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“DOCENDO DECIMUS”

DCMC Emergency Department Radiology Case of the Month

These cases have been removed of identifying information. These cases are intended for peer review and educational purposes only.

Welcome to the DCMC Emergency Department Radiology Case of the Month!

In conjunction with our pediatric radiology specialists from ARA, we hope you enjoy these monthly radiological highlights from the case files of the Emergency Department at DCMC. These cases are meant to highlight important chief complaints, cases, and radiology findings that we all encounter every day.

If you enjoy these reviews, we invite you to check out Pediatric Emergency Medicine Fellowship Radiology rounds, which are offered quarterly and are held with the outstanding support of the pediatric radiology specialists at Austin Radiologic Association.

If you have and questions or feedback regarding the Case of the Month format, feel free to email Robert Vezzetti, MD at rmvezzetti@seton.org.

This Month: There is a reason that seatbelt are recommended when one is traveling in a car. The patient this month sustained an unfortunate injury after being involved in a motor vehicle accident. The injury was unique, but a solemn reminder to buckle up when in a car!

Conference Schedule: NOVEMBER 2016

2nd - 9:15 Eating Disorders……………………………..……….Dr Monge 10:15 Lung Ultrasound……………………………………..Dr Levine 11:15 Legislative Advocacy…………………..Drs Iyer and Yanger

4th - PEM Fellow Interviews! 9th - 9:15 GYN Surgical Emergencies……..……………………..Dr Gorn 10:15 National Healthcare Issues……………………………Dr Iyer 11:15 - Grand Rounds……………………………Benjamin Hoffman

16th - 9:15 Grand Rounds TBD……………………………………Dr Cruz 10:15 Biostats 3……………………………………….Dr Wilkinson 11:15 TBD 12:00 ED Staff Meeting

23rd - THANKSGIVING!

29th - Journal Club

30th - 9:15 M&M………………………………….Drs Keinstra and Vaidya 10:15 Board Review: Trauma…………………………….Dr Remick

Guest Speakers for November:Dr Benjamin Hoffman (Oregon HSC) and Dr Andera Cruz (Texas Children’s)

Simulations are held at the CEC at UMC Brackenridge.

Lectures are held at DCMC Command Rooms 3&4.Locations subject to change.

All are welcome!

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Case History You settle in for what appears to be a typical October shift; coughs and congestion, some gastroenteritis cases, but overall nothing new or exciting. Then comes the radio transmission: EMS is bringing a child involved in a motor vehicle crash. Apparently the car she was in struck another car. The collision was head on and the rate of speed was approximately 50-60 MPH. There was significant damage to both vehicles. The car that our child was traveling in also continued two other siblings: the cousin and brother of our patient. All were restrained, except for our patient! EMS reports that everyone was ambulatory at the scene except for the child they are bringing in now, who didn’t want to walk because she felt dizzy and had a head injury. The child was placed in a cervical collar and they are bringing her and her relatives in for evaluation. The child’s mother, is being transported to University Medical Center Brackenridge with non life-threatening injuries. In the meantime, you prepare for your next three patients. The children arrive and immediately you can see that two of them look perfectly fine; they are ambulating and have no complaints of any kind. The last patient, though, looks pretty banged up. This is the child that was unrestrained during the collision. You immediately notice that she is bleeding from a large wound to her forehead. That can’t be good. The child is alert and conversing, but clearly in pain. The ED staff obtains vitals for you: Temp - 98.1 HR - 115 RR - 18 BP - 128/67 Pulse Ox - 98 (RA). You begin a primary trauma survey: The child’s airway is patent (she’s speaking to you); her breathing is unlabored and she has clear breath sounds bilaterally; her cap refill is brisk and she is well perfused; her GCS is 15 (she’s alert and oriented with clear sensorium); aside from the large wound to her forehead, she is moving all of her extremities and she does not seem to have any injuries or extremity deformities (Trauma ABCDE’s..see below). You move on to the secondary survey (head to toe exam…see below). You note that large formed laceration as well as right eye subconjunctival hemorrhage without hyphen or proptosis; her ocular muscles are grossly intact and her vision is grossly intact. She has infraorbital ecchymoses and tenderness without crepitus; the right eyelids have mild edema as well. Her tympanic membranes are clear, there is no septal hematoma, and her dentition is intact. Her neck (cervical collar in place) is contender without crepitus or step-off. Her chest and abdominal examinations are benign. Her back is also contender. Neurologically, she still has a GCS of 15. It is is apparent that this child has a physical examination concerning for an intracranial injury (either a skull fracture, intracranial hemorrhage, or both) and she may very well have sustained a facial fracture. With the laceration, is this fracture open? At any rate, she needs imaging. Will plain radiographs be sufficient to detect a fracture? Perhaps a head CT? Does her neck need imaging as well? Who’s going to repair that laceration?

