Laryngeal Fracture

Laryngeal Fracture and TraumaFew things are more synonymous with pediatric emergency care than “throat pain” and “trauma.” If you are seeing children in the ED right now, I’m sure there is one complaining of sore throat and another has had a recent traumatic injury. We’ve addressed many topics that cause throat pain in children (ex, Strep Pharyngitis, PTA, RPA, Neck Mass, and Lemierre’s) and we have covered numerous traumatic conditions (ex, Thoracic, Abdominal, and Major Head Trauma), but what happens when one patient complains of both issues? Could it be a Cervical Spine Injury or Penetrating Neck Trauma? Perhaps, but let us not overlook the traumatic blow to the anterior neck (the hip kids today talk a lot about “throat punching”… so let’s be hip too). Let’s take a minute to review Laryngeal Injury and Fracture:

 

Laryngeal Injury: Basics

  • Incidence of laryngotracheal injury in children is rare. [Waseem, 2009]
    • When it occurs, it is most often in the context of severe, multi-organ trauma. [Sidell, 2011]
    • Overall mortality rate of ~8-9% [Sidell, 2011]
    • Typically seen in older children. No laryngeal injuries found in children < 2 years of age. [Sidell, 2011]
  • More often associated with blunt force trauma. (~83%) [Sidell, 2011]
    • MVCs are the most common cause.
      • Impact of the anterior neck on dashboard or front seat.
      • Larynx is compressed between that object and the cervical spine.
      • Rapid deceleration injuries can also cause shearing of the airway.
    • Direct impact from fall or “clothesline” event onto an object also seen.
      • Bicycle handlebars are described in the literature as a cause.
      • Being kicked by a horse (horse hoof vs neck – not good) [Kadish, 1994]
      • Strangulation
    • Compressive forces can lead to:
      • Laryngeal fracture (fracture of any of the laryngeal cartilages)
      • Tracheal transection
      • Damage to the recurrent laryngeal nerve

 

Laryngeal Injury: Age & Anatomy Matters

  • The larynx of the young child is more protected from trauma than the adult larynx.
    • It is more cephalad, residing at the level of C4.
    • The position allows for the mandible to be overlying a larger portion of the larynx.
  • The larynx of the young child is more elastic and pliable.
    • More mobile
    • The laryngeal cartilage is the last to ossify.
      • This can lead to the larynx “splaying” open rather than fracturing. [Sidell, 2011]
      • This can be protective, but also can increase risk for avulsion of vocal folds.
  • There is greater risk for soft tissue injuries though. [Shire, 2011; Sidell, 2011]
    • Submucosal tissues are less fibrous and loosely attached to the larynx.
    • Predisposes to edema or post-traumatic fluid collection.
    • May be involved in delayed presentation of respiratory distress.

 

Laryngeal Injury: Presentation

  • Presentation can be subtle or difficult to discern initially. [Shire, 2011; Sidell, 2011; Waseem, 2009]
    • Polytrauma patient may be too injured to convey symptoms suggestive of laryngeal fracture or trauma.
    • Well appearing patients may have minimal symptoms / asymptomatic at first.
    • Be alert for dysfunction of any of the 3 primary functions of the larynx: [Sidell, 2011]
      • Airway
      • Swallowing
      • Speech
  • Red Flags for Laryngeal Fracture or Injury [Sidell, 2011; Waseem, 2009]
    • Hoarseness of voice (hoarse voice after horse hoof to neck?… that could be bad).
    • Palpable crepitance
    • Dysphagia
    • Dysphonia
    • Hemoptysis
    • Stridor
    • Respiratory Distress
  • Be leery of the the patient who has increasing pain with coughing or swallowing as this may indicate a hyoid bone fracture. [Waseem, 2009]

 

