Tag Archives: pediatric

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.

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 you 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.

How Do I Clear the Pediatric Cervical Spine?

There is quite a bit of controversy surrounding clearing the cervical spine in children. The trauma and emergency medicine literature have few high quality studies to base recommendations on. However, a few very good studies have been carried out that did include children, and they are the basis for this suggested method for clearance.

There are a few key concepts that must be understood before approaching spine clearance in this patient group.

  1. Clinical clearance is key! The majority of children’s cervical spines can be cleared clinically
  2. Limit routine radiographic evaluation, especially by CT. The head and neck is packed with glandular tissue that is sensitive to radiation, especially in early childhood.
  3. If radiographs are required, be sure to have them read by a radiologist who routinely reads pediatric images. There are many nuances in ossification and bony positioning that may falsely lead to injury diagnoses.
  4. Memorize the NEXUS criteria. This study included enough children to allow treatment recommendations to be validated. They are:
    • Midline cervical tenderness
    • Focal neurologic deficit
    • Altered level of consciousness
    • Evidence of intoxication
    • Painful distracting injury

The first step is to determine whether the child is eligible to be clinically cleared. They must be able to verbalize and cooperate with your exam. They may not have a developmental delay, since this may interfere their ability to cooperate with your exam. Frequently, younger children are apprehensive around doctors, and I recommend that you have a parent perform appropriate parts of the exam under your verbal guidance.

Next, evaluate to see if any of the NEXUS critieria are met. The distracting injury criterion is the most difficult to assess. This is a judgment call, but if the child is aware of multiple potentially painful areas, then a distracting injury is probably not present.

If no NEXUS criteria are met, the spine is cleared and should be documented as such. If any are present, a lateral cervical spine xray should be ordered. If the child is >8 years old, a plain odontoid xray should also be obtained. If all are normal, the spine is cleared and should be documented. Children 8 or younger do not have an odontoid that visualizes well. In such cases, a CT from occiput to the base of C2 should be obtained, with appropriate shielding in place.

If, at any point, an abnormality is encountered, expert consultation must be sought in order to safely clear the cervical spine and remove any stabilization.