Post concussive symptoms in children

Concussion in kids

Concussion is divided loosely into two categories.
Mild concussion is a bang on the head where the patient was not knocked out.

Classic concussion is when a person was knocked out.

When assessing patients after a closed head injury, nurses and doctors often use a multitude of tools and questions about the event.  On average about 30% of adults who receive concussions, go on to have persistent symptoms of headache and concentration loss, memory disturbances and dizzyness for months.   This is called Persistent post concussion syndrome (PPCS).
Predicting who will have PPCS is difficult, but one team of researchers in Canada have just published a paper that summarises the process in children.

They state that  "clinician prediction is no better than a coin toss".

In assessing long term risk of PPCS in children the research team found some surprising things.

Where we as clinicians have long thought that loss of consciousness and vomiting post head injury were somewhat prognostic for post concussion symptoms, these researchers consider these as less predictive.

Using a 12 point scoring system the researchers looked at some 3000 five to 18 year olds,
Higher scoring data (2 points) Included
Gender=female
Age >13
Fatigue

Points are also allocated for
Headache
Previous concussion
Slow to answer questions
Sensitivity to noise
History of Migraine
Poor balance
For

A score of 9-12 correlated with a 93% incidence of prolonged post concussion symptoms.

Ref:
Zemek et. al  2016
Clinical Risk Score for Persistent Postconcussion Symptoms among children with acute concussion in ED
JAMA. 2016;315(10):1014-1025.
 doi:10.1001/jama.
http://jama.jamanetwork.com/mobile/article.aspx?articleid=2499274

Breath Sounds -part 4. Ergophony and whispering Pectoriloquy

Breath Sounds -part 4

Whispering to a Goat??

Ergophony and Whispering Pectoriloquy.

In this short mini-series, we look at the basics of auscultation of lung sounds.

Few things are cooler than listening to a sick patient's chest and hearing the classic sounds that highly suggest a specific diagnosis.

Pneumonia (lobar consolidation), is one such diagnosis.  With alveoli collapsed and congested under the strain of pus, and other inflammatory debris, the way sound is transmitted becomes characteristically different.  If reading about this for the first time, you will be itching to give this a go.

Ergophony

Assume Mr Chester in bed 6 has a diagnosis of Right middle lobe pneumonia. He is admitted on the ward for IV antibiotics and supplemental oxygen.  As part of your routine assessment, you auscultate his lung sounds.  

You ask Mr Chester to repeat the letter E, over and over while you listen the the resonance of his voice, through your stethoscope, at different locations on his chest.  Across his left chest you hear the familiar sound of him chanting "Eeeee, Eeeee,Eeeee...." Over and over.

But as you place your stethoscope over the consolidated region of his right chest, the sound changes to a muffled "Aaaahhh, Aaaahhh, Aaaahhh..." sound.   It sounds to you like the bleat of a goat or sheep.   This is called Ergophony and literally means "voice of the goat".  It is caused by changes to the sound waves as they travel through different densities of lung. When transmitted through pus filled dense pneumonia lobes, the Eeee resonates to Aaahhh.

Whispering Pectoriloquy

Say it out loud :

"Peck - tor- rill- oh- Kwee"

Apart from being a cracking scrabble word, this funky phenomenon is another one that can be heard in patients with pneumonia.

Normally if I listen to your lung fields with my stethoscope while you are whispering, I wont hear your words.  The light air filled matrix of your ventilating lung filters out whispered sounds, rendering them inaudible on auscultation of a normal chest.  However, when Mr Chester has pneumonia and an area of consolidation, sound is transmitted well through more dense tissue.  

Start by asking your patient to sit upright and chant through the alphabet or count to 100 but only whispering.  As you listen to the healthy areas of his chest you'll not hear his whispers, but when the stethoscope is placed over pneumonia consolidation of lung masses, you will hear the whispered words through your stethoscope. This is called whispering pectoriloquy, and is a symptom of consolidation.