Laryngeal Injury: Management

  • The critically ill/injured child needs to have rapid assessment and management of the airway.
    • Bag ventilations need to be done carefully… as you may worsen subQ emphysema. [Shire, 2011]
    • INTUBATE CAREFULLY, but oral intubation can be done successfully in these patients. [Shire, 2011; Kadish, 1994]
  • In clinically stable patient in whom you suspect laryngeal fracture or injury [Waseem, 2009]
    • Flexible fiberoptic laryngoscopy can help visualize possible injuries while remaining at bedside.
    • CT of neck is an option, but only if patient stable enough to leave department.
      • CT is most useful for defining fluid collections or fractures. [Sidell, 2011]
      • CT should not be done if that patient has obvious tracheal injury in need of surgical repair. [Shires, 2011]
      • May want to include CT of Cervical Spine, Soft Tissues, and Chest.
        • Remember that poly-trauma is most common.
        • Cervical spine injuries are often concomitant. [Kadish, 1994]
  • There is wide variation in the management by subspecialists. [Sidell, 2011; Shire, 2011; Waseem, 2009]
    • Patients with minor or non displaced fractures are often managed conservatively. [Sidell, 2011]
      • Close observation
      • Steroids
      • Humidified oxygen
    • Patients with more significant injuries require endoscopic evaluation.
      • Newer endoscopic techniques can also allow for more complex repairs.
      • Stenting may be used.
    • Tracheostomy may still need to be performed to stabilize pediatric patients with laryngeal trauma. [Sidell, 2011]
    • Therapeutic strategies should be tailored for the individual. [Sidell, 2011]

 

Moral of the Morsel

  • While laryngeal injury in kids is rare, it can be deadly!
  • Presentation can be subtle and delayed!
  • Respect any derangement in Speech, Swallowing, or Airway after an injury to the anterior neck.

 

References

Sidell D1, Mendelsohn AH, Shapiro NL, St John M. Management and outcomes of laryngeal injuries in the pediatric population. Ann Otol Rhinol Laryngol. 2011 Dec;120(12):787-95. PMID: 22279950. [PubMed] [Read by QxMD]

Shires CB1, Preston T, Thompson J. Pediatric laryngeal trauma: a case series at a tertiary children’s hospital. Int J Pediatr Otorhinolaryngol. 2011 Mar;75(3):401-8. PMID: 21242005. [PubMed] [Read by QxMD]

Waseem M1, Kane MR. An uncommon cause of throat pain. Pediatr Emerg Care. 2009 Jan;25(1):35-6. PMID: 19148011. [PubMed] [Read by QxMD]

Merritt RM1, Bent JP, Porubsky ES. Acute laryngeal trauma in the pediatric patient. Ann Otol Rhinol Laryngol. 1998 Feb;107(2):104-6. PMID: 9486903. [PubMed] [Read by QxMD]

Kadish H1, Schunk J, Woodward GA. Blunt pediatric laryngotracheal trauma: case reports and review of the literature. Am J Emerg Med. 1994 Mar;12(2):207-11. PMID: 8161397. [PubMed] [Read by QxMD]

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B-Type Natriuretic Peptide (BNP) use in Children

B-Type Natriuretic Peptide (BNP) use in ChildrenWe doctors love to order tests, often only to confirm things we already know. Did that lactate level for the child in SHOCK help your decision to start vasopressors? Better yet, did that WBC count really help us determine whether the child with fever has a bacterial infection? Yet, there are times when our clinical assessment can still leave us struggling to decide between two significant entities: like respiratory distress due to heart failure or pulmonary disease. In adults, we often us the B-Type Natriuretic Peptide (BNP) to help us distinguish between these two issues, but can we use the BNP in children? Let us review the BNP use in children:

 

BNP: Basics

  • B-Type Natriuretic Peptide (BNP): [Neves, 2016]
    • Is derived from proBNP which is cleaved into biologically inactive NT-proBNP and proBNP (typically referred to as BNP), which is biologically active.
    • Has a half life of 15-20 min (versus NT-proBNP with half life of 1-2 hours)
    • Testing results vary between different immunoassay methods.
  • The active segment of BNP: [Neves, 2016]
    • Has natriureticvasodilatory, and diuretic effects.
    • Counteracts the renin-angiotensin-aldosterone and sympathetic nervous systems.
  • BNP is released from ventricular myocardium in response to wall stress due conditions that lead to: [Neves, 2016]
    • Increased Preload
    • Increased Afterload
    • Decreased Systolic Ventricular Function
    • Decreased Diastolic Ventricular Function
  • While we often think of BNP as being related to heart failure, it can be elevated for a variety of reasons, including:
    • Liver failure
    • Renal impairment (although, BNP can still serve as a marker of heart strain in these patients) [Rinat, 2012]
    • Hemodynamically significant pulmonary emboli
    • Cor pulmonale
    • Inflammatory diseases

