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PED-EM-L  March 2009

PED-EM-L March 2009

Subject:

Re: PED-EM-L

From:

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Reply-To:

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Date:

Tue, 31 Mar 2009 19:26:38 EDT

Content-Type:

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Parts/Attachments:

Parts/Attachments

text/plain (275 lines)

Hi Chuck, Hope all is well,
I am actually looking into developing an informed consent for CT scans for  
children. It is a tedious task.
I personally try to practice that if they have RLQ pain/tenderness, a WBC  > 
15K, a CRP > 7 or 8, they likely will have appendicitis. Equivocal cases  get 
observed and/or CT with surgical consult. Our US techs are not proficient at  
US as of yet. I can only hope and pray.
Interestingly, Peds Emergency Medicine Reports recently eluded to a sort of  
standard being to officially consult a surgeon prior to ordering a CT. We can  
all interpret this in many ways I can imagine.
No set protocols, I think protocols can medical-legally get us into  trouble, 
I DO like Guidelines however.
I like the quote at the end of your note, I have a quote from someone as  
well, I'm not sure of the exact language, but it goes something like:
"Experience in medicine allows you to come up with the wrong diagnosis with  
that much more confidence".
I love that...
 
Regards,
Todd Z
 
Dr. Todd Zimmerman
 
 
message dated 3/31/2009 6:14:50 P.M. Central Daylight Time,  [log in to unmask] 
writes:
 
This is  an interesting question especially when extended to the frequently 
ordered  abdominal/pelvis CT (more radiation) for abdominal pain R/O appy 
clinical  scenario.

I think a discussion of radiation exposure should always be  done, and a 
careful assessment  of the need for CT imaging made.  

But the questions:
Does anyone ask for written informed consent  prior to CT scanning?
Does anyone use the excellent information  "information for parents" 
downloadable from the image gently web site?
Does  anyone use a "protocol" to guild CT scanning usage?

In non academic (no  surgical resident coverage) institutions: Do you require 
a surgical  consultation prior to ordering a CT?  Have set protocols for  
ordering CTs.

I practice in a large Community based ED (limited hour -  separate Peds ED, 
no peds surgery or surgical resident coverage),
We  discuss radiation issues when ordering CTs (US for appys not reliable as 
an  alternative) , usually make the decision to scan before asking for  
surgical consultation. Don't scan the more obvious cases without surgical  
consultation. But have no set protocols.

I'm interested in what others  are doing especially in the non teaching 
setting?
Chuck


Charles  Nozicka DO, FAAP, FAAEM
Medical Director 
Pediatric Emergency  Medicine
Advocate Condell Medical Center
Libertyville,  Illinois

“The difference between a
successful person and others is  not
a lack of strength, not a lack of
knowledge, but rather in a lack  of
will.”
Vince Lombardi


-----Original Message-----
From:  ed vargas=2
0<[log in to unmask]>
To:  [log in to unmask]
Sent: Tue, 31 Mar 2009 12:41 pm
Subject: Re:  am i missing sumthin?



Just curious?
What are all you  DOCS  EXACTLY telling your patient's partents regarding CT
cans and  radiation exposure? Are you keeping it simple? Or are you throwing
umbers  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 have20obtained 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,
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>> 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
>  or20abrasion.  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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