Use of Cardiac Point-of-Care Ultrasound in the Pediatric Emergency Department

Abstract

Background Point-of-Care Ultrasound (POCUS) has many uses at the bedside of patients seen in the emergency department (ED) including providing diagnostic information and procedural guidance. Cardiac POCUS is widely used in adults in the ED but its use in pediatric patients is less well-characterized despite endorsement from the American Academy of Pediatrics and American College of Emergency Physicians. Objective To evaluate how cardiac POCUS is utilized in the pediatric ED of a tertiary children’s hospital including: indications for use, frequency of detecting pathology and of prompting cardiologist consultation, and test characteristics compared to expert sonographer review and/or echocardiogram. Design/Methods We performed a retrospective cohort study of patients seen in the pediatric ED between July 2015 and December 2017. A POCUS image storage and quality assurance (QA) database was queried for POCUS image interpretation and QA data for all patients who underwent clinically indicated cardiac POCUS. These POCUS exams were obtained by pediatric ED physicians who had undergone formal training on cardiac POCUS and completed at least 25 exams. Patients’ charts were reviewed for demographic and clinical data. Expert POCUS reviewer and cardiologist review of echocardiogram were used as gold standards for the test characteristic analysis. STATA was used for descriptive statistics and analyses. Results: 1,241 POCUS exams were performed, of which 558 (45%) were clinically indicated and included. 139 (25%) had a cardiac medical history and 95 (17%) were recently hospitalized. Chest pain, dyspnea, and tachycardia were the most common indications for POCUS. Compared to expert reviewer, sensitivity for pericardial effusion and decreased systolic function were 98.2% (95% CI 90.5-99.95) and 95.0% (95% CI 75.1-99.9) with specificity of 99.6% (95% CI 98.5-99.95) and 99.4% (95% CI 98.2-99.9), respectively. 234 (42%) underwent cardiology consultation, and 125 (22%) had echocardiograms. Compared to echocardiogram, sensitivity for pericardial effusion and decreased systolic function were 85.0% (95% CI 70.2-94.3) and 63.2% (95% CI 38.4-83.7) with specificity of 89.9% (95% CI 80.2-95.8) and 94.6% (95% CI 87.8-98.2), respectively. Conclusion Cardiac POCUS is sensitive and specific for pericardial effusion and global systolic function. A large proportion of patients undergoing cardiac POCUS ultimately undergo formal cardiology consultation and echocardiogram.