 

BNP: Age Matters

BNP / NT-proBNP levels are influenced by the patient’s age (come on people, it’s pediatrics… of course the age matters)

  • In the ED, if there is clinical suspicion for cardiovascular disease, the current described discriminatory levels are: [Cantinotti, 2014; Law, 2009; Maher, 2008]
    • For 1st week of life – cutoff of 170 pg/mL (Sen- 94%; Spec- 73%)
    • Older infants and children (up to 19 years) – cutoff of 41 pg/mL (Sen- 87%; Spec- 70%)
    • Below the discriminatory level, the presentation is not likely related to cardiovascular etiology (thus, more likely related to something like Bronchiolitis). [Maher, 2008]
  • Levels are most elevated in the first 3-4 days of life: [Neves, 2016; Cantinotti, 2014; Law, 2009; Maher, 2008]
    • Potentially to help with natriuresis and reduction of pulmonary vascular resistance.
    • Additionally, kidneys are more immature and after load increases.
  • Levels fall throughout first month of life. [Neves, 2016; Cantinotti, 2014]
  • From 1 month of age to ~12 years of age, BNP levels remain relatively stable in healthy individuals. [Neves, 2016; Cantinotti, 2014]
  • After puberty, levels can increase toward adult levels and are higher in females than males. [Neves, 2016]

 

BNP: Uses in Children

Diagnosis of newly developed heart failure in children is very challenging as it often initially presents with subtle and non-specific findings.

  • BNP / NT-proBNP levels, in the clinical setting of suspicion for possible heart failure, have been shown to be valuable.
    • Improves the diagnostic accuracy in the evaluation of heart disease in children. [Neves, 2016; Cantinotti, 2014; Maher, 2008]
    • Increase the accuracy of neonatal screening for Congenital Heart Disease. [Neves, 2016; Cantinotti, 2014]
  • BNP / NT-proBNP levels can also be used to evaluate patients with known heart failure and monitor the effectiveness of therapies and need for surgery. [Neves, 2016; Cantinotti, 2015; Cantinotti, 2014; Auerbach, 2010]
  • BNP levels need to be assessed based on specific commercial assay (cannot compare different assays’ levels). NT-proBNP measurements are not affected by different assays though. [Cantinotti, 2014]
  • NT-proBNP might be an adjunctive marker for hyper-acute phase of Kawasaki Disease. [Kwon, 2016]

 

Moral of the Morsel

  • Are you sure it’s bronchiolitis? Is that liver enlarged? Clinical concern for CHF? Check a BNP.
  • Know that the BNP levels need to be assessed based on the patient’s age. Don’t use the adult cutoffs.

 

References

Amdani SM1, Mian MUM2, Thomas RL3, Ross RD4. NT-pro BNP-A marker for worsening respiratory status and mortality in infants and young children with pulmonary hypertension. Congenit Heart Dis. 2018 Mar 25. PMID: 29575641. [PubMed] [Read by QxMD]

Neves AL1, Henriques-Coelho T, Leite-Moreira A, Areias JC. The Utility of Brain Natriuretic Peptide in Pediatric Cardiology: A Review. Pediatr Crit Care Med. 2016 Nov;17(11):e529-e538. PMID: 27749513. [PubMed] [Read by QxMD]

Kwon H1, Lee JH2, Jung JY1, Kwak YH3,4, Kim DK2, Jung JH5, Chang I2, Kim K1. N-terminal pro-brain natriuretic peptide can be an adjunctive diagnostic marker of hyper-acute phase of Kawasaki disease. Eur J Pediatr. 2016 Dec;175(12):1997-2003. PMID: 27798729. [PubMed] [Read by QxMD]

Cantinotti M, Giordano R, Scalese M, Molinaro S, Della Pina F, Storti S, Arcieri L, Murzi B, Marotta M, Pak V, Poli V, Iervasi G, Kutty S, Clerico A. Prognostic role of BNP in children undergoing surgery for congenital heart disease: analysis of prediction models incorporating standard risk factors. Clin Chem Lab Med. 2015 Oct;53(11):1839-46. PMID: 25901715. [PubMed] [Read by QxMD]

