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Geriatric EM: Falls Can Be Sentinel Events

falls

 

A 72-year-old woman is brought to your Emergency Department (ED) after falling while rushing to the toilet. She has no visible deformity on examination and is discharged with pain medications. Two weeks later, EMS transports her to the ED after a loss of consciousness. Computed tomography (CT) of the head at that time shows a subdural hematoma.

Unfortunately, this scenario is common. Given time constraints in the ED, management plans often miss opportunities to assess a patient’s risk for falling and may not be compliant with recommendations [1, 2]. However, falling can be a sentinel event for older adult patients [3].

Falls can be sentinel events

While emergency physicians may focus on trauma burden or concern for cardiac arrhythmia acutely, falls have a surprisingly high one-year mortality rate at 21.9% [4]. Falling causes up to 12% of deaths in the geriatric population [5]. They can lead to both serious and non-serious complications, for example, fractures and intracranial injury, a decline in health and function, social isolation, increased risk of nursing home admission, and loss of confidence [6-11]. Providers in the ED can begin the process of detecting who is at high-risk for falling in the future to prevent such high morbidity and mortality.

Quick assessment in the ED

Unfortunately, while there are many tools to screen for fall risk, none have been validated in the ED. Below are some tools that can be used as part of a more complete clinical assessment.

The STEADI Algorithm [12, 13] comprises various components, including:

  1. Screening questions
    • Have you fallen in the past year? If so, how many?
    • Do you feel unsteady when standing or walking?
    • Do you worry about falling?
  2. Timed Up and Go (TUG) test [12, 14, 15]
    • The patient sits in a standard armchair. When the provider says “Go,” the patient stands up from the chair, walks 3 meters (10 feet), turn, and walk back to sit at the chair. The provider records the time.
  3. Observe the patient for gait/balance instability.

If “Yes” to any question, a TUG ≥12 seconds, or gait or balance instability, the patient may be at risk of fall and further assessment should be considered.

 

Tiedemann’s Brief Performance-Based Fall Risk assessment tool [16]

  1. History taking
    • Previous fall? (Y/N)
    • Medication review
      • Four or more (excluding vitamins)? (Y/N)
      • Any psychotropic? (Y/N)
  1. Visual acuity test – Unable to see all of line 16 on a low contrast visual acuity test (Y/N)
  2. Peripheral sensation test – Unable to feel 2 out of 3 trials (Y/N)
  3. Balance/Coordinated Stepping/Strength
    • Near tandem stand test (balance)- Unable to stand for 10 secs (Y/N)
    • Alternate step test (coordinated stepping)- Unable to complete in 10 secs (Y/N)
    • Sit to stand test (strength)- Unable to complete in 12 secs (Y/N)

Each “Yes” gets 1 score. We can compare the score(s) with the probability of falling.

Number of risk factorsProbability of falling
0-17%
2-313%
4-527%
6+49%

 

Carpenter’s ED fall risk questions [6]

  1. Presence of non-healing foot sore?
  2. Any fall in the past 12 months?
  3. Inability to cut his/her own toenails?
  4. Self-reported depression?

If there is more than 1 factor present, the patient is at increased risk for a fall in 6 months. If you are unable to use one of these screening tools, it may be most useful to review high-risk medications and observe them walk.

 

High-risk medications [17]

  • Sedative-hypnotic and anxiolytic drugs (especially long-acting benzodiazepines)
  • Tricyclic antidepressants
  • Major tranquilizers (phenothiazines and butyrophenones)
  • Antihypertensive drugs
  • Cardiac medications
  • Corticosteroids
  • Nonsteroidal anti-inflammatory drugs
  • Anticholinergic drugs
  • Hypoglycemic agents
  • Any medication that is likely to affect balance

 

Educate the patient

An important consideration is to educate the patient on fall prevention. The American College of Emergency Physicians sponsored the creation of a video, the 7 Step Challenge to Prevent Falls, that you can include in your patient’s discharge summary or have them watch prior to discharge.

