Initial assessment and management of pediatric trauma patients

Characteristics and Validation of Pediatric Extremity Vascular Trauma in Dedicated Pediatric and Adult Trauma Centers: A Scoping Review Protocol

BACKGROUND

Pediatric extremity vascular injuries constitute a rare yet serious entity that can lead to serious complications especially if left untreated or become late diagnosed. In our scoping review, we sought to evaluate different characteristics and outcomes of pediatric and combined adult trauma centers (ATCs) in the management of pediatric extremity vascular injury.

METHODS

We sought to analyze various characteristics and parameters that differentiate a dedicated pediatric and a combined pediatric ATC in terms of effectiveness and quality of care in the acute setting and to describe special features and characteristics of an acute vascular disease that constitute pediatric population unique from the aspect of diagnosis and management. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews guidelines to conduct the study.

RESULTS

The search identified 8,815 records in title using MeSH terms from PubMed/MEDLINE database among which 12 studies reporting a total of 2,124 pediatric patients with vascular extremity injuries were included for analysis. Incidence of pediatric extremity vascular injury was 0.5%. Upper extremity injuries were the most frequent presenting in 63% of cases followed by lower extremity injuries in 37% of cases. Blunt injuries were marginally more common than penetrating injuries (58% vs. 42%). In-hospital mortality and morbidity ranged from 13.2% to 0.9% and 13% to 30%, respectively. Limb-salvage rates were high, ranging from 92% to 99%. Furthermore, there are no clearly defined clinical guidelines involving the mode of imaging and diagnosis, the surgical specialties involved and the competency of nursing or medical staff overall.

CONCLUSIONS

Dedicated children trauma centers theoretically represent the optimal path for acute pediatric trauma admission, especially in complex trauma necessitating vascular reconstruction. However, in the current setting of rapidly increasing health costs and economic crisis worldwide, regional or resource-related factors make this option rather unavailable. In any case, it is imperative the clinicians have a high index of suspicion when confronting with these types of injuries because early diagnosis is highly related with reduced morbidity and superior outcomes.

A Retrospective Study to Compare the Glasgow Coma Score, Pediatric Trauma Score, and Injury Severity Score and Outcomes in 118 Pediatric Trauma Patients at a Single Emergency Center in Turkey

BACKGROUND The main causes of accidental trauma in children include road traffic accidents (RTAs) and falling from height (FFH). Rapid and accurate assessment of severity of injury is required to guide effective management. This retrospective study aimed to compare the Glasgow Coma Score (GCS), Pediatric Trauma Score (PTS), and Injury Severity Score (ISS) and outcomes for 118 pediatric trauma patients at a single Emergency Department (ED) in Turkey. MATERIAL AND METHODS Patients admitted to Ankara City Hospital due to high-energy trauma between November 1, 2019 and April 30, 2020 were analyzed retrospectively. Data for 118 patients with trauma by major mechanisms, aged 0-17, were collected. Demographic characteristics, trauma-related characteristics, outcomes, and GCS, PTS, and ISS values were compared. It was examined whether there was a relationship between trauma severity and prognosis. In this context, trauma severity was defined by these scores. RESULTS Of the 118 admitted patients, 66 (55.9%) were discharged from the ED, 33 (28%) were transferred to the intensive care unit (ICU), and 19 (16.1%) were admitted to non-ICU departments in the hospital. With hospitalization, patients with thoracic trauma (P<0.001; OR 11.1; 95% CI 3.0-40) and patients with abdominal trauma (P=0.003; OR 4.0; 95% CI 1.5-10.8) were discharged significantly less frequently than patients with other types of trauma. Patients with low ISS (P<0.001) and high PTS (P<0.001) were discharged more often. The relationship between diagnosis and hospitalization was significant (P<0.001). CONCLUSIONS RTA and FFH are the leading trauma mechanisms in children. Boys experience more trauma. ISS and PTS provide accurate predictions of severe and poor prognosis in pediatric trauma cases.

Delphi Process for Validation of Fluid Treatment Algorithm for Critically Ill Pediatric Trauma Patients

INTRODUCTION

While intravenous fluid therapy is essential to re-establishing volume status in children who have experienced trauma, aggressive resuscitation can lead to various complications. There remains a lack of consensus on whether pediatric trauma patients will benefit from a liberal or restrictive crystalloid resuscitation approach and how to optimally identify and transition between fluid phases.

METHODS

A panel was comprised of physicians with expertise in pediatric trauma, critical care, and emergency medicine. A three-round Delphi process was conducted via an online survey, with each round being followed by a live video conference. Experts agreed or disagreed with each aspect of the proposed fluid management algorithm on a five-level Likert scale. The group opinion level defined an algorithm parameter's acceptance or rejection with greater than 75% agreement resulting in acceptance and greater than 50% disagreement resulting in rejection. The remaining were discussed and re-presented in the next round.

RESULTS

Fourteen experts from five Level 1 pediatric trauma centers representing three subspecialties were included. Responses were received from 13/14 participants (93%). In round 1, 64% of the parameters were accepted, while the remaining 36% were discussed and re-presented. In round 2, 90% of the parameters were accepted. Following round 3, there was 100% acceptance by all the experts on the revised and final version of the algorithm.

CONCLUSIONS

We present a validated algorithm for intavenous fluid management in pediatric trauma patients that focuses on the de-escalation of fluids. Focusing on this time point of fluid therapy will help minimize iatrogenic complications of crystalloid fluids within this patient population.

Pediatric Age-adjusted Shock Index (SIPA): From Injury to Outcome in Blunt Abdominal Trauma

Purpose

The Shock Index Pediatric Age-Adjusted (SIPA) score is a useful tool for identifying pediatric trauma patients at a risk of poor outcomes and for triaging. We are studying the relationship between elevated SIPA score and specific outcomes in pediatric trauma patients.

Materials and Methods

A retrospective study was conducted in which case records of 58 pediatric patients with blunt abdominal trauma were evaluated and tabulated for their SIPA scores only at the time of their initial presentation and categorized into two groups - normal SIPA and elevated SIPA. The primary outcomes were need for blood transfusion, need for any intervention, and need for emergency surgery, and the secondary outcomes were need for computed tomography (CT) scan, need for a ventilator, intensive care unit (ICU) stay, length of hospital stay, and mortality. Statistical methods were applied to find a relationship between elevated SIPA score and the primary and secondary outcomes.

