Paediatric Chest Drains

Cite this article as:
Andrew Tagg. Paediatric Chest Drains, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.18913

We know that critical procedures are rare in clinical practice but that when they do need to be done they need to be done right. Whether for relieving a haemo-pneumothorax or a large empyema it is incumbent upon us to know what to do when the need arises. With the exception of our South African colleagues, most of us may only ever insert a chest drain every other year. So let’s take a look at what you need to know with the help of this paper from the trauma team at the Royal Children’s Hospital in Melbourne.

Teague WJ, Amarakone KV, Quinn N. Rule of 4s: Safe and effective pleural decompression and chest drain insertion in severely injured children. Emergency Medicine Australasia. 2019 Apr 30.

Why do a chest drain?

When blood, pus or air fill the pleural space they disrupt the normal negative intrathoracic pressure leading to unopposed elastic recoil of the lung and thus collapse. When a chest drain is inserted blood, pus or air can drain to the outside world allowing re-expansion of the lung.

Reasons for putting in a chest drain

Blood

Although, as a whole, penetrating chest injuries are rare in children, the rising incidence of knife crime means that that the management of penetrating chest injuries is something that we are gaining more experience with. Blunt thoracic injuries are uncommon in children with 204 cases reported in Victoria over a 5 year period. These were overwhelmingly as a result of motor vehicle accidents.

Massive empyema

In my part of the world, there has been an increase in the number of cases of massive empyema. These often seem to develop as a simple parapneumonic effusion (from Staph. pneumoniae), before developing interleaving septae and then becoming a loculated collection of lung custard. As the lung fills respiratory embarrassment becomes outright failure and cardiovascular instability. These children benefit from early drainage, prior to transfer if PICU is not available on-site, although whether this is best achieved via thoracocentesis or formal chest drain is still up for debate.

Air

The pleural space is a virtual space until it becomes filled with either fluid or air. Whilst most pneumothoraces can be managed with either a conservative watch-and-wait approach, simple aspiration or insertion of a pigtail drain they do occasionally need insertion of a more formal intercostal drain.

How often do we do them?

When Nguyen and Craig looked at how often emergency paediatricians performed critical procedures across their network they found that only three were placed over the entire year. I’m sure our colleagues in South Africa have much more experience than I ever will ever get in this area of practice.

Rule of 4s

The paper describes an aide-memoire for the time-poor clinician – handily titled the “The Rule of 4s“.

  • 4 steps in a good plan
  • 4th (or 5th) intercostal space as the basis for a ‘good’ hole
  • 4 x uncuffed ET tube size as a guide to a good sized chest tube
  • 4cm mark for a good stop

As big fans of using infographics to get complex points across it is great to see Teague et al. take that on board. It is well worth taking the time to read through the whole article as it discusses some of the finer points of inserting an intrapleural drain.

Infographic for safe insertion of chest drains

How to secure them

Perhaps you have been taught that a purse-string is the way to go (it’s not) or perhaps you have spent some time in South Africa and have become a fan of the Jo’Burg knot as demonstrated by Neel Bhanderi.

One thing remains true – chest drains must be securely fastened before they get the chance to ‘fall’ out. That means sutures, an appropriate sandwich dressing and a mesentery of tape to take the strain in case someone pulls at the drainage tube.

What can possibly go wrong?

Sticking a needle in somebodies chest is not without risk. Even when I qualified from medical school the trocar method of inserting a drain was falling out of favour. Many a surgeon took them home to use in the garden rather than relegate them to the recycling bin.

Immediate complications include the following:-

  • damage to underlying structures e.g. thoracic duct, lung, oesophagus, stomach (rare unless there is an undiagnosed diaphragmatic injury)
  • bronchopleural fistula formation
  • recurrent pneumothorax
  • intercostal artery haemorrhage
  • chylothorax
  • re-expansion pulmonary oedema

Delayed adverse events include:-

  • infection
  • empyema
  • Horner’s syndrome

What should you do if…

…it stops swinging?

If that spirit level like bubble stops swinging it may mean that the tube is kinked or compressed in some way. I’ve seen it happen as the tubing has been passed through the cot sides and been squashed as the side has been put down so be mindful.

…the drain stops bubbling?

Generally, this is a good thing as it means the air has drained out of the pleural space and the lung has re-expanded. You want to be more concerned when it continues to bubble and bubble and bubble as that would suggest a persistent air leak. If it seems to bubble more than a hookah pipe then you need to get out your trusty clamps to figure out where the leak is. If, when you clamp near the point of insertion, the bubbling stops then the problem must be either in the lung or at the insertion site (perhaps one of the eyelets has migrated outside?). If that fails to isolate the cause then you can work your way down to the collection chamber until the bubbling stops and you have found your leak/disconnect.

…it falls out?

If it’s just the connection between the drain and the tubing connecting to the underwater seal it is time to clamp the tube to prevent air going the wrong way, i.e. back into the chest, and causing a pneumothorax before fixing the problem.

If the whole drain falls out then cover up the hole with an occlusive dressing and decide if you actually need one in the first place. If another one is required it should go through a new incision.

Selected References

Balfour-Lynn IM, Abrahamson E, Cohen G, Hartley J, King S, Parikh D, Spencer D, Thomson AH, Urquhart D. BTS guidelines for the management of pleural infection in children. Thorax. 2005 Feb 1;60(suppl 1):i1-21.

Brandt, M.L., Luks, F.I., Lacroix, J., Guay, J., Collin, P.P. and Dilorenzo, M., 1994. The paediatric chest tube. Clinical intensive care: international journal of critical & coronary care medicine5(3), pp.123-129.

Course CW, Hanks R, Doull I. Question 1 What is the best treatment option for empyema requiring drainage in children?. Archives of disease in childhood. 2017 Jun 1;102(6):588-90.

Kwiatt M, Tarbox A, Seamon MJ, Swaroop M, Cipolla J, Allen C, Hallenbeck S, Davido HT, Lindsey DE, Doraiswamy VA, Galwankar S. Thoracostomy tubes: a comprehensive review of complications and related topics. International journal of critical illness and injury science. 2014 Apr;4(2):143.

Laws D, Neville E, Duffy J. Pleural Diseases Group SoCCBTS. BTS guidelines for the insertion of a chest drain. Thorax. 2003;58(Suppl 2):i53-9.

Mehrabani D, Kopelman AE. Chest tube insertion: a simplified technique. Pediatrics. 1989 May 1;83(5):784-5.

Playfair GE. Case of empyema treated by aspiration and subsequently by drainage: recovery. Br Med J 1875;1:45.

Porcel JM. Chest tube drainage of the pleural space: A concise review for pulmonologists. Tuberculosis and respiratory diseases. 2018 Apr 1;81(2):106-15.

Samarasekera SP, Mikocka-Walus A, Butt W, Cameron P.  Epidemiology of major paediatric chest trauma.  J of Paediatrics and Child Health.  2009; 45: 676-680

Shoseyov D, Bibi H, Shatzberg G, Klar A, Akerman J, Hurvitz H, Maayan C. Short-term course and outcome of treatments of pleural empyema in pediatric patients: repeated ultrasound-guided needle thoracocentesis vs chest tube drainage. Chest. 2002 Mar 1;121(3):836-40.

Stather P, Cheshire H, Bogwandas H, Peek G. Pneumothorax post paediatric chest drain removal. The Thoracic and cardiovascular surgeon. 2011 Aug;59(05):302-4.

Strachan R, Jaffé A. Assessment of the burden of paediatric empyema in Australia. Journal of paediatrics and child health. 2009 Jul;45(7‐8):431-6.

Strutt J, Kharbanda A. Pediatric Chest Tubes And Pigtails: An Evidence-Based Approach To The Management Of Pleural Space Diseases. Pediatric emergency medicine practice. 2015 Nov;12(11):1-24.

Tovar JA, Vazquez JJ. Management of chest trauma in children. Paediatric respiratory reviews. 2013 Jun 1;14(2):86-91.

Walcott-Sapp S. A history of thoracic drainage: from ancient Greeks to wound sucking drummers to digital monitoring.

Adolescent trauma – destination unknown

Cite this article as:
Rie Yoshida. Adolescent trauma – destination unknown, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33178

Amit is a 16-year-old male who lives in a city in England. He is the front seat passenger in a serious road traffic accident and has sustained multiple severe injuries. The ambulance arrives. There is a child, mixed and adult major trauma centre within a similar distance. Which one should Amit be taken to? Will it affect the outcome?  

A recent EMJ publication by Evans et al. aimed to answer this question by comparing adolescent mortality rates in England between children’s, mixed and adult major trauma centres (MTCs). The results suggest mortality rates are lower in children’s major trauma centres and is worth exploring further. 

Evans J, Murch H, Begley R, et al.  Mortality in adolescent trauma: a comparison of children’s, mixed and adult major trauma centres. Emergency Medicine Journal Published Online First: 30 March 2021. http://dx.doi.org/10.1136/emermed-2020-210384

Firstly, how common is adolescent trauma and how do trauma networks work in England? 

Among children and young people, adolescence is the stage of life that carries the second-highest risk of death after infancy. There were approx. 1,330 deaths for young people aged 10 to 19 years across the UK in 2018 and this has increased since 2014 (ONS, 2018).  The leading cause of adolescent mortality is trauma.  

In a previous EMJ publication, Roberts et al. provided an overview of adolescent trauma epidemiology in England from 2008-2017 using the TARN (Trauma Audit Research Network) database. This paper, along with the Evans et al. study, extends the age definition of adolescents to 10-24 years as endorsed by the RCPCH. Over a 10 year period, they found that there were 40680 trauma cases. 80.5% of these cases were aged 16–24 years and 77.3% were male. The main mechanism of injury was road traffic collisions accounting for 50.3% of cases.

NB: The TARN database includes patients of any age who sustain injury resulting in hospital admission for three days or greater, critical care admission, transfer to a tertiary/specialist centre or in-hospital death within 30 days. 

Mechanism of injury in adolescent trauma in England 2008 – 2017

Trauma networks were established in England in 2012 with the designation of major trauma centres (MTCs) and linked trauma units (TUs). The 27 MTCs are divided into 11 adult, 5 paediatric and 11 mixed major trauma centres (MTCs).  Where you are treated depends on age and location. As a general rule,  trauma patients under 16 years will be triaged to children’s MTCs whilst those 16 years and above are triaged to adult MTCs. Mixed MTCs are able to treat both adult and paediatric trauma patients. Major trauma is defined as having an Injury Severity Score (ISS) of over 15.

Why was this study needed and what did it find?

Since the establishment of trauma networks, there have been no studies comparing the outcomes for adolescent trauma between MTC types. Adolescents are a unique and often neglected cohort, especially those at the age when services transition between children and adult services.  

In their cross-sectional study, Evans et al present data from TARN comparing the outcomes of adolescent trauma patients who had a primary transfer to an MTC from 2012 to 2018. Using this data, they compare mortality rates for severely injured adolescents in the different MTC types. Note the study does not include trauma units (TUs) or transfers from a TU to an MTC. 

The study population included 30321 patients aged 10–24.99 years in the 6 year period.  The majority were treated in mixed MTCs (54%) with the fewest being treated in children’s MTC (8%). Even accounting for the variation in numbers seen, the study found that children’s MTCs had a lower 30-day mortality rate for adolescent trauma than adult or mixed MTC.  

Percentage patients seen and mortality by MTC

So does this mean Amit should be taken to a children’s MTC after his road traffic collision? 

We need to take a look at this further under two themes: patients and setting.   

Patients

As you might imagine, the study found that mixed and adult MTCs were more likely to see patients with more severe injuries. Stabbings and shootings were more frequent in adult and mixed MTCs. Patients in children’s MTCs had a lower median Injury Severity Score and fewer comorbidities. All of these trends could reasonably contribute to the higher mortality rate in mixed and adult MTCs. However, the study accounted for all of these potential confounding factors and found that the lower mortality associated with children’s MTC remained statistically significant (Table 1).  

You could argue that comparing the treatment of 10-year-olds to 24-year-olds is unrealistic and that the extremes of age are not where the interest lies. Recognising this, the study analysed those aged 14-17.99 years given the potential of this age group to be treated in any MTC. In this subgroup, the adjusted odds ratio for mortality was significantly higher in adult MTCs in comparison to children’s MTCs. There was no significant difference between mixed and children’s MTCs.  

Adjusted odds ratio for mortality by MTC type – variables include mechanism, the severity of trauma, comorbidities, baseline physiological parameters and GCS

Setting

Could the difference in mortality rate be explained by differences in staff experience and specialism at each MTC type? Do the MTCs use different management strategies or guidelines that could account for the difference in outcomes? These questions were not within the scope of this study although it did look at the most senior clinician present at the initial resuscitation and time to CT as secondary outcomes. It found that consultants were the most senior clinician likely to be present at all MTC types. With regards to imaging, trauma cases were less likely to have a CT if they presented to a children’s MTC reflecting one of the differences in managing adult and childhood trauma cases. It also took longer to perform a CT at children’s MCTs when compared with other MTC types but this does not seem to have affected the outcome.  

