Pediatrics

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]:

Picture2.png

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 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

Faculty Reviewer: Jane Preotle, MD

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

Orbital Floor Blowout Fracture

CASE

A 16-year-old male presents with head trauma. The patient was in gym class when another classmate ran into him, kneeing him in the left eye. There was no loss of consciousness. On presentation, the patient complains of headache, dizziness, nausea, visual disturbance, and photophobia. He has vomited several times. On review of systems, the patient also endorses double vision and numbness over the left cheek. The patient’s mother notes he is alert but is slow to respond to questions.  He has no prior history of facial fractures.

Physical Exam

BP 130/70, HR 58, RR 20, SpO2 99% on RA, Temp 98.6 F

The patient is alert and oriented.  He appears uncomfortable but is in no acute distress.

HEENT exam with left periorbital ecchymosis and edema, with tenderness to palpation. Diminished sensation to light touch over cheek and upper lip. Nasal bridge swelling and tenderness, with subtle nasal deviation to the right. No septal hematoma. Symmetric smile.

Pupils are equal, round, and reactive to light. No hyphema or subconjunctival hemorrhage. Left eye with decreased up-gaze as compared to the right. Extraocular movements of the left eye are painful.

The neck has normal range of motion. There is no cervical midline tenderness to palpation.

The patient’s history and examination are significant for trauma to the left eye and face. His examination reveals bony tenderness, with decreased sensation to light touch, and evidence of inferior rectus entrapment as evidenced by abnormal extraocular movements. These findings are concerning for orbital blow-out fracture. There is also concern for nasal bone fracture given nasal bridge swelling, tenderness, subtle deviation, and epistaxis. Given patient’s nausea, vomiting, dizziness, and slowed responses to questions (as per patient’s mother), intracranial injury was also considered.

The patient underwent a CT of the brain and face, with thin (1mm) cuts through the orbits (Figure 1).

Figure 1: Axial CT of the face (bone window) with fracture through the left orbital floor, with herniation of the orbital fat (“teardrop” sign) and inferiorly displaced inferior rectus muscle

Figure 1: Axial CT of the face (bone window) with fracture through the left orbital floor, with herniation of the orbital fat (“teardrop” sign) and inferiorly displaced inferior rectus muscle

DISCUSSION

Figure 2: Anatomy of the orbit (https://en.wikipedia.org/wiki/File:Orbital_bones.png)

Figure 2: Anatomy of the orbit (https://en.wikipedia.org/wiki/File:Orbital_bones.png)

The orbit is composed of six bones. The frontal bone forms the superior orbital rim and the roof of the orbit. The sphenoid bone and the zygomatic bone form the lateral wall of the orbit. The maxilla and the zygomatic bone form the infraorbital rim and floor of the orbit. Finally, the maxilla and ethmoid bones form the medial wall of the orbit (Figure 2).

Housed within, or within in close proximity to the bony orbit are the globe, six extra-ocular muscles, the infraorbital and supraorbital nerves, lacrimal duct system, medial and lateral canthal ligaments, and 4 pairs of sinuses (Neuman).

A blowout fracture is a fracture through any of the orbital walls, with an inferior fracture through the floor being the most common (Knipe). It is caused by direct force to the orbit. In children, nearly 50% of these injuries occur during sports, with the direct blow usually coming from a ball or another player (Hatton).

A trap door fracture is a sub-type of the orbital floor fracture. It is a linear fracture that inferiorly displaces and then recoils back to near-anatomic position. With this movement there is concern for entrapment of orbital fat and inferior rectus muscle, resulting in ischemia, restriction of ocular movement, and visual disturbance (Hacking). The trap door fracture is predominantly seen in the pediatric population, owing to increased elasticity of the orbital floor (Chung, Grant).

Clinically, a patient will present with periorbital edema and ecchymosis. Altered sensation or numbness over the cheek, upper lip, and upper gingiva is suggestive of infraorbital nerve injury. Proptosis of the eye is suggestive of orbital hematoma. A posteriorly displaced globe (enophthalmos) is suggestive of increased orbital volume secondary to fracture. An inferiorly displaced globe (orbital dystopia) is a result of muscle and fat prolapse into the maxillary sinus. Restricted and/or painful extraocular movements are suggestive of muscle entrapment (Neuman).

