Right ventricular (RV) strain refers to the state of increased pressure or volume overload that impairs RV function. These processes can lead to structural and functional changes in the RV that can be detected on ultrasound. RV strain is a critical consideration in pediatrics, particularly in cases of acute respiratory distress syndrome (ARDS), pulmonary hypertension, diffuse myocarditis and ). These clinically significant conditions highlight the importance of assessing RV morphology and hemodynamics in pediatric patients, especially as it relates to switching to positive pressure ventilation.
Physical exam findings for cardiac symptoms can be inconclusive. The standard of care is generally to request formal cardiology echocardiogram to be interpreted by a cardiologist. This can delay diagnosis and initiation of treatment, compromising patient care, particularly during overnight or weekend hours when cardiology services may be limited.
Point-of-care ultrasound (PoCUS) has emerged as an important tool in the assessment of RV pressure, size and function, offering more timely and focused clinical insights than physical exam alone. Additionally, PoCUS findings can provide cardiologists with relevant preliminary information that helps streamline decision-making and enhance the efficiency of patient care, particularly when images and documentation are captured appropriately and shared with cardiology in real time for review (center specific). If there is concern about an undiagnosed or presumed CHD, consultation with cardiology for formal echocardiogram should not be delayed.
This course focuses on guiding learners through a preliminary assessment for RV strain using PoCUS. While the evaluation of CHDs and valvular abnormalities is common in pediatric cardiology, these are beyond the scope of PoCUS and should be reserved for formal echocardiography. By course completion, learners should feel confident assessing for RV strain using the five standard PoCUS cardiac views.
Ultrasound has many advantages. It is low cost, portable, and free from ionizing radiation. This, in addition to its ability to look at the heart and its function in real time, makes it the diagnostic modality of choice for cardiac evaluation [1]. PoCUS is now widely available in most emergency departments (EDs), pediatric intensive care units (PICUs) and hospital wards, providing rapid, real-time evaluation of cardiac function in critically ill patients. When managing patients with respiratory or circulatory compromise, prompt and accurate diagnosis is crucial. Adult studies have demonstrated that PoCUS enables clinicians to diagnose more quickly and accurately than clinical assessment alone, facilitating more targeted and timely interventions [2,3]—and in some cases, improving mortality outcomes [4,5].
The ability of cardiac PoCUS to evaluate RV strain in pediatric patients is limited in the current literature. However, several adult studies, primarily in the context of suspected pulmonary embolism, have demonstrated that physicians without formal cardiology training can reliably assess RV morphology, pressure, and function using cardiac POCUS following appropriate training [6-9]. Reported diagnostic performance varies but generally shows moderate to high agreement with formal imaging (CTA or formal echocardiography), with reported sensitivities ranging from 50% to 100% and specificities up to 98%.
To date, only one pediatric study has specifically evaluated the diagnostic accuracy of cardiac PoCUS for assessing RV size and function. s, following focused PoCUS training, used RV size, Tricuspid Annular Plane Systolic Excursion (TAPSE), and visual assessment of RV function to evaluate RV strain. Their interpretations showed perfect agreement with formal echocardiography (κ = 1) and substantial agreement with blinded cardiologist review (κ = 0.72), with both sensitivity and specificity reported at 100% [10].
PoCUS facilitates repeatable scanning, allowing practitioners to monitor the effectiveness of interventions and changes in RV filling and preload, and structure and function over time. PoCUS is a skill that can be learned and acquired through training, including both didactic and hands-on practice. Research supports that once undergoing short but dedicated training, PoCUS can safely and accurately be used by practitioners at the bedside in both adult and pediatric populations [2, 11-15]. Given these benefits, PoCUS use for cardiac assessments is supported by various professional societies [16,17].
| A4C | Apical four chamber |
| AOV | Aortic valve |
| FAC | Fractional area change |
| HV | Hepatic vein |
| IVC | Inferior vena cava |
| IVS | Interventricular septum |
| IAS | Interatrial septum |
| LV | Left ventricle |
| PLAX/PSLA | Parasternal long axis |
| PSAX/PSSA | Parasternal short axis |
| PoCUS | Point-of-Care Ultrasound |
| PPV | Positive pressure ventilation |
| RV | Right ventricle |
| RVPO | Right ventricle pressure overload |
| RVVO | Right ventricle volume overload |
| TAPSE | Tricuspid Annular Plane Systolic Excursion |
| TV | Tricuspid Valve |
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Ocular POCUS in children should be considered primarily a “rule-in” tool, where abnormal findings can support the diagnosis and expedite ophthalmology consultation, but a normal scan should not be used to exclude disease when the history or examination raises concern.
