To scan or not to scan - my thoughts

If you recall from my previous post we were considering when to get a head CT on a pediatric patient with a closed head injury, and specifically how to approach this with the family. In general I find that its best to be honest and discuss the criteria outlined in the Kuppermann article. Even if there is a parental expectation of a getting a head CT even before you enter the room, I've found that most parents understand where your coming form when you approach things in a straightforward and honest manner. They just want what's best for their kid - scan or not after all.

But what about those parents that still demand a scan for their child who is making shadow puppets with the otoscope light? First, it's important to address their concerns honestly and without pretension. Find out what they are worried about. Perhaps they had a family member who died in a car crash. Or just had an experience where "the doctors missed something." It's also important to remember that we aren't perfect diagnostic machines. Parents do know their children best. And on the flip side, if a situation seems fishy, especially in cases of suspected non accidental trauma, go ahead and get the scan.

The bottom line is that you should be familiar with how to explain the current evidence to your patients, and to openly acknowledge the risks, benefits, and parental concerns. Even with zero of the predictors for clinically important traumatic brain injury, there is still a 0.5% chance that the kid has a head bleed - even if they look perfect. Every parent - including this one - views their kid as one in a million.

To scan or not to scan - that is not the (only) question

Inspired by the cadre of closed head injuries that I saw in a recent shift I figured I'd launch phase 2.0 of The PEMTweets website with a discussion about how we manage closed head injuries in children. The issue I'll be addressing here is not one of when to scan or not to scan - that is an important decision that is now well supported by existing literature. Instead, allow me to focus on how we communicate our decision to an anxious family. 


So, if you haven't already done so , go ahead and read the seminal Lancet 2009 article.
Kuppermann - Lancet, 2009


OK, welcome back... I ended up seeing three patients, all of whom presented by smacking their heads on hard surfaces. I've changed their names and ages to protect the innocent, and to avoid the wrath of Hungry Hungry HIPAA. 

1. The first patient was a school aged male whose bike failed him, and whose helmet was hanging in his garage. He ended up introducing his occiput to the pavement, though his recollection of this event was foggy at best. His sensorium was mired in the same fog.
   
2. The second was an infant, who despite her mother's best efforts, wriggled free from her arms and fell to the concrete below. The baby cried immediately, and aside from the large hematoma on her forehead, looked great.
   
3. Sensing a theme, you might wager that the third cranium contacted concrete in a concussive cacophony (sorry about the alliteration). It did, but 2 days ago. A visit to an urgent care, and a 'medical' neighbor later - had filled the family with enough information to seek care at my ED as they wondered whether or not their robust toddler needed a head CT.

There is a delicate balance between managing the anxieties and expectations of a parent, when they are (justly so) legitimately worried about their child's well-being. Perhaps they are a medical professional themselves, and armed with just enough (mis)information to make them worry more than they should. Or maybe, they consulted Dr. Google, or worse, Dr. facebook in that back alley clinic that would make Dr. Nick Riviera of the Simpson's blush.


Go ahead and think for a moment about whether or not you would order a head CT on each patient (I know you are thinking about the decision to scan in each,  as your natural medicine brains will not allow you to avoid pursuing a diagnoses). But, hopefully this post will instead stimulate you to think about another very important question. Namely, how do you summarize the literature for an anxious, perhaps tearful family, and how do you communicate your recommendations to them, given the evidence that suggests when to scan, in the face of mounting concerns about the exposure to ionizing radiation.


Check out the next post where I'll share my thoughts. until then I'm interested in seeing what all of you are thinking.

Video laryngoscopy with the GlideScope

Check out this video detailing the use of the GlideScope for endotracheal intubation

Video laryngoscopy with the Stroz C-MAC

Here is a video detailing use of the Storz C-MAC system for video laryngoscopy

Final Leaderboard Update

Thanks to all who participated! As announced at today's Noon Conference, the winner of the 2012 #PEMTwitterTriviaContest was...


@Bedingaj



Coming in at 2nd place we found
@paulbunchmd


Followed by the 3rd place finisher
@MarlinaLovett

Introduction to Video Laryngoscopy

Check out this video as a follow up to last week's lecture on RSI and video laryngoscopy by Gary Geis.

Spinal cord injury syndromes

Central cord syndrome

Incomplete spinal cord injury

Weakness in the arms with relative sparing of the legs with variable sensory loss

Ischemia, hemorrhage, or necrosis involving the central portions of the spinal cord

May be seen in recovery from spinal shock due to prolonged swelling around or near the vertebrae, causing pressure on the cord. Can be transient or permanent.

Anterior cord syndrome

Associated with flexion type injuries to the cervical spine

Damage to the anterior portion of the spinal cord and/or anterior spinal artery

Below the level of injury motor function, pain sensation, and temperature sensation are lost

Touch, position and vibration are intact

Posterior cord syndrome

Posterior portion of the spinal cord and/or posterior spinal artery

Loss of proprioception and epicritic sensation (e.g. stereognosis, graphesthesia) below the level of injury

Motor, pain, and sensitivity to light touch are intact

Brown-Séquard syndrome

Hemisectioned or lateral injury side (penetrating trauma)

Ipsilateral side loss of motor function, proprioception, vibration, and light touch

Contralateral side loss of pain, temperature, and crude touch sensations

NEXUS and Canadian C-spine rule: When to get films

Think about what you do in the ED? Do you recognize how following studies have impacted your practice?


National Emergency X-Radiography Utilization Study
Multicenter, prospective, observational study of patients with blunt trauma for whom cervical spine X-rays were obtained.


Get C-spine films if:

• Patients with abnormal neurologic examination
• Distracting or painful injury (like a femur fracture)
• Depressed or altered mental status
• Intoxication
• Midline cervical tenderness should get an X-Ray

http://www.nejm.org/doi/full/10.1056/NEJM200007133430203


Canadian C-spine rule
A prospective cohort study in Canada evaluating patients with head or neck trrauma.


Radiography in high risk factors

• Dangerous mechanism
• Paresthesias

Assess range of motion in low-risk factors. If none of the following are present and the patient can actively rotate 45 degrees to left and right, then C-spine films may not be needed.

• Simple rear-end MVC
• Sitting position in the ED
• Ambulatory at any time since injury
• Delayed onset neck pain
• Absence of midline C-spine tenderness

http://jama.jamanetwork.com/article.aspx?volume=286&issue=15&page=1841

Pop! goes the appendix

Perforation is more likely in younger kids because:
1. More thin walled appendix, predisposing to early perforation
2. Younger children can’t communicate as well, resulting in prolonged symptoms before diagnosis
3. The level of suspicion for appendicitis is lower in younger age groups

Pro-Tip: In addition, appendicitis can progress to peritonitis quicker in infants, because they have a less well developed omentum, and thus cannot contain infection as well.

Pediatric Appendicitis Score

Pediatric Appendicitis Score

(1 point) anorexia

(1 point) fever

(1 point) nausea/vomiting

(1 point) migration of pain

(2 points) pain with cough, percussion, or hopping

(2 points) RLQ tenderness

(1 point) Leukocytosis (WBC > 10,000)

(1 point) Left shift (ANC >6750)

• 10 point scale incorporating history, physical and lab components
• Initial study (Samuels, 2002) with N = 1170
• Prospective cohort age 4-15 with abdominal pain suggestive of appendicitis
• Cutoff of >=6 provides 1.00 sensitivity and 0.92 specificity
• Logistic regression to determine best fit of diagnostic variables for sum of true-positive and true-negative results (total joint probability for a single cutoff)

• Validation studies have shown better performance at the ends of the spectrum (using 2 cutoffs)
• Validated prospectively and retrospectivelyIn ages > 1
• Using various combinations of cutpoints
• High risk scores (> 7) had a specificity of 95-98%
• Low risk scores (<3) had a negative predictive value of 98%
• Moderate risk scores indicated the need for further imaging
• Use of the PAS would have decreased the need for imaging