Improving Throughput, Mythbusting, Pediatrics

Inching closer to discharging an ICH from the ED?

A few years ago, I was with an attending who was discharged a pediatric patient.  Staff in general seemed hesitant, but this was a well-loved doc who’s reply was somewhere along the lines of, “this kid looks great! Do you know how many times my kids probably had a bleed and did fine? We over CT these young things! And if he has a bleed, what are they really going to do anyway besides charge a lot of money for no appreciable intervention?”

And with that, comes this retrospective single center study of 202 children 0-18 years of age with an acute CHI, an abnormal CT (defined as both nondepressed and depressed skull fractures, subdurals, epidurals, subarachnoids, intraparenchymal hemorrhage, and intraventricular hemorrhage), and a GCS 14 or higher.

Essentially, the question is, can these patients be safely treated in an obs unit?

Exclusions were multisystem trauma, nonaccidental trauma, prior neurosurgical conditions and coagulopaths were excluded as well.   86% of patients were 5 years of age and under, and only half of all patients presented to the ED in under 6 hours.  My first reaction to this was “huh?” –  but the authors go on to state the 73% of patients had a hematoma, 11% had LOC, 30% vomited, 28% had a change in behavior, etc… so I guess it makes sense that there was a delayed presentation since parents may have initially thought their child was alright, only to later to suspect something was afoot (or perhaps patients were transferred to their ED from outside facilities?).

Fun sidenote: 17% of patients had no exam findings, so I gotta ask – why were they scanned?  To put it another way, much like the aforementioned doc had asked- how many kids have we discharged without a head CT with clinically insignificant ICH?

 

So what did the authors find?  ZERO children were intubated, required neurosurgical intervention, PICU admission, or died.  All were discharged within 72 hours, and 86% of patients with >1 CT finding were discharged within 24 hours!   Surprisingly, this is actually somewhat consistent with prior studies.

 

Ultimately, before starting this at your institute, note that there are some subtleties in the data- like that 25% epidurals with a repeat CT (3 of 12) showed a larger bleed. But really, looking at the data on patients that were admitted, I have to ask – which of these *really* needed an admission? None had an intervention aside from continued analgesia / anti-emetics.

 

Of note, this hospitals EDOU had an admission rate of 3-4 % – wayyyyy below national average of 15-20% – so either they’re sending home a ton of kids from obs unnecessarily, their ED is placing way too many in obs, or the rest of us have it wrong.  Which leads me to agree with the authors on the following:

“For those well-appearing children in whom CT abnormalities are visualized, an EDOU is still an appropriate place for these patients, or should early discharge with home observation also be considered?”

 

Will we see a time when certain types of head bleeds are treated like low risk chest pain – accelerated protocols and an abundance of EBM suggesting early discharge? Or arranging for telemedicine to circumvent many of these transfers to tertiary care centers?

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Mythbusting

The Ketamine vs All battle continues

ketamine. Ketamine. Ketamine! KETAMINE!!!!

Is there anything the SoMe wonderdrug can not do? I mean, isn’t the answer *always* ketamine?

This is a single center, randomized, prospective parallel study for patients aged 18-70 with moderate to severe acute, traumatic, orthopaedic pain with pain scale >80 on VAS. With about 25 patients per treatment arm, they compared intranasal Ketamine (1 mg/kg), IV morphine (0.1mg/kg), and IM morphine (0.15 mg/kg).

 

The details:

Rule ins: Must have GCS 15, weight 50-110kg, systolic bp 90-160 mmHg, HR <100 bpm.

Rule outs: head trauma, history of regular opiates or psychiatric disorder, analgesia within 3 hours, “a large meal ingested within the previous hour,” any LOC, dizziness, vomiting, or nausea were excluded as well.

 

The group measured pain scales every 5 minutes for 1 hour, as well as ADRs at end of 1 hour. They deemed a 15 mm score reduction in pain deemed significant.

 

Time to onset was fastest in the IV morphine route at 8.9 minutes, Ketamine came in second at 14.3 minutes, and IM morphine, unsurprisingly, brought up the rear with 26 minutes. The time of onset between Ketamine and the two morphine routes was insignificant, though the time to onset between IM and IV morphine was statistically significant.  Also not surprisingly, Ketamine had significantly higher ADRs (difficulty concentrating 58% vs ~21%, confusion 50% vs ~15%).  While pain reduction at one hour was similar across all treatments, there was a trend for decreased patient satisfaction with Ketamine (58% satisfaction vs ~70% with morphine – this was not statistically significant).