Take Home Points

  • Falls can be sentinel events and represent a high risk for morbidity and mortality for older adult patients.
  • Emergency physicians can play a crucial role in identifying patients at risk and preventing future injury.

 

References:

  1. Davenport K, Alazemi M, Sri-On J, Liu S. Missed Opportunities to Diagnose and Intervene in Modifiable Risk Factors for Older Emergency Department Patients Presenting After a Fall. Ann Emerg Med. 2020;76(6):730-738. doi:10.1016/j.annemergmed.2020.06.020. PMID: 33010956
  2. Tirrell G, Sri‐on J, Lipsitz LA, Camargo CA Jr, Kabrhel C, Liu SW. Evaluation of Older Adult Patients With Falls in the Emergency Department: Discordance With National Guidelines. Academic Emergency Medicine. 2015;22(4):461-467. doi: 10.1111/acem.12634. PMCID: PMC6778963
  3. Carpenter CR, Cameron A, Ganz DA, Liu S. Older Adult Falls in Emergency Medicine-A Sentinel Event. Clin Geriatr Med. 2018;34(3):355-367. doi:10.1016/j.cger.2018.04.002. PMID: 30031421
  4. Tan MP, Kamaruzzaman SB, Zakaria MI, Chin A-V, Poi PJH. Ten-year mortality in older patients attending the emergency department after a fall: Ten-year ED fall mortality. Geriatrics & Gerontology International. 2016;16(1):111-117. doi:10.1111/ggi.12446
  5. Greenhouse AH. Falls among the elderly. In: Clinical Neurology of Aging. 2nd ed. Oxford University Press; 1994:611-626.
  6. Carpenter CR, Scheatzle MD, D’Antonio JA, Ricci PT, Coben JH. Identification of Fall Risk Factors in Older Adult Emergency Department Patients. Academic Emergency Medicine. 2009;16(3):211-219. doi:10.1111/j.1553-2712.2009.00351.x. PMID: 19281493
  7. Tinetti ME, Williams CS. Falls, Injuries Due to Falls, and the Risk of Admission to a Nursing Home. N Engl J Med. 1997;337(18):1279-1284. doi:10.1056/NEJM199710303371806. PMID: 9345078
  8. Boele van Hensbroek P, van Dijk N, van Breda GF, et al. The CAREFALL Triage instrument identifying risk factors for recurrent falls in elderly patients. The American Journal of Emergency Medicine. 2009;27(1):23-36. doi:10.1016/j.ajem.2008.01.029. PMID: 19041530
  9. Tromp AM, Pluijm SMF, Smit JH, Deeg DJH, Bouter LM, Lips P. Fall-risk screening test. Journal of Clinical Epidemiology. 2001;54(8):837-844. doi:10.1016/S0895-4356(01)00349-3. PMID: 11470394
  10. Bergen G, Stevens MR, Burns ER. Falls and Fall Injuries Among Adults Aged ≥65 Years — United States, 2014. MMWR Morb Mortal Wkly Rep. 2016;65:993–998. doi:10.15585/mmwr.mm6537a2. PMID: 27656914
  11. Gill TM, Murphy TE, Gahbauer EA, Allore HG. The Course of Disability Before and After a Serious Fall Injury. JAMA Intern Med. 2013;173(19):1780. doi:10.1001/jamainternmed.2013.9063. PMCID: PMC3812391
  12. Stevens JA, Phelan EA. Development of STEADI: A Fall Prevention Resource for Health Care Providers. Health Promotion Practice. 2013;14(5):706-714. doi:10.1177/1524839912463576. PMCID: PMC4707651
  13. Centers for Disease Control and Prevention. STEADI Algorithm for Fall Risk Screening, Assessment, and Intervention among Community-Dwelling Adults 65 years and older. Published online 2019. Accessed November 20, 2020. https://www.cdc.gov/steadi/pdf/STEADI-Algorithm-508.pdf
  14. Podsiadlo D, Richardson S. The Timed “Up & Go”: A Test of Basic Functional Mobility for Frail Elderly Persons. Journal of the American Geriatrics Society. 1991 Feb;39(2):142–8. doi: 10.1111/j.1532-5415.1991.tb01616.x. PMID: 1991946
  15. Barry E, Galvin R, Keogh C, Horgan F, Fahey T. Is the Timed Up and Go test a useful predictor of risk of fall in community dwelling older adults: a systematic review and meta-analysis. BMC Geriatr. 2014;14:14. doi:10.1186/1471-2318-14-14. PMCID: PMC3924230
  16. Tiedemann A, Lord SR, Sherrington C. The Development and Validation of a Brief Performance-Based Fall Risk Assessment Tool for Use in Primary Care. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2010;65A(8):896-903. doi:10.1093/gerona/glq067. PMID: 20522529
  17. Fuller GF. Falls in the elderly. Am Fam Physician. 2000;61(7):2159-2168, 2173-2174. PMID: 10779256