Results

An elevated SIPA score was noted in 27 (46%) patients. There was a significant relationship between elevated SIPA scores and patients needing blood transfusion (68.75%, n = 11) and length of hospital stay (10.48 ± 7.54 days). A significant relationship between elevated SIPA score and need for emergency surgery (54.54%, n = 6), need for a CT scan (56%, n = 14), and ICU stay (50%, n = 2) was not found.

Conclusion

We have seen in our study that elevated SIPA scores at presentation are significantly related to need for blood transfusion and length of hospital stay. In more than half of the patients, elevated SIPA was associated with need for emergency surgery and requirement of CT scan, but it was statistically not significant. Therefore, assessment of this parameter can help in identifying such poor outcomes.

The Tertiary Survey as a Quality Improvement Initiative in Pediatric Trauma Care

BACKGROUND

Patients are at risk of missed or delayed injuries in the setting of multisystem trauma, which may be identified with a tertiary trauma survey (TTS). There is limited literature to support the utilization of a TTS in pediatric trauma population. We aim to assess the impact of the TTS as a quality and performance improvement tool in identifying missed or delayed injuries and improving the quality of care among pediatric trauma population.

METHODS

A retrospective study assessing a quality improvement/performance improvement (QI/PI) project focusing on the administration of tertiary surveys to pediatric trauma patients was conducted at our level 1 trauma center between 08-2020 and 08-2021. Patients with injury severity scores (ISS) greater than 12 and/or an anticipated hospital stay greater than 72 hours met inclusion criteria and were included.

RESULTS

Of the 535 trauma patients admitted to the pediatric trauma service during the study period, 85 (16%) patients met the criteria and received a TTS. Thirteen unaddressed or undertreated injuries were found in 11 patients: 5 cervical spine injuries, 1 subdural hemorrhage, 1 bowel injury, 1 adrenal hemorrhage, 1 kidney contusion, 2 hematomas, and 2 full thickness abrasions. Following TTS, 13 patients (15%) had additional imaging, which identified 6 of the 13 injuries.

CONCLUSION

The TTS is a valuable quality and performance improvement tool in the comprehensive care of trauma patients. Standardization and implementation of a tertiary survey have the potential to facilitate the prompt detection of injuries and improve the quality of care for pediatric trauma patients.

LEVEL OF EVIDENCE

III.

Pediatric Panfacial Fractures

Pediatric panfacial trauma is a rare occurrence with poorly understood implications for the growing child. Treatment algorithms largely mirror adult panfacial protocols with notable exceptions including augmented healing and remodeling capacities that favor nonoperative management, limited exposure to avoid disruption of osseous suture and synchondroses growth centers, and creative fracture fixation techniques in the setting of an immature craniomaxillofacial skeleton. The following article provides a review of our institutional philosophy in the management of these challenges injuries with important anatomic, epidemiologic, examination, sequencing, and postoperative considerations.

Public perception of household risks for pediatric burn injuries and assessment of management readiness

INTRODUCTION

Children are uniquely vulnerable to injury because of near-complete dependence on caregivers. Unintentional injury is leading cause of death in children under the age of 14. Burns are one of the leading causes of accidental and preventable household injuries, with scald burns most common in younger children and flame burns in older ones. Education is a key tool to address burn prevention, but unfortunately these injuries persist. Critically, there is a paucity of literature investigating adult comprehension with respect to potential risks of household burns. To date, no study has been performed to assess management readiness for these types of injuries without seeking medical care.

METHODS

Qualtrics™ surveys were distributed to laypersons via Amazon Mechanical Turk. Demographics were self-reported. The survey was divided into two parts, management knowledge, and risk identification. The management part involved a photograph of a first-degree pediatric burn injury and required identification of the degree of injury and three potential initial managements. The risk-identification section required correctly identifying the most common mechanisms of burn injury for different age groups followed by general identification of 20 household burn risks. Survey responses were analyzed using two-tailed Student's t-tests and chi-square analyses, univariate and multivariate analysis, and linear regression.

RESULTS

Of the 467 respondents, the mean age was 36.57 years, and was 59.7% (279) male. Only 3.2% of respondents were able to correctly identify all 20 potential risks listed in our survey. Additionally, only 4.5% of respondents correctly identified all three appropriate initial management options (cool water, sterile gauze, and over-the-counter analgesics) without misidentifying incorrect options. However, 56.1% of respondents were able to select at least one correct management option. For image-based injury classification, the most common response was incorrectly second-degree with 216 responses (42.2%) and the second-most common response was correctly first-degree with 146 responses (31.3%). Most respondents claimed they would not seek medical attention for the injury presented in the photograph (77.7%). When comparing the responses of individuals with children to those without, there were no statistically significant differences in ability to assess household risks for pediatric burns. For the entire population of respondents, the mean score for correctly identifying risks was 38%.

CONCLUSION

This study revealed a significant gap in public awareness of household risks for pediatric burns. Furthermore, while most individuals would not seek medical care for a first-degree pediatric burn injury, they were readily available to identify proper initial management methods. This gap in knowledge and understanding of household pediatric burn injuries should be addressed with increased burn injury prevention education initiatives and more parental counseling opportunities.

Paauglio politrauma žemdirbystės pramonėje: klinikinio atvejo analizė

Polytrauma is a condition when a patient has sustained multiple injuries, which can lead to disability or death. While the agriculture industry is growing, the number of polytrauma patients in children is increasing as well. It is high-energy traumas when it is important to immediately assess injuries and life-threatening conditions and to start trauma protocols guided treatment. In this article, we present a case of a 17-year-old boy who suffered extensive injuries caused by a straw pellets machine. We discussed the importance of prehospital care, multidisciplinary team involvement, and treatment methods.

Management of Children and Adolescents with Chest Trauma in Pediatric and Non-Pediatric Departments—A Claims Data Analysis

Background: To investigate the management of children and adolescents with isolated and combined chest trauma in pediatric (PD) and non-pediatric departments (non-PD). Methods: Anonymized claims data were provided by two large German statutory health insurance funds, covering 6.3 million clients over a 10-year period (2010–2019). Data were extracted for patients who had an inpatient ICD diagnosis of section S20–S29 (injuries to the thorax) and were ≤18 years of age. Demographic and clinical data were analyzed. Results: A total of 4064 children and adolescents with chest trauma were included (mean age 12.0 ± 5.0 years; 55% male). In 1928 cases (47.4%), treatment was provided at PD. Patients admitted to PD underwent CT imaging less frequently (8.1%; non-PD: 23.1%; p < 0.0001). Children with a chest drain treated at university/maximum care hospitals (UM) showed more injuries involving multiple body regions compared with non-UM (25.8% vs. 4.5%; p = 0.0061) without a difference in the length of hospital stay. Conclusion: Children and adolescents with chest trauma are treated almost equally often in pediatric and adult departments. CT is significantly less frequently used in pediatric departments. Patients with a chest drain treated at a UM showed more concomitant injuries without a longer hospital stay. However, the clinical validity of this finding is questionable.

