Hey Kiddo, Take a Seat…

Case 1:

A 13-month-old boy arrives by EMS after a motor vehicle accident. He was a rear passenger, restrained in a front-facing car seat when the vehicle struck a utility pole at high speed. Initially, he was responsive and crying, but became unresponsive and lost vital signs en-route to the ED. In the trauma bay, ROSC is achieved after a brief period of CPR and airway management. His imaging is notable for significant fractures at C1/C2 as well as complex ligamentous disruption; he requires emergent surgical intervention for his spinal injuries, and suffers a severe anoxic brain injury.

Case 2:

Two boys, a 4-month-old and a 3-year-old, arrive by EMS after a low speed, T-bone motor vehicle accident with airbag deployment. Both patients were restrained rear passengers, the 4-month-old in a rear-facing seat, and the 3-year-old in a front-facing seat. In the ED, exam is significant only for some mild abrasions, and both are discharged after a period of observation. The car seats involved in the accident are brought to the ED, and family attempts to use them to transport the children home.

Case 3:

A 5-year-old girl arrives by EMS unresponsive after a front-end collision. She was restrained in her front-facing car seat, when the vehicle struck a telephone pole. Per EMS providers, the seat was not properly restrained within the vehicle. She is apneic with obvious, severe head injuries and asymmetric pupils, with imaging confirming multiple skull fractures and intracranial hemorrhage. Despite maximal interventions, she succumbs to her injuries.

 

Case 4:

A new mother brings her 31-day-old infant for evaluation of vomiting. An exam is performed and is reassuring, consistent with likely reflux, and she is discharged home with close pediatrician follow up in the coming days. On the way out of the exam room, she asks if her car seat is safe to use, as it was a hand-me-down from another family member, and she is not sure if this seat is “expired.”

The Facts:

Unintentional injuries remain a leading cause of death in children. While the number of fatalities from motor vehicle collisions has declined, it remains the cause of death in 1 out of 4 children ages 1-13[1]. Car safety seats (CSS) have been demonstrated to reduce the risk of injury and death in children, and are credited with saving the lives of 328 children under age 4 in 2016[2]. Currently, laws exist in all 50 states and Washington D.C. governing the use of child safety seats. The use of car safety seats has been well studied by multiple agencies, including the National Highway Traffic Safety Administration, the Center for Disease Control and Prevention, the Insurance Institute for Highway Safety, and the American Academy of Pediatrics.

We have a duty to our pediatric patients and their families to be familiar with the current recommendations for car safety seats, and provide education and resources when necessary to help prevent morbidity and mortality. In two of the above cases, provider knowledge about these recommendations is critical, and allows rapid intervention on discharge to prevent possible further injuries. As unfortunately common to practitioners in the emergency department, the remaining two cases help reinforce the need for a high index of suspicion for injuries when children present with a history consistent with improper restraint.

 

Current Recommendations [3,10]:

The American Academy of Pediatrics recently released a policy statement published November 2018, highlighting the current recommendations for child safety seats. A summary of recommendations along with a useful flow chart is shown below*:

  • All infants and toddlers should ride in a rear-facing car seat as long as possible, until they reach the height or weight limit listed by the car seat manufacturer

    • It is important to check which type of seat is used rear-facing: infant-only seats have a much lower height and weight limit than convertible or 3-in-1 car seats

  • All children that have outgrown the height or weight limit on a rear-facing seat should ride in a forward-facing seat with a harness until they reach the height/weight limit listed by the manufacturer

  • When children outgrow the height or weight limit of a forward-facing seat, they should use a booster seat until the vehicle lap and shoulder belt fits appropriately, typically when they reach a height of 4 feet 9 inches, and between the age of 8-12

  • When children are old/tall enough to use the vehicle seat belt alone, they should always use both a lap and shoulder belt

  • All children under age 13 should remain restrained in the back seat for optimal protection

*Modified from Table 1: Summary of Best Practice Recommendations, Durbin and Hoffman, Pediatrics, Vol 145 No 5, November 2018

Algorithm to guide implementation of best practice recommendations for optimal child passenger safety:

From: Durbin and Hoffman,  Pediatrics,  Vol 145 No 5, November 2018

From: Durbin and Hoffman, Pediatrics, Vol 145 No 5, November 2018

For the visual learners, the CDC has a graphical representation of the seats with corresponding ages[9]:

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In Rhode Island, specific laws were enacted in 2017, outlining the proper restraint of passengers in vehicles, including children, with a pertinent summary below[4]:

  • All children under age 8, less than 57 inches in height (4 feet 9 inches), and less than 80 pounds should be restrained in a rear sitting position in an approved child restraint system

  • All infants and toddlers less than 2 years of age, or weighing less than 30 pounds, should be restrained in a rear-facing car seat

  • All children 2 years of age or older who outgrow rear-facing car seats should use a forward-facing car seat with harness, up to the maximum allowed by the car seat manufacturer

Frequently Asked Questions:

I have a car seat and am not sure it is installed properly, or am expecting a new baby and not sure how to install my car seat. Where can I go to make sure this is done correctly?

  • There are several options to ensure a child safety seat is installed correctly. The easiest way to do this is to simply search through the National Child Passenger Safety Certification webpage, listed below for a car seat check station. Several options exist, including locating a local agency that will perform a car seat check/installation teaching (most often a local police or fire department), attending a child safety event, or locating a specific inspection station not included in the above[5]. Many children’s hospitals, such as Hasbro Children’s Hospital, also have staff certified for safe car seat installation.

I received a car seat as a hand-me down from another family member, but heard car seats expire. Is this true, and how can I tell if this seat is okay?

  • This is an important, sometimes overlooked fact of child safety seats. While both vehicle and car seat technology have dramatically improved the safety of children riding in vehicles, there are limitations of the seats. Most car seats carry an expiration date 6 years after the manufacture date (although this may vary slightly based on seat construction)[6]. The primary reason for this is the wear and tear placed on the seats themselves, including temperature variation, spills, and physical wear from use of the seat. It is also important to recognize that new technology is continually being produced, which quickly makes older seats less superior in safety. Find the label on the child’s seat, which will list both the manufacture date and expiration date. An example of a label can be found below, as seen in a blog post about this topic from Cincinnati Children’s Hospital[7]:

Picture3.png
  • An additional checklist is provided in the “Additional Resources” section below that should be reviewed before purchasing, and using a used car seat

My child was involved in a car accident in a car seat. Is this seat safe to use after the accident?

  • The National Highway Traffic Safety Administration has some guidelines for when a car seat should be replaced. In cases of minor accidents, a car seat does not necessarily have to be replaced, but the accident must meet all of the following criteria8:

  • The National Highway Traffic Safety Administration has some guidelines for when a car seat should be replaced. In cases of minor accidents, a car seat does not necessarily have to be replaced, but the accident must meet all of the following criteria[8]:

    • Vehicle was driven away from crash site

    • Vehicle door nearest car seat was not damaged

    • No passengers in the vehicle sustained injuries

    • No airbag deployment in the vehicle

    • The car seat has no obvious damage

  • If there is any doubt about the severity of the accident, or of the integrity of the car seat, the safest option is to replace the seat

Is there anything else I should do after purchasing a car seat to help ensure it remains up-to-date?

  • Like all new technology, product failures sometimes happen, requiring replacement parts or adjustments. After purchasing a car seat, it is important to register the seat with the appropriate manufacturer to ensure prompt notification of any recall notices in a timely manner. Most manufacturers provide a card that can be submitted, which can also be done online through the specific manufacturer’s page, or using the finder link on the National Highway Traffic Safety Administration website.

Additional Resources:

 

* A special thank you to the providers, nurses, staff, and most importantly, patients/families at Hasbro Children’s Hospital, and to my faculty reviewer, Dr. Jane Preotle

References:

  1. Insurance Institute for Highway Safety, Highway Loss Data Institute, accessed at: https://www.iihs.org/iihs/topics/t/child-safety/fatalityfacts/child-safety, posted December 2017.

