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Background There is a growing body of evidence to support the utility of lung point-of-care ultrasound (POCUS) in pediatric patients with multiple pulmonary pathologies, particularly pneumonia. As we increase our use of lung POCUS for pediatric patients with respiratory complaints, we must be mindful of the normal anatomy and sonographic findings within the pediatric chest and aware of how to distinguish normal findings (e.g., thymus) from pathologic findings (e.g., consolidation). Case Reports We report four cases of pediatric patients who presented to the Emergency Department with respiratory complaints for which POCUS was able to distinguish lung consolidation and normal thymus in the anterior chest. Why Should an Emergency Physician Be Aware of This? The use of lung ultrasound to detect pneumonia is extensively documented in the pediatric literature. Emergency physicians may not be aware of how to discriminate the normal sonographic appearance of the thymus from lung consolidation on POCUS. The ability to identify normal and pathologic findings within the pediatric chest by POCUS will be increasingly important to appropriately reduce the use of plain radiography for pediatric patients with respiratory complaints.

Eighty-eight percent of pediatric emergency department (ED) visits occur in general EDs. Exposure to critically ill children during emergency medicine (EM) training has not been well described.The objective was to characterize the critically ill pediatric EM case exposure among EM residents.This is a secondary analysis of a multicenter retrospective review of pediatric patients (aged 18 years) seen by the 2015 graduating resident physicians at four U.S. EM training programs. The per-resident exposure to Emergency Severity Index (ESI) Level 1 pediatric patients was measured. Resident-level counts of pediatric patients were measured; specific counts were classified by age and Pediatric Emergency Care Applied Network diagnostic categories.There were 31,552 children seen by 51 residents across all programs; 434 children (1.3%) had an ESI of 1. The median patient age was 8 years (interquartile range [IQR] 3-12 years). The median overall pediatric critical case exposure per resident was 6 (IQR 3-12 cases). The median trauma and medical exposure was 2 (IQR 0-3) and 3 (IQR 2-10), respectively. For 13 out of 20 diagnostic categories, at least 50% of residents did not see any critical care case in that category. Sixty-eight percent of residents saw 10 or fewer critically ill cases by the end of training.Pediatric critical care exposure during EM training is very limited. These findings underscore the importance of monitoring trainees' case experience to inform program-specific curricula and to develop strategies to increase exposure and resident entrustment, as well as further research in this area.

Return visits to the Emergency Department (ED) requiring admission are frequently reviewed for the purpose of quality improvement. Treating physicians typically perform this review, but it is unclear if they accurately identify the reasons for the returns.To assess the characteristics of pediatric return visits to the ED, and the ability of treating physicians to identify the root causes for these return visits.This retrospective cohort study reviewed all returns within 96 h of an initial visit over a 2-year period at a tertiary care pediatric ED. Baseline characteristics were determined from review of patients' charts. The treating physicians, the primary author, and independent reviewers identified the root cause for the returns.There were 97,374 patients that presented to the ED during the study, and 1091 (1.1%) of these children returned to the ED and were admitted. Returns were most common among children aged5 years, arriving between 3:00 p.m. and 11:00 p .m. via private transportation, with infectious diseases. The physician involved in the care of the patient attributed 3.1% of returns to potential deficiencies in medical management, whereas the independent reviewers attributed 13% to potential deficiencies.Both returns and the subset of returns due to potential deficiencies in management are more common than previously estimated, rendering review of returns a valuable quality improvement tool. However, EDs should not rely exclusively on the treating physicians to identify the reason for returns, as they seem to underestimate the frequency of returns due to potential deficiencies in medical management.