Thoracolumbar spine x-rays

Cite this article as:
Tessa Davis. Thoracolumbar spine x-rays, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17581

Read our step-by-step guide to interpreting thoracic and lumbar spine x-rays.

Thoracolumbar spine x-ray involves two views – AP and lateral.

 

  1. Check it’s an adequate view

For a lumbar spine view

  • you should be able to see L1-L5 but also the full T12 vertebral body, T11/12, and the sacrum on the AP view
  • the vertebral bodies, facet joints, and pedicles should be clearly visible on the lateral view
  • the transverse processes should also be visible (and are often obscured by gas)

For the thoracic spine view

  • make sure the whole thoracic spine is visible
  • you should be able to see the pedicles, spinous processes, and vertebral bodies
  • the ribs can cause difficulty seeing the thoracic spine on a lateral view

 

2. Know your anatomy

  • Clavicle is at T3
  • Tracheal bifurcation is T4/5
  • 12th rib is at T12
  • In the lumbar spine, the disc spaces also increase in size, although note that the L5/sacral space is narrower than the L4/L5 space

From https://www.wikiradiography.net/

3. Check the alignment

On the AP check that the vertebral bodies and spinous processes are aligned. On the lateral, check the alignment of the vertebral bodies.

 

 

4. Look for loss of vertebral height

In the thoracic spine, the vertebral bodies (and the disc spaces) should gradually increase in size as you get further down the spine.

Check all the vertebral bodies looking specifically for loss of height. This indicates a compression fracture.

 

 

 

5. Look for widened inter-spinous or inter-pedicle distance and check the processes

In the lumbar spine check that all the pedicles, spinal, and transverse processes are intact.

See below (under burst fracture) for an example of widened inter-pedicle distance and (under Chance fracture) widened spinous process process distance.

Transverse process fracture From https://www.imageinterpretation.co.uk/thoracolumbar.php

 

6. Check for translation/rotation or distraction

Translation or rotation is displacement in horizontal plane; and distraction is displacement in the vertical plane.

Translation/rotation is due to a side-to-side motion (can be left-to-right or front-to-back). It is a serious injury and always involves the posterior ligamentous complex.

Distraction is where the vertebrae are pulled apart and carries a high risk of cord injury. Often there is compression at the other side (see Chance fracture below).

 

7. Know the common types of fractures

Compression fracture

This is the most common type of fracture and is identified through loss of vertebral height (see number 4 above). It involves one column only and is a stable fracture.

 

Burst fracture

On x-ray alone 25% of burst fractures are misdiagnosed as vertebral compression fractures. A burst fracture is where there is a compression, but part of the vertebral body has been projected out anteriorly.

On AP view there will be an increased interpedicular distance in 80% of burst fractures.

On lateral view there will be reduced vertebral height and disrupted anterior alignment.

A burst fracture involves two columns and is usually considered to be unstable.

 

Chance fracture

Usually from a seatbelts injury and is commonly at L2/L3

This is a flexion-distraction injury where there is horizontal splitting of the vertebral body with ligament rupture. This is an unstable fracture and involves all three columns

Sometimes there is increased distance between the spinous processed on the lateral view (but not always).

On the AP view there can be increased distance between the spinous processes at the level of the Chance fracture.

 

Jumper’s/lover’s fracture

So-called because it’s usually from people jumping out of windows to escape the police or angry partners. This is severe axial loading leading to compression/burst fractures alongside a calcaneus fracture.

https://radiopaedia.org/articles/lovers-fracture-2?lang=us

References

Radiopaedia

Radiology Assistant

Norwich Image Interpretation Course

Radiology Masterclass

Abnormal Treatment Behaviour: Jannie Geertsema at DFTB18

Cite this article as:
Team DFTB. Abnormal Treatment Behaviour: Jannie Geertsema at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17711

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFT19, which will be held in London, UK, are now on sale from www.dftb19.com.

Jannie Geertsema is a Child and Adolescent Psychiatrist at the Queensland Children’s Hospital. In this talk he reminds us of one of the challenges that faces all doctors – who are we actually treating? Is it the child in front of us, is it their mother, is it the family dynamic?

