A Retrospective Look at a Cervical Spine Clearance Protocol in Pediatric Trauma Patients at a Level-1 Trauma Center.

BACKGROUND: Adult studies have demonstrated the efficacy of written protocols for clearance of the cervical spine. However, less than half of recently surveyed pediatric trauma centers report using a documented protocol. Little data exists on such protocols in pediatric populations, but interest remains because of potential reductions in radiation exposure, time to clearance, hospital stay, and specialist referral. However, missed injury can have devastating consequences. The purpose of this study is to examine the efficacy in detecting injury of an implemented cervical spine clearance protocol at a level-1 pediatric trauma hospital. METHODS: A retrospective review was performed on pediatric patients presenting as activated traumas to the emergency department of a single level-1 pediatric trauma hospital between May 2010 and October 2018. This institution has utilized a written cervical spine clearance protocol throughout this time. Presence of cervical spine injury, documented clearance, cervical spine imaging, and follow-up documentation were reviewed for any missed injuries. RESULTS: There were no missed cervical spine injuries. Five-hundred sixty-three clinically significant cervical spine injuries were identified, representing 16.5% of patients. Of these, 96 were fractures, dislocations, or ligamentous injuries, representing 2.8% of all patients. Most cervical spine clearances were performed by trauma surgery. Advanced imaging of the cervical spine was ordered for 43.2% of patients overall and trended down over time. CONCLUSION: Documented cervical spine clearance protocols are effective for detection of significant injury in pediatric trauma patients. This study suggests these protocols minimize risk of missed injury and may prevent unnecessary radiation exposure, delayed clearance, prolonged hospitalization, or unnecessary specialist referral. CLINICAL RELEVANCE: Utilization of a standard written protocol for cervical spine clearance likely prevents missed injury and helps to minimize radiation exposure in pediatric populations. Further research is needed on evaluation and management of pediatric cervical spine trauma.

OBJECTIVE GAIT ANALYSIS IN HUMBOLDT PENGUINS (SPHENISCUS HUMBOLDTI) USING A PRESSURE-SENSITIVE WALKWAY.

Assessment of pododermatitis, osteoarthritis, and other causes of lameness in penguins can be challenging. Subjective gait analysis using visual observation and response to analgesic therapy can be affected by observer variation and caregiver placebo bias. A pressure-sensitive walkway (PSW), however, allows for objective gait analysis and assessment of analgesic therapeutic response. In this study, a 3-m-long PSW was used to analyze gait in 21 adult Humboldt penguins (Spheniscus humboldti). Medical record reviews and comprehensive examinations were performed on all penguins; five penguins were considered abnormal, with either right-sided (n = 3) or bilateral historical lameness-causing disease (n = 2) and were analyzed separately from the normal data set. All penguins walked across the PSW four times and gait parameters (step and stride distances and velocities, maximum force, impulse, and peak pressure) were calculated for each foot in each penguin. Statistical comparisons were made between right and left feet, sexes, and normal and abnormal penguins for each gait parameter. Among normal penguins, there were no significant differences between feet or sex. Left step width was shorter in abnormal penguins than that of normal penguins. Study results established baseline values for Humboldt penguins. This will allow objective monitoring of progression and response to therapy in penguin lameness cases, both current and future. The data also provide a foundation to compare gait parameters with other penguin populations and species.

Pharmacokinetics of orally administered tramadol in Muscovy ducks (Cairina moschata domestica).

This study documents the pharmacokinetics of oral tramadol in Muscovy ducks. Six ducks received a single 30 mg/kg dose of tramadol, orally by stomach tube, with blood collection prior to and up to 24 hr after tramadol administration. Plasma tramadol, and metabolites O-desmethyltramadol (M1), and N,O-didesmethyltramadol (M5) concentrations were determined by high-pressure liquid chromatography (HPLC) with fluorescence (FL) detection. Pharmacokinetic parameters were calculated using a one-compartment model with first-order input. No adverse effects were noted after oral administration. All ducks achieved plasma concentrations of tramadol above 0.10 µg/ml and maintained those concentrations for at least 12 hr. Elimination half-life was 3.95 hr for tramadol in ducks, which is similar to other avian species. All ducks in this study produced the M1 metabolite and maintained plasma concentrations above 0.1 µg/ml for at least 24 hr.