 

 

 

 

By |2021-02-28T09:28:47-08:00Feb 8, 2021|Emergency Medicine, Geriatrics|
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IDEA Series: Handheld Ultrasound for Emergency Medicine Residents Rotating on Cardiology Services

US System

Point-of-care ultrasound (PoCUS) has become an essential skill that emergency medicine (EM) residents learn during their training [1]. Accordingly, most EM programs schedule a block early in residency dedicated to obtaining and interpreting high-quality PoCUS images. Likewise, the ability to efficiently diagnose and manage acute cardiovascular pathologies is a critical aspect of EM, and most EM residents also rotate on a cardiology service to develop these skills. Despite evidence that PoCUS improves the ability of both cardiologists and non-cardiologists to quickly diagnose cardiac disease at the bedside, integration of this relatively novel technology on cardiology services is often limited by lack of PoCUS availability as well as lack of a convenient platform to share recorded images [2]. Equipping EM residents on cardiology rotations with a portable, handheld ultrasound (US) system (Figure 1. Philips Lumify handheld US system with tablet) can enhance the learning of echocardiography acquisition and interpretation while simultaneously providing cardiology teams with clinically actionable information [3]. In addition to improving patient care, performing and interpreting PoCUS from the lens of a cardiologist is a simple yet innovative way to solidify the skills that are crucial to becoming an excellent bedside echocardiographer.

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By |2021-02-03T21:14:52-08:00Feb 5, 2021|IDEA series, Medical Education, Ultrasound|
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SAEM Clinical Image Series: Edema Got Your Tongue?

angioedema

A 57-year-old male presented to the emergency department with a swollen mouth for three hours. He reported never having experienced this before and denied starting any new medications. The patient endorsed a feeling that his mouth was swollen and had difficulty swallowing. The edema had been increasing in size since its onset. He had been drooling for the past hour and endorsed mild pain around the area. He denied any shortness of breath, rash, nausea, vomiting, or other areas of edema. His past medical history included hypertension, diabetes, and allergies, with no known drug allergies. His family history was unknown. His medications included Metformin and Lisinopril.

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By |2021-01-30T20:03:13-08:00Feb 1, 2021|Academic, Emergency Medicine, ENT, SAEM Clinical Images|
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SAEM Clinical Image Series: Sun-burnt Hands and Lips

blistering

A 44-year-old Caucasian male with a past medical history of hepatitis C presents with a complaint of pain, swelling, and skin blistering of his hands. He also notes skin sores on his nose, lower lip, and the tops of his ears. The patient claims that these have become progressively worse since starting work a month ago in outdoor construction. The patient denies the use of medications or illicit drugs and denies any medical allergies. He admits to tobacco use and daily alcohol use. The patient denies any other symptoms.

