strategy that Dr. Jennifer Marin started
out with, now director of Pediatric Emergency Ultrasound at the
Children’s Hospital of Pittsburgh. "I began my ultrasound
experience when I was a first year fellow, being introduced to
the FAST exam during my trauma rotation. From there, I
developed a research interest using bedside ultrasound and
then decided to improve my skills even further by creating a
training program for myself during an extra year of fellowship."
By obtaining a grant through the NIH to fund an additional year
of research, she was also able to design her own EUS
experience that mirrored the EUS fellowship at the neighboring,
general emergency department in which she attended weekly
video clip reviews, had mentored scanning shifts, and pursued
further ultrasound teaching responsibilities.
leading many to pursue further training. We spoke with several
leaders in the field to learn more about their paths to expertise
Wait, fellowships
do exist?
and where they see the future of this exciting new field.
Have no fear, formal training
opportunities for PEM trainees are
rapidly on the rise. Many have already
“Scan as much as possible - even
What is the best way
to learn during my PEM
fellowship?
if you don't know what you are
looking at!” says Dr. Alex Arroyo,
Director of Pediatric Emergency
Medicine Ultrasound Research at
Maimonides Medical Center. But warns, “there are some things
you just can’t get from self-teaching and an informal "mini"
fellowship,” says Dr. Arroyo.
“Scan, scan, scan, there is no substitute for actually using
ultrasound on a regular basis and getting hands-on instruction
by knowledgeable attending staff,” agrees Dr. Adam Sivitz, the
Director of Pediatric Emergency Medicine at the Children's
Hospital of New Jersey at Newark Beth Israel Medical, where
they currently have a 2-day bootcamp and 2-week elective for
their PEM fellows, along with regular education and hands-on
use throughout fellowship. While Dr. Sivitz recommends
fellowship for those interested in pursuing an US career or
taken advantage of formal specialization in EUS
through tailor-made curriculums at one of the many non-ACGME
accredited 1 or 2 year fellowships (www.eusfellowships.com).
There are currently 86 EUS fellowships nationwide, with an
increasing number of pediatric EUS fellowships offering US
expertise tailored to PEM. Directors of EUS programs around
the country, such as Dr. J. Christian Fox from University of
California, Irvine School of Medicine, Dr. Arun Nagdev from
Highland General Hospital, Dr. John Bailitz from Cook County
Emergency Medicine in Chicago, Dr. Resa E. Lewiss from St.
Luke’s Roosevelt Hospital Center in New York City, Dr. John
Kendall from Denver Health Medical Center, and Dr. Gregory
Press from University of Texas at Houston, to name a few, have
begun to train PEM fellows in their fellowships as well because
they “realize PEM is in need of ultrasound leaders.”
Recently, several pediatric emergency medicine divisions
have also created additional fellowship training programs in
[2]

3. pediatric EUS (e.g. Boston Children’s Hospital, Columbia
Dr. Arroyo adamantly agreed that the extra year was
University, Maimonides Medical Center, and Oakland Children’s
worthwhile, “If you took my ultrasound skills away I would rather
Hospital).
not practice medicine - that’s how much I depend on it on a daily
Fellowships provide time for intensive hands-on scanning with
basis.”
direct feedback on performance to allow for rapid improvement
and expertise in ultrasound scanning and interpretation. Additional
“I think any good PEM fellowship will have an
focus on relevant literature, scholarly projects, teaching
ultrasound component, and most
responsibilities, and administrative topics round out a fellow’s
As training becomes more
pervasive, will fellowships become
obsolete one day?
experience to help nurture them as true experts in the field.
When training pediatric EUS fellows, the fellowship
should have “access to a busy pediatric ED with extensive
opportunities to scan kids, [since the pediatric US] applications
fellows will be looking to have
this built into their curriculum”
says Dr. Nagdev. And Dr. Fox
suggests that “It will only
[become obsolete] when all medical
are so unique [they] can't be reproduced in an adult population,”
schools have fully integrated ultrasound into
states Dr. John Kendall, the Director of Emergency Ultrasound at
their curricula.”
Denver Health Medical Center, where they have had an EUS
But as the field of pediatric EUS develops, there will still
fellowship since 2005 and incorporated pediatric US fellowship
always be a demand for pediatric EUS-trained leaders to train our
training into the standard EUS curriculum.