Analgesic Efficacy of Tramadol Compared With Meloxicam in Ducks (Cairina moschata domestica) Evaluated by Ground-Reactive Forces.

The purpose of this study was to determine the efficacy of tramadol and meloxicam in an induced, temporary arthritis model in ducks as assessed by ground-reactive forces measured by a pressure-sensitive walkway (PSW) system. Twelve ducks (Cairina moschata domestica) were randomly separated into 3 equal groups of 4 birds each: water control, tramadol treatment, and meloxicam treatment. Baseline measurements were collected by having all ducks walk along a 3-m-long PSW in a custom-built corral before anesthesia and induction of arthritis. Arthritis was induced in all groups through injection, under anesthesia, of a 3% monosodium urate (MSU) solution into the intertarsal joint. One hour after MSU injection, birds were orally gavage fed 1 mL of tap water (control), tramadol (30 mg/kg), or meloxicam (1 mg/kg). After treatments, all ducks were reevaluated on the PSW at 1, 2, 3, 4, 8, and 24 hours post-MSU injection. The difference in maximum force was significantly greater in the control group than in both the tramadol- (P = .006) and meloxicam-treated (P = .03) individuals. Post hoc comparisons revealed differences between control and treated birds occurred only at the 3- and 4-hour time points after administration. No differences were found in the absolute difference in maximum force between tramadol- and meloxicam-treated birds at any time point (P > .05). Results of this study support the hypothesis that tramadol (30 mg/kg PO) and meloxicam (1 mg/kg PO) improve certain objective variables in an induced arthritis model in ducks. Our findings also support studies in other avian species that determined that both tramadol and meloxicam are effective analgesic drugs in some birds.

VENOUS BLOOD GAS AND SELECTED BIOCHEMICAL VALUES FROM AWAKE AND ANESTHETIZED WHITE-BELLIED PANGOLINS ( PHATAGINUS TRICUSPIS).

Pangolins are one of the most-trafficked endangered species and are rare in zoologic collections. Blood gas and select biochemical analysis was performed on nine African white-bellied tree pangolins ( Phataginus tricuspis). Paired blood samples were collected from the ventral tail vasculature prior to (T1) and after 10 min (T2) of sevoflurane anesthesia, and selected blood gas and biochemical parameters were measured using a portable blood gas analyzer. Median (min-max) values for corrected venous blood were pH = 7.372 (7.207-7.529) at T1 and 7.278 (7.124-7.418) at T2. Corrected values were PCO2 = 51.7 (29.6-69.0) mmHg at T1 and 58.431 (38.1-90.8) mmHg at T2. Clinicians should be aware that this species may hypoventilate while anesthetized with sevoflurane and develop a respiratory acidosis. Concomitant administration of respiratory depressants could compound this effect in a species where oro-tracheal intubation has not been described.

REPEATED ANESTHESIA IN A BLACK RHINOCEROS ( DICEROS BICORNIS) TO MANAGE UPPER RESPIRATORY OBSTRUCTION.

This report describes weekly repeated anesthesia in a 7-yr-old, 1,030 kg, female Eastern black rhinoceros ( Diceros bicornis michaeli), that was immobilized six times using a combination of 2 mg etorphine (0.002 mg/kg), 5 mg medetomidine (0.005 mg/kg), 25 mg midazolam (0.024 mg/kg), and 300 mg ketamine (0.29 mg/kg) delivered intramuscularly (IM) via remote dart to facilitate long-term medical care of a bilateral, obstructive Actinomyces sp. rhinitis. The drug combination described in this study resulted in reliable, rapid recumbency of the animal within 2-8 min after initial administration via dart and produced deep anesthesia for 34-78 min without supplemental anesthetic administration. Antagonist drugs (100 mg naltrexone [0.1 mg/kg] and 25 mg atipamezole [0.024 mg/kg] IM) produced reliable and uneventful recoveries in all the procedures. During each anesthetic procedure, the animal was intubated and provided intermittent positive pressure ventilation with a megavertebrate demand ventilator. Tachycardia and hypoxia noted after induction resolved after positive pressure ventilation with oxygen. This report provides useful information on a novel anesthetic protocol used repeatedly for intensive medical management in a black rhinoceros.

