Use of angioembolization in pediatric polytrauma patients: WITH BLUNT SPLENIC INJURYAngioembolization in Pediatric Blunt Splenic Injury

Analysis of Preventable Transfers of Pediatric Trauma Patients From Montana to an Out of State Tertiary Level I Pediatric Trauma Center

BACKGROUND

The process of transferring pediatric trauma patients to specialized centers is essential for providing high-level trauma care to critically injured children. However, preventing unnecessary transfers is also a crucial component of optimizing healthcare utilization. The aim of this study was to identify and describe patients who underwent preventable transfers from hospitals in Montana to a single out-of-state Level I Pediatric Trauma Center (PTC).

METHODS

We performed a retrospective review of pediatric trauma patients who underwent transfer from hospitals in Montana to an out-of-state Level I PTC from 2013 to 2022. Our primary outcome, preventable transfer, was defined as discharge within 48 h without advanced imaging (CT or MRI) or surgical intervention. We performed a secondary analysis to identify possibly preventable transfers (i.e. patients that could have been safely managed at an in-state Level II Adult Trauma Center).

RESULTS

Out of 132 total patients, 22 patients (16 %) met criteria for preventable transfer and 31 patients (23 %) met criteria for possibly preventable transfer. The majority of preventable transfers involved head trauma (68 %), followed by isolated orthopedic injuries (18 %), and burns (9 %). The majority of the possibly preventable transfers involved head trauma (48 %), followed by orthopedic injuries (16 %). The average distance travelled was 466 miles (SD: 110 miles) for preventable transfers and 458 miles (SD: 81 miles) for possibly preventable transfers.

CONCLUSIONS

A significant proportion of pediatric trauma patients in Montana who underwent long-distance transfer to an out-of-state Level I PTC likely could have received appropriate care at facilities closer to home.

LEVEL OF EVIDENCE

IV, Prognostic and Epidemiological.

Management of pediatric lower extremity vascular trauma: adult vs pediatric level I trauma centers

BACKGROUND

Pediatric lower extremity vascular injury (PLEVI) is uncommon and the availability of granular data is sparse. This study evaluated the surgical management of PLEVIs between a Level I adult (ATC) vs pediatric (PTC) trauma center.

METHODS

We performed a retrospective review of PLEVIs (< 18 years) managed surgically between 01/2009-12/2022. Demographics and outcome data were obtained. Primary outcomes included amputation and fasciotomy rates. Secondary outcomes included type of vessel repair, mortality, and hospital length of stay.

RESULTS

Seventy-nine patients were identified, 41 at the ATC and 38 at the PTC, totaling 112 vessels injured. ATC patients were older (median years 16.0 vs 12.5) and almost exclusively (97.6% vs 29.0%) gunshot wounds. Vascular surgeons managed 50% of injuries at the ATC vs 73.7% at the PTC (p = 0.10). Amputations were uncommon and not significantly different between centers. Seventeen patients (44.7%) required fasciotomies at the PTC vs 21 (51.2%) at the ATC (p = 0.56). Rates of vessel repair, ligation, grafting, mortality, and hospital length of stay were not significantly different.

CONCLUSIONS

PLEVI can be managed safely at ATCs and PTCs with acceptable outcomes. However, important nuances in patient triage and management need to be considered. Multi-institutional comprehensive datasets are needed.

LEVEL OF EVIDENCE

 Level III.

Persistent disparities between trauma center types in the management of children with high-grade blunt splenic injuries

BACKGROUND

In the early 2000s, substantial variations were reported in the management of pediatric patients with blunt splenic injury (BSI). The purpose of this study was to assess the recent trends and disparities between different types of trauma centers. We hypothesized that there would be persistent disparities despite decreased trends in the rate of splenectomy.

METHODS

This is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database. We included patients (age ≤18 years) with high-grade BSI (Abbreviated Injury Scale 3-5) between 2014 and 2021. The patients were divided into three groups based on trauma center types (adult trauma centers [ATCs], mixed trauma centers [MTCs], and pediatric trauma centers [PTCs]). The primary outcome was the splenectomy rate. Logistic regression was performed to evaluate the association between trauma center types and clinical outcomes. Additionally, the trends in the rate of splenectomy at ATCs, MTCs, and PTCs were evaluated.

RESULTS

A total of 6601 patients with high-grade BSI were included in the analysis. Overall splenectomy rates were 524 (17.5%), 448 (16.3%), and 32 (3.7%) in the ATC, MTC, and PTC groups, respectively. ATCs and MTCs had significantly higher splenectomy rates compared to PTCs (ATCs: OR = 5.72, 95%CI = 3.78-8.67, and p < 0.001 and MTCs: OR = 4.50, 95%CI = 2.97-6.81, and p < 0.001), while decreased trends in the splenectomy rates were observed in ATCs and MTCs (ATCs: OR = 0.92, 95%CI = 0.87-0.97, and p = 0.003 and MTCs: OR = 0.92, 95%CI = 0.87-0.98, and p = 0.013).