Failure-to-rescue and mortality after emergent pediatric trauma laparotomy: How are the children doing?

INTRODUCTION

Emergent trauma laparotomy is associated with mortality rates of up to 40%. There is a paucity of data on the outcomes of emergent trauma laparotomies performed in the pediatric population. The aim of our study was to describe the outcomes, including mortality and FTR, among pediatric trauma patients undergoing emergent laparotomy and identify factors associated with failure-to-rescue (FTR).

METHODS

We performed a one-year (2017) retrospective cohort analysis of the American College of Surgeons Trauma Quality Improvement Program dataset. All pediatric trauma patients (age <18 years) who underwent emergent laparotomy (laparotomy performed within 2 h of admission) were included. Outcome measures were major in-hospital complications, overall mortality, and failure-to-rescue (death after in-hospital major complication). Multivariate regression analysis was performed to identify factors independently associated with failure-to-rescue.

RESULTS

Among 120,553 pediatric trauma patients, 462 underwent emergent laparotomy. Mean age was 14±4 years, 76% of patients were male, 49% were White, and 50% had a penetrating mechanism of injury. Median ISS was 25 [13-36], Abdomen AIS was 3 [2-4], Chest AIS was 2 [1-3], and Head AIS was 2 [0-5]. The median time in ED was 33 [18-69] minutes, and median time to surgery was 49 [33-77] minutes. The most common operative procedures performed were splenectomy (26%), hepatorrhaphy (17%), enterectomy (14%), gastrorrhaphy (14%), and diaphragmatic repair (14%). Only 22% of patients were treated at an ACS Pediatric Level I trauma center. The most common major in-hospital complications were cardiac (9%), followed by infectious (7%) and respiratory (5%). Overall mortality was 21%, and mortality among those presenting with hypotension was 31%. Among those who developed in-hospital major complications, the failure-to-rescue rate was 31%. On multivariate analysis, age younger than 8 years, concomitant severe head injury, and receiving packed red blood cell transfusion within the first 24 h were independently associated with failure-to-rescue.

CONCLUSIONS

Our results show that emergent trauma laparotomies performed in the pediatric population are associated with high morbidity, mortality, and failure-to-rescue rates. Quality improvement programs may use our findings to improve patient outcomes, by increasing focus on avoiding hospital complications, and further refinement of resuscitation protocols.

LEVEL OF EVIDENCE

Level IV STUDY TYPE: Epidemiologic.

Pediatric traumatic brain injury in a high-income developing country: experience at a level 1 neuro-trauma center

BACKGROUND

Data on the incidence, prevalence and mortality of pediatric traumatic brain injuries (TBIs) in developing countries are not readily available or do not exist.

AIM

The aim of this study was to study the epidemiology of pediatric TBI in developing countries.

METHODS

A retrospective study was conducted in a high-volume Neurosurgery Department where we reviewed pediatric cases presenting with TBI between January 2015 and December 2019. Data were collected from the electronic medical records including the patients' demographics, neuro-vital signs, mechanism of TBI and treatment types. Radiological images were screened, and patients were classified according to the type of intracranial hemorrhage. The patient's outcome and Glasgow Coma Scale on discharge were also recorded.

RESULT

Nine hundred and eighty-five cases with TBI were admitted over the period of 5 years. The average age was 53.3 months standard deviation (SD) of 39.4. Male gender accounted for 63.7% of the cases. The most common mechanisms of injuries were falls and road traffic accidents/motor vehicle collisions (63.3%, 18.3%), respectively. Nausea and vomiting followed by altered consciousness and drowsiness were the commonest presenting symptoms. Mild TBI accounted for 85.2% of the cases and the majority (92.08%) were treated conservatively (P < 0.005). 93.3% of the cases were categorized as mild head injury upon discharge. The mortality rate was 1.6% in severe TBI cases.

CONCLUSION

Children less than 4 years of age were highly affected by TBI. This study gives emergency physicians and neurosurgeons in developing countries an expectation about TBI in pediatric cases and the immediate management to prevent further complications.

Pediatric trauma in the rural and low resourced communities

Death and disability associated with traumatic injury can be significantly decreased with timely and appropriate care. Patients in rural areas tend to have disproportionately decreased access to this care, with the pediatric age group acting as a particularly difficult challenge for pre-hospital and rural hospital settings due to the unfamiliarity of those trauma response teams with pediatric age specific management guidelines as well as a disparity in resource availability. In this review, we attempt to discuss the challenges facing pediatric trauma care in the rural and low resourced communities, as well as initiatives that are being carried out to optimize this kind of care, such as pediatric readiness, rapid transportation to higher levels of care, availability of blood in rural centers as well as in transit, and the utility of telemedicine in improving rural pediatric trauma care.

Pediatric craniocerebral gunshot injuries: A National Trauma Database study

BACKGROUND

We aimed to determine the outcomes and prognostic factors in pediatric craniocerebral gunshot injury (CGI) patients. Pediatric patients may have significantly different physiology, neuroplasticity, and clinical outcomes in CGI than adults. There is limited literature on this topic, mainly case reports and small case series.

METHODS

We queried the National Trauma Data Bank for all pediatric CGI between 2014 and 2017. Patients were identified using International Classification of Diseases, Ninth Revision, codes. Demographic, emergency department, and clinical data were analyzed. Subgroup analysis was attempted for groups with Glasgow Coma Scale (GCS) scores of 9 to 15 and ages 0 to 8 years.

RESULTS

In a 3-year period, there were 209 pediatric patients (aged 0-18 years) presenting to American hospitals with signs of life. The overall mortality rate was 53.11%. A linear relationship was demonstrated showing a mortality rate of 79% by initial GCS in GCS score of 3, 56% in GCS scores of 4 to 8, 22% in GCS scores of 9 to 12, and 5% in GCS scores of 13 to 15. The youngest patients, aged 0 to 8 years, had dramatically better initial GCS and subsequently lower mortality rates. Regression analysis showed mortality benefit in the total population for intracranial pressure monitoring (odds ratio, 0.267) and craniotomy (odds ratio, 0.232).