Well that is it for part 4 of our breath sounds .  Stay tuned for part 5 where we discuss some other adventitious noises.

If you missed our other KYJs in this series click them here.

Www.knowingyourjargon.blogspot.com

Please comment on and share these. I'd love to see you at one of my nursing seminars.  They can be found on our ECT4Health web page.

Breath Sounds -Part 3- location

Breath Sounds -part 3

Continuing on with our series on breath sounds. Today we look at stethoscope position.

First, knowing your stethoscope. The  flat disk like part of your stethoscope is called the diaphragm, and is the surface that is used for high pitched sounds. Lung auscultation and bowel sounds are examples.

If your stethoscope is a dual head, with the cone shaped bell, then low pitched sounds are heard best through this part of the scope.  Heart sounds can usually be heard better with the bell.

Anatomic placement

Listening to breath sounds is as simple or as complex as you want to make it.

Start with anterior (front of chest) for a quick listen for normal.

Location 

2nd intercostal space in the mid clavicular line.  Listen left then right in a patient sitting upright.

Then 5th Intercostal space in the mid axillary line (same spot you place the V6 lead on an ECG).

Again listen left then right.

You are listening for equality between two anatomically opposite locations. Read that again.... It's important!

R=L at the 2nd ICSMCL

R=L at the 5th ICSMAL

Listen to a couple of breaths in and out with the patient breathing through their mouth.

Focus on the duty cycle (time taken to breathe in vs out, focus on the equality between left and right and listen for abnormal sounds like wheeze or crackles.

Record any adventitious sounds or inequality.

These two locations complete a basic respiratory auscultation.  If a comprehensive assessment is needed (usually not) then the patient should be propped forward and auscultation is performed on the back.

This allows you to hear the largest portion of lung fields.  The posterior chest is called the base, which is often erroneously confused with the inferior aspect of the anterior chest.  More alveolar area is in the base of the lung.

Now say out loud... "2,4,6,8,10"

Did you say it? Are people looking at you funny? 

2,4,6,8,10.

These are the intercostal spaces.  Either side of the vertebral column, you listen at the 2nd ICS left then right 

4th ICS left then right

6th ICS left then right

8th ICS left then right

8th ICS at the Axillary line .

10th ICS left then right

Then finish at the 10th ICS out on the widest part of their chest - the posterior axillary line.

Don't be daunted by these 6 sites.  You are only listening to compare Left to right at each spot. 

Practice these locations on your partner or kids. Listen to normal chests to get your ear in for the nuances of normal.

Know normal so you can recognise abnormal sounds as they arise.

Next episode we will discuss classic consolidation/pneumonia and the funky sounds you can experience to identify a pneumonia in your patient. 

#KYJ Wound care series - part 4 Venous Insufficiency

Wound care series part 4.
Venous insufficiency.

In this #KYJ episode we look at venous insufficiency as a cause of leg ulcers and as an inhibitor to healing.

To begin to grasp the impact that venous disease has, we must understand a few truths about leg circulation.  Arteries in legs transport oxygenated blood to the tissues of the legs and feet. Arteries deliver nutrients to the capillary beds that perfuse tissue.  I like to think of arteries as a garden hose, and the capillaries as that soaker-hose weaved around the garden bed.  There is a blood pressure gradient that is highest as blood leaves the heart, that reduces in arteries and almost zero by the time that blood reaches the legs capillaries.
To return that blood to the heart, the veins and muscles of the legs are structured to "pump" blood back.
Three types of veins are featured.
Superficial
Perforating
Deep veins

Superficial veins are often seen as swollen inflamed spiderweb like varicose veins on the feet and ankles of people with venous congestion.  They drain their blood into communicating veins called "Perforating veins" , that take blood from the superficial veins and direct blood flow into the deep veins located deep in the muscle fascia.