World Series Time! The first World Series took place in 1903, between the Pittsburgh Pirates and the Boston Americans, who later became the Red Sox.

In 1945, Billy Sianis – the owner not coincidentally of the Billy Goat Tavern – was ordered to leave the Cubs’ World Series game against the Detroit Tigers. Apparently the pet goat that Billy travelled with was so smelly it was upsetting the other fans. Outraged at this insult to his goat, Billy announced that the Cubs wouldn’t win. They didn’t, and in fact the Cubs never made back to the World Series - until 2016!

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If you’re not familiar with the Primary and Secondary portions of a Trauma Survey, to the right is a brief review. Trauma codes should ideally be run using this system, ensuring the best chance that injuries won’t get missed.

Primary Trauma Survey A - Airway (including cervical spine protection) B - Breathing C - Circulation D - Disability/Neurological E - Exposure (environmental control and removing all clothing)

Secondary Trauma Survey Comprehensive physical exam (head to toe) More detailed history Diagnostic studies.

Pediatric Glasgow Coma Scale (GCS)

The Pediatric GCS is an extremely useful tool used during the evaluation of children who are involved in trauma. While it’s use in head trauma is obvious, this score is used in all Pediatric trauma scenarios, even those where a head injury is not a concern. The reason for this is that this scale is provides a tremendous amount of information regarding not only neurologic status, but pulmonary and perfusion status as well (ie gotta have an airway to talk and a perfusing brain to speak). This scoring system was developed 1974 by Graham Teasdale and Bryan Jennett, both of whom were professors of neurosurgery at, you guessed it, the Univ. of Glasgow.

Back to our patient…The photograph to the left shows the large forehead laceration that this child sustained. A couple of things are readily noticeable. For starters, the laceration is, well, large, and involves a flap in the middle and inferior portion (red arrow). There are portions of skull that are seen as well (blue arrow). While the majority of lacerations seen in the Pediatric Emergency Department are repaired by Pediatric Emergency Medicine physicians, this laceration is much more complex and, there is a more concerning issue: is there a fracture associated with this laceration? If so, then this is an open laceration and, given the right periorbital findings, concern that there is an orbital fracture as well.

Which imaging test will be most useful in this patient?

Wrapping your head around head trauma imaging: The question to ask is whether a plain radiography for this patient’s head and facial injury is appropriate, or whether to go with a CT. While plain radiographs can be used as a screening test, in the majority of patients in whom imaging is indicated, a more appropriate imaging modality is CT. While this does mean more radiation, CT has definite advantages. It provides higher resolution, can find subtle fractures, can image the soft tissues, can delineate intracranial hemorrhage (which plain radiography cannot) and, in this patient’s case, you can obtain a craniofacial CT, and image the face and head at the same time, with very little increase in ionizing radiation. Plain radiography can be useful for facial trauma if a low suspicion for fracture exists or as a test when CT may not be available. Plain radiographs can also be used to screen for skull fractures, but, if a fracture is found, CT is usually needed to rule out intracranial hemorrhage. Given all of this, CT it is!

The tradition of giving rings to the players who win the World Series started in 1922, and by the 1930s all the teams were giving their players and coaches special rings for winning the Series. Frank Crosetti – who played for the New York Yankees for 17 years and then coached with them for 20 more – decided after 17 World Series wins that he’d finally had enough rings and asked for an engraved shotgun instead.

Even though baseball had been playing night games since the 1930s it wasn’t until 1971 that the World Series had a game at night.