Number of patients receiving CT scan by MTC and average time taken to perform

In their editorial, Leech et al (2021)  suggest further reasons for the outcomes found in this study. They highlight that the majority of trauma patients present to non-children’s MTCs with the inherent danger of ‘trauma alert fatigue’. The rarer incidence of these alerts in paediatric centres may, however, give a more focused response. Other influences may be different approaches to education and training and also the nature of parents often being present for children and young people. What impact this has will probably need to be the subject of further research and evaluation.

Back to Amit, our 16-year-old patient post-RTC.  He is being transferred to the nearest adult MTC as per current protocol. 

Has this study changed your opinion on where he should be seen? Should the cut-off age for triage for adolescents be changed based on this study? More research is required but this study does show us that children’s MTCs can manage adolescent trauma with good outcomes despite seeing a lower volume of cases.  

Some thoughts from Jordan Evans

Adolescent healthcare crosses paediatric and adult services with transition predominantly based on age (16 in the UK). The same applies for trauma provision, with an adolescent trauma patient potentially treated in a children’s, adult or mixed MTC. What I wanted to know was does the centre type (children’s, adult or mixed) that an adolescent trauma patient attends affect the outcome?

We used one of the largest trauma databases in Europe (TARN) to help answer this question, defining adolescence as 10-24, in keeping with our previous research and international consensus. Appreciating that some would find this definition too broad, we performed sub-group analysis narrowing the age to 14-17.99 and for those defined as severe trauma (ISS>15). The primary outcome was mortality at 30 days and secondary outcomes included grade running resus, CT and length of stay. Both crude and adjust statistical analysis were performed (adjusting for mechanism, ISS, physiology amongst others).

Our total population for the study was 30 321 patients of which 54% presented to a mixed MTC, 38% to an adult MTC and 8% to a children’s MTC. Mortality within 30 days of injury was higher in mixed (4.4%) and adult MTCs (4.9%) compared with children’s MTCs (2.5%, p<0.0001). The same trend was noted in the adjusted analysis. For those aged 14–17.99 the crude OR of mortality was 1.73 (p=0.032) and adjusted 2.77 (p=0.030) in adolescents treated at the adult MTC. The trend for improved outcomes in children’s MTC was also noted in those with severe trauma.  For secondary outcomes, there was no difference in median total or ICU length of stay although less CT’s were performed in the children’s MTCs compared to the others. A slightly higher proportion of cases were managed by juniors in adult MTCs.

I think this is a timely paper and I feel greater attention is being paid to the adolescent cohort who are often appropriately labelled as the ‘forgotten tribe. The divided approach to adolescent healthcare is certainly a hindrance, with neither adult or paediatric services fully embracing the challenge to help drive down the high mortality and morbidity rates. A sister paper to this, reported an increase in adolescent trauma cases within the UK and a marked rise in stabbings, placing the onus on us to formulate a cross speciality approach to address the needs of this cohort.

I would thoroughly recommend reading the commentary in EMJ by Caroline Leech and Rachel Jenner who give a balanced discussion on the results with the authors hailing from adult and paediatric EM backgrounds. Personally, I would not suggest changing current trauma provision based solely on this data but that it acts as a conduit for further research and discussion. 

Selected references

  1. Office for National Statistics. Deaths registered in England and Wales – 21st-century mortality: November 2018.
  2. Roberts Z, Collins J, James D. On behalf of PERUKI, et al. Epidemiology of adolescent trauma in England: a review of TARN data 2008–2017Emergency Medicine Journal 2020;37:25-30.
  3. Evans J, Murch H, Begley R, et al.  Mortality in adolescent trauma: a comparison of children’s, mixed and adult major trauma centres. Emergency Medicine Journal Published Online First: 30 March 2021. doi: 10.1136/emermed-2020-210384
  4. Leech C, Jenner R Injured adolescents—should they be treated as big kids or little adults?Emergency Medicine Journal Published Online First: 30 March 2021. doi: 10.1136/emermed-2020-211105

Notes

Given the age cut-off of 16 years of age, there is limited overlap in the patients treated at children’s and adult MTCs making the comparison difficult.  However, there are times when triaging by age is not possible.  Indeed, the study found that there were 430 patients in the study under 16 years old who were treated in adult MTCs (9.9% of all aged <16 years) and 17 patients over 16 years attended a children’s MTC (0.1% of all aged 16–24.99 years). 

Foot and toe injuries

Cite this article as:
Taskin Kadri. Foot and toe injuries, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32663

A child’s foot is significantly more cartilaginous than an adult foot, making foot fractures an uncommon injury in children. Foot fractures constitute about 5-8% of paediatric fractures. Evaluation and management of a paediatric foot injury requires an understanding of paediatric anatomy, a careful history, clinical examination, and potentially radiography.

Normal anatomy

The foot is anatomically divided into 3 sections: hindfoot, midfoot and forefoot.

The hindfoot includes the talus and calcaneus. The inferior surface of the talus is more prone to avascular necrosis due to its retrograde blood supply. The part of the calcaneus most prone to fracture is its large posterior facet.

The midfoot includes the navicular, cuboid and the three cuneiform bones.

The forefoot includes the metatarsals and phalanges.

Evaluation of foot injuries

History

The following specific enquiries should be made about the injury:

  • The mechanism of injury (high/low velocity, twisting, compression, direct blow)
  • Characteristics of pain (worse at the time of injury vs late onset)
  • Location of pain
  • Consistency and plausibility of the history, excluding concerns about non-accidental injury
  • The effect of the injury on the child (limping, the distance the child can move)
  • The efficacy of pain relief

Examination

Clinical examination should be tailored to the history.

Look

For external skin abrasions or obvious open fractures.

Feel

Palpation of the bones: tarsals, metatarsals, toes and the base of the 5th metatarsal.

Palpation for tenderness along the ligaments: deltoid ligament on medial side and anterior talofibular, calcaneofibular and posterior talofibular ligaments on the lateral side.

Move

The active movement should be followed by passive movement as much as pain allows.

The usual range of movements are: subtalar eversion (15-20°), subtalar inversion (35-40°), forefoot adduction (20°), forefoot abduction (10°), 1st metatarsal phalangeal (MTP) flexion (45°), 1st MTP extension (70-90°) and free motion of lesser toes.

Neurovascular examination

Two pulses: dorsalis pedis and posterior tibial.

Five sensory nerves: saphenous (medial calf and hindfoot), superficial peroneal (dorsum of the foot), deep peroneal (1st dorsal webspace), sural (lateral foot) and posterior tibial nerve (plantar foot and heel).

Imaging

The Ottawa foot rules can be applied to children. The rules have 97-100% sensitivity in paediatric injury investigation. According to the rules, x-rays of the foot are required if the child is unable to weight bear both immediately after the injury and in the ED, plus bony tenderness over the base of 5th metatarsal or the navicular.  

Accessory ossicles

Accessory foot ossicles can cause pain as a result of stress injuries. The navicular ossicles, arise either on the medial side of (os tibiale externum) or on the lateral tubercle of the navicular bone (os trigonum).

Os tibiale externum

This is an ossification centre that arises at the site of the tibialis posterior tendon on the medial side of the navicular bone. It becomes an accessory bone when it fails to fully ossify.  It is present in 4-14% of patients.

The usual presentation is in adolescence when the patient has pain from overuse, especially in athletes.

Os tibiale externum

Examination may reveal pes planus (flat foot). This happens as the tibialis posterior tendon, maintaining the medial longitudinal arch, attaches to the accessory bone rather than the navicular bone.

Investigations include plain films and, occasionally, MRI scan.  

Treatment is initially conservative with orthotics and casting. The ossicle is excised if these measures fail to resolve the pain.

Os trigonum

This is present in 10-25% of the population. It is often associated with heel pain in ballet dancers due to repetitive microtrauma.

Hindfoot fractures

These are rare, constituting only 0.008% of all paediatric fractures. Children usually present after falling from height or after a motor vehicle injury. The talus can be fractured in multiple places including avulsion fracture.

Case courtesy of Assoc Prof Craig Hacking, Radiopaedia.org. From the case rID: 77140

‘Snowboarder’s fracture’ is a fracture of the lateral process of the talus. The mechanism of injury involves dorsiflexion and inversion.

Do not miss: Snowboarder’s fractures are often misdiagnosed as an ankle sprain. If not evident on x-ray, a CT or MRI should be performed if there is clinical suspicion. Think carefully about the mechanism.

Calcaneus fractures typically occur due to axial loading and are frequently associated with vertebral compression fractures. Radiography should include AP, lateral and axial views. The axial view offers a better view of the fracture.

Treatment of talus and calcaneus fractures is dependent on the degree of displacement.

  • Non or minimally displaced avulsion fractures, or extra-articular fractures should be managed in a posterior short leg splint and should be non–weight bearing with crutches for 3 to 4 weeks.
  • Displaced fractures require reduction, by an orthopaedic surgeon, followed by immobilisation with a splint or cast. Severely displaced, comminuted or intra-articular fragments may require ORIF.

Midfoot fractures

These are also rare fractures and usually result from severe blunt injury. Most fractures are avulsion or stress fractures and are associated with other injuries.

Treatment depends on the severity of displacement of the fracture and associated injuries.

  • Non or minimally displaced fractures (the majority of these fractures) can be treated with a walking cast.
  • Displacement of the fracture fragment greater than 2mm should be managed with reduction and stabilisation before immobilisation.

Midfoot fractures have minimal long term sequelae.

Forefoot fractures

Forefoot fractures represent about 60% of paediatric foot fractures and can result from either direct or indirect trauma. They are easily missed: about 41% are missed due to high energy trauma causing other significant injuries.

Lisfranc fracture

Lisfranc fractures occur due to axial loading with forced plantar flexion (commonly seen in bicycle or horseback riders where a foot gets caught in a pedal or stirrup) or with a crush injury.

Clinical examination

  • Tenderness over the dorsum of the foot with swelling and inability to bear weight.
  • Plantar bruising is a consistent sign and if present should raise suspicion of the injury.  

Diagnosis is made with a weight bearing x-rays (as the fracture may not be evident on non-weight bearing views) – AP, lateral and oblique radiographs of the foot. The normal alignment of the foot should have the 2nd metatarsal aligning with the intermediate cuneiform on the dorsoplantar view and the 3rd metatarsal aligning with the lateral cuneiform on the oblique view. The Lisfranc ligament connects the cuneiforms to the 2nd metatarsal. Disruption of this ligament leaves the foot unstable and hence it is an important not to miss this injury. Due to the ligament attachment, there is often associated fracture of the bases of the 1st or 2nd metatarsal in a Lisfranc injury.

https://emergencymedicineireland.com/

Treatment depends on the degree of severity of the injury.

  • Partial tears with < 2mm malalignment require immobilisation or a walking boot for 4-6 weeks. The patient should be referred to orthopaedic surgeons within 3-5 days due to the high rate of late complications.
  • More severe injuries require operative treatment with internal fixation.

There is a high rate of residual pain in children with a Lisfranc injury.

Metatarsal fractures

Metatarsal fractures are associated with athletic activity and are becoming more common. The 5th metatarsal is the most commonly fractured metatarsal in paediatric patients. It can result from twisting, repetitive stress or direct trauma. 1st and 5th metatarsal fractures can be isolated whereas 2nd-4th metatarsal fractures often occur along with other metatarsal fractures. It is a frequently missed fracture on a radiograph.

Children younger than 5 years of age are more likely to be injured by a fall from height and fracture the 1st metatarsal. Older children are more likely to fracture it from falling from a standing position, during sports and tend to fracture the 5th metatarsal.

Pseudo-Jones fracture

A Pseudo-Jones fracture is an avulsion fracture of the base of the 5th metatarsal resulting from a twisting injury of the foot. The examination will reveal focal point tenderness. The patient should be immobilised for 3-4 weeks in a weight-bearing cast.

Treat with a short walking boot or hard sole shoe for 6 weeks. Follow-up with orthopaedic surgeons.

Jones fracture

The Jones fracture is a fracture of the metaphyseal-diaphyseal junction at the base of the 5th metatarsal bone. It is the most common of metatarsal fractures (40%), representing about 25% of all paediatric foot fractures.

Jones fracture (metaphyseal-diaphyseal junction fractures of the 5th metatarsal).

Fractures at or distal to the metaphyseal-diaphyseal junction require 6 weeks in a non–weight bearing cast, with crutches. All patients should be referred to orthopaedic surgeons as there is a high incidence of delayed union of the fracture. Many of these patients will require ORIF subsequently.

The apophysis of the base of the 5th metatarsal appears at age 10 for girls and at age 12 for boys. An unfused apophysis runs longitudinally whereas pseudo-Jones fracture runs transversely.

Normal apophysis of the 5th metarasal (note it runs longitudinally rather than transversely). Case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 8802

Toe fractures

Toes fractures are one of the most common fractures in the paediatric population. Phalangeal fractures constitute about 3-7% of all physeal fractures and are usually Salter-Harris I or II injuries. They are more common in boys than girls and are mostly closed in nature.