CONCLUSIONS

This study suggested persistent disparities between different trauma center types in the management of children with high-grade BSI.

Pediatric vs Adult or Mixed Trauma Centers in Children Admitted to Hospitals Following Trauma: A Systematic Review and Meta-Analysis

Importance

Adult trauma centers (ATCs) have been shown to decrease injury mortality and morbidity in major trauma, but a synthesis of evidence for pediatric trauma centers (PTCs) is lacking.

Objective

To assess the effectiveness of PTCs compared with ATCs, combined trauma centers (CTCs), or nondesignated hospitals in reducing mortality and morbidity among children admitted to hospitals following trauma.

Data Sources

MEDLINE, Embase, and Web of Science through March 2023.

Study Selection

Studies comparing PTCs with ATCs, CTCs, or nondesignated hospitals for pediatric trauma populations (aged ≤19 years).

Data Extraction and Synthesis

This systematic review and meta-analysis was performed following the Preferred Reporting Items for Systematic Review and Meta-analysis and Meta-analysis of Observational Studies in Epidemiology guidelines. Pairs of reviewers independently extracted data and evaluated risk of bias using the Risk of Bias in Nonrandomized Studies of Interventions tool. A meta-analysis was conducted if more than 2 studies evaluated the same intervention-comparator-outcome and controlled minimally for age and injury severity. Subgroup analyses were planned for age, injury type and severity, trauma center designation level and verification body, country, and year of conduct. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to assess certainty of evidence.

Main Outcome(s) and Measure(s)

Primary outcomes were mortality, complications, functional status, discharge destination, and quality of life. Secondary outcomes were resource use and processes of care, including computed tomography (CT) and operative management of blunt solid organ injury (SOI).

Results

A total of 56 studies with 286 051 participants were included overall, and 34 were included in the meta-analysis. When compared with ATCs, PTCs were associated with a 41% lower risk of mortality (OR, 0.59; 95% CI, 0.46-0.76), a 52% lower risk of CT use (OR, 0.48; 95% CI, 0.26-0.89) and a 64% lower risk of operative management for blunt SOI (OR, 0.36; 95% CI, 0.23-0.57). The OR for complications was 0.80 (95% CI, 0.41-1.56). There was no association for mortality for older children (OR, 0.71; 95% CI, 0.47-1.06), and the association was closer to the null when PTCs were compared with CTCs (OR, 0.73; 95% CI, 0.53-0.99). Results remained similar for other subgroup analyses. GRADE certainty of evidence was very low for all outcomes.

Conclusions and Relevance

In this systematic review and meta-analysis, results suggested that PTCs were associated with lower odds of mortality, CT use, and operative management for SOI than ATCs for children admitted to hospitals following trauma, but certainty of evidence was very low. Future studies should strive to address selection and confounding biases.

European Pediatric Surgeons' Association Survey on the Use of Splenic Embolization in Blunt Splenic Trauma in Children

INTRODUCTION

 This article assesses (1) access to splenic embolization (SE), (2) indications for SE, and (3) post-embolization management in high-grade splenic trauma in children.

MATERIALS AND METHODS

 An online questionnaire was sent in 2021 to all members of European Pediatric Surgeons' Association.

RESULTS

 There were a total of 157 responses (50 countries, 83% academic hospitals). Among them, 68% have access to SE (SE) and 32% do not (nSE). For a hemodynamic stable patient with high-grade isolated splenic trauma without contrast extravasation (CE) on computed tomography (CT) scan, 99% SE and 95% nSE respondents use nonoperative management (NOM). In cases with CE, NOM decreases to 50% (p = 0.01) and 51% (p = 0.007) in SE and nSE centers, respectively. SE respondents report a significant reduction of NOM in stable patients with an associated spine injury requiring urgent surgery in prone position, both without and with CE (90 and 28%, respectively). For these respondents, in stable patients the association of a femur fracture only tends to decrease the NOM, both without and with CE (93 and 39%, respectively). There was no significant difference in NOM in group nSE with associated injuries with or without CE. After proximal SE with preserved spleen vascularization on ultrasound Doppler, 44% respondents prescribe antibiotics and/or immunizations.

CONCLUSION

 Two-thirds of respondents have access to SE. For SE respondents, SE is used even in stable patients when CE showed on initial CT scan and its use increased with the concomitant need for spinal surgery. There is currently a variation in the use of SE and antibiotics/immunizations following SE.