Singhal N1, Saha A1. Bedside biomarkers in pediatric cardio renal injuries in emergency. Int J Crit Illn Inj Sci. 2014 Jul;4(3):238-46. PMID: 25337487. [PubMed] [Read by QxMD]

Cantinotti M1, Law Y, Vittorini S, Crocetti M, Marco M, Murzi B, Clerico A. The potential and limitations of plasma BNP measurement in the diagnosis, prognosis, and management of children with heart failure due to congenital cardiac disease: an update. Heart Fail Rev. 2014 Nov;19(6):727-42. PMID: 24473828. [PubMed] [Read by QxMD]

Rinat C1, Becker-Cohen R, Nir A, Feinstein S, Algur N, Ben-Shalom E, Farber B, Frishberg Y. B-type natriuretic peptides are reliable markers of cardiac strain in CKD pediatric patients. Pediatr Nephrol. 2012 Apr;27(4):617-25. PMID: 22038201. [PubMed] [Read by QxMD]

May LJ1, Patton DJ, Fruitman DS. The evolving approach to paediatric myocarditis: a review of the current literature. Cardiol Young. 2011 Jun;21(3):241-51. PMID: 21272427. [PubMed] [Read by QxMD]

Auerbach SR1, Richmond ME, Lamour JM, Blume ED, Addonizio LJ, Shaddy RE, Mahony L, Pahl E, Hsu DT. BNP levels predict outcome in pediatric heart failure patients: post hoc analysis of the Pediatric Carvedilol Trial. Circ Heart Fail. 2010 Sep;3(5):606-11. PMID: 20573993. [PubMed] [Read by QxMD]

Law YM1, Hoyer AW, Reller MD, Silberbach M. Accuracy of plasma B-type natriuretic peptide to diagnose significant cardiovascular disease in children: the Better Not Pout Children! Study. J Am Coll Cardiol. 2009 Oct 6;54(15):1467-75. PMID: 19796740. [PubMed] [Read by QxMD]

Maher KO1, Reed H, Cuadrado A, Simsic J, Mahle WT, Deguzman M, Leong T, Bandyopadhyay S. B-type natriuretic peptide in the emergency diagnosis of critical heart disease in children. Pediatrics. 2008 Jun;121(6):e1484-8. PMID: 18519452. [PubMed] [Read by QxMD]

Geiger M1, Harake D, Halnon N, Alejos JC, Levi DS. Screening for rejection in symptomatic pediatric heart transplant recipients: the sensitivity of BNP. Pediatr Transplant. 2008 Aug;12(5):563-9. PMID: 18086251. [PubMed] [Read by QxMD]

Davis GK1, Bamforth F, Sarpal A, Dicke F, Rabi Y, Lyon ME. B-type natriuretic peptide in pediatrics. Clin Biochem. 2006 Jun;39(6):600-5. PMID: 16430880. [PubMed] [Read by QxMD]

Nir A1, Nasser N. Clinical value of NT-ProBNP and BNP in pediatric cardiology. J Card Fail. 2005 Jun;11(5 Suppl):S76-80. PMID: 15948106. [PubMed] [Read by QxMD]

The post B-Type Natriuretic Peptide (BNP) use in Children appeared first on Pediatric EM Morsels.

Renal Trauma

Renal Trauma in ChildrenSeeing blood in a child’s urine will catch a parent’s attention. We’ve discussed several causes of blood in the urine (ex, Microscopic Hematuria, Sickle Cell Trait, Kidney Stones, UTI), but the one that deserves special attention is Abdominal Trauma. Since accidental injuries are an important source of morbidity and mortality for children, let us take a minute to consume a morsel of info about Renal Trauma in Children:

 