The patient may present with localised tenderness to the toe, a limp or inability to bear weight. Nail bed bleeding and bleeding from or around the nail fold should prompt the possibility of an open fracture through the nail bed. Alignment, rotation and neurovascular status should be checked.

Fractures of the 2nd-5th toes are usually treated by buddy strapping and weight bearing as much as possible. Healing can take up to 3-4 weeks. A hard-soled shoe or walking boot may be used for patient comfort. Follow-ups with orthopaedic surgeons can cease 3 weeks after the injury. If there is possible injury to physis then follow-up should continue for 1-2 years to detect abnormal growth.

The big toe

The big toe plays an important part in bearing weight. Fractures of the big toe are therefore managed slightly differently.  Salter-Harris III or IV fractures of the proximal phalanx of the hallux are often intra-articular.

Urgent orthopaedic consultation for closed or open reduction for K wiring if:

  • more than one third of the joint surface is involved or
  • displacement is more than 2-3mm

In other cases, toe platform cast or a walking boot is used.

The epiphysis of the proximal phalanx of the 1st toe is sometimes bipartite, simulating a Salter-Harris III fracture. If there is no tenderness on the 1st toe, no treatment is indicated.

Phalangeal open fractures require thorough irrigation and debridement in addition to antibiotics to avoid osteomyelitis.  A nail-bed injury to the germinal matrix will require surgical repair.

Long term complications include growth arrest and angular deformities from physeal injury, degenerative joint disease from intra-articular fractures and osteomyelitis from open fractures.

References

Boutis K: Paediatric metatarsal and toe fractures. Up to Date 2019

Boutis, K., 2021. UpToDate. [online] Uptodate.com. Available at: <https://www.uptodate.com/contents/foot-fractures-other-than-metatarsal-or-phalangeal-in-children> [Accessed 4 April 2021].

Boutis, K., 2021. UpToDate. [online] Uptodate.com. Available at: <https://www.uptodate.com/contents/foot-fractures-other-than-metatarsal-or-phalangeal-in-children> [Accessed 4 April 2021].

Eiff, M. and Hatch, R. Fracture management for primary care and emergency medicine. Elsevier.

Halai, M., Jamal, B., Rea, P., Qureshi, M. and Pillai, A., 2015. Acute fractures of the pediatric foot and ankle. World Journal of Pediatrics, 11(1), pp.14-20.

Horner K and Tavarez M, 2016. Paediatric Ankle and Foot Injuries. Clin Pediatr Emerg Med, 17 pp. 38-52

Juliano, P., 2018. Lateral Talar Process Fractures – FootEducation. [online] FootEducation. Available at: <https://footeducation.com/lateral-talar-process-fractures/> [Accessed 4 April 2021].

Malanga, G. and Ramirez – Del Toro, J., 2008. Common Injuries of the Foot and Ankle in the Child and Adolescent Athlete. Physical Medicine and Rehabilitation Clinics of North America, 19(2), pp.347-371.

Metaizeau, J. and Denis, D., 2019. Update on leg fractures in paediatric patients. Orthopaedics & Traumatology: Surgery & Research, 105(1), pp.S143-S151.

Smit, K. Foot Fractures – Phalanx | Pediatric Orthopaedic Society of North America (POSNA). [online] Posna.org. Available at: <https://posna.org/Physician-Education/Study-Guide/Foot-Fractures-Phalanx> [Accessed 4 April 2021].

Shoulder examination

Cite this article as:
Mark Webb. Shoulder examination, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31287

Johnny is five. He fell onto his outstretched arm and now is sat in your ED, crying and holding his shoulder adducted. Triage has been ace and given him analgesia so he is adequately comfortable before you examine him.

Joint examinations can be easily remembered by “look, feel, move” and special tests. It’s important that in addition to the joint you’re interested in that you also examine the joint above and below.

Look

  • Deformity
  • Swelling
  • Atrophy: Asymmetry  
  • Wounds
  • Bruising
  • Skin tenting (typically clavicular fractures, whereby the bony fragment is causing pressure on the skin and thought to cause skin necrosis, although this is controversial) 

A chaperone may be needed to expose the joint adequately in older children.

Feel

Feel for warmth, which could indicate septic arthritis.

From the front:

Start medially at sternoclavicular joint

Anatomy of the acromio-clavicular joint

From the back:

  • Scapula: spine, supraspinatus, infraspinatus muscle

Neurovascular assessment:

  • Check for distal pulses: brachial/ radial.
  • Always check the regimental patch for axillary nerve injury and document it.

Move

Assess for range of motion, both active and passive.

Girl flexing and extending at shoulder showing range of movement

Flexion: 180 degrees. Raise arm forward up until they point to the ceiling.

Extension: 45-60 degrees. Stretch the arm out behind them.

Girl showing range of adduction and abduction at the shoulder

ABduction: 150-160 degrees. Put arms out to the side like an aeroplane’s wings and then bring them above their head to point to the ceiling.

ADduction: 30-40 degrees. Put arms out to the side like an aeroplane’s wings and move them in front of their body so they cross over.

Girl showing range of internal and external rotation

External rotation: 90 degrees. Tuck their elbows to their side and swing the hands out.

Internal rotation: 70-90 degrees. Tuck elbows to the side and bring their hands across their tummy.

Scapula winging: Ask the child to push against the wall or your hand. If the scapula wings out this suggests long thoracic nerve pathology.

Some special tests

It is easy to get lost in the number of special tests when examining the shoulder and the trick is to perform those most relevant to the patient in front of you. Many are to test the integrity of the rotator cuff tendons, i.e. Supraspinatus, Infraspinatus, Teres minor and Subscapularis. (SITS)

Girl performing Apley scratch test

“Appley Scratch” test: (1) Ask the child to reach behind their back to touch the inferior border of the opposite scapula (internal rotation and aDDuction) and then (2) reach behind their head to touch the superior angle of the opposite scapula (external rotation an Abduction). A positive test of pain indicates tendinitis of the rotator cuff, usually supraspinatus.

Girl performing empty can test

Empty can test: Ask the child to hold their arm raised parallel to the ground and then point their thumbs towards the ground as if they were holding an empty can (this rotates the shoulder in full internal rotation while in abduction). Then push down on the child’s wrist while asking them to resist. A positive test is pain or weakness, suggestive of supraspinatus tear or suprascapular nerve neuropathy.

Girl performing lift off test

Lift off test: The child stands and places the back of their hand against their back. Put your hand against theirs, palm to palm, and ask them to push against you. A positive test is pain or weakness, indicating subscapularis muscle pathology.

Girl and boy performing scarf test

Scarf test: Ask the child to wrap their arm over the front of their neck reach down over their opposite shoulder towards the scapula (like a scarf). Pain over ACJ when doing this indicates ACJ pathology.

Although the standard approach to limb examination involves a LOOK, FEEL and MOVE (and special tests) structured assessment, in reality, if a young patient has a significant injury, a more pragmatic approach is needed. An X-ray may be warranted before a more thorough exam. This doesn’t mean that you can get away without a documented range of motion exam (even if you explain it is limited by pain) and neurovascular assessment.

Back to Johnny. You noticed a deformity over the middle third of the clavicle, but no skin tenting. He was neurovascularly intact and range of movement only marginally reduced by pain, so you discharged him with a broad arm sling and follow-up (or not) according to your local guidelines.

Selected references

Carson, S., Woolridge, D.P., Colletti, J. and Kilgore, K. (2006) Pediatric upper extremity injuries. Pediatric Clinical North American: 53(1) pp. 41-67

Chambers, P.N., Van Thiel, G.S. and Ferry, S.T. (2015) Clavicle Fracture more than a theoretical risk? A report of 2 Adolescent cases. The American Journal of Orthopedics. 44(10) 

https://fpnotebook.com/Ortho/Exam/ShldrExm.htm [Accessed April 2019]

McFarland, E.G., Garzon-Muvdi, J., Jia, X., Desai, P. and Petersen, S.A. (2010) Clinical and diagnostic tests for shoulder disorders: a critical review. British Journal of Sports Medicine. 44(5) pp. 328-32.

NationwideChildrens.org/Sports-Medicine

https://shouldercomplexgocatsnmu.weebly.com/range-of-motion.html [Accessed April 2019]

Femoral shaft fractures

Cite this article as:
Joanna Wawrzuta. Femoral shaft fractures, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32484

An 18-month-old boy presents to the emergency department at 1am in the morning, brought in by ambulance with leg pain and inability to mobilise, with crying when being moved or attempting to move. His father tells you that he fell downstairs when they forgot to close the stairgate. On examination, his right thigh is swollen, possibly shortened and he is clearly guarding it. Given your high clinical suspicion of a femur fracture, you prescribe simple and opiate analgesia and organise an x-ray.

Incidence

Femoral shaft fractures account for 1.5 – 2% of paediatric fracture presentations. The average number of annual cases is 20 per 100,000. Despite accounting for a small proportion of all fractures, they are the most common cause for hospitalisation for a fracture.

Femoral shaft fractures can happen at any age depending on mechanism however, there is a clear bimodal age distribution with increased rates in toddlers (between 2-4 years of age) and adolescents (approximately greater than 10 years of age).  Any femur fracture before ambulatory age is uncommon and should be treated as suspicious for non accidental injury (NAI). This is especially true for femoral fractures in children less than 12 months of age (more on this later).

History

Toddlers commonly present as a result of a fall of some kind – sometimes from a height, but it can be from as little as 60cm or less. They are often running, or falling after tripping on an object.

Adolescents, on the other hand, tend to fracture their femur as a result of high mechanism trauma, such as motor vehicle accident or a fall or jump from a significant height.

Regardless of age, patients typically report thigh pain, swelling and an inability to weight bear.

Ask about the mechanism of injury, if it was witnessed, and the time of the injury particularly in the younger age group (<5 years). An unclear history, an unwitnessed fall and delay to presentation are risks factors for NAI.

Examination

The limb deformity may be gross or subtle. Significant swelling results in a tense, or firm-feeling, thigh on palpation and/or a shortened limb. Sometimes the swelling can be very mild, particularly in a toddler, but a clue to injury is a child who is not moving the leg. Always check for neurovascular compromise and for other injuries. One study by Rewers et al. (2005), suggested that 28.6% of children with a femur fracture had another associated injury.

Investigations

Plain radiograph with AP and lateral views of the femur. Imaging the ipsilateral knee and hip is recommended to rule out associated injuries.

Classification

There is no universal classification system for femur fractures so \ use description characteristics, location, stability of the fracture and whether it is open or closed.

Descriptive examples include: transverse, spiral, oblique, comminuted, greenstick, displaced/nondisplaced.

Location: proximal, middle, distal third

Stability:  stable or unstable. Stable fractures are typically transverse or short oblique; while unstable fractures are long spiral and comminuted.

Note: long spiral fractures occur when the fracture length is more than twice the diameter of the bone at that level.

Management

General principles should be adhered to as for any ED presentation. Start with a primary and secondary survey. These injuries occur as a result of trauma and other significant and life-threatening injuries need to be excluded. Next is analgesia, fracture reduction then immobilisation.

Adequate analgesia can be achieved with intranasal, oral and intravenous medications. Start with simple analgesia first (paracetamol, NSAIDS) as they are easy and quick to administer. Then move on to opioids via the oral, IV or intranasal route. Consider benzodiazepines, particularly diazepam, if muscle spasm is an issue (which it often is). While analgesia is taking its effect, start setting up for a regional nerve block. This can be a femoral nerve block (usually under ultrasound guidance), fascia iliaca block (landmark or ultrasound-guided) or a haematoma block.

Once adequate analgesia has been given, it is time to reduce the fracture using skin traction. Generally, femoral fractures are not put in a backslab in ED unless a traction splint is not available and transfer of the patient is required.

Skin traction

Skin traction requires 10% of the patient’s weight to be applied through an appropriate traction mechanism. This may occur in the ED if there are adequately trained personnel and equipment available. There are also traction splints available that can be used pre-hospital or if a traction bed is not available. Sedation may be required to apply skin traction or a traction splint.

There is a variety of traction splint available. The most common in use are the Thomas splint, CT-6 splint and Kendrick splint. Others include the Slishman Traction Splint, Mustang traction splint, Sager splint, Hare Splint and Donway splint.  The Thomas splint is recommended for transfer and is available in a paediatric size.

Taken from https://www.embeds.co.uk/

In Queensland, the ambulance service uses the CT-6 splint. It can also be used in the paediatric population. Have a look at this video by Queensland Ambulance Service on its application. The Slishman traction splint and Mustang traction splint are not specifically designed for children but the linked videos demonstrate brilliantly on child volunteers how you can adapt them for kids.

Definitive management

Spica cast application is typically done under general anaesthetic by the orthopaedic surgeons depending on the age of the child. Older children will require other definitive management.

The table summarises the guidance from The American Academy of Orthopaedic Surgeons (AAOS) of management of femoral fractures by age.

Complications

The most common complication is leg length discrepancy. This occurs due to overgrowth in younger patients. Conversely, shortening can also be an issue but is acceptable up to 2-3cm. Other complications include: osteonecrosis of the femoral head, non union, malunion and re-fracture. In terms of osteonecrosis of the femoral head, this can depend on the surgical procedure performed.

