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References

1. Valley, V & Stahmer, S. Targeted Musculoarticular Sonography in the Detection of Joint Effusions. Academic Emergency Medicine. 2001. 8:361-367
2. Cruz, C et al. Point-of-care hip ultrasound in a pediatric emergency department. American Journal of Emergency Medicine. 2018. 36:1174-1177. https://doi.org/10.1016/j.ajem.2017.11.059
3. Kane, Balint, & Sturrock. Ultrasonography is superior to clinical examination in the detection and localization of knee joint effusion in rheumatoid arthritis. J Rheumatology. 2001; 30(5):966-971.
4. Zieger, M et al. Ultrasonography of hip joint effusions. Skeletal Radiology. 1987. 16:607-611
5. Tsung, J & Blaivas, M. Emergency Department Diagnosis of Pediatric Hip Effusion and Guided Arthrocentesis Using Point-of-Care Ultrasound. The Journal of Emergency Medicine. 2008. 35:393–399. doi:10.1016/j.jemermed.2007.10.054
6. Shavit, I et al. Sonography of the Hip Joint by the Emergency Physician: Its role in the evaluation of children presenting with acute limp. Pediatric Emergency Care. 2006. 22:570-573.
7. Vieira, R & Levy, J. Bedside Ultrasonography to Identify Hip Effusions in Pediatric Patients. Annals of Emergency Medicine. 2010. 55:284-289. doi:10.1016/j.annemergmed.2009.06.527
8. Adhikari & Blavais. Utility of bedside sonography to distinguish soft tissue abnormalities from joint effusions in the emergency department. J Ultrasound Med. 2010; 29(4):519-526.
9. Deanehan, J et al. Bedside Hip Ultrasonography in the Pediatric Emergency Department: A Tool to Guide Management in Patients Presenting with Limp. Pediatric Emergency Care. 2014. 30:285-287.
10. Alves, T et al. US of the Knee: Scanning Techniques, Pitfalls, and Pathologic Conditions. RadioGraphics. 2016. 36:1759-1775. https://doi.org/10.1148/rg.2016160019
11. Wiler, J et al. Comparison of Ultrasound-Guided and Standard Landmark Techniques for Knee Arthrocentesis. The Journal of Emergency Medicine. Vol 39. No 1. 2010. https://doi.org/10.1016/j.jemermed.2008.05.012
12. Wu, T et al. Ultrasound-guided versus landmark in knee arthrocentesis: A systematic review. Seminars in Arthritis and Rheumatism. 2016. http://dx.doi.org/10.1016/j.semarthrit.2015.10.011
13. Lueders, D, Smith, J, & Sellon, J. Ultrasound-Guided Knee Procedures. Physical Medicine Rehabilitation Clinics of North America. 2016. 27:631-648. http://dx.doi.org/10.1016/j.pmr.2016.04.010]
14. Daniels, J & Williams, D. Basics of musculoskeletal ultrasound. Springer. 2013.
15. Edsonoshare.com

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References

1. Grimberg et al. Diagnostic accuracy of sonography for pleural effusion: systematic review. Sao Paulo Med J (2010) 128;2: 90-95.

2. Asthon-Cleary, DT. Is thoracic ultrasound a viable alternative to conventional imaging in the critical care setting? BJA (2013) doi:10.1093/bja/aet076

3. Kurian et al. Comparison of Ultrasound and CT in the Evaluation of Pneumonia Complicated by Parapneumonic Effusion in Children. AJR (2009) DOI:10.2214/AJR.09.2791

4. Calder and Owens. Imaging of parapneumonic pleural effusions and empyema in children. Ped Rad (2009) DOI: 10.1007/s00247-008-1133-1

5. Volpicelli et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med (2012) DOI:10.1007/s00134-012-2513-4

6. Islam et al. The diagnosis and management of empyema in children: a comprehensive review from the APSA Outcomes and Clinical Trials Committee. J Ped Surg (2012) DOI: 10.1016/j.jpedsurg.2012.07.047

7. Peris et al. The Use of Point-of-Care Bedside Lung Ultrasound Significantly Reduces the Number of Radiographs and Computed Tomography Scans in Critically Ill Patients. Anesth&Analg (2010) DOI: 10.1213/ANE.0b013e3181e7cc42

8. Jones BP, Tay ET, Elikashvili I, Sanders JE, Paul AZ, Nelson BP, Spina LA, Tsung JW, Feasibility and Safety of Substituting Lung Ultrasound for Chest X-ray When Diagnosing Pneumonia in Children: A Randomized Controlled Trial, CHEST (2016), doi: 10.1016/j.chest.2016.02.643

Summary

• PoCUS is sensitive, and specific for the detection of pleural effusions.
• Position the probe in the posterior axillary line with the marker towards the head
• Identify the liver/spleen, diaphragm, vertebral bodies and lung
• The characteristic (positive) finding is a hypoechoic collection above the diaphragm with distinct borders and dynamic movement.
• Don’t forget to document your findings in the chart and save images for QA.

 

 

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References

1. Patel, G et al. Point-of-Care Cardiac Ultrasound (POCCUS) in the Pediatric Emergency Department. Clinical Pediatric Emergency Medicine. 2018. 19: 323-327. DOI: 10.1016/j.cpem.2018.12.009
2. Guevarra K, Greenstein Y. Ultrasonography in the Critical Care Unit. Curr Cardiol Rep. 2020;22(11):145. doi:10.1007/s11886-020-01393-z
3. Volpicelli G, Lamorte A, Tullio M, et al. Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department. Intensive Care Med. 2013;39(7):1290-1298. doi:10.1007/s00134-013-2919-7
4. Potter SK, Griksaitis MJ. The role of point-of-care ultrasound in pediatric acute respiratory distress syndrome: emerging evidence for its use. Ann Transl Med. 2019;7(19):507-507. doi:10.21037/atm.2019.07.76
5. Mojoli F, Bouhemad B, Mongodi S, Lichtenstein D. Lung Ultrasound for Critically Ill Patients. Am J Respir Crit Care Med. 2019;199(6):701-714. doi:10.1164/rccm.201802-0236CI
6. Longjohn M, Wan J. Point-of-Care Echocardiography by Pediatric Emergency Physicians. Pediatric Emergency Care. 2011;27(8).
7. Miller AF, Arichai P, Gravel CA, et al. Use of Cardiac Point-of-Care Ultrasound in the Pediatric Emergency Department. Pediatr Emer Care. 2022;38(1):e300-e305. doi:1097/pec.0000000000002271
8. Riera A, Weeks B, Emerson BL, Chen L. Evaluation of a Focused Cardiac Ultrasound Protocol in a Pediatric Emergency Department. Pediatr Emer Care. 2021;37(4):191-198. doi:1097/pec.0000000000001495
9. Spurney CF, Sable CA, Berger JT, Martin GR. Use of a hand-carried ultrasound device by critical care physicians for the diagnosis of pericardial effusions, decreased cardiac function, and left ventricular enlargement in pediatric patients. Journal of the American Society of Echocardiography. 2005;18(4):313-319. doi:1016/j.echo.2004.10.016
10. Conlon TW, Himebauch AS, Fitzgerald JC, et al. Implementation of a Pediatric Critical Care Focused Bedside Ultrasound Training Program in a Large Academic PICU*. Pediatric Critical Care Medicine. 2015;16(3):219-226. doi:1097/pcc.0000000000000340
11. Moore CL, Rose GA, Tayal VS, Sullivan DM, Arrowood JA, Kline JA. Determination of Left Ventricular Function by Emergency Physician Echocardiography of Hypotensive Patients. Academic Emergency Medicine. 2002;9(3):186-193. doi:1197/aemj.9.3.186
12. Vorel ES, Jacquemyn X, Cohen JS, Kutty S, Deanehan JK. Pediatric Reference Ranges and Test Characteristics of E-point Septal Separation as a Marker for Left Ventricular Dysfunction: A Retrospective Study. Pediatric Emergency Care. Published online April 14, 2025. doi:1097/pec.0000000000003393
13. Griffee MJ, Merkel MJ, Wei KS. The role of echocardiography in hemodynamic assessment of septic shock. Crit Care Clin. 2010;26(2):365-382, table of contents. doi:10.1016/j.ccc.2010.01.001
14. Watkins LA, Dial SP, Koenig SJ, Kurepa DN, Mayo PH. The Utility of Point-of-Care Ultrasound in the Pediatric Intensive Care Unit. J Intensive Care Med. Published online October 9, 2021:088506662110478. doi:10.1177/08850666211047824
15. Gaspar HA, Morhy SS. The Role of Focused Echocardiography in Pediatric Intensive Care: A Critical Appraisal. BioMed Research International. 2015;2015:1-7. doi:10.1155/2015/596451 de Boode WP, van der Lee R, et al. The role of Neonatologist Performed Echocardiography in the assessment and management of neonatal shock. Pediatr Res. 2018;84(S1):57-67. doi:10.1038/s41390-018-0081-1
16. Arnoldi S, Glau CL, Walker SB, et al. Integrating Focused Cardiac Ultrasound Into Pediatric Septic Shock Assessment*. Pediatric Critical Care Medicine. 2021;22(3):262-274. doi:10.1097/PCC.0000000000002658
17. Ranjit S, Aram G, Kissoon N, et al. Multimodal Monitoring for Hemodynamic Categorization and Management of Pediatric Septic Shock: A Pilot Observational Study*. Pediatric Critical Care Medicine. 2014;15(1):e17-e26. doi:10.1097/PCC.0b013e3182a5589c
18. Singh Y, Tissot C, Fraga MV, et al. International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). Crit Care. 2020;24(1):65. doi:10.1186/s13054-020-2787-9
19. Lu JC, Riley A, Conlon T, et al. Recommendations for Cardiac Point-of-Care Ultrasound in Children: A Report from the American Society of Echocardiography. Journal of the American Society of Echocardiography. 2023;36(3):265-277. doi:1016/j.echo.2022.11.010 1.
20. Sengupta PP, Tajik AJ, Chandrasekaran K, Khandheria BK. Twist Mechanics of the Left Ventricle. JACC: Cardiovascular Imaging. 2008;1(3):366-376. doi:1016/j.jcmg.2008.02.006
21. Engle SJ, DiSessa TG, Perloff JK, et al. Mitral valve E point to ventricular septal separation in infants and children. The American Journal of Cardiology. 1983;52(8):1084-1087. doi:1016/0002-9149(83)90537-4
22. Tissot C, Singh Y, Sekarski N. Echocardiographic Evaluation of Ventricular Function—For the Neonatologist and Pediatric Intensivist. Front Pediatr. 2018;6. doi:3389/fped.2018.00079
23. Margossian R, Schwartz ML, Prakash A, Wruck L, Colan SD, Atz AM, et al. Comparison of echocardiographic and cardiac magnetic resonance imaging measurements of functional single ventricular volumes, mass, and ejection fraction (from the Pediatric Heart Network Fontan CrossSectional Study). Am J Cardiol (2009) 104(3):419–28. doi:10.1016/j. amjcard.2009.03.058 1.
24. Muniz RT, Mesquita ET, Souza Junior CV, Martins WDA. Pulmonary Ultrasound in Patients with Heart Failure – Systematic Review. Arquivos Brasileiros de Cardiologia. Published online 2018. doi:5935/abc.20180097
25. van Royen N, Jaffe C, Krumholz H, Johnson K, Lynch P, Natale D, Atkinson P, Deman P, Wackers F. Comparison and Reproducibility of Visual Echocardiographic and Quantitative Radionuclide Left Ventricular Ejection Fractions. American Journal of Cardiology. 1996;77.