CONCLUSION

This study uses the National Trauma Data Bank to quantify the prevalence of pediatric intracranial gunshot wounds, with the goal to determine risk factors for prognosis in this patient population. Significant effects on mortality for invasive interventions including intracranial pressure monitoring and craniotomy for all patients suggest low threshold for use of these procedures if there is any clinical concern. The presence of a 79% mortality rate in patients with GCS score of 3 on presentation suggests that as long as there is not a declared neurologic death, intracranial pressure monitoring and treatment measures including craniotomy should be considered by the consulting clinician.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

Pediatric Facial Fractures

Facial trauma is common in the pediatric population with most cases involving the soft tissue or dentoalveolar structures. Although facial fractures are relatively rare in children compared with adults, they are often associated with severe injury and can cause significant morbidity and disability. Fractures of the pediatric craniomaxillofacial skeleton must be managed with consideration for psychosocial, anatomical, growth and functional differences compared with the adult population. Although conservative management is more common in children, displaced fractures that will not self-correct with compensatory growth require accurate and stable reduction to prevent fixed abnormalities in form and function.

Pediatric upper extremity firearm injuries: an analysis of demographic factors and recurring mechanisms of injury

BACKGROUND

Little is known regarding risk factors specific to pediatric upper extremity firearm injuries. The purpose of this study is to evaluate pediatric patients treated for these injuries to identify at-risk populations and recurring mechanisms of injury.

METHODS

A 20-year retrospective review was conducted. Patients 17 years of age and younger, with upper extremity injuries related to a firearm, were included. Analysis involved Fisher's exact and Chi-square tests.

RESULTS

One hundred and eighty patients were included. The mean age was 12.04 ± 4.3 years. Most included patients were male (85%). Interestingly, females were more frequently victims of assault (P = 0.03), and males were more frequently injured due to accidental discharge (P < 0.001). The most affected race/ethnicity was White-not Hispanic or Latino (48%). The hand was the most frequent location injured (31%) and was more likely to be accidental than proximal injuries (P = 0.003). Air rifles were the most common firearm type used (56%). Pistols were implicated in 47 (26%) cases, rifles in 17 (9%), and shotguns in 10 (6%). Ninety-nine (55%) patients had procedures in the operating room. The most frequent procedure was foreign body removal (55%).

CONCLUSIONS

Risk factors such as male sex, White-not Hispanic or Latino race/ethnicity, and adolescent age were attributed to increased risk for injury. Male sex was associated with increased risk of injury by accidental discharge and female sex with intentional assault. Air rifles were the most common firearm type overall, although female sex was associated with increased risk for injury by powder weapon.

Injury Severity, Arrival Physiology, Coagulopathy, and Outcomes Among the Youngest Trauma Patients

BACKGROUND

Although physiologic differences exist between younger and older children, pediatric trauma analyses are weighted toward older patients. Trauma-induced coagulopathy, determined by rapid thrombelastography (rTEG), is a predictor of outcome in trauma patients, but the significance of rTEG values among very young trauma patients remains unknown. Our objective was to identify the prehospital or physiologic factors, including rTEG values, that were associated with mortality in trauma patients younger than 5 y old.

MATERIALS AND METHODS

Patients younger than 5 y old that met the highest-level trauma activation criteria at an academic children's hospital from 2010-2016 were included. Data regarding demographics, pre-hospital management, laboratory values, injury severity, and outcome were queried. Univariate and multivariate analyses were performed comparing survivors and non-survivors.

RESULTS

A total of 356 patients were included. 60% were male, and the median age was 3 y (IQR 1-4). Overall mortality was 13% (n = 45); brain injury (91%) and hemorrhage (9%) were the causes of death. Compared to survivors, rTEG values in nonsurvivors showed longer activated clotting time and slower speed of clot formation. Clot strength was also decreased in nonsurvivors. On stepwise regression modeling, rTEG values were not significant predictors of mortality. Admission base deficit, arrival temperature, and head injury severity were identified as independent predictors of mortality.

CONCLUSIONS

While rTEG identified coagulopathy in trauma patients < 5 y old, it was not an independent predictor of mortality. Our findings suggest that trauma providers should pay close attention to admission base deficit, arrival temperature, and head injury severity when managing the youngest trauma patients.

Delta Shock Index Predicts Outcomes in Pediatric Trauma Patients Regardless of Age

INTRODUCTION

Changes in the shock index (ΔSI) can be a predictive tool but is not established among pediatric trauma patients. The aim of our study was to assess the impact of ΔSI on mortality in pediatric trauma patients.

METHODS

We performed a 2017 analysis of all pediatric trauma patients (age 0-16 y) from the ACS-TQIP. SI was defined as heart rate(HR)/systolic blood pressure(SBP). We abstracted the SI in the field (EMS), SI in the emergency department (ED) and calculated the change in SI (ΔSI = ED SI-EMS SI). Patients were divided into four age groups: 0-3 y, 4-6 y, 7-12 y, and 13-16 y and substratified into two groups based on the value of the age-group-specific ΔSI cutoff obtained with receiver operating characteristic ROC analysis; +ΔSI and -ΔSI. Our outcome measure was mortality. Multivariable logistic and Cox regression analyses were performed.

RESULTS

We included 31,490 patients. Mean age was 10.6 ± 4.6 y, and 65.8% were male. The overall mortality rate was 1.4%. In the age group 0-3 y the cutoff point for ΔSI was 0.29 with an area under the curve (AUC) 0.70 [0.62-0.79], ΔSI cutoff 4-6 y was 0.41 AUC 0.81 [0.70-0.92], ΔSI cutoff 7-12 y was 0.05 AUC 0.83 [0.76-0.90], and ΔSI cutoff 13-16 y was 0.13 AUC 0.75 [0.69-0.81]. On the Cox regression analysis, +ΔSI was independently associated with increased in-hospital mortality and 24-h mortality (P ≤ 0.01).

CONCLUSIONS

Vital signs vary by age group in children, but ΔSI inherently accounts for this variation. ΔSI predicts mortality and may be utilized as a predictor to help guide triage of pediatric trauma patients.

LEVEL OF EVIDENCE

Level III Prognostic.

Damage control laparotomy in a paediatric trauma patient in a regional hospital

INTRODUCTION

Trauma is a major cause of death in children (Brown et al., 2001). It has far-reaching impacts on a child's development and function, and is a major contributing factor to disability in the young. Pediatric patients in trauma demonstrate different clinical signs and have different resuscitation requirements, often masking symptoms and compensating well before rapidly deteriorating.

CASE PRESENTATION

The authors present a case of a 13-year-old patient with major trauma receiving surgical management in an adult regional hospital. The patient was involved in a high-speed head on motorcar collision. This report emphasizes the importance of early mobilisation of a trauma team and appropriate surgical stabilisation of a child in an adult regional centre without access to specialised pediatric surgeons.

