Here’s an interesting pediatric trauma case to test your skills. A 10 year old boy was playing tag on the playground at school. He ran head-on into another player, chest to chest. Neither child struck their head.
When the boy arrived home after school, he coughed up some blood. This freaked his mother out, who brought him to your ED for evaluation. He continues to cough up thin, bloody sputum occasionally.
How do you approach this problem? What diagnostic tests do you need? What do you think the diagnosis is? How do you treat, and does he need to be admitted?
Tweet, email or send your comments below. I’ll compile and discuss the replies, and reveal what I think is the correct diagnostic and management sequence.
Source: hypothetical case. Not treated at Regions Hospital.
The CDC released an iPhone app covering the Field Triage Guidelines for Injured Patients a few months ago. It’s not received much attention, but could be helpful for some trauma professionals.
The app consists of 2 components: a copy of the triage guidelines pocket card, and a quiz about the use and impact of the guidelines. The app is pretty bare-bones, but is a convenient way to keep the guidelines available for immediate reference. It doesn’t look like it’s available for Android yet.
Click the link below to go to the Apple App Store for more information or to download.
I’ve received a fair amount of commentary on Twitter and via email regarding my statements about FAST. Many people said that FAST and physical exam can and should happen simultaneously.
In principle, I agree. My previous statements were based on the way that we organize our trauma team and trauma activations at this hospital. The reality is that everyone’s team is different and they may run their trauma activations differently.
The goal is to get all information critical to keeping your patient alive as quickly as possible. In some cases, knowing if there is a significant amount of fluid in the abdomen can be very important. Most trauma resuscitation schemes at trauma centers make use of multiple personnel so that various portions of the patient evaluation can be carried out simultaneously.
But there is also a tradeoff between speed, trauma team size and number of trainees. Centers with fewer or no trainees will have a leaner team with experienced examiners and more room around the patient. At our hospital, we have 8 people clustered immediately around the patient, with half of them being surgery or emergency medicine residents. This means it is more difficult for a physician to step in and do a FAST exam easily. So typically, this physician is the same resident doing the torso portion of the physical exam. This is the main reason for my exhortation to wait until the end of the physical exam and do the FAST quickly.
So it is really up to each center to determine their priorities for the FAST exam based on the people who make up their trauma team. At ours, it will have to remain fast and last.
Please comment or tweet your thoughts!
Deep venous thrombosis has been a problem in adult trauma patients for some time. Turns out, it’s a problem in injured children as well although much less common (<1%). However, the subset of kids admitted to the ICU for trauma have a much higher rate if not given prophylaxis (approx. 6%). Most trauma centers have protocols for chemical prophylaxis of adult patients, but not many have similar protocols for children.
The Medical College of Wisconsin looked at trends prior to and after implementation of a DVT protocol for patients < 19 years old. They used the following protocol to assess risk in patients admitted to the PICU and to determine what type of prophylaxis was warranted:
The need for and type of prophylaxis was balanced against the risk for significant bleeding, and this was accounted for in the protocol. The following significant findings were noted:
- The overall incidence of DVT decreased significantly (65%) after the protocol was introduced, from 5.2% to 1.8%
- The 1.8% incidence after protocol use is still higher than most other non-trauma pediatric populations
- After the protocol was used, all DVT was detected via screening. Suspicion based on clinical findings (edema, pain) only occurred pre-implementation.
- Use of the protocol did not increase use of anticoagulation, it standardized management in pediatric patients
Bottom line: DVT does occur in injured children, particularly in severely injured ones who require admission to the ICU. Implementation of a regimented system of monitoring and prophylaxis decreases the overall DVT rate and standardizes care in this group of patients. This is another example of how the use of a well thought out protocol can benefit our patients and provide a more uniform way of managing them.
Reference: Effectiveness of clinical guidelines for deep vein thrombosis prophylaxis in reducing the incidence of venous thromboembolism in critically ill children after trauma. J Trauma 72(5):1292-1297, 2012.
Intracranial Hypertension In Pediatric Head Trauma
This 44 minute video is a good introduction to pediatric head trauma and intracranial hypertension. It covers physiology, diagnosis, as well as management using medications, position, decompression and hypothermia.
Presented at Multidisciplinary Trauma Conference at Regions Hospital on May 3, 2012 by Debbie Song MD, a pediatric neurosurgeon.