Tag Archives: pediatric

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!

General

Pediatric Trauma Case

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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.

General

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:

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.