A note about other femoral injuries

Other types of fractures of the femur include proximal fractures (including neck of femur), distal femoral physeal fractures and slipped capital femoral epiphysis (SCFE, also known as SUFE)

Proximal femur fractures are rare in paediatric populations accounting for <1% of fractures. They most commonly occur due to high energy trauma such as motor vehicle accident [1,4,8]. They can occur with a low impact mechanism, but if this occurs a pathological fracture should be considered. Proximal fractures tend to need operative management with an ORIF. The most common complication for a proximal femur fracture is avascular necrosis.

The do not miss bits

Non accidental injury

The incidence of NAI in children with femoral fractures has been reported between 12-60%. In one study by Rewers et al. (2005), it was found that in children less than 3 years of age, NAI was the second most common cause of femoral fractures. This is supported by Schwend et al. (2000), who suggested that a femur fracture in children who are not yet of walking age was the strongest predictor of abuse.

Vigilance is the key to detecting NAI. The best predictors for NAI include: An unclear history, particularly with respect to the mechanism, a suspicious history, an unwitnessed fall (particularly in the younger age group), young age, a delayed presentation (typically >24hours), and associated injuries particularly of chest, abdomen and pelvis if not associated with a high speed mechanism. They also include physical and/or radiographic evidence of prior injury (multiple different aged bruises, old healing fractures on XR). In one study, 53% of children who had been abused and had a femoral fracture had evidence of polytrauma. 62% had physical and/or radiographic evidence of prior trauma and 33% had history suspicious for abuse. In terms of the risk factors listed above, children who had no risks factors had a 4% chance of NAI being the cause of their fracture compared to 24% with one risk factor, and 87% if they had 2 risk factors.

Is the type of femoral fracture a predictor of NAI? There is no current evidence that supports it being a strong predictor. Some evidence suggests that fractures associated with NAI are more likely to found in the distal femur, compared to diaphyseal fracture alone. In contrast to popular belief, there is no current evidence to strongly support that spiral fractures are more likely to be associated with NAI.

In essence, never forget to consider NAI. It is easy to miss if it isn’t thought about as a differential.

Associated injuries

Remember secondary and tertiary survey. Subtle injuries can be missed in patients with high velocity mechanisms or significant life-threatening injuries.

Pathological fractures

These should be considered if a femoral fracture occurs as a result of a low mechanism trauma. Children with metabolic disorders or malignancy are also at higher risk.

Traction

If considering applying a traction splint, don’t forget to assess for ankle/foot fractures as these are a contraindication to application. This is because the ankle and foot are generally support sites for the traction splint.

A femoral nerve block was completed with good effect after some intranasal opioid analgesia. The case was discussed with the orthopaedic team and concerns raised around NAI given the child’s age. The case was also discussed with the hospital child protection team. Traction was applied in the ED under ketamine sedation before he was admitted under orthopaedics and a spica cast was applied in theatre under general anaesthesia.

  1. https://www.orthobullets.com/pediatrics/4019/femoral-shaft-fractures–pediatric?expandLeftMenu=true
  2. Wright JG, Wang EL, Owen JL, Stephens D, Graham HK, Hanlon M, Nattrass, GR, Reynolds RK, Coyte P. Treatments for paediatric femoral fractures: a randomised trial. Lancet 2005;365:1153-58.
  3. Capra L, Levin AV, Howard A, Shouldice M. Characteristics of femur fractures in ambulatory young children. Emerg Med J 2013;30:749-753.
  4. https://radiopaedia.org/cases/paediatric-neck-of-femur-fracture
  5. Baldwin K, Pandya NK, Wolfgruber H, Drummond DS, Hosalkar HS. Femur Fractures in the Pediatric Population. Abuse or Accidental Trauma? Clin Ortop Relat Res 2011; 469:798-804.
  6. Clarke NP, Shelton FM, Taylor CC, Khan T, Needhirajan S. The incidence of fractures in children under the age of 24months in relation to non-accidental injury. Injury 2012;43(6):762-5
  7. Wood JN, Fakeye O, Mondestin V, Rubin DM, Localio R, Feudtner C. Prevalence of abuse among young children with femur fractures: a systemic review. BMC Pediatrics 2014; 14:169
  8. Rewers A, Hedegaard H, Lezotte D, Meng K, Battan FK, Emery K, Hamman, RF. Childhood Femur Fractures, Associated Injuries, and Sociodemographic Risk Factors: A Population-Based Study. Pediatrics 2005; 115; e543.
  9. Davis DD, Ginglen JG, Kwon YH, et al. EMS Traction Splint. [Updated 2020 Jul 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan
  10. https://www.rch.org.au/clinicalguide/guideline_index/fractures/femoral_shaft_emergency/
  11. https://www.embeds.co.uk/2019/02/03/thomas-spint-how-to-apply/
  12. http://www.orthoguidelines.org/topic?id=1015
  13. Cooperman DR, Merten DF. Skeletal manifestations of child abuse. In: Reece RM, Christian CW, Eds. Child abuse: medical diagnosis and management, 3rd Ed. American Academy of Pediatrics, 2009;315.
  14. Hui C, Joughin E, Goldstein S, et al. Femoral fractures in children younger than three years: the role of nonaccidental injury. J Pediatr Orthop 2008;28:297-302.
  15. Shrader MW, Bernat nM and Segal. Suspected nonaccidental trauma and femoral shaft fractures in children. Orthopedics 2011; 34(5):360
  16. Schwend RM, Werth C, Johnston A. Femur shaft fractures in toddlers and young children: rarely from child abuse. J Pediatr Orthop 2000;20:475-81.
  17. Coffe C, Haley K, Hayes J, Groner JI. The risk of child abuse in infants and toddlers with lower extremity injuries. J Pediatr Surg. 2005; 40:120-123
  18. Son-Hing JP and Olgun DZ. The frequency of nonaccidental trauma in children under the age of 3 years with femur fractures: is there a better cutoff point for universal workups? J Pediatr Orthop B 2018; 27(4): 366-388
  19. Thompson NB, Kelly DM, Warner Jr WC, Rush JK, Moisan A, Hanna Jr WR, Beaty JH, Spence DD, Sawyer JR. Intraobserver and interobserve reliability and the rold of fracture morphology in classifying femoral shaft fractures in young children. J Pediatr Orthop 2014; 34(3):352-8
  20. Leaman LA, Henrikus WL and Bresnahan JJ. Identifying non-accidental fractures in children aged <2 years. J Child Orthop 2016; 10:335-341
  21. https://coreem.net/core/pediatric-femur-fractures/

Predicting paediatric traumatic brain injuries

Cite this article as:
Dani Hall and Mieke Foster. Predicting paediatric traumatic brain injuries, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.30993

The biggest challenge in managing a child with a mild to moderate head injury is deciding whether to organise a CT scan or not. Balancing the risk of ionising radiation (and with it the small, but definite, risk of a future brain tumour or leukaemia) against the risk of missing a significant brain injury is mitigated to some extent by using a clinical decision rule, like the PECARN, CATCH or CHALICE rules. These rules are extremely sensitive with very few false negatives and excellent negative prediction values, meaning if you follow them, you’re unlikely to miss a clinically important brain injury (cTBI). Their problem is their specificity is low with plenty of false positives, meaning most of the children who have a scan won’t actually have a brain injury. (If you’d like a refresher on sensitivity, specificity, NPV and PPV in head injury decision rules, check out Damian’s critical appraisal talks in DFTB Essentials.)

Over the last 6 years, Australasia’s PREDICT network has been a publishing powerhouse on paediatric head injuries from their Australasian Paediatric Head Injury Research Study (APHIRST for short). In their cohort of 20,000 children the team have been able to tell us that of PECARN, CATCH and CHALICE, the PECARN rule has the highest sensitivity. They’ve also shown that planned observation leads to significantly lower CT rates, with no difference in missed cTBI. And probably most telling of all, they’ve told us  that, without using any rules, their clinicians are already very good at identifying children with a cTBI with a sensitivity almost as high as PECARN’s, but with a very low baseline CT rate.

Nonetheless, clinical decision rules do play their role. And so, when they asked their network what an ideal decision rule would tell them, their clinicians highlighted the gaps in the existing guidelines: What should we do with a child with a delayed presentation up to 72 hours after the head injury? What about a child with a bleeding disorder and a head injury? What about a child with a VP shunt and a head injury? Or an intoxicated child with a head injury? The list goes on.

And so, in true PREDICT style, they decided to develop their own guideline.

This week marks a landmark day for paediatric head injury management worldwide as PREDICT launch their guideline for mild to moderate head injuries in children. The risk criteria from the PECARN rule, the best performing prediction rule in the APHIRST study, play a central role, supported by an extensive literature search, including studies from PECARN and PREDICT on the risk associated with VP shunts and bleeding risks. PREDICT have pulled all the data into one comprehensive, evidence-based guideline for managing, what has previously been considered, some of the less clear-cut paediatric head injury presentations. Let’s explore the algorithm and run through a series of cases.

Babl FE, Tavender E, Dalziel S. On behalf of the Guideline Working Group for the Paediatric Research in Emergency Departments International Collaborative (PREDICT). Australian and New Zealand Guideline for Mild to Moderate Head injuries in Children – Algorithm (2021). PREDICT, Melbourne, Australia.

How was the guideline derived?

Building on the existing high-quality clinical decision rules, the PREDICT group conducted a systematic review of the literature to include more recently published evidence. To develop the new PREDICT guideline, they used a GRADE-ADOLOPMENT approach, adopting, adapting or developing new recommendations, which are labelled in the main guideline as ‘evidence-informed recommendations’, ‘consensus-based recommendations’ or ‘practice points’.

What does it say?

This guideline is here to tell us what to do with children with a mild or moderate head injury, with a GCS of 14 or 15, or a child with a GCS ≤ 13 with a normal CT scan. The ‘who to discharge, who to observe and who to scan’ part of the guideline is succinctly summarised with a two-page algorithm. Page 1 has an easy to follow flowchart, supplemented by footnotes and Appendix with modified guidance for special conditions on page 2.

Page 1
Page 2

The bottom line

What I like so much about this guideline is that it answers so many of our “what about the child with a head injury plus…?” questions. With the evidence-based recognition that senior clinicians who choose to observe rather than scan a child reduce the CT rate without increasing the number of missed cTBIs, this guideline also allows senior clinicians to make a risk assessment on a case by case basis, while remaining fluid enough to upgrade or downgrade a child’s risk if their clinical picture changes. Although designed for use in Australia and New Zealand, I can see it being immensely useful outside Australasia and am looking forward to putting its pearls of wisdom to use.

Case 1

Case 2

Case 3

Case 4

Case 5

Cases 6 and 7

Case 8

Cases 9 and 10

Case 11

Case 12

Case 13

Case 14

Case 15

References

 Babl FE, Tavender E, Dalziel S. On behalf of the Guideline Working Group for the Paediatric Research in Emergency Departments International Collaborative (PREDICT). Australian and New Zealand Guideline for Mild to Moderate Head injuries in Children – Algorithm (2020). PREDICT, Melbourne, Australia.

Babl FE et al. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. 2017. 389;10087:2393-2402. DOI: https://doi.org/10.1016/S0140-6736(17)30555-X

Babl FE et al. A prospective observational study to assess the diagnostic accuracy of clinical decision rules for children presenting to emergency departments after head injuries (protocol): the Australasian Paediatric Head Injury Rules Study (APHIRST). BMC Pediatr. 2014. 13;14:148. DOI: 10.1186/1471-2431-14-148

Singh S et al. The Effect of Patient Observation on Cranial Computed Tomography Rates in Children With Minor Head Trauma. Acad Emerg Med. 2020. 27:832–843. DOI: 10.1111/acem.13942

Borland M et al. Delayed Presentations to Emergency Departments of Children With Head Injury: A PREDICT Study. Ann Emerg Med. 2019. 74:1-10. DOI: 10.1016/j.annemergmed.2018.11.035

Chest compressions in traumatic cardiac arrest

Cite this article as:
Karl Kavanagh and Nuala Quinn. Chest compressions in traumatic cardiac arrest, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31093

Traumatic cardiac arrest (TCA) is an infrequent event in paediatrics, and a cause of significant stress in the busy trauma resuscitation room. Outcomes are similar in both paediatric and adult arrests, with poor survival rates in both. There are now international guidelines on the management of traumatic cardiac arrest. A traumatic cardiac arrest (TCA) is traumatic not just for patients but also for staff and all those involved. The guidelines were published in 2016, however, the role of chest compressions is still a source of confusion for medical and nursing staff alike. Advanced Paediatric Life Support algorithms and supporting medical evidence have correctly engrained chest compressions into medical management of life threats. However, there is a paucity of studies examining trauma-induced hypovolaemic arrests to base the decision to change the “normal practice”. It is counter-intuitive for medical staff to not start compressions when an arrest is presented to you and withholding them inevitably leads to the question “Well, what can I do then?”.