DISCUSSION

Approximately 600 individuals aged 19 or less are fatally injured in Australia each year. Management of pediatric trauma requires early mobilization of a trauma team, to ensure high levels of expertise are available. However, managing these patients with specialized pediatric surgery teams is not always possible. As such, peripheral hospitals need to have trained general surgeons who can manage the deteriorating pediatric patient.

CONCLUSION

All peripheral hospitals with access to emergency operating should have general surgeons willing and able to manage pediatric trauma, with the confidence for a low threshold for laparotomy.

Negative Pressure Wound Therapy With Flap Reconstruction for Extensive Soft Tissue Loss in the Foot: A Case Report

Negative pressure wound therapy (NPWT) can create the healing granulation tissue that will form a wound bed for the skin graft, thereby reducing the volume of the soft tissue defect. The application of uniform negative pressure, which is delivered by vacuum-assisted closure (VAC) therapy, induces a physical response (macrostrain) and a biological response (microstrain). The patient in the current case report presented with an alleged history of a road traffic accident, sustaining a crush injury to his right heel pad, resulting in an open comminuted fracture of the right calcaneum with bone loss. A total of seven days of NPWT was allowed. Negative pressure sponge dressing was then applied in this region and adhesive drapes were sealed. Once sealed, suction was set at the continuous pressure of -125 mm Hg. The authors noted that the benefits significantly outweigh the costs of the VAC system, making it an essential treatment option for patients similar to the one presented in this case report.

The transfer of clinical prediction models for early trauma care had uncertain effects on mistriage

OBJECTIVES

This study aimed to assess how transfers of clinical prediction models for early trauma care between different care contexts within a single health system affected mistriage rates.

STUDY DESIGN AND SETTING

Patients aged 15 years or older, registered between 2011 and 2016 in the Swedish national trauma registry, SweTrau, were included. Three data set groups were created: high- and low-volume centers, metropolitan and nonmetropolitan centers, and multicenters and single centers. Clinical prediction models were developed using logistic regression in each data set group and transferred between data sets within groups. Model performance was evaluated using mistriage rate, undertriage rate, and overtriage rate. Multiple imputation using chained equations was used to handle missing data. Model performance was reported as medians with 95% confidence intervals (CIs).

RESULTS

A total of 26,965 patients were included. Changes in mistriage rates after transfer ranged from -0.25 (95% CI -0.21 to 0.04) to 0.29 (95% CI 0.13-0.39). Both overtriage and undertriage rates were affected.

CONCLUSIONS

Transferring clinical prediction models for early trauma care is associated with substantial uncertainty in regards to the effect on model performance. Depending on the care context, model transfer led to either increased or decreased mistriage. Overtriage was more affected by model transfer than undertriage.

Pediatric Emergency Medicine Disaster Simulation Curriculum: The 5-Minute Trauma Assessment for Pediatric Residents (TRAP-5)

INTRODUCTION

Pediatric trauma management is a high-stress, high-risk, low-frequency event, and exposure through simulation can help identify and address knowledge gaps. Pediatric residents are likely to provide care for children with traumatic injuries, and it is important they are skilled in performing a rapid trauma assessment.

METHODS

We developed a simulation-based rapid pediatric trauma assessment curriculum for pediatric residents in the setting of a mass casualty disaster. The patients were 5-year-olds portrayed by mannequins with varying injuries including intracranial hemorrhage, solid organ injury, and open extremity fractures. Critical actions included assigning roles, completing primary assessment within 2 minutes, and giving summary statement and management priorities within 5 minutes using clear communication techniques. We created a badge-sized reference card as well as scenario-specific debriefing tools to facilitate assessment and discussion of learning objectives following the simulation.

RESULTS

We conducted two sessions with a total of 49 participants. The case was rated as highly relevant (session 1, m = 4.7; session 2, m = 4.9) and realistic (session 1, m = 4.8; session 2, m = 4.4) by participants on a 5-point Likert scale. During the two sessions participants completed the primary survey in an average of 2.46 and 2.29 minutes, respectively, and the secondary survey with summary statement in an average of 5.08 and 4.27 minutes, respectively.

DISCUSSION

This educational resource supports the setup, production, and debriefing of a low-fidelity simulation focused on the pediatric trauma assessment for the novice learner. Also included are educational reference materials and a participant evaluation form.

Outcomes of civilian pediatric craniocerebral gunshot wounds: A systematic review

BACKGROUND

Pediatric craniocerebral gunshot injuries (CGIs) occur both in the context of accidental and intentional trauma. The incidence and physiology of pediatric CGIs merit reexamination of prognostic factors and treatment priorities. This study characterizes the current understanding of mortality and prognostic factors in this patient population.

METHODS

A systematic search was conducted. Selection criteria included all studies published since 2000, which described civilian isolated CGIs in pediatric patients. Data were analyzed qualitatively and quantitatively to identify factors prognostic for the primary outcome of mortality. Secondary outcomes included functional outcome status, requirement for surgery, and injury complications. Study quality was assessed with the Newcastle-Ottawa Scale. This study was registered with PROSPERO (CRD42019134231).

RESULTS

Initial search revealed 349 unique studies. Forty underwent full text screening, and eight studies were included in the final synthesis. The overall mortality rate was 44.8%. Most CGIs occurred in older teenagers. Aggressive surgical treatment was recommended by one author, while remaining studies emphasized clinical judgment. Reported prognostic factors include initial Glasgow Coma Scale, pupil reactivity, involvement of multiple lobes or deep nuclei, and bihemispheric injuries. Reported complications from CGIs included seizure, meningitis, abscess, cerebrospinal fluid leak, bullet migration, focal neurological deficits, endocrine abnormalities, cognitive deficits, and neuropsychological deficits. The Glasgow Outcome Scale was the predominant measure of function and demonstrated a moderate recovery in 17.4% and a good recovery in 27.3% of patients.

CONCLUSION

This systematic review analyzed the existing evidence for prognostic factors in the context of pediatric CGIs. Significant long-term clinical improvement is possible with interventions including urgent surgical therapy. Fixed bilateral pupils and low initial Glasgow Coma Scale correlate with mortality but do not predict all patient outcomes. Patients younger than 15 years are underreported and may have differences in outcome. The literature on pediatric CGIs is limited and requires further characterization.

LEVEL OF EVIDENCE

Systematic Review, level IV.

