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DCMC Emergency DepartmentRadiology Case of the Month

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

Welcome to the DCMC Emergency Department Radiologycase of the month!

In conjunction with our pediatric radiologyspecialists from ARA we hope you enjoy these monthlyradiological highlights from the case files of the EmergencyDepartment at DCMC. These cases are meant to highlightimportant chief complaints, cases, and radiology findings thatwe all encounter every day.

If you enjoy these reviews we invite you check outPediatric Emergency Medicine Fellowship RadiologyRounds, which are currently offered quarterly and are heldwith the outstanding support of the pediatric radiologyspecialists at Austin Radiologic Association.

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

PEM Fellow Conference Schedule February 2016

3rd 9:15 - Chest pain/syncope........Drs Whitaker & Gardiner 10:15 - CHD pre & post op..................Drs Vezzetti & Yee 11:15 - Cardiovascular infections..........Drs Allen & Berg 12:15 - Fellowship Meeting

10th 9:15 - Radiology: Head CT..........Drs Patel, Vezzetti, Hill 10:15 - Head injuries....................Drs Kienstra & Yanger 11:15 - Pediatric Sepsis Care/Collaboration......Dr Scott

17th 9:15 - ED Legal Issues....................Drs Allen & Rencher 10:15 - Headaches 11:15 - Active Shooter in the ED........Drs Allen & Wallin 12:00 - ED Staff Meeting

24th 9:15 - M&M................................................Drs Gorn & Hill 10:15 - Board review: Misc..............................Dr Pittman 12:15 - Research Update...Dr Wilkinson & PEM Fellows Guest Speaker: Halden Scott, MD Pediatric ED Sepsis Care and National Collaborative

All conferences are held in the DCMC Command Center Rooms 3&4.Simulations are held in the CEC and University Medical Center - Brackenridge.Locations, times, speakers are subject to change.All are welcome to attend!

This Month: I didn’t win the Powerball lottery, so here are this month’s cases....enjoy!

The first case involves a party that got out of hand. It seems someone stabbed a young lady while she was dancing. Some party! The wound, though, is not what it appears to be.......

The second case is, unfortunately, quite common in Central Texas. This young man was involved in a car accident that produced a very classic, and very concerning, injury.

“Docendo Decimus”

While its precise European origins are shrouded in mystery, Mardi Gras received its first mention in North America in 1699. French explorer Pierre le Moyne, Sieur d'Iberville camped on the Mississippi River on a spot 60 miles south of the present location of New Orleans. Knowing the date, March 3, was being celebrated as a holiday in his native France, he christened the site Point du Mardi Gras. During the next century, the celebration of Mardi Gras came to include private masked balls and random street maskings in the cities of Mobile and New Orleans. By the 1820s, maskers on foot and in decorated carriages began to appear on Fat Tuesday, and in 1837 the first documented procession in New Orleans occurred, but it bore no resemblance to today's Carnival. -Arthur Hardy

Laissez les bon temps rouler!Happy Mardi Gras!

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CASE 1: It’s kind of a slow night in the ‘ol Pediatric Emergency Department. The relative quiet is shattered by the urgent-sounding, rather concerning, call from the Triage Nurse, announcing that a 15 year old girl was “dropped off” (really, pushed out of a slowly moving car with one of her friends) in front of the ED. She states she was stabbed by an unknown person at a party she was at. This occurred approximately 15 minutes ago. She is not sure what she was stabbed with but she is sure it was “sharp” (really?). She is healthy otherwise and, aside from the pain at the stab site and feeling nauseated, she has not other complaints or injury.

