Algorithm For Clearing the Pediatric Cervical Spine
I previously wrote about a straightforward way to clear the cervical spine in children. Click here to see the article. Alfred I. DuPont Children’s Hospital has condensed their clearance technique into a relatively simple algorithm that can be used in conjunction with my previous tips.
Some notes on this algorithm:
Can be performed only by attending physicians or a trauma resident in consultation with the attending trauma surgeon
Clinical clearance alone may be carried out in select cases
If radiographs are required, cross-table lateral, anterior/posterior, and odontoid views should be obtained (age 8 and above, non-intubated)
Flexion / extension views should only be ordered in consultation with neurosurgery
Management of severe traumatic brain injury (TBI) routinely involves monitoring and control of cerebral perfusion pressure. Monitoring is typically accomplished with an invasive monitor, with the extraventricular drain (EVD) and fiberoptic intraparenchymal monitors (IP) being the most common.
The extraventricular drain is preferred in many centers because it not only monitors pressures, but it can also be used to drain cerebrospinal fluid (CSF) to actively try to decrease intracranial pressure (ICP). But could less really be more? Surgeons at Massachusetts General reviewed 229 patients with one of these monitors, looking at outcomes and complications. They found the following interesting results:
There was no difference in mortality between the two monitor types
The EVD patients did not require surgical decompression as often, possibly because of the ability to decrease ICP through drainage
The EVD patients were monitored longer, and had a longer ICU length of stay. This was also associated with a longer hospital length of stay.
Complications were much more common in the extraventricular drain group (31%). The most common complications were no drainage / thrombosis (15%) and malposition (10%). Hemorrhage only occurred in 1.6% of patients.
Fiberoptic monitors had a lower complication rate (8%). The most common was malfunction leading to loss of monitoring (12%). Hemorrhage only occurred in 0.6% of patients.
Bottom line: Don’t change your monitoring technique yet. Much more work needs to be done to flesh out this small retrospective study. But it should prompt us to take a critical look for better indications and contraindications for each type of monitor.
Reference: Intraparenchymal versus extracranial ventricular drain intracranial pressure monitors in traumatic brain injury: less is more? Presented at the 34th Annual Residents Trauma Papers Competition at the American College of Surgeons 89th Annual Meeting, March 10, 2011, Washington DC.
It’s warm weather time (in the Northern hemisphere) and the windows are opening. Unfortunately, many parents forget that window screens are not strong enough to keep a child in if they put their weight against it.
Please share the following prevention tips with your patients to keep their children safe:
Install window guards on all windows above the first floor
Windows without guards should only be opened from the top
Keep beds, cribs, sofas and other furniture away from windows so children can’t play near open windows
Lock closed windows and do not let children sit or play near open windows
Occult pneumothorax is the most common incidental finding on CT imaging, occurring in 2% to 10% of trauma patients. By definition, an occult pneumothorax is a pneumothorax that is seen only on CT and not a conventional chest x-ray. When detected, the question that comes to mind is, will this patient need a chest tube?
The AAST conducted a trial encompassing the experience at 16 Level I and II trauma centers around the US. They looked at injury severity, specific chest injuries, ventilator settings if on positive pressure ventilation (PPV) and size of pneumothorax. The size was calculated by measuring the largest air collection along a line perpendicular to the chest wall (see image above). Failure of observation meant that a thoracostomy tube was placed.
The 2 year study looked at a total of 448 occult pneumothoraces that were initially observed. Key findings of the study were:
Injury severity was no different between failure and non-failure groups
There was a 6% failure rate overall
PPV alone was associated with an increased failure rate of 14%
Surgical intervention requiring PPV was not associated with an increased failure rate
Pneumothorax size > 7mm, positive pressure ventilation, progression of the pneumothorax, respiratory distress and presence of hemothorax were associated with failure.
Pneumothorax size was not entirely reliable for predicting failure, since patients with sizes as small as 5mm on PPV and 3mm not on PPV failed in this series
Bottom line: Most blunt trauma patients with an occult pneumothorax can be safely observed. A followup chest x-ray should be obtained to look for progression. If the patient progresses, is placed on PPV, has a hemothorax or develops respiratory distress, have a low threshold for inserting a drainage tube. Maximum pneumothorax size may predict failure when large, but it can still happen with very small air collections.