Blood is forced along the length of the vein by the action of leg muscle movement.  If there is no leg exercise, this blood pools and congestion occurs, forcing the pressure inside veins to rise.

To ensure blood travels in one direction through veins, veins have one way valves. As congestion and pooling occurs, these valves fatigue and fail.  Venous insufficiency is a combination of high venous pressures from congestion & pooling of blood, and the valves no longer being efficient at transporting blood in the Leg to Heart direction.

Pooling of blood is called 'stasis'. In veins it is referred to as venoustasis.  If there is one thing that pooled blood loves to do, it's coagulate...Badness!

Venous pressures are strongly influenced by gravity.  Standing and sitting for long periods are the leading cause. Once we walk or contract leg muscles, the pump like action promotes momentum of pooled blood and the congestion eases.  This is true for healthy legs, but in patients with long term valve failure walking does little to alleviate pressure.

So what is the link between this venous disease and wounds?  Wounds need a constant clean flow of blood delivering nutrients to the wound bed.  Congestion seen in patients with valve disease or venoustasis slows or stops momentum, stops removal of waste and hence; stops healing.

In many patients with venous insufficiency, their disease actually causes ulceration.  Always on the lower leg and almost always on the medial ankle (malleolus) or anterior shin.

Patients with venous disease often have classic tell tale symptoms.
Ankle swelling
Superficial varicose veins
Spider veins on the inside of their ankle.
Discolouration to their skin ranging from red to rust to purple.
Occasionally slow healing wounds

As congestion increases, red blood cells are forced out of capillaries and fracture in the superficial skin.  The iron in red blood cells oxidises to iron oxide (rust).  It is called haemosiderin and is a permanent rusty discolouration of patients with advanced venous insufficiency .  Sometimes this is called venous eczema .

Next wound care episode we will look at compression as a treatment.

Stay tuned...
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Breath Sounds part 2 - Wheezes

#KYJ -Knowing your Jargon

Breath sounds part 2. 

Wheezes.

In part one http://knowingyourjargon.blogspot.com.au/2016/02/breath-sounds-part-1.html?m=1

We looked at the concept of pitch in breath sounds. In that episode we discussed the two major groups of abnormal (adventitious) lung sounds. We focused on crackles.

In this episode we look at the other group, the Wheezes.

Wheezes are a sound produced by air being squeezed through narrow swollen oedematous bronchi/bronchioles.  They can occur during inspiration (stridors) or expiration (wheezes).

Like crackles, wheezes are pitched differently, depending on the area of lung affected.  High pitched wheezes are heard in the periphery of the lung, whereas low pitched wheeze come from larger airways.  Like crackles, wheezes are termed differently depending on the area they originate.

High pitched wheeze is called a sibilant wheeze.   Sibilant is a whistle like sound of high frequency (high pitch). It is characteristically heard in asthmatic flare-ups.

Low pitched wheezes originate from bronchi and trachea, and sound like snoring.  In fact this is exactly what they are called, "snorous wheezes".  In older texts, you may hear these called Rhonchi (pronounced 'Ronk-Eye').

Typically these wheezes are heard in multiple areas of the lung field.  For this reason it is not uncommon to hear multiple different pitches.  Wheezes of this nature that demonstrate both snorous and sibilant qualities are frequently documented as widespread polyphonic (many voices) wheezes.  Asthma is a classic presentation.

Listen carefully to a wheeze; especially if the patient has cardiac or hepatic history, and after any rapid IV fluid infusion.  If crackles can be heard along side a sibilant wheeze, then a diagnosis of acute pulmonary oedema (APO) needs to be excluded.

So similar is an acute asthma wheeze and an acute pulmonary oedema wheeze, that at one time APO was called "Cardiac Asthma".

So that is it for this short episode. Next edition we look at where a stethoscope is placed.

Check out our blog site for all the KYJs you've missed. Www.knowingyourjargon.blogspot.com

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