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By |2021-01-30T19:50:28-08:00Feb 1, 2021|Academic, Dermatology, Emergency Medicine, Heme-Oncology, SAEM Clinical Images|
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Colchicine Toxicity: A New Threat from COVID-19 Treatments

In the continued fight against COVID-19, a January 22, 2021 press release from the Montreal Heart Institute touted the potential of colchicine, citing results from the COLCORONA trial [1, 2]. We’ve learned to be especially skeptical of any study results reported only via press release before undergoing full peer-review and publication. Nevertheless, the authors claim a non-significant (p=0.08) relative risk reduction of 19% (absolute risk reduction 1.1%) in hospitalizations, mechanical ventilation, and death. Note that the pre-print of the study has still not been peer-reviewed [3]. This study comes on the heels of the much smaller GRECCO-19 study published in June 2020 [4].

Early in 2020, promising results on hydroxychloroquine for treatment of COVID-19 led to a large increase in its use in outpatients and inpatients. It is now known that there is virtually no role for hydroxychloroquine and that this spike in use led to serious toxicity both from therapeutic use and overdose [5, 6]. The same may be anticipated for colchicine. And, if there is a drug that toxicologists fear more than hydroxychloroquine in overdose, it’s colchicine.

5 things to know about colchicine toxicity

1. Colchicine inhibits microtubule formation and function, thereby inhibiting mitosis.

  • It also is a GABA-A antagonist.

2. Acute toxicity occurs in 3 phases.

  • 0-24 hours: Nausea, vomiting, diarrhea, salt and water depletion, and  leukocytosis
  • 1-7 days: Sudden cardiac death (24-48 hours), pancytopenia, acute kidney injury, sepsis, acute respiratory distress syndrome, rhabdomyolysis, and electrolyte imbalance
  • >7 days: Alopecia, myopathy, neuropathy, and myoneuropathy

3. Colchicine levels are not helpful.

  • They also aren’t readily available at most institutions.

4. Hemodialysis doesn’t remove the toxin.

  • Colchicine’s volume of distribution is large.
  • Extracorporeal treatment can be employed if kidney toxicity results from the poisoning.

5. There is no antidote.

  • Management is largely supportive with IV fluids, vasopressors, and colony-stimulating factors.
  • Experimental anti-colchicine Fab fragments are being studied [7].

This 2010 Clinical Toxicology review article provides further information and education on colchicine toxicity.

Want to learn more about EM Pharmacology?

Read other articles in the EM Pharm Pearls Series.

References:

  1. Montreal Heart Institute. Colchicine reduces the risk of COVID-19-related complications. GlobalNewswire website. January 22, 2021. Accessed January 26, 2021.
  2. Montretal Heart Institute. ColCorona. Accessed January 26, 2021.
  3. Tardif J-C, Bouabdallaoui N, L’Allier PL, et al. Efficacy of colchicine in non-hospitalized patients with covid-19. medRxiv. doi: 10.1101/2021.01.26.21250494. Epub 2021 Jan 27.
  4. Deftereos SG, Giannopoulos G, Vrachatis DA, et al. Effect of colchicine vs standard care on cardiac and inflammatory biomarkers and clinical outcomes in patients hospitalized with coronavirus disease 2019: the grecco-19 randomized clinical trial. JAMA Netw Open.  2020;3(6):e2013136. doi: 10.1001/jamanetworkopen.2020.13136. PMID: 32579195.
  5. Mahan KM, Hayes BD, North CM, et al. Utility of hypertonic saline and diazepam in covid-19–related hydroxychloroquine toxicity. The Journal of Emergency Medicine. doi: 10.1016/j.jemermed.2020.10.048. Epub 2020 Oct 2020. PMID: 33353811.
  6. Chai PR, Ferro EG, Kirshenbaum JM, et al. Intentional hydroxychloroquine overdose treated with high-dose diazepam: an increasing concern in the covid-19 pandemic. J Med Toxicol. 2020;16(3):314-320. doi: 10.1007/s13181-020-00790-8. PMID: 32514696.
  7. Eddleston M, Fabresse N, Thompson A, et al. Anti-colchicine Fab fragments prevent lethal colchicine toxicity in a porcine model: a pharmacokinetic and clinical study. Clinical Toxicology. 2018;56(8):773-781. doi: 10.1080/15563650.2017.1422510. PMID: 29334816.