I fought the law…

Cite this article as:
David McDonald. I fought the law…, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17508

I recently attended my forty-year post-graduation reunion – I graduated from Sydney University in September 1978. It was a cheerful night and great to see old friends.  I am still recovering from the humiliating ritual of dancing the Village People YMCA number. (I was the cowboy).

There has been a lot of awareness about medico-legal matters among junior doctors since the Bawa-Garba case. I thought I would share a retrospective view on some aspects of my personal experience interacting with the legal profession over a long career. The medico legal area is so complicated that I will not comment upon specifics other than saying that joining a Medical Defence Organisation (MDO) is essential for any practicing doctor. MDOs know stuff that you will never know.

 

Choosing a Medical Defence Organisation

Choosing a MDO that suits your needs is one of the most important decisions you will make during your career. The decision should be considered carefully as not all insurance companies are the same. I recommend a Mutual Defence Organisation (MDO) that is not necessarily a part of a large commercial insurance company.  I have remained with the same company very successfully with all the ups and downs for over forty years.  A good Mutual Defence Organisation has the commitment to care about the doctor’s personal welfare as well as the other legal matters. The good ones have experienced and sympathetic medical advisors, and you will need their emotional support as well as expertise if things get sticky.

A public hospital has its own insurance to cover claims for financial compensation made by patients against it. Legally, the employer hospital is liable for its employees, so the cover extends to resident staff. But such staff may be the subject of other, personal, types of legal situations such as HCCC complaints and coronial inquiries and whatever help the hospital may provide is discretionary. You cannot assume that the hospital will provide representation for you personally. A colleague of mine had assistance denied only a short time before an inquest where his management was a focus of attention. An MDO will provide assistance in these other legal situations.

 

How do you manage if you hear that you are being involved in a legal matter?

 This is one of the most stressful things that can occur for a doctor so be prepared in advance. Step 1 is to find a good experienced mentor that suits your personal style as early as possible in your career and before bad stuff has happened. There are differences between a supervisor and a mentor. A supervisor is appointed by the hospital administration, whereas you can choose your own mentor. Accordingly, a mentor is a better fit for your personality and aspirations. Sensible mentors recognise that being asked to mentor a junior colleague is a compliment in the Hippocratic tradition, and don’t mind helping when approached. You don’t have to propose formally.

If you do hear that you are being involved or sued, contact your MDO immediately. You will need emotional support from understanding contacts like your mentor or peer colleagues. This support may come from your partner; however non-medical partners may not understand the paradigm completely. It is difficult when you “put yourself out there” doing what you hope is the very best for your patients, usually because have a great deal of internal self-drive, and then have the whole thing turn into a mess. Also, you may reasonably wish to quarantine work stuff and home stuff, especially if you have a young family.

Friends and colleagues that have been sued often say it is the reassurance and support of their colleagues who remind them that “you really are a good doctor” that is most helpful. In addition to your mentor and colleagues, consider professional support from your organisations Employee Assistance Program. Most of all, do not personalise it excessively nor let it affect your sense of self or enjoyment of your profession. Many people that have been through the difficult journey find that they emerge with a greater sense of destiny and fulfilment and greater skill and knowledge.  It takes some effort and luck to get to that point.

If you do have to attend court get specific orientation and support from your MDO. Be prepared – you may be permitted to carry your notes into the witness stand and read from them, for example. Know what type of proceedings that you are giving evidence -is it Criminal or civil? At all times, with or without a lawyer’s help, you must tell the truth about the facts and not be evasive (e.g. if you did tell a superior about something), even if the truth may not help others.

 

How is medical conduct adjudicated?

The Bawa-Garba case showed that doctor’s performance is judged “on the facts of that specific case”. That principle was a factor in why the Bawa-Garba case judgement appeared so unreasonably harsh. Despite the sadness of the whole affair, the court took the view based on the bare facts of the case that the management of the patient was well below reasonable professional standards. Mitigation for prolonged shift length/personal situation was not a consideration.

