Category Archives: General

What The Heck? Pediatric Abdomen

Here’s an interesting case for you to think about. A three year old female is brought to your ED with a three day history of abdominal pain which has been getting worse. She started vomiting yesterday, and hasn’t wanted to eat for two days. The child has been completely healthy until now. The parents deny any history of trauma.

On exam, the child appears to be ill. She has a distended abdomen bordering on rigidity, and is markedly tender. A FAST exam is performed, which shows a small amount of fluid only in the pelvis.

Here are my questions for you:

  • What tests would you like to order?
  • What is going on here?

Remember, this is the Trauma Professional’s Blog, after all!

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Nursing Tips for Managing Pediatric Orthopedic Trauma

Nurses have a complementary role with physicians in caring for children with orthopedic injuries. Typically, the child will have been evaluated and had some sort of fracture management implemented. In children, nursing management is easer than in adults since a child is less likely to need an invasive surgical procedure. Many fractures can be dealt with using casts and splints alone.

Here are a few tips for providing the best care for your pediatric patients:

  • Ensure adequate splinting / casting. You will have an opportunity to see the child at their usual level of activity. If it appears likely that their activity may defeat the purpose of the cast or splint, inform the surgeon or extender so they can apply a better one.
  • Focus on pain control. Nothing aggravates parents more than seeing their child in pain! Make sure acetominophen or ibuprofen is available prn if pain is very mild, or scheduled if more significant. Ensure that mild narcotics are available if pain levels are higher. Remember, stool softeners are mandatory if narcotics are given.
  • Monitor compartments frequently. If a cast is used, check the distal part of the extremity for pain, unwillingness to move, numbness or swelling. If any are present, call the physician or extender and expect prompt attention to the problem.
  • Always think about the possibility of abuse. Fractures are rarely seen in children under 3, and almost never if less than 1 year old. If you have concerns about the physical findings or parent interactions, let the physician and social workers know immediately.
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Contrast Blush in Children

A contrast blush is occasionally seen on abdominal CT in patients with solid organ injury. This represents active arterial extravasation from the injured organ. In most institutions, this is grounds for call interventional radiology to evaluate and possibly embolize the problem. The image below shows a typical blush.

Splenic contrast blush

This thinking is fairly routine and supported by the literature in adults. However, it cannot be generalized to children!

Children have more elastic tissue in their spleen and tend to do better with nonoperative management than adults. The same holds true for contrast blushes. The vast majority of children will stop bleeding on their own, despite the appearance of a large blush. In fact, if children are taken to angiography, it is commonplace for no extravasation to be seen!

Angiography introduces the risk of local complications in the femoral artery as well as more proximal ones. That, coupled with the fact that embolization is rarely needed, should keep any prudent trauma surgeon from ordering the test. A recently released paper confirms these findings.

The only difficult questions is “when is a child no longer a child?” Is there an age cutoff at which the spleen starts acting like an adult and keeps on bleeding? Unfortunately, we don’t know. I recommend that you use the “eyeball test”, and reserve angiography for kids with contrast extravasation who look like adults (size and body habitus).

Reference: What is the significance of contrast “blush” in pediatric blunt splenic trauma? Davies et al. J Pediatric Surg 2010 May; 45(5):916-20.

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October Trauma MedEd Newsletter Released

The October newsletter is now available! Click the image below or the link at the bottom to download. This month’s topic is “Inside Stuff”.

In this issue you’ll find articles on:

  • Retained foreign objects after penetrating injury
  • A cool way to remove embedded foreign objects
  • Can lead poisoning occur after a gunshot?
  • Orthopedic hardware and TSA metal detectors
  • Technology: the Vein Viewer
  • Using a 3D printer to plan orthopedic surgery

Subscribers received the newsletter first last weekend. If you want to subscribe (and download back issues), click here.

Click here to download the current issue.

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Flying And Pneumothorax: Part 2

Some time ago, I wrote about the effect of flying on pneumothorax (PTX). It was more of a hypothetical treatise, discussing Boyle’s law and such. I also cited a practice guideline and another empiric guideline from the Aerospace Medical Association. But there was little, if any, real data to base recommendations on.

A recent study has tried to rectify this. They performed a prospective, observational study of 20 patients with traumatic pneumothorax. All were treated with either a chest tube (70%) or high flow oxygen therapy (30%) (they must not have read my many posts on the futility of this; see the links below). If a chest tube had been inserted, it had to have been removed for 4 to 48 hours before enrollment in this study, and the PTX had to be resolved to the satisfaction of the surgeon. This did not necessarily mean complete resolution.

Here are the factoids:

  • A hyperbaric chamber was used to simulated the cabin altitudes of commercial jetliners
  • 10 patients were taken up to 8400 feet, the typical cabin altitude when a jet flies at 40000 feet
  • 10 patients were taken up to 12650 feet to compensate for the fact that the altitude of the medical center conducting the study was already 4500 feet (Murray, UT). This simulated an 8400 foot altitude increase for ground dwellers in Murray.
  • Results were measured using portable chest x-ray (!??)
  • PTX etiology was 90% blunt, 10% penetrating
  • At 8400 feet, average PTX size doubled from 4.5mm to 10mm
  • At 12650 feet, average PTX size nearly tripled from 3.2 to 8.7mm. Three of 4 patients without a baseline PTX developed one at this altitude. 
  • Some patients in each group required supplemental O2 to maintain normal oxygen saturation readings

Based on these results, the authors believe that patients who had a PTX might be able to fly sooner than 2 weeks. But there are many problems with this study. First, using a chest x-ray to monitor increases in size (or judge pre-flight size) is notoriously inaccurate. Next, the statistical methods and sample size are just not adequate. And finally, the fact that PTX size increases predicted by Boyle’s law and O2 sat changes occurred is very worrisome.

Bottom line: This study was a nice try, but not robust enough to change anything. Yes, there is little data to support the 2 week no-fly rule after pneumothorax. But the size increases of the PTX in this study were worrisome, particularly because they used a diagnostic test that notoriously underestimates their size. I recommend sticking with the current recommendations and constructing a much better study.

Related posts:

Reference: Cleared for takeoff: The effects of hypobaric conditions on traumatic pneumothoraces. J Trauma 77(5):729-733, 2014.

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