 

While I would love to say this trial adds to the data for usage of Ketamine… not quite. It really does not look at the patients for which we would **want** to use ketamine – namely, say those with poor access that an IN analgesic may work wonders; those with an opiate habit; and seriously, what trauma patient doesn’t come in a bit tachycardic?  And while yes, the results are about in line with what we’ve seen in the past and sort of come to expect (reasonable analgesia, somewhat decreased patient satisfaction, higher ADRs) this just is not a real world study that we can point to and say, “this is why we need IN Ketamine in our protocols.”

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Improving Outcomes, Improving Throughput, Mythbusting, Pediatrics, Pediatrics, Pediatrics

SCI still rare in kids.

This paper demonstrates that once again, kids are quite durable.

The authors looked at 3701 patients under 19 years old evaluated for a cervical spine injury. Of the 44 patients with clinically significant cervical spine injury (CSI), 32 had plain films, none of which missed an injury.

32 out of 3701… or 0.86%

-There were ZERO patients under two years old with a CSI

Here is the caveat- one injury begets another. Of the 32 patients with CSI, ten (31%) had multiple lesions, with plain films not identifying all lesions in 4 patients. Given that, I think its fair to say CT (or admission for MRI) is warranted once an abnormality is found.

In summary, relevant cervical injuries in kids are rare (<1%), and plain films are a reasonable screening tool. CT is once again rarely needed, but beware since one injury seemingly begets another. I pretty much agree with the authors on this one,

Our calculated 100 % sensitivity (90% on PECARN, finding 168 of 186 CSI) does come with a large confidence interval and it should be expected that plain films sensitivity for CSI is likely lower in clinical practice. However, the small risk of missed injuries from plain films must be balanced against the increased risk of malignant trans- formation from performing CT scans on all children with suspected CSI.

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Improving Throughput, Mythbusting, Radiology

Distracting Injuries & the Pan-Scan

So, what is really distracting? According to NEXUS (multiple links here), it is any long bone fracture, visceral injury requiring surgical consultation, lacs >10cm, degloving injuries, crush injuries, large burns, or anything causing functional impairment. Do these requirements dictate the need for head CT as well?

In the ongoing debate of EM vs Trauma for selective imaging, comes this paper.  From April 2014 – September 2014, the authors looked at 330 patients with mild TBI (GCS 13 or higher), to determine if distracting injuries were truly an indication for head CT. Patients were excluded if 18 months or younger of age, over age 60, moderate/severe or progressive headache, 2 or more episodes of vomiting, +LOC, amnesia, seizure or antiepileptic use, intoxication, uncontrolled hypertension, anticoagulated, had a neurologic deficit, penetrating injury, or craniofacial deformity.

Of 184 patients with fractures & severe pain (90 lower limb, 56 upper limb, 36 thoracolumbar, and 2 pelvis fractures – note there were NO cervical fractures noted), 2 (1.1%) had brain edema on CT, while of the 146 patients with no fractures/dislocations and no/mild pain, only 1 (0.7%) had brain edema on CT. No patient in any group had any neurologic symptoms at 1 month or 3 month follow up.

For many of us, this confirms our practice.  Please share with your pan-scanning colleagues.

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Improving Throughput, Mythbusting, Radiology, Radiology

Who is really distracted by distracting injuries?

Those that (still) recommend the pan-scan in trauma, it would seem.  Over a once year period, this 803 patient prospective study (451 of which with distracting injuries) evaluated all awake, alert, blunt trauma patients with a GCS of 14-15 to determine the validity of an abdominal exam.  Endpoints were injuries which required the OR and those which required a transfusion.

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A ten percent failure rate of the abdominal exam for an intra-abdominal injury seems rather high, but this is ten percent of all who actually had an injury. When you consider “all-comers,” it’s more like 1.1% of those with a distracting injury and 0.57% for those without a distracting injury.  With that, you would need to scan over a hundred patients to find one intra-abdominal injury that you would have otherwise missed.  Throw in the fact that all five missed injuries in the distracted cohort had solid organ injuries, and that none of them required surgical intervention or blood transfusion, and you can see how the authors come to their conclusion:

These data suggest that clinical examination of the abdomen is valid in awake and alert blunt trauma patients, regardless of the presence of other injuries.”

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