As with all pediatric POCUS, child cooperation remains a challenge. An uncooperative child can lead to motion artefact, incomplete views, or missed findings. Short, focused sweeps combined with distraction or parental assistance can improve image acquisition, while definitive diagnosis should always involve ophthalmology when cooperation or image quality is limited. Artefacts also present a challenge. Reverberation artefact within the vitreous may mimic hemorrhage or other pathology. Optimizing gain and depth, performing sweeps in multiple planes, and comparing both eyes can reduce the risk of misinterpretation.
Even with optimal technique, certain conditions, such as anterior segment pathology may limit visualization of the posterior segment, reducing diagnostic confidence and making comparisons with the unaffected eye especially important [5]. If there is uncertainty due to limited visualization, an ophthalmology referral should always be organized.
Differentiating vitreous hemorrhage/detachment from retinal detachment is another common difficulty, as both appear as echogenic material within the posterior chamber. A key distinction is that retinal detachments remain tethered to the optic nerve head, while vitreous hemorrhage is more mobile and free-floating with eye movement. Vitreous detachment also will remain horizontal when the patient moves their eye side to side.
In suspected globe rupture, POCUS is contraindicated because even minimal probe pressure can worsen the injury. If rupture is a leading concern, POCUS should be avoided; however, in cases where scanning was performed for another indication and a rupture is incidentally suspected, the study should be stopped immediately and urgent ophthalmology consultation obtained.
Safety is another important consideration. Ocular tissues are particularly sensitive to ultrasound acoustic output, so the MI/TI should always be kept as low as possible. Ideally, an “ocular” preset should be used. If the machine does not offer one, the user must manually minimize output settings (MI ≤ 0.23, TI ≤ 1.0). Users should also refrain from applying color or pulsed wave doppler to avoid increasing the power output.
Several pathologic findings can disrupt normal patterns in the eye as seen on ultrasound. The following conditions represent important pediatric ocular pathologies that can be identified with ultrasound and should be recognized as abnormal.
Abnormalities of the lens are observed either by changes in its position within the eye (dislocation) or by alterations in its contour or echogenicity (cataracts).
Lens dislocation is the displacement of the lens from its normal position. It can be acquired (often traumatic) or congenital (ectopia lentis).
· Sonographic appearance: The normally circular, echogenic lens is displaced from its central location behind the iris, floating or tilted in the posterior chamber or vitreous. “Floating lens sign” refers to when the lens is seen moving freely with eye movements.
Figure 8. Lens dislocation evidenced by the displacement of the lens in the vitreous at the posterior aspect of the globe. Video courtesy of Dr. Jade Seguin, used with permission.
Any variation from the normal smooth, anechoic lens can indicate an abnormality of the lens.
· Sonographic appearance: If the lens appears heterogeneous, thickened, irregular in contour, or hyperechoic, this suggests a structural or developmental abnormality, such as congenital or acquired cataracts.
Figure 9. Abnormal lens evidenced by its irregular contour with a thickened, hyperechoic appearance. Findings were ultimately consistent with cataracts. Video courtesy of Dr. Jade Seguin, used with permission.
Vitreous Hemorrhage refers to bleeding into the vitreous chamber of the eye. In children, it can be caused by various intraocular diseases, however, is most commonly caused by trauma [20].
· Sonographic appearance: The appearance will vary depending on the amount of blood. It may appear as echogenic debris within the vitreous chamber, or a hyperechoic focus/membrane deep in the vitreous.
Figure 10. Vitreous hemorrhage as seen by the echogenic debris within the vitreous. Video courtesy of Dr. Jade Seguin, used with permission.
Vitreous detachment is usually benign and does not lead to vision loss. It refers to the separation of the posterior vitreous body from the retina. It is uncommon in children and usually occurs secondary to trauma.
