Injured Children Research Articles

New Standards for Critically Ill Children: towards a unified approach

The new Standards for Critically Ill Children (2010) have just been published. What do these add? First and foremost, these Standards explicitly recognize that the treatment of a critically ill child wherever it first presents requires teamwork, not only between different disciplines within a hospital, but also across different hospitals and specialities across the whole Region. This can only be achieved by recognizing the crucial role that district general hospital (DGH) staff play in the early management of these children. With this in mind, it is envisaged that these Standards will effectively build upon the Department of Health’s guidance: ‘The acutely or critically sick or injured child in the district general hospital: A team response’— Dept of Health (England), 2006—known widely as the ‘Tanner Report’ after the Chair of the Working Party, Prof. Stuart Tanner. Since the last Standards Document regarding Critically Ill Children in 2001, the Working Party has been extended to ensure that as far as possible, the new Standards reflect the views and aspirations of clinicians from all disciplines along this patient journey, both medical and nursing, and those of parent representatives and commissioners as well. Additionally, it has also drawn heavily on the work of the West Midlands Group who for some years have set Standards for Critically Ill Children across that Region but concentrating mainly on DGH clinical areas. Both processes were therefore aligned to synchronize their recommendations. The Working Party membership comprised representatives from the Association of Paediatric Anaesthetists of Great Britain and Ireland, the Royal College of Anaesthetists, the British Association of Critical Care Nurses, the College of Emergency Medicine, the Intensive Care Society, the Royal College of Nursing, the Royal College of Paediatrics and Child Health, the Royal College of Surgeons, lay representation including Action for Sick Children, Commissioners, the Department of Health, and representatives from the Paediatric Intensive Care Society. In the final stages of its production, a joint Foreword was signed by the Presidents of the Royal College of Anaesthetists, the Royal College of Paediatrics and Child Health, the College of Emergency Medicine, the Intensive Care Society, and the Chief Executive of the Royal College of Nursing. It is hoped that these new Standards will achieve a set of realistic and achievable standards across all the areas where critically ill children present and consider the care needed in a journey starting in the Emergency Department or Children’s ward areas, through to HDU, the General ICU, and then retrieval or other transfer to a Paediatric Intensive Care Unit (PICU). All regions should have a clear Network led by a Tertiary Centre Paediatric Intensive Care Unit or, possibly, by the larger amalgamated Retrieval Services that are being increasingly commissioned. These Networks should bring together emergency department clinicians, paediatric ward nurses, paediatricians, anaesthetists, intensivists, surgeons, retrieval teams, ICU and PICU nurses, physiotherapists, and pharmacists. This network would benefit from including hospital and commissioning management. To understand the place of the Standards in today’s practice, it would be useful to review recent history.

Evaluación de la actuación de los pediatras de atención primaria en un escenario simulado de trauma pediátrico

IntroductionTraining by means of advanced simulation can improve the paediatrician's abilities in the management of paediatric trauma patients, as well as decreasing errors and increasing patient safety. The initial management is an essential factor in the outcome of an injured child. Material and methodsA trauma patient scenario was included in a national simulation training program. The performances of 156 paediatric primary care providers, divided into 39 teams, who participated in the courses carried out from May 2008 until February 2010 were retrospectively analysed. The evaluation of the scenario was based both on the primary survey suggested by the Working Group on Trauma of the SECIP, and in the 8 main targets of a simulation evaluation tool from the Cincinnati Children's Hospital trauma care program. ResultsA pulse oximeter was placed, the intravenous/intraosseous access was indicated, the blood pressure was checked, and the oxygen was applied In 100% of the scenarios. An intravenous fluid bolus was indicated in 87% of the scenarios. The Glasgow scale was performed in 5.1%, and the appropriate warming measures in 25.6%. The bilateral cervical immobilisation was incorrect in 35% of the scenarios (89.7%). The primary survey (ABCDE) was checked correctly in only one scenario. With a top score of 16, based on Cincinnati Hospital, the teams mean score was 5.3 ±1.8. ConclusionsPrimary care paediatricians have problems applying the primary ABCDE trauma care sequence and the cervical spine precautions in a trauma simulation scenario. Educational programs for paediatricians must improve the practical check points of the initial approach to trauma management.