Renal Trauma: Basics

  • Renal trauma is commonly encountered in pediatric trauma patients.
    • It is more common after blunt trauma; <10% are due to penetrating [Fernandez-Ibieta, 2018; Grimsby, 2014]
    • Most often in patients > 5 years of age. [Grimsby, 2014]
    • The majority of pediatric renal trauma are Low Grade. [Grimsby, 2014]
      • ~60% are Grade I or II
      • ~80% are Grade I, II, or III
  • Renal trauma rarely occurs in isolation in children. [Fernandez-Ibieta, 2018]
  • Signs suggestive of renal trauma: [Fernandez-Ibieta, 2018]
    • Hematuria
    • Flank ecchymosis
    • Penetrating injury in the region 
    • Fractured ribs (especially lower ribs)
    • Abdominal mass
    • Abdominal tenderness
  • Possible complications: [Fernandez-Ibieta, 2018]
    • Urine extravasation
      • Most common complication of Stage IV injuries
    • Urinoma
      • May be acute, or present weeks-months later.
      • Pain, fever, ileus, and palpable mass may be signs
    • Perinephric abscess
      • Rare complication
    • Secondary hemorrhage
      • Delayed bleeding occurs in 13-25% of Grade III-V injuries
      • Usually seen in first 2-3 weeks after trauma
    • AV fistula formation
      • Rare and exclusively from stab wounds
    • Pseudoaneurysm
    • Impaired renal function
    • Hypertension
      • Still controversial

 

Renal Trauma: Anatomy Matters

Compared to adults, children’s kidneys are believed to be more vulnerable to traumatic injury. [Fernandez-Ibieta, 2018]

  • Relatively larger size compared to surrounding structures
  • Compliant chest wall / rib cage is not as protective
  • More mobile kidneys / only tethered by vascular pedicle and ureter
  • Thinner protective layer of perirenal fat and Gerota’s fascia
  • Immature renal lobulations may be more prone to cleavage

 

Renal Trauma: Grading System

  • GRADE I – Contusion or non-expanding sub capsular hematoma
  • GRADE II – Non-expanding perinephric hematoma < 1cm deep
  • GRADE III – Hematoma >1cm in depth. No urine extravasation.
  • GRADE IV – Laceration involving collecting system. Segmental vein/artery injury. Renal pelvis laceration or complete ureteric pelvic disruption. “Shattered kidney
  • GRADE V – Main renal vein/artery laceration or avulsion of main artery or thrombosis of renal vein.

The American Association for the Surgery of Trauma grading system is not perfect and leads to some debate[Murphy, 2017]

  • “Shattered Kidney” seems to be the worst sounding… but is not the highest Grade).
  • Based predominantly on the adult population and may not adequately describe the pediatric population. [Murphy, 2017]
  • Some further subdivide Grade IV for this reason.
  • “Regardless of grading system, Grade IV injuries are a heterogenous population and cannot all be managed identically, especially among pediatric patients…” [Murphy, 2017]

 

Renal Trauma: Evaluation

  • There is debate over what is considered “significant hematuria” after trauma in children. [Fernandez-Ibieta, 2018]
    • Some advocate for >5 RBC/hpf seen on first aliquot of urine
    • Others, advocate for >50 RBC/hpf on first aliquot of urine
    • Renal injury, however, can be present even without hematuria.
    • The degree of hematuria does not correlate with degree of injury.
    • With this in mind, others recommend investigating any hematuria (microscopic or macroscopic) in any child with blunt abdominal trauma associated with a decelerating mechanism (MVC, Pedestrian strike, Fall from height). [Fernandez-Ibieta, 2018]
  •  Imaging Options:
    • CT with IV contrast is the current standard
      • Ideally a “Four-phase” CT with IV contrast that images the arterial, nephrographic, and pyelographic phases
      • Standard CT imaging obtains arterial phase and early cortical phase… which may miss some parenchymal injuries. [Fernandez-Ibieta, 2018]
      • CT allows for grading of injury.
      • CT findings alone do NOT determine management. [LeeVan, 2016]
    • Ultrasound 
      • U/S with Doppler can be used for those with very mild trauma and lower suspicion for significant injury.
      • U/S cannot distinguish extravasated urine from blood.
      • U/S cannot image the vascular pedicle well.
      • FAST can be done as an initial evaluation, but is insufficient to rule out injury.
        • FAST has been able to identify high grade injuries [Root, 2018]
    • Angiography or intraoperative IV Urography are also tools to image in certain cases.
    • In an alert and communicative child with minimal symptoms and no concerning physical findings who has <50 RBC/hpf, observation or screening U/S with Doppler rather than obtaining CT simply for evaluation of kidneys may be reasonable. [Fernandez-Ibieta, 2018]