You get her hooked up to a monitor as a Trauma page goes out. Her vitals show a heart rate of 120, blood pressure of 90/50, respiratory rate of 25, pulse ox of 98% on room air. She is moaning and stating her back hurts. You go over the ABCDE’s (Airway, Breathing, Circulation, Disability, Exposure) of a primary trauma survey. Everything checks out, but you do find a 4 cm elongated laceration just lateral to the mid thoracolumbar area on her right; you probe the wound and it appears to be at least 8 cm deep, maybe more. As you place some oxygen on her (she’s working a little hard to breath but you see no obvious chest wounds) and the ED nurses working this trauma get two IV’s in very quickly. You order a 20 cc/kg bolus of normal saline (BP’s a little low, especially for someone in pain), and get some labs, including a toxicology screen and pregnancy test (she denies she’s pregnant, by the way). Now that you’ve gotten the primary survey out of the way, you launch into your secondary survey and do a more detailed examination; you find no other injuries. After the first saline bolus, the blood pressure is improved (110/60) and her heart rate is down (100); you have also given her some Zofran and Morphine, which undoubtedly has helped.

Now that this patient is more stable, you start to think about whether or not this patient needs imaging. She will likely go to the operating room, as the wound appears pretty deep and will need to be explored. You discuss the need for imaging with the Trauma Surgeon: ultrasound (the Trauma FAST exam)? CT scan? Just go to the OR?

A word about Trauma...DCMC is a Level 1 Pediatric Trauma Center, so the ED is very used to seeing all manner of trauma in children. Depending where you practice, you may or may not have this resource and in some places, the general surgeon, pediatrician, emergency medicine physician, or family medicine physician will be called upon to treat pediatric trauma victims. This can be an extremely daunting task. Be prepared! How? Well, one of the best ways is to take an Advanced Trauma Life Support Course (combine this with Pediatric Life Support [PALS] or Advanced Pediatric Life Support [APLS] for even better preparation). These courses won’t replace a Pediatric Emergency Medicine or Trauma Surgery fellowship, but they are VERY helpful for anyone treating injured children!

Carnival, loosely translated from Latin as "farewell to flesh," is the season of merriment that begins in New Orleans each year on January 6, the Twelfth Night feast of the Epiphany (the day the three kings visited the Christ Child). Mardi Gras, French for "Fat Tuesday," is the single-day climax of the season. While Mardi Gras undoubtedly has pagan and pre-Christian origins, the Catholic Church legitimized the festival as a brief celebration before the penitential season of Lent. The date of Mardi Gras is set to occur 46 days before Easter and can fall as early as February 3 or as late as March 9. -Arthur Hardy

CASE 2: Now that you’ve gotten the teen from Case 1 settled in, EMS brings in a 9 year old male who was involved in a motor vehicle accident. Apparently he was a restrained front seat passenger when the car he was riding in struck the car in front of them; the accident occurred on the highway and the speed was presumed to be highway speed. Airbags deployed. There were three other sibling in the vehicle; all were in the back seat and all were restrained. The driver of the car, the child’s mother, also was restrained. He is complaining of abdominal pain. He self-extricated from the car, as did everyone else.

On arrival to the ED, he is alert and conversing. (Cool..A and B out of the way). He is well-perfused and moving all of his extremities (neat..there go C and D). You see no obvious injuries on him except for a linear bruise that transverses his abdomen. His vitals are appropriate for his age. You begin your secondary survey (see Primary and Secondary Survey below); he is diffusely tender to his abdomen and, when rolled onto his side, he has tenderness around his lumbar spine without step-off or crepitus.

You begin to think about imaging this child. He has an abdominal seat belt sign and back tenderness...FAST vs CT? Should you get plain films to start? You order some lab tests (you’re especially interested in the AST and ALT) and contemplate your next move.

Infants/Toddlers - Rear-facing only seats and rear-facing convertible seatsKeep infants and toddlers younger than 2 years of age in a rear-facing car seat until they reach the weight or height limit provided by the car seat's manufacturer.

Toddlers/Preschoolers - Convertible seats and forward-facing seats with harnessChildren over age 2 who have reached the manufacturer weight or height limit for their rear-facing car seat should use a forward-facing car seat with a harness.They should stay in this seat until they reach the highest weight or height limit allowed by the car seat's manufacturer. This also applies to any child younger than 2 years who has outgrown the rear-facing weight or height limit of their seat.

