Tag Archives: emergency medical care

How Doctors Use Ultrasound to Spot Dangerous Fluid After a Child Is Hurt

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When children are seriously hurt in accidents, doctors need to act fast. One of the biggest worries after a child is hurt in the belly area is internal bleeding (blood that collects deep inside where you can’t see it). This type of bleeding can be life-threatening but hard to detect just by looking at the child or doing a physical exam.

That’s where a tool called FAST, short for Focused Assessment with Sonography for Trauma, comes in. FAST is a type of ultrasound test used in emergency care to quickly look for problem areas inside the body. It’s safe, it doesn’t use radiation like X-rays or CT scans, and it gives doctors real-time pictures of what’s happening inside.

One important part of FAST is checking the pelvis, the lower part of the belly area, for what doctors call “free fluid.” In trauma patients, free fluid almost always means blood from an injury. The more fluid that’s there, the more likely that serious internal bleeding is happening. But not all fluid is easy to see or measure, especially when the amount is small. So how well can doctors actually estimate the amount of fluid when they look at the ultrasound screen?

How reliable are doctors when they make a quick judgment by eye, or gestalt, about fluid volume on a pelvic FAST exam in children? Can doctors consistently recognize when there’s enough fluid to be concerning versus when the fluid is minor and probably not dangerous.

  • Doctors who are trained in ultrasound do a good job of distinguishing between larger amounts of fluid and smaller amounts. In other words, experienced clinicians can reliably tell when the fluid is significant enough to warrant concern versus when there is just a little bit.
  • The challenge is with very small amounts of fluid. When the fluid is minimal, doctors are less consistent in their estimates. Small amounts of fluid can be subtle on ultrasound, and even experienced eyes may disagree about what they see.

Why This Matters for Children Hurt in Accidents

When a child arrives at the emergency department after an accident, time is of the essence. FAST exams are often done right at the bedside so that decisions about further care, like whether to get a CT scan or go straight to surgery, can be made quickly.

The fact that doctors trained in point-of-care ultrasound can reliably spot significant fluid means that FAST remains a valuable tool in pediatric trauma care. It helps teams identify children who may need urgent intervention without waiting for longer, more complicated tests.

At the same time, small volumes of fluid are harder to judge, which highlights the limits of quick visual estimation. In cases where only a little fluid shows up, doctors may need to be cautious and consider other clinical signs, or use additional imaging tools when possible.

Improving Ultrasound Use in Emergencies

Understanding the strengths and limits of physician judgment can help hospitals train their teams better and make more informed decisions about when to rely on FAST and when to follow up with more detailed imaging.

In a field where every second counts and where radiation exposure is a real concern, especially in children, having reliable, fast, bedside tools like FAST is a big advantage. Knowing how well those tools work in the hands of real doctors helps make pediatric trauma care safer and more effective.

Cynthia Owens, BA, is the Publications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

To read more about the FAST exam in pediatric patients, check out this article from the Journal of Ultrasound in Medicine (JUM):

A Potential Pitfall of Using Focused Assessment With Sonography for Trauma in Pediatric Trauma – Baer Ellington – 2019 – Journal of Ultrasound in Medicine – Wiley Online Library

Pick-Up-and-Go Block Bags for Fascia Ilaca Blocks

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Ultrasound-guided regional anesthesia is a mainstay of multimodal pain control and is becoming an increasingly important part of emergency medical care. Regional anesthesia allows for maximal analgesia while minimizing the adverse effects of opioids, such as respiratory depression and sedation. The fascia iliaca block is one such procedure that provides regional anesthesia in the Emergency Department (ED) for proximal femur fractures and hip fractures.1 This plane block is performed by depositing a moderate volume of local anesthetic, usually bupivacaine, into the potential space between the fascia iliaca and the iliopsoas muscle. The procedure provides analgesia in the distribution of the femoral nerve, as well as the obturator nerve and lateral femoral cutaneous nerve. 1 Patients who receive this procedure experience improved pain scores and a reduction in the need for opioid medication.2–5 The use of preoperative regional nerve blocks, specifically including older patients with hip fractures, is supported by 2022 American Association of Orthopedic Surgeon guidelines.5,6

At Rutgers New Jersey Medical School, we developed a teaching paradigm for the fascia iliaca block, with an online didactic session followed by a hands-on simulated skills session offered to faculty and residents (Figure 1, Rutgers NJMS Emergency Medicine residents learning to perform the fascia iliaca block on a porcine simulation model).