Cerebrovascular Complications of Pediatric Blunt Trauma

Ischemic and hemorrhagic stroke can occur in the setting of pediatric trauma, particularly those with head or neck injuries. The risk of stroke appears highest within the first two weeks after trauma. Stroke diagnosis may be challenging due to lack of awareness or concurrent injuries limiting detailed neurological assessment. Other injuries may also complicate stroke management, with competing priorities for blood pressure, ventilator management, or antithrombotic timing. Here we review epidemiology, clinical presentation, and diagnostic approach to blunt arterial injuries including dissection, cerebral sinovenous thrombosis, mineralizing angiopathy, stroke from abusive head trauma, and traumatic hemorrhagic stroke. Owing to the complexities and heterogeneity of concomitant injuries in stroke related to trauma, a single pathway for stroke management is impractical. Therefore providers must understand the goals and possible costs or consequences of stroke management decisions to individualize patient care. We discuss the physiological principles of cerebral perfusion and oxygen delivery, considerations for ventilator strategy when stroke and lung injury are present, and current available evidence of the risks and benefits of anticoagulation to provide a framework for multidisciplinary discussions of cerebrovascular injury management in pediatric patients with trauma.

Current Status of Indications, Timing, Management, Complications, and Outcomes of Tracheostomy in Traumatic Brain Injury Patients

Tracheostomy is the commonest bedside surgical procedure performed on patients needing mechanical ventilation with traumatic brain injury (TBI). The researchers made an effort to organize a narrative review of the indications, timing, management, complications, and outcomes of tracheostomy in relation to neuronal and brain-injured patients following TBI. The study observations were collated from the published literature, namely original articles, book chapters, case series, randomized studies, systematic reviews, and review articles. Information sorting was restricted to tracheostomy and its association with TBI. Care was taken to review the correlation of tracheostomy with clinical correlates including indications, scheduling, interventions, prognosis, and complications of the patients suffering from mild, moderate and severe TBIs using Glasgow Coma Scale, Glasgow Outcome Scale, intraclass correlation coefficient, and other internationally acclaimed outcome scales. Tracheostomy is needed to overcome airway obstruction, prolonged respiratory failure and as indispensable component of mechanical ventilation due to diverse reasons in intensive care unit. Researchers are divided over early tracheostomy or late tracheostomy from days to weeks. The conventional classic surgical technique of tracheostomy has been superseded by percutaneous techniques by being less invasive with lesser complications, classified into early and late complications that may be life threatening. Additional studies have to be conducted to validate and streamline varied observations to frame evidence-based practice for successful weaning and decannulation. Tracheostomy is a safer option in critically ill TBI patients for which a universally accepted protocol for tracheostomy is needed that can help to optimize indications and outcomes.

Comparison of drugs used for intubation of pediatric trauma patients

PURPOSE

Rapid sequence intubation (RSI) drugs, such as propofol, affect clinical outcomes, but this has not been examined in the pediatric population. This descriptive study compares the outcomes associated with intubation drugs used in pediatric traumatic brain injury (TBI) patients.

METHODS

A retrospective chart review and descriptive analysis of intubated TBI patients, ages 0-17, admitted to Children's Hospital London Health Sciences Centre (LHSC) from January 2006-December 2016 was performed.

RESULTS

Out of 259 patients intubated, complete data was available for 107 cases. Average injury severity score was 28; 46 were intubated at LHSC, 55 at primary care site, and 6 on scene. Intubation attempts were recorded in 87 of 107 paper charts. First-pass intubation success rate was 88.5%. Propofol (n = 21), midazolam (n = 31), etomidate (n = 13), and ketamine (n = 7) were the most commonly used intubation drugs. Paralytics were used in 50% of patients. Following use of propofol, Pediatric Adjusted Shock Index was increased as a result of worsening hypotension. Mean total hospital length of stay was 21 days with 7.5 days in ICU. Survival was 87%.

CONCLUSION

Great variability exists in the use of induction agents and paralytics for RSI. Propofol was commonly used and is potentially associated with poorer clinical outcomes.

TYPE OF STUDY

Retrospective.

LEVEL OF EVIDENCE

IV.

Rethinking the definition of major trauma: The need for trauma intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers

BACKGROUND

Patients' trauma burdens are a combination of anatomic damage, physiologic derangement, and the resultant depletion of reserve. Typically, Injury Severity Score (ISS) >15 defines major anatomic injury and Revised Trauma Score (RTS) <7.84 defines major physiologic derangement, but there is no standard definition for reserve. The Need For Trauma Intervention (NFTI) identifies severely depleted reserves (NFTI+) with emergent interventions and/or early mortality. We hypothesized NFTI would have stronger associations with outcomes and better model fit than ISS and RTS.

METHODS

Thirty-eight adult and pediatric U.S. trauma centers submitted data for 88,488 encounters. Mixed models tested ISS greater than 15, RTS less than 7.84, and NFTI's associations with complications, survivors' discharge to continuing care, and survivors' length of stay (LOS).

RESULTS

The NFTI had stronger associations with complications and LOS than ISS and RTS (odds ratios [99.5% confidence interval]: NFTI = 9.44 [8.46-10.53]; ISS = 5.94 [5.36-6.60], RTS = 4.79 [4.29-5.34]; LOS incidence rate ratios (99.5% confidence interval): NFTI = 3.15 [3.08-3.22], ISS = 2.87 [2.80-2.94], RTS = 2.37 [2.30-2.45]). NFTI was more strongly associated with continuing care discharge but not significantly more than ISS (relative risk [99.5% confidence interval]: NFTI = 2.59 [2.52-2.66], ISS = 2.51 [2.44-2.59], RTS = 2.37 [2.28-2.46]). Cross-validation revealed that in all cases NFTI's model provided a much better fit than ISS greater than 15 or RTS less than 7.84.

CONCLUSION

In this multicenter study, NFTI had better model fit and stronger associations with the outcomes than ISS and RTS. By determining depletion of reserve via resource consumption, NFTI+ may be a better definition of major trauma than the standard definitions of ISS greater than 15 and RTS less than 7.84. Using NFTI may improve retrospective triage monitoring and statistical risk adjustments.

LEVEL OF EVIDENCE

Prognostic, level IV.

Comparison of Injury Severity Score, Glasgow Coma Scale, and Revised Trauma Score in Predicting the Mortality and Prolonged ICU Stay of Traumatic Young Children: A Cross-Sectional Retrospective Study

Introduction

The purpose of this study was to examine the capacity of commonly used trauma scoring systems such as the Glasgow Coma Scale (GCS), Injury Severity Score (ISS), and Revised Trauma Score (RTS) to predict outcomes in young children with traumatic injuries.