 

Renal Trauma: Management

  • Overall, renal trauma in children is managed conservatively, even with higher grade injuries. [Fernandez-Ibieta, 2018; Murphy, 2017; LeeVan, 2016]
    • All Grade I-III injuries can be managed non-operatively. [Bartley, 2012]
    • There is evidence that Grade IV and V can also be managed conservatively… [LeeVan, 2016]
    • These higher grade injuries require a careful, tailored approach to each individual. [Fernandez-Ibieta, 2018]
  • Surgery is recommended for: [Fernandez-Ibieta, 2018]
    • Hemodynamically UNSTABLE patients (kinda goes without saying)
    • Those with severe intra-abdominal PENETRATING injuries.
  • Surgery or interventional radiology may be required for: [Fernandez-Ibieta, 2018]
    • Massive urinary extravasation
    • Extensive (>20%) nonviable tissue
    • Arterial injury
    • Incomplete staging

 

Moral of the Morsel

  • Don’t overlook the hematuria! Not everyone needs a CT scan though!
  • If you see hematuria… don’t just think about the kidneys… renal trauma rarely occurs in isolation.
  • Know the limitations of your imaging! You can’t see what you don’t image.

 

References

Root JM1, Abo A, Cohen J. Point-of-Care Ultrasound Evaluation of Severe Renal Trauma in an Adolescent. Pediatr Emerg Care. 2018 Apr;34(4):286-287. PMID: 29324634. [PubMed] [Read by QxMD]

Fernández-Ibieta M1. Renal Trauma in Pediatrics: A Current Review. Urology. 2018 Mar;113:171-178. PMID: 29032236. [PubMed] [Read by QxMD]

Murphy GP1, Gaither TW1, Awad MA1,2, Osterberg EC3, Baradaran N4, Copp HL1, Breyer BN5,6,7. Management of Pediatric Grade IV Renal Trauma. Curr Urol Rep. 2017 Mar;18(3):23. PMID: 28233229. [PubMed] [Read by QxMD]

LeeVan E1, Zmora O, Cazzulino F, Burke RV, Zagory J, Upperman JS. Management of pediatric blunt renal trauma: A systematic review. J Trauma Acute Care Surg. 2016 Mar;80(3):519-28. PMID: 26713980. [PubMed] [Read by QxMD]

Lee JN1, Lim JK2, Woo MJ3, Kwon SY4, Kim BS5, Kim HT6, Kim TH7, Yoo ES8, Chung SK9. Predictive factors for conservative treatment failure in grade IV pediatric blunt renal trauma. J Pediatr Urol. 2016 Apr;12(2):93. PMID: 26292911. [PubMed] [Read by QxMD]

Fuchs ME1, Anderson RE2, Myers JB2, Wallis MC2. The incidence of long-term hypertension in children after high-grade renal trauma. J Pediatr Surg. 2015 Nov;50(11):1919-21. PMID: 26078210. [PubMed] [Read by QxMD]

Grimsby GM1, Voelzke B2, Hotaling J3, Sorensen MD4, Koyle M5, Jacobs MA6. Demographics of pediatric renal trauma. J Urol. 2014 Nov;192(5):1498-502. PMID: 24907442. [PubMed] [Read by QxMD]

Bartley JM1, Santucci RA. Computed tomography findings in patients with pediatric blunt renal trauma in whom expectant (nonoperative) management failed. Urology. 2012 Dec;80(6):1338-43. PMID: 23206778. [PubMed] [Read by QxMD]

Cannon GM Jr1, Polsky EG, Smaldone MC, Gaines BA, Schneck FX, Bellinger MF, Docimo SG, Wu HY. Computerized tomography findings in pediatric renal trauma–indications for early intervention? J Urol. 2008 Apr;179(4):1529-32; discussion 1532-3. PMID: 18295268. [PubMed] [Read by QxMD]

Nguyen MM1, Das S. Pediatric renal trauma. Urology. 2002 May;59(5):762-6; discussion 766-767. PMID: 11992916. [PubMed] [Read by QxMD]

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