NEXUS Criteria

Emergency Evaluation Of The Pediatric Cervical Spine Cost Effective Tips

Cost and Time-Effective Strategies:

1. Clinically clear the cervical spine when possi­ble. Avoiding radiographic studies saves not only their cost, but also time in the emergency room.

2. Don’t waste a lot of time or effort on getting the odontoid view. Successful attempts to ob­tain this view are rare in children under the age of 9 years.

3. If ordering a head CT, consider extending it to include the cervical spine from the occiput to C2. This eliminates the need for an odontoid and guarantees adequate visualization of the area most prone to injury in the small child.

4. If the patient has cervical pain or an abnormal­ity on plain film, consult an expert early. An orthopedic surgeon or neurosurgeon may have preferences about which further studies will be done. This can prevent redundant or unneces­sary imaging.

5. REMEMBER: The cost of a missed injury is far greater than the cost of additional imaging. During the time period from 1997 to 2000, the average hospital bill for a pediatric CSI patient was $57,280, and the average length of hospital stay was 13.47 days.

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Emergency Evaluation Of The Pediatric Cervical Spine Risk Management Pitfalls

Risk Management Pitfalls:

“I didn’t think she needed a cervical collar because she was up and walking around at the scene of the accident.” It is safer to provide cervical spine immobiliza­tion until the history can be reviewed, the child can be examined thoroughly, and the appropriate radiographic evaluations can be performed.

“They didn’t have a pediatric backboard in the ambulance, and they forgot to put anything under him. Since he’s already secured on the adult board, we’ll just leave him on it.” Immobilization on an adult backboard with no adjustment to allow for the proportionately greater head and occiput size keeps the cervical spine of a child from being positioned in neutral alignment. The resulting position, with the neck flexed and the chin tucked, can lead to upper airway obstruction.

“She said her neck didn’t hurt, so I thought it was OK to take her out of the collar.” Remember that children will often tell you whatever you want to hear, partly to please you and partly because they don’t want to wear a cervical collar! This is especially true if the child is scared or overwhelmed by the situation. Also, the impact of other distracting injuries can be more challenging to sort out in young children. It is most prudent to leave the collar in place until other injuries have been cared for and the child can be reassured by a more familiar face.

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Emergency Evaluation Of The Pediatric Cervical Spine Case Study

Case Study:

The Friday night shift brings a variety of traumatic injuries. First, a 15-year-old football player tackled the opposing quarterback while leading with his helmet. At the end of the play, he could not stand and stated his arms were tingling and both his legs were numb. Next, a 3-year-old fell down a flight of stairs after tripping on a toy. She is alert and crying but will not allow anyone other than her parents near her. Finally, an 8-year-old is brought in as a trauma alert, following a motor vehicle crash where another passenger was killed at the scene. This boy is unresponsive and is being bag-mask ventilated by the emergency response team.

Each of these children arrives to the emergency department with a cervical-spine-immobilizing collar in place. Despite very different mechanisms, each will require a complete cervical spine evaluation. What is required to safely remove the collar? Could any of these children be clinically cleared? What radiographic studies are indicated? When is expert consultation required?

Case Study Conclusion:

Each of the three patients had a mechanism of injury that required cervical spine evaluation. Neurosurgery was consulted to see the 15 year-old football player. A cervical spine CT demonstrated no bony injury. An urgent MRI demonstrated soft tissue and spinal cord edema. Cervical spine immobilization was continued, and he was admitted for neurological monitoring. At the time he was trans¬ported to his room, the tingling in his arms was subsid¬ing, but his lower extremity deficits persisted.

After some time, the three year old became less distressed and more active. Despite her cervical collar, she was playful and walked to the soda machine with her mom. At that point she cooperated with a physical exam, during which she had no neck tenderness and she demon¬strated a full active range of motion. Her cervical spine was cleared clinically and she was discharged to home.

The 8 year old was admitted to the Pediatric Inten¬sive Care Unit, where an intracranial pressure monitor revealed severe intracranial hypertension. Despite no obvious bony abnormality on plain films, his clinical course prevented MRI evaluation for ligamentous injury within 72 hours of his accident. Therefore, he remained in a cervical collar at the time of transfer to a rehabilitation facility. He was scheduled to follow up with Orthopedics for further evaluation in 6 weeks.

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Pregnant Patient Considerations For Medications Commonly Used In Trauma Care

Physiologic Changes in Pregnancy

Management Of The Pregnant Trauma Patient: Risk Management Pitfalls

Risk Management Pitfalls:

1. Failing to obtain a pregnancy test in any woman of childbearing age. A female trauma patient may be either unaware or unable to communicate that she is pregnant. A positive pregnancy test has important impli­cations for the subsequent management of the patient including avoiding unnecessary radia­tion, monitoring the fetus, and assessment of potential pregnancy complications.

2. Leaving a trauma patient in the later stages of pregnancy in a supine position. After 20 weeks, the gravid uterus can compress the vena cava, which reduces cardiac output and results in hypotension, when the patient is positioned on her back. reducing cardiac output with resulting hypotension.

3. Failing to anticipate a difficult airway when intubating a pregnant trauma patient. Pregnant patients present a potentially difficult airway for several reasons including soft tis­sue edema, decreased pulmonary reserves, and increased aspiration risk.

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Management Of The Pregnant Trauma Patient: Case Study

Case Study:

 A radio call interrupts your otherwise routine night shift. The EMS driver reports, “We are en route to your emergency department with a 31-year-old female, G2P1 at 33 weeks, belted driver, in a moderate-speed motor vehicle collision. Patient’s car was heavily damaged in the front, and the airbag did deploy. Following a brief loss of consciousness, patient is now awake but slightly confused. She has an obvious deformity of the right ankle and is complaining of lower abdominal pain and mild shortness of breath. Patient’s vital signs are as follows: heart rate is 110 and BP is 100/45. Our arrival time to your facility is approximately 3 minutes.” You now have 3 minutes to collect your thoughts and prepare your team for what is sure to be a challenging resuscitation.

Case Study Conclusion:

Upon arrival to the ED, your patient is awake and protecting her airway. Two 14-gauge IV catheters are placed and she is given 2 liters of crystalloid. The patient’s initial blood pressure is 90 /40 systolic; a nurse manually displaces the uterus to the left, and the next pressure is 105/60. A portable chest x-ray reveals a 30% pneumothorax on the patient’s right side. A chest tube is placed in the right 4th intercostal space. OB-GYN is consulted upon the patient’s arrival and a cardiac toco monitor is placed. The fetal heart rate pattern is reassuring, but a couple of uterine contrac-tions are noted. The patient has no appreciable abdomi¬nal tenderness, and a bedside FAST exam reveals no intraperitoneal hemorrhage. Vaginal exam reveals no evidence of bleeding or amniotic fluid. Given the loss of consciousness, the patient has a CT of the head which is negative, and a right ankle film reveals a right tib/fib fracture which is splinted. The patient receives pain medication and a dose of Rhogam is administered. She is admitted to the hospital and after a 24-hour period of monitoring reveals no other uterine contrac¬tions, she is taken to the operating room for repair of her ankle fracture. She is discharged from the hospital 5 days later and delivers a healthy baby 6 weeks later.

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