Pediatric Trauma: Rooftop Fall · McGovern Medical School Differential Diagnosis for Pediatric...

$: Pediatric Trauma: Rooftop Fall · McGovern Medical School Differential Diagnosis for Pediatric Trauma • Skull fractures • Brain hemorrhage • Spinal injuries • Splenic/Liver$
Pediatric Trauma:Rooftop Fall

Robert Martin

2/6/2020

RAD 4001

McGovern Medical School

Clinical History

• Previously healthy 13 yo male fell from roof (20+ feet) onto concrete

• Immediate altered LOC w/ vomiting and labored breathing

• GCS of 7 in the field, deteriorated to 3 on arrival & was intubated

• Vitals stable • HR 90s, Systolic BP 130s, RR 18-20

• Pupils 2-3 mm/reactive, blood/emesis in oropharynx and right ear

• FAST exam negative; CXR Obtained

• CT brain, temporal bone, cervical spine and abdomen/pelvis obtained


Differential Diagnosis for Pediatric Trauma

• Skull fractures

• Brain hemorrhage

• Spinal injuries

• Splenic/Liver injuries

• Pneumo/hemothorax

http://www.pediatricnursing.net/conf/handouts/2010/Session_124_Johnson-Moore.pdf


ACR Appropriateness

https://acsearch.acr.org/docs/3101274/Narrative/ https://acsearch.acr.org/docs/3083021/Narrative/


PECARN

https://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm#use-cases


ACR Appropriateness

https://acsearch.acr.org/docs/3102405/Narrative/


CXR

https://undergradimaging.pressbooks.com/chapter/chest/


Imaging

CT

• Uses x-rays and computer technology to produce images

• Better for bony structures

• Quick and more cost effective

MRI

• Uses magnets and radiofrequencies to produce detailed images

• Great for soft tissues

• No radiation

MRA/MRV

• Uses MRI tech to focus on arteries/veins

• Less invasive and less radiation compared to CT angio

https://www.hopkinsmedicine.org/health/conditions-and-diseases/head-injury-in-childrenhttps://www.radiologyinfo.org/en/info.cfm?pg=angiomr


CT Head – Bone Window

https://radiopaedia.org/images/13071736

Normal Patient’s


CT Maxillofacial


Pediatric Skull Fractures

http://caringforspecialneedskids.com/infant-skull-fracture/


CT Chest – Lung Window

https://radiologypics.com/2013/03/20/ct-of-the-chest-lung-windows-axial-anatomy/


CT Chest – Lung Window


CT Abd/Pelvis – Bone Window


MRI Brain - Modality


MRV Brain

https://mrimaster.com/anatomy%20brain%20ceribral%20veins.html


MRV Brain


Key Imaging Findings

• FAST and CXR normal (adequate placement of ETT and enteric tube)

• CT Head: Fx through middle portion of occipital bone and scattered compartmental hemorrhage

• CT Maxillo: Mildly comminuted fx of right temp bone extending into diastatic right lambdoid suture

• CT Chest: Pulmonary contusions in right lung; right basilar pneumo


Key Imaging Findings

• CT Abd/Pelv: A0 spine A1 compression fx of sup. endplate of L1

• MRI Brain: Interval increase in right temporoparietal hemorrhage (1 cm vs 2 mm)

• MRV Brain: Right distal transverse sinus short segment thrombosis with right sigmoid sinus near complete occlusion from compression by epidural hemorrhage


https://radiopaedia.org/articles/ao-classification-of-thoracolumbar-injuries?lang=us


Treatment/Outcome

• Due to patient’s improving clinical condition and absence of surgical injuries, no surgery was needed

• Given AED ppx for 7 days (Keppra)

• Patient was discharged within a week to Shriner’s for rehab

• Returned a few days later due to headache and increasing edema of soft tissues in the head

• Repeat studies insignificant, condition improved and was discharged back to rehab the next day


Pricing

• CXR = $683 charged; $250 with insurance

• CT Brain = $3157 charged; $98 with insurance

• CT Maxillofacial = $4909 charged; $743 with insurance

• CT Chest = $3936 charged; $432 with insurance

• CT Abd/Pelvis = $7998 charged; $480 with insurance

• MRI Brain = $7431 charged; $345 with insurance

• MRA Head = $6905 charged; $604 with insurance

https://www.memorialhermann.org/patients-caregivers/pricing-estimates-and-information/


Take Home Points

• Pediatric cases need special attention and trust in clinical judgement in order to avoid excess radiation

• Kids are resilient!

• Important to be familiar with imaging you’re ordering so you know how to interpret and use the findings


References

• https://www.memorialhermann.org/patients-caregivers/pricing-estimates-and-information/

• https://radiopaedia.org/articles/ao-classification-of-thoracolumbar-injuries?lang=us

• https://mrimaster.com/anatomy%20brain%20ceribral%20veins.html

• https://radiologypics.com/2013/03/20/ct-of-the-chest-lung-windows-axial-anatomy/

• http://caringforspecialneedskids.com/infant-skull-fracture/

• https://radiopaedia.org/images/13071736

• https://www.hopkinsmedicine.org/health/conditions-and-diseases/head-injury-in-children

• https://www.radiologyinfo.org/en/info.cfm?pg=angiomr

• https://undergradimaging.pressbooks.com/chapter/chest/

• https://acsearch.acr.org/docs/3102405/Narrative/

• https://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm#use-cases



• http://www.pediatricnursing.net/conf/handouts/2010/Session_124_Johnson-Moore.pdf

Questions?

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