David Schnadower

We present data from recently conducted research regarding controversial aspects of the evaluation and management of children with minor blunt head trauma. Clinicians frequently but at times indiscriminately perform computed tomography scans for children with minor blunt head trauma resulting in potentially harmful radiation exposure. Recent guidelines recognize the limited but increasing data available to make strong recommendations regarding appropriate neuroimaging decisions. Investigators have derived and validated clinical prediction models to accurately identify patients with substantial traumatic brain injury, though no clear definitive rule exists. Children younger than 2 years appear to have a higher risk of intracranial injury following minor head trauma. These patients can be difficult to assess, with the evidence suggesting the need for a more conservative approach to diagnostic imaging. We present current and accepted definitions of concussion along with risk factors and treatment for postconcussion syndrome. Current return-to-play guidelines suggest that athletes who have sustained concussion should not resume play until symptoms have resolved because of the possibility, though rare, of second impact syndrome. Research in the management of children with minor head trauma is actively evolving. We present a review of recent developments that can influence current clinical practice.

To determine whether peripheral veins can be detected by ultrasound (US) and to determine vein characteristics, as measured by US, that are associated with successful peripheral venous (PV) catheterization in young children. The authors conducted an observational study in the pediatric emergency department (ED), with a convenience sample of children younger than 7 years. They evaluated attempts at PV catheterization in two groups on the basis of the visibility and palpability of the patients' veins: 1) clinically apparent (visible or palpable) and 2) not clinically apparent (nonvisible and nonpalpable). The authors obtained sonographic measurements in a transverse view (vertical diameter, circumference, and area) and in a longitudinal view (maximal uninterrupted length). Practitioners blinded to the US images then attempted to catheterize veins in the usual manner. The proportion of clinically apparent veins and the proportion of veins that were successfully catheterized that were identified by US were assessed, and the association between ultrasonographic vein measurements and success at catheterization, controlling for possible confounders, was determined. The authors assessed 120 attempts (90 clinically apparent and 30 not clinically apparent) at PV catheterization in 83 patients. US detected all 90 clinically apparent veins, and cannulation success rate was 62/90 (69%). In the not clinically apparent vein group, the rate of success was only 3/30 (10%), and US detected all successfully catheterized veins. In no instance was cannulation successful when the vein was not detected by US. Maximal vein length in longitudinal view was an independent predictor of cannulation success in multivariate analysis. Ultrasound appears to be capable of detecting peripheral veins in children younger than 7 years of age, with lack of US vein visualization likely leading to unsuccessful PV placement. Greater vein length visualization may be a useful predictor of successful PV catheterization.

Nutritional rickets and osteomalacia are reemerging in Western societies, particularly in young children and in adolescents of African or Asian descent. Hypocalcemic seizures resulting from vitamin D deficiency are rare in adolescents, whereas fractures caused by seizures without evidence of direct trauma have not yet been reported in this population. We present an unusual case of secondary bilateral femoral fractures caused by hypocalcemic seizures in a 17-year-old boy with primary vitamin D deficiency. We examine the epidemiology and the clinical presentation of rickets and osteomalacia in the adolescent population, the risk of secondary injuries in patients with seizures, and the evaluation and management of hypocalcemic seizures and primary vitamin D deficiency.