 

By |2021-01-29T10:38:07-08:00Jan 30, 2021|EM Pharmacy Pearls, Tox & Medications|
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PEM Pearls: To Scan or Not to Scan? CT Abdomen in Children with Blunt Torso Trauma

blunt torso traumaAn 18-month-old female with no past medical history is brought in by ambulance after a motor vehicle collision (MVC) at highway speed, restrained in an appropriate car seat. Mom was also brought in after delayed extrication with an obvious femur deformity. EMS reports that the patient had emesis on the scene, was fearful but calm, and has been moving all extremities.

Vitals per EMS: HR 120, BP 100/60, RR 30, SpO2 99%, Temp 36.5 C

Initial Exam:

  • General: crying
  • Neuro: Glasgow Coma Scale (GCS) of 13 (eyes shut unless talked to, crying spontaneously, moving all extremities)
  • MSK: atraumatic chest, erythema on the left leg
  • Abdomen: without tenderness

Blunt Torso/Abdominal Trauma

An intra-abdominal injury (IAI) is considered to be any radiographically or surgically apparent injury to an intra-abdominal structure (urinary tract, gastrointestinal tract, spleen, liver, pancreas, gallbladder, adrenal gland, vasculature, and fascia). An intra-abdominal injury requiring intervention (IAI-I) is any IAI that causes death or requires an intervention such as laparotomy, angiographic embolization, blood transfusion, or even admission for intravenous fluids [1].

Despite our curiosity and desire to diagnose all injuries, emergency medicine teams must focus on recognizing IAI-I and tailor their workup accordingly given the negative consequences of excessive workup and treatment of stable IAIs (e.g., unnecessary splenectomies, hepatectomies, increased length of stay, radiation, and increased medical costs/resources).

Although the incidence of pediatric blunt torso trauma in the United States was 110,525 cases in 2016, the prevalence of IAI has been quoted to be as low as 6.3%; more importantly, the prevalence of IAI-I is less than 2% [1]. Non-pediatric level 1 trauma centers were more likely to use computed tomography (CT) in pediatric trauma patients compared to pediatric trauma centers, even after adjusting for injury severity [2].

Clinical Decision Rule

The Pediatric Emergency Care Applied Research Network (PECARN) conducted a prospective study of over 12,000 children ages 0-18 years presenting to pediatric and general EDs with blunt torso trauma. Significant predictors of IAI-I were low GCS, abdominal tenderness, abdominal wall trauma, thoracic wall trauma, decreased breath sounds, and vomiting. The authors developed a prediction rule with a sensitivity of 97% (93.7, 98.9) and a negative predictive value of 99.9% (99.7, 1.00) [1]. External validation had similar sensitivity (99% 96-100%) reinforcing the utility of this clinical decision rule (CDR) in identifying low-risk individuals and decrease the use of CT [4].

In comparison to other CDRs, this rule does not include a gestalt variable but outperforms clinical gestalt with a lower miss rate (6 compared to 23) [5]. Of note, this prediction rule is not a two-way tool and was created only to determine individuals at low risk of IAI-I, rather than to assist providers in deciding who needs a CT scan.

IAI

Adapted from Holmes JF et al 2013 [1]

Reviewing the cases missed by the prediction rule in the initial study, possible clinical findings that could be captured with adjuncts, such as labs and imaging, include:

  • Gross hematuria
  • Microscopic hematuria (Red Blood Cells on Urinalysis)
  • Elevated AST/ALT
  • Rib fracture

Adjuncts

No single test effectively screens for IAI-I or IAI, but additional testing can increase the index of concern in cases that already have a higher pre-test probability (individuals who have any of the variables factored into the prediction rule). The following adjuncts can be considered for children who are not deemed very low risk.

Labs

  • Hematocrit <30% [3,7-8]
  • AST>200 U/L, ALT>125U/L [3,7, 9-10]
  • Lipase >100 U/L [9,11-12]
  • UA Gross hematuria [12-17]

Focused Assessment with Sonography for Trauma (FAST)

  • The diagnostic role of a FAST in pediatric trauma is less established than in adult trauma [18].
  • Application of FAST increases as provider suspicion for IAI increases [19].
  • As an adjunct to the clinical exam, FAST can be incorporated into decision making for selected cases of increased IAI concern [20].

