Sideline coverage: when to get radiographs? A review of clinical decision tools
CONTEXT: Sidelines coverage presents unique challenges in the evaluation of injured athletes. Health care providers may be confronted with the question of when to obtain radiographs following an injury. Given that most sidelines coverage occurs outside the elite level, radiographs are not readily available at the time of injury, and the decision of when to send a player for radiographs must be made based on physical examination. Clinical tools have been developed to aid in identifying injuries that are likely to result in radiographically important fractures or dislocations. EVIDENCE ACQUISITION: A search for the keywords x-ray and decision rule along with the anatomic locations shoulder, elbow, wrist, knee, and ankle was performed using the PubMed database. No limits were set regarding year of publication. We selected meta-analyses, randomized controlled trials, and survey results. Our selection focused on the largest, most well-studied published reports. We also attempted to include studies that reported the application of the rules to the field of sports medicine. STUDY DESIGN: Retrospective literature review. LEVEL OF EVIDENCE: Level 4. RESULTS: The Ottawa Foot and Ankle Rules have been validated and implemented and are appropriate for use in both pediatric and adult populations. The Ottawa Knee Rules have been widely studied, validated, and accepted for evaluation of knee injuries. There are promising studies of decision rules for clinically important fractures of the wrist, but these studies have not been validated. The elbow has been evaluated with good outcomes via the elbow extension test, which has been validated in both single and multicenter studies. Currently, there are no reliable clinical decision tools for traumatic sports injuries to the shoulder to aid in the decision of when to obtain radiographs. CONCLUSION: Clinical decision tools have been developed to aid in the diagnosis and management of injuries commonly sustained during sporting events. Tools that have been appropriately validated in populations outside the initial study population can assist sports medicine physicians in the decision of when to get radiographs from the sidelines.
A pediatric massive transfusion protocol
BACKGROUND: Pediatric massive blood transfusions occur widely at hospitals across the nation; however, there are limited data on pediatric massive transfusion protocols (MTPs) and their impact. We present a pediatric MTP and examine its impact on morbidity and mortality as well as identify factors that may prompt protocol initiation. METHODS: Using a prospective cohort, we collected data on all pediatric patients who required un-cross-matched blood from January 1, 2009, through January 1, 2011. This captured patients who received blood products according to the protocol as well as patients who were massively transfused at physician discretion. Outcomes between groups were compared. RESULTS: A total of 55 patients received un-cross-matched blood, with 22 patients in the MTP group and 33 patients receiving blood at physician discretion (non-MTP group). Mortality was not significantly different between groups. Injury Severity Score for the MTP group was 42 versus 25 for the non-MTP group (p = 0.01). Thromboembolic complications occurred more exclusively in the non-MTP group (p = 0.04). Coagulopathy, evidenced by partial thromboplastin time (PTT) greater than 36, was associated with initiation of the MTP. CONCLUSION: MTPs have been widely adopted by hospitals to minimize the coagulopathy associated with hemorrhage. Blood transfusion via MTP was associated with fewer thromboembolic events. Coagulopathy was associated with initiation of the MTP. These results support the institution of pediatric MTPs and suggest a need for further research on the protective relationship between MTP and thromboembolic events and on identifying objective factors associated with MTP initiation. LEVEL OF EVIDENCE: Therapeutic study, level IV.
Is the "seat belt sign" associated with serious abdominal injuries in pediatric trauma?
BACKGROUND: The 'seat belt sign' (SBS) has been reported to be highly associated with intra-abdominal injury. This study defines its predictive value in identifying injuries in a large pediatric trauma population. METHODS: At a level I pediatric trauma center, we performed a retrospective review of trauma flow sheets for all motor vehicle crash victims (ages, 0-20) requiring trauma team activation during 2005 and 2006. All patients with an abdominal SBS recorded were included in the analysis. RESULTS: Of 331 patients (mean age, 9.96 years), an SBS was present in 54 (16%) of these children. Abdominal injury was identified by computed tomography scan or intraoperatively in 12 (22%) of these children. Three (6%) children with SBS required operative intervention. Two had a bowel injuries and one had a negative laparoscopy. SBS and abdominal tenderness were reported in 30 (56%) patients; 8 (15%) of whom sustained abdominal injury. Of the 277 (84%) children without SBS, 36 (13%) had abdominal injuries. Four (11%) of these had a positive laparotomy with three having a bowel injuries. The relative risk of an abdominal injury given an SBS was 1.7 (CI 0.96-2.69; p = 0.078). Four (1.4%) children without SBS died of head injuries compared with zero with SBS. The SBS had a sensitivity of 25% and a specificity of 85%. CONCLUSIONS: The SBS was not significantly associated with abdominal injury in our population. Patients without SBS had a higher Injury Severity Score and accounted for all of the deaths. SBS may not be as predictive of abdominal injury as previously reported