Paediatric pneumonia? Lung Ultrasound.

If you are a regular reader then you will know that I have been spruiking lung ultrasound for a few years now.  In fact I wrote this post [ Ultrasound for pneumonia – sounds crazy? ]  way back in early 2012.  There continues to be a slow trickle of studies looking at US for pneumonia – and like a lot of US literature – the numbers are small in each paper.

In March 2015 Pediatrics published a systematic review titled:

Lung Ultrasound for the Diagnosis of Pneumonia in Children: A Meta-analysis by Perada et al.  This was a metanalysis of 8 smaller studies (2 in neonates) which showed that lung US performed well as a diagnostic tool compared to CXR.  The papers used a variety of “US users” from expert to novice sonographers.

The diagnostic characteristics have been reasonably variable across these small trials and they give the following as their overall analysis of lung US for pneumonia:

  • Sensitivity 96%,  Specificity  93%,
  • + Likelihood ratio = 15.3      -ve Likelihood ratio = 0.06
  • if you are into “area under the ROC” – it was 0.98 – which is pretty good!

These figures are our best estimate of the utility of LUS for pneumonia in kids.  They are significantly better than the characterisitics of traditional plain film.

So, are we there yet?  Is there enough evidence to change practice?

I think that there is.

Lung US is at least “non-inferior” to CXR.  US carries no risk of radiation and is a fast and technically easy scan to do in small people.  The cost is …  a few dollops of gel and the time to do the scan.

There will certainly be a risk of overdiagnosis given the relatively high sensitivity of US and the potential to misinterpret findings.  This is going to require education and training around image interpretation.  As with all point-of-care US – one needs to interpret the images in the clinical context and be prepared to do another test if the data doesn’t make sense.

So I would love to hear your thoughts –

  • is there enough here to change practice?
  • what barriers are there in your practice to change imaging preferences?

Want to learn how to do this scan??

check this video tutorial from Sonokids / Kasia Hampton

My tips on technique:

  • lots of data to get by looking at the bases: look for effusion, unilateral B lines,
  • The middle lobes collapse to leave a wedge based laterally – this is high in the axilla in little kids – so you need to get up into the armpits to see this common site of consolidation.
  • Anterior zones are easy to scan – zip down each midclavicular line
  • Always correlate with you clinical findings. e.g.. if you think it is bronchiolitis clinically, and you see bilateral posterobasal, small sub-pleural consolidations – then it is bronchiolitis…. NOT bilateral pneumonia
  • Keep using CXR and correlate until you are comfortable, but remember that 20 -30 % of sonographic pneumonias will be invisible on CXR [it is a more sensitive test]. So don’t be surprised if you get imaging that disagree

Let me know how you go.



Chest Pain? HEART Score Attack

Gday, Bonjour.

I have just returned to Broome after a month or so eating and drinking my way around Europe.  Heading back to work this week and I have been doing quite a bit of listening to the EM:RAP podcasts.  Long flights and waiting in airports!

The one podcast that caught my eye (ears) was an episode of ERCast featuring Ammal Mattu (ED ECG guru and super nice guy).  It was about the risk stratification of ED chest pain patients.  This is a continual bug-bear in most city EDs, and the rural areas struggle even more with less access to specialists, highly-sensitive troponin assays and provocative testing.  So when I heard this episode, my rural ED brain went into overdrive.

The scoring system that Dr Mattu was speaking of is the HEART score.  Oh great! I hear you all moan – another Cardiology scoring system with a smart acronym… put it with the others eg. TIMI, GRACE…  but wait – this one is a bit different.  It actually can be used in small EDs, is simple, and now has been externally validated in trials including some centres in Australia.  So it ticks all the boxes for my practice.

HEART was derived in the Netherlands by Drs Six and Backus – it has now been externally validated in other countries and settings.  The HEART score also differs from previous scores in that it was derived in a general ED population (i.e. the folk we see, whereas TIMI and GRACE were done in CCU patients – ie. folk who already got admitted.

So what is the HEART score?  It is in the image below.   [ Or you can access an interactive version over at MDCalc here ]

Check out the shape of that curve – it is a beautiful sigma with a nice flat tail on the left!  this is a discriminating tool with a good number of “low scoring” punters whom we can send home with confidence.

Other bonuses:

(1) It did not require a super high-sensitive troponin assay (not available in most rural places).

(2) All of the components of the score can be readily available within minutes – history, ECG, troponin. No serum rhubarb to send away to city labs!

(3) It did require a senior, experienced clinician to take the history, look at the patient and the ECG – this is something we DO have in spades in our EDs!

(4) You can use the HEART score with a single “admission” troponin and the low risk group has a 1.7% risk of badness over 6 weeks….

(5) Now –  if you repeat the troponin in say 3 hours you increase the sensitivity (NPV) of the score to > 99%.. which is as good as it gets for these chest pain pathways.  [Read Mahler et al in Circ Outcome from March 2015]

(6) And you can do all of this in 3.5 hours i.e. still discharge before the dreaded 4-hour target kicks in and you have to “admit” the low-risk chest pain for another troponin after  midnight.


So I am sort of looking forward to my first shift back and secretly hoping to see a patient or two with low-risk sounding chest pain.