Pharmacokinetics of dexmedetomidine in isoflurane-anesthetized New Zealand White rabbits.

OBJECTIVE: To characterize the pharmacokinetics of dexmedetomidine when administered as a short intravenous (IV) infusion to isoflurane-anesthetized rabbits. STUDY DESIGN: Experimental study. ANIMALS: A total of six healthy adult female New Zealand White rabbits. METHODS: Rabbits were anesthetized with isoflurane in oxygen. Following determination of isoflurane minimum alveolar concentration (MAC), the anesthetic dose was reduced to 0.7 × MAC, and dexmedetomidine hydrochloride (20 µg kg-1) was infused IV over 5 minutes. Arterial blood samples were obtained immediately before and at 1, 2, 5, 6, 7, 10, 15, 30, 60, 90, 120, 240 and 360 minutes following termination of the infusion. Samples were transferred into tubes containing ethylenediaminetetraacetic acid and centrifuged immediately. The plasma was harvested and stored at -80 °C until analyzed. Concentrations of dexmedetomidine in plasma were determined by liquid chromatography mass spectrometry. Compartment models were fitted to the time and concentration data using nonlinear regression. RESULTS: A three-compartment model best fit the data set. Median volume of distribution at steady state and terminal half-life were 3169 mL kg-1 (range, 2182-3859 mL kg-1) and 80 minutes (range, 72-88 minutes), respectively. CONCLUSIONS AND CLINICAL RELEVANCE: The pharmacokinetics of dexmedetomidine in isoflurane-anesthetized, healthy, New Zealand White rabbits were characterized in this study. Data from this study can be used to determine dosing regimens for dexmedetomidine in isoflurane-anesthetized rabbits.

A retrospective review of the rate of septic knee arthritis after retrograde femoral nailing for traumatic femoral fractures at a single academic institution.

Background: Retrograde intramedullary nailing of the femur is a popular treatment option for femoral shaft fractures. However, this requires accessing the intramedullary canal through the knee, posing a risk of intra-articular infection. The purpose of this study was to examine the rate of intra-articular infection of the knee after retrograde nailing of femoral shaft fractures. Methods: All patients who underwent retrograde intramedullary nailing for femoral shaft fractures between June 2004 and December 2017 at a level 1 trauma center were reviewed. Six months of follow-up or documented fracture union was required. Records were reviewed for documentation of septic arthritis of the ipsilateral knee during the follow-up period. Results: A total of 294 fractures, including 217 closed and 77 open injuries, were included. Eighteen had an associated ipsilateral traumatic arthrotomy; 188 cases had an associated ipsilateral lower extremity fracture. No cases of septic arthritis were identified. Conclusion: There were no cases of septic arthritis in 294 fractures treated with retrograde intramedullary nailing. Retrograde nailing appears safe for risk of postoperative septic arthritis of the knee even in the face of open fractures and traumatic wounds.

Mandibular advancement reduces pharyngeal collapsibility by enlarging the airway rather than affecting velopharyngeal compliance.

Mandibular advancement devices (MADs) are frequently prescribed for obstructive sleep apnea (OSA) patients, but approximately one third of patients experience no therapeutic benefit. Understanding the mechanisms by which MADs prevent pharyngeal collapse may help optimize MAD therapy. This study quantified the relative contributions of changes in airspace cross-sectional area (CSA) versus changes in velopharyngeal compliance in determining MAD efficacy. Sixteen patients with moderate to severe OSA (mean apnea-hypopnea index of 32 ± 15 events/h) underwent measurements of the velopharyngeal closing pressure (PCLOSE ) during drug induced sedated endoscopy (DISE) via stepwise reductions in nasal mask pressure and recording of the intraluminal pressure with a catheter. Airspace CSA was estimated from video endoscopy. Pharyngeal compliance was defined as the slope of the area-pressure relationship of the velopharyngeal airspace. MAD therapy reduced PCLOSE from a median of 0.5 cmH2 O pre-advancement to a median of -2.6 cmH2 O post-advancement (p = 0.0009), increased the minimal CSA at the velopharynx by approximately 20 mm2 (p = 0.0067), but did not have a statistically significant effect on velopharyngeal compliance (p = 0.23). PCLOSE had a strong correlation with CSA but did not correlate with velopharyngeal compliance. Our results suggest that MADs reduce velopharyngeal collapsibility by increasing airway size as opposed to affecting velopharyngeal compliance. This contradicts the speculation of previous literature that the effectiveness of MADs is partially due to a reduction in velopharyngeal compliance resulting from stretching of the soft palate. These findings suggest that quantification of velopharyngeal CSA pre- and post-MAD advancement has potential as a biomarker to predict the success of MAD therapy.

