Management of Pediatric Wrist Injuries

Case Study:
A 13-year-old boy fell on an outstretched hand during a soccer game and sat out the rest of the game. Afterwards he is brought to the ED for wrist swelling and pain. His swelling is localized to the wrist with tenderness to palpa¬tion of the snuffbox and distal radius.

The x-rays look normal to you but the amount of pain and swelling are concerning for fracture. Several ques¬tions come to mind. Do children get wrist sprains? Could he have a Salter-Harris I (SH I) fracture of the radius or a scaphoid fracture? Is additional imaging indicated? What is the best plan for management?

You immobilize the wrist in a forearm splint. The patient wants to know when he can return to practice and if he will be able to play in the game a week from today. When is it safe for children to return to sports activities? What kind of follow-up does he need?

Case Study Conclusion:
No fracture was noted on the soccer player’s x-rays. He had a thumb spica splint applied in the ED. On orthope¬dic follow-up 2 days later, his wrist remained tender and an MRI showed a fracture of the distal third of the scaph¬oid. A thumb spica cast was applied. His fracture healed without complications.

Risk Management Pitfalls:

“I don’t see any wrist tendon involvement.” Don’t be fooled. Short lacerations can conceal deep underlying injury. Physical examination tends to underestimate the amount of damage to tendons, arteries, and nerves. If there are localized findings or the examination is inconclusive, referring your patient for operative exploration is indicated.

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Management of Pediatric Ankle Injuries

Case Study:
A 14-year-old male is out in triage with an ankle injury. The nurse calls back to see if you want to send him di¬rectly to radiology. You decide to examine the patient first. On the way out to triage, you ask yourself some ques¬tions about ankle injuries in the pediatric patient. Do the Ottawa ankle rules apply? Are adolescents more likely to get a sprain or a fracture? Are there any differences in the fracture patterns seen in younger children, adolescents, and adults?

When you arrive in triage, you see a football player still in pads, with his ankle elevated. The patient tells you he was just standing when someone playfully pushed him down from the side. He reports no previous ankle injuries and has been unable to bear weight since the accident. You notice he has a large amount of swelling about the ankle, but his pulses and sensation are intact. His pain is diffuse around the ankle, but it appears most intense over the distal anterior tibia. You decide to provide him with some narcotic analgesia and send him to radiology.

Case Study Conclusion:
Your 14-year-old football player has made it back from radiology and is awaiting your interpretation of his films. He has an SH IV triplane fracture of the distal tibia with minimal displacement. You recall that this is one of the few instances where more advanced radiology is helpful in ankle injuries, so you send him back to radiology for a CT of the distal tibia and ankle. Fortunately, CT does not reveal any displacement or fragmentation, as can occur with these fractures. After orthopedic consultation, the patient is admitted to the hospital with a bulky posterior splint and no weight-bearing until definitive surgical repair can take place in the morning. You wish the family luck since the triplane fracture carries quite a bit of risk for growth dysfunction no matter what is done due to significant damage to the growth plate.

Risk Management Pitfall:

“My patient has anterior ankle pain but I don’t see any evidence of a fracture on her x-rays.” Always look closely at the mortise views to best see the distal tibia, and pay close attention to make sure spacing around the mortise is equal.

Ottawa Ankle Rules:

The Ottowa Ankle Rules state radiographs are only required when there is an ankle/midfoot injury with:
• Bony tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus
• Bony tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus
• Bone tenderness at the base of the fifth metatarsal (for foot injuries)
• Bone tenderness at the navicular bone (for foot injuries)
• An inability to bear weight both immediately and in the emergency department for 4 steps

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Management of Pediatric Knee Injuries

Case Study:
In the middle of a rather chaotic shift in the ED, you pick up a chart that notes a chief complaint of knee injury in a 14-year-old male. The adolescent and his family have emigrated from Nigeria and speak broken English, but they are able to explain he was playing basketball when this injury oc¬curred. You wonder if any further history is helpful or if you should just send him for radiographs. With a little more investigating you discover he was “faking” a shot when this injury occurred and there was no contact with another player. His physical exami¬nation reveals tenderness surrounding the patella and proximal tibia, but his pain appears out of proportion to the degree of acute swelling you notice. You explain to the family that pain control is going to be started with hydro¬codone, and radiographs will follow.