PEM colleagues and to conduct cutting-edge research to support
the integration of EUS into routine PEM practice. At the end of the
day, regardless of how you choose to tailor your pediatric EUS
According to Dr. Stephanie Doniger, who is
Is it worth the
extra year?
training, whether it is supplementing your PEM fellowship with
now Director of Ultrasound at the Children’s
independent scanning or pursuing a pediatric EUS fellowship, the
Hospital and Research Center in Oakland
most important thing to do is follow Dr. Sivitz’s advice and “Scan,
and runs a PEM EUS fellowship, it was “the
scan, scan!”
absolute best decision I ever made.” As the first
PEM trainee to ever do a formal fellowship at St Luke’s Roosevelt
Hospital Center in New York City, she learned the skills necessary
to become an internationally renowned educator, develop her own
training curriculum, and oversee faculty development at her next
job. “A one month rotation just didn’t seem enough to [learn] to
ULTRASOUND BLOG/PODCAST
http://
www.ultrasoundpodcast.com
http://pointofcare.blogspot.com
ULTRASOUND LISTSERVE
Email saguarochip@gmail.com and
ask to be added to receive weekly
updates of articles published on
emergency ultrasound topics
1. Akhtar S, Theodoro D, Gaspari R, Tayal V, Sierzenski P, LaMantia J, Stahmer
S, Raio C. Resident Training in Emergency Ultrasound: Consensus Recommendations
from the 2008 Council of Emergency Medicine Residency Directors Conference.
Academic Emergency Medicine. 2009; 16:S32-36.
2. Marin JR, Zuckerbraun NS, Kahn JM. Use of emergency ultrasound in United
States Pediatric Emergency Medicine Fellowship programs in 2011. J Ultrasound
Med. 2012;31:1357-63.
effectively teach other people.”
Useful Ultrasound
Links
References:
ULTRASOUND SOCIETIES OR
http://sinaiem.us
http://cmedownload.com/courses/
SECTIONS:
soundbytes
http://www.susme.org
http://www.aium.org/
http://www.saem.org/narratedlectures
http://www.winfocus.org
http://www.saem.org/academy-
http://www.yale.edu/imaging/
echo_atlas/views/index.html
emergency-ultrasound
http://www.acep.org/ultrasound/
ULTRASOUND app:
http://www.imedicalapps.com/
ULTRASOUND LEARNING/
SHARING WEBSITES:
2012/10/emultrasound-app-
www.sonoguide.com
iphone/
www.sonocloud.org
[3]
These links will also
be available on the
ultrasound sub-site of
PEMNetwork.org

4. Pearls and Pitfalls of Bedside Ultrasound
- an Interview with Lei Chen
- Michelle Alletag
Q
Can you tell me a bit about when/how ultrasound became a commonly-used modality in Emergency medicine?
A
Q
In the late 90's European trauma surgeons started using ultrasound to diagnose intra-abdominal
injuries. With the rapid technological breakthroughs of miniaturization portable US became a reality.
How much time and training does it take to become proficient with the ultrasound machine? What are some easyto-learn diagnoses/applications?
A
I think the FAST scan is the one that novice should start with. Not because it's the easiest but
because it helps illustrate several salient features of ultrasound: different tissues, different
orientations, dynamic imaging, etc. etc. It's hard to say how many scans. ACEP has a consensus
statement on training for a variety of modalities and is a good reference.
Procedural applications are often easier to learn. These include vascular access, abscess I&D,
nerve blocks, etc. The success and failure of the procedures give you immediate feedback on your
study.
Q
There are few faculty in my ED who use the ultrasound machine - how do I get existing faculty on-board with
bedside ultrasound?
A
Q
There was one patient in our PICU where no one could obtain vascular access except for the EM
resident with a borrowed ultrasound machine. The next week a machine was delivered.
Ultrasound is becoming very popular and the PEM community has embraced it as a skill we need, but what are
some caveats and pitfalls to PEM physicians using ultrasound?
A
In general for diagnostic studies specificity is higher than sensitivities. Therefore bedside ultrasound
is not good, in general, to rule OUT diagnosis. So for conditions with high potential morbidities such
as ovarian / testicular torsion, appendicitis, etc. I would be very careful in using a negative bedside
ultrasound to discharge the patient.
Q
What are the medico-legal implications of adding ultrasound to our skill set and credentialing? Our malpractice
rates are already pretty high...How can we ensure an appropriate review process and quality assurance?