Methods

This retrospective study was conducted for the period from 2009 to 2016 in Kaohsiung Chang Gung Memorial Medical Hospital, a level I trauma center. We included all children under the age of 6 years admitted to the hospital via the emergency department with any traumatic injury and compared the trauma scores of GCS, ISS, and RTS on patients' outcome. The primary outcomes were mortality and prolonged Intensive Care Unit (ICU) stay, with the latter defined as an ICU stay longer than 14 days. The secondary outcome was the hospital length of stay (HLOS). Receiver operating characteristic (ROC) analysis was also adopted with the value of the area under the ROC curve (AUC) for comparing trauma score prediction with patient mortality. Cutoff values from each trauma score for mortality prediction were also measured by determining the point along the ROC curve where Youden's index was maximum.

Results

We included a total of 938 patients in this study, with a mean age of 3.1 ± 1.82 years. The mortality rate was 0.9%, and 93 (9.9%) patients had a prolonged ICU stay. An elevated ISS (34 ± 19.9 vs. 5 ± 5.1, p=0.004), lower GCS (8 ± 5.0 vs. 15 ± 1.3, p=0.006), and lower RTS (5.58 ± 1.498 vs. 7.64 ± 0.640, p=0.006) were all associated with mortality. All three scores were considered to be independent risk factors of mortality and prolonged ICU stay and had a linear correlation with increased HLOS. With regard to predicting mortality, ISS has the highest AUC value (ISS: 0.975; GCS: 0.864; and RTS: 0.899). The prediction cutoff values of ISS, GCS, and RTS on mortality were 15, 11, and 7, respectively.

Conclusion

Regarding traumatic injuries in young children, worse ISS, GCS, and RTS were all associated with increased mortality, prolonged ICU stay, and longer hospital LOS. Of these scoring systems, ISS was the best at predicting mortality.

Negative pressure wound therapy in reconstructing extensive leg and foot soft tissue loss in a child: a case study

Open fractures of the leg with large loss of tissue require extensive reconstructive methods that can injure the donor area. The use of negative pressure wound therapy (NPWT) may minimise the impact of these reconstructive methods because of its capacity to create granulation tissue that will form a wound bed for the skin graft, thus reducing the volume of soft tissue defect and saving the donor region. This case study describes the effectiveness of NPWT in the treatment and reconstruction of an open fracture of the leg, with massive loss of soft tissue, associated with elastic intramedullary nailing in a 10-year-old female patient, who was a victim of a car accident. Clinical examination revealed a Gustilo-Anderson IIIB open fracture of the left leg, with the avulsion of the fifth toe, disarticulation of the fifth metatarsal bone, extensively damaged skin and subcutaneous tissue in the medium and distal third of the left leg and left foot. The bone was exposed in the distal part of the leg, external malleolus and left calcaneus. Profuse lavage, reduction of the tibial fracture and elastic intramedullary nailing, amputation of the fifth left toe, necrectomy and debridement of devitalised tissue were performed. NPWT was started, with the dressing changed every five days. After 55 days of using NPWT, granulation tissue covered the soft tissue defect and created a wound bed for the skin graft. NPWT helped the management of this open wound, achieving a wound bed for the skin graft, avoiding the use of complex reconstructive methods.

Effects of the application of a checklist during trauma resuscitations on ATLS adherence, team performance, and patient-related outcomes: a systematic review

PURPOSE

In this systematic literature review, the effects of the application of a checklist during in hospital resuscitation of trauma patients on adherence to the ATLS guidelines, trauma team performance, and patient-related outcomes were integrated.

METHODS

A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist. The search was performed in Pubmed, Embase, CINAHL, and Cochrane inception till January 2019. Randomized controlled- or controlled before-and-after study design were included. All other forms of observational study designs, reviews, case series or case reports, animal studies, and simulation studies were excluded. The Effective Public Health Practice Project Quality Assessment Tool was applied to assess the methodological quality of the included studies.

RESULTS

Three of the 625 identified articles were included, which all used a before-and-after study design. Two studies showed that Advanced Trauma Life Support (ATLS)-related tasks are significantly more frequently performed when a checklist was applied during resuscitation. [14 of 30 tasks (p < 0.05), respectively, 18 of 19 tasks (p < 0.05)]. One study showed that time to task completion (- 9 s, 95% CI = - 13.8 to - 4.8 s) and workflow improved, which was analyzed as model fitness (0.90 vs 0.96; p < 0.001); conformance frequency (26.1% vs 77.6%; p < 0.001); and frequency of unique workflow traces (31.7% vs 19.1%; p = 0.005). One study showed that the incidence of pneumonia was higher in the group where a checklist was applied [adjusted odds ratio (aOR) 1.69, 95% Confidence Interval (CI 1.03-2.80)]. No difference was found for nine other assessed complications or missed injuries. Reduced mortality rates were found in the most severely injured patient group (Injury Severity score > 25, aOR 0.51, 95% CI 0.30-0.89).

CONCLUSIONS

The application of a checklist may improve ATLS adherence and workflow during trauma resuscitation. Current literature is insufficient to truly define the effect of the application of a checklist during trauma resuscitation on patient-related outcomes, although one study showed promising results as an improved chance of survival for the most severely injured patients was found.

Error traps and culture of safety in pediatric trauma

Trauma is the leading cause of morbidity and mortality in the pediatric population. Due to a variety of factors, many pediatric trauma patients are initially evaluated and stabilized at adult hospitals that lack pediatric specific emergency medicine and surgical expertise. While similar to adult patients, the initial evaluation and resuscitation of pediatric patients does differ. Many of these key differences contribute to missed injury and susceptibility to error in the treatment of children. Here, we highlight a variety of differences between pediatric and adult trauma patients and clarify reasoning for these differences. Error traps that are discussed include missed cases of non-accidental trauma, missed blunt cerebrovascular injury, over use of CT (computed tomography) scans with unnecessary radiation exposure, missed small bowel or mesenteric injury, and unrecognized hemodynamic instability.

Mapping the Flow of Pediatric Trauma Patients Using Process Mining

BACKGROUND

Inhospital pediatric trauma care typically spans multiple locations, which influences the use of resources, that could be improved by gaining a better understanding of the inhospital flow of patients and identifying opportunities for improvement.

OBJECTIVES

To describe a process mining approach for mapping the inhospital flow of pediatric trauma patients, to identify and characterize the major patient pathways and care transitions, and to identify opportunities for patient flow and triage improvement.

