Antibiotic Awareness Week: What’s your spiel?

Welcome back!  It is ANTIBIOTIC AWARENESS WEEK here in Australia.

The slogan I have been pushing with my trainees is: “Take time to have the chat, Don’t just write the script.”

Of course, that “chat” can turn nasty!  We have trained generations of families to expect, crave and depend upon the magical pills to cure every cough, sneeze and fever…. but we know that it is largely snake oil!  So my challenge to you all is to share your best spiel.  What do you say to the eager parent who really, really wants a bottle of Amoxil for that slight red ear?  How do you rationalise the need for a penicillin suspension for a runny nose with your next man-flu?

So I have a challenge for you all…


Send me your favourite lines.  The throw away comments and phrases you use to talk em outta the pills.

You can comment below if you like – or better still send me an audio recording of your favourite spiel – just talk it into your phone and send it over to

You might wing a prize.  But better still you might allow the rest of us to share your wisdom with our patients and keep the lid on the Antibiotic Armageddon that may be not too far away!

GO on!

Hit me with your best lines.


Clinical Case 121: Supracondylar Sono Subtlety

Another quick case from the Paeds files…

Simple story – 5 year old boy playing with his 6 year old sister on bunk beds.  Mum heard a thud then a scream and found him on the floor – he has fallen about 1 metre onto his outstretched arm.  No other injury seen.

On arrival to the ED he is holding his arm by his side in 90 degrees flexion, when asked – he points to his antecubital fossa to show where he is sore.

He has good pulses distally, there is some localised swelling but no deformity of the elbow.

So what is going on?  Well as usual it is 3 AM and there is no Xray available…  but as I said at SMACC Chicago: “No Xray, No Problem.”

So lets pull out the US machine and have a gander:

First view is a transverse of the posterior humeral condyles and fat pad.  The is abnormal – usually the fat pad lies beneath a line, convex down between the condyles – this pad is billowing up – this is a sonographic “sail sign” the tell tale for an elbow haemarthrosis.posterior fat pad

The second image is a long view of the posterior humerus with triceps tendon overlying.  There is  a subtle cortical break evident (can you see it?)  These can be tricky as they look a lot like normal growth plates in little kids – so luckily he has 2 arms and we can scan the other one to compare.  Asymmetry suggests a fracture – you can also use the probe to illicit tenderness to check fracture vs. growth plate.triceps

The third image is a long view of the proximal radius – checking for a fracture of the radial head – this was normal.  The other side looked the same and there was no tenderness over the radial neck.  The elbow was enlocated on further scanning.radial head

So we have a good story for a supracondylar fracture, a definite haemarthrosis, a subtle crack in the distal humerus and a normal looking radial head/neck.

So he got a long arm plaster and returned for review and an Xray to be sure…

Here are the plain film images:

So the subtle signs are seen – but I reckon they are more obvious on the US. What do you think?supra latsuprAP?

So a few controversial questions….

(1) Do we really need to Xray this kid?  It is a subtle undisplayed fracture which will always be managed conservatively.

(2) If the plain film had been reported as “Normal” or “non-diagnostic” what would you do given these US images?

Let me know your thoughts

And go check out the Sonowars podcast from Mike & Matt over at USPodcast for a more in depth look at how to do this scan. Fast forward tot he 20 minute mark for “fat pad sign”

And here is the 2012 paper by Rabiner et al [Crit US Journal ] that showed a 98% sensitivity for detecting elbow fractures.  The specificity was only 70%, against Xray as a god standard.  So beware of overcalling these?




PEMLit Review: Ultrasound for bronchiolitis?

Hi Broome Dockers

I started following and reading the PEMLit blog a while ago and have found it a really useful tool for staying abreast of all the latest from the Paeds ED and hospital literature.  You should definitely check it out.  Anyway, since I am always banging on about all things ultrasound and chests – I have been collared by the delightful Dr Natalie May to do a quick review for the site.  So you can read it here or check it out on the PEDLit blog.

So here is my review of:

Screen Shot 2015-10-15 at 10.08.34 pm


Where can I find this paper?  Here

What is this paper about (what is the research question)?

This paper aimed to correlate sonographic lung findings with clinically diagnosed bronchiolitis in infants.  The authors also attempted to provide some prognostic information [the need for oxygen support] based on sonographic lung features.

Summary of the Paper: 

The subjects were infants admitted for clinically suspected bronchiolitis.  There was also a cohort of “normal controls” used as a comparison.  The children underwent a clinical scoring by the treating Paediatrician and lung ultrasound by both a radiologist and Paediatrician sonographer.  The scans were all completed by two of the authors.

Design: This was a single-centre, observational cohort study conducted in an Italian Paediatric unit.

Objective: Aim of this study is to evaluate the accuracy of lung ultrasonography in the diagnosis and management of bronchiolitis in infants.

Outcome of interest:  To assess the correlation between clinical and sonographic lung findings in bronchiolitic infants.  Can LUS findings be used to predict the need for supplemental oxygen requirements?

Participants: One hundred six infants, aged from 9 to 239 days old were enrolled.

Inclusions: Clinically “suspected bronchiolitis” in infants.  Unclear as to whether these were consecutive cases – only 106 over a 3 year study period.