A
You need to work with your hospital / institution credentialing body which have their own rules. For
procedural studies there is general consensus that ultrasound
improves success rates and decreases complications. For
diagnostic tests it gets much trickier. Again I would avoid those
conditions mentioned previously, or at least not rely on the
bedside reading exclusively, without confirmatory testing.
[4]
Dr. Chen is an
Associate Professor of
Pediatric Emergency
Medicine at Yale
University and has
contributed extensively
to the study and
development of
ultrasound in PEM.

5. BOARD REVIEW:
IMAGING IN PEDIATRIC
EMERGENCY MEDICINE
Questions used with
permission by Jennifer
Pai, MD, editor of
Pediatric Emergency
Medicine Practice.
For full text and more
review topics, visit
EBMedicine.net/
topics.php. All
reviews published >36
months ago are free for
viewing.
1. The amount of experience and training required by a
non-radiologist to perform a focused exam is:
c. A low-frequency probe is most appropriate for evaluation of the
superficial soft tissues.
d. Ultrasound is of no value in evaluating simple cellulitis.
a. Not definitively established
b. 300 completed studies
5. Which of the following is true?
c. 150 completed studies
a. A-mode ultrasound is the most frequently used today
d. 8 hours of hands-on training
b. M-mode is a form of Doppler ultrasound
c. Color Doppler gives a quantitative measurement of flow
2. Which of the following is NOT true?
d. Doppler ultrasound is dependent on how the probe is held relative
a. Ultrasound is defined as frequency greater than 20,000 hertz.
to the direction of the moving object.
b. Hypoechoic objects appear dark on the ultrasound screen.
c. High-frequency ultrasound penetrates deeper into tissues than
6. An intrauterine pregnancy can be confirmed earliest
low-frequency ultrasound.
by:
d. Urine in the bladder will appear black because it does not reflect
ultrasound waves well.
a. Quantitative human chorionic gonadotropin (HCG)
b. Endovaginal sonography (EVS)
3. With respect to FAST scans, which of these
statements are true?
c. Transabdominal sonography (TAS)
d. Doppler
a. The most common practice uses four ultrasound views, but
7. The indirect method of venous cannulation using
ultrasound guidance requires:
additional views are sometimes obtained.
b. FAST scans are useful for identifying free fluid in the abdomen
and somewhat less so for solid organ injury.
a. Sterile transducer sleeve
c. A normal FAST scan may occur if there is not enough free
b. At least 2 people to perform
intraperitoneal fluid.
c. Sterile gel
d. All of the above.
d. One person without special preparations
4. Choose the best statement.
8. The most common ultrasound probe placement for a
rapid cardiac exam is:
a. For soft tissue ultrasound, use of a curved ultrasound probe
allows for better contact with the skin.
a. Transesophageal
b. A spacer or stand-off may help place the are of interest within the
optimal focal zone of the ultrasound probe.
b. Parasternal
c. Apical
d. Subxiphoid
[5]
Answers and
discussion, next
page

6. Imaging in PEM: Answers
1. a. Not definitively established
5. d. Doppler ultrasound is dependent on how the probe is
held relative to the direction of the moving object.
Though all of the above choices have been issued in consensus
statements, studies have shown that ED physicians can accomplish a
high degree of accuracy in as little as 4 hours of training. More important
“bright”), with object intensity corresponding to echogenicity. M-mode is
than following consensus statements is implementing a process for
a time-motion mode that shows both the traditional B-mode image and a
continued experience and quality review.
tracing of tissue motion (e.g. fetal heartbeat). Doppler ultrasound utilizes
The most commonly used mode of ultrasound is B-mode (or
the fact that ultrasound (or any sound wave, to be exact) beam frequency
2. c. High-frequency ultrasound penetrates deeper into
increases if an object moves toward it, and decreases as it moves away.
tissues than low-frequency.