Summary

• PoCUS is a rapid and focused tool for assessing cardiac function, offering more timely insights than the physical exam alone and providing useful preliminary information to guide further cardiology evaluation and management.
• PoCUS should be used as a rule-in tool, not a rule-out test, especially when clinical suspicion for LV dysfunction is high. A normal or unclear PoCUS exam does not exclude pathology and should not replace formal imaging when concern persists
• Multiple views = more confidence. Always assess LV systolic function from the standard windows (PLAX, PSAX, A4C, and subxiphoid 4-chamber) to ensure consistency and accuracy.
• An EPSS ≤ 7 mm is generally considered within normal limits, though values should always be interpreted in context and with consideration of the clinical picture.
• Be mindful of the limitations, both technical (e.g., foreshortening, off-axis views, poor acoustic windows) and interpretive (e.g., variability in qualitative and quantitative measures).

Pitfalls & Limitations

A common limitation when assessing cardiac function is foreshortening of the ventricle, particularly in the PLAX and A4C views (Figure 28,29). Foreshortening occurs when the imaging plane cuts through the heart at an angle that misses the true apex, making the LV appear shorter and more rounded than it actually is. This leads to underestimation of LV size, overestimation of LVfx and poor visualization of true wall motion. To minimize this, adjust your probe position, often one intercostal space lower, if you notice a truncated LV. That said, in some patients, a foreshortened view may be the only achievable window due to body habitus, lung interference, or cooperation. In such cases, it is essential to recognize the limitation and interpret findings with caution. This is why the heart should always be imaged in as many views as possible.

Figure 28: Comparison of PLAX foreshortened VS not foreshortened.