Is this adolescent more likely to have a fracture or a ligamentous injury based on his age, history, and physical examination? Do the clinical decision rules regarding knee injuries apply to the pediatric patient? Do the injury pat¬terns in this adolescent differ from those in an 8-year-old or a 17-year-old? If his knee radiographs are inconclusive, what should you do? What are the latest trends in treating pediatric anterior cruciate ligament (ACL) injuries?

Case Study Conclusion:
The 14-year-old Nigerian basketball player who presented to the ED with knee pain after playing basketball came back from radiology without an obvious finding on his radiograph. Further questioning revealed after “pump-faking” a shot, he had intense anterior knee pain and has been unable to ambulate since. He had previously been healthy without any chronic symptoms. His degree of ten¬derness with palpation around the patella and proximal tibia were still concerning. He was sent back for compari¬son views of the uninjured knee. Upon closer comparison, a slightly higher riding patella was noted in the injured knee, and there appeared to be a small “fleck” of bone where the inferior patella normally resides. With his pain now under better control, he was still unable to extend the knee which confirmed the diagnosis. This young athlete had a patellar “sleeve” fracture after a forceful contraction of his quadriceps. After consultation with orthopedics, he was discharged home in extension with a knee immobi¬lizer and instructions for no weight-bearing. Follow-up the next day confirmed the diagnosis and surgical repair was arranged.

Risk Management Pitfalls:

1. “I found a large, traumatic effusion of the knee in my patient who was involved in a motor vehicle accident, but I could not find any evi¬dence of a fracture.” Knee dislocations of the femur and tibia may spontaneously reduce before arriving to the ED. A high degree of suspicion should be main¬tained for this dislocation because of the risk of neurovascular injuries which may necessitate amputation. If a dislocation is suspected, ortho-pedic consultation and admission with frequent neurovascular checks are essential.

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Predictive Factors of Failure For Non-invasive Positive Pressure Ventilation (NPPV)

Ventilator Management: Risk Management Pitfalls

1. “My patient’s peak inspiratory pressure alarm kept beeping, so I decided to decrease the tidal volume.” Did you check the plateau pressure first? Plateau pressure represents the force required to overcome the lung’s elastic recoil. It will increase with decreased compliance, overdistention of the lungs, or hyperinflation. It is important to note the difference between overdistention (too much tidal volume and subsequent alveolar stretching) and hyperinflation (trapped air in the lungs). If the plateau pressure did not change then the lung’s recoil force did not change, and the ventilator alarmed for another reason.

Peak inspiratory pressure (PIP) also reflects the total force required to flow air through the lungs. Increases in PIP without change in plateau pressure may be due to an obstruction to airflow or an increase in airway resistance. In this case, higher PIP levels would not indicate overdistention. Consider increased secretions (suction the airway), bronchospasm (give bronchodilators), and obstruction (check ETT placement).

2. “My patient’s peak inspiratory alarm kept beeping, and I couldn’t find the silent button.” What if the increase in PIP was the result of decreased compliance? If the plateau pressure increased to the same extent that peak pressure increased without a difference between the two (no change in resistance: R = PIP – Pplat/Flow) then decreased compliance is to blame. Factors that decrease compliance include alveolar collapse/atelectasis (measure auto-PEEP and apply PEEP), lung collapse (decompress the pneumothorax), overdistention of the lung (decrease tidal volume), air trapping (reduce I-time or rate), and right mainstem intubation (confirm with CXR).

Please compare pitfall 1 and 2. Note that the PIP alarm in pitfall 1 resulted from increased airway resistance whereas it represents an increase in plateau pressure due to decreased compliance in this example. While these events may appear similar and the alarms sound the same, understand that their etiologies and management are quite different.

3. “Since my asthmatic had extremely high inspiratory resistance, I chose to use a lower inspiratory flow rate.” While a high inspiratory flow may exaggerate the high resistance in asthma and result in increased peak inspiratory pressures, a short inspiratory time is necessary to allow for a prolonged expiratory time. The expiration phase of breathing must be extended so air trapping is avoided. A careful balance must be obtained between adequate inspiratory flow, PIP, and sufficient expiratory times. Longer E-times are necessary to minimize air trapping and hyperinflation. Setting the ventilator to deliver a high inspiratory flow rate shortens I-time (thus, longer exhalation time).

