Point-of-Care Ultrasound for Suspected Appendicitis in Children Deemed Effective Front-Line Tool

Portable ultrasound used as a first-line imaging tool in children with suspected appendicitis helps cut emergency room length of stay and reduces the need for computed tomography (CT) scanning. Bedside ultrasound, also known to as point-of-care (POC) ultrasonography, has a specificity of about 94%, according to recent research.

The study’s findings were published online February 2014 in the journal Academic Emergency Medicine. “From an institutional perspective, this is the most common surgical problem that we encounter with children in the emergency department,” said the study’s senior author, James W. Tsung, MD, MPH, associate professor of emergency medicine and pediatrics at the Icahn School of Medicine at Mount Sinai (New York, NY, USA). “CT scans have been the best imaging test for diagnosing appendicitis, but they expose children to radiation, which cumulatively can prove harmful, as increasing numbers of studies have shown.”

Several studies have reported lifetime risks of cancer from abdominal and pelvis CT scanning in children results in one cancer death for every 500 to 3,000 CT scans ordered, depending on age and sex. Efforts to try to reduce the four million radiation-emitting CT scans obtained in children annually are underway, led by front-line radiologists, physicians, and radiologic professional societies. “CT scanning rate was reduced by over 35%, from a 44% CT scan rate prior to the study to a 27% rate during the study,” commented Ee Tay, MD, assistant professor of emergency medicine and pediatrics, Icahn School of Medicine at Mount Sinai, and the study’s second author.

Investigators, in their research, used a prospective observational sample of 150 children seen consecutively between May 1, 2011 and October 1, 2012 in an urban pediatric emergency department. All children were under evaluation for suspected appendicitis. Outcomes were determined by surgical or pathology report in those found to have appendicitis and three weeks later in patients who were considered not to have appendicitis. Operator accuracy reading the ultrasound scans was reviewed in a blinded fashion by trained pediatric emergency medicine sonologists. The time to perform the POC ultrasound and CT scan use was measured.

The study’s findings revealed that emergency department length of stay decreased by two hours and 14 minutes (46% decrease) for those requiring radiology department ultrasound and almost six hours (68% decrease) for those requiring CT scanning when POC ultrasound was inconclusive as a first-line imaging study. Significantly, no instances of appendicitis were overlooked with the POC ultrasound protocol and no needless surgeries were performed for a normal appendix. Pediatric emergency clinicians, with the use of focused ultrasound training, were able to assess ultrasound exams with the similar accuracy as radiologists (approximately 94% accuracy). Dr. Tsung noted, “Surgeons are becoming more comfortable using ultrasound for decision-making and that is a big change from reliance on CT scans.”

The Mt. Sinai division of emergency ultrasound is involved with an effort to educate providers to use safer ultrasound as a faster first-line study in children.

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Icahn School of Medicine at Mount Sinai