Children and Terror Casualties Receive Preference in ICU Admissions

Trauma casualties caused by terror-related events and children injured as a result of trauma may be given preference in hospital emergency departments (EDs) due to their perceived importance. We investigated whether there are differences in the treatment and hospitalization of terror-related casualties compared to other types of injury events and between children and adults injured in terror-related events. Retrospective study of 121 608 trauma patients from the Israel Trauma Registry during the period of October 2000-December 2005. Of the 10 hospitals included in the registry, 6 were level I trauma centers and 4 were regional trauma centers. Patients who were hospitalized or died in the ED or were transferred between hospitals were included in the registry. All analyses were controlled for Injury Severity Score (ISS). All patients with ISS 1-24 terror casualties had the highest frequency of intensive care unit (ICU) admissions when compared with patients after road traffic accidents (RTA) and other trauma. Among patients with terror-related casualties, children were admitted to ICU disproportionally to the severity of their injury. Logistic regression adjusted for injury severity and trauma type showed that both terror casualties and children have a higher probability of being admitted to the ICU. Injured children are admitted to ICU more often than other age groups. Also, terror-related casualties are more frequently admitted to the ICU compared to those from other types of injury events. These differences were not directly related to a higher proportion of severe injuries among the preferred groups.

The forgotten trauma patient

Injured patients who are not transported by an ambulance to the hospital are often not included in trauma registries. The outcomes of these patients have until now been unknown. Understanding what happens to nontransports is necessary to better understand triage validity, patient outcomes, and costs associated with injury. We hypothesized that a subset of patients who were not transported from the scene would later present for evaluation and that these patients would have a nonzero mortality rate. This is a population-based, retrospective cohort study of injured adults and children for three counties in California from 2006 to 2008. Prehospital data for injured patients for whom an ambulance was dispatched were probabilistically linked to trauma registry data from four trauma centers, state-level discharge data, emergency department records, and death files (1-year mortality). A total of 69,413 injured persons who were evaluated at the scene by emergency medical services were included in the analysis. Of them, 5,865 (8.5%) were not transported. Of those not transported, 1,616 (28%) were later seen in an emergency department and discharged and 92 (2%) were admitted. Seven (0.2%) patients later died. Patients evaluated by emergency medical services, but not initially transported from the field after injury, often present later to the hospital. The mortality rate in this population was not zero, and these patients may represent preventable deaths. III, therapeutic study.

Preventing unintentional injuries: what does NICE guidance mean for primary care?

Unintentional injuries are the second most common cause of child death, accounting for one in seven deaths between the ages of 1 and 14 years.1 These deaths represent just the tip of the iceberg. Every year, around 100 000 children are admitted to hospital2 and 2 million attend emergency departments.3 How many seek treatment only from their GP is not known. The impact of injuries on children, their families, and society can be considerable. The immediate effect of an injury is pain, followed by the psychological trauma of having to visit hospital, and loss of enjoyment of everyday activities such as play. But children can also be left disabled and disfigured, and lose education, potentially affecting the rest of their lives. Caring for an injured child can cause family breakdown and loss of employment, as well as having immediate economic consequences. Society has to bear the costs of treatment, rehabilitation, and long-term support. Unintentional injuries are often thought of as accidents, but they are not random, unpredictable events as the term accident implies. We can identify children at risk of injuries and the injuries they are likely to suffer. Those from disadvantaged families are at greatest risk.4 Not surprisingly, the types of injuries experienced are strongly related to a child's stage of development. For example, the more active children become, the more likely they are to run and trip, and climb and fall; the exploratory stage of child development results in children putting objects in their mouth leading to choking and poisoning. Copying adult tasks, such as food preparation, can lead to lacerations and burns. GPs and primary health care teams (PHCTs) have multiple opportunities to contribute to injury prevention and these are highlighted in three …