  2. US Department of Transportation, National Highway Traffic Safety Administration, “Quick Facts 2016”, accessed at: https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812451

  3. Durbin, DR, Hoffman, BD; “Child Passenger Safety”, AAP Council on Injury, Violence, and Poison Prevention Policy Statement, Pediatrics, Volume 142, No. 5, November 2018

  4. Rhode Island State Police, Department of Public Safety, “Seat belt laws and car seat recommendations”, accessed at: http://risp.ri.gov/safety/vehiclesafety/seatbelts.php

  5. National Child Passenger Safety Certification webpage, accessed at: https://cert.safekids.org/get-car-seat-checked

  6. National Safety Commission Alert, published October 2011, accessed at: http://alerts.nationalsafetycommission.com/2011/10/child-safety-seats-have-expiration-date.html

  7. Cincinnati Children’s Blog, “Car seat expiration dates: have you checked yours?”, published online June 22, 2015, accessed at: https://blog.cincinnatichildrens.org/safety-and-prevention/car-seat-expiration-dates-have-you-checked-yours/

  8. National Highway Traffic Safety Administration, “Car seat use after a crash”, accessed at: https://www.nhtsa.gov/car-seats-and-booster-seats/car-seat-use-after-crash

  9. Centers for Disease Control and Prevention, Child  Passenger Safety summary page, accessed at: https://www.cdc.gov/features/passengersafety/index.html

  10. Car Seats: Information for Families, accessed at: https://www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Car-Safety-Seats-Information-for-Families.aspx

Money Minutes for Doctors #12 - Market Updates

The market is up…the market is down…the sky is falling…the best year ever!!

Welcome back to our monthly financial podcast, Money Minutes for Doctors. This month we talk with Ms. Katherine Vessenes, JD, CFP®, RFC, Founder and President of MD Financial Advisors, about the rollercoaster that was the world of finance in 2018 and where the market appears to be headed in the coming months.

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About Ms. Vessenes:

Ms. Vessenes works with over 300 physicians and dentists from Hawaii to Cape Cod. Her firm uses a team of experts to provide comprehensive financial planning to help doctors build their wealth and protect their wealth while reducing taxes now and in the future. Katherine is a longtime advocate for ethics in the financial services industry; and has written three books on the subject of investment strategies. She has received many honors and awards including: numerous tributes from Medical Economics as a top advisor for doctors, multiple 5-Star Advisor Awards, honored as a Top Woman in Finance, in addition to being selected to be on the CFP® Board of Ethics. Katherine can be reached at: Katherine@mdfinancialadvisors.com or 952-388-6317. Her website: www.mdfinancialadvisors.com.

Quick Summary:

By now you’ve probably seen nerve- racking headlines in the news about the stock market.  Not to worry, we wanted to give you a short update to let you know what’s going on and how it might impact your portfolio.

  • Here’s the short version. : In While in 2017, both Emerging markets and International markets were the largest performers in your portfolio, in 2018 they are were the biggest losers. 

  • Bonds are the only positive asset class for 2018, which is a great reminder as to why a balanced portfolio is needed.

Below is a graph of the loss value of $1 in 2018 in the markets for various key benchmarks sectors.  The blue line is the entire US Market, the green is the International markets, and the teal is Emerging markets. You will notice all three were down by the end of December.

2018 Sector Returns

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Why are the markets down in 2018?

  • There is never one reason why the market behaves the way it does. Thousands, if not millions of factors, go into changing market prices.

  • Two key things to remember when thinking about stock markets; (1) markets are predictive, meaning they are looking at what’s coming in the future & (2) market prices can be summed up as the present value of all the future cash flows these companies expect to make. Thus, if markets go down, it means the millions of people participating in the market expect the companies being traded on stock exchanges to make less in the future.

Most economists would agree that there are three main reasons as to why the stock market has been down in 2018.

  1. Many economists believe world growth is slowing down.

  2. There is uncertainty as to what central banks will do with interest rates. The largest being the United States Federal Reserve.

  3. Trade uncertainty - There’s a standoff going on b/w China & US.  Multinationals that do business with China are currently evaluating whether they will need to move their manufacturing operations and this uncertainty is causing businesses to wait to spend money.