Haemorrhage is one of the three common causes of early preventable death in trauma. This paper, from Sarah Watts et al, sought to determine whether compressions are beneficial and with what fluid the patient should be resuscitated with (if at all). Of course there are ethical and practical issues with a prospective randomised control study involving children as the subjects. Instead, this animal study is a helpful surrogate for analysis of the question surrounding the role of chest compressions in haemorrhage-induced traumatic cardiac arrest.

Disclaimer: not suitable for vegetarians!

Watts S, Smith JE, Gwyther R and Kirkman E. Closed chest compressions reduce survival in an animal model of haemorrhage-induced traumatic cardiac arrest. Resuscitation. 2019; 140:37-42. Doi: 10.1016/j.resuscitation.2019.04.048

PICO image

Population

39 pigs were enrolled and treated as per UK Animals (Scientific Procedures) Act 1986 ethics standards. The baseline data of all animals involved were within normal ranges and differences between them was not clinically significant. Each subjects’ vital signs were invasively monitored throughout the study.

Intervention

There were 5 phases through which all participants/subjects went.

  • Injury phase
  • Shock phase
  • TCA phase
  • Resuscitation phase
  • Post-resuscitation phase

Each subject was anaesthetised and the same injury was reproduced in each. Subjects were allowed to exsanguinate in a controlled pattern. Once terminal hypovolaemia was declared, three rounds of resuscitation were commenced. After resuscitation, subjects were categorised according to MAP and Study End was defined as 15 minutes after the end of the third resuscitation cycle.

Patients were blindly randomised into 5 different groups:

  1. Closed chest compressions(CCC)
  2. Whole blood (WB)
  3. 0.9% Saline (NaCl)
  4. WB+ CCC
  5. NaCl+ CCC

Outcome

The primary outcome was achievement of ROSC at study end.

Secondary outcomes were differences in survival and attainment and maintenance of ROSC during the resuscitation and post-resuscitation phases.

Results

To summarise the numerous results:

  1. All the subjects in compressions only group died.
  2. All the subjects that received whole blood only survived.
  3. Resuscitation with blood had improved outcomes over normal saline.
  4. Addition of compressions had a detrimental effect on fluid resuscitation.
  5. Subjects that received any combination of CCC showed a more significant metabolic acidosis, reflecting increased tissue ischaemia.
  6. In the group that received both CCC and WB, 5 of 8 subjects achieved partial ROSC (MAP 20-50mmHg). Once partial ROSC was ascertained, CCC’s ceased and fluid resuscitation alone was continued. This led to the subjects improving to such a degree that there was no longer a difference between this group and that resuscitated by WB alone from the beginning.
  7. All results can be attributed to the groups’ interventions as confounding variables were minimised and the initial injury reproduced in each case.

Discussion

While this is a small population study, it has become a sentinel paper as it demonstrates clear evidence that chest compressions in a TCA are detrimental and that our reflexive management of medical arrests is not transferable. We need to shift our focus to optimising fluid resuscitation. It shows a clinically relevant outcome that is internationally applicable. It is important to note that it was terminal hypovolaemia, not true cardiac arrest with no output, which was being measured. However terminal hypovolaemia is an imminent precursor of cardiac arrest.

Reflections from Nuala Quinn

I have listened to Dr Sarah Watts present this paper and listening to her reinforced my opinion that this paper is superb. It challenges the dogma and forces us to push beyond traditional management strategies in what is arguably the most stressful paediatric emergency: major trauma.

Closed chest compressions are a mainstay of medical management. They are firmly embedded in resuscitation culture and indeed have become a mainstay of civilian culture. When healthcare practitioners hear the word “arrest” they automatically move into the “chest compressions” mindset. However medical cardiac arrest and traumatic cardiac arrest are two completely different entities with ensuing separate management. Anecdotally it is difficult to separate the two and advising a team that no-one needs to do chest compressions in an arrest causes anxiety and confusion. This happened only recently in our department where advising one of our staff that we didn’t need to do chest compressions as a priority was met with “but it says in APLS so we need to do them”. 

So how do we get around this? In my mind we do this in two ways: 

Firstly, we use and promote the life-saving bundle of interventions for TCA and keep it as a completely separate entity. When leading a TCA, as the pre-brief I will usually start with This is a Traumatic Cardiac Arrest which will need the bundle of life-saving interventions before anything else”. I write the bundle of life-saving interventions on the adjacent whiteboard and assign specific people to them. I focus on the bundle, rather than ABCDE. Focusing the team on the bundle, rather than the “arrest” per se, helps to separate the medical arrest from the traumatic arrest. 

Nuala's priorities for traumatic cardiac arrests
Team priorities in a traumatic cardiac arrest

I follow the PERUKI guideline which can be found here. The bundle needs to be prioritised over chest compressions and defibrillation. For revision, here is the bundle:

Secondly, we use the evidence and this is where papers like Watts et al come in. Evidence is fluid, it changes all the time. It takes years for resuscitation courses and bodies to update manuals and so it is our responsibility to use emerging evidence and use it sensibly and progressively. Watts’ paper helps me to educate and challenge dogma, particularly with compressions and saline resuscitation. Again, anecdotally the practice of giving saline as the initial resuscitation fluid in trauma exists.  We seem to be hesitant to give blood immediately, with view that to try with saline first is better, to not waste blood. The literature is now abound with papers describing the deleterious effects of saline in trauma, particularly with regard to its dilutional effects and role in worsening trauma coagulopathy. Again, this paper supports the choice of whole blood over saline and is in keeping with the life-saving bundle.  This paper cements for me, the reasons for the importance of the life-saving bundle before anything else and should empower us to make better decisions in the trauma reception and resuscitation:

Should we just give a saline bolus first?

Should we just get someone to do chest compressions as they have no pulse?

The answer here should always be no, and this paper is evidence to support that. The TCA algorithms are almost exactly the same, between adults and paediatrics and in institutions all over the world. This has really helped to standardize the management of TCA and have people trust the bundle, rather than revert back to what feels safe for them (compressions and saline in most instances). 

As to our case above, I wasn’t team-leading and with 10min to the patient’s arrival, didn’t want to push the issue, so the plan for compressions went ahead and the role was assigned. However, at the end of the trauma resuscitation, I realised that the chest compressions hadn’t actually been performed. So in that clinician’s subconscious, there was an understanding and mutual trust in the process of changing and progressing how we better manage traumatic cardiac arrest. Watts and PERUKI are leading the way. It is up to us to follow them.

Selected references

Watts S, Smith JE, Gwyther R and Kirkman E. Closed chest compressions reduce survival in an animal model of haemorrhage-induced traumatic cardiac arrest. Resuscitation. 2019; 140:37-42. Doi: 10.1016/j.resuscitation.2019.04.048

Rickard AC, Vassallo J, Nutbeam T, Lyttle MD, Maconochie IK, Enki DG, et al. Paediatric traumatic cardiac arrest: a Delphi study to establish consensus on definition and management. Emerg Med J. 2018;35(7):434-9.

Vassallo J, Nutbeam T, Rickard AC, Lyttle MD, Scholefield B, Maconochie IK, et al. Paediatric traumatic cardiac arrest: the development of an algorithm to guide recognition, management and decisions to terminate resuscitation. Emerg Med J. 2018;35(11):669-74.

(ANZCOR) AaNZCoR. Australian Resuscitation Council Guidelines 2016 [Available from: https://resus.org.au/guidelines/.]

Clavicle fractures

Cite this article as:
PJ Whooley. Clavicle fractures, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29144

Darragh is a 7 year old who needed to get his ball back from his neighbour. He decided to jump the tall fence but fell before he got over the top and landed on his right shoulder. Mum brings him in and he is holding right arm to his side and not happy when you try and examine his shoulder. The ED doctor has ordered an x-ray.

Epidemiology

Clavicular fractures are the most common shoulder fracture in children (8% to 15% of all paediatric fractures). They are common during delivery too and occur in 0.5% of all normal and 1.6% of breech deliveries, accounting for 90% of obstetric fractures.

Anatomy

80% of clavicular growth occurs at the medial epiphysis. It ossifies between 12-19 years of age and fuses fully by 22-25 years. The clavicle is the first bone in the body to ossify (intrauterine week 5), but the medial clavicular epiphysis is the last to appear and close. There are multiple ligamentous connections that are relevant.

Mechanism of injury

There are two mechanisms of injury: indirect and direct.

Indirect injuries commonly occur after a fall onto an outstretched hand (FOOSH).

Direct fractures are sustained from direct trauma to the clavicle or acromion and are associated with a higher incidence of injury to underlying neurovascular and pulmonary structures.

Evaluation

Children typically present with a painful, palpable and tender mass. There is usually a discrete tender swelling, but tenderness may be diffuse in the cases of a plastic bowing. Bony crepitus and ecchymosis are often present. It is important to ensure there is no overlying skin compromise.

Assess neurovascular status as although brachial plexus and subclavian artery injuries are rare, they can occur and will require urgent orthopaedic intervention.

In the setting of direct trauma, assess the child’s respiratory status. Rarely medial clavicular fractures may be associated with tracheal compression in the setting of significant posterior displacement.

Radiology

Clavicle plain films are often sufficient rather than full shoulder x-rays. Often a single view might be all that is obtained. The diagnosis may be made as an incidental finding on other x-rays such as a chest x-ray. In the trauma setting, 2 views are ideally better than one: a frontal view and a cephalic tilt (15-45 degree).

In most cases, clavicle fractures are easily identified on plain x-ray. There is commonly displacement of the fracture; the medial fragment is pulled upwards by the sternocleidomastoid while the distal fragment is pulled downwards by the weight of the arm. Occult fractures may also be present. When describing a clavicle fractures note the location of the fracture along the shaft. The Allman Classification of clavicle fractures separates the segments into thirds.

Look for angulation and/or displacement of the fracture. Is it comminuted?  If there is shortening, measure, and document the degree of overlap (> or < 2cm), sometimes best seen on a PA chest x-ray.

Note any relevant negatives and associated findings. Comment on any variation in sternoclavicular (SC) joint, acromioclavicular (AC) and coracoclavicular (CC) alignment and distances.

Normal acromio-clavicular alignment

Midshaft clavicular fractures

Midshaft clavicular fractures are the most common paediatric shoulder fractures, accounting for 10-15% of all fractures. Half of these are in children <10 years. They almost always heal but if they don’t, the malunion is usually not of clinical significance. There is excellent remodeling within one year and complications are very uncommon. Thankfully, like many other children’s fractures, they commonly fracture in a greenstick pattern.

Operative management is reserved for adults and children over the age of 10 years, particularly if the clavicle is significantly shortened or displaced.

Case courtesy of Dr Ian Bickle, Radiopaedia.org. From the case rID: 53795

Neer classification of midshaft fractures

  • Non-displaced: If there is less than 100% displacement, these are managed conservatively
  • Displaced: If there is greater than 100% displacement, the non-union rate is 4.5%. These are managed operatively.

Medial Clavicular Injuries

Medial clavicular injuries are much less common in children. Most medial clavicular injuries are Salter-Harris type I or II.

True sternoclavicular (SC) joint dislocations, though rare, may occur and in the case of posterior dislocations, 30% are associated with life-threatening mediastinal injuries.

I’ll take a minute to describe this as it’s an important point. In SC joint dislocations, the clavicle typically displaces anteriorly in up to 90% of cases.

If concerned, then x-raying both sides (called a serendipity view) would help make a diagnosis.  If there remains concern, then a CT scan of the SC joint can be helpful, and is generally favoured as the imaging modality of choice.

Clinical image showing a protrusion over the right SCJ. Corresponding AP plain film demonstrating widening of the SCJ. From brownemblog.com

Most children with an anterior SC joint dislocation can be managed with a sling or collar and cuff.

Much less often the clavicle moves posteriorly in relation to the sternum, especially in the setting of tremendous force applied to the shoulder or the medial clavicle. If there is no evidence of medial epiphyseal fracture but pain and swelling is present you must consider a dislocation. Posterior dislocations can present with pain over the anterior chest, increased on shoulder movement. A dislocation may impact the structures behind including the trachea and blood vessels in that region. Hoarseness could indicate a recurrent laryngeal nerve injury or airway compromise.

SC joint dislocations are classified as Grades I-V, with Grade V being a posterior dislocation. Any child with a suspected posterior SC joint dislocations should be referred to the on-call orthopaedic team – these are orthopaedic emergencies, with CT angiograms favoured to characterise the extent of vascular injury and operative reduction performed, often in consultation with vascular surgeons.

Lateral third clavicle fractures

These can be easily confused with acromioclavicular (AC) joint injuries. Both present clinically with pain and tenderness around the AC joint plus swelling and bruising. The ‘cross-arm test’ (ABDuction across the chest) results in increased pain in both conditions. Little or no deformity may be seen on x-ray unless a Salter-Harris II fracture is present.

Management

Nonoperative management involves sling immobilisation with gentle range of motion exercise at 2-4 weeks and strengthening at 6-10 weeks. This is indicated in fractures of the middle 1/3, if there is shortening and displacement that is under 2cm with no neurology.

Operative management, open reduction and internal fixation (ORIF), is indicated in open fractures, displaced fractures with skin compromise and/or subclavian artery or vein injury and in major trauma with a floating shoulder where the clavicle and scapular neck are both fractured.

