Tag Archives: pediatric

General

Delayed Diagnosis In Kids: How Often?

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Delayed or missed diagnoses happen. It’s a reflection on the state of technology and our own diagnostic acumen. Unfortunately, a few cases of delayed diagnosis result in morbidity, potential lawsuits, and rarely, death.

How often does delayed diagnosis occur? A few spot check type articles were published about 15 years ago, but little has been done to slice and dice the data. And as usual, the old data ranged widely in its assessment of the incidence of this problem (1-18% !). However, I managed to find a (somewhat) more recent one that gives a little clearer picture of this issue.

A single pediatric hospital in Indiana reported its experience from 1997 to 2006. This interval included the time that it was verified as a Level II Trauma Center (2000 onwards). They included children 0-14 who had sustained “major trauma.” This was defined as multiple system injuries, high-energy impacts, and gunshots. In this study, delayed diagnosis was defined as one found after a stable patient was admitted to their room. In patients taken directly to OR, it was one found after the patient left the recovery room.

Here are the factoids:

  • 1100 patients met study criteria. 98% were blunt trauma.
  • Only 44 patients had delayed diagnoses of 47 injuries
  • Average time to diagnosis was 4 days (range 8 hours to 28 days)
  • 34% of diagnoses were made within 24 hours
  • 3 diagnoses were made at a followup visit, all for upper extremity/should fractures
  • 80% of delayed diagnoses required a change in therapy, most commonly a sling or cast. 15% required surgery.
  • The long-term delayed diagnosis rate was 4%

Bottom line: Delayed diagnosis remains an issue in patient of all ages. The reported 4% rate subjectively seems about right to me. The most important lesson from this study is the extremely high percentage of delayed diagnoses that required further therapy. This is why it is so important to implement a specific system (the tertiary survey) to seek out these diagnoses.

A tertiary survey is a repeat head-to-toe physical exam and a review of all radiographic imaging performed to date. The trauma center should define the time interval from admission, and I recommend no more than 24-48 hours. We do not count any diagnoses found during this exam as being delayed. However, if a tertiary exam was not performed, or injuries are found after it was completed, we do consider it delayed an run it through our performance improvement process.

Related posts:

Reference: Ten-Year Retrospective Study of Delayed Diagnosis of Injury in Pediatric Trauma Patients at a Level II Trauma Center. Pediatric Emerg Care 25(8)-489-493, 2009.

General

Nursing Tips for Managing Pediatric Orthopedic Trauma

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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.
General

More On DVT In Children

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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:

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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.

General

State Laws And Pediatric Firearms Injuries

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The US federal government records some basic statistics regarding firearm injuries, mostly related to deaths. However, the Agency for Healthcare Research and Quality maintains a database that contains detailed information on pediatric hospitalizations, including injury information. A group at Tufts University used this database to compare injury trends in pediatric firearm injury (age 0-20) in states with and without a Stand Your Ground law (SYG). Stand Your Ground laws, which many first became aware of after the death of Trayvon Martin in Florida, allow an individual to defend themelves from an unlawful threat without having to retreat first.

The database used was fairly robust. Data were submitted from 44 states, and 4 years were reviewed for the study. Over 19,000 pediatric firearm injury records were analyzed. The following interesting reslts were uncovered:

  • Nearly two thirds were assualts, and 27% were accidental injury.
  • Average length of stay for both mechanisms was about 3 days
  • Hospital cost for assault was $61,000 and for accidental injury was $46,000, per child
  • Children were about 10% more likely to suffer a firearm assault in SYG states
  • Kids in SYG states were also more likely to suffer accidental firearm injury and commit suicide with a firearm(?!)
  • Statistical association of firearm injury with the usual culprits (race, age > 16, male sex, socioeconomic status) was also noted

Bottom line: At best, this is a weak observational study. And of course, it is impossible to say that Stand Your Ground laws are the cause of a greater number of pediatric firearm injuries. The fact that (even greater) increases in accidental injury and suicide were noted points out this weakness even better. Although it is tempting to blame SYG laws on this perceived increase in injuries, it’s not correct. Much better analyses need to occur before we can really draw any actionable conclusions on the effects of these laws..

States with Stand Your Ground laws: AL, AK, AZ, CA, FL, GA, IA, IL, IN, KS, KY, LA, ME, MI, MS, MO, MT, NH, NC, ND, OH, OK,, PA, RI, SC, SD, TN, X, UT, WV, WI, WY

General

Pediatric Trauma Case: The Answer

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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!