School-Aged Children – Booster seatsChildren who outgrow the weight and height limits of a forward-facing car seat should use a belt-positioning booster seat until the vehicle seat belt fits properly, usually after reaching a height of 4'9 and are between age 8 and 12.

Older Children – Seat beltsOlder children should always use lap and shoulder seat belts to provide the best protection and should sit in the back seat until 13 years of age.

Restraint Guidelines By Age

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Trauma: Primary SurveyWithout getting too detailed, it’s nice to have a brief review about when, how, and why things are done in a trauma. This is a team effort, with one provider for airway management, nurses establishing IV access/obtaining laboratory studies, ED techs getting patients on a monitor, radiology techs getting films, ED and trauma providers performing procedures, all while the ED and Trauma physicians are overseeing the whole operation.

Airway with cervical spine precautions/protection

Breathing with ventilation

Circulation with hemorrhage control, blood pressure management

Disability including neurologic status

Exposure including removing clothing and environmental control in

the trauma resuscitation room (warm room)

Trauma: Secondary SurveyOnce the primary survey is complete, you can move on to a more detailed head to toe examination of the patient. Remember, COMMUNICATION is key; let everyone know what is going on!

Keeping things orderly and systematic will

help the trauma run smoothly and maximize the best possible outcome for a

patient!

Case 1Part of the problem here is that you really don’t know how deep this wound actually is. Abdominal and flank/back wounds can be notoriously difficult to determine wound depth and extension. The fact that you can probe 8 cm in is concerning. The child will likely go to the OR, but an imaging test may be helpful in determining if there is significant damage or not. Ultrasound could be helpful, especially in the form of a trauma FAST exam. A contrast CT would be the definitive imaging test, looking for renal damage specifically.

The modern-day celebration of Mardi Gras in New Orleans was born in 1857 with the flambeaux-lit (torch-lit) nighttime parade of the Mystic Krewe of Comus. In 1871, the Twelfth Night Revelers presented Mardi Gras with its first queen. In 1872, Mardi Gras' first daytime procession was presented by Rex, the King of Carnival. -Arthur Hardy

Focused Assessment with Sonography for Trauma

Consists of Four Views:

1. Subxiphoid - assess the heart.

2. Perisplenic - designed to detect free fluid above the spleen and along the splee tip.

3. Hepatorenal.

4. Bladder - looking for fluid around the bladder.

Here’s a perisplenic view. Above is a normal view. To the left shows fluid between the spleen and diaphragm (yellow arrow).

Spleen

Spleen

Kidney

Normal bladder view

Bladder

Diaphragm

This view evaluates the hepatorenal pouch (Morrison’s pouch); fluid here suggests blood.Here we see the

liver, kidney, diaphragm, and Morrison’s puch (yellow arrow) Kidney

Diaphragm

Liver Advantages of FAST

Noninvasive and easily performed.

Portable (can be done at bedside).

No radiation.

Disadvantages to FAST

Can’t assess retroperitoneal injuries.

Operator dependent. ? reliability in children.

Subxiphoid view showing a pericardial effusion

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Case 1So, a FAST was actually performed in the Trauma Bay on this patient. The images were not available for review, but looked normal. The patient’s vital signs stabilized after the normal saline bolus and the decision was made to obtain a CT scan to assess if there was any significant injury, since the the wound appeared quite deep. If the child was unstable or critically ill, she would have gone immediately to the operating room for exploration. The results of the scan are below:

OK, there is a big issue that can be seen with these images. The right kidney clearly has fluid around it (red arrow), and, in the setting of trauma,this could be blood or urine. There is a laceration that extends in the upper pole of the right kidney (blue arrow).

Look at the left kidney, which is unharmed and compare it to the right. There is no surrounding fluid or laceration. The liver and spleen are also uninjured.