Avoid Market Timing

  •  We don’t think it benefits you to try and time the market

  • Studies show it is impossible to predict market returns therefore, we highly discourage trying to flee to cash while you wait for a recovery.

What can you do? Control the things you can control.

  1.  Fund a Roth IRA in 1st Quarter - The stock market is currently down, which is perversely good news for savers.

  2.  Switch to a Roth Option at Work in Your 401-k/403-b - Not all doctors have a Roth option through their retirement plan through work, but if you do, we suggest switching to funding a Roth option ASAP. 

  3.  Do a Roth Conversion - If you’ve already maxed out your other tax advantaged savings options and have IRA money that is eligible to do a Roth Conversion, you might convert some funds while the market is lower.

  4.  Review your Risk Tolerance - If the volatility in the stock market is keeping you up at night, it means we should review your risk tolerance again to see if you’re investing with the appropriate amount of risk.

  5. Update Your Retirement Plan - markets should be looked at through the context of your goals and dreams

  6. Save, Save, and Save - When markets are down, perversely this is the best time to save b/c your dollars buy more shares

  7. Have Hope - With proper planning and adjustments you will be fine.

The chart below describes the value of a dollar invested globally from 1970 to 2017 and the impact of world events. Over time the market goes up so don’t let short term set backs derail your long-term goals!  

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Snap, Crackle, and Pop: Imaging and Management of Blunt Laryngeal Trauma

The Case

A 26 year-old male presents after a motorcycle accident. He was the helmeted, single-occupant of a motorcycle that crashed into the back of a stopped car. There are no external signs of injury, but he believes his neck may have hit the handlebars as he was thrown from the bike.  He denies loss of consciousness. His only complaint is that his voice sounds hoarse and he is having difficulty swallowing. He denies any intoxicants.

The patient has a normal primary traumatic survey. His secondary survey is notable for crepitus of the anterior neck. No chest wall crepitus is noted. No stridor or bruit is appreciated on anterior neck auscultation.  There is no cervical hematoma or ecchymosis. There is no midline C-spine tenderness. There is no blood in the oropharynx. His voice is raspy, but he is able to phonate and adequately handle his secretions. He has no other traumatic complaints or physical exam abnormalities on secondary survey.

A chest x-ray is without any evidence of pneumothorax.

You wonder what imaging should be performed next. Does he need a CT brain based on his history? Does crepitus count as a distracting injury? Should he have a CTA in the absence of any hard vascular signs? After discussion with the trauma team, CT imaging including a CTA neck is performed (Figure 1).

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Figure 1: Non-contrast portion of the CTA neck.

Figure 1: Non-contrast portion of the CTA neck.

CT imaging reveals a left hyoid bone fracture, as well as a comminuted fracture of the right thyroid cartilage. His CTA is normal. He has no intracranial injuries, face or C-spine fractures. There is considerable soft tissue emphysema.

Background on blunt laryngeal trauma

Blunt laryngeal trauma is rare.  The reported incidence of laryngeal fractures is 1:30,000 patients presenting to the ER. The low incidence is secondary to the relative protection by adjacent bony structures (the mandible, manubrium, and vertebral bodies). Furthermore, humans are equipped with a protective reflex to flex their heads downward when startled, further shielding this vulnerable region from trauma.  

Laryngotracheal injury occurs when patients lose their ability to protect this area, and are most commonly associated with motor vehicle accidents, when a hyperextended neck strikes a fixed object (steering wheel, dash board).  Recreational vehicles are also increasingly implicated (motorcycles, four-wheelers striking branches). Other mechanisms of injury include strangulation, assault, or hanging.

The patterns of injury vary depending upon the age and gender of the patient. Women are at increased risk for subglottic and cervical tracheal injuries owing to their tendency towards longer necks.  The thyroid and cricoid cartilage also ossify as part of the normal aging process (typically beginning around age 18-20), and for this reason, elderly patients are at increased risk for comminuted fractures of these structures. Conversely, children have flexible cartilage and are much less likely to sustain laryngeal fractures.