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A Craniofacial CT scan was performed on this patient. At DCMC, this is c combination of a head CT and finer imaging of the face; the ionizing radiation load is not much more than a head CT and takes, in most cases, 1-2 seconds to perform. Here are the images:

Well well well…this is why seatbelt are in every car and you should be wearing one each time you go out for a nice drive! This child has sustained some significant injury from this car accident. There are several findings on these selected images from the patient’s craniofacial CT scan. There is a right medial orbital wall fracture (red arrow). There is also herniation of the orbital fat into the ethmoid sinus (yellow arrow). It is difficulty to tell from this film, but the ocular muscles ( blue arrow) may be entrapped, given the herniation of muscle fat and the involvement of the medial wall. The globes look normal. This is a pretty bad injury. for starters, the laceration is not only complex but open as well. She will need IV antibiotics, in addition to lots of pain control (she has already been given Morphine). This child will also require Plastic Surgery to evaluate the laceration and Pediatric Ophthalmology to evaluate the orbital wall fracture. Perhaps Pediatric ENT may need to be involved as well. What about the forehead?

A testament to the Yankees’ dominance in the Fall Classic, the top seven players in total World Series games played were all Bronx Bombers: Yogi Berra (pictured) (75), Mickey Mantle (65), Elston Howard (54), Gil McDougald and Hank Bauer (53), Phil Rizzuto (52) and Joe DiMaggio (51).

It's been a longer timespan between the Chicago Cubs winning a World Series and today (1908-2016, 108 years) than there was between the last Chicago Cubs World Series and the presidency of John Adams (1801-1908, 107 years).

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Halloween may be over, but…. Here are selected images from the child’s cranial portion of the craniofacial CT. The most obvious injury is that there is a a frontal bone fracture (red arrow), with elements of the fracture (which is comminuted) extending into the frontal sinus (green arrow). You can also make out the forehead laceration in the CT scan (blue arrow). The good news is that the brain appears normal, without hemorrhage; the ventricles (purple arrow) look normal; the facial bones themselves (not seen on these images) are normal; the mandible is also intact. One other nice thing about CT is the ability to reconstruct images (3D recon); one can see the frontal bone fracture on the 3D recon quite well on the image to the right.

Antibiotics for Open Facial Fractures Since this fracture is open, antibiotics are suggested, although this is controversial and sub specialist dependent. The studies are not completely clear if antibiotics are useful, but in this case, they were begun, since the child had a significant laceration with significant fractures. Typical coverage should be for normal skin and respiratory flora. In this case, Zosyvn was begun.

Only nine teams from back in 1908 still exist in their same form today. Back in 1932 the NFL only had three teams that survive today. 

The best pitcher on the 1908 Cubs was Mordecai "Three Fingers" Brown. He was paid $3,500 for his efforts. That’s roughly between $50,000 and $75,000 in today’s money!

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FROM: AAO.com

Eye injuries: Hyphema In any child with an eye injury, one has to look out for hyphema. This is a collection of blood between the cornea and iris (anterior chamber) and results from a tear to the iris or the pupil of the eye. Hyphemas are typically painful, although not always. Contrast this with a subconjunctival hemorrhage, which are typically painless and, more importantly harmless. Hyphemas can also be spontaneous, although trauma is usually the cause. If a spontaneous hyphema occurs, then the differential includes bleeding disorders, eye tumors, uveitis, vascular anomalies, and abnormal blood vessel growth. Treatment includes rest and head elevation. While this his usually done as an outpatient, in small children this can be difficult and they may be admitted for sedation! Most hyphemas will resolve spontaneously (less than 1 week). Complications include re-bleeding and elevated intraocular pressures.

Above, a hyphema. Notice how it layers out. To the right is a sunconunctival hemorrhage, which can, when extensive, look like a hyphema. Symptoms can often help differentiate between the two.

Orbital fractures are often seen following blunt facial trauma. All patients with orbital fractures are at risk for eye injury, so this needs to be identified and addressed. The orbital has 7 bones to it: Frontal, Zygoma, Maxilla, Lacrimal, Ethmoid, Sphenoid, and Palatine. Common orbital fractures include: 1. Blow Out Fracture: Blunt trauma to the eye results in a

fracture, typically the weaker floor of the orbit or the medial wall (like our patient). Periorbital fat and ocular muscles may become entrapped. Upwards of 33% of these fractures will have associated eye injury.

2. Maxillary Fracture: This involves a bow out fracture of the orbital floor. This may cause entrapment of the inferior rectus muscle (impaired upward gaze).

3. Superior Orbital Rim Fracture: This frontal bone fracture is often associated with high speed (and therefore high risk) injuries.

4. Zygomaticomaxillary Fracture: This is a mouthful! These fractures also involve high impact mechanisms to the zygoma. They are also typically associated with eye injuries.