Grade 1 Grade 2 Grade 3

Grade 4 Grade 5

More than 500,000 king cakes are sold each year in New Orleans between January 6 and Fat Tuesday, and another 50,000 are shipped out-of-state via overnight courier. The king cakes include a tiny plastic baby doll inside; the person who finds the doll is declared "king" and must buy the next cake or give the next party. -Arthur Hardy

Well, this patient has sustained quite an injury! The CT shows significant renal damage which meets criteria for a Grade IV laceration. She is lucky, though, in that there is no other intra-abdominal injury.

Grade 2Grade 1

Grade 3 Grade 5Kidney Laceration Grades

1 - Subcapsular hematoma (arrow arrow). Comprise the majority of renal injuries (80%).

2 - Perinephric hematoma (arrow arrow) cortical lacerations < 1 cm in depth.

3 - Perinephric hematoma (arrow arrow) cortical lacerations > 1 cm in depth (arrow arrow).

4 - Lacerations into the collecting system, vascular injuries, or segmental infarctions.

5 - Shattered, devascularized, thrombosis, or UPJ avulsions. From: Medscape Online

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Mardi Gras organizations are non-profit clubs called krewes, and many are named after mythological figures such as Aphrodite, Eros, Hermes, Pegasus and Thor. Each krewe is completely autonomous, and there is no overall coordinator of Carnival activities. The secrecy with which some of the older krewes cloak themselves is part of the mystique of Mardi Gras. Several do not reveal the theme of the parade until the night of the event, and the identity of their royalty is never publicized. Most of the newer organizations take a more public approach. -Arthur Hardy

Case 2The concerning physical examination findings in this patient include a seatbelt sign across the abdomen, the abdominal pain, and the back pain to palpation. While it could very well be that this child has musculoskeletal contusions, the possibility of intra-abdominal injury and vertebral fractures is very real and needs to be investigated. Again, the question is where to start. Plain images of the chest and pelvis are often obtained in high speed MVC’s, as symptoms may be subtle in children. Performing an ultrasound (FAST exam) is also reasonable, but the reliability of FAST in children is still being established. If the child had a normal FAST and normal laboratory tests (ie looking to see if the liver function tests are elevated, which may indicated hepatic injury), and his pain improved, certainly one could make a case for no further imaging and observing the child for the development of concerning symptoms (either as an inpatient or a very closely watched outpatient setting). But this is a high risk mechanism. The decision was made by the Trauma Team to obtain a CT scan.

Good thing you got this study! There is a Grade II liver laceration that can be seen on this CT (red arrow). There is also findings of XXXX concerning for a mesenteric hematoma (blue arrows). There is another finding, though, that is classic for this mechanism of injury. Look at the CT scan images on the next page!

For an in-depth discussion about liver lacerations and treatment, see the August 2014 Newsletter.

The millions of colorful beaded necklaces thrown from floats are the most visible symbols and souvenirs of Mardi Gras. In addition, millions of cups and toy coins known as "doubloons" are decorated with krewe logos and thrown to parade-watchers. Some "throws" are especially prized: only the luckiest folks manage to take home the hand-decorated coconuts from the Krewe of Zulu.

The majority of children with renal lacerations are able to be treated conservatively, with very careful observation and monitoring of the patient’s hemoglobin and hematocrit. This is especially true in the setting of blunt trauma.

Some patients develop complications, including urinomas and perinephric fluid collections. These patients can be treated with interventional radiology techniques. In patients with acute renal hemorrhage, often renal artery embolization can be used.

In some patients, surgical exploration may be indicated. The only absolute indication for surgical treatment is persistent renal hemorrhage. Otherwise, the presence of other intra-abdominal injuries, urinary extravasation, large retorperitoneal hematomas, incomplete staging of a renal laceration by imaging, or suspicion for nonviable tissue are other indications for exploration.

A study that compared non=operative and operative management of major renal lacerations due to blunt trauma found that in the setting of other intra-abdominal injures, complication rates were much higher. They recommended surgical repair of such lacerations when they are accompanied by other intra-abdominal injuries. Husmann DA, Morris JS. Attempted nonoperative management of blunt renal lacerations extending through the corticomedullary junction: the short-term and long-term sequelae. J Urol. 1990 Apr. 143(4):682-4.

This images demonstrates a urinoma. The mechanism of injury was an MVC. The image shows collection of contrast material one week later after the initial injury, which indicates active urine leakage. Titton Rl, Gervais DA, Hahn PF, et al. Urine Leaks and Urinomas: Diagnosis and Imaging-guided Intervention. RSNA Radiographics. September 2003. 23(5).

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New Orleans held its first Mardi Gras parade in 1837. Floats appeared 20 years later.

Masks are a fun part of Mardi Gras, but if you're riding on a float, don't leave home without one. It is illegal to ride on a Mardi Gras parade float in New Orleans without a mask!

The CT images on the left demonstrate a vertebral bone fracture. (red arrow). Often these are discovered when performing imaging on a trauma patient where there is concern for abdominal injury, as in this patient who demonstrated a seat belt sign on physical exam.

In children with abdominal trauma, especially due to a motor vehicle crash, intra-abdominal injury becomes a concern. Sometimes this concern is first raised during a patient’s physical examination (ie abdominal pain on palpation or the ever concerning seat belt sign), or historical factors (a high speed crash, ejection, or complaints of abdominal pain at the scene or in the Emergency Department), or elevated transaminases (the cutoffs vary, but most centers are using AST/ALT values greater than 80 in the setting of trauma).

Once fractures are identified on an abdominal/pelvis CT, or if there is a specific concern for fractures, the images are reconstructed by the Radiology techs to get a better view of the vertebrae. This does not require additional imaging or radiation (the CT machine is pretty cool) and allows for a great look at the spine.

The recon of the thoracic spine looks normal. The lumbar spine, though, is not. There is a fracture of L3 and a fracture of the spinous processes of L2 (red arrows). There is also traumatic diastasis of L2 on L3 (purple arrow).

This child has a classic injury seen in motor vehicle accidents: the Chance Fracture. These fractures are also sometimes called “seatbelt fractures”. They are unstable fractures and associated with intra-abdominal injuries in a large percentage of patients.

The fracture itself is a combination of a flexion injury involving the vertebral body and a distraction injury involving the posterior elements. This fracture involves the anterior and middle columns (where compression occurs) and the posterior column (where distraction occurs) of the spinal column. The majority of these fractures occur in the lumbar spine, with about half of injuries involving the thoracolumbar junction.

Chance fractures can lead to kyphosis and are associated with increased mortality due to the high impact mechanisms that produce these fractures and the association of additional injuries (usually abdominal and often involving the duodenum and pancreas, as well as mesenteric injuries.

Chance fractures are less commonly seen due to the use of shoulder belts.

The Chance FractureThe arrows show the path of the fracture (along the horizontal plane); the black line is the anterior column; the red line is the middle column; and the blue line is the posterior column.

FROM: MEDSCAPE.COM

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Teaching Points1. Renal contusions or lacerations should always be considered in patients with both blunt and penetrating abdominal or flank trauma.

Initial workup should included a urinalysis as well as basic laboratory studies (CMP or BMP, CBC).2. Imaging options in the setting of abdominal trauma, and specifically for renal trauma, included ultrasound and contrast-enhanced

CT. US has the advantage of availability, ease of use, and lacks ionizing radiation. However, this modality will miss retroperitoneal fluid collections and requires skill to perform as well as interpret results. The reliability of ultrasound in trauma (FAST exam, for example), has not been completely proven in children. CT is advantageous for availability and is excellent for detecting blood, grading lacerations, and finding other injuries. However, ionizing radiation must be taken into account.

3. Most renal trauma can be managed with careful observation and followup (often in the hospital). Some situations require operative exploration and repair (ie ongoing hemorrhage, multiple injuries) or interventional radiology drainage (urinomas).