Initial assessment and management of pediatric trauma patients

Injury is the leading cause of death and disability in children. Each year, almost one in six children in the United States require emergency department (ED) care for the treatment of injuries, and more than 10,000 children die from injuries. Severely injured children need to be transported to a facility that is staffed 24/7 by personnel experienced in the management of children, and that has all the appropriate equipment to diagnose and manage injuries in children. Anatomical, physiological, and emotional differences between adults and children mean that children are not just scaled-down adults. Facilities receiving injured children need to be child and family friendly, in order to minimize the psychological impact of injury on the child and their family/carers. Early recognition and treatment of life-threatening airway obstruction, inadequate breathing, and intra-abdominal and intra-cranial hemorrhage significantly increases survival rate after major trauma. The initial assessment and management of the injured child follows the same ATLS® sequence as adults: primary survey and resuscitation, followed by secondary survey. A well-organized trauma team has a leader who designates roles to team members and facilitates clear, unambiguous communication between team members. The team leader stands where he/she can observe the entire team and monitor the “bigger picture.” Working together as a cohesive team, the members perform the primary survey in just a few minutes. Life-threatening conditions are dealt with as soon as they are identified. Necessary imaging studies are obtained early. Constant reassessment ensures that any deterioration in the child's condition is picked up immediately. The secondary survey identifies other injuries, such as intra-abdominal injuries and long-bone fractures, which can result in significant hemorrhage. The relief of pain is an important part of the treatment of an injured child.

Pro patria et spes gentis: military medicine, paediatric surgery and those who care for children

Children and military medicine have many links. On humanitarian and disaster deployments, the surgery of war has increasingly seen children as the focus of clinical salvage. When Romans spoke of children, they used the phrase 'spes gentis'-'the hope of the race'. In modern times, there developed a synergy, in the context of defensive war, that its prosecution depended not only on the defence of territory but also on its hopes for continuation of people and culture, into the future. In the 19th century, in Australia, several regiments had the motto 'Pro Aris et Focis'-'For the Defence of Hearth and Home'. Hearth implies the family and that implies children. From the point of view of an attending military clinician, the centrum of all medical care is the patient himself, and that centrality is reflected equally in the helplessness of a bomb-blast or gunshot victim as it is in the vulnerability of a sick or injured infant or child. The life and service of Major General Rupert Downes (1885-1945), whom the Downes Memorial Lecture commemorates, reflected this nexus. His career was that of a national leader in military medicine and that of paediatric surgery. The 2011 Rupert Downes Lecture explores and documents the extraordinary corpus of service of Australian paediatric surgeons and their contributions to military medicine from the 19th to the 21st centuries.

Head injury secondary to suspected child maltreatment: Results of a prospective Canadian national surveillance program

Objective We sought to determine the incidence, clinical features, and demographic profile of head injury secondary to suspected child maltreatment (abuse or neglect) in Canada to help inform the development and evaluation of prevention programs for abusive head injuries. Methods From March 1, 2005 to February 28, 2008, an average of 2,545 paediatricians and paediatric subspecialists were surveyed monthly through the established network of the Canadian Paediatric Surveillance Program. We calculated incidence rates using the number of confirmed cases over the product of the duration of the study (3 years) and population estimates by age group. Results There were 220 confirmed cases of head injury from suspected child maltreatment. The annual incidence rate was 14.1 per 100,000 for children less than 1 year of age and 1.4 per 100,000 for those less than 15 years. Seventy three percent (141) of cases involved infants less than 12 months of age and 52% (100) of cases involved infants less than 6 months of age. Seventy-five percent (165) of cases presented to the emergency room. With regard to outcome, 12% (27) of cases resulted in death and 45% (75) of survivors had neurological sequelae at discharge. Thirty percent (67) of all cases, as well as 30% (8) of deaths were previously known to child welfare authorities. Conclusion This study provides an estimate of the rate of head injury secondary to suspected child maltreatment in Canada. The young age and poor medical outcomes of those involved highlights the need for prevention efforts that are implemented early in life. Given that a significant percentage of injured infants and children were already known to child welfare authorities, the study also highlights the need to establish and evaluate additional preventive efforts for parents and caregivers already in the child welfare system.