Color doppler provides a visual interpretation of directionality and velocity
High-frequency transducers (such as the linear probe commonly
of flow.
used in bedside ultrasound) have beams that are more unidirectional and
focused with shorter wavelengths, so images are high resolution but
6. b. Transvaginal ultrasound
attenuate quickly. Attenuation is the process of “losing power” as the
While quantitative HCG can confirm a pregnancy earlier that ultrasound, it
ultrasound beam travels through tissue. Lower frequency transducers,
is not specific for intrauterine pregnancy (IUP). At 5-6 weeks gestation, TV
such as the curvilinear probe, have longer wavelengths, are more
ultrasound can confirm the presence of a gestational sac, with
multidirectional, and penetrate deeper into tissues, providing a lower-
transabdominal able to confirm slightly later. At 6-7 weeks, a fetal pole
resolution but deeper picture.
and, at 7-8 weeks, a cardiac flicker may be then visible by either modality,
though TV provides higher quality images and can detect each
3. d. All of the above
approximately one week earlier than TAS. Confirming an IUP in the female
patient with abdominal pain or bleeding can effectively rule out ectopic
The FAST exam is designed primarily to detect free fluid in the
abdominal cavity, which translates to blood in the setting of abdominal
pregnancy (though the risk of a second ectopic pregnancy may be as high
trauma. The classic FAST method is a four-view scan, beginning with the
as 1:4000, or greater if fertility agents are used)
RUQ and Morrison’s pouch, followed by the LUQ, subxiphoid region (to
assess for pericardial effusion), and the suprapubic region. If free fluid is
7. d. One person without special preparation
found, the adjacent organ may be assessed to evaluate for injury, thought
the FAST is less sensitive for this. While FAST is highly sensitive and
method of cannulation, and simply uses the ultrasound probe to locate
specific in adult trauma, its sensitivity decreases in the pediatric setting.
and mark the site of a vessel prior to attempted cannulation. Light
This is due to many factors, but primarily because children are more likely
pressure on the vessel to flatten and thus confirm that it is a vein is
to have organ injury without corresponding major blood loss, and are less
performed prior to attempted cannulation. This method can be performed
likely to bleed with a volume sufficient to produce the anechoic strip that
by a single provider without any special preparation. The direct method
indicates free fluid. Specificity of FAST, however, remains high for children
requires more preparation and is best performed with 2 operators, and
as well as adults.
uses ultrasound to directly visualize the needle as it is being cannulated.
The indirect method provides less guidance than the direct
A linear high-frequency probe should be used for this method, as
4. b. A spacer or stand-off may help place the are of interest
curvilinear will distort the image. Ultrasound-guided central line
placement is currently considered standard of care in the adult emergency
within the optimal focal zone of the ultrasound probe.
setting, though formal guidelines in the pediatric setting have not yet been
High-frequency linear transducers produce the best quality
images of superficial soft tissue structures and can be useful in evaluating
established.
cellulitis and presence/absence of drainable abscesses. A spacer or
stand-off can be useful in cases of very superficial skin and soft tissue
8. d. Subxiphoid
structures that are closer to the probe than the usual focus zone -
commercial products are available, but the use of a glove filled with water
evaluating pericardial effusions and cardiac standstill, and is the view
is an excellent and inexpensive alternative. For foreign body evaluation, a
included in ATLS and PALS teaching. The parasternal views may provide
stand-off, made by placing the extremity in a basin of water and then
additional information about cardiac function. The subcostal view is
placing the probe on the water’s surface, is also useful.
obtained by placing the transducer just below the xiphoid and aiming
A single subcostal (subxyphoid) view is the most useful for
toward the patient’s left shoulder. This places the right ventricle at the top
of the screen, and provides a “reverse” image of standard
echocardiography images.
[6]

7. CASE HIGHLIGHT: A NASTY CASE
OF INTUSSUSCEPTION
Carrie Busch MD, William S Russell MD, Jeanne Hill MD,
Christian Streck MD
Medical University of South Carolina
The Patient:
A 3yo afebrile female presented to the
received 60cc/kg of NS with
improvement in her vital signs. Bedside
emergency department (ED) with 1 day of
ultrasound was performed and there
abdominal pain in “waves” with emesis and
was evidence of fluid filled loops of
negative hemoccult. She had a negative
bowel, abnormal thick-walled bowel without
laboratory evaluation and had an abdominal
blood flow on color doppler and extensive
ultrasound (US) that demonstrated
complicated fluid. [Figures 2, 3 & 4] The
intussusception. [Figure 1] She was taken for
patient was taken to the operating room for
an air enema during which the
exploratory laparotomy and was found to
intussusception was no longer visualized.
have 40cm of necrotic bowel. [Figure 5] Intra-
This was confirmed with repeat US
operatively, she was coagulopathic and septic
immediately after the enema. She was then
requiring resection and temporary abdominal
observed in the PED where her pain resolved
closure with a delayed re-anastomosis
and she was discharged home after tolerating
following resuscitation in the PICU.