Sonographic appearance:
· A Hyperechoic membrane will be seen floating in the vitreous. The membrane will NOT be tethered to the optic disc, but rather it will be free floating in the posterior chamber.
· Vitreous hemorrhages remain horizontal when the patient moves their eye side to side.
· Most often seen in the middle section of the posterior eye
Figure 11. Vitreous detachment. Note how there is no connection to the optic nerve and the horizontal appearance of the detachment membrane. Video courtesy of Dr. Eric Roseman, Kings County Emergency Medicine, via POCUS Atlas . Used under CC BY-NC 4.0 license.
Any disruption of the normally thin, echogenic, and anchored retinal layer can indicate a pathology.
Retinal detachments can lead to permanent vision loss if not treated in a timely manner. Retinal detachment occurs when the sensory layer of the retina separates from the underlying layer. In children, trauma is the most common cause, although other congenital or acquired conditions can also lead to detachment [20].
Sonographic appearance:
· A thin, hyperechoic membrane will be seen floating in the vitreous. The membrane will be tethered posteriorly at the optic nerve head. This gives a “V-shaped” appearance.
· A detached retina will move with eye motion but remain anchored posteriorly at the ON head.
** This anchoring will distinguish retinal detachment from a vitreous hemorrhage and detachment**
· Small detachments will be tethered closed to the posterior aspect of the eye and will move less with eye movements [21].
Figure 12. Retinal Detachment, with a “V-shaped” appearance due to anchoring to the ON head. Image courtesy of Dr. Michael Kidon, Denver Health Emergency Medicine, via POCUS Atlas . Used under CC BY-NC 4.0 license.
Any thickening or focal lesion arising from or within the retina should be considered abnormal. This may represent tumors (e.g. retinoblastoma), bleeding (retinal hemorrhages), vascular anomalies (e.g. Coat’s disease), or developmental structural changes.
· Sonographic appearance: Thickening or echogenic structures within or extending from the retinal layer, distinct from the thin, normally smooth retina. Echogenicity may be variable, and calcifications may be present (e.g. retinoblastoma).
Figure 13. Posterolateral mass protruding from the retina in a child with Coats disease. Image courtesy of Dr. Jade Seguin, used with permission.
Foreign materials (metal, glass, wood, etc.) can become lodged in the globe of the eye and can often be visualized with ultrasound.
Key Considerations: IOFB may be associated with vitreous hemorrhage, retinal detachment and/or globe rupture. If an IOFB is visualized, stop scanning immediately and notify ophthalmology. This helps prevent further displacement of the foreign body and protects against worsening injury if the globe is ruptured, since any pressure could precipitate complications or extrusion of intraocular contents.
· Sonographic appearance: Foreign material will appear as a hyperechoic object with posterior acoustic shadowing, reverberation or comet tail artifact [20]. IOFB can be located in the anterior chamber, lens, vitreous, retina, or other regions of the globe, depending on the mechanism and trajectory of injury.
Figure 14. Hyperechoic structure seen anteriorly, adjacent to the globe. Note that with dynamic eye movements the foreign body does not move suggesting this is outside of the globe. Video courtesy of Dr. Robert Jones, MetroHealth Medical Center / Case Western Reserve University, via POCUS Atlas . Used under CC BY-NC 4.0 license.
Abnormalities of the periorbital tissues can be identified by changes in tissue echogenicity, swelling, or the presence of fluid collections. Assess for hypoechoic or anechoic areas, asymmetry between orbits, restricted extraocular eye movement, and disruption of normal soft tissue planes. Examples include:
· Soft tissue edema/cellulitis: Diffuse hypoechoic thickening of the periorbital soft tissues. Often poorly defined and may involve the eyelids and surrounding orbital tissues
· Abscess: Well-defined, localized hypoechoic or anechoic collection with irregular borders; may show internal echoes and sometimes posterior enhancement.
· Glioma: A mass arising from the optic nerve or adjacent to the orbit, which may cause displacement of ocular tissue
· Orbital Fractures: PoCUS can he used to assess for fractures of the infraorbital rim and lateral orbital wall [22-25]. Fractures will be seen as a discontinuity or displacement of the echogenic bone cortex [25].
