Category Archives: General

Not Your Usual Pneumothorax?

You’ve been called to the ED to see a patient with a “spontaneous pneumothorax”, but once you meet him you see that he doesn’t fit the classic profile (tall, slim male). What gives?

After closer questioning, he admits to have been smoking crack cocaine at the time. Freak coincidence?

There are a number of case reports dating from 1984 describing this association. A number of reasons have been cited:

  • A high incidence of tobacco smoking
  • Bullous disease caused by inhaled drug use
  • Inhalation of hot gas followed by frequent Valsalva maneuvers

I’ve seen this presentation about 5 times in my career. I always ask about drug use so I can ensure that a chemical dependency screen is ordered.

Reference: Pneumothorax, pneumomediastinum, and pneumopericardium following Valsalva’s maneuver during marijuana smoking. N Y State J Med 84(12):619-20, 1984.

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Pediatric Trauma Case: The Answer

So you’ve been called to the ED to see this 10 year old boy who ran into a buddy on the playground while playing tag. They hit chest to chest, but neither had any apparent injuries at the time. Once home, your patient proceeded to cough up a little blood. Mom promptly brought him to your ED for evaluation.

The first thing to do is a good history and physical. No previous illnesses, nothing like this before. No other obvious injuries, no symptoms of concussion. Just some mild anterior chest wall tenderness in the mid-sternum where he hit the other kid.

Most likely diagnosis: pulmonary contusion. Now, think about what you need to do and the risks and benefits of the tests you could order. What you need to do is rule out a pneumothorax large enough to be treated. A simple chest X-ray will do this. It won’t detect an occult pneumo, but this is not necessary.

A chest X-ray won’t necessarily show you a pulmonary contusion, either. But do you need to see it to make the diagnosis? No! The clinical evidence is enough. A chest CT is almost never indicated in children, and this is certainly not a reason to get one. EKG: not needed unless your pulse exam was abnormal.

if the child has no complaints of dyspnea and appears to be breathing normally, he can go home. This is such a Low energy injury that progression of the contusion is not an issue. Hospitalization offers no benefit, and will certainly inflict more trauma. Instruct the parents to watch for any apparent breathing problems and give typical non-prescription kiddie analgesics if needed. And be sure to tell them that their son may cough up blood for several more days, but it should disappear soon.

Bottom line: unfortunately, we’ve gotten into the habit of ordering lots of tests to confirm things that we already know. We tend to consider the impact in children a little more, especially when it involves radiation. But we really need to start thinking this way for all patients!

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Pediatric Trauma Case

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.

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Part 2: FAST Is Fast And FAST Is Last

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!

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DVT In Children

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.

Related posts:

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.

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