What is it?
This is a review of a retrospective, single center review of cervical spine injuries at a level one trauma center from 1998 to 2010 in children ages 0-5 years old.

Why do I care?
Cervical spine injuries are something we worry about and evaluate for nearly every day, whether we are on trauma or in the department. Although we have pretty good guidelines and are comfortable with the approach to the adult patient, there is more of a gray area when it comes to kids. Factor in the very young, preverbal or potentially unreliable exams one can experience in this age group, and the task is more challenging. This article sheds some light on the topic.

What do I need to know?
The pediatric cervical spine is different than adults. With a proportionally larger head, weak neck muscles, higher fulcrum of flexion/extension (C2-C3 versus C5-C6) than adults, horizontally oriented facet joints, kids can be higher risk for injury.

However CSI in children is rare. Over this extended time period, only 22 out of 2972 (0.74%) pediatric trauma patients were found to have CSI. The most common mechanism of injury was MVC. Of those injured children, 50% died. Most children had a GCS of 3, and many had other significant injuries. All children with CSI were found to have an abnormal exam, with the majority having a neurological deficit. Others had neck pain or torticollis. The authors also mentioned all asymptomatic children who were able to be evaluated (not in a coma) did not have an unstable CSI.

What do I need to do?
You need to know this information because this, as well as other articles, suggests that peds with a normal exam have a very low risk of CSI and therefore do not require imaging. Further, the authors emphasize that if there is still a need for imaging, it should begin with XR and not CT. This is much in line with the current guidelines on the approach to pediatric blunt neck trauma. If you would like to develop your own take, the reference for the article is listed below and is still available through the library. Till next time...


Reference
Hale DF, Fitzpatrick CM, Doski JJ, Stewart RM, Mueller DL. Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger. Journal of Trauma and Acute Care Surgery. 2015; 78(5): 943-948.

Submitted by Dr. Michael Craddick, PGY-1

Following Dan's great post on "Dermergencies," I thought I would follow it up with another important dermatology topic.  The goal of this is not to provide an extensive review (there is not much information on this topic anyway), but rather to have this pop in your mind every time you evaluate a new rash.  To keep it simple, this and future posts like this, will follow a basic format with the questions listed below.

What is it?
Why do I care?
What do I need to know?
What do I need to do?

What is it?
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome. The name is actually misleading. Not all patients will present with a rash or eosinophilia. This is because what is now being grouped into DRESS syndrome was once before multiple individual drug reactions. Rather than get hung up on the details, think of this as a drug reaction on a continuum. Or just think of this for what it is...a drug reaction gone bad.

Why do I care?
Because there is so much variation, this is a syndrome that can easily be missed. What is the big deal you ask? Turns out DRESS syndrome carries with it a 10% mortality rate. That's why you need to care.

What do I need to know?
The basic things to know are that this exists, it is bad, and recognize it when it is there. That is easier said than done. Because of clinical heterogeneity, it can be very hard to make the diagnosis. However, the "classic" presentation findings are below.

• Exposure to offending drug with a 2-6 week latency period
• Fever
• Rash
• Lymphadenopathy
• Hematologic findings
• Visceral inflammation

As listed in the first bullet point, there is a delayed onset from when the drug was started. This is very important and may be the only thing that clues you into the diagnosis. It also underscores the importance of taking a good, detailed medication history in any patient with a rash.

Although many drugs can be implicated, the most commonly associated are anticonvulsants, minocycline, allopurinol, abacavir, and nevirapine. The main culprits are commonly anticonvulsants such as phenytoin, carbamazepine and lamotrigine. To make it simple, group the drugs into the diseases they treat. Think of seizures/migraines, gout and HIV.

Any time there is a rash with systemic findings such as fever or lymphadenopathy, you should think of this. Get a CBC to lok for the hematologic findings.

When visceral involvement is present, it is most commonly the liver. This can range from hepatitis to hepatocellular necrosis. However, over systems can be involved as well and lead to pneumonitis, myocarditis, pericarditis, nephritis and colitis. As you can imagine, this is why people can die.

What do I need to do?
Step one - stop the drug. From there, treatment is mainly supportive. Although steroids are often used, there is no good evidence supporting them. Call dermatology and get these people in the hospital.




Reference
Choundhary S, McLeod M, Torchia D, Romanell P. The Journal of Clinical and Aesthetic Dermatology. 2013; 6(6): 31-37.

Submitted by Dr. Michael Craddick, PGY-1