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.
Rapid infusion systems of some type are available in most EDs. However, this equipment is not routinely available in the field or in ground ambulances. Here’s a creative way to fashion one in a pinch for my overseas readers.
Note: The system described relies on an IV infusion set called the Intrafx SafeSet, available in Europe. The drip chamber in this set has a hydrophilic filter membrane integrated into the drip chamber that prevents air from passing through. This is critical for avoiding air embolism. Any product that traps air bubbles will work.
Here are the key components:
- A – a fluid bottle with your choice of resuscitation fluid
- B – an Intrafix SafeSet, or other drip chamber containing an air trap
- C – another infusion set, spiked into A to pressurize it
- D – a bulb from a sphygmomanometer for pressurizing A
Bottom line: This barebones, low cost rapid infuser can be used in hostile environments and can achieve rapid flow rates. But remember, the drip chamber (B) must be of an air-trapping type!
Reference: Novel rapid infusion device for patients in emergency situations. Scand J Trauma Resus Emerg Med 19:35, 2011.
Ever been in a trauma activation where it seems like the first thing that happens is that someone steps up to the patient with the ultrasound probe in hand? And then it takes 5 minutes of pushing and prodding to get the exam done?
Well, it’s not supposed to be that way. The whole point of adhering to the usual ATLS protocol is to ensure that the patient stays alive through and well after your exam. And FAST is not part of the primary or secondary surveys, it is an adjunct.
As always, there are a few exceptions to the rule above.
- If an unstable patient arrives without an obvious source of bleeding, FAST of the abdomen should be able to detect if a large hemoperitoneum is present. This will expedite the patient’s transfer to the OR.
- A patient in cardiac arrest may benefit from a quick FAST to determine if cardiac activity is present. If not, it may be time to terminate resuscitation.
Bottom line: With the exceptions noted above, always complete the ATLS primary and secondary surveys first. Then pull out the ultrasound machine, but be quick about it. If it takes more than about 60 seconds to do the exam, someone probably needs a little more practice.
The radiologist made me order that (unnecessary) test! I’ve heard this excuse many, many times. Do these phrases look familiar?
- … recommend clinical correlation
- … correlation with CT may be of value
- … recommend delayed CT imaging through the area
- … may represent thymus vs thoracic aortic injury (in a 2 year old who fell down stairs)
Some trauma professionals will read the radiology report and then immediately order more xrays. Others will critically look at the report, the patient’s clinical status and mechanism of injury, and then decide they are not necessary. I am firmly in the latter camp.
But why do some just follow the rad’s suggestions? I believe there are two major camps:
- Those that are afraid of being sued if they don’t do everything suggested, because they’ve done everything and shouldn’t miss the diagnosis
- Those that don’t completely understand what is known about trauma mechanisms and injury and think the radiologist does
Bottom line: The radiologist is your consultant. While they are good at reading images, they do not know the nuances of trauma. Plus, they didn’t get to see the patient so they don’t have the full context for their read. First, talk to the rad so they know what happened to the patient and what you are looking for. Then critically look at their read. If the mechanism doesn’t support the diagnosis, or they are requesting unusual or unneeded studies, don’t get them! Just document your rationale clearly in the record. This provides best patient care, and minimizes the potential complications (and radiation exposure) from unnecessary tests.
Reference: Pitfalls of the vague radiology report. AJR 174(6):1511-1518, 2000.