oral hydration. The family received strict
discharge instructions to return to the ED with
Discussion:
any recurrence of symptoms. However, they
Intussusception is a common cause of
did not return until 2 days later despite return
bowel obstruction in children and carries a
of emesis, abdominal pain and fever shortly
mortality of less than 1%. US is the initial
after discharge. At that time, the patient
imaging modality of choice and has been
presented to her primary physician in
reported to be 92% sensitive for
uncompensated shock. She was transported
intussusception. Many studies have sited
to the PED with a surgical abdomen. She
non-operative reduction techniques as
[7]
Figure 1 (Top Left)
demonstrates
pathognomonic target
sign of intussusception.
From Top, Figures 2
(fluid filled loops), 3
(absence of flow), 4
(complicated fluid
collection), and 5
(necrotic bowel at time
of surgery).

8. successful with minimal reported
however, illustrates that necrosis can be
of intussusceptions can be handled non-
seen in the absence of a distinct re-
operatively with maximal success rates in
intussusception episode. While we
the setting of <24 hours of symptoms and
cannot rule out recurrence, we suspect
in the typical age range of 6 months to 3
the clinical course observed is the result of
years. An enema reduction using air or
an ischemic segment that evolved to full
water soluble contrast is recommended
thickness necrosis in the 48 hours post
for the most common location, ileocolic.
reduction. We present this case as a rare
In some centers, a short observation
complication that illustrates the necessity
period and discharge is routine
for strict return precautions and next day
management providing patients tolerate
follow-up when an early discharge model
oral hydration and have no return of
is followed. This extreme case illustrates
abdominal pain. However many
that even seemingly routine cases of
institutions routinely admit for a longer
intussusception can have complications.
observational period secondary to
It also demonstrates that in the setting of
concern for recurrence. This is estimated
symptom return after intussusception
to happen in approximately 10% of cases.
reduction, a negative US for recurrent
Bowel wall compromise and necrosis is a
intussusception does not exclude
known complication of unreduced or
Case Highlight:
Intussusception,
cont.
recurrent intussusception. Our case,
complications. The overwhelming majority
intussusception- related pathology.
HIGHLIGHTS FROM SOEM
A Note from the Head Site Administrator
Angela Lumba, MD, FAAP
St. Louis Childrens Hospital
In October 2012, the AAP held its annual National
Conference Exhibit in New Orleans. The Section on
Emergency Medicine (SOEM) and its Committee for the
Future opened the session with Technology in Pediatric
Emergency Medicine. Through speeches and poster
presentations, physicians shared ways they had
innovated PEM education through advancing technology.
The PEMNetwork was one of the many ideas highlighted!
The SOEM continued to deliver our annual favorites:
EmergiQuiz – a platform for fellows to explore the
diagnosis and management of unique cases
PEMPix – A collection of photo submissions of
interesting to extreme presentations
I first attended the SOEM NCE plenary session as a
resident with hopes of PEM fellowship. To this day, I am
inspired by the presentations I hear, by the camaraderie at
the meeting, and by the depth and breadth of topics
covered. I recommend that every trainee or junior faculty
member attend this energetic and
dynamic conference.
Abstract sessions
Top 10 PEM articles of 2012 - see next page for list
[8]
EmergiQuiz
presentations can be
viewed on
PEMNetwork.org. Visit the
AAP SOEM website to
see PEMPix entries
and winners.

9. #5
Top 10 PEM Articles
2011-2012
Diagnosis
of
Intussuscep:on
by
Physician
Novice
Sonographers
in
the
Emergency
Department
Antonio
Riera,
MD,
Allen
L.
Hsiao,
MD,
Melissa
L.
Langhan,
MD,
T.
Rob
Goodman,
MBBChir;
Lei
Chen,
MD,
MHS
Michelle D. Stevenson, MD MS FAAP
Ann
Emerg
Med.
2012;60:264-­‐268.
PMID:
22424652
University of Louisville
#4
#10
Yield
of
Emergent
Neuroimaging
Among
Children
Presen:ng
With
a
First
Complex
Febrile
Seizure
Amir
A.
