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!
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.
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.
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.
Intracranial Hypertension In Pediatric Head Trauma
This 44 minute video is a good introduction to pediatric head trauma and intracranial hypertension. It covers physiology, diagnosis, as well as management using medications, position, decompression and hypothermia.
Presented at Multidisciplinary Trauma Conference at Regions Hospital on May 3, 2012 by Debbie Song MD, a pediatric neurosurgeon.
CT scan is essential in diagnosing injury, although concerns for unnecessary radiation exposure are growing. These concerns are even greater in children, who may be more likely to have long-term effects from it. This makes avoiding duplication of CT scanning extremely important.
Unfortunately, there are only about 50 pediatric trauma centers in the US, so the majority of seriously injured children are seen at another hospital before transfer. Does CT evaluation at the first hospital increase the likelihood that a repeat scan will be needed at the trauma center, increasing radiation exposure and risk?
Rainbow Babies and Children’s Hospital in Cincinnati looked at 3 years of transfers of injured children from community hospitals. They then looked at how many of those children had an initial head and/or abdomen scan at the outside hospital, and whether a repeat scan of those areas was performed within 4 hours or arrival at Rainbow.
Numbers were small, but here are the results:
- 33 had an outside CT scan, 28 (90%) were repeated
- 6 had an outside abdominal scan, 2 (33%) were repeated
- 55 did not have outside scans, none were repeated at Rainbow. (This is a weird thing to look at. I would hope that the trauma center didn’t have to repeat any of their own scans within 4 hours!)
Bottom line: It is critically important for referring hospitals to use radiation wisely! First, if the patient has obvious injuries that require transfer, don’t scan, just send. If you need to scan to decide whether you can keep the patient, use the best ALARA* technique you can. And trauma centers, please send a copy of your CT protocols to your referring hospitals so they can get the best images possible.
*ALARA = As low as reasonably achievable (applied to radiation exposure). Also known as ALARP outside of North America (as low as reasonably practicable). Click here for more info.
Reference: Computed tomography before transfer to a level I pediatric trauma center risks duplication with associated radiation exposure. J Pediatric Surg 43(12): 2268-2272, 2008.