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PED-EM-L  March 2009

PED-EM-L March 2009

Subject:

Re: am i missing sumthin?

From:

ed vargas <[log in to unmask]>

Reply-To:

ed vargas <[log in to unmask]>

Date:

Tue, 31 Mar 2009 10:41:05 -0700

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (184 lines)

Just curious?

What are all you DOCS  EXACTLY telling your patient's partents regarding CT
scans and radiation exposure? Are you keeping it simple? Or are you throwing
numbers at them?   (like one kid in a 2,000 will get a cancer).

thanks

EV



On Mon, Mar 30, 2009 at 5:44 PM, Manoj Mittal <[log in to unmask]> wrote:

> Don,
>
> I share your concern, and have limited CTs for infants significantly in
> my practice. Another important issue (other than radiation induced
> neoplasia) is the effect of radiation on the developing brain in young
> children. There is emerging evidence that radiation doses equivalent to
> that used for head CT in infancy may influence cognitive abilities in
> adulthood. Hall et all showed in their population based cohort study
> that infants who received radiation therapy (dose equivalent to that for
> head CT) to head for cutaneous hemangioma were less likely to attend
> high school and performed significantly poorer on cognitive tasks than
> controls (1).
>
> Just to show that I do what I preach, recently I had a somewhat similar
> case; about 10 month old infant whose mother had noticed a soft spot on
> her head; No h/o injury; went to PMD 2 days after first noticing it, who
> organized an outpatient Xray skull which showed a simple parietal bone
> fracture, at which stage the infant was sent to the ED for evaluation.
> NO symptom or sign suggestive of intracranial injury; mother in the ED
> with 3 children; very good interactions among the family; discussed the
> issue with PMD and mother about doing CT; all of us agreed that
> considering the time period elapsed since the injury was first noticed,
> the potential harm of CT was probably greater than the benefit; no CT
> done; detailed discharge instructions given to mother and followup
> arranged with PMD for the next day. Our social worker also met with the
> family and did not think that NAI was likely.
>
> A recent study in Pediatrics suggests low return from skeletal sueveys
> in such patients as well (2)
>
> References:
> (1) Hall P, Adami HO, Trichopoulos D, et al. Effect of low doses of
> ionising radiation in infancy on cognitive function in adulthood:
> Swedish population based cohort study. BMJ. 2004;328(7430):19
>
> (2) Skeletal Surveys in Infants With Isolated Skull Fractures. Joanne N.
> Wood, Cindy W. Christian, Cynthia M. Adams, and David M. Rubin
> Pediatrics 2009; 123: e247-e252
>
> Regards,
> Manoj K Mittal, MD
> Emergency Medicine, CHOP
>
>
> >>> don zweig <[log in to unmask]> 03/30/09 5:02 PM >>>
> Well, i did get a ct scan and there was just the fluid that appeared
> to be a moderate size hematoma and no underlying injury or fx.  All
> labs including crp, cbc, ua, pt/ptt were normal.  i thought the
> responses were quite helpful, especially the possiblity of late
> resolving cephalohematoma.  what i was looking for was that all you
> dudes and dudesses would almost all have obtained a ct even with the
> attendant radiation risk and need for propofol sedation.  the parents
> were freaked about the cancer risk i quoted them and then the scanner
> mis fired and we had to repeat the scan!!  I, too, was a bit horrified/
> embarrassed.
>
> don
> On Mar 30, 2009, at 12:33 PM, Joe Nemeth, Mr wrote:
>
>  > Beware....
> >
> > Saw this recently...
> >
> > Same story...no Hx of trauma...
> >
> > Dg: Skull #, Trauma X
> >
> > Joe
> >
> >
> > Joe Nemeth MD CCFP EM
> > Director,
> > Emergency Medicine
> > Montreal General Hospital
> > Assistant Professor
> > Pediatrics
> > Montreal Children's Hospital
> > McGill University Health Center
> > [log in to unmask]
> > Tel: 1-514 299 6190
> > Fax: 1-514 934 8421
> >
> >
> > ________________________________
> >
> > From: Pediatric Emergency Medicine Discussion List on behalf of Lyn
> > Dos Santos, MD
> > Sent: Mon 3/30/2009 2:52 PM
> > To: [log in to unmask]
> > Subject: Re: am i missing sumthin?
> >
> >
> >
> > Leptomeningeal cyst??  I have only seen one in the last 15 years so I
> > know it is rare.  Since this follows a skull fracture by weeks/months
> > there is often no other sign of trauma.  Did you get a head CT?
> >
> > Dr. Lyn Dos Santos
> > Clinical Assistant Professor
> > Department of Pediatrics, Stanford University
> > Director, Pediatric Hospitalist Program
> > Washington Hospital
> > 2000 Mowry Ave
> > Fremont, CA 94538
> > 510-795-2002
> > CONFIDENTIALITY NOTICE:  This e-mail communication and any attachments
> >> may contain confidential and privileged information for the use of
> >> the
> >> designated recipients named above.  If you are not the intended
> >> recipient, you are hereby notified that you have received this
> >> communication in error and that any reivew, disclosure,
> >> dissemination,
> >> distribution or copying of it or its contents is prohibited.  If you
> >> have received this communication in error, please call (510)-795-2002
> > immediately and destroy all copies of this communication and any
> >> attachments.  Thank you.
> >
> >
> > -----Original Message-----
> > From: Pediatric Emergency Medicine Discussion List
> > [mailto:[log in to unmask]] On Behalf Of don zweig
> > Sent: Monday, March 30, 2009 7:42 AM
> > To: [log in to unmask]
> > Subject: am i missing sumthin?
> >
> > 11 m old prev healthy girl brought in by two very appropriate
> > intelligent parents; sent in by pediatrician after seen for a soft
> > spot on left temp parietal portion of skull that began misteriously
> > this am.  they are with child constantly and there has been no
> > trauma.  child is acting normal and is playful and into everything and
> > very cute.  there is no nv. on exam she has a surprise temp of 38.7 r
> > and other vitals normal but no bp taken.  she has a normal fontanel
> > but on the left side of scalp is an area maybe 3x3 inch of non tender
> > soft fluid filled area like a hematoma but no discoloration/tenderness
> > or abrasion.  no battles raccoon and the remainder exam is entirely
> > normal.  what would you do?
> >
> > don
> >
> > For more information, send mail to [log in to unmask] with
> > the
> > message: info PED-EM-L
> > The URL for the PED-EM-L Web Page is:
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> >
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> >
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