Brain Teaser: Signs of pneumothorax when seen on thoracic ultrasound September 13, 2019


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The pediatric patient is arguably more suited for emergency ultrasound than the adult patient. Children generally have a smaller body habitus than adults and, therefore, less tissue for the ultrasound beams to penetrate. This often leads to clearer images of the different organ systems, which should yield better diagnostic accuracy.

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Ultrasound Assessment for Skull Fractures August 15, 2019


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The use of ultrasound at the point of care by emergency clinicians, as well as by other specialists, has become increasingly common over the last 25 years. Emergency POCUS can be used as a diagnostic test and also to visualize anatomy for procedural guidance. It allows the emergency clinician to rapidly rule in or rule out disease processes and guide ongoing investigation and management of patients in the ED.

Pediatric emergency ultrasound has been slower to progress than adult emergency ultrasound. However, the use of emergency ultrasound for pediatric patients has recently begun to formalize.

The pediatric patient is arguably more suited for emergency ultrasound than the adult patient. Children generally have a smaller body habitus than adults and, therefore, less tissue for the ultrasound beams to penetrate. This often leads to clearer images of the different organ systems, which should yield better diagnostic accuracy.

Ultrasound can be used in the evaluation of children with blunt head trauma to assess for skull fractures. (See Figure Below) The presence of a skull fracture increases the risk of traumatic intracranial hemorrhage 4- to 6-fold.

While the absence of a skull fracture does not rule out the presence of intracranial injury, assessment for skull fracture has been used to risk stratify.

Skull Fracture on Ultrasound

Patients with blunt head trauma. In a meta-analysis published in 2000, skull x-rays had a sensitivity of 38% and a specificity of 95% when interpreted by radiologists. Given this poor sensitivity, skull x-rays have been falling out of favor for assessment of skull fracture. However, there has been a renewed interest in skull ultrasound as perhaps a better tool to assess for skull fracture and to risk stratify patients with blunt head trauma.

Technique
Skull ultrasound is performed with a high-frequency linear array probe. The probe should be placed on the area of the skull with maximal tenderness, hematoma, or other sign of possible fracture. It should be scanned in 2 planes, looking for disruptions in the cortex. Sutures can be differentiated from fractures by following the cortical break to a fontanelle and by scanning the contralateral side for comparison. Additionally, the cortical break in a fracture will appear ragged, with sharp margins, while a suture will have a smooth appearance.

Several prospective studies have evaluated bedside ultrasound for skull fractures in children. Rabiner et al pooled data from previous trials along with their own data. They reported a sensitivity of 94% and specificity of 96% for ultrasound detection of skull fractures. Parri et al performed another study not captured in the Rabiner et al study, and showed a sensitivity of 100% and a specificity of 95%, with 1 false-positive result. A limitation of these studies was that the ultrasounds were performed on patients for whom a CT scan was planned. Therefore, the study population was already determined to be at higher risk for injury as compared to the entire spectrum of head trauma patients presenting to the ED. Nonetheless, it can be concluded that the diagnostic accuracy of skull ultrasound is superior to that of skull x-ray.

Future Applications
The current trend in the evaluation and risk stratification of pediatric head trauma is the incorporation of clinical decision rules, with the PECARN pediatric head injury prediction rule being the most sensitive and most commonly used in the United States.56 An area of future research is the incorporation of skull ultrasound in conjunction with a clinical decision rule to better risk stratify patients and possibly further decrease the number of CT scans being performed.

To read more about the PECARN Pediatric Head Injury Prediction Rule, go to: www.ebmedicine.net/PECARN-head-rule

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It is Trauma Awareness Month! Can you solve the trauma case below? May 10, 2019


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Do you need to do anything regarding the missing fragment? — ED Management of Dental Trauma in Pediatric Patients

Case Recap:
You are then asked to see a 15-year-old adolescent boy who has come in with a tooth avulsion. He was at basketball practice when another player accidentally elbowed him in the mouth. He did not lose consciousness and has pain only in his mouth. He was immediately brought to your ED, which is about 15 minutes away from where the accident happened. His coach arrives with the boy’s tooth in a container of milk. On physical examination, the patient has lost his right lateral incisor and a clot remains where his tooth had been. How much time do you have to replace the tooth to have the best success of replantation? What do you need to consider while handling, storing, and cleaning the tooth?

Case Conclusion:
For the 15-year-old boy, you decided to replace the tooth as soon as possible. The patient had no other medical problems. You used Yankauer suction and light irrigation to remove the clot from the socket. You held the tooth by the crown, briefly rinsed it off, and used firm, gentle pressure to reinsert the tooth without any difficulty. You had Coe PakTM paste available at your facility, and you created a temporary splint to secure the tooth. You instructed the mother to follow up with the dentist tomorrow and to provide only a soft diet until then. You told the coach and the boy’s mom that, in the future, they should attempt to reimplant the tooth at the time of the accident and instructed them on the steps involved.

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Click here to review the issue, Emergency Department Management of Dental Trauma: Recommendations for Improved Outcomes in Pediatric Patients (Trauma CME and Pharmacology CME).

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Do you need to do anything regarding the missing fragment? — ED Management of Dental Trauma in Pediatric Patients April 11, 2019


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Case Recap:
Your first patient of the day is a 2-year-old girl who tripped and fell while walking, hitting her mouth on the concrete sidewalk. On your examination, her left central incisor tooth appears to be fractured, with a yellow dot visible inside the tooth. The tooth is nontender and nonmobile. The parents don’t have the other part of the tooth and think it fell onto the street. You start to consider: How do you determine what kind of fracture this is and how serious it is? How does management differ between primary teeth versus permanent teeth, and how can you tell if this is a primary tooth or a permanent tooth? Do you need to do anything regarding the missing fragment?

Case Conclusion:
After seeing the 2-year-old girl with the chipped tooth, you realized that, given her age, this was likely primary dentition, which you confirmed with the parents. You could also tell on examination that the upper right central incisor was more of a milky-white color with a smooth edge, which is also consistent with primary dentition. You decided that the management priorities were to prevent further harm to the developing permanent dentition and to confirm that the tooth fragment was truly lost. You were unable to detect any retained foreign bodies on your physical examination, but you decided to obtain radiographic images to confirm. On facial radiography, there appeared to be a small foreign body inside her right upper lip. You repeated your physical examination and were able to extract the small tooth fragment. The girl’s left central incisor appeared to be an uncomplicated crown fracture. The girl was able to drink without difficulty. You did not have dental panoramic radiography available at your institution, so you instructed the parents to follow up with the girl’s dentist for assessment of her permanent dentition. You recommended a soft diet and to clean the tooth with chlorhexidine until the patient was able to see the dentist.

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