Kimia,
MD;
Elana
Ben-­‐Joseph,
MD;
Sanjay
Prabhu,
MD,
MBBS,
FRCR;
Tiffany
Rudloe,
MD;
Andrew
Capraro,
MD;
Dean
Sarco,
MD;
David
Hummel,
MSc;
Marvin
Harper,
MD
Rapid
Versus
Standard
Intravenous
Rehydra:on
in
Paediatric
Gastroenteri:s:
Pragma:c
Blinded
Randomised
Clinical
Trial
Stephen
B.
Freedman,
MD;
Patricia
C.
Parkin,
MD;
Andrew
R.
Willan,
PhD;
Suzanne
Schuh,
MD
Pediatr
Emerg
Care
2012;28:
316-­‐321
PMID:
22453723
BMJ
2011;343:d6976
PMID:
22094316
Vasopressin
rescue
for
in-­‐pediatric
intensive
care
unit
cardiopulmonary
arrest
refractory
to
ini:al
epinephrine
dosing:
A
prospec:ve
feasibility
pilot
trial
Prevalence
of
Clinically
Important
Trauma:c
Brain
Injuries
in
Children
With
Minor
Blunt
Head
Trauma
and
Isolated
Severe
Injury
Mechanisms
#3
#9
Timothy
G.
Carroll,
MD;
Vivian
V.
Dimas,
MD;
Tia
Tortoriello
Raymond,
MD
Pediatr
Crit
Care
Med
2012;
13:265–272
PMID:
21926666
#8
Lise
E.
Nigrovic,
MD,
MPH;
Lois
K.
Lee,
MD,
MPH;
John
Hoyle,
MD;
Rachel
M.
Stanley,
MD;
Marc
H.
Gorelick,
MD;
Michelle
Miskin,
MS;
Shireen
M.
Atabaki,
MD;
Peter
S.
Dayan,
MD,
MSc;
James
F.
Holmes,
MD,
MPH;
Nathan
Kuppermann,
MD,
MPH;
for
the
TraumaXc
Brain
Injury
(TBI)
Working
Group
of
the
Pediatric
Emergency
Care
Applied
Research
Network
(PECARN)
Arch
Pediatr
Adolesc
Med.
2012;166(4):356-­‐361.
PMID:
22147762
U:lity
of
Plain
Radiographs
in
Detec:ng
Trauma:c
Injuries
of
the
Cervical
Spine
in
Children
Lise
E.
Nigrovic,
MD,
MPH;
Alexander
J.
Rogers,
MD;
Kathleen
M.
#2
Adelgais,
MD,
MPH;
Cody
S.
Olsen,
MS;
Jeffrey
R.
Leonard,
MD;
David
M.
Prevalence
of
Abusive
Injuries
in
Siblings
and
Household
Jaffe,
MD;
and
Julie
C.
Leonard,
MD,
MPH;
for
the
Pediatric
Emergency
Contacts
of
Physically
Abused
Children
Care
Applied
Research
Network
(PECARN)
Cervical
Spine
Study
Group
Daniel
M.
Lindberg,
MD;
Robert
A.
Shapiro,
MD;
AntoineUe
L.
Laskey,
Pediatr
Emerg
Care
2012;28:
426-­‐432.
MD,
MPH;
Daniel
J.
Pallin,
MD,
MPH;
Emily
A.
Blood,
PhD;
Rachel
P.
PMID:
22531194
Berger,
MD,
MPH;
and
for
the
ExSTRA
InvesXgators
Pediatrics
2012;130;193-­‐201.
PMID:
22778300
#1
Intramuscular
versus
Intravenous
Therapy
for
Prehospital
Status
Epilep:cus
#7
Occult
Serious
Bacterial
Infec:on
in
Infants
Younger
Than
60
to
90
Days
With
Bronchioli:s
Shawn
Ralston,
MD;
Vanessa
Hill,
MD;
Ami
Waters,
MD
Arch
Pediatr
Adolesc
Med.
2011;165(10):951-­‐956.
PMID:
21969396
Robert
Silbergleit,
MD;
Valerie
Durkalski,
PhD;
Daniel
Lowenstein,
MD;
Robin
Conwit,
MD;
Arthur
Pancioli,
MD;
Yuko
Palesch,
PhD;
and
William
Barsan,
MD;
for
the
NETT
InvesXgators
#6
The
Spectrum
and
Frequency
of
Cri:cal
Procedures
Performed
in
a
Pediatric
Emergency
Department:
Implica:ons
of
a
Provider-­‐Level
View
N
Engl
J
Med
2012;366:591-­‐600.
PMID:
22335744
MaUhew
R.