 

Figure 29: Comparison of A4C foreshortened VS not foreshortened

 

PoCUS relies primarily on qualitative assessment of LV systolic function. While visual evaluation and “eyeballing” EF is a valuable and necessary skill, it is inherently subjective and can vary significantly between users. Studies have shown that qualitative assessment alone can miss borderline or mild systolic dysfunction [7, 25]. Beginners may find it especially challenging. Comparing PoCUS impressions to formal echocardiography reports is a practical way to increase accuracy and build clinical confidence over time.

EPSS can be a helpful quantitative supplement, but it has important limitations. Obtaining an accurate EPSS measurement can be technically challenging, particularly in pediatric patients as it requires placing the M-mode cursor through the tip of the AMVL. Errors in positioning can lead to inaccurate measurements. It is also important to reiterate that EPSS should never be used as a single measure of LV systolic function. EPSS should be interpreted only in conjunction with other functional assessments

Additionally, EPSS is unreliable in the presence of mitral valve pathology, aortic regurgitation, LV dilation and IVS motion abnormality/arrythmia. Structural abnormalities or altered leaflet motion can distort EPSS measurements and reduce their reliability for assessing systolic function. In these cases, the EPSS should not be used. EPSS alone is insufficient to guide decisions regarding cardiology referral or formal echocardiography without corroborating functional findings.

More generally, if significant structural, valvular, or electric dysfunction is present, PoCUS 2D assessment of LVfx may also be unreliable. When blood is not flowing normally, the usual 2D indicators, such as wall thickening or change in chamber size, can appear preserved even though effective stroke volume is reduced and may provide false reassurance about systolic function.

FS and EF can also provide helpful quantitative data, but it is important remember that these linear dimensions rely on key assumptions. When these conditions are not met, FS and EF derived from M-mode may not accurately reflect true LVfx. Moreover, because EF calculations involve cubing linear dimensions, they are more sensitive to variations in heart size and shape than FS. Therefore, these measurements should always be interpreted in the context of the overall clinical and imaging picture.

Arrhythmias also limit the accuracy of PoCUS assessments [7]. Bradycardia can make interpretation of LV systolic function challenging, as slow contractions may mimic systolic dysfunction or give the appearance of hypokinesis of the LV walls. Conversely, tachycardia can make it difficult to accurately assess function and wall motion due to reduced filling time and motion blur and may also create the illusion of hyperdynamic function. In cases of tachycardia it is important to focus on the ventricular wall motion and not the speed of contraction, and consider slowing the clip playback to assess function more accurately. Other arrhythmias with variable heart rates, such as bundle branch blocks, fibrillation, and frequent ectopy can complicate both qualitative and quantitative evaluation by causing beat-to-beat variability in ventricular filling and contraction, making both visual interpretation and consistent measurements difficult to obtain.

 

Figure 30. PLAX(a) and PSAX(b) views in a child with tachycardiac mimicking hyperdynamic function.

 

Figure 31. PLAX view demonstrating beat-to-beat variation in LV filling due to frequent premature ventricular contractions, illustrating the challenge of visual interpretation of LVfx in presence of arrythmias.

 

As with all cardiac ultrasound, patient factors can significantly affect image quality. Lung interference (figure 32), body habitus, and poor cooperation (especially in children) may limit visualization. Try multiple child positions (e.g., supine, left lateral decubitus) and use caregiver involvement, such as having the child sit in a parent’s arms, to increase comfort and cooperation. Utilize the most accessible windows, such as subcostal views, if other views are limited.

Figure 32. PLAX view with lung interference

 

Finally, formal echocardiography should be pursued when image quality is suboptimal, interpretation is uncertain, or there are clinical concerns for cardiac dysfunction or injury, even if PoCUS findings appear normal [19].

 

In addition to the cardiac windows, lung ultrasound (LUS) can also provide valuable indirect information about LV performance. LUS is highly sensitive to detect early or subtle increases in left ventricular end diastolic filling pressures (LVEDP) [24].

In the setting of LV systolic dysfunction or congestive heart failure, elevated LVEDP leads to pulmonary congestion, which manifests on LUS as the progressive appearance of B-lines. B-lines occur as the edema or excess extravascular lung water interact with air-filled alveoli to create a reverberation artifact. The distribution and severity of B-lines correlate with the degree of pulmonary interstitial edema or fluid overload and, by extension, can reflect deterioration in LVfx.

Integrating LUS findings with cardiac PoCUS can provide a more comprehensive assessment of LVfx.

 

For details on performing and interpreting LUS in the context of heart failure and pulmonary congestion, please refer to the dedicated KidSONO Interstitial Disease module