It means that if you are in a situation where you believe that workplace practices impair your ability to practice safely, consider raising a paper trail or at least initiate a discussion that objectively states your concerns with your supervisor. Situations could include excessive clinical workload or roster lengths, systematically poor communication, unavailable supervision, or being directed to provide care or undertake a procedure that is outside your level of expertise.

 

Workplace matters

Workplace matters are another area that MDOs can be very worthwhile. There is the potential for an enormous range of conflicts or difficulties. I was once threatened with substantial legal action for defamation by another clinician following a complaint I made to a teaching hospital about the medical care that was provided to one of my patients. It was a difficult time. I was able to deter the threatened defamation action with the assistance of my MDO. My painful teaching lesson was that “You can express an opinion and relate facts about what happened but don’t be malicious, and tell the truth”.

Your MDO can assist with workplace disputes such as bullying and harassment from staff or patients, or if you are accused of that. There are processes in place for this and many other workplace scenarios of which you may not be aware. An example could be if you feel the need to withdraw from providing medical care to a patient if they are harassing you. That needs a number of carefully calibrated steps including making satisfactory to the patient alternative arrangements for care.

Medical insurance does not substitute for a professional organisation such as ASMOF or the AMA and all doctors should belong to one of these.

 

Root cause analyses

NSW Health does have a process for misadventure called Root Cause Analysis (RCA), and most Public Health Organisations have similar processes. They are supposed to look at systems rather than individuals. They have legal privilege and confidential recommendations, although the information can leak out. RCAs can be a useful means of improving patient care. Even if it is difficult I advise honest engagement with this process. RCAs are humbling and stressful. If there is senior medical staff engagement and diligent exploration of the facts, clinically useful outcomes are possible.

 

Expert certificates and reports

There are some differences between an “Expert Certificate” and an “Expert Report”. An Expert Certificate is prepared for the court by doctors involved in a case, such as for the Coroner. Any grade of doctor can be approached. Senior doctors are much more likely to be approached to write expert reports, which may seek review of a case that they did not personally manage. In both areas, sticking carefully to the facts of the case is crucial, and not being tempted to step outside your area of expertise or to conjecture. A skilful barrister can make even the most caring doctor look pretty stupid in the witness stand. In both circumstances look at them as an objective means of assisting the court, and not representing or supporting any individual. Don’t run the risk of appearing biased (or excessively sympathetic to a colleague).

 

If you are asked to provide a mandated expert certificate I would advise that is done with the assistance of your MDO. Expert reports are generally a request rather than a directive. Although agreeing to write an expert report is “doing the right thing”, it exposes the doctor to what may not be a nice experience. You need to ask what it will involve for you e.g. being subpoenaed to court, maybe having to attend joint conferences with other experts. Enquire about fees and a timeline for “when you will be paid”. I personally accept those expert report requests with my eyes wide open, and agree to cooperate if the matter is of sufficient merit, the request is put reasonably and originates from a reputable source (such as a MDO).

 

Dealing with legal profession is stressful but it is also a crucial part of our professional responsibility. An important lesson from the Bawa-Garba case is that it is essential for any doctor of any grade to be a member of a good Medical Defence Organisation. Ask your senior colleagues about their experience. Choose your MDO carefully – you could be married to them for life.

Attention Deficit Hyperactivity Disorder: David Coghill at DFTB18

Cite this article as:
Team DFTB. Attention Deficit Hyperactivity Disorder: David Coghill at DFTB18, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17604

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFT19, which will be held in London, UK, are now on sale from www.dftb19.com.

The 25th Bubble Wrap [Holiday Edition]

Cite this article as:
Leo, G. The 25th Bubble Wrap [Holiday Edition], Don't Forget the Bubbles, 2018. Available at:
https://dontforgetthebubbles.com/the-25th-bubble-wrap/

With millions upon millions of journal articles being published every year it is impossible to keep up.  Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye.

The Crying Infant: Katie Tinning at DFTB18

Cite this article as:
Team DFTB. The Crying Infant: Katie Tinning at DFTB18, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17500

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families.