In children, a phenomenon called the oculocardiac reflex can occur. Stimulation of the ophthalmic division of the trigeminal nerve due to traction or pressure on the extraocular muscles or globe results in excitation of the vagus nerve, leading to bradycardia, nausea, and syncope. In severe cases, asystole can occur (Sires).

CT of the face, with thin (1mm) cuts through the orbit is the primary modality used for identification of orbital blowout fractures. Plain radiographs of the face and orbits are no longer the gold standard as they have poor sensitivity and specificity.  Trap door fractures may be occult, but any evidence of soft tissue herniation into the maxillary sinus (also known as the “teardrop” sign) should raise suspicion for a clinically significant fracture.

These injuries can be severe, and are often more significant in the pediatric population than the adult population, owing to associated soft tissue and muscular injuries. Almost half of children with this injury will require surgery, most frequently due to entrapment. Nearly half of pediatric patients will have ocular injuries (globe rupture, hyphema, retinal tear) and nearly one third of patients will have a second facial fracture (Hatton). 

Urgent ophthalmology and facial surgery consultations are indicated for orbital floor fractures with concern for entrapment (Chung).

Symptomatic treatment includes:

  • Head of bed elevation

  • Ice

  • Sinus precautions: no nose blowing, sneeze with the mouth open, no straw use or sniffing

  • Analgesia and anti-emetics as needed

 

For orbital fractures with extension into a sinus, the use of prophylactic antibiotics has limited data and often varies by institution (Neuman).

Corticosteroids are recommended for patients with diminished extraocular movements to reduce swelling and expedite improvement in diplopia (Neuman).

For orbital blowout fractures with evidence of entrapment and/or oculocardiac reflex, repair should be performed within 24-48 hours. Delayed repair (more than 2 weeks after injury) can be considered if mild-moderate diplopia is not spontaneously improving, or patient has worsening of enopthalmos > 2mm after initial edema and inflammation has resolved.  Other indications for surgical repair include large fracture (involvement of greater than 50% of the orbital floor) or multiple fractures (Chung).

 

CASE CONCLUSION

The patient was admitted for observation overnight in the setting of persistent nausea, vomiting, borderline bradycardia, and diplopia. He was placed on oral prednisone, as well as anti-inflammatory medication. Overnight his symptoms and heart rate improved, although he had persistent diplopia, with diminished upward gaze of the left eye. He was discharged home on hospital day 1, with plan for ophthalmology and facial surgery follow-up for operative planning.

Faculty Reviewer: Dr. Jane Preotle

 

REFERENCES & FURTHER READING

  1. Chung, Stella Y., and Paul D. Langer. “Pediatric Orbital Blowout Fractures.” Current Opinion in Ophthalmology, vol. 28, no. 5, 2017, pp. 470–476., doi:10.1097/icu.0000000000000407.

  2. Grant, John H., et al. “Trapdoor Fracture of the Orbit in a Pediatric Population.” Plastic and Reconstructive Surgery, vol. 109, no. 2, 2002, pp. 490–495., doi:10.1097/00006534-200202000-00012.

  3. Hacking, Craig. “Trapdoor Fracture.” Radiopaedia.org, radiopaedia.org/articles/trapdoor-fracture.

  4.  Hatton, Mark P., et al. “Orbital Fractures in Children.” Ophthalmic Plastic and Reconstructive Surgery, vol. 17, no. 3, 2001, pp. 174–179., doi:10.1097/00002341-200105000-00005. 

  5. Knipe, Henry, and Frank Gaillard.  “Orbital Blowout Fracture.” Radiopaedia.org, radiopaedia.org/articles/orbital-blowout-fracture-1.

  6. Neuman, Mark, and Richard G Bachur. “Orbital Fractures.” UpToDate, www.uptodate.com/contents/orbital-fractures.

  7. Sires, Bryan S. “Orbital Trapdoor Fracture and Oculocardiac Reflex.” Ophthalmic Plastic & Reconstructive Surgery, vol. 15, no. 4, 1999, p. 301., doi:10.1097/00002341-199907000-00014.

  8. Soll, D. B., and B. J. Poley. “Trapdoor Variety of Blowout Fracture of the Orbital Floor.” Plastic and Reconstructive Surgery, vol. 36, no. 6, 1965, p. 637., doi:10.1097/00006534-196512000-00017. 

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