This score will not replace commonsense, or that sinking-feeling you get when you see the rotund man sweating bullets on the trolley… but it just might help us sort out the low-risk punters in a practical and EBM happy manner!

Let me hear your thoughts – are you going to use the in your practice?

CaseyScreen Shot 2015-09-29 at 10.23.24 pm

Clinical Case 120: Vomiting VBG

Gday – I am off on leave this month – so here is a quick case from the files.

It’s an unusual VBG.  I will tell you a few features on the history and you need to work out the diagnosis and tell me how you are going to manage this!

The patient is a 25 year old chap who presents with 2 main symptoms: intractable vomiting and the near obsessive need to shower – long hot showers.  He has presented today because the ondansetron wafers that his GP prescribed have not been helping with the vomiting and his hot-water system is not able to keep up his need for hot showers!

He certainly looks dry and miserable.  His palms and soles are macerated from all the hot water.  He gets an IV sited and a quick blood gas is drawn….

So here are the questions:

(1) What is the diagnosis?

(2) Which meds will you try to truncate the vomiting?

(3)  What fluid will you choose to correct his metabolic derangement ??


thanks to @davebergie for the gas image


PODCAST: Really Rural Surgery with Dr. Bret Batchelor

Dr Bret Batchelor is a Canadian GP working in rural British Columbia.  He is also a part-time surgeon practicing his “Extended Surgical Skills” in a small town.

Over the last year Bret has been podcasting at “Really Rural Surgery“.  The podcast is a heavily evidence-based look at the practice of Surgery & procedural Obstetrics with a focus on doing common procedures in the small towns.  There is a strong flavour of “medical myth busting” which we love!

Bret was kind enough to spend half an hour chatting with me about his practice, the ethos of rural procedural work and how to train in the field.

If you are interested in Rural Surgery or EBM check out the podcast and site here.

Bret is on Twitter @ReallyRuralSurg  – he is a super smart guy and keen to spread the word – so ask him some questions and send some comments to the site.  Are there any questions you want answered about everyday Surgery?

Here is the podcast:



Clinical Case 119: Trauma & the Sensitive New Age Ultrasound

OK tonight I have a trauma case for you.

Billifred is a 24 year old man whom lives with his partner.  There relationship took a turn for the worse this evening when she found her sister’s underpants in his car.

Billifred is a “lover, no a fighter…” but tonight he was forced to defend himself against a series of stabbings.  He is brought in by taxi with multiple bleeding wounds.

Editorial note:   Presentation by taxi carries a significantly increased risk of serious badness in my world.  Ambulance services are essentially free, so they often get used as a public transport service.  However, if you are sick / worried enough to fork out $20 for a cab fare – there is a good chance that you are actually pretty sick.  Auto triage is a real thing IMHO.

On arrival he is bleeding from cuts to both hands and his ulnar forearms.  He has blood on his leg from wounds on his lateral calf.  There is a small spot of blood on his left shirt pocket.  He is not really very cooperative.  When asked what happened he says he “fell whilst sharpening his hunting knife…”

Obs:  HR 120/min,   RR 28/min,  SpO2 on RA = 90% but up to 98% on 6L/min HM,  BP140/100.  He looks sweaty and anxious.

After stripping off his shirt you see a 1 cm stab wound just below the clavicle on the (L) anterior chest, midclavicular line…

So – control the bleeders – he gets a tourniquet to his arm to stem the loss from the cuts there and then needs a chest US….  bugger, the O&G doc has taken the machine to labour ward.

After securing IV access x2 and giving him some analgesia the radiographer pops in and does a quick portable CXR.  It is a rough shot with him breathing fast, not really vertical and taking shallow breaths.

Whilst you are waiting for the films to be processed ( yes, we still use actual plastic films!!) the Bedside US machine reappears.  So you do a quick chest scan looking for pneumothorax or haemothorax on the left.

You scan from the clavicle down the anterior chest and…  no sliding.  A static pleural line with no sliding.  His right chest is normal with good sliding easily seen.  The heart looks good and there is no pericardial effusion.

Being a super-sleuth sonowarrior, you scan now across the chest laterally towards the bed looking for a lung point [contact point] – and at about the posterior axillary line you see this:   CLICK TO SEE US CLIP

Now – that is golden – a good sized pneumothorax with the whole anterior chest showing no sliding and a lung point around laterally.  The evidence suggests 100% specificity for US when a clear lung point is seen.

A quick look at the left lung base shows a small effusion ~ 1cm deep, looks like partially clotted blood with mixed echo texture .

Meanwhile the friendly radiographer has returned with the plain film and the verbal report is ” ALL Clear, no pneumothorax…”  Here is the CXR…

CXR norm

Alright then – we will pause the case at this point.

This is the “le moment decisif” the point in time where you need to decide what are you going to do next.

Do you:

(A)  Crack on a put in a chest tube

(B)  Sit on the patient, admit and observe.

(C)  Fly them to the closest CT scanner (1000 km away) for a CT chest.

We covered the pneumothorax / Airplane transfer debate a while back in Clinical Case 108.

(D) Something else / smarter??


You have about 20 minutes of suturing time to think about it as you close his lesser injuries.

You even decide to repeat the chest US after sewing up his limbs – and it looks the same – pneumothorax to the posterior axillary line with a small effusion – stable in size.

OK let me know how you will play this one.