Chest X-ray (CXR)

  • Injuries noted on a CXR may contribute to increased concern for IAI depending on location, mechanism, and type of injury [21].

Review of Case

Returning to our case, findings of concern include her GCS of 13 and reported emesis. Although it was a high-speed MVC and may represent a more severe mechanism, this variable was not found to be a predictor of IAI-I and should not in isolation inform your evaluation of her abdominal injury.

Application of the PECARN CDR demonstrates that the patient is not at very low risk for IAI-I. Labs and a FAST are performed and medications are given for symptom control.

The patient’s results are:

Labs:

  • HCT 35%
  • Lipase 20 U/L
  • AST 23 U/L, ALT 30 U/L
  • UA: no gross hematuria

FAST: Negative

On re-evaluation after ondansetron and acetaminophen, the patient has a GCS of 15 and is excitedly playing with her new teddy bear from the fire department while sipping apple juice. The patient is safely discharged home with her dad after a very frightening experience without unnecessary costs or radiation.

Take-Home Points

  • While blunt pediatric abdominal trauma has a high incidence, the prevalence of IAI-I is rather low.
  • The PECARN prediction rule for blunt torso trauma can identify patients that are very-low-risk for an IAI-I.
  • Notably, the mechanism of injury is not a predictable factor in determining IAI-I.
  • Clinicians should consider the use of labs, FAST, and CXR for risk stratification of patients that are not found to be very-low-risk.

Read more pediatric emergency medicine topics as part of the PEM Pearls Series on ALiEM.

References

  1. Holmes JF, Lillis K, Monroe D, et al. Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med. 2013;62(2):107-116.e2. doi:10.1016/j.annemergmed.2012.11.009. PMID: 23375510
  2. Marin JR, Wang L, Winger DG, Mannix RC. Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits. J Pediatr. 2015 Oct;167(4):897-904.e3. doi: 10.1016/j.jpeds.2015.06.052. PMID: 26233603
  3. Holmes JF, Sokolove PE, Brant WE, et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med. 2002;39(5):500-509. doi:10.1067/mem.2002.122900. PMID: 11973557
  4. Springer E, Frazier SB, Arnold DH, Vukovic AA. External validation of a clinical prediction rule for very low risk pediatric blunt abdominal trauma. Am J Emerg Med. 2019 Sep;37(9):1643-1648. doi: 10.1016/j.ajem.2018.11.031. PMID: 30502218.
  5. Mahajan P, Kuppermann N, Tunik M, et al. Comparison of Clinician Suspicion Versus a Clinical Prediction Rule in Identifying Children at Risk for Intra-abdominal Injuries After Blunt Torso Trauma. Acad Emerg Med. 2015;22(9):1034-1041. doi:10.1111/acem.12739. PMID: 26302354
  6. Nishijima DK, Yang Z, Clark JA, Kuppermann N, Holmes JF, Melnikow J. A cost-effectiveness analysis comparing a clinical decision rule versus usual care to risk stratify children for intraabdominal injury after blunt torso trauma. Acad Emerg Med. 2013;20(11):1131-1138. doi:10.1111/acem.12251. PMID: 24238315
  7. Taylor GA, Eichelberger MR, O’Donnell R, Bowman L. Indications for computed tomography in children with blunt abdominal trauma [published correction appears in Ann Surg 1992 Jul;216(1):99]. Ann Surg. 1991;213(3):212-218. doi:10.1097/00000658-199103000-00005. PMID: 1998402
  8. Taylor GA, O’Donnell R, Sivit CJ, Eichelberger MR. Abdominal injury score: a clinical score for the assignment of risk in children after blunt trauma. Radiology. 1994;190(3):689-694. doi:10.1148/radiology.190.3.8115612. PMID: 8115612
  9. Streck CJ, Vogel AM, Zhang J, et al. Identifying Children at Very Low Risk for Blunt Intra-Abdominal Injury in Whom CT of the Abdomen Can Be Avoided Safely. J Am Coll Surg. 2017;224(4):449-458.e3. doi:10.1016/j.jamcollsurg.2016.12.041. PMID: 28130170
  10. Streck CJ Jr, Jewett BM, Wahlquist AH, Gutierrez PS, Russell WS. Evaluation for intra-abdominal injury in children after blunt torso trauma: can we reduce unnecessary abdominal computed tomography by utilizing a clinical prediction model?. J Trauma Acute Care Surg. 2012;73(2):371-376. doi:10.1097/TA.0b013e31825840ab. PMID: 22846942
  11. Adamson WT, Hebra A, Thomas PB, Wagstaff P, Tagge EP, Othersen HB. Serum amylase and lipase alone are not cost-effective screening methods for pediatric pancreatic trauma. J Pediatr Surg. 2003;38(3):354-357. doi:10.1053/jpsu.2003.50107. PMID: 12632348
  12. Capraro AJ, Mooney D, Waltzman ML. The use of routine laboratory studies as screening tools in pediatric abdominal trauma. Pediatr Emerg Care. 2006;22(7):480-484. doi:10.1097/01.pec.0000227381.61390.d7. PMID: 16871106
  13. Mee SL, McAninch JW, Robinson AL, Auerbach PS, Carroll PR. Radiographic assessment of renal trauma: a 10-year prospective study of patient selection. J Urol. 1989;141(5):1095-1098. doi:10.1016/s0022-5347(17)41180-3. PMID: 2709493
  14. Morey, Allen F., et al. “Efficacy of Radiographic Imaging in Pediatric Blunt Renal Trauma.” Journal of Urology, vol. 156, no. 6, 1996, pp. 2014–2018., doi:10.1016/s0022-5347(01)65422-3.
  15. Brown SL, Haas C, Dinchman KH, Elder JS, Spirnak JP. Radiologic evaluation of pediatric blunt renal trauma in patients with microscopic hematuria. World J Surg. 2001;25(12):1557-1560. doi:10.1007/s00268-001-0149-6. PMID: 11775191
  16. Santucci RA, Langenburg SE, Zachareas MJ. Traumatic hematuria in children can be evaluated as in adults. J Urol. 2004;171(2 Pt 1):822-825. doi:10.1097/01.ju.0000108843.84303.a6. PMID: 14713834
  17. Levy JB, Baskin LS, Ewalt DH, et al. Nonoperative management of blunt pediatric major renal trauma. Urology. 1993;42(4):418-424. doi:10.1016/0090-4295(93)90373-i. PMID: 8212441
  18. Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. J Pediatr Surg. 2007 Sep;42(9):1588-94. doi: 10.1016/j.jpedsurg.2007.04.023. PMID: 17848254
  19. Menaker J, Blumberg S, Wisner DH, et al. Use of the focused assessment with sonography for trauma (FAST) examination and its impact on abdominal computed tomography use in hemodynamically stable children with blunt torso trauma. J Trauma Acute Care Surg. 2014;77(3):427-432. doi:10.1097/TA.0000000000000296. PMID: 25159246
  20. Retzlaff T, Hirsch W, Till H, Rolle U. Is sonography reliable for the diagnosis of pediatric blunt abdominal trauma? J Pediatr Surg. 2010 May;45(5):912-5. doi: 10.1016/j.jpedsurg.2010.02.020. PMID: 20438925
  21. Holmes JF, Sokolove PE, Brant WE, Kuppermann N. A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma. Ann Emerg Med. 2002 May;39(5):492-9. doi: 10.1067/mem.2002.122901. PMID: 11973556

Read more pediatric emergency medicine topics as part of the PEM Pearls Series on ALiEM.

By |2022-09-25T00:08:13-07:00Jan 29, 2021|Academic, Emergency Medicine, Pediatrics, PEM Pearls, Trauma|
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