Complications

Non-union can occur in up to 5% of all types of clavicular fractures. Clavicular injuries that are most at risk of non-union include comminuted fractures and 100% displaced fractures with shortening that is over 2cm, resulting in decreased shoulder strength and endurance. Children over the age of 10 with displaced clavicular fractures will often have a face to face consultation in fracture clinic to discuss operative options to optimize outcome.

Who doesn’t need follow-up?

Children under 10 with an undisplaced fracture don’t need follow-up (although some places offer virtual follow-up), with simple management with a broad arm sling for 2 weeks and no contact sports for another 6 weeks after the sling is removed. It’s important to tell the child’s parents that a lump will form at the fracture site and will last for about a year. Give safety netting advice to return if they develop any sensory changes.

Thankfully Darragh only suffered a midclavicular greenstick fracture with minimal angulation. His arm was placed in a broad arm sling and his parents were told to keep it on for 2 weeks and no fence vaulting for a couple of months! As Darragh’s only 7 years old and his fracture was not significantly displaced, his parents were reassured that it would heal nicely. Most importantly he eventually got his ball back. Phew!

References

JS. Zember, ZS Rosenberg, S. Kwong, SP. Kothary, MA. Bedoya. Normal Skeletal Maturation and Imaging Pitfalls in the Pediatric Shoulder.  Radiographics. 2015 Jul-Aug;35(4):1108-22

https://radiopaedia.org/articles/paediatric-shoulder-radiograph-an-approach

Intraosseous access

Cite this article as:
Gavin Hoey and Owen Keane. Intraosseous access, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.31005

It is 15.50 hrs on a Tuesday when the call comes in. A 3-year-old female is in cardiac arrest.

When it is an adult patient, we can manage this without even breaking stride…but as you begin to formulate your action plan, your brain now needs to focus on areas that you don’t tend to dwell on when it comes to a grown-up patient – How will I gain access? What are my medication doses? What are those novel airway features again? While we are more confident and experienced managing adult patients in cardiac arrest, it is important to remember that – Familiarity Breeds Contempt” – and this is different.

We are weaving in and out of rush hour traffic while deriving our WETFAG when we get updated information that an FBAO* may have led to this arrest.

*EM/prehospital speak for foreign body airway obstruction

My colleague and I discuss a plan of action:  we allocate roles, make a difficult airway plan, and agree to ensure that exceptional high-quality Basic Life Support is delivered in the first instance. We know that fundamentals matter most.

We discuss access options:

  • Intravenous (IV) – but will it be possible?
  • Intraosseous (IO) – we know that this is both possible and effective.

On arrival we find a 3-year-old old girl lying in a playroom. She is being tended to by a crew of firefighter-paramedics who have arrived just ahead of us.

I can see she is unresponsive but breathing. Her breathing does not look normal. She looks very unwell.

I get a handover from those on scene while Simon gets straight to work with airway assessment.

We voice our plan to the team:

  • Team role allocation reaffirmed.
  • Assess and manage the airway.
  • Assess and assist breathing.
  • Get access.
  • Complete a rapid A-E assessment to ensure we are not missing vital information.
  • Maximise team dynamics, performance, and optimise management of scene environment.

The decision to proceed with vascular access in paediatric patients is not an easy (or common) one to make for pre-hospital practitioners. Knowing that this patient was “Big Sick” makes the decision somewhat easier, but not so the challenge.  

When to IO?

Intraosseous (IO) is a rapid and effective method for accessing non-collapsible marrow veins without sacrificing pharmacokinetics.

Any delay in establishing vascular access can be potentially life threatening.

The Royal Children’s Hospital Melbourne states In decompensated shock IO access should be established if IV failed or is going to be longer than 90 seconds”.

The decision to gain IO access should be considered in the following scenarios

Selecting the site

How do we choose a site for placing an IO line and what can influence our decision?

Is the case medical or trauma? If it is a trauma, where are the injuries? Fractures at, or above, the insertion site can compromise the integrity of the underlying anatomic structures. Importantly, what sites are practical and accessible to me in this case right now?

Having never attempted IO access on a paediatric patient before, I stuck with what I had done most frequently in training and decided on “proximal tibia” as my site for IO insertion.

“In the pre-hospital environment, it is sometimes as important to know when not to do something as it is to know when to do something”

Justification for tibial IO access in this not-arrested patient was based on the following case elements for me:

  • IV access had failed.
  • I had a small child, obtunded and unresponsive, requiring airway and breathing support, tachycardic, tachypnoeic, and hypoxic. Big Sick.
  • Activities “up top” were busy, very busy – although the airway did not appear to have a FBAO, it did require my colleague to maintain a good seal. I did not feel positioning for humeral IO was viable at this moment.
  • This was a medical case with no apparent lower limb or pelvic trauma.

Of course, one must always consider contraindications before proceeding with IO access.

Contraindications

  • Fractures at (or above) the insertion site
  • Crush Injuries
  • Ipsilateral vascular injury
  • Illness or anomalies to the underlying bone e.g. osteomyelitis, osteogenesis imperfecta, osteoporosis.
  • Previous failed IO attempts at this location
  • Overlying skin infection
  • Pain associated with infusion may be considered a reason not to continue using the line if it cannot be controlled.

Landmarks

I considered all potential options for IO insertion before choosing the site most familiar to me– proximal tibia. Other possible sites included:

  • Distal tibia
  • Distal femur
  • Humeral head
Intraosseous insertion sites

Anatomical landmarks for the insertion site depend on whether you can palpate the tibial tuberosity or not. The tibial tuberosity does not develop until around 2 years of age. If you cannot feel the tibial tuberosity in the smaller child, palpate two fingerbreadths down from the inferior border of the patella, then one finger breath medial to this point. Where the tuberosity is palpable, just go one fingerbreadth medial to it.

Target flat bone and pinch the tibia (especially in the very young patient) to reduce bone mobility, and to prevent the skin rotating with the driver before starting needle insertion.

Surface anatomy for insertion around knee
Landmarks for proximal tibial insertion

This is a small child. While it might seem like there is no time to hesitate; training, planning, awareness, and observation are vital I recalled the phrase “Power and Pressure”. This was not going to require as much force as I usually use in adult IO insertion. “Let the driver do the work” and be careful not to overshoot through the bone.

Placing the needle over the landmark site at 90 degrees, I visualised the line I wanted to drill. After careful, but firm, passing of the needle through the skin, I pressed the trigger. After the first pop, I was careful not to overshoot. Anticipation here is key so avoid putting too much pressure on the driver. Similarly, be careful to avoid excessive recoil when you feel you have reached the medullary space as this can result in dislodgement of the needle.

But am I in the right space?

Attempt to aspirate marrow from your line (though it might not always be present). Flushing saline through with little to no resistance is very reassuring. No Flush = No Flow!

The line needs to be secured in place and the extension tubing attached properly with no identifiable leak points. What we give through the line should generate a physiological response – if it does not, always consider if the line has become displaced.

The proximal tibial site may not always be an option, so we where else can we go?

Medial view of ankle
Landmarks for distal tibial insertion

Distal Tibia

Place one finger directly over the medial malleolus; move approximately 3 cm or 2 fingerbreadths proximal and palpate the anterior and posterior borders of the tibia to assure that your insertion site is on the flat center aspect of the bone. 

Distal femur surface anatomy
Landmarks for distal femoral site of insertion

Distal Femur

Midline, 2-3 cm above the external condyle or two fingerbreadths above the superior border of the patella. This is often an accessible site due to children having less muscle bulk. To ensure you avoid the growth plate, the leg should be outstretched when performing your landmarking’s above and aim about 15 degrees cephalad too.

Landmarks of the humeral head for IO insertion
Landmarks for insertion in the proximal humerus

Humeral Head:

The humeral head represents an excellent access point for large proximal vasculature (lies closer to the heart). Flow rates may be higher here too due to lower intramedullary pressures. The greater tuberosity secondary ossification centre doesn’t appear until about 5 years of age making palpation of this landmark more of a challenge in the younger child.  For this reason, it is more often used in older children, typically over 7 years of age or only in those in whom the anatomy can be readily identified.

You may need to consider using a longer needle here due to the larger amount of soft tissue over this axillary area.

The insertion site is located directly on the most prominent aspect of the greater tubercle. 1 cm above the surgical neck. The surgical neck is where the bone juts out slightly – you will find this by running a thumb up the anterior aspect of the humerus until you feel a prominence. This is the greater tuberosity. The insertion site is approximately 1cm above this.

It is important to position the arm correctly.

hand on belly or thumb to bum position for humeral IO
Positioning the arm for humeral IO

Humeral IO placement techniques:

  • Thumb to Bum – Move the patient’s hand (on the targeted arm) so that the patient’s thumb and dorsal aspect of hand rest against the hip (“thumb-to-bum”).
  • Palm to umbilicus – Move the patient’s hand (on the targeted arm) so that the palm rests over the umbilicus, while still maintaining the elbow close to the body.

Site versus flow

As mentioned above, the proximal humerus is very close to the heart and this, coupled with seemingly lower intramedullary pressures, lends itself to higher flow rates when compared to the lower limb sites.

Important to note, however, that any abduction or external rotation of the arm during resuscitative efforts (easy to picture this happening when moving your patient from scene to ambulance!) can lead to dislodgment of you IO. Nice and easy does it.

An awake IO?

The sound of the driver buzzing brings back dentist chair memories for all of us. No less so for your patient who, if conscious during the insertion, will be particularly anxious and upset. Anticipate this and control anxiety with reassurance, distraction, and parental explanation if you can.

Pain in the conscious patient with an IO in situ can be from the area around the insertion site as well as the volume expansion caused by infusion. A small volume of 2% lidocaine can be given through the line prior to commencing the infusion to help with pain – this is slowly infused over 120 seconds, left for 60 seconds, then flushed with 2-5ml of saline.

Always consider line dislodgment or compartment syndrome with gross discomfort and inspect/flush the line to ensure it is still functioning adequately.

Size of IO – credit to Tim Horeczko

What about the gear itself?

The EZ-IO 10 driver and needle Set is a semi-automatic intraosseous placement device commonly found in our EDs. All needle catheters are 15 gauge giving gravity flow rates of approximately 60-100ml/min. The use of pressure bags can greatly increase these rates. It is important to make sure you pre-flush the connector set to ensure no residual air can be injected after attachment.

Fail to Prepare, Prepare to Fail”. Practice really makes perfect and so frequent familiarisation sessions are encouraged to get used to both the IO equipment and identifying the various access sites and their relevant anatomy.

A recent study by Mori et al (2020) showed a high rate of successful placement at 92.7%. This paper also described the complications encountered with the use of EZ-IO in a paediatric population in a paediatric ED. The complication rate seems to be consistent across all needle sizes at around 21%. Complications (particularly the more commonly occurring extravasation and skin) are important considerations for PEM IO training programmes.

Potential complications

  • Extravasation or subperiosteal infusion – the highest reported complication in the Mori paper was 17% of all IO insertions. This occurs if you fail to enter the bone marrow or happen to go through the entire bone itself and overshoot the medullary canal. Dislodgement of a well-placed IO line during resuscitation can lead to this occurring too.
  • Dermal abrasion4% in Mori study. A more recently described complication of using the semi-automatic IO approach, these injuries can occur due to friction from the rotating plastic base surrounding the EZ-IO needle. While these all seemed to settle with conservative treatment it is important to watch out for this during insertion.
  • Compartment syndrome – rare…but the smaller the patient the higher the risk.
  • Fracture or physeal plate injury.
  • Osteomyelitis – very rare, reported as 0.6% (Rosetti et al).
  • Fat embolus

The use of POCUS to rapidly confirm intraosseous line placement and reduce the risk of misplacement with extravasation has been discussed in recent times. This paper by Tsung et al in 2009 comments on its feasibility and describes using colour Doppler signal with a saline flush to identify flow in the bone around the IO to confirm placement. Misplacement may also be identified if flow is seen in the soft tissues rather than bone.  

The Super Smallies

Achieving safe and reliable intraosseous access in the neonate or infant can be a big challenge as they have smaller medullary canal diameters. Higher risks of misplacement and extravasation also put this group at risk of compartment syndrome. Case reports of limb amputation secondary to iatrogenic compartment syndrome from IO misplacement are almost exclusively in neonates and small infants.

A case report by Suominen et al. in 2015 described proximal tibia mean medullary diameters on x-ray as 7mm in neonates, 10mm in 1-12-month infants, and 12mm in 3-4-year old children. The EZ-IO needle set for this group is 15mm in length and 12mm in length once the needle stylet is removed. This leaves a narrow margin of safety for the correct positioning and the avoidance of dislodgement of the IO needle.

With the measurements above, it makes sense that one would need to stop a few mm short to avoid throuugh-and-through insertion and subsequent extravasation. Stopping short like this could make the line more difficult to protect…Scott Wingart and Rebecca Engelman outline some neat tricks to “SEAL THE HECK OUT OF…” these delicate lines over here.

