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Board Questions

1. Your patient is a 5 yo boy who fell while climbing a tree (approximately 5 feet). According to witnesses, he fell on his head, cried immediately and moved his arms and legs. EMS arrived and placed him in a C collar. As you examine him, he actively reaches in an attempt to remove the C-collar. When asked what hurts, he states that everything hurts (head, neck, stomach, arms, legs). Tone and strength appear normal in upper and lower extremities. With child life distracting him, he does not react to palpation of his neck. Which is the most appropriate study to order in this situation? 

a) CT Head and Neck
b) Flexion-Extension films of the cervical spine
c) MRI of C-and T spine
d) Ap and Lateral X-rays of the cervical spine

2. You are caring for a 4 yo girl who was involved in a pedestrian vs. auto accident approximately 6 hours ago. She has evidence of multiple trauma including a chest XR with fractures of the left 6th and 7th ribs, pulmonary contusion, a left femur fracture, and a small subdural hematoma. The cardiomediastinal silhouette appears normal. GCS is 11. Which of the following is true? 

a) Echocardiography is indicated to rule out myocardial contusion
b) Pericardial effusion is the most common cardiac injury in blunt pediatric trauma
c) A patient who has not had any noted dysrhythmias is at low risk for developing significant dysrhythmias
d) An elevated troponin level correlates with the severity of cardiac injury

3. A 11 yo boy comes to the ED after being struck in the face with a baseball bat. He has obvious facial injuries including nasal deformity with significant epistaxis, upper lip laceration, and periorbital edema. Plastic surgery and neurosurgery request a CT. Unfortunately, due to his level of distress, he will have to be intubated for the procedure. Which of the following is the most appropriate method for intubating this child ? 

a) Cricothyrotomy in the operating room with ENT
b) Administer nasal phenylephrine and perform nasal intubation with ketamine
c) Intubate orally after utilizing fentanyl, midazolam, rocuronium, cricoid pressure, and bag-valve-mask ventilation
d) Intubate orally with fentanyl and midazolam




ANSWERS & EXPLANATIONS

1. D- AP and lateral films of the cervical spine are the most appropriate imaging study in suspected spinal trauma. The lateral c-spine view has the highest sensitivity for detecting C-spine injury compared to other x-ray views. Flexion/extension views are sometimes used to evaluate patients suspected of having ligamentous injury but are difficult to obtain (secondary to pain), particularly in pediatric patients. These patients should undergo MRI or CT scan if they have suspected ligamentous injury with negative plain films. CT of the spine and head exposes the child to significant radiation and should be used judiciously given the increased risk of cancer later in life. Guidelines from the American College of Neurosurgeons state that “CT of the C-spine should be used judiciously to define bony anatomy at specific levels, but it is not recommended as a means to clear the entire cervical spine in children.” MRI, while better at detecting ligamentous injury, often requires sedation in pediatric patients. Most patients can be evaluated using simply plain films and the physical exam, with MRI limited for cases where doubt remains or where the physical exam may be limited. Spinal cord injury without radiographic abnormality (SCIWORA) is more common in pediatric patients due to the laxity of their spine (bends before breaking), leading to more soft tissue injuries. IF there is continued concern for soft tissue or ligamentous injury, than MRI would be indicated. Nonetheless, the initial study of choice in this patient with some concern for neck injury is lateral/AP views of the cervical spine.

2. C-This patient may have suffered a cardiac contusion, which is the most common traumatic cardiac injury (not pericardial effusion). However, most patients with cardiac injury do not develop severe cardiac dysfunction. Similarly, if the patient has not developed significant dysrhythmias within several hours, they are unlikely to develop them. Without clinical evidence of cardiac injury, echocardiography is not indicated at this time. Troponins are a marker of myocardial injury but do not correlate with the severity of traumatic cardiac injury. 

3. D- this patient is obviously at risk for being a difficult airway. He is also at risk for aspiration of blood given epistaxis as well as possible cribiform plate injury or basilar skull fracture. Hence, nasal intubation is contraindicated. Furthermore, spontaneous respirations should be preserved if at all possible and BVM ventilation avoided if possible as it also increase the risk of aspiration. Hence, judicious use of fentanyl and midazolam is the preferred method amongst the choices provided. 
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