Figure 1, Rutgers NJMS Emergency Medicine residents learning to perform the fascia iliaca block on a porcine simulation model.
Figure 1A
Figure 1, Rutgers NJMS Emergency Medicine residents learning to perform the fascia iliaca block on a porcine simulation model.
Figure 1B

Later in the year, we performed a quality assurance project in order to determine what barriers existed to performing this block, in order to maximize the number of eligible patients that received this valuable procedure. We found that the fascia iliaca block was performed about 16% of the time when indicated (Figure 2).

A bar graph indicating that, of those who received a nerve block, 87 were for hip/femur fractures (~3-4 per week), 16% (95CI: 10% to 25%) received the block, and 90% (95CI: 82% to 95%) completed the survey.
Figure 2. Percentage of eligible patients who received the block.

The most common reason for the block not being performed was the perceived lack of time during a busy clinical shift (Figure 3), which was a factor that was present in more than ¾ of missed opportunities.7 We theorized that this limitation came from a combination of the time required to obtain consent from the patient, gather supplies, coordinate with the admitting Orthopedics service, and ultimately perform the procedure.

A bar graph indicating the number and strength of each agreement for each response.
Figure 3. Reasons that the block was not performed.

To address this barrier, we created ready-made pick-up-and-go nerve block kits containing all the necessary materials for performing ultrasound-guided nerve blocks in the ED (Figure 4). These kits include sterile gloves, ultrasound probe covers, sterile drapes, spinal needles, syringes, IV tubing, nerve block reference materials, and a consent form. We placed the kits in a centralized location in the ED for ease of access.

Figure 4A. A collection of nerve block kits ready for use.
Figure 4B. Contents of a nerve block kit.

As a result of this intervention, we have anecdotally noted an increased number of procedures performed, with a complete analysis forthcoming. As our program increases the scope and scale of regional anesthesia procedures offered to patients, the nerve block kits will hopefully eliminate a barrier to performing nerve blocks and thus facilitate the deliverance of high-quality patient-centered analgesia to the largest number of patients possible.

References

  1. Chesters A, Atkinson P. Fascia iliaca block for pain relief from proximal femoral fracture in the emergency department: a review of the literature. Emerg Med J 2014; 31(e1):e84–e87. doi:10.1136/emermed-2013-203073.
  2. Groot L, Dijksman LM, Simons MP, Zwartsenburg MM, Rebel JR. Single fascia iliaca compartment block is safe and effective for emergency pain relief in hip-fracture patients. West J Emerg Med 2015; 16:1188–1193. doi:10.5811/westjem.2015.10.28270.
  3. Ritcey B, Pageau P, Woo MY, Perry JJ. Regional nerve blocks for hip and femoral neck fractures in the emergency department: A systematic review. CJEM 2016; 18:37–47. doi:10.1017/cem.2015.75.
  4. Haines L, Dickman E, Ayvazyan S, et al. Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department. J Emerg Med 2012; 43:692–697. doi:10.1016/j.jemermed.2012.01.050.
  5. Kolodychuk N, Krebs JC, Stenberg R, Talmage L, Meehan A, DiNicola N. Fascia iliaca blocks performed in the emergency department decrease opioid consumption and length of stay in patients with hip fracture. J Orthop Trauma 2022; 36:142–146. doi:10.1097/BOT.0000000000002220.
  6. O’Connor M, Switzer J. AAOS Clinical practice guideline summary: Management of hip fractures in older adults. J Am Acad Orthop Surg 2022; 30(20):e1291–e1296. doi: 10.5435/JAAOS-D-22-00125.
  7. Alsharif P, Muckey E, Lu H, et al. Emergency department workflow limits the utilization of fascia iliaca blocks for hip and femur fractures. Academic Emergency Medicine 2022; 29(S1). https://doi.org/10.1111/acem.14511.

Peter Alsharif MD, Marwa Ali MD, Helen Lu MD, Robert James Adrian MD, Annette Mueller MD MBA, Ilya Ostrovsky MD, and Stephen Alerhand MD, are from the Department of Emergency Medicine at Rutgers New Jersey Medical School in Newark, New York.