The systematic review by Scrivens et al in 2019 describe IO as an important consideration for timely access in neonatal resuscitation practice. They comment on the importance of incorporating IO insertion techniques into neonatology training. While a more recent study of IO access in neonatal resuscitation by Mileder et al reports lower success rates for insertion at 75%, clearly further studies are needed to scrutinise this access modality in neonates and whether it can be considered as a standard reliable and fast alternative to umbilical vein access in a time-critical scenario.

What are the take homes?

  • Have a vascular access plan before arriving at the scene for every paediatric patient – consider adding this to the end of you WETFLAG.
  • There are clinical scenarios outside of the patient in cardiac arrest where IO placement may be necessary – the decision to IO after failed IV should be rapid in the shocked child.
  • Familiarise yourself with the equipment, needle sizes and gauge, and be aware of the age-related anatomical considerations when landmarking sites for IO insertion.
  • Let the driver do the work – nice and easy does it!
  • Complications can occur and are not always rare – extravasation from dislodgement or misplacement, as well as skin abrasions, are well reported.
  • The smaller the patient, the higher the risk of through-and-through misplacement – these “super smallies” are at a greater risk of compartment syndrome. 
  • Keep it simple….“No Flush = No Flow!”. POCUS may be used to confirm satisfactory line placement too.

References

Arrow EZ-IO Intraosseous Vascular Access System. 2017 The Science and Fundamentals of Intraosseous Vascular Access. Available at: https://www.teleflex.com/usa/en/clinical-resources/ez-io/documents/EZ-IO_Science_Fundamentals_MC-003266-Rev1-1.pdf#search=’flow%20rates’

Ellemunter H, Simma B, Trawöger R, et al. Intraosseous lines in preterm and full-term neonates. Archives of Disease in Childhood – Fetal and Neonatal Edition 1999;80:F74-F75.

Santa Barbara County Emergency Medical Services Agency Intraosseous (IO) Vascular. https://countyofsb.org/uploadedFiles/phd/PROGRAMS/Emergency_Medical_Services/Policies_and_Procedures/Policy%20538A.pdf.

Royal Children’s Hospital Clinical Practice Guideline – Intraosseous Access. https://www.rch.org.au/clinicalguide/guideline_index/Intraosseous_access/

Advanced Paediatric Life Support, Australia & New Zealand: The Practical Approach, 5th Edition Published October 2012.

Weingart et al. How to place and secure an IO in a peds patient. https://emcrit.org/emcrit/how-to-secure-an-io-in-a-peds-patient

Wade, T. Intraosseous Access in Neonates, Infants and Children. 2019. https://www.tomwademd.net/intraosseous-access-in-neonates-infants-and-children/

Mori, T., Takei, H., Sasaoka, Y., Nomura, O. and Ihara, T. (2020), Semi‐automatic intraosseous device (EZ‐IO) in a paediatric emergency department. J Paediatr Child Health, 56: 1376-1381. doi:10.1111/jpc.14940. Available at: https://onlinelibrary.wiley.com/doi/10.1111/jpc.14940

Rosetti VA, Thompson BM, Miller J, Mateer JR, Aprahamian C. Intraosseous infusion: An alternative route of pediatric intravascular access. Ann. Emerg. Med. 1985; 14: 885–8.

Ngo AS, Oh JJ, Chen Y, Yong D, Ong ME. Intraosseous vascular access in adults using the EZ-IO in an emergency department. Int J Emerg Med. 2009;2(3):155-160. Published 2009 Aug 11. doi:10.1007/s12245-009-0116-9.Available at:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2760700/

Tsung JW, Blaivas M, Stone MB. Feasibility of point-of-care colour Doppler ultrasound confirmation of intraosseous needle placement during resuscitation. Resuscitation. 2009 Jun;80(6):665-8. doi: 10.1016/j.resuscitation.2009.03.009. Epub 2009 Apr 22. PMID: 19395142. Available at: https://pubmed.ncbi.nlm.nih.gov/19395142/

Suominen PK, Nurmi E, Lauerma K. Intraosseous access in neonates and infants: risk of severe complications – a case report. Acta Anaesthesiol Scand. 2015 Nov;59(10):1389-93. doi: 10.1111/aas.12602. Epub 2015 Aug 24. PMID: 26300243.Available at: https://pubmed.ncbi.nlm.nih.gov/26300243.

Intraosseous (IO) – Salford Royal NHS Foundation Trust.  https://www.srft.nhs.uk/EasysiteWeb/getresource.axd?AssetID=45337&type=full&servicetype=Inline

Mileder LP, Urlesberger B, Schwaberger B. Use of Intraosseous Vascular Access During Neonatal Resuscitation at a Tertiary Center. Front Pediatr. 2020 Sep 18;8:571285. doi: 10.3389/fped.2020.571285. PMID: 33042930; PMCID: PMC7530188 Available at: https://pubmed.ncbi.nlm.nih.gov/33042930/.

Scrivens A, Reynolds PR, Emery FE, Roberts CT, Polglase GR, Hooper SB, Roehr CC. Use of Intraosseous Needles in Neonates: A Systematic Review. Neonatology. 2019;116(4):305-314. doi: 10.1159/000502212. Epub 2019 Oct 28. PMID: 31658465. Available at: https://www.karger.com/Article/FullText/502212.

Lefèvre Y, Journeau P, Angelliaume A, Bouty A, Dobremez E. Proximal humerus fractures in children and adolescents. Orthop Traumatol Surg Res. 2014 Feb;100(1 Suppl):S149-56. doi: 10.1016/j.otsr.2013.06.010. Epub 2014 Jan 4. PMID: 24394917. Available at: https://pubmed.ncbi.nlm.nih.gov/24394917/.

Wrist x-rays

Cite this article as:
Sian Edwards. Wrist x-rays, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29082

The wrist is one of the most commonly requested X-Rays in the children’s emergency department. Wrist views are requested when injury to the distal radius/ulna or carpal bones are suspected. Below is a systematic approach to interpretation.

The wrist series examines the carpal bones (scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate and hamate), the radiocarpal joint and the distal radius and ulna. 

There are eight carpal bones present and each one is named according to its shape:

  1. Scaphoid (boat-shaped)
  2. Lunate (crescent moon-shaped)
  3. Triquetrum (pyramidal)
  4. Pisiform (pea-shaped)
  5. Trapezium (irregular trapezium-shaped)
  6. Trapezoid (wedge-shaped)
  7. Capitate (head-shaped) – *the largest of the carpal bones
  8. Hamate (wedge-shaped with a bony extension, or ‘hook’)
Labelled XR of carpus
AP
Proximal carpal rowDistal carpal row
ScaphoidTrapezium
LunateTrapezoid
TriquetrumCapitate
PisiformHamate

How to best remember the carpal bones

There are many mnemonics around – some too rude for mention here! You will need to find the one that works for you… here’s one that’s super suited for clinicians working with kids:

Sam Likes To Push The Toy Car Hard

Failing that, save an image to your phone for quick reference!

Mnemonic for remembering carpal bones

Ossification

The carpal bones are formed entirely from cartilage at birth – this is important from a radiological viewpoint as it means they are not visible on x-ray initially. They begin to ossify from about 1-2 months of age and are fully developed by the age of 8-12 years. Although there is variability in the timing, the order is always the same.

  1. Capitate 1-3 months
  2. Hamate 2-4 months
  3. Triquetrum 2-3 years
  4. Lunate 2-4 years
  5. Scaphoid 4-6 years
  6. Trapezium 4-6 years
  7. Trapezoid 4-6 years
  8. Pisiform – 8-12 years

Generally, on x-ray, one carpal bone is visible every year until full development – this acts as a handy (pun intended) ageing tool!

On requesting wrist X-Rays, most commonly you will receive posteroanterior and lateral projections, with oblique views forming part of the series usually when carpal injury is suspected.

1. Check the soft tissues

Look for signs of swelling or any incidental findings.

2. Trace the bony cortices

Trace each bone in turn to look for breaks or irregularities in the cortex.

Look closely at the distal radius, proximal carpal row (especially the scaphoid) and the proximal metacarpals. Disruptions in the cortex may be very subtle as in the case of this torus fracture (aka a buckle fracture)

Buckle fracture of radius
Buckle fracture

3. Check bony alignment

On the AP view:

The distal radial articular surface should curve round the carpals with the articular surface getting more distal towards the ulnar styloid. The articular surfaces of the proximal and distal carpal rows should form three smooth arcs – these can be traced on the AP film.

The spacing between all carpal bones should be 1-2mm.

If the arc is broken or there is widening or lack of uniformity between the spaces, think about carpal dislocation.

The articular cortex at the base of each metacarpal parallels the articular surface of the adjacent carpal bone.

The carpo-metacarpo (CMC) joint spaces should be clearly seen and of uniform width (1-2mm).

The 2nd to 5th CMC joints are visualised as a zigzag tram line – on a normal view, there will always be the “light of day” seen between the bases of the 4th and 5th metacarpals and the hamate bone. If this is narrowed, think dislocation of the 4th or 5th metacarpal.

Labelled AP view of wrist
AP view

On the lateral view:

The distal radius, lunate and capitate should articulate with each other in a straight line on the lateral x-ray – the apple, cup, saucer analogy – the cup of the lunate should never be empty.

Lateral view of carpus
Normal capitate – lunate – radius alignment. Image adapted from a case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 37947

If the cup is empty, this suggests a perilunate dislocation.

Perilunate dislocation
Perilunate dislocation. Image adapted from a case courtesy of Dr Ian Bickle, Radiopaedia.org. From the case rID: 46714
The apple and cup model of perilunate dislocation
The slipped cup of the perilunate dislocation

References

https://radiopaedia.org/articles/wrist-radiograph-an-approach?lang=gb

Immobilizing the cervical spine

Cite this article as:
Shane Broderick. Immobilizing the cervical spine, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.30298

Pre-alert: 3-year-old male, fall from a 2nd story window. No obvious external injury and is moving all 4 limbs. Vital signs not available but he is alert. He has IV access, pelvic immobilisation, 3-point spinal immobilisation and had been given intranasal analgesia. ETA 5 minutes.

What is my role in this clinical situation? As a Specialist Registrar in Emergency Medicine, I am the one standing in resus with a red sticker across my chest, preparing myself, my team, my environment, and my equipment to receive this potential traumatised patient. 

Once my head is in the right space, I brief my team on the pre-alert and set out a shared mental model of the best- and worst-case scenarios. Space is made available and we set about gathering our equipment. 

  • Haemostatic dressings
  • Pelvic binder
  • IV/IO
  • Rapid infuser
  • Cervical collar

As the impending clinical challenges of this patient play out in my head, I prepare my team to deliver a trauma package of care. This may involve managing a brain injury, decompressing a tension, binding an open book, or drawing a long bone out to length. Major trauma is uncommon in paediatrics with only 5% occurring in those less than 14 years of age. Most children are injured in their own home (38%) with falls from height accounting for over half of the cases. While always being cognisant of possible spinal injuries in paediatric trauma, the actual incidence is low. Paediatric cervical spine injuries account for 1-10% of all spinal injuries. Various anatomic (large head size) and physiologic reasons (flexible spine) account for this, which of course, will change with age. 

Trauma resuscitation is being rewritten. ABC is now about turning off the tap and has become CACBCDE. If cervical spine consideration comes so early in our primary survey, can we just pop a hard collar on the neck and move on? As I ponder the clinical case outlined, I recall my early days as a newly qualified doctor and indeed think back to the very start and the Hippocratic oath; ‘before we try to make things better, first and foremost, don’t make things worse’. Is the collar more a curse than a cure?

The cervical collar was introduced into pre-hospital practice in 1967, but its perceived benefit has always been more theory than evidence. More and more of the evidence suggests that collars are not likely to make things better and more likely to make things worse. So why do we apply collars in the first place? Time for a little MYTHBUSTING.

MYTH: We reduce the risk of secondary injury

Studies have shown that in patients with a primary cervical spine injury, there were no significant differences in secondary injuries in those with or without a cervical collar. More worryingly, some of the available evidence points to larger neurological deficits in trauma patients with the cervical collar versus without. MYTH BUSTED.

MYTH: We can immobilise the injury

The collar is an ineffective means of immobilisation as it does not prevent movement. How often have you seen a patient looking around for the toilet or for their mate? The cervical collar can lead to increased movement in the upper parts of the neck compared to no collar as patients struggle to deal with its presence. Advanced Trauma Life Support (ATLS) 10th edition has acknowledged this futile exercise and has changed its terminology from C-spine immobilisation and replaced it with restriction. 

Cadaveric studies have shown that collars do not effectively reduce motion in cervical spine fractures with studies showing three-dimensional movement of up to 23 degrees during application of the collar. MYTH BUSTED.

MYTH: Use the collar, as a label

Some courses and institutions advocate using a collar as a label, a label to say that the team remain concerned about possible c-spine injuries. While I can understand the thought process, this may detract from the detailed examination of the neck that is required as we search for potential life-threatening neck or thoracic injuries such as Tracheal deviation, Wounds and haematomas, External markings, Laryngeal disruption, Venous distention, Emphysema. 

The collar may interfere with airway assessment and management and research supports this and may pose an aspiration risk. 

