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Case report

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by

Kieran Sweeney

on 13 December 2012

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Transcript of Case report

paediatric chest trauma Case Report 09:30 12th October 2012 Road traffic accident airway patent, speaking

no respiratory distress, basal crackles on right, respiratory rate 18-20

no hemorrage evident, cap refill < 2secs, hr 102bpm, bp 117/71

GCS 15, PEARL 10:00 Grosseto A&E

Child arrives by ambulance
- awake, alert and responsive
- complaining of pain in left shoulder & thorax Primary survey carried out abrasions on face, chest, abdomen

hematoma over left clavicle

log roll: no lesions on back, no spine tenderness

pelvis stable

peripheral sensation normal

abdomen soft, non-tender Initial management Cervical collar and spinal board
3 x IV access
Fentanyl 50 mcg
30% Oxygen by mask (SaO2 100%)
Fluid infusion 1500ml
Antibiotics
Urinary catheter Boy expelled from front seat of car 12 years old, 60kg Grosseto Investigations at Grosseto 2 x chest
left shoulder
left wrist
cervical spine “multiple parenchymal contusion...more obvious on the right”
"right costofrenic angle obscured by effusion" "no radiological evidence of traumatic bone changes" “distal fracture of clavicle, with dislocation of shaft at both sternal and acromial ends" "limited by artifacts" 13.23 transferred to Meyer
Vital parameters stable Fracture of left clavicle
Right pulmonary contusion 15:29 Meyer A&E Primary survey repeated
Collar and spinal board removed 12th

15th

16th

18th

23rd Imaging at Meyer ? Were all these investigations all necessary? Understanding Clavicle Fractures A:

B:


C:


D: E: normal
normal Patient observed on ward awaiting surgery

Condition continues to improve
Vital parameters remain within limits
Cardiac markers fall to normal by 17th

Arm in sling

Oxygen and analgesia PRN 12th - 22nd October

injury to neurovascular structures Clavicle fractures Pneumothorax and Pulmonary Injury Aortic and Great Vessel Injury
"The clinical significance of pneumothoraces only detectable CT is questionable" "When combined with high clinical suspicion, the sensitivity of CXR is 98% for detection of aortic or great vessel injury" Victor et al, 2012 Cardiac Injury "Recent studies reported low sensitivity and specificity of CK-MB for cardiac injury"


"However, latest studies showed high accuracy of trop I and trop T in diagnosis of cardiac injury" "In the presence of both sternum and clavicle injury, we recommend the routine use of a contrast-enhanced CT scan to aid in the diagnosis of a great vessel injury" Aiding diagnosis in acute setting Reasons for imaging 1 in 20 of all fractures
boys 13-20
sports, RTA, simple falls

3% medial
69% mid shaft
28% lateral

52% simple non-displaced
28% simple displaced
20% comminuted fractures

80-90% conservative management 1, 2, 3
A, B
i, ii Robinson classification Trauma and Clavicle Fractures complex fractures increasingly seen due to improved survival from major trauma trop-I & CK-MB raised
sinus rhythm, hr 98 Abdominal US
CT head Bloods
ECG Echo, CXR

CT shoulder

Angio-MRI

CXR

X-ray shoulder Were any images not done, that should have been? "no changes are observed in size and course of the left subclavian artery" epidemiology & aetiology
classification
complications what to do and when Radiology in
Paediatric Chest Trauma Patient stable Diagnosis Condition IV fluid continued
Furosemide
Antibiotics continued
Echocardiogram and ECG Initial management
Admitted to surgical ward 16:20 Chest X-ray 19:00 our patient had 3bii and 1bii type 1 - least complications
type 3Bii - most complications
all 3B's need surgery medial, mid shaft, lateral
non-, displaced
simple, comminuted "the use of CT should be reserved for those patients who have strong clinical indicators of significant underlying injury" General recommendations 1. Moore et al, 2009, Pediatr Radiol Sinclair, 2002 Gottschalk et al, 2011 Moore et al, 2009, Paediatr Raiol aortic & great vessel injury
pneumothorax & pulmonary injury
cardiac injury (head injury) Guiding management i.e. surgery 2. "US has been shown in adults to be more sensitive than CXR for the diagnosis of pulmonary contusion...with sensitivity and specificity rates of >90%" Sybrandy et al, 2003 Smekal et al, 2009, Arch Orthop Trauma Surg Robinson, 1998, J Bone Joint Surg Robinson, 1998, J Bone Joint Surg Sybrandy et al, 2003, Heart Kieran Sweeney 4th Year, University Hospital of South Manchester Conclusions CT was not necessary in acute setting
It was correct to perform an Echocardiogram acutely
The relevance of a third chest X-ray is questionable
The relevance of an MRI-Angiogram on day 4 is questionable other thoracic injury

pulmonary contusion
pneumothorax
rib fracture Patterns of Chest Trauma in Children different anatomy and physiology aortic or great vessel injury
tracheobronchial tear
haemothorax
cardaic injury Moore et al, 2009, Pediatr Radiol Sinclair, 2002, Emerg Radiol Gottschalk et al, 2011, J Orthop Trauma, Victor et al, 2012, Intensive Care Med X-rays CXR remains first and most important imaging tool in paediatric chest trauma Combine with CLINICAL ASSESSMENT

malunion

changes to shoulder girdle
Full transcript