A National Comparison of Volume and Acuity for Adult and Pediatric Trauma: A Trauma Quality Improvement Program Cohort Study

Pediatric Resuscitative Thoracotomy in Infants, Children, and Early Adolescents: A Scoping Review

INTRODUCTION

Recent publications sought to define the role of resuscitative thoracotomy (RT) in the pediatric population; however, few studies guide its use in young children and infants. This review characterizes the presentation and outcomes of patients ≤15 y old undergoing RT.

METHODS

A scoping review querying publications in PubMed, Embase, and Scopus prior to March 2024 was conducted using Covidence software. Eligible articles reported outcomes of patients aged ≤15 y old receiving RT for traumatic injury. The exclusion criteria included non-English, data in aggregate with patients >15 y old or lack of outcomes. Eligible articles underwent data extraction for mechanism of injury, hospital presentation, procedure details, and survival.

RESULTS

The search imported 1550 articles, 294 underwent full-text review, and 26 were included. Notably, 85 articles were excluded for failing to separate pediatric and adult outcomes. Reviewed literature reported on 459 pediatric patients, of which 81 survived (17.6%). Age reporting varied as follows: 10 articles reported the exact age, 5 reported age buckets, and 11 reported an age range only. Of the survivors with known ages, three were <1 y old, seven were 1-4 y old, ten were 5-9 y old, and 39 were 10-15 y old.

CONCLUSIONS

The utility and indications for pediatric RT are understudied in the youngest children. Current literature is limited by inconsistent reporting and poor data granularity. Establishing universal reporting guidelines for pediatric RT will help build complete, uniform databases. A preliminary reporting checklist is proposed to improve data sharing in pediatric RT literature, serving as a first step toward developing evidence-based protocols for young children and infants undergoing RT.

Fluid Management in Critically Ill Children: Single-Center Retrospective Comparison of Trauma and Postoperative Patients, 2020-2022

OBJECTIVE

Injury and surgery both represent well-defined starting points of a predictable inflammatory response, but the consequent response to IV fluids has not been studied. We aimed to review and compare our single-center fluid management strategies in these two populations.

DESIGN

Retrospective cohort study from January 2020 to July 2022. The primary outcome was total IV fluid volume administered. Net fluid balances and select clinical outcomes were also evaluated.

SETTING

Single tertiary academic center and level 1 pediatric trauma center in New York.

PATIENTS

A dataset of critically ill trauma and surgical patients aged 0-18 years who were admitted to the PICU, 2020-2022. Trauma patients had at least moderate traumatic injuries (Injury Severity Score ≥ 9) and surgical patients had at least a 1-hour operation time.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified 25 trauma and 115 surgical patients. During the first 5 days of hospitalization, we did not identify an association between grouping and total IV fluids administered and fluid balance in the prehospital, emergency department, and operating room ( p = 0.90 and p = 0.79), even when adjusted for weight ( p = 0.96). Time trend graphs of net fluid balance and IV fluid administered illustrated analogous fluid requirement and response with the transition from net positive to net negative fluid balance between 48 and 72 hours. There was an association between total IV fluid and ventilator requirement ( p = 0.003).

CONCLUSIONS

Critically ill pediatric trauma and postoperative patients seem to have similar fluid management and balance after injury or surgery. In our opinion, these two critically ill populations could be combined in large prospective studies on optimal fluid therapy in critically ill children.

Educational Strategies in Pediatric Trauma Resuscitation Across Disciplines: A Scoping Review

INTRODUCTION

Trauma is the leading cause of death and disability in children. Differences in mechanism, injury pattern, severity, and physiology in this population distinguish pediatric trauma patients from adults. Educational techniques including simulation and didactics may improve pediatric readiness in this setting. We summarize the literature across disciplines, highlighting the curricular approaches, target provider population, educational content, content delivery method, and Kirkpatrick level for pediatric trauma resuscitation education.

METHODS

The MEDLINE (via Ovid), Embase (via Elsevier), Cumulative Index to Nursing & Allied Health Literature Complete (via EBSCO), Education Database (via ProQuest), and Web of Science Social Science Citation Index and Science Citation Index (via Clarivate) were searched. We reviewed 90 manuscripts describing pediatric trauma resuscitation education programs. When available, target provider population, curricular content, delivery method, and Kirkpatrick level were obtained.

RESULTS

Nurses (50%), residents (45%), and attending physicians (43%) were the most common participants. Airway management (25%), shock (25%), and general trauma (25%) were the most frequently taught concepts, and delivery of content was more frequently via simulation (65%) or didactics (52%). Most studies (39%) were Kirkpatrick Level 1.

CONCLUSIONS

This review suggests that diverse strategies exist to promote pediatric readiness. Most training programs are interdisciplinary and use a variety of educational techniques. However, studies infrequently report examining the impact of educational interventions on patient-centered outcomes and lack detail in describing their curriculum. Future educational efforts would benefit from heightened attention to such outcome measures and a rigorous description of their curricula to allow for reproducibility.

Quality Improvement Practices and Resources Targeting Firearm Injuries: A Survey of U.S. Pediatric Trauma Centers

BACKGROUND

The increase in firearm injuries at U.S. pediatric trauma centers is a national public health crisis. This spike in penetrating trauma has challenged even the most mature pediatric trauma centers.

OBJECTIVE

This project aims to identify U.S. pediatric trauma center best practices for the evaluation and resources dedicated to pediatric firearm injuries.

METHODS

This study used an exploratory cross-sectional survey design using a study-specific questionnaire. An electronic survey was distributed to 159 verified U.S. pediatric trauma centers targeting patients younger than 15 years with firearm injuries from 2017 to 2021. Trauma approaches to injury prevention, advocacy, and common performance improvement events were surveyed. A follow-up survey provided a drill-down on the top three performance improvement events.

RESULTS

A total 159 surveys were distributed, of which 63 (40%) submitted partial responses and 32 (20%) completed the initial survey in full. A 49% increase in pediatric firearm injuries occurred between 2019 and 2020. Eighty-six percent of the trauma centers identified at least one to two opportunities for improvement events related to firearm injuries, with most of these events requiring a tertiary level of review. The top three performance improvement events included the massive transfusion protocol/fluid resuscitation, emergency department procedures, and operating room resource availability.

CONCLUSIONS

This study provides the first known examination of U.S. pediatric trauma center quality improvement efforts to address the crisis of pediatric firearm injuries. Our results indicate that most pediatric trauma centers are engaged in quality improvement and resource enhancement to combat firearm injuries.