MiVga,
MD,
Gary
L.
Geis,
MD,
Benjamin
T.
Kerrey,
MD,
MS,
Andrea
S.
Rinderknecht,
MD
Ann
Emerg
Med.
2012;
Jul
26.
[Epub
ahead
of
print]
PMID:
22841174
[9]
Visit
PEMNetwork.org or
the AAP SOEM site for
article summaries,
description of article
selection methodology,
honorable mentions
and more!

10. IMAGE HIGHLIGHT:
BEDSIDE ECHO IN THE EVALUATION OF A BABY IN
RESPIRATORY FAILURE
David Rodriguez, MD
His anterior fontanelle was flat. Rhinorrhea and
UT Southwestern Medical Center
congestion were present but mucous
A 19 week old term male, with no
significant medical problems presents to the
Emergency Department (ED) with difficulty
breathing. He has had 1 week of congestion and
increased work of breathing but no fever. Over
the past 2-3 days he has had decreased activity,
decreased oral intake, and mildly decreased
urine output but normal stools. He was seen at
an Urgent Care Center 3 days prior and started
on amoxicillin for “infection.” Seen by PCP 2
days prior, started on albuterol and steroids for
bronchiolitis. Also seen yesterday and again
today by PCP for follow up, again given
nebulizer treatments, but sent to the ED due to
increased wob. O2 sats reportedly improved
from 90 to 94% RA after nebulizer treatments.
Presenting vital signs are as follows:
BP 110/44 | Pulse 157 | Temp(Src) 36.6 °C
(97.9 °F) (Temporal) | Resp 58 SpO2 98% (RA)
On physical exam, he was well-developed
and well-nourished, active and with a strong cry.
A very abnormal subxiphoid
view
CXR shows severe
cardiomegaly. Bedside
ultrasound demonstrates no
cardiac effusion, but the
right ventricle is
severely dilated, with
poor contractility easily
noted on video.
Watch the
ultrasound video clip
of this heart on
PEMNetwork.org
[10]
membranes were moist. Oropharynx and ears
were clear. Neck was supple. Cardiac exam
was normal, with no murmur.
Tachypnea, subcostal retractions, and
accessory muscle usage present. Transmitted
upper airway sounds were present but no
wheezes, rales, or rhonchi.
Abdomen was soft with normal bowel
sounds and no organomegaly. Skin was warm
with a normal capilary refill time. No purpura,
rash, pallor or cyanosis were noted.
The patient had bulb suction and lavage,
but became dusky and cyanotic. He was taken
to the critical care room. There he was in severe
respiratory distress with a respiratory rate in the
80's, using accessory muscles. He was
intubated using atropine, fentanyl, and
rocuronium. Bedside US showed decreased
cardiac contractility. CXR showed good tube
placement and severe cardiomegaly. EKG
showed inverted T waves in the lateral leads.
Cardiology was called to perform an emergent
bedside echo prior to admission to the cardiac
ICU, with the diagnosis of myocarditis.

11. Case Highlight
THE BABY WITH
A NECK MASS
Peter Moyer, MD; Yale University
Michelle Alletag, MD; UT Southwestern Medical Center
The Case:
An 8 day old male born via SVD presents to the ED with a left neck mass.
The mother first noted the mass three days prior, and states it has been getting
darker but not larger in size. Per mother, the patient has been feeding well, alert,
and afebrile. The patient did require forceps extraction, but birth was otherwise
uncomplicated.
On exam, the baby is alert, with normal vital signs for age. He has two
palpable masses on the left neck; one is 1x3cm over the mastoid, with a second
1x1cm mass over the angle of the mandible. Both are red and firm, with no
fluctuance or induration. The patient’s neck is supple, and a right parietal
cephalohematoma is also noted. He has a slight head tilt to the left but full
passive and active ROM. The remainder of the exam is unremarkable.
Ultrasound of the neck demonstrated two echogenic masses along the
anterior aspect of the sternocleidomastoid, with Doppler evidence of internal
vascularity and no cystic component. The diagnosis of congenital fibromatosis
coli (or psuedotumor of infancy) was made. The patient’s mother was instructed
on home care for congenital torticollis, and the patient had resolution of the
masses at his two-month well-child visit.