METHODS

From the trauma registry of a level I pediatric trauma center, data were extracted regarding the two highest trauma activation levels, Alpha (n = 228) and Bravo (n = 1,713). An event log was generated from the admission, discharge, and transfer data from which patient pathways and care transitions were identified and described. The Flexible Heuristics Miner algorithm was used to generate a process map for the cohort, and separate process maps for Alpha and Bravo encounters, which were assessed for conformance when fitness value was less than 0.950, with the identification and comparison of conforming and nonconforming encounters.

RESULTS

The process map for the cohort was similar to a validated process map derived through qualitative methods. The process map for Bravo encounters had a relatively low fitness of 0.887, and 96 (5.6%) encounters were identified as nonconforming with characteristics comparable to Alpha encounters. In total, 28 patient pathways and 20 care transitions were identified. The top five patient pathways were traversed by 92.1% of patients, whereas the top five care transitions accounted for 87.5% of all care transitions. A larger-than-expected number of discharges from the pediatric intensive care unit (PICU) were identified, with 84.2% involving discharge to home without the need for home care services.

CONCLUSION

Process mining was successfully applied to derive process maps from trauma registry data and to identify opportunities for trauma triage improvement and optimization of PICU use.

Common Pediatric Medical Emergencies in Office Practice

General Practitioners frequently see children with medical conditions that may evolve into an emergency if not promptly attended to. The most common emergencies encountered in pediatric office practice are respiratory distress, dehydration, anaphylaxis, seizures and trauma. Assessment of children is sometimes difficult as the signs and symptoms might be subtle and not markedly expressed. Also, normal value of vital signs vary with age, thus their interpretation requires discrete knowledge of age appropriate values. Initial approach to a sick child involves formation of initial impression, doing primary assessment, proper history taking and classifying the condition into following categories: Respiratory distress, Respiratory failure, Compensated shock, Decompensated shock and Primary brain dysfunction. Initial management of any pediatric emergency involves assessment of airway, breathing and circulation and providing relevant adequate support. Majority of cardiac arrests in pediatric practice are secondary to progressive respiratory failure and thus, if intervened timely and effectively, will prevent fatal outcome. In a child with shock, compensated state can rapidly evolve to decompensated state, thus necessitating its early recognition and rapid intervention. Anaphylaxis should be suspected in any child with sudden onset of skin or mucosal symptoms along with respiratory, circulatory or gastro-intestinal involvement and adrenaline should be given by intra-muscular route.

Pathophysiology and Treatment of Severe Traumatic Brain Injuries in Children

Traumatic brain injuries (TBIs) in children are a major cause of morbidity and mortality worldwide. Severe TBIs account for 15,000 admissions annually and a mortality rate of 24% in children in the United States. The purpose of this article is to explore pathophysiologic events, examine monitoring techniques, and explain current treatment modalities and nursing care related to caring for children with severe TBI. The primary injury of a TBI is because of direct trauma from an external force, a penetrating object, blast waves, or a jolt to the head. Secondary injury occurs because of alterations in cerebral blood flow, and the development of cerebral edema leads to necrotic and apoptotic cellular death after TBI. Monitoring focuses on intracranial pressure, cerebral oxygenation, cerebral edema, and cerebrovascular injuries. If abnormalities are identified, treatments are available to manage the negative effects caused to the cerebral tissue. The mainstay treatments are hyperosmolar therapy; temperature control; cerebrospinal fluid drainage; barbiturate therapy; decompressive craniectomy; analgesia, sedation, and neuromuscular blockade; and antiseizure prophylaxis.

Admission hematocrit predicts the need for transfusion secondary to hemorrhage in pediatric blunt trauma patients

BACKGROUND

Pediatric trauma uses a substantial amount of resources. Quick and cost-effective measures that can be used to identify children with clinically relevant injuries are essential to resource allocation and optimization of patient care. Admission hematocrit is rapid and inexpensive, causes minimal harm, and can potentially aid in critical decision making. We hypothesize that admission hematocrit predicts the need for transfusion in pediatric blunt trauma patients.

METHODS

Records of trauma patients age 0 year to 17 years (2005-2013) who presented to a pediatric Level 1 trauma center were retrospectively reviewed. Data collected include demographics, computed tomographic scan findings, need for an intervention secondary to bleeding (blood transfusion, angioembolization, or operation), and admission hematocrit.

RESULTS

We found a significant decrease in admission hematocrit between patients requiring a transfusion and patients who did not (27% vs. 36%, p < 0.01). We evaluated a subset of patients who had an abdominal computed tomographic scan and found a significant decrease in admission hemocrit between those who required a transfusion for an intra-abdominal injury and those who did not (29% vs 37%, p < 0.01). In this subset, serial hematocrit values remained significantly lower in the patients requiring a transfusion up to 67 hours after admission (p = 0.04). A cutoff admission hematocrit of 35% or less has a sensitivity of 94% and a negative predictive value of 99.9% in identifying children who need a transfusion after blunt trauma.

CONCLUSION

An admission hematocrit of 35% or less provides a reliable screening test because of its low false negative rate and high specificity for identifying patients at an increased risk of bleeding after injury. Admission hematocrit could be widely implemented to identify patients who may need a transfusion with low expense and minimal harm for our pediatric patients and may be able to alter the entire course of their trauma resuscitation.

LEVEL OF EVIDENCE

Epidemiologic/prognostic study, level III.

Heart rate in pediatric trauma: rethink your strategy

BACKGROUND

The optimal heart rate (HR) for children after trauma is based on values derived at rest for a given age. As the stages of shock are based in part on HR, a better understanding of how HR varies after trauma is necessary. Admission HRs of pediatric trauma patients were analyzed to determine which ranges were associated with lowest mortality.

MATERIALS AND METHODS

The National Trauma Data Bank was used to evaluate all injured patients ages 1-14 years admitted between 2007 and 2011. Patients were stratified into eight groups based on age. Clinical characteristics and outcomes were recorded, and regression analysis was used to determine mortality odds ratios (ORs) for HR ranges within each age group.

RESULTS

A total of 214,254 pediatric trauma patients met inclusion criteria. The average admission HR and systolic blood pressure were 104.7 and 120.4, respectively. Overall mortality was 0.8%. The HR range associated with lowest mortality varied across age groups and, in children ages 7-14, was narrower than accepted resting HR ranges. The lowest risk of mortality for patients ages 5-14 was captured at HR 80-99.

CONCLUSIONS

The HR associated with lowest mortality after pediatric trauma frequently differs from resting HR. Our data suggest that a 7y old with an HR of 115 bpm may be in stage III shock, whereas traditional HR ranges suggest that this is a normal rate for this child. Knowing when HR is critically high or low in the pediatric trauma population will better guide treatment.