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. Inspired by the PECARN guideline, supported with an extensive literature search, PREDICT have pulled 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)):

Concussion: Neha Raukar at DFTB19

Cite this article as:
Team DFTB. Concussion: Neha Raukar at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22181

After spending 12 years as the Director of the Division of Sports Medicine in the Department of Emergency Medicine at the Warren Alpert Medical School at Brown University, Dr. Raukar joined the Department of Emergency Medicine at the Mayo Clinic in 2018 as full-time faculty.

In this fascinating talk she explores what happens to those children we see every weekend in the emergency department. Whether it is a clash of elbow versus head on the footy oval or a punch to the face at karate practice or something as innocuous as a simple fall from the monkey bars we don’t give these head injuries the attention they deserve.

 

 

©Ian Summers

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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Maturing your approach to trauma: Anne Weaver at DFTB19

Cite this article as:
Team DFTB. Maturing your approach to trauma: Anne Weaver at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22196

Anne Weaver is a consultant in Emergency Medicine & Prehospital Care at The Royal London Hospital and Lead Clinician for London’s Air Ambulance. In this talk she shares her experience of caring for the ever-increasing number of stabbing victims in the United Kingdom. 


There is a disconnect between what adult trauma surgeons and paediatric trauma surgeons are exposed to and are expected to manage. Just one year shy of 16 and the paediatric surgeon, who may never have performed a paediatric thoracotomy, is looking after you, one year over and it’s the adult trauma surgeon with many a notch on their Finochietto.

©Ian Summers

 

DoodleMedicine sketch by @char_durand 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. 

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

iTunes Button
 

Blast Injuries: Paul Reavley at DFTB19

Cite this article as:
Team DFTB. Blast Injuries: Paul Reavley at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21941

Paul Reavley works as a consultant at the Bristol Royal Infirmary.  In this talk he uses his experience in the armed forces to talk about blast injuries. According to Save the Children, one in five children worldwide is living in a conflict zone.  We heard from Nat Thurtle about the crisis in Syria and the bombing of those places which should be safe havens for all. It is a public health problem. And unfortunately, as we have seen recently in Manchester, no one is immune.

 

 

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

iTunes Button
 

 

Taking your trauma team to the next level: Anna Dobbie at DFTB19

Cite this article as:
Team DFTB. Taking your trauma team to the next level: Anna Dobbie at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22066

Anna Dobbie works in HEMS, PEM, and Adult ED and is a badass at all of them. She is the person you’d want leading your trauma team. Want to be just a little more like Anna? Then watch her talk and find out how to step up.

As we are so fond of saying, “You set the tone.” That first two minutes of any resus is critical – and not just because of the decisions you make. If you can appear calm and in control, your teams’ actions will reflect that. Running every trauma call the same allows for cognitive off-loading as some behaviours become automatic. Whether they are ‘real’ calls or not so serious ones the team is expected to act the same either way.

 

 
 
DoodleMedicine sketch by @char_durand 
 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

iTunes Button
 

 

Orbital fractures

Cite this article as:
Orla Kelly. Orbital fractures, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21843

Epidemiology

Facial fractures in children accounted for just 4.6% of paediatric trauma admissions on review of the American National Trauma Databank. However, even though they are less prevalent than in an adult population, they are associated with other severe injuries and higher mortality compared with adults. The pattern of injury descends the face as the patient ages – the under 5s are more likely to sustain frontal bone and orbital roof fractures, while the 6-16-year-olds are more likely to have midface and mandibular fractures. Orbital fractures as a subset comprise between 5 to 25% of facial fractures.