Discussion:
Congenital fibromatosis coli is a benign condition in neonates, which may
result in congenital muscular torticollis and positional plagiocephaly. It presents
as a palpable, firm, nontender mass along the border of the sternocleidomastoid
(SCM) muscle. It often leads to contracture and fibrosis of the underlying SCM,
resulting in congenital torticollis and head tilt. It occurs equally among boys and
girls, and is associated with other congenital musculoskeletal anomalies (most
often hip dysplasia). The cause of fibromatosis coli is unclear, but is thought to be
the result of one of two insults: fetal malpositioning in utero leading to
contracture and fibrosis, or birth trauma resulting in muscular fibrosis. The
forceps delivery, cephalohematoma, and visible hematoma over our patient’s
masses support the latter etiology in his case. Differential diagnosis must include
more pathologic conditions such as lymphadenitis, congenital cystic lesions with
abscess, and oncologic processes, including sarcomas, teratomas, or
lymphomas.
Diagnosis is best made by ultrasound evaluation, which shows echogenicity
with fusiform enlargement of the SCM, and excludes the diagnoses of
lymphadenitis, congenital cysts, or abscess. While CT, MRI, and fine needle
aspirate will also establish the diagnosis, ultrasonography has the advantage of
lower cost, lack of radiation exposure, and avoidance of sedation.
Treatment for fibromatosis coli consists of massage, heat, and passive
stretching, with the majority of patients having complete resolution with home
treatment alone. Those who do not resolve within the first year of life should be
referred to an otolaryngologist, as they may require surgical intervention.
[11]
Above, the baby presents with a large
erythematous region near the mastoid.
Ultrasound of the affected area (Figure
2) shows hypertrophy of the SCM as
compared with the contralateral normal
side (Figure 3). No evidence of cellulitis,
“cobblestoning”, lymphadenopathy, or
fluid collections was noted.

12. From the Fellowship Corner
Hello everyone,
First and foremost, we would like to congratulate everyone who matched into PEM this year! It was
a great match with a 143 individuals matching into PEM fellowship positions at 71 different
programs around the country after completing either a Pediatrics or Emergency Medicine
residency. We are very excited to have these individuals join the ranks of PEM and look forward to
having them as colleagues. Congratulations again!
We are also eagerly anticipating this year’s PEM Fellows’ Conference, which will be taking place
from February 23rd through February 25th, 2013 in Austin, Texas. This year’s conference will be
supported by the EMSC Program and Austin Children’s Hospital Medical Center. A wonderful
program has been planned and we look forward to this opportunity for so many PEM fellows from
around the country to come together for a weekend.
We hope you all had a wonderful holiday season.
Saranya Srinavasan, MD
Pediatric Emergency Medicine Fellow
Children's Hospital Los Angeles
[12]

13. WANT TO BE A PART OF PEMNETWORK.ORG?
Now it’s easier than ever! PEMNetwork is a dynamic, ever-evolving organization and we
are always looking for new ideas and input. Do you have a great case or interesting
teaching point that you wish you could share with someone besides those same fellows you
see every week? Send it to us at pemfellows.com@gmail.com!
Recommended Newsletter Submission Formats:
Case Reports: May include presentation of uncommon diagnoses or of unusual presentation or complications of common
diagnoses seen in the Pediatric Acute Care setting. Should consist of a brief, 1-2 paragraph description of the case, followed by a
discussion of diagnosis and management of the disease process reported. Inclusion of images, either of physical exam findings or
radiographic studies, are recommended. A minimum of 3 references for the discussion section is requested.
EKG Submissions: Classic EKG findings of disease processes found in the acute care setting are welcome. Please include an
image of the EKG, description of the EKG findings, 1-2 sentences describing the case, and a brief discussion of the disease process
being shown. References are requested but not required.
Image Highlights: May include an image of an interesting physical exam finding, or a radiologic
image of significant teaching value. Please include a brief description of the case, followed by 1-2
paragraph discussion of the disease process being highlighted and the characteristic features of the
image. References are requested but not required.
Literature Review: May be in case report format, or topical only. Reviews of current or new AAP
subcommittee recommendations or of specific disease processes are desired. Please limit to one
page, references required.
Recommended
formats will be
available for review at
PEMNetwork.org, on
the newsletter
page
Editors:
Purva Grover
Michelle Alletag
Angela Lumba
Send Us Your Cases!
We are currently accepting submissions for our spring newsletter. The focus
for the spring newsletter will be on innovations in medical education. Email
submissions to pemfellows.com@gmail.com.
[13]