The presence of a collar limits neck exposure and thereby inhibiting procedures such as vascular access or indeed front of neck access. Many of the time-critical interventions that are required in complex trauma resuscitation are potentially hampered by a decision paralysis. One way of mitigating this risk is to plan and anticipate interventions such as using point of care ultrasound to mark the cricothyroid membrane in the predicted difficult airway or in cases of massive facial trauma. The presence of a collar, even if used as a label, may impact this lifesaving procedure.

Collars may raise intracerebral pressure with recent studies demonstrating the affect that collar application has on optic nerve sheath diameter.

Collar application may result in respiratory compromise with studies demonstrating a significant decrease in lung capacity and spirometry parameters in those with collars versus without. MYTH BUSTED.

MYTH: How about using international guidelines to clear the c-spine without imaging and removing the collar in this case?

We cannot use NEXUS (sensitive but not specific and PPV of only 1.2% in patients <8 years of age) or Canadian C-spine rules (excluded patients <16 years of age). MYTH BUSTED.

I doubt many will disagree that cervical collars have proved as much of a pain in the neck for practitioners as their patients. They are intrusive, distressing, anxiety-inducing and may exacerbate pain, fear, and stress. They are difficult to size, awkward to fit, require at least two practitioners and never seem to be perfect. Poorly fitted or prolonged use has even been associated with pressure wounds.  

And so, back to the case. Our patient suffered a dangerous mechanism of injury, but with no evidence of improved patient outcome to support the use of cervical collars in trauma, we need to ask ourselves the question, before you intervene, do you need to? We should manage our patient in a gentle, supportive and age appropriate manner and where possible with their parents by their side who themselves could provide manual inline stabilisation in accordance with APLS (Advanced Paediatric Life Support) guidelines. What we do need to do is to trust patient intuition. If doing something causes them pain, they will not do it.  Recalling our Oath and our promise not to do harm, it is worth bearing in mind that our three-year-old patient may be better able to protect their own injury than we can. 

References

Reid C, Brindley P, Hicks C, Carley S, Richmond C, Lauria M, Weingart S. Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness. Clin Exp Emerg Med. 2018 Sep;5(3):139-143. doi: 10.15441/ceem.17.269. Epub 2018 Sep 30. PMID: 30269449; PMCID: PMC6166036.

National Office of Clinical Audit, (2020) Major Trauma Audit National Report 2018.

Benger J, Blackham J: Why do we put cervical collars on conscious trauma patients? Scand J Trauma, Resuscitation Emerg Med. 2009, 17: 44-10.1186/1757-7241-17-44.

Hauswald M, Ong G, Tandberg D, Omal Z: Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998, 5 (3): 214-219. 10.1111/j.1553-2712.1998.tb02615.x.

Liao S, Schneider NRE, Hüttlin P, Grützner PA, Weilbacher F, Matschke S, Popp E, Kreinest M. Motion and dural sac compression in the upper cervical spine during the application of a cervical collar in case of unstable craniocervical junction-A study in two new cadaveric trauma models. PLoS One. 2018 Apr 6;13(4):e0195215. doi: 10.1371/journal.pone.0195215. PMID: 29624623; PMCID: PMC5889057.

https://litfl.com/airway-in-neck-trauma/

Yuk M, Yeo W, Lee K, Ko J, Park T. Cervical collar makes difficult airway: a simulation study using the LEMON criteria. Clin Exp Emerg Med. 2018 Mar 30;5(1):22-28. doi: 10.15441/ceem.16.185. PMID: 29618189; PMCID: PMC5891742.

Rai Y, You-Ten E, Zasso F, De Castro C, Ye XY, Siddiqui N. The role of ultrasound in front-of-neck access for cricothyroid membrane identification: A systematic review. J Crit Care. 2020 Aug 13;60:161-168. doi: 10.1016/j.jcrc.2020.07.030. Epub ahead of print. PMID: 32836091

J, Richman PB, Leeson B, Leeson K, Youngblood G, Guardiola J, Miller M. The Influence of Cervical Collar Immobilization on Optic Nerve Sheath Diameter. J Emerg Trauma Shock. 2019 Apr-Jun;12(2):141-144. doi: 10.4103/JETS.JETS_80_18. PMID: 31198282; PMCID: PMC6557047.

Ala A, Shams-Vahdati S, Taghizadieh A, Miri SH, Kazemi N, Hodjati SR, Jalilzadeh-Binazar M. Cervical collar effect on pulmonary volumes in patients with trauma. Eur J Trauma Emerg Surg. 2016 Oct;42(5):657-660. doi: 10.1007/s00068-015-0565-1. Epub 2015 Sep 3. PMID: 26335538.

Professionals prepare properly

Cite this article as:
Shane Broderick. Professionals prepare properly, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29456

Throughout my career, I’ve always had a keen interest in trauma. As I prepare to depart to take up a trauma fellowship at the Alfred hospital in Melbourne, I was interviewed for the case report podcast and asked for some of my ‘tips and tricks’ of the trauma care trade. When I started to prepare for that talk and now this blog post, I thought, what would I like to have known when I started off receiving major trauma patients? What advice would I give to my more junior self?

Professionals prepare properly”. That phrase that I first heard from friend/colleague/mentor Dr Cian McDermott (@cianmcdermott) is still ringing in my ears. We need to prepare now for that patient that we might meet on shift later on today, perhaps tomorrow or maybe even years into the future. If preparation is key, then I feel that the ‘zero-point survey’ from Cliff Reid et al. is a great place to start. It represents somewhat of a change to the traditional teaching that we are all familiar with such as ATLS (Advanced Trauma Life Support) in that it asks you to prepare to receive the patient before the point of first patient contact. It asks you to ready yourself, your team, your environment, and your system. So here are some of my hopefully helpful hints, framed around the survey.

Me, myself and I

Is it just me or does a major trauma pre-alert bring about the flight before the fight response? How often does a team member come to you and their first contribution is… do I have time to run quickly to the toilet? They do. You do. Always. Manage your own stress.

Tip 1: Take 30 seconds for yourself

When I am the Trauma Team Lead (TTL) preparing to receive a patient, I often walk the long way around to the resus room. This may seem strange when time is of the essence, but it affords me that thirty seconds of headspace for a quick personal pep/prep-talk. It allows me to clear my mind, focus on the task at hand, formulate a plan, rationalise my ‘fight-flight’ response that will allow me to optimise my ability and to meet the patient on the correct side of the Yerkes-Dobson curve. When a patient is at their worst, they demand your best!

The Yerkes-Dobson curve of how stress affects performance

Tip 2: Acknowledge your weakness and then address it

As trainees, at the end of each year, we are asked to fill out an end of year assessment for ourselves and our training sites. The questions are straightforward until, question four. List your weaknesses.

This can sometimes be hard, not because we are perfect (far from it), but because we often either do not acknowledge our weaknesses or indeed somewhat suppress them. We need to look critically at ourselves, to find our weaknesses and then, to address them. For me, as a junior trainee, I felt that I needed to improve my airway skills, so I attended the TEAM course. I wanted to enhance my critical care management, so I attended the ED-Critical care course in Ede, Netherlands with Cliff Reid. Are you confident with the advanced resuscitation skills that are required in trauma?  Could you perform a lateral canthotomy, pericardiocentesis or thoracotomy? If not, find a course (shameless plug www.resuscitate.ie)!

Trauma is a team sport

Emergency Medicine is far better than General Surgery (cue onslaught)! To qualify this, I started life as a basic surgical trainee before transitioning to Emergency Medicine and for me, my work-life balance instantly became better! There were many reasons for this.

  • I no longer had a bleep
  • I only had to be in one place at one time (albeit often that means being thinly spread over a large department). And most importantly…
  • My team were always with me (onsite).

I am passionate about Trauma Teams (TTs) as they have been shown to optimise patient care by reducing time to diagnostics and interventions. In Ireland, there are currently no accepted TT configuration or activation criteria for such a team. This presents a massive challenge in terms of data capture with only 8% of major trauma patients documented as being met by a trauma team on arrival. I have recently written a position paper for IAEM (Irish Association for Emergency Medicine) and the Emergency Medicine Programme (EMP) on TTs that can be used for collaborative engagement with the National Trauma Office as well as to engage with the key stakeholders including Surgery, Critical Care, Trauma & Orthopaedic Surgery and nursing amongst others to aid the development and roll-out of TTs for Ireland so, watch this space!

Back to the survey. Prepare the team. As the TTL; assess the pre-alert (remembering Mansoor Khan’s wise words that in major trauma, “the word stable only refers to the place where a horse lives”), activate the appropriate team, allocate appropriate roles, and anticipate what this resus may entail.

Tip 3. In expecting the unexpected, set out a shared plan.

What is the best-case scenario? What is the worst-case scenario? Create a shared mental model with the team. If a thoracotomy is required then having anticipated this prior to the patient’s arrival might alleviate some of the fear factor. If a team member is not comfortable witnessing such a resuscitation, then it allows them to excuse themselves at an earlier stage.

Tip 4. Insist on a silent resuscitation

Noise suggests chaos. It may indeed be the pen perfect resuscitation, but if people have to raise their voice and even shout to be heard, this can often be disruptive.

Centre stage

Is the environment ready? Is there sufficient space to receive the trauma? If anticipating a Code Red (massive transfusion), could two resus bays be made available? Is there a dedicated trauma bay? If not, can one be established?

Tip 5. Better to be looking at it than looking for it

Check and re-check equipment. Are there blood products in the fridge? Have the rapid infusers been primed and readied? Is there any additional equipment that is likely to be required such as good trauma shears (preferably ones with no plaster of Paris on it!), pelvic binder, good haemostats (not Kaltostat), bite blocks etc. If the equipment that you require is not available, where can you get it from? Can you improvise?  Two quick tips; CAT (Combat Application Tourniquet) MIA? Use a manual blood pressure cuff. No McKesson bite blocks for your Le fort II/III? No problem! Use a few tongue depressors taped together (Thanks to Jason van der Velde).

If the equipment is there, then use it. When it comes to POCUS, you may not be using E-FAST, but, in a major trauma patient with complex facial fractures, marking the CTM (cricothyroid membrane) ultrasonographically informs the team that surgical cricothyroidotomy is a potential. Pre-empting the requirement for life, limb and sight-saving procedures and discussing them out loud, as a group in advance will go a long way to help avoid decision paralysis.

A Trauma System for Ireland? Hopefully.

We can start today by ensuring that our own house is in order. How do we do this? Teach. Train. Simulate. MDT simulation in your resus room allows new processes to be vetted and existing systems tested. Logistics are far more difficult to test in simulation labs. Practice where we preach. Can processes be streamlined? Can default trauma identifications be used? Does the trauma call generate the same response as your STEMI or FAST call? Out-of-hours are trauma calls consultant-led? If not, can telemedicine be used for offsite support? 

Tip 6. TRAUMA CALL = STEMI CALL = FAST CALL

Are there checklists out there that will allow trauma care delivery in a safer manner? Trauma proformas allow accurate and efficient documentation and also serve to prompt the delivery of time-critical actions.

Multidisciplinary teaching is key. Having a regular trauma forum to discuss the major trauma cases that have attended is crucial.  Too often the only forum that these cases are openly discussed is in some Morbidity and Mortality meeting when there has been a bad, or at least unexpected outcome? Do we discuss the ‘good’ cases? Do we hot and cold debrief? Have we Schwartz rounds in our institution?

Nobody will forget 2020 in a hurry. COVID-19 has had a profound impact on each of us. Has it all been bad? I suggest not. Staff numbers have increased (perhaps not as good as they were in May, but certainly an improvement). Emergency Departments have increased in size. Equipment that was on an exceptionally long wish list has suddenly appeared. With this newfound political resource and energy, healthcare has by-in-large, improved (or maybe it is just less bad). With this in mind, trauma care in Ireland is set to undergo reconfiguration with the development of an inclusive System and based on similar international systems, destined to save lives. The political standstill that marred healthcare might be changing. Trauma Care delivery is changing. The Southern and Central trauma leads for Ireland have recently been appointed.  With very tightly crossed fingers and a few more grey hairs for the Clinical Lead for Trauma Mr Keith Synnott, a trauma system for Ireland seems to be on the horizon.

Lastly, the handover from your pre-hospital colleagues.

Final tip. Before taking handover, ask three important questions

  1. Does the patient have any exsanguinating haemorrhage?
  2. Do they have a central pulse?
  3. Are they protecting their airway? If so, carry on with the patient transfer.

Sometimes in my career, I have felt like the proverbial rabbit in headlights, nodding in seeming agreement with my paramedic colleague but occasionally with little information being retained. Nowadays, I try to summarise the handover in a one-sentence synopsis. This helps me to focus and hopefully the team to do likewise. Always ask for silence and sterility for handover. It only takes 30 seconds and may save much more than this if there is a missed communication piece.

References

1. Reid C, Peter Brindley P, Hicks C, Carley S, Richmond C, Lauria M, and Weingart S. Zero pointsurvey: a multidisciplinary idea to STEP UP resuscitation effectiveness. Clin Exp Emerg Med;Sept (5(3)):