Rhinomanometry Versus Computational Fluid Dynamics: Correlated, but Different Techniques.

BACKGROUND: Past studies reported a low correlation between rhinomanometry and computational fluid dynamics (CFD), but the source of the discrepancy was unclear. Low correlation or lack of correlation has also been reported between subjective and objective measures of nasal patency. OBJECTIVE: This study investigates (1) the correlation and agreement between nasal resistance derived from CFD (RCFD) and rhinomanometry (RRMN), and (2) the correlation between objective and subjective measures of nasal patency. METHODS: Twenty-five patients with nasal obstruction underwent anterior rhinomanometry before and after mucosal decongestion with oxymetazoline. Subjective nasal patency was assessed with a 0-10 visual analog scale (VAS). CFD simulations were performed based on computed tomography scans obtained after mucosal decongestion. To validate the CFD methods, nasal resistance was measured in vitro (REXPERIMENT) by performing pressure-flow experiments in anatomically accurate plastic nasal replicas from 6 individuals. RESULTS: Mucosal decongestion was associated with a reduction in bilateral nasal resistance (0.34 ± 0.23 Pa.s/ml to 0.19 ± 0.24 Pa.s/ml, p = 0.003) and improved sensation of nasal airflow (bilateral VAS decreased from 5.2 ± 1.9 to 2.6 ± 1.9, p < 0.001). A statistically significant correlation was found between VAS in the most obstructed cavity and unilateral airflow before and after mucosal decongestion (r = -0.42, p = 0.003). Excellent correlation was found between RCFD and REXPERIMENT (r = 0.96, p < 0.001) with good agreement between the numerical and in vitro values (RCFD/REXPERIMENT = 0.93 ± 0.08). A weak correlation was found between RCFD and RRMN (r = 0.41, p = 0.003) with CFD underpredicting nasal resistance derived from rhinomanometry (RCFD/RRMN = 0.65 ± 0.63). A stronger correlation was found when unilateral airflow at a pressure drop of 75 Pa was used to compare CFD with rhinomanometry (r = 0.76, p < 0.001). CONCLUSION: CFD and rhinomanometry are moderately correlated, but CFD underpredicts nasal resistance measured in vivo due in part to the assumption of rigid nasal walls. Our results confirm previous reports that subjective nasal patency correlates better with unilateral than with bilateral measurements and in the context of an intervention.

Advances in Minimally Invasive Techniques in Pediatric Orthopedics: Percutaneous Spine Fracture Fixation.

Pediatric spine trauma presents unique management challenges. These injuries are often the result of high-energy mechanisms and are associated with other serious injuries that can complicate surgical and nonsurgical approaches. The pediatric population presents a host of challenges related to patient compliance, healing challenges, and patient tolerance of therapy. Percutaneous pedicle screw instrumentation, temporary fixation without fusion, continues to expand in its role of pediatric spine fracture treatment. Compared with open instrumentation and fusion, this technique addresses many of the previously mentioned challenges. Additional study is needed to evaluate the clinical utility of this approach in pediatric spinal fractures.

Evaluation of a pressure sensitive walkway for objective gait analysis in normal and arthritic domestic ducks (Cairina moschata domestica).