Short- and long-term work-related consequences associated with childhood injuries on agricultural operations: Regional Rural Injury Study III

ObjectivesTo evaluate the short- and long-term physical, psychosocial, and economic consequences of injuries to youth on agricultural operations.MethodsBaseline and follow-up telephone interviews were completed with 1474 eligible agricultural operation households...

(A83) Pediatric Disasters: Key Elements for Improving Care

80% of children are seen in non-Pediatric Emergency Departments (EDs). In a disaster, most children and their caregivers will go to the closest or their regularly identified ED for treatment. In disasters, the preservation of the Pediatric Tertiary Infrastructure for the sickest and most injured children is critical. Surge capacity for pediatrics may involve both ante-grade and retrograde distribution of pediatric patients and health care staff to preserve Tertiary capacity. Reverse Triage of stable pediatric patients to other hospitals with adapted units and staff can decompress tertiary facilities. General hospitals can allow an expanded care for pediatric patients. Surge capacity needs to be addressed to allow non-pediatric facilities to surge for pediatric patients. Disaster Credentialing by immediate cross-credentialing of appropriate health care staff needs to be reciprocal and internet based to allow appropriate staff to attend pediatric patients. Pediatric consultants can augment healthcare staff to allow input into expanded care roles. Pre-hospital providers should have more pediatric training. Rotated regional caches of pediatric equipment would expedite safe pediatric disaster site care and pre-hospital transportation to definitive care. Pediatric patients should routinely be included in disaster drills and in all-inclusive disaster plans, rather than in separate drills and plans. Pediatric patients are usually accompanied by caregivers who may need care as well. Secure tracking and reunification of unaccompanied minors needs to be addressed to allow tracking across jurisdictional boundaries. Limited access to data on children, and credentialing of shelter staff would preclude access by anyone without a specific need to know. There are no clear uniform liability statutes for care in declared disasters as well as no uniform agreements for reimbursement for medical care. These issues are an important facet of disaster care that still needs to be addressed.

In the absence of a central venous catheter, risk of venous thromboembolism is low in critically injured children, adolescents, and young adults: Evidence from the National Trauma Data Bank*

To describe the incidence and risk factors of venous thromboembolism in a large sample of critical care pediatric, adolescent, and young adult trauma patients. The National Trauma Data Bank-the largest and most complete aggregation of trauma registry data in the United States. Seven hundred eighty-four level I to level IV trauma centers. Patients ≤ 21 yrs of age who spent at least 1 day in a critical care unit during a trauma admission between 2001 and 2005. To characterize differences between patients with and without venous thromboembolism, we extracted variables regarding patient demographics, injury pattern and severity, procedures, total length of stay, and intensive care unit and ventilator days. Odds ratios for predictors of venous thromboembolism were estimated with a logistic regression model. Among the 135,032 critical care patients analyzed, venous thromboembolism was uncommon (6 per 1,000 discharges). Placement of a central venous catheter was a significant predictor of venous thromboembolism (odds ratio = 2.24; p < .0001) when populations were analyzed collectively. When we narrowed our focus to injuries associated with venous thromboembolism, such as lower-extremity fractures, the effects of central venous catheter were of even greater magnitude, particularly in adolescents and young adults. The risk of venous thromboembolism in critical care patients without a central venous catheter was <1% even in adolescents/young adults. Venous thromboembolism is rare in young critical care trauma patients, even older adolescents. The absence of published data on both the baseline risk of venous thromboembolism in pediatric critical care patients and the efficacy and safety of venous thromboembolism prophylaxis preclude the ability to make definitive recommendations for the use of venous thromboembolism prophylaxis in this setting. Our results, however, suggest that venous thromboembolism prophylaxis may need to be considered only in critically injured adolescents and young adults with a continuing need for central venous access.