Cuffed or uncuffed tubes?

Cite this article as:
Tessa Davis. Cuffed or uncuffed tubes?, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17511

The debate over uncuffed versus cuffed endotracheal tubes (ETTs) is a long-standing one. In a paper published in Pediatric Anesthesia this week, one paediatric critical care unit has published the results of their experience of introducing cuffed ETTs.

Greaney D, Russell J, Dawkins I, Healy M, A retrospective observational study of acquired subglottic stenosis using low-pressure, high-volume cuffed endotracheal tubes. Pediatric Anesthesia, 2018, DOI: 10.1111/pan.13519

 

What’s the background?

Many intensive care units use uncuffed ETTs in neonates due to concerns of cuff-related trauma and subglottic stenosis. The estimated incidence of ETT-related subglottic stenosis (SGS) ranges from 0.3-11%.

The benefits of a cuffed tube are thought to be: accurate ETCO2 monitoring, protection from aspiration, fewer tube changes due to air leaks, and continuous lung recruitment.

The concerns about cuffed tubes are that they cause increased trauma and that this trauma can lead to erosion, infection, cricoid perichondritis, and ultimately sub-glottic stenosis.

The author introduced the use of Microcuff ETTs into their unit hypothesizing that it may lead to less ulceration, chondritis, and fibrosis in the subglottic space. Microcuffs are a specific type of ETT (low-pressure, high-volume), but the smallest type is 3.0mm internal diameter which is not recommended for neonates less than 3kg.

 

Who were the patients?

This was a retrospective analysis of all patients admitted to the Paediatric Critical Care Unit in Australia over a five year period.

Patients were included if they also had a microlaryngobronchoscopy (MLB) procedure.

Patients were excluded if they were >18 years old; had congenital SGS; had previous airway surgery, or had a previous SGS diagnosis.

 

What were the outcomes?

MLB reports were reviewed to look for findings consistent with clinically significant acquired endotracheal tube-related pathology (within six months of intubation).

Demographics were analyzed including age, sex, prematurity, comorbidities, duration of ventilation, number of intubations, duration of admission.

 

What did they find?

There were 5309 PCCU admissions over the five year period, and 61% required intubation.

297 patients had an MLB.

23 children (0.68% of all intubations) had a clinically significant ETT-related pathology: 8 had acquiredsub-glottic stenosis; the other 15 had other ETT-related pathology (granulomas, ulcers, or cysts).

5 of the 8 children with sub-glottic stenosis required tracheostomies.

All those who required surgical correction of the SGS were ex-prem neonates who had received invasive ventilation in a NICU with an uncuffed tube prior to admission to PCCU.

 

What conclusions did they draw?

They demonstrated a low incidence (but high morbidity) of acquired SGS.

There were a few issues around the conclusions drawn:

  • The authors state ‘there was no single case of de novo clinically significant acquired SGS with the use of cuffed ETTs‘. I’m not sure that this is a fair conclusion, as there were 8 cases of acquired SGS. Yes, these cases all had an uncuffed tube initially in NICU, but they also had a cuffed tube in PCCU.
  • It would be good to be able to compare the rates of SGS before the introduction of Microcuff ETTs with these rates after its introduction – this would help to see whether rates have increased. It would also be helpful to look at the neonatal group in particular as this study reports the overall percentage of SGS in all patients, and then draws conclusions about its safety in neonates.

 

However, in spite of concerns around the use of cuffed tubes that exist, no study has previously shown that cuffed ETTs lead to a higher incidence of SGS than uncuffed ETTs. This is an interesting paper to open the discussion around the use of cuffed ETTs in neonates.

If you want to learn more about tiny tubes then catch this talk from Shabs Rajapaksa from DFTB18.

 

Expert Opinion – Eric Levi, Consultant Paediatric Otolaryngologist

I would love to see other data to enhance this paper: comparison with rates of SGS prior to cuffed tubes and comparison of rates of SGS in other patients who did have an uncuffed tube but did not develop SGS. Surely in the 3000 or so intubations, there would have been others who were also tubed with uncuffed tube and yet not develop any tube related pathology.