Objective gait evaluation with a pressure sensitive walkway (PSW) has been used to assess welfare of poultry and to assess lameness and response to therapy in domestic mammals. Objective gait analysis of birds with lameness due to pododermatitis, osteoarthritis, and other common diseases could provide non-biased assessment and therapeutic monitoring for zoo clinicians. The objective of this study was to evaluate the use of a PSW for objective gait analysis in normal domestic ducks (Cairina moschata domestica) and those with experimentally induced arthritis. Eighteen healthy adult ducks walked across the PSW four times in each experiment at each time point. For experiment 1, gait parameters (step and stride distances and velocities, maximum force, impulse, and peak pressure) were calculated for each foot in each duck (time 0). For experiment 2, six of these ducks were randomly selected, anesthetized, and administered a unilateral intra-tarsal injection of monosodium urate solution to induce arthritis. Serial PSW trials were repeated at 1, 2, 3, 4, 8, and 24 hours post-injection. Gait parameters were calculated and compared at each time point, including baseline at time 0. Among the normal ducks, there were no significant differences between right and left feet for any gait parameter. Maximum force and impulse were significantly lower for the affected limb at the 3- and 4-hour time points in ducks with unilateral induced arthritis. This asymmetry was resolved by 8 hours post injection. This PSW transient arthritis model allows for objective assessment of lameness in domestic ducks with maximum force and impulse serving as the most sensitive gait parameters for lameness detection. This method has potential as a model to assess analgesic efficacy for zoo-housed waterfowl and other avian species.

Correlation of Nasal Mucosal Temperature With Subjective Nasal Patency in Healthy Individuals.

IMPORTANCE: Historically, otolaryngologists have focused on nasal resistance to airflow and minimum airspace cross-sectional area as objective measures of nasal obstruction using methods such as rhinomanometry and acoustic rhinometry. However, subjective sensation of nasal patency may be more associated with activation of cold receptors by inspired air than with respiratory effort. OBJECTIVE: To investigate whether subjective nasal patency correlates with nasal mucosal temperature in healthy individuals. DESIGN, SETTING, AND PARTICIPANTS: Healthy adult volunteers first completed the Nasal Obstruction Symptom Evaluation (NOSE) and a unilateral visual analog scale to quantify subjective nasal patency. A miniaturized thermocouple sensor was then used to record nasal mucosal temperature bilaterally in 2 locations along the nasal septum: at the vestibule and across from the inferior turbinate head. MAIN OUTCOMES AND MEASURES: Nasal mucosal temperature and subjective patency scores in healthy individuals. RESULTS: The 22 healthy adult volunteers (12 [55%] male; mean [SD] age, 28.3 [7.0] years) had a mean (SD) NOSE score of 5.9 (8.4) (range, 0-30) and unilateral VAS score of 1.2 (1.4) (range, 0-5). The range of temperature oscillations during the breathing cycle, defined as the difference between end-expiratory and end-inspiratory temperatures, was greater during deep breaths (mean [SD] change in temperature, 6.2°C [2.6°C]) than during resting breathing (mean [SD] change in temperature, 4.2°C [2.3°C]) in both locations (P < .001). Mucosal temperature measured at the right vestibule had a statistically significant correlation with both right-side visual analog scale score (Pearson r = -0.55; 95% CI, -0.79 to -0.17; P = .008) and NOSE score (Pearson r = -0.47; 95% CI, -0.74 to -0.06; P = .03). No other statistically significant correlations were found between mucosal temperature and subjective nasal patency scores. Nasal mucosal temperature was lower (mean of 1.5°C lower) in the first cavity to be measured, which was the right cavity in all participants. CONCLUSIONS AND RELEVANCE: The greater mucosal temperature oscillations during deep breathing are consistent with the common experience that airflow sensation is enhanced during deep breaths, thus supporting the hypothesis that mucosal cooling plays a central role in nasal airflow sensation. A possible correlation was found between subjective nasal patency scores and nasal mucosal temperature, but our results were inconsistent. The higher temperature in the left cavity suggests that the sensor irritated the nasal mucosa, affecting the correlation between patency scores and mucosal temperature. Future studies should consider noncontact temperature sensors to prevent mucosa irritation. LEVEL OF EVIDENCE: NA.