Anatomy

Bones of the orbit
  • The orbit is comprised of 7 bones – maxilla, zygomatic, frontal, ethmoid, lacrimal, sphenoid and palatine.
  • The rim is formed by the frontal bone, maxilla, and zygoma.
  • The orbits are pyramidal structures, with a wide base opening on the face, with its apex extending posteromedially.
  • They lie anterior to the middle cranial fossa and inferior to the anterior cranial fossa.
  • Their close proximity to the sinuses coupled with the ophthalmic veins communicating with the cavernous sinus creates a possible introduction of infection into the intracranial cavity.
Location of the facial sinuses
  • The infra-orbital nerve exits through the inferior orbital foramen inferior to the orbital rim and innervates lateral aspect of the external nose, inferior eyelid and cheek and upper lip and related oral mucosa.
  • Paediatric anatomy and development confer different injuries depending on age, with orbital floor fractures becoming more common than roof fractures at approximately age 7 due to the development of the maxillary sinus.

History and Examination

Mechanism of injury is always important to elicit in trauma as well as careful and thorough (and documented) examination. Initial assessment as always in trauma is by the ATLS ABC approach followed by a careful secondary survey.

Children are prone to a pronounced oculocardiac reflex which may become apparent in the initial ABC assessment; this is caused by compression of the globe or traction on the extra-ocular muscles. Connections between the sensory afferent fibres of the ophthalmic division of the trigeminal nerve and visceral motor nucleus of the vagus nerve cause bradycardia and hypotension often with headache, nausea, and vomiting.

Have a systematic approach to examination so as to ensure all important aspects are covered. Always examine and document:

  • General inspection – oedema, laceration, and bruising
  • Enophthalmos/proptosis
  • Subconjunctival haemorrhage
  • Periorbital emphysema
  • Pupillary response including RAPD
  • Eye movements in all directions
  • Visual acuity
  • Diplopia
  • Palpation of the orbital rim for tenderness or step
  • Abnormalities of the nasal bridge (saddle nose deformity) and widening of the midface (telecanthus)
  • Disruption to the infraorbital nerve: numbness of the ipsilateral cheek, lip, and upper gum
Sensory distribution of infra-orbital nerve

Investigation and Management

Investigation of orbital fractures is by x-ray and CT, with CT being the modality of choice, though it can be unreliable in children with blowout fractures. A CT may already be appropriate due to a mechanism of injury or red flags for a head injury.

The aim of initial management in the ED is to prevent further damage to the globe.

Patients should be advised to not blow their nose and to sneeze with their mouths open. A cold compress and raising the head of the bed can help alleviate periorbital oedema. Ensure the eyelids can close fully and lubricate the cornea. Provide a protective patch if necessary.

 

Types of Injuries

 Orbital Floor and Medial Orbital Wall Fractures

The term ‘blow out fracture’ has historically meant a fracture of the orbital floor secondary to a direct blow to the globe, causing an increase in pressure that results in the thin orbital floor fracturing. Children presenting with floor or medial wall fractures are at high risk of entrapment, as paediatric bones are more prone to greenstick fracture, which then creates a ‘trapdoor’ effect ensnaring the inferior oblique and inferior rectus muscles or other orbital contents. Clinically, the child will be unable to complete upwards gaze. Entrapment is a surgical emergency, as ischaemia of the involved musculature can cause permanent damage. The infraorbital nerve is commonly damaged in these injuries.

Orbital blow out fracture

Children with orbital floor fractures may not have any facial bruising, classically presenting with a ‘white-eyed’ fracture with the only sign being limitation of eye movement secondary to entrapment.

(A) Restriction of upgaze in the right eye with no evidence of periocular trauma. (B) CT scan of the orbits demonstrating inferior rectus muscle entrapped within inferior orbital wall fracture (arrow). Reproduced with permission from www.emj.bmj.com

Orbital Roof Fractures

Orbital roof fractures are more common in childhood as the frontal sinus has not yet pneumatised, therefore all posterior force to the superior orbital rim is transferred to the anterior cranial base. Another mechanism of injury is a ‘blow-in’ fracture, where there is an inferiorly directed supraorbital force.