Indications For Surgical Intervention: Ocular Injuries

Aside from complex lacerations and the need to repair depressed skull fractures, orbital fractures need surgical intervention in the following circumstances: 1. Rectus muscle entrapment. 2. Exophthalmos. 3. Central gaze diplopia or extra ocular movement deficit

after swelling has subsided. 4. Loss of orbital support that may affect future vision.

FROM: Medscape: Orbital Fractures in Emergency Medicine, 2016.This patient has a left orbital floor blow out fracture with entrapment; note the inability to gaze upwardly on the left. (The swelling has subsided by the way).

FROM: BMJ Best Practice

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Teaching Points1. Wear seatbelts! Be sure to tell your patients and their families each time, every time you see them!2. Patients with orbital trauma need to be carefully evaluated for ocular injuries, including hyphema, orbital

fractures, ocular muscle entrapment, in addition to other injuries.3. The imaging modality of choice for facial trauma, including orbital trauma, is a non contrast CT scan.

While plain radiography can be used as a screen in patients who are at low risk for facial fractures, subtle fractures can be missed. CT is also useful for delineating soft tissue injuries, orbital muscle entrapment, and, when a craniofacial protocol is used, intracranial injury, such as fractures and hemorrhage.

4. Orbital fractures involve multiple subspecialty involvement, including Pediatric Ophthalmology and Pediatric Trauma. Plastic surgery often is involved as well, especially in the case of lacerations.

5. Surgical intervention for orbital fractures is indicated when there is ocular muscle entrapment, exopthalmos, or vision deficits.

6. Hyphema is an important consequence of eye trauma and often can be managed with rest, but admission may be needed if a child can’t comply with rest and limited activity (typically younger children). Do not patch a hyphema; an eye shield is used.

Case ResolutionGiven the results of the CT scans and the laceration complexity, multiple subspecialties were involved in the care of this child. Plastic Surgery was consulted to repair the laceration, which was done in the Pediatric Emergency Department. Because of the presence of the flap, devitalization of the tissue was a concern. The thought was briefly entertained about using leeches to help keep the tissue vitalized, but the proximity to the anterior table (where the open fracture was) made this not feasible. Pediatric Ophthalmology and Pediatric Neurosurgery were also consulted. There was no entrapment of the ocular muscles and Pediatric Neurosurgery did not feel that repair of the frontal bone could be accomplished by Plastic Surgery. The child was admitted to the Pediatric Trauma Service for observation and pain control. Her cervical collar was removed the next day (she was clinically cleared and had a normal cervical spine CT) and she was discharged on Augmenting pending definitive repair. The child was taken to the operating room subsequently a week later for open internal fixation and reconstruction of the frontal wall of the sinus. She did well with this procedure and, as of this writing, she is recovering from her injuries.

REFERENCES 1. Winegar BA, Gutierrez JE. Imaging of Orbital Trauma and Emergent Non-traumatic Conditions. Neuroimaging Clin N Am. 2015 Aug. 25 (3):439-56.Rhea JT,

Novelline RA. How to simplify the CT diagnosis of Le Fort fractures. AJR Am J Roentgenol. 2005;184 (5): 1700-5. 2. Lelli GJ Jr, Milite J, Maher E. Orbital floor fractures: evaluation, indications, approach, and pearls from an ophthalmologist's perspective. Facial Plast Surg. 2007 Aug. 23(3):

190-9. 3. Cruz AA, Eichenberger GC. Epidemiology and management of orbital fractures. Curr Opin Ophthalmol. 2004 Oct. 15(5):416-21. 4. Kubal WS. Imaging of orbital trauma. Radiographics. 2008 Oct. 28(6):1729-39. 5. Righi S, Boffano P, Guglielmi V, Rossi P, Martorina M. Diagnosis and imaging of orbital roof fractures: a review of the current literature. Oral Maxillofac Surg. 2015 Mar. 19 (1):

1-4. 6. Kozakiewicz M, Elgalal M, Loba P, Komunski P, Arkuszewski P, Broniarczyk-Loba A, et al. Clinical application of 3D pre-bent titanium implants for orbital floor fractures. J

Craniomaxillofac Surg. 2009 Jan 29. 7. Caranci F, Cicala D, Cappabianca S, Briganti F, Brunese L, Fonio P. Orbital fractures: role of imaging. Semin Ultrasound CT MR. 2012 Oct. 33(5):385-91.

From 1969 until 1989, Cleveland finished in last place or second-to-last place in 16 of 21 seasons. In those other five seasons, they finished third-to-last.

GO CUBS!