This will increase inspiratory flow and increase PIP. The severe airway resistance seen in asthmatics actually prevents the complete transference of this pressure to the alveoli (Poiseuille’s law) thus averting alveoli from experiencing the full effect of the PIP. Recall the difference between PIP and plateau pressures. If you raise the PIP, there may not be a corresponding change in the plateau pressure after you shorten the I-time and lengthen the expiration because you’ve reduced the auto-PEEP somewhat. As a result, the plateau pressure will tend to decrease. A high peak airway pressure is not necessarily dangerous unless it corresponds to a dangerously high transalveolar pressure (Pplat).

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Ventilator Management: Case Study

Case Study:

You realize that it’s been just a little too quite tonight when the radio suddenly cackles to life: “Teenage girl asthma can’t breathe diaphoretic giving nebs No IV 2-minute ETA.” Within minutes, two medics rush in with a diaphoretic cyanotic girl perched forward on her hands. Her pleading glance catches yours as you watch her take her last voluntary breath; intubation is obviously required ventilator management is your concern since you realize her life depends on it

As you resuscitate the crashing asthmatic, your 60-year-old male patient on the other side of the curtain, who has been sleeping comfortably, begins to complain that his breathing is getting worse. He is a frequent flyer with a known history of bad emphysema and a worse attitude. He adamantly refuses ‘the mask’ ventilation. You think back about his chest x-ray, which showed extensive bilateral pulmonary infiltrates, and wonder how long your luck can hold up before you need to intervene with him. His voice and attitude sound oddly weak, but you remember that the last time he was intubated he developed a pneumothorax.

Just as you ponder these thoughts, a seasoned pair of medics burst into the ED. The hiss of nebs can be heard under the rushing sound of high pressure CPAP. “Sorry Doc, tried to raise you on the radio but no one answered. This lady is sick and not moving much air. We got her on CPAP at 20, 100%, but we’re not making much progress; heart rate of 170 and can’t get her sats higher than 60%. She’s got CHF. Had no time to intubate.” Just then their short, morbidly obese, pale, diaphoretic patient rips her CPAP mask aside and screams, “I can’t breathe.” Her eyes then roll back, and she begins to have a hypoxic seizure.

Case Study Conclusion:
Case #1: You intubate the young asthmatic and start her on pressure control ventilation. She is adequately sedated and paralyzed as you obtain your initial settings. Because of severe obstruction and prolonged expiratory phase, you have the following settings: FIO2 100% and PCAC to achieve target tidal volume of 400 mL. The inspiratory occlusion maneuver reveals an acceptable plateau pressure of 27 cm H2O. After initial PEEP of 5, the P-flex suggests you set the PEEP at 8 cm H2O. The patient is adequately sedated with ketamine and morphine and therefore tolerates a respiratory rate of 6 breaths per minute and a short inspiratory time with a prolonged expiratory time. With these settings, you get an ABG of pH 7.28, PaO2 85, and PaCO2 of 110. The nurses are uncomfortable and ask to increase the respiratory rate and oxygen. Instead, you recognize the role of permissive hypercapnia and lung protective strategies. The whistling of the continuous nebs comforts you as you arrange an ICU admission.

Case #2: Your frail COPD patient deteriorated soon after you stabilized the asthmatic. You wondered if this man would ever come off the vent as you deftly slid the 8.0 ETT through the cords. After airway stabilization, you set your ventilator as follows: PCAC, FIO2 100%, PIP 22 (corresponds to volumes between 600 cc and 800 cc), PEEP 14 (based on P-flex), sedated with midazolam drips and morphine, short inspiratory time with a prolonged expiratory time, and a respiratory rate of 8. This gives you an ABG of pH 7.40, PaO2 170, and PaCO2 of 30. You ask the respiratory therapist to reduce the FIO2 based on the oxygenation pleth (there is a good wave) and to reduce the PIP. She remarks that the plateau pressures are already below 30, but you explain that the corresponding volumes are a bit too large for a 60 kg man.

Case #3: Stabilizing this patient was a chore that involved management of her myocardial infarction, flash pulmonary edema, and new onset seizure (either hypoxic or a run of ventricular tachycardia). Her short neck, large size, and frothy pink sputum made intubation difficult. She ended up with a 7-0 ETT tube, volume control ventilation, FIO2 100%, set tidal volumes of 400 (corresponding plateau pressure 35), initial PEEP of 5, sedated with morphine and propofol, and a respiratory rate of 14. A P-flex shows an optimal PEEP of 15. You set this and notice, with satisfaction, that her plateau pressures come down as you recruit more lung volume. You adjust her tidal volumes up to 500 as you maintain her plateau pressures < 30. You also reduce your FIO2 to 50% to avoid absorption atelectasis.

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