Impact of Fractures on School Attendance

The purpose of this study was to determine the average prevalence of children across the nation who experience difficulty in attending school after an acute orthopaedic injury. A survey was created to obtain information on school absence for children with acute orthopaedic injuries. All members of the Pediatric Orthopaedic Society of North America were invited to complete the survey. The survey was sent by e-mail to 936 members of the Pediatric Orthopaedic Society of North America. A total of 283 surgeons from 45 states responded to the survey, which resulted in a response rate of 30.2%. The survey found a correlation with difficulty in attending school with a cast and the size of the population served. Communities with the larger populations are less likely to permit children to attend school with a cast. The most common reasons given by schools for a child not being permitted to attend school with a cast were concern for the safety of the child and inability to accommodate the needs of the child. Most physicians participating in the survey reported no difficulty with their patients attending school with a cast. There was more difficulty with children in attending school with a cast in metropolitan areas and in communities with greater than 1 million people. To decrease or to eliminate absence from school, it may be best to identify schools in a physician's community that do not allow attendance of children with a cast. Once individual schools are identified, advocacy can be targeted. At the very least, when it is known which schools are involved, the surgeon can anticipate difficulties and plan accordingly. As a child's absence from school has substantial negative consequences, we strongly support intervention to enable injured children to appropriately return to a regular educational setting in a timely manner. Future studies with school participation would help to identify reasons for school absence after a musculoskeletal injury. Level V, Prognostic.

Blood Transfusion In Injured Children Is Associated With Early Death And Late Morbidity

Blood Transfusion In Injured Children Is Associated With Early Death And Late Morbidity

More Than Bike Helmets and Car Seats

More Than Bike Helmets and Car Seats

Traumatic dental injuries among schoolchildren in Valencia, Spain

The aim of the present study was to identify some factors related to the occurrence of dental trauma in mixed and permanent dentition. Over a period of two months 1325, 6 to 18 year olds from three primary schools in Valencia were examined. Data was collected through clinical examinations and interviews and their Dental trauma was classified according to IADT's criteria. The prevalence of dental injuries was 6%; boys aged between 12-18 years old experienced more injuries than girls. There was a statistical difference between the types of fractures. Non complicated coronal fractures were the most frequent (9.18%). Games were the main cause of trauma (40%) in both sexes. In 14.3% of patients a dental colour change was observed. Angle's class I was the most frequent in traumatized injured children (41.2%). The present study revealed a relatively low prevalence of dental trauma, but this figure still represents a large number of children. Therefore, educational programs are to be initiated for the community regarding causes , prevention and treatments of traumatic dental injuries.

Injuries in children and adolescents seen during 2006 at the emergency department of the National District Hospital, Bloemfontein

Background: Most children and adolescents recover fully from injuries. However, permanent disabilities may occur. The objective of the study was to investigate the prevalence and profile of injuries in children and adolescents five to 19 years of age seen at the emergency department of the National District Hospital in Bloemfontein. Methods: A retrospective descriptive study was conducted. Demographic and injury-specific information obtained from hospital records of 2006 was entered into a data-capturing form. Data were analysed by using descriptive statistics. Results: The prevalence of injuries in this age group was 20.3%. Two hundred and nine records were investigated. The majority of cases were male (68.3%). The median age was 15 years, and 43.5% of injuries occurred in the age group 15 to 19 years. Approximately half (51.7%) were Afrikaans-speaking and resided in suburban areas (50%). Most injuries occurred at home (40.2%) between 12h00 and 17h00 (38.7%). Falls (33.7%) were the most common cause of injury. Soft tissue injuries (35.9%) occurred most commonly, fol lowed by lacerations (33.0%) and fractures (16.7%). Upper limb injuries (42.1%) were seen more than lower limb injuries (27.8%). Facial injuries occurred in 12% of cases. X-rays were performed in 57.9% of cases. Most patients (93.3%) received medication, while 22% were referred for specialist treatment. All cases except one were discharged from the emergency department. Parents accompanied patients in 65.6% of cases. Conclusions: Optimal treatment should be given to the injured child or adolescent to avoid possible long-term injuryrelated sequelae. Preventive strategies should be formulated, enforced and evaluated. Keywords: injuries; children; adolescents; prevalence; prevention

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