Brief review of anatomy

The larynx consists of a cartilaginous skeleton, the intrinsic and extrinsic muscles, and a mucosal lining. The cartilaginous skeleton houses the vocal cords. It consists of the thyroid cartilage, the cricoid cartilage, and the paired arytenoid cartilages. The thyroid cartilage is connected superiorly to the hyoid bone. The extrinsic muscles connect the cartilage of the larynx to other structures of the head and neck (i.e. sternothyroid muscle, etc.). The intrinsic muscles alter the shape, tension and position of the vocal cords (Figure 2).

Figure 2: Anatomy of the laryngotracheal complex.

Figure 2: Anatomy of the laryngotracheal complex.

Injuries range from mucosal hematomas and lacerations to fractured cartilage. The most severe laryngeal injury is complete laryngotracheal separation (Figure 3). Classification of these injuries will be covered in the Classification and Definitive Management section.

Figure 3: Types of laryngotracheal injuries.  http://www.utmb.edu/otoref/grnds/laryng-trauma-070328/laryng trauma-070328.pdf

Figure 3: Types of laryngotracheal injuries.
http://www.utmb.edu/otoref/grnds/laryng-trauma-070328/laryng trauma-070328.pdf

Signs and Symptoms

The mechanism of injury is important. The provider should take careful consideration of any history which lends itself to the possibility of “clothesline” type injury, namely forced hyperextension and forward propulsion or direct trauma to the anterior neck (strangulation, hanging).

Patients will report dysphonia, odynophagia, dysphagia, neck pain, dyspnea or hemoptysis. Studies suggest that hoarseness is the most common presenting symptom of laryngeal trauma.  Juutilainen et al reviewed 33 cases of external laryngeal trauma, and 28 (85%) of those cases presented with hoarseness. Physical exam may reveal stridor, dyspnea, ecchymosis, subcutaneous emphysema, hemoptysis, loss of the thyroid prominence or drooling. However, it is important to note that no single symptom correlates with injury severity and the absence of these findings does not exclude the possibility of laryngeal injury.

Initial Management

Airway management is crucial. If a patient with a suspected laryngeal injury has no evidence of respiratory distress or airway compromise, proceed with a standard traumatic work-up.

If the airway is not patent (respiratory distress, airway obstruction, stridor, not handling secretions, hypoxic), establishing an airway becomes a priority.  In these cases, tracheotomy is preferred to endotracheal intubation, as intubation can exacerbate laryngeal trauma and precipitate complete obstruction. It can also be extremely challenging to intubate because of distorted anatomy and poor visualization, with a risk for passing the ET tube through a false lumen created by the trauma. Furthermore, adequate positioning can be challenging if there is associated maxillofacial injuries and/or the need for C-spine precautions. That being said, there is no absolute contraindication for endotracheal intubation and if the patient is crashing, the most experienced airway provider should attempt it. Again, most of the otolaryngology literature favors tracheotomy, but if palpation of the larynx reveals continuity of the thyroid cartilage and cricoid cartilage, cricothyroidotomy can be performed if it is the only available, expedient airway. 

Importantly, laryngeal trauma carries a high risk of concomitant injury. There is a 13-15% incidence of associated intracranial injuries; skull base and facial fractures are seen in approximately 21%; C-spine fractures are seen in 8%; and esophageal/pharyngeal injuries occur in approximately 3% of these cases. Thus, it is best to have a low threshold for additional imaging studies. CT is the imaging modality of choice, but should only be undertaken in those patients with a stable or secured airway. There is no definite literature on the utility of CTA in blunt laryngeal trauma, but if a patient has any hard signs of vascular injury (bruit/thrill, expanding hematoma, pulse deficit) or signs of an acute ischemic stroke, there should be significant concern for an associated vascular injury.

Classification and Definitive Management

The Schafer-Fuhrman Classification scheme has been created to characterize laryngeal injuries.