Exclusions: Radiological pneumonia, other “concomitant pathology” or the unavailability of the study sonographer.
Results: There was a high level [ ~90%] of agreement between the clinician’s severity rating and the predetermined sonographic severity scores.  There was also a high level of agreement between the two sonographers scoring of the LUS findings (K = 89.6%).  The lung US scoring predicted the need for oxygen supplementation with good accuracy [sensitivity: 96.6 %, specificity 98.7 % ] although there were wide confidence intervals as a result of the small numbers in this trial.

Authors’ Conclusions:

In summary, this pilot study demonstrates that the use of LUS in bronchiolitis can be considered as an extension of the clinical evaluation and could be incorporated into clinical algorithms to aid decision-making. Our promising data needs to be confirmed in larger cohort studies also involving critical patients.

On the study design:  This study design is typical of many pilot ultrasound papers.  Small numbers of patients in which sonography is compared to a gold-standard that may not be entirely accurate of itself.  Bronchiolitis is a clinical diagnosis, with no really objective diagnostic standard.  The use of just 2 experienced Paediatric sonographers in a single centre does raise questions about the external validity of the results and there is a high likelihood of bias here.  The clinicians were blinded to the sonographic findings – and therefore the risk of bias here was removed. The use of “normal cohort” and the “RSV swabs” in the study design was a little confusing and does’t really add to the results.

What were the results and what does this mean?  The results suggest that clinically diagnosed bronchiolitis looks like sonographic bronchiolitis as per the defined criteria used in this paper.  The protocol used did identify infants with more severe lung disease.  The need for supplemental oxygen was consistent with severe LUS changes.  However, given the “standard” was clinical examination it is unclear exactly what LUS would add to the prognostication by paediatricians.  The high degree of agreement between the two study sonographers is difficult to extrapolate given they are both highly skilled, ultrasound enthusiasts – a larger mix of observers would be needed to draw any conclusions about our ability to utilise LUS in small kids.

What can we take from this paper into clinical practice?

Lung ultrasound for the diagnosis and severity scoring of bronchiolitis is reasonably accurate.  Does it add anything?  Probably not, unless you are currently using CXR to ‘diagnose’ bronchiolitis.  This paper does provide some useful descriptions of the spectrum of disease and their sonographic appearance.

More questions to ask

Can ultrasound reliably differentiate bronchiolitis from important differential diagnoses in infants ? (e.g.. pneumonia, heart failure, upper airway obstruction… )

Are the sonographic findings in bronchiolitis consistent when obtained by sonographers of various experience?

Previous papers have compared LUS to conventional CXR for the diagnosis of bronchiolitis – and LUS was favourable.  It would be nice to see a paper looking at children with severe disease in which clinicians often turn to CXR to “reconfirm the working diagnosis” in order to ascertain it’s utility at that end of the spectrum.

Summary:  I think this paper is interesting in that it describes the sonographic spectrum of a common disease of infants.  The study is not really large enough, nor does it have the external validity to make it a “practice changer”.   This pilot can help inform us about the appearance of bronchiolitis – and in the future this may become a more commonplace part of our clinical assessment of children – but for now I am not sure it adds to our quiver.

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.



Clinical Case 118: Thinking outside the box

OK team – a Paeds case for you today.  It’s one where I am going to give you just a few clues and you have to think up the diagnosis.

Here we go…..

Jemimanisha is an 8  yo. girl who lives in an Aboriginal community about an hour away.

She has been brought to ED by her mother after being up all night complaining of a headache.  She has never had headaches before.  Her Mum is concerned that she ate too much junk food at her friend’s home the night before.

On further questioning – the headache is really quite global – she points at both parietal areas and rubs her head on both sides to show where it hurts.  She has had no recent URTI sxs, no fevers, cough or injury.  She isn’t bothered by lights or the ED noise.  Up until bedtime she was fine.  She woke around 11 PM with the headache &  slept in with her mother after that – her mum says she was restless and crying out all night long [Mum looks tired!].  This morning she vomited after eating toast.  Her belly feels OK and she reports no diarrhoea.


  • Obese with a BMI of 32 [currently seeing dietician]
  • Recurrent ear disease with grommets as a child, multiple presentations with acute OM in last 5 years. None recently.
  • Had a laceration to her ankle last month that required repair under sedation in ED – that went well and she was discharged.  Wound healing OK.

On examination

  • Afebrile, HR 90 SR, well perfused,  SpO2 = 99% RA,  RR = 15/min
  • Neuro exam is NAD – PEARL, no meningism, walking well, coordinated and fundi look ok – no papilloedema.
  • ENT – old scarred TMs bilaterally, no coryza, throat NAD
  • Chest and abdo unremarkable, soft, no signs of lung disease
  • No LN or rash, mucosa looks moist.
  • Leg wound has healed but there is a 3mm dehiscence of the edge of the scar – there is clear, serous fluid oozing out.  It is non-tender, no pus or cellulitis.

OK, that is all I am going to give you at this stage…

Here are the questions:

Q1:  What further information do you want [it is a weekend in Broome – so no labs or X-rays !]

Q2:  What is the diagnosis?

Q3:  What do you need to confirm the diagnosis?

I am sure you super sleuths can work this out!  Who is fastest?

OK – after that whirlwind diagnostic Tweetoff – I have uploaded a BroomeDocs podcast looking at the diagnosis and the our recent experiences with this disease here in the Kimberley – there’s a few pearls in there if you care to listen – 10 minutes!

The summary – its a disease that you will not diagnose if you do not think about it!  Ok Here is the podcast: