MEdIC Series | The Case of the Backroom Blunder

Are you ready??website cpr image 2 Season 2 of the ALiEM MEdIC series is about to begin! We are so excited to kick off the ‘school year’ with a riveting new case from our Medical Education in Cases series.

Join us now to discuss the case of the Backroom Blunder wherein Trevor, the 3rd year medical student, finds himself reflecting about the use of humor by his colleagues in the resuscitation bay.

MEdIC Series: The Concept

Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

The Case of the Absentee Audience

by Heather Murray (@HeatherM211)

Trevor, the 3rd year medical student rotating in the Emergency Department, sat down in the staff changing room to gather his thoughts. He had never seen a cardiac arrest before, and this one had been a doozy. An elderly, obese man had come in by EMS after suffering cardiac arrest from a huge lower GI bleed. The ED team had run the arrest for a really long time, transfusing blood, IV fluids and tons of drugs, intubating, bedside ultrasound, everything. The room had been a mess when they finally called it. Trevor had gone with Dr. Elliott, the attending, to break the news to the family. He had been impressed with her gentle compassion as she talked with them.

Trevor was thinking about the code. He was pretty pleased with his CPR – he’d practiced in the sim lab to get the timing and compression depth just right. Dr. Elliott had even complimented him on it. He thought about the smell – melena, rectal bleeding, vomit… it had been really awful. He hoped they could make the room smell better before the family came in. They had been so upset. He thought about the rest of the code. It seemed like Jeff, the senior resident, had struggled with the intubation. There had been quite a scene at the head of the bed. Jeff had needed 3 extra suction catheters to deal with all the airway vomit. Dr. Elliott had even asked if Jeff wanted her to take over. Trevor thought that it should have been a bit smoother.

He got up and left the change room. As he was about to come around the corner, he overhead Dr. Elliott and Jeff talking. He stopped, not wanting to interrupt, but as he listened he realized they were laughing together about the code! He heard them making jokes about the smell and the rectal bleeding, calling the patient a “frequent flyer” and talking about his “red underpants.” They didn’t seem to care at all that he had died, or about how awful it had been. And Jeff had screwed up the airway, Trevor was sure of it. Shouldn’t he be apologizing to Dr. Elliott instead of laughing? Dr. Elliott had seemed so nice and sympathetic to the family… was that all pretend? A fake show of sympathy?! Now Trevor was angry.

After Dr. Elliott and Jeff went back into the ED, Trevor stayed in the back hall, fuming. Sonia, another 3rd year student, arrived for her shift. When Trevor told her about Dr. Elliott and Jeff’s conversation, she pursed her lips and thought for a minute.

“Weird. Dr. Elliott always seems like she cares about people to me. Maybe it upset them, too? Maybe they’re just blowing off steam?”

“No way. A caring doctor would never talk like that. And the slang? That’s just awful. That man was somebody’s dad, and grandpa. I’m thinking of writing a complaint.”

Key Questions

  1. Medicine has a lot of slang – words that are specific to our particular culture, and sometimes derogatory. Is there a role for this language? Should medical educators be held to a higher standard?
  2. Black humour has been used as a coping strategy for stressful or traumatic events. Is this appropriate in a patient-centered care world?
  3. How should physicians cope with stressful or horrifying situations? How can we “blow off steam” effectively, and how can we support our learners?

 

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses one week after the case was published. This month the two experts are:

  • Dr. Brian Goldman (@NightShiftMD) is a staff ED physician at Mount Sinai Hospital and host of White Coat, Black Art on CBC Radio One.  His new book The Secret Language of Doctors is about hospital slang and what the slang reveals about modern medical culture.
  • Liz Crowe (@LizCrowe2) is an Advanced Clinician Social Worker in the Pediatric Intensive Care Unit at the Mater Children’s Hospital, Brisbane Australia. She also is involved in a large research project on Advance Care Planning with Griffith University. She is doing a doctorate examining staff wellbeing in critical care to inform interventions of support and education. Liz is a passionate and humorous educator and the successful author of ‘The Little Book of Loss and Grief You Can Read While You Cry’. When Liz is not working, studying, or writing, she hangs out with her kids and husband and enjoys walking, cycling, and reading.

On October 3, 2014 the Expert Responses and Curated Community Commentary for the Case of the Backroom Blunder will be posted.  After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary which was released on October 3, 2014.  That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Author information

Teresa Chan, MD

ALiEM Associate Editor

Emergency Physician, Hamilton

Assistant Professor, McMaster University

Ontario, Canada
+ Teresa Chan

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High risk back pain: Spinal Epidural Abscess

epidural-abscess-282x300-modifiedSpinal epidural abscess (SEA) is a rare but potentially catastrophic cause of back pain. Classically these patients are described as having back pain, fever, and clear neurologic deficits. In reality, patients often present with less obvious symptoms which often leads to a delay in diagnosis. Missed cases of SEA are a source of significant risk to both the patient and the provider. To improve outcomes and minimize risk, providers must identify and promptly evaluate patients who are at increased risk of developing a SEA.

Risk to the patient

SEA typically occurs from hematogenous spread, extension of nearby infection, or from iatrogenic inoculation. Staphylococcus aureus is responsible for the majority of infections [1]. 20% of SEAs occur anterior to the spinal cord. These lesions, which are typically associated with vertebral osteomyelitis, are thought to cause more systemic features which can make the diagnosis more obvious. Unfortunately most (80% of cases) occur in the posterior region, and these patients are less likely to experience systemic symptoms such as a fever [2]. Lesions occur most commonly in the lumbar region, however cervical and thoracic lesions often present atypically, are commonly missed, and account for a disproportionate number of cases that result in a lawsuit.

Overall mortality ranges from 5-34%, down from near 100% at the beginning of the 20th century. About 45% of patients will have a complete recovery, and the majority of patients will have some degree of neurologic compromise [3]. SEA is commonly missed during the patient’s initial visit, causing a delay that can significantly increase the patient’s morbidity. Davis et al. found that about 75% of SEA patients had a delay before imaging was performed, leading to a significant increase in motor weakness with 45% of these patients demonstrating residual weakness compared to 13% who did not have a diagnostic delay [4].

Risk to the provider

Missed SEA is a source of significant medicolegal risk in the United States with an average verdict against the physician of $398,000. Delay in treatment was associated with bad outcomes for both the patient and the provider. In cases where there was a delay of over 48 hours from presentation to surgery, the odds of a plantiff’s verdict increased significantly. In one series, patients with SEA who were initially misdiagnosed and not offered treatment within 48 hours of symptom onset won their cases against the physician 100% of the time [1].

Don’t count on the “classic” symptoms

The “classic triad” of fever, back pain, and neurologic deficits does not accurately identify patients with SEA. In a review of patients with SEA, Davis et al. found that only 13% of patients had this “classic triad” on presentation. The physical exam was also unreliable as 68% of SEA patients had a normal neurologic exam on initial presentation.  Findings such as urinary incontinence and perineal parasthesias can significantly increase the likelihood of the patient having a SEA, however lack of these findings does not reliably rule out the disease.

Know who is truly at risk

A wide variety of at-risk conditions include:

  • Diabetes mellitus
  • IV drug use
  • Chronic kidney/liver disease
  • Recent spine procedure or indwelling spinal hardware
  • Indwelling vascular catheter
  • Recent spine fracture
  • Immunocompromised status
  • Other site of infection

In one study, 98% of patients in the SEA group had at least one of these risk factors compared to 21% of a matched control group with “spine pain” [4].

ESR can help risk stratify high risk patients

Based on these high risk criteria, Davis et al. developed a clinical decision guideline in an attempt to expedite the workup and diagnosis of SEAs using a combination of high risk features and laboratory tests. In this study, 100% of patients with a SEA had at least one risk factor, with IV drug use being the most common risk factor.

Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were ordered for the majority of the patients. The CRP was elevated (>1.0 mg/L) in 87% of SEA patients, but was also elevated in 50% of non-SEA patients who had at least one risk factor. ESR had better test characteristics than CRP and was elevated (>20 mm/hr) in 100% of patients with an abscess compared to 33% of the abscess-free cohort. The combination of one or more clinical risk factors and an elevated ESR was 100% sensitive and 67% specific for SEA. Patients with these positive findings underwent further testing, which was usually MRI [5]. After implementing the guideline, Davis et al. noted a decreased of delays in diagnosis from 84% to 10% (OR 47.7). Similarly motor deficits at the time of diagnosis dropped from 82% to 20% (OR 18.8) [5].

 

SEA algorithm

Is the algorithm ready for prime time?

If all patients with back pain and a clinical risk factor for SEA have an ESR performed, there are going to be a large number of patients who have an elevated level but who ultimately do not have a SEA. The authors did not mention the rate of MRI use after the implementation of the algorithm, but it would be reasonable to assume that if the guideline is followed closely then there would be an increase in the rate of imaging as more patients are identified as being potentially at risk. From a logistical standpoint, most departments would have difficulty obtaining emergent MRIs on all patients with one risk factor for SEA and a mildly elevated ESR.

From a diagnostic standpoint, it would be reasonable to use clinical criteria and ESR in conjunction with overall provider determined pre-test probability. A patient with a history of diabetes with lumbar pain that started after a recent motor vehicle accident has a very low pre-test probability of having a SEA, and contrary to the algorithm needs no further testing. Conversely a patient with fever, IVDA, and unexplained back pain likely needs an MRI, even with a normal ESR. The algorithm proposed by Davis et al. provides an effective means of risk stratification in patients who potentially have a SEA, but given its broad inclusion parameters and poor specificity it should not be used on all patients who present with back pain.

Protect yourself

From a risk management standpoint, the possibility of SEA should be considered and documented in all patients with back pain. A reasonable approach would be to chart:

“I have considered the possibility of SEA, the patient has no features that place them at increased risk of SEA, and they have a normal neurologic exam in the emergency department. I think the pre-test probability of SEA is sufficiently low that they do not need any further workup emergently.”

Patients with no specific risk factors for SEA and a normal exam do not need further testing emergently. In patients with a risk factor, an ESR can be used for further risk stratification. When the ESR is elevated, providers should have a low threshold to obtain imaging.

 

This post belongs to Dr. Matthew DeLaney’s series on Everyday Risk in Emergency Medicine (EREM). 

References

  1. French KL, Daniels EW, Ahn UM, et al. Medicolegal cases for spinal epidural hematoma and spinal epidural abscess. Orthopedics. 2013;36 (1): 48-53.  Pubmed
  2. Soehle M, Wallenfang T. Spinal epidural abscesses: clinical manifestations, prognostic factors, and outcomes. Neurosurgery. 2002;51 (1): 79-85. Pubmed
  3. Reihsaus E, Waldbaur H, Seeling W. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev. 2000;23 (4): 175-204.  Pubmed
  4. Davis DP, Wold RM, Patel RJ, et al. The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. J Emerg Med. 2004;26 (3): 285-91. Pubmed
  5. Davis DP, Salazar A, Chan TC, et al. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain. J Neurosurg Spine. 2011;14 (6): 765-70. Pubmed

 Image (modified)

Author information

Matthew DeLaney, MD

Matthew DeLaney, MD

Assistant Professor of Emergency Medicine

Assistant Medical Director

University of Alabama at Birmingham

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Diagnose on Sight: “I feel like I am having a heart attack”

Pneumothorax-Deep-SulcusCase: A 18-year-old male with no medical history presents to the emergency department (ED) complaining of “feeling like I am having a heart attack” which started suddenly 1 hour ago. The patient ate from a food truck the night before and developed several episodes of forceful vomiting prior to arrival in the ED. What finding in this supine chest radiograph aids in the diagnosis? Click on image for a larger view.

Poll

 

Answer

Deep Sulcus Sign

Explanation

The deep sulcus sign was first described by Gordon in 1980 as a deep lateral costophrenic angle on the involved side [1]. In this example, it is on the patient’s left side (arrow). It is an important radiograph finding to be aware of in making the diagnosis of pneumothorax, because it may often be the only abnormal finding [2]. The cause of the sign is air tracking anteriorly and caudally along the pleural space and can be found on supine films. Which makes this finding particularly important for SUPINE critically ill patients. Air appears as a hyperlucency on radiographs which leads to the appearance of a deep lateral costophrenic angle on the side with the pneumothorax.

Pneumothorax-Deep-Sulcus-Arrow

Wrong Answers

Screen Shot 2014-09-09 at 3.18.48 AM

 

References

  1. Gordon R. The deep sulcus sign. Radiology. 1980 July;136(1):25-7. PMID: 7384513
  2. Smally AJ. Suozzi JC. Images in emergency medicine. Deep sulcus sign. Ann Emerg Med. 2007 May;49(5):717;725. PMID: 17452270
  3. Bhardawaj B. Bhardwaj H. Air-fluid level in the right lung. Lung India. 2014 Apr;31(2):179-81. PMID: 24778488
  4. Koga T. Fujimoto K. Images in clinical medicine. Kerley’s A, B, and C lines. N Engl J Med. 2009 Apr 9;360(15):1539. PMID: 19357409
  5. Lai V. Tsang WK. Chan WC. Yeung TW. Diagnostic accuracy of mediastinal width measurement on posteroanterior and anteroposterior chest radiographs in the depiction of acute nontraumatic thoracic aortic dissection. Emerg Radiol. 2012 Aug;19(4):309-15. PMID: 22415593

Author information

Nikita Joshi, MD

Nikita Joshi, MD

ALiEM Associate Editor

Editorial Board Member

ALiEM-CORD Fellowship Director

ALiEM-EMRA Fellowship Director

Clinical Instructor

Stanford University, Division of Emergency Medicine

The post Diagnose on Sight: “I feel like I am having a heart attack” appeared first on ALiEM.

I am Dr. Rob Mac Sweeney, Editor for Critical Care Reviews: How I Work Smarter

How I Work Smarter LogoIn this new installment in the “How I Work Smarter” series, we feature Dr. Rob Mac Sweeney (@CritCareReviews), who is the editor for the prolific and very popular blog Critical Care Reviews. Twitter fans nominated him: “Everyone would like to know how you manage to produce such a resource and find the time to breath!” and “Rob never sleeps. Can be no other explanation!” Rob has agreed to share his trade secrets on how he works smarter and seeming finds more time in the day than us mere mortals.

 

Rob Mac Sweeney - optimised

  • Name: Rob Mac Sweeney
  • Location: Belfast, Northern Ireland
  • Current job: Intensivist, Royal Victoria Hospital, Belfast
  • One word that best describes how you work: Focused
  • Current mobile device: Some sort of HTC
  • Current computer: ASUS Ultrabook 13’

 

What’s your office workspace setup like?

I do virtually all my extra-curricular work at home. I keep my workspace sparse, just my laptop, notepad & pen, earphones, and coffee. Minimal distraction. Earphones to help me concentrate.

Rob's Workspace - Optimised

At work, I share a single office with the other intensivists. As a result, it’s busy and full of interruptions, so I only do what I have to there.

What’s your best time-saving tip in the office or home?

Be time focused – only allow a certain amount of time for each task. When that time is up, move onto the next task regardless. When work time is up, put it away. Work expands to fill the available time, so condense that time, work hard during that time, and have something non-work related planned to do afterwards.

When a new task is generated, I schedule time for it on my google calendar. I also use to-do and deadline lists, to help keep track of my projects.

What’s your best time-saving tip regarding email management?

I’m another zero in-box person. I get a lot of email with my literature scanning, so I need to be able to deal with it efficiently. I check my email at a few specific times during the day, as well as opportunistically if a couple of free minutes come up, but not when I’m in the middle of a task – then it becomes an interference and prevents me accomplishing what I need to in that time period.

What’s your best time-saving tip in the ICU?

Write less. It’s the digital age. Most information is already electronically collected, especially in an ICU. Duplicating it by transcribing it is a waste of time.

ICU Charting: Macros or no macros?

Macros – without doubt.

What’s the best advice you’ve ever received about work, life, or being efficient?

Spend time doing what you enjoy. Work hard and efficiently to free up as much of this time as you can.

Is there anything else you’d like to add that might be interesting to readers?

I repeatedly get asked how I put together the weekly Critical Care Reviews Newsletter, which is a journal watch resource. I receive journal-emailed table of contents and e-published, ahead-of-print notifications, plus recurring database searches for specific topics. In addition, I manually check certain journals and use Twitter for other notifications. Every evening I scan what’s left in my inbox, picking out the relevant articles, which I add to the website. At the weekend, I combine these articles into the newsletter, based on a template saved on my site, so I’m not starting from scratch each time.

Who would you love for us to track down to answer these same questions?

  1. Chris Nickson
  2. Oli Flower
  3. Scott Weingart

Author information

Michelle Lin, MD

ALiEM Editor-in-Chief

Editorial Board Member, Annals of Emergency Medicine

UCSF Academy Endowed Chair for EM Education

UCSF Associate Professor of Emergency Medicine

San Francisco General Hospital

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ALiEM Bookclub: A History of Present Illness

louise-aronson-book-cover“Late that afternoon, Quentin jogged along the Crissy Field promenade without paying much attention to the dogs frolicking on the beach or the windsurfers leaning low on their boards off Fort Point. Since Ralph was on call and not coming home, he reheated leftover spaghetti for his dinner and curled up on their bed with a textbook to study the surgical management of hip fractures. He would have liked to read about the nonsurgical management of hip fractures as well or, more important, about how to approach patients who can’t talk, or what to do when you’ve made an inexcusable mistake, but his book didn’t have chapters on those topics.”

- A History of Present Illness [1], Louise Aronson

Clinical Relevance

One of the earliest and most essential skills we learn during our medical training is how to properly obtain a patient history, best known as the HPI (History of the Present Illness). We are taught a systematic approach beginning with open-ended questions and leading to more specific questions relevant to the patient’s complaint. We are advised to build rapport with our patients, and to probe them when needed. The patient’s responses are then condensed into a concise format and medical language, which is then used to guide our clinical reasoning and decision-making. With time we become comfortable gathering and reporting HPI’s.

Yet, it is the stories we acquire beyond what is documented in our charts that we most remember. These are stories from every day interactions and experiences, stories of our patients and their families, of our own struggles and triumphs. By the end of our training, many of us feel we have enough stories to write a book!

Brief Synopsis

A History of the Present Illness is an incredible collection of sixteen beautifully crafted stories, intended to immerse the reader into the lives of patients and physicians. Through a diverse line-up of characters, Dr. Louise Aronson (@LouiseAronson) delves deep into the heart of medicine. Among these stories, we meet an immigrant man coping with end-of-life decisions for his dying wife; a female medical student finding her way in medicine despite many distractions; a young veteran with debilitating injuries but a strong will to live. Through the characters and emotionally wrought stories, Aronson makes a compelling argument for the value of narratives in medicine. Medicine is rich in stories. How we acknowledge and make meaning of these stories matters for our patients and our profession. As the reader, we are drawn to reflect on our own experiences in the health field, both in and outside the hospital walls, and share our stories.

***We are very fortunate to have the author, Dr. Louise Aronson, join us in our discussion.***

Narrative Medicine

Central to narrative medicine is the ability to absorb, reflect, interpret, and act on our own experiences and the stories of others. Narrative medicine includes developing skills in reading literature, and reflective writing. In the article, Narrative Medicine: A Model of Empathy, Reflection, Profession, and Trust, Dr. Charon summarizes “with narrative competence, physicians can reach and join their patients in illness, recognize their own personal journeys through medicine, acknowledge kinship with and duties toward other health care professionals, and inaugurate consequential discourse with the public about health care [2].” Many medical schools recognize the benefits of the narrative model and have incorporated such courses into their curriculum. In addition, literary groups and book clubs also provide a platform to interpret stories and discuss the human aspects of medicine.

Book Club Question

  1. Historically, there has been a separation between science and the arts. Incorporating humanities into medical training is now gaining popularity. What are your thoughts on this? Could reading fiction make us better physicians?
  2. At the end of the book, Dr. Aronson talks about her experience writing medical stories. What is the role of narratives in medical education? Do you think it is important for physicians to achieve narrative competency? Should reflective writing be a mandatory part of the medical training experience?
  3. In the book, there are several stories that disclose a medical student’s or resident’s feelings of inadequacy, fear, and hopelessness. What factors in the medical culture contribute to this phenomenon? Have you had similar experiences during your training? How do you think we can we improve the current experience?
  4. The book is filled with stories. Which story most resonated with you and why?

HOW TO JOIN IN THE DISCUSSION

There are two main way to join our ALiEM Book club discussion this month:

  • You can comment directly below in the comment section.
  • Tweet us directly at @ALiEMBook, use hashtag #ALiEMbook.
  • Don’t forget to tag your questions/responses Q1, Q2,Q3, and Q4.
  • You can write us a few words in the comment section below.

References

  1. Aronson L. A History of the Present Illness. Bloomsbury Publishing, 2013. [Amazon]
  2. Charon R. The patient-physician relationship. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA. 2001 Oct 17;286(15):1897-902. PMID: 11597295.

* Disclaimer: We have no affiliations financial or otherwise with the authors, the books, or Amazon

Author information

Jordana Haber, MD

Jordana Haber, MD

Medical Education Fellow

Department of Emergency Medicine

Maimonides Medical Center

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Vomiting in Kids After Head Trauma: To CT or Not to CT?

figure_sick_by_toilet_12153A 6-year-old male is brought to the emergency department (ED) after falling from the monkey bars at a local playground. Physical examination reveals no scalp hematoma, and the child appears alert and well oriented. You decide to observe him over the next 30 minutes hours to determine if he develops any disconcerting symptoms. After 15 minutes of observation within the ED the patient has an episode of vomiting witnessed by the nurses. The patient’s mother wants to know if this means he has failed his observation period and needs to receive a head CT. Your answer?

Background

EDs frequently evaluate children with blunt head trauma accounting for more than 450,000 annual ED visits. Due to increased awareness of radiation risks extrapolated from population based studies, particularly to the pediatric cohort, a great deal of attention has been given to decision instruments designed to reduce the rates of CT scanning in children. The most widely received and utilized rule, the PECARN rule [1], allows one to clinically classify risk based upon distinct and measurable clinical parameters. The instrument functions as a whole, and each branch point is reliant upon the interconnected network of variables that form the rule as derived. Since its derivation, however, questions have arisen regarding the individual variables most commonly encountered in clinical practice, such as vomiting. So Dayan et al from the PECARN research group looked to determine if the isolated variable of vomiting independently predicted traumatic brain injury (TBI) in children.

Article Citation

Dayan PS, Holmes JF, Atabaki S, et al; Traumatic Brain Injury Study Group of the Pediatric Emergency Care Applied Research Network (PECARN). Association of traumatic brain injuries with vomiting in children with blunt head trauma. Ann Emerg Med. 2014 Jun;63(6):657-65. PMID: 24559605.

Study Objectives

Determine the association between children presenting with vomiting and traumatic brain injury with blunt head trauma

Study Methods

  • Secondary analysis of prospective observational cohort
  • Patients
  • Exclusion criteria
    • Ground-level falls
    • Running into stationary objects
    • Penetrating head trauma
    • Preexisting neurological disease
    • Syncope/seizure
    • Bleeding disorders
    • VP shunts
  • Isolated vomiting was defined using the “extensive definition” rather than the PECARN definition (from Table 1 in Dayan et al)

Table1 Isolated Vomiting

  • Outcome measures
    • Any TBI on CT
    • Clinically important TBI (ciTBI)
      • Death, neurosurgical procedure, intubation for 24 hours, hospitalization for 2 or more nights

Results

  • 5,392 patients included in the final analysis
  • 4,577 (84.9%) with non-isolated vomiting
    • Had at least 1 other symptom of head trauma based on the extensive definition
  • 815 (15.1%) with isolated vomiting, as defined by the “extensive” definition (Table 1 above)
 
Isolated vomiting
Non-isolated vomiting
Clinically important TBI2/815 (0.2%; 95% CI 0-0.9%)114/4,577 (2.5%; 95% CI 2.1-3.0%)
TBI on CT5/298 (2.5%; 95% CI 0.5-3.9%)211/3,284 (6.4%; 95% CI 5.6-7.3%)
  • Note:  The different denominators for “TBI on CT” were due to not all included patients in the final analysis actually receiving a CT.
  • Note: There was no association found between vomiting and specific clinical variables (i.e. LOC) to aid prediction.

Analysis

Though this study is severely limited by its post-hoc methodology and rather disparate definition of ciTBI, it confirms what is standard practice across EDs — that is obtaining a head CT for any evidence of vomiting in blunt head trauma. Isolated vomiting as a symptom is instinctually more disconcerting than many other symptoms as providers colloquially associate its presence with an artificially high risk assessment of poor outcomes. However, this study finds that isolated vomiting (extensively defined) had an extraordinarily low risk of association with clinically relevant brain injury.

In the case of isolated vomiting, the benefit is unclear as the cohort had a total 0.2% risk of ciTBI, which is well below a reasonable testing threshold to recommend routing CT screening. Balance this with the most recent retrospective cohort study [2] assessing leukemia and brain tumor risk from pediatric head CT, which estimates that one case of leukemia and one brain tumor will be caused by every 10,000 children CT-scanned. While this is an extraordinarily low malignancy risk, it needs to be counterbalanced by the purported benefit of CT in the appropriate clinical presentation should such a benefit exist.

Even with non-isolated vomiting, the aggregate risk is low enough to recommend against the routine and wonton scanning of children presenting in this fashion without alternative considerations. What seems clear from this and many previous studies is that observation remains key for true risk assessment and clinical stratification of potential disease. An observation period in the ED can serve to reduce one’s pre-test probability for TBI well below the already low disease thresholds established within this study. This would save a great many patients from an unnecessary CT and help identify those who will most benefit from the diagnostic capabilities of CT.

Take Home Points

  1. Isolated vomiting has an extraordinarily low risk of ciTBI.
  2. Non-isolated vomiting confers a higher risk, but the risk should be counterbalanced by the risk of CT in the pediatric cohort.
  3. ED observation periods may aid in further risk stratification and safely reduce CTs in children.

References

  1. Kuppermann N, Holmes JF, Dayan PS, et al; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70. Erratum in: Lancet. 2014 Jan 25;383(9914):308. PMID: 19758692.
  2. Pearce MS, Salotti JA, Little MP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012 Aug 4;380(9840):499-505. PMID: 22681860

Author information

William Paolo, MD

William Paolo, MD

Residency Program Director

Assistant Professor of Emergency Medicine

SUNY-Upstate Medical Center

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