Grade I: Minor endolaryngeal hematomas or lacerations, no fracture

Grade II: Edema, hematoma, minor mucosal disruption without exposed cartilage, non-displaced fracture, varying degrees of airway compromise

Grade III: Massive edema, large mucosal lacerations, exposed cartilage, displaced fracture(s), vocal cord immobility

Grade IV: Group III with severe mucosal disruption, disruption of the anterior commissure, and unstable fracture, 2 or more fracture lines

Grade V: Complete laryngotracheal separation

This classification scheme relies on both CT imaging and direct visualization. As part of the work-up for laryngeal injury, flexible fiberoptic laryngoscopy should be performed, usually by otolaryngology. During laryngoscopy, care should be taken to observe for any deformities, edema, hematomas, lacerations, exposed cartilage and partial or complete vocal cord fixation (suggesting a recurrent laryngeal nerve injury).

There is no definite recommendation for the work-up of esophageal injury. In some instances, esophageal injury can be seen on CT imaging (paraesophageal stranding or gas, lumen communicating with gas/fluid).  If, however, the suspicion for esophageal injury is high, additional studies can be pursued, beginning with a gastrograffin swallow study, followed by a dilute barium swallow for more complete evaluation.

The definitive management of laryngeal injuries depends on the injury pattern. Group I and some Group II injuries can be conservatively managed. This generally consists of humidified air, voice rest, head of bed elevation, steroids, anti-reflux medications, and antibiotics. Patients will often be admitted to the ICU for the first 24-48 hours given the potential airway compromise. They may undergo serial laryngoscopy for daily injury surveillance.

Group III-Group V injuries require operative intervention. These are the injury patterns that usually undergo tracheotomy.  Group V patients always have tracheotomies and represent a significant surgical challenge. Notably, there are multiple operative approaches and interventions for laryngeal trauma that are beyond the scope of this post.

Case Outcome

The patient was seen and scoped by otolaryngology in the ED.  This showed a supraglottic hematoma, but no lacerations or exposed cartilage. His vocal folds were mobile.  He was admitted to the trauma ICU, where he underwent a negative barium swallow, and ultimately, did not require operative intervention.

Faculty Reviewer: Dr. Kristina McAteer


References 

  1. Becker M, Leuchter I, Platon A, Becker CD, Dulguerov P, Varoquaux A. Imaging of laryngeal trauma. Europeal Journal of Radiology. Jan 2014: 83(1):142-154.  

  2. Eller RL, Dion G, Spadaro E. Management of Acute Laryngeal Trauma. http://www.cs.amedd.army.mil/FileDownloadpublic.aspx?docid=a1ab55ed-56b2-4a65-ade1-666e80a582cf. Accessed on 12.05.07.  

  3. Font JP, Quinn FB, Rayan MW. Laryngeal Trauma. http://www.utmb.edu/otoref/grnds/laryng-trauma-070328/laryng trauma-070328.pdf Accessed on 12.05.17.  

  4. Jalisi S, Zoccoli M. Management of laryngeal fractures—A 10-year experience. Journal of Voice. Jul 2011;25(4):473-479.

  5. Jewett BS, Shockley WW, Rutledge R. External laryngeal trauma analysis of 392 patients. Archives of Otolaryngology–Head & Neck Surgery. Aug 1999;125(8):877-880.

  6. Juutilainen M, Vintturi J, Robinson S, Bäck L, Lehtonen H, Mäkitie AA. Laryngeal fractures: clinical findings and considerations on suboptimal outcome. Acta Otolaryngol. Feb 2008: 128(2):213–218.

  7. Murr AH and Amin MR. "Laryngeal Trauma"In CURRENT Diagnosis & Treatment in Otolaryngology - Head & Neck Surgery, 2nd Edition Ed. by Anil K. Lalwani.

  8. Mendelsohn AH, Sidell DR, Berke GS, John MS. Optimal timing of surgical intervention following adult laryngeal trauma. Laryngoscope. Oct 2011;121(10):2122-2127.

  9. Schaefer SD. The acute management of external laryngeal trauma. A 27-year experience. Arch Otolaryngol Head Neck Surg. Jun 1992 :118(6):598–604

  10. Schaefer N, Griffin A, Gerhardy B, Gohchee P. Early Recognition and management of Laryngeal Fractures: A Case Report. Ochsner J. 2014: 14)10):264-265.