NOE (nasal-orbital-ethmoidal) Fractures

Nasal bone injuries are common in older children and adults and must always be assessed for an underlying NOE fracture. When direct force is applied to the nasal bone, it can cause a collapse of the paired nasal, lacrimal, and ethmoidal bones. If this fracture is missed in a child, significant midface deformities can result.

Midfacial fractures

Although children are more likely than adults to suffer isolated orbital rim fractures, orbital fractures are often involved in midfacial fractures of the maxilla and zygoma: the orbit is involved in Le Fort II and III; zygoma fractures are often accompanied by orbital floor or medial wall fractures.

Globe Injuries

Orbital fractures can often result in globe injuries ranging from corneal abrasion to rupture. If there are any signs of globe rupture (360 degrees conjunctival haemorrhage, misshapen pupil or a flat anterior chamber) a gross visual examination should be completed, vaulted eye protection applied, and immediate ophthalmology consult sought. Do not apply pressure to a possibly ruptured globe.

Retrobulbar haemorrhage

A rare but sight-threatening complication is a retrobulbar haemorrhage which causes increased pressure, stretching of the optic nerve and can result in permanent blindness. If optic pressure is low, medical management with mannitol, steroids, and acetazolamide can be used after expert involvement. However, if there is an indication that the pressure is high, a lateral canthotomy should be performed as a matter of urgency. The procedure should ideally be performed by an ophthalmologist, but when ophthalmology are delayed or unavailable, the procedure must be performed by an emergency clinician in the ED. Do not delay a lateral canthotomy for imaging if sight is threatened.

Indications for lateral canthotomy include:

  • Retrobulbar haematoma
  • Decreased visual acuity
  • Afferent pupillary defect
  • Proptosis

Pearls

  • Repeat a child’s eye examination while they are in the emergency – repeated examination can drastically change disposition from maxillofacial non-urgent transfer to a blue light ophthalmological review
  • Oculo-cardiac reflex can cause bradycardia and hypotension
  • Children are more likely to have other and significant injuries: the secondary and tertiary survey is imperative.
  • Children are more likely to suffer ‘trapdoor’ floor fractures causing entrapment that can present as a ‘white eye’ fracture– this is a surgical emergency, act fast.
  • Patients should avoid nose blowing and should sneeze with their mouth open following injury.
  • Ophthalmological assessment should be sought in all patients with orbital trauma.

Selected references

Imahara SD, Hopper RA, Wang J, Rivara FP, Klein MB. Patterns and outcomes of pediatric facial fractures in the United States: a survey of the National Trauma Data Bank. J Am Coll Surg. 2008;207:710–716

Oppenheimer AJ, Monson LA, Buchman SR. Pediatric orbital fractures. Craniomaxillofac Trauma Reconstr. 2013;6(1):9–20.

Koltai PJ, Amjad I, Meyer D, Feustel PJ. Orbital fractures in children. Arch Otolaryngol Head Neck Surg. 1995;121:1375–1379

Cohen SM, Garrett CG. Pediatric orbital floor fractures: nausea/ vomiting as signs of entrapment. Otolaryngol Head Neck Surg. 2003;129:43–47

Grant JH III, Patrinely JR, Weiss AH, Kierney PC, Gruss JS. Trapdoor fracture of the orbit in a pediatric population. Plast Reconstr Surg. 2002;109:482–489; discussion 490–495

Boyette, J. R., Pemberton, J. D., & Bonilla-Velez, J. (2015). Management of orbital fractures: challenges and solutions. Clinical ophthalmology. 2015;9:2127–2137.

Cobb ARM, Jeelani NO, Ayliffe PR. Orbital fractures in children. British Journal of Oral and Maxillofacial Surgery. 2013;41–46

Kassam K, Rahim I, Mills C. Paediatric orbital fractures: the importance of regular thorough eye assessment and appropriate referral. Case Rep Emerg Med. 2013:376564. doi:10.1155/2013/376564