Figure 15. Hypoechoic collection in the medial retro-orbital fat of the right orbit. Subsequent CT confirmed a right medial orbital abscess. Image courtesy of Dr. Jade Seguin, used with permission.
Both anatomical variants and optic disc pathologies may occasionally be observed during ocular ultrasound. While these are discussed in greater detail in the KidSONO Optic Nerve Module, it is useful to recognize how they may appear in relation to the posterior globe and retinal plane:
· Optic Disc Drusen (figure 16): Drusen are acellular deposits that calcify over time. They are typically buried in early childhood, becoming superficial around age 12 [27]. In early childhood, the buried deposits push the optic nerve head anteriorly into the vitreous, appearing as focal elevations of the optic disk from the posterior globe. Late in childhood they can appear as echogenic foci (due to calcified deposits) with posterior shadowing located at the optic disk. They are typically bilateral.
· Tilted Optic Discs (figure 17): Represent an anatomical variant in which the optic disc is oriented obliquely. This results in an apparent elevation or irregular contour of the posterior globe that can mimic pathology, buts its simply due to the disc’s oblique angle.
Figure 16. Optic disk drusen. Image courtesy of Dr. Jade Seguin, used with permission
Figure 17. Video demonstrating a tilted optic disc, which can pathology at the posterior globe/retinal plane. Video courtesy of Dr. Jade Seguin, used with permission
PoCUS can be used as an adjunct to assess pupillary response through closed eyelids using standardized light stimulation. It can be particularly valuable in pediatric trauma and critically ill children where direct assessment may be limited. Ultrasound assessment has shown excellent agreement with clinical examination for pupillary light reflex, including direct and consensual responses (ICC 0.93–0.96; agreement 87.36%) [28].
The transducer is placed transversely on the lower eyelid at approximately a 45-degree angle from the globe, using a torchlight for pupillary light reflex examination [28].
Sonographic findings suggestive of abnormal pupillary response include:
· Absent or reduced pupillary constriction
· Delayed or asymmetric response,
· Absent consensual response
Figure 18. Ocular PoCUS assessment of pupillary response through closed eyelids. B-mode images demonstrate pupillary diameter measurement at baseline (left) and following light stimulation (right). Image courtesy of Dr. Jade Seguin, used with permission
In suspected globe rupture, POCUS is contraindicated because even minimal probe pressure can worsen the injury. In children with obvious trauma to the eye presenting with a misshapen globe, peaked pupil, Seidel sign, or extrusion of intraocular contents, POCUS should NOT be performed.
In the case that globe rupture was not the clinical suspicion, and PoCUS was performed, it will appear as:
· Loss of normal spherical shape of the globe
· Flattening of the anterior chamber
· Buckling of the sclera
· Vitreous hemorrhage
Figure 19. POCUS of the right orbit following blunt ocular demonstrating complete loss of normal globe architecture, consistent with globe rupture. Video courtesy of Dr. Earl Cummings, MUSC Emergency and Pediatric Emergency Medicine, via POCUS Atlas . Used under CC BY-NC 4.0 license.
The normal pediatric eye appears symmetric and well-structured, with clear chambers, a centered lens, and an intact retina on ultrasound. Because a generous amount of gel is used in ocular ultrasound to minimize pressure on the eye, a thin layer of gel will be visible on the image. The eye will have the same appearance in both sagittal and transverse planes, reflecting its round, symmetric shape.
Figure 5. Normal ocular ultrasound of the right eye, labeled.
Figure 6. Normal eye on PoCUS.
Eye movements are seen as smooth, coordinated shifts of the globe. The lens and iris move together, and the retina remains attached and stable. Uniform motion in all directions indicates normal extraocular muscle function.
Figure 7. Normal ocular movements seen on ultrasound
The eye is made up of several key structures, each with its own role in vision. A basic understanding of ocular anatomy is essential for orienting the probe and interpreting ocular PoCUS findings. Figure 4 illustrates the key anatomical structures of the eye as visualized with ultrasound.
Figure 4: Anatomical diagram of the eye in relation to ocular ultrasound
** Details on optic nerve POCUS for ICP/papilledema is covered in a separate KidSONO Module