4. Chance fractures are not common, but can lead to significant morbidity if not detected and treated properly.5. Plain radiographs can detect Chance fractures, but they are often found during abdominal/pelvis CT examination. The recon images

provided are useful in detecting these fractures.6. Chance fractures are commonly associated with other intra-abdominal injures.7. Treatment of Chance fractures involves immobilization or, in some cases, surgical stabilization.

References1. Smith KJ, Lobera A, Kenney PJ, and Dheer AK. Imaging in Kidney Trauma. In Medscape Article: Online. December 2015.2. Broghammer JA, Fisher MB, Santucci RA. Conservative management of renal trauma: a review. Urology. 2007 Oct. 70(4):623-9.3. Fox JC, Boysen M, Gharahbaghian L, et al. Test Characteristics of Focused Assessment of Sonography for Trauma for Clinically Significant Abdominal Free Fluid in Pediatric Blunt Abdominal

Trauma. Acad Emerg Med. 2011;18(5): 477-482.4. Santucci RA, Wessells H, Bartsch G, Descotes J, Heyns CF, McAninch JW, et al. Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee. BJU Int.

2004 May. 93(7):937-54.5. Santucci RA, McAninch JW, Safir M, Mario LA, Service S, Segal MR. Validation of the American Association for the Surgery of Trauma organ injury severity scale for the kidney. J Trauma. 2001 Feb.

50(2):195-200.6. Davis JM, Beall DP, Lastine C et-al. Chance fracture of the upper thoracic spine. AJR Am J Roentgenol. 2004;183 (5): 1475-8.7. Aebi M. Classification of thoracolumbar fractures and dislocations. Eur Spine J. 2010;19 Suppl 1 : S2-7.

Follow Up:CASE 1: The laboratory studies from this patient were unremarkable, except for + blood on the UA dip; the hemoglobin and hematocrit were 10 and 32, respectively. Shortly after the CT scan, clear fluid was observed coming out the wound site. Given the depth of the wound, the degree of the renal laceration, and the presence now of what might be urine draining from the wound, the patient was taken to the operating room for exploration and repair of the laceration. This was done by both Pediatric Surgery and Pediatric Urology. During the procedure, the renal laceration was explored and repaired (she actually had 2, one involving the upper pole and the other involving the supermedial pole). Some extravasation of urine was noted, but this was minimal. Cystoscopy was also performed; an intraoperative pyelogram (which was normal) was also performed and a right ureteral stent was placed. There were no other injuries. She did well post-operatively and recovered without sequela.

CASE 2: In addition to the Chance fracture, this child also had a Grade II liver laceration and mesenteric vessel hematoma (see the August 2014 newsletter for a discussion of liver lacerations). He underwent a spinal MRI which confirmed the presence of the fracture, as well as cervical ligamentous injury of C2-3. Pediatric Neurosurgery and Pediatric Orthopedics were consulted. The child was taken to the operating room for fusion of the lumbar fractures. He was placed in cervical collar for 2 weeks and had followup with Pediatric Neurosurgery. At that time, further imaging was obtained showing no instability. He is doing well.

In a motor vehicle crash, the weight of the body moves forward (to the spine, demonstrated by the red arrow) while the upper body and the waist are in a fixed position (pink arrows).

FROM: MEDSCAPE.COM

This fracture was first described in 1948. It is not a common fracture, though, as fewer than 10% of lumbar spine fractures are the result of Chance fractures.

You can see this fracture on plain radiographs (AP and lateral views) as well.

It’s important to note that the ligaments involved in this fracture are preserved; only osseous structures are involved.

Here is a plain radiograph demonstrating some common findings of Chance fractures: a vertebral body fracture (red arrow); widening of the interspinous spaces (blue arrow); fracture of the laminae/articular processes (yellow arrow). FROM: MEDICALOPEDIA.ORG