Although this is not a perfect paper, I do think the authors are onto something, and that they are adding to the body of knowledge suggesting that in their cohort, cuffed tubes are not associated with SGS.

Neonatal intubation: Shabs Rajapaksa at DFTB18

Cite this article as:
Team DFTB. Neonatal intubation: Shabs Rajapaksa at DFTB18, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17490

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFT19, which will be held in London, UK, are now on sale from www.dftb19.com.

Thinking FAST, and slow

Cite this article as:
Andrew Tagg. Thinking FAST, and slow, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17324

10-year-old Elliott is brought into your emergency department after falling off his bike. Whilst trying to escape from a gang of bullies he went off-road, left the ground and landed awkwardly. The front wheel twisted and the handlebars hit his belly. He is complaining of pain in the left upper quadrant. He has been treated with intranasal fentanyl and is haemodynamically stable. Your registrar asks if he can do a FAST exam on him.

 

Basics principles of the FAST exam

The Focused Abdominal Sonography for Trauma exam superseded diagnostic peritoneal lavage in the late 1980s as a means of determining significant intra-abdominal free fluid. The actual monicker, FAST, was first used by Royzycki et al back in the mid-90s.

The FAST exam is a rapidly performed test that looks at four specific areas – RIGHT upper quadrant, LEFT upper quadrant, subxiphoid region, and pelvis. The wielder of the probe is looking for free fluid rather than directly looking for solid organ injury.

The 4 traditional FAST views – RUQ, LUQ, subxiphoid and pelvic.

It’s important to remember that the FAST exam came about as a tool to examine haemodynamically UNSTABLE patients in order to determine who needed to go to the operating theatre or needed a critical intervention (such as pericardiocentesis).

According to Rippey and Royce, the sensitivity of FAST in adults ranges from 64-98%. But…

 

What about in kids?

CT is considered the gold standard for the examination of intra-abdominal injury in children but it is not without risk. As clinicians we are reluctant to expose kids to needless radiation and try and act within the ALARA (As Low As Reasonably Possible) principle. With an increased focus on the use of point of care ultrasound throughout paediatrics it can be tempting to translate the adult approach of using the FAST scan, in kids.

A couple of concerns have been raised regarding the use of FAST in children:

 

Not all children with abdominal injuries have free fluid

A number of studies in haemodynamically stable children have found significant solid organ injuries (liver, spleen or kidney lacerations) on CT with normal bedside ultrasound. Whilst 22% of abdominal injuries in adults are not associated with free fluid this rises to a whopping 37% in children.

A 2007 meta-analysis by Holmes et al found an 80% sensitivity for detecting intra-peritoneal fluid via sonography. When the authors only looked at the more methodologically rigorous studies the sensitivity dropped to 66%.

 

The management of solid organ injuries in the paediatric population is different

Nearly all intra-abdominal injuries in children are managed conservatively and so accurate delineation is important. Finding free fluid on sonographic assessment does not mandate them going to theatre, even in the setting of haemodynamic instability. Operative management of hepatic injuries in children has been associated with higher mortality than a conservative approach.

 

So what does this all mean?

CT scanning does have its drawbacks – it involves ionising radiation, IV contrast and is time and money intensive in comparison with the FAST scan. But if ultrasound cannot tell us what we need to know then there is no comparison. A number of studies that have shown a better correlation between CT and US do not use the FAST scan but a modified form or even complete abdominal sonography by qualified sonographers. Given that US is very much an operator-dependent imaging modality it is vital that anyone using it has been trained (and accredited) in its use.

Emergency physicians may think they are amazing at performing a focused abdominal assessment and wield the probe at every given opportunity ‘for practice’. This will skew the accuracy of the test. If the pre-test probability of a positive result is low in the first place then the number of true negatives will, of course, be higher and the accuracy of the test will appear to be higher than it actually is.

In my attempt to trawl through some of the data I have consistently come across the idea that FAST is great because it is so accurate. The only way of knowing this is to look at the studies that compare it with a CT. Just because you do not pick up an injury immediately does not mean that one is not there. For example, in the Soudack et al. paper they described three negative FAST, positive CT cases – a haemo-peritoneum, one splenic laceration, and one hepatic laceration. Because the CT did not show free fluid these did not count as false-negatives!

A positive FAST is helpful but a negative one…not so much.

 

What do I do?

What I am really interested in is the Negative Predictive Value of the test i.e. the chance that if my scan is NEGATIVE there is NO free fluid. Unfortunately, a negative scan, in isolation does not tell me that there is not a significant intra-abdominal injury. In the setting of a worrying mechanism (e.g. handlebar versus spleen) with bruising and tenderness to the left upper quadrant and a NEGATIVE fast I cannot say that the child is okay and send them home. This is the concern that I have. That the test will stop the less astute clinician from thinking.

One has to be very wary when interpreting the literature surrounding FAST scans in paediatrics. All the scan tells you is that there is no free fluid. If the patient is haemodynamically stable and there is suspicion of an intra-abdominal injury then the patient should have a CT.

Haemodynamically stable patients

In the haemodynamically stable patient with an unconcerning physical exam, good quality images on a comprehensive abdominal ultrasound and the ability to serially examine the patient then a CT may not be warranted. A comprehensive abdominal ultrasound is NOT the same as FAST.

One might think that the use of ultrasound might have other benefits but a large study by Holmes et al. in 2017 showed no alteration in the number of CT scans requested, number of patients hospitalized or requiring surgery.

 

Haemodynamically unstable patients

These patients need resuscitation, often with blood products, until they are stable enough to enter the CT scanner/IR suite. A FAST scan is likely to be positive but given that over 90% of intra-abdominal injuries in children are managed without going to theatre it is unlikely to change my management.

Whilst this is clearly not a comprehensive review, any collection of data that has such a wide range of specificity needs to be considered. I could add another 10 studies and they might tighten up my spread but in the largest trials, involving ED physicians we are just not that great.

So the bottom line, when taken in isolation, as I see it is this best case/worst case…

Thanks to Arun Ilancheran and Ross Fisher for pushing me down this rabbit hole.

 

Selected references

Ashrafi A, Heydari F, Kolahdouzan M. The Utility of Ultrasound and Laboratory Data for Predicting Intra-abdominal Injury among Children with Blunt Abdominal Trauma. International Journal of Pediatrics. 2018 Aug 1;6(8):8047-59.

Calder BW, Vogel AM, Zhang J, Mauldin PD, Huang EY, Savoie KB, Santore MT, Tsao K, Ostovar-Kermani TG, Falcone RA, Dassinger MS. Focused assessment with sonography for trauma in children after blunt abdominal trauma: A multi-institutional analysis. Journal of Trauma and Acute Care Surgery. 2017 Aug 1;83(2):218-24.

Coley BD, Mutabagani KH, Martin LC, Zumberge N, Cooney DR, Caniano DA, Besner GE, Groner JI, Shiels WE. Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma. Journal of Trauma and Acute Care Surgery. 2000 May 1;48(5):902-6.

Emery KH, McAneney CM, Racadio JM, Johnson ND, Evora DK, Garcia VF. Absent peritoneal fluid on screening trauma ultrasonography in children: a prospective comparison with computed tomography. Journal of pediatric surgery. 2001 Apr 1;36(4):565-9.

Fox JC, Boysen M, Gharahbaghian L, et al. Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med 2011; 18:477– 482.

Holmes JF, Brant WE, Bond WF, Sokolove PE, Kuppermann N. Emergency department ultrasonography in the evaluation of hypotensive and normotensive children with blunt abdominal trauma. Journal of pediatric surgery. 2001 Jul 1;36(7):968-73.

Holmes JF, Kelley KM, Wootton-Gorges SL, Utter GH, Abramson LP, Rose JS, Tancredi DJ, Kuppermann N. Effect of abdominal ultrasound on clinical care, outcomes, and resource use among children with blunt torso trauma: a randomized clinical trial. Jama. 2017 Jun 13;317(22):2290-6.

Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. Journal of pediatric surgery. 2007 Sep 1;42(9):1588-94.

Kessler DO. Abdominal Ultrasound for Pediatric Blunt Trauma: FAST Is Not Always Better. Jama. 2017 Jun 13;317(22):2283-5.

Menaker J, Blumberg S, Wisner DH, Dayan PS, Tunik M, Garcia M, Mahajan P, Page K, Monroe D, Borgialli D, Kuppermann N. Use of the focused assessment with sonography for trauma (FAST) examination and its impact on abdominal computed tomography use in hemodynamically stable children with blunt torso trauma. Journal of Trauma and Acute Care Surgery. 2014 Sep 1;77(3):427-32.

Moore C, Liu R. Not so FAST—let’s not abandon the pediatric focused assessment with sonography in trauma yet. Journal of thoracic disease. 2018 Jan;10(1):1.

Murphy R, Ghosh A. The accuracy of abdominal ultrasound in paediatric trauma. Emergency medicine journal: EMJ. 2001 May;18(3):208.

Mutabagani KH, Coley BD, Zumberge N, McCarthy DW, Besner GE, Caniano DA, Cooney DR. Preliminary experience with focused abdominal sonography for trauma (FAST) in children: is it useful?. Journal of pediatric surgery. 1999 Jan 1;34(1):48-54.

Retzlaff T, Hirsch W, Till H, Rolle U. Is sonography reliable for the diagnosis of pediatric blunt abdominal trauma?. Journal of pediatric surgery. 2010 May 1;45(5):912-5.

Rippey JC, Royse AG. Ultrasound in trauma. Best Practice & Research Clinical Anaesthesiology. 2009 Sep 1;23(3):343-62.

Rozycki GS, Ochsner MG, Jaffin JH & Champion HR. Prospective evaluation of surgeons’ use of ultrasound in the evaluation of trauma patients. The Journal of Trauma 1993 Apr; 34(4): 516–526. discussion 26–7.

Scaife ER, Rollins MD, Barnhart DC, Downey EC, Black RE, Meyers RL, Stevens MH, Gordon S, Prince JS, Battaglia D, Fenton SJ. The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation. Journal of pediatric surgery. 2013 Jun 1;48(6):1377-83.

Schonfeld D, Lee LK. Blunt abdominal trauma in children. Current opinion in pediatrics. 2012 Jun 1;24(3):314-8.

Soudack M, Epelman M, Maor R, Hayari L, Shoshani G, Heyman‐Reiss A, Michaelson M, Gaitini D. Experience with focused abdominal sonography for trauma (FAST) in 313 pediatric patients. Journal of Clinical Ultrasound. 2004 Feb;32(2):53-61.

Soundappan SV, Holland AJ, Cass DT, Lam A. Diagnostic accuracy of surgeon-performed focused abdominal sonography (FAST) in blunt paediatric trauma. Injury. 2005 Aug 1;36(8):970-5.

Suthers SE, Albrecht R, Foley D, Mantor PC. Surgeon-Directed Ultrasound for Trauma is a Predictor of Intra-Abdominal Injury in Children/DISCUSSION. The American surgeon. 2004 Feb 1;70(2):164.

Podcast archives: paediatric cardiac disease

Cite this article as:
Emily Pascoe. Podcast archives: paediatric cardiac disease, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17411

This month’s Podcast of the Month from the archives is from dasSMACC.

In a 15 minute podcast Michele Domico (Cardiac Intensivist, California) discusses finding the needle in the haystack – life threatening cardiac disease in children over one month of age. Through five cases she illustrates the most commonly missed cardiac ‘zebras’, and provides some helpful hints on how not to miss them.

What are the differences between the presentations of viral myocarditis and ALCAPA in infants?

If you only get pre-excited about one podcast this month, make it this one.

Feeding problems in infancy: David Tickell at DFTB18

Cite this article as:
Team DFTB. Feeding problems in infancy: David Tickell at DFTB18, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17426

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFT19, which will be held in London, UK, are now on sale from www.dftb19.com.