The pelvic X-ray in paediatric blunt trauma- Another example of “What NOT to do”?

Annals of Emergency Medicine has another great article on one of my favourite topics in medicine - What Not to Do.

The article, titled Sensitivity of Plain Pelvis Radiography in Children with Blunt Torso Trauma by Kwok, et al and from the Pediatric Emergency Care Applied Research Network (PECARN), is a prospective observational study from 20 sites of 12,044 children with blunt torso trauma.

451 (3.7%) had a pelvic fracture and/or a dislocation. Sixty-five underwent operative intervention and 21 were hypotensive on initial presentation.

Using this dataset the authors examined the utility of the pelvic x-ray. In these blunt torso trauma patients, the sensitivity of a pelvic x-ray was 78%. Another way to say it: pelvic x-rays missed about 25% of fracture dislocations identified on CT.

For the 21 (4.7%) of the hypotensive patients (7 of whom died), only 17 had pelvic x-rays, and only 14 (82%) identified the pelvic fracture or dislocation. In the entire dataset, there were 5 patients with fractures that were missed on pelvic x-ray that required operative intervention. 

Low-level falls, falls from bicycles, and falls down stairs very rarely resulted in fractures or dislocations. Patients who could ambulate never required an intervention.

The authors reported that children are at low risk for pelvic injury if they: are able to give a reliable exam (not altered, not distracted, not intoxicated), lack a lower extremity injury, lack an abnormal pelvic physical exam, and had NO other indication for a CT Abdo-Pelvis.

So we should only go by physical exam? Well it turns out that the physical exam for “pelvic instability” also performed very poorly, with 89 (0.8%) of the patients without fractures being documented as “unstable” and only 4 of 14 (36%) patients with open-book fractures being documented as “unstable.” That seems like an unacceptably low specificity or sensitivity.

I like this study for several reasons.

First, it is a great example of the value of reading the literature. You show me a person who claims they’ve treated 65 significant paediatric pelvic injuries, and I’ll show you a person whose math skills or memory sucks. There are just not that many out there.  But you don’t need to treat this many to be knowledgeable. A quick read of this paper gives anyone some experience on an important condition.

Second, it supports my previous biases:

1) Patients who are sick, physiologically unstable, and difficult to evaluate patients require evaluations with high sensitivity and specificity (CT scans).

2) Patients who are well, physiologically stable, and who can be clinically evaluated can safely be evaluated with serial and tertiary exams.

Reflexively ordering insensitive and nonspecific radiology (pelvic x-rays), produces unhelpful results that don’t improve patient management and require providers to order the correct tests down the road.

My one-sentence take-homes from this data are:

1) Don’t trust the pelvic exam or the pelvic x-ray on patients who are "unstable" or difficult to evaluate. 

2) Don't waste time, cost, and radiation by getting pelvic-x-rays on “stable” patients who are getting a CT abdo-pelvis anyway.

3) Don't get pelvic x-rays on "stable" patients who are NOT getting a CT abdo-pelvis who you can then monitor and test for ambulation.

Andy

Kwok MY, Yen K, Atabaki S, Adelgais K, Garcia M, Quayle K, Kooistra J, Bonsu BK, Page K, Borgialli D, Kuppermann N, Holmes JF. Sensitivity of Plain Pelvis Radiography in Children With Blunt Torso Trauma. Ann Emerg Med. 2014 Jul 29.

 

 

Letture da ombrellone: Coagulopatia da Trauma

Il trauma rappresenta una delle principali cause di mortalità e morbilità a livello mondiale, in particolare per la popolazione giovane. Si stimano circa 1.2 milioni di decessi l’anno e molto superiori sono i pazienti ospedalizzati (circa 24 milioni) e che necessitano di cure mediche extra-ospedaliere (circa 84 milioni), con un forte impatto in termini di […]

The post Letture da ombrellone: Coagulopatia da Trauma appeared first on EM Pills.

Train with the best! PEM POC u/s fellowship @ Columbia University in NYC

Disruptive innovationsAnd last but not least it’s my great pleasure to introduce the Pediatric Emergency Ultrasound Fellowship program @ Columbia University Medical Center in NYC. Large PEM group with dedicated (& fellowship trained) pediatric POC u/s faculty – Level 1 Peds Trauma Center – could you possibly ask for more? I know… :-)

The information below was kindly provided by Dr. Ng:

New York Presbyterian Morgan Stanley Children’s Hospital, located in New York City, is now accepting applications to our Pediatric Emergency Ultrasound Fellowship.  This fellowship is hosted by the academic Pediatric Emergency Medicine division at Columbia University Medical Center.

New York Presbyterian Morgan Stanley Children’s Hospital is a Level 1 Pediatric Trauma Center that sees over 60,000 pediatric patients per year in a newly built, state-of-the-art Pediatric Emergency Department. We represent one of the largest group of pediatric emergency ultrasound specialists in the country, with 3 fellowship trained Pediatric Emergency Ultrasound faculty and a growing number of faculty in our ultrasound division.

As one of the only pediatric-focused emergency ultrasound fellowships, our mission is to provide a strong foundation in basic and cutting edge point-of-care pediatric emergency ultrasound. We provide a comprehensive hands-on scanning experience with an aim to train strong scholars and future researchers in the field of pediatric emergency ultrasound capable of running their own ultrasound programs. 

We are now accepting applications for a 1-year ultrasound fellowship position from July 2015 – June 2016.  Fellows will work clinically in our Pediatric Emergency Department as faculty overseeing pediatric emergency medicine fellows, pediatric residents, and emergency medicine residents.

*Applications, including a letter of interest, CV and three letters of recommendation, may be submitted online.

Application deadline: November 1st.

For more information please contact:

Fellowship Director, Pediatric Emergency Ultrasound: Lorraine Ng, MD, RDMS, email: lorraine.ng@gmail.com

Director of Pediatric Emergency Ultrasound: David Kessler MD, MSc, RDMS, email: dk2592@columbia.edu

Program Administrator: Conor Sheehan, email: mcs2216@columbia.edu


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SonoKids weekly literature picks – Aug 3rd, 2014

I am disastrously late this week… Mea culpa :-( Quite ambitious though – to tickle those amazing neonatal and pediatric critical care SonoSenses! While rather advanced, the idea is to stimulate the reflection and interest – cranial sonography and transcranial Dopplers.

P2share Journal Club

Furthermore, I decided to share the weekly journal club articles chosen by the SickKids SonoTeam from Toronto! They have one of the most amazing pediatric ultrasound programs in the world! Check out the last two papers and stay tuned for future info on online journal clubs offered by this brilliant group led by Jason Fischer, Charisse Kwan and Mark Tessaro!

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Pediatr Crit Care Med. 2014 Jul 28. [Epub ahead of print]

Transcranial Doppler-Based Assessment of Cerebral Autoregulation in Critically Ill Children During Diabetic Ketoacidosis Treatment.

Ma L1, Roberts JS, Pihoker C, Richards TL, Shaw DW, Marro KI, Vavilala MS.

Abstract

OBJECTIVES:

Impaired cerebral autoregulation may be associated with poor outcome in diabetic ketoacidosis. We examined change in cerebral autoregulation during diabetic ketoacidosis treatment.

DESIGN:

Prospective observational cohort study.

SETTING:

Tertiary care children’s hospital.

PATIENTS/SUBJECTS:

Children admitted to the ICU with diabetic ketoacidosis (venous pH < 7.3, glucose > 300 mg/dL, HCO3 < 15 mEq/L, and ketonuria) constituted cases, and children with type I diabetes without diabetic ketoacidosis constituted controls.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

Between 2005 and 2009, 32 cases and 50 controls were enrolled. Transcranial Doppler ultrasonography was used to measure middle cerebral artery flow velocities, and cerebral autoregulation testing was achieved via tilt-table testing. Cases underwent two and controls underwent one cerebral autoregulation test. Cerebral autoregulation was quantified by the autoregulatory index (autoregulatory index < 0.4 = impaired and autoregulatory index 0.4-1.0 = intact autoregulation). The first autoregulation test was obtained early (time 1, 12-24 hr; median [interquartile range], 8 hr [5-18 hr]) during diabetic ketoacidosis treatment, and a second autoregulation test was obtained during recovery (time 2, 36-72 hr; median [interquartile range], 46 hr [40-59 hr]) from time 0 (defined as time of insulin start). Cases had lower autoregulatory index at time 1 than time 2 (p < 0.001) as well lower autoregulatory index than control subjects (p < 0.001). Cerebral autoregulation was impaired in 40% (n = 13) of cases at time 1 and in 6% (n = 2) of cases at time 2. Five cases (17%) showed persistent impairment of cerebral autoregulation between times 1 and 2 of treatment. All control subjects had intact cerebral autoregulation.

CONCLUSIONS:

Impaired cerebral autoregulation was common early during diabetic ketoacidosis treatment. Although the majority improved during diabetic ketoacidosis treatment, 17% of subjects had impairment between 36 and 72 hours after start of insulin therapy. The observed impaired cerebral autoregulation appears specific to the diabetic ketoacidosis process in patients with type I diabetes.

PMID: 25072475 [PubMed - as supplied by publisher]

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Curr Pediatr Rev. 2014;10(1):16-27.

Cranial Ultrasound – Optimizing Utility in the NICU.

Wezel-Meijler Gv, de Vries LS1.

Abstract

Cranial ultrasonography (cUS) is a reliable tool to detect the most frequently occurring congenital and acquired brain abnormalities in full-term and preterm neonates. Appropriate equipment, including a dedicated ultrasound machine and appropriately sized transducers with special settings for cUS of the newborn brain, and ample experience of the ultrasonographist are required to obtain optimal image quality. When, in addition, supplemental acoustic windows are used whenever indicated and cUS imaging is performed from admission throughout the neonatal period, the majority of the lesions will be diagnosed with information on timing and evolution of brain injury and on ongoing brain maturation. For exact determination of site and extent of lesions, for detection of lesions that (largely or partially) remain beyond the scope of cUS and for depiction of myelination, a single, well timed MRI examination is invaluable in many high risk neonates. However, as cUS enables bedside, serial imaging it should be used as the primary brain imaging modality in high risk neonates.

PMID: 25055860 [PubMed - in process]

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Eur J Radiol. 2014 May 10. pii: S0720-048X(14)00235-6. doi: 10.1016/j.ejrad.2014.04.033. [Epub ahead of print]

Neonatal neurosonography.

Riccabona M.

Abstract

Paediatric and particularly neonatal neurosonography still remains a mainstay of imaging the neonatal brain. It can be performed at the bedside without any need for sedation or specific monitoring. There are a number of neurologic conditions that significantly influence morbidity and mortality in neonates and infants related to the brain and the spinal cord; most of them can be addressed by ultrasonography (US). However, with the introduction of first CT and then MRI, neonatal neurosonography is increasingly considered just a basic first line technique that offers only orienting information and does not deliver much relevant information. This is partially caused by inferior US performance – either by restricted availability of modern equipment or by lack of specialized expertise in performing and reading neurosonographic scans. This essay tries to highlight the value and potential of US in the neonatal brain and briefly touching also on the spinal cord imaging. The common pathologies and their US appearance as well as typical indication and applications of neurosonography are listed. The review aims at encouraging paediatric radiologists to reorient there imaging algorithms and skills towards the potential of modern neurosonography, particularly in the view of efficacy, considering growing economic pressure, and the low invasiveness as well as the good availability of US that can easily be repeated any time at the bedside.

Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

PMID: 24890085 [PubMed - as supplied by publisher]

SonoKids P2 SickKids

Am J Emerg Med. 2014 Apr 18. pii: S0735-6757(14)00267-8. doi: 10.1016/j.ajem.2014.04.023. [Epub ahead of print]

Acute pediatric stroke-what’s the hurry? A case for emergency physician-performed echocardiography.

Thom CD1, Sparks SE2.

No abstract available – though a great case report – try to look it up!

PMID: 24856752 [PubMed - as supplied by publisher]

SonoKids P2 SickKids

J Pediatr. 2014 Jul;165(1):78-84.e2. doi: 10.1016/j.jpeds.2014.02.055. Epub 2014 Apr 13.

Ultrasonography of the colon in pediatric ulcerative colitis: a prospective, blind, comparative study with colonoscopy.

Civitelli F1, Di Nardo G1, Oliva S1, Nuti F1, Ferrari F1, Dilillo A1, Viola F1, Pallotta N2, Cucchiara S1, Aloi M3.

Abstract

OBJECTIVES:

To evaluate the usefulness of colonic ultrasonography (US) in assessing the extent and activity of disease in pediatric ulcerative colitis (UC) and to compare US findings with clinical and endoscopic features.

STUDY DESIGN:

Consecutive pediatric patients (n = 60) with a diagnosis of UC and suspected disease flare-up were prospectively enrolled; of these, 50 patients were eligible for the study. All underwent clinical evaluation, bowel US with color Doppler examination and colonoscopy. Blind US was performed the day before endoscopy in all patients. The US assessed variables were bowel wall thickness >3 mm, bowel wall stratification, vascularity, presence of haustra coli, and enlarged mesenteric lymph nodes.

RESULTS:

The endoscopic extent of disease was independently confirmed in 47 patients by US that yielded a 90% concordance with endoscopy (95% CI 0.82-0.96). Multiple regression analysis showed that US measurements with an independent predictive value of severity at endoscopy were increased bowel wall thickness (P < .0008), increased vascularity (P < .002), loss of haustra (P = .031), and loss of stratification of the bowel wall (P = .021). Each variable was assigned a value of 1 if present. The US score strongly correlated with clinical (r = 0.94) and endoscopic activity (r = 0.90) of disease (P < .0001).

CONCLUSIONS:

Colonic US is a useful first line noninvasive tool to assess the extent and activity of disease in children with UC and to estimate the severity of a flare-up, prior to further invasive tests.

PMID: 24725581 [PubMed - in process]


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Prognoseabschätzung nach Reanimation

Reanimation ist eines der Kernthemen unseres notfallmedizinischen Know Hows. Für die Zuordnung der Ressourcen wichtig ist es, die Prognose von betroffenen Patienten abzuschätzen, evtl. auch weitere Maßnahmen zu limitieren. Aus diesem Grund …… finde ich eine Arbeit des letzten Jahres sehr interessant, die ich erst im Nachgang gefunden habe:

Bei Herz-Kreislaufstillstand sollte sofort defibrilliert werden. Gelegentlich wird diskutiert, zunächst eine CPR durchzuführen, um eine Defibrillation überhaupt zu ermöglichen. Diese “verzögerte Strategie” zeigt in aktuellen Studien jedoch keine Überlegenheit.

Die Wellenform von Kammerflimmern ist geeignet, um die Prognose der betroffenen Patienten abzuschätzen. In der nun vorliegenden Studie, wurde die Wellenform des Kammerflimmerns vor Defibrillation genutzt, um die Chance der Defibrillation abzuschätzen und dann gezielt eine verzögerte CPR strategie zu veranlassen (Priming the Pump). Und das Ganze randomisiert, prospektiv. Mit anderen Worten, die Analyse des Kammerflimmerns wird genutzt, ob direkt defibrilliert werden sollte oder zunächst eine CPR vor Defibrillation sinnvoll sind.

IN dieser großen Studie, die in den Rettungssystemen von New York und London durchgeführt wurde, zeigte sich leider keine Überlegenheit der Wellform-Analyse-Gruppe. Beide Gruppen (first shock vs. waveform analysis and delayed shock) zeigten ähnliche, aber doch hohe Überlebensraten (ca. 17%).

Die Schlußfolgerungen der Autoren lauten:

VF waveform analysis to selectively guide the initial management of out-of-hospital cardiac arrest patients presenting in VF did not result in improved overall survival. We demonstrated the prognostic value of waveform analysis scores as a determinant of resuscitation outcomes, and we further identified a subgroup of patients for whom guided management via waveform analysis was associated with improved waveform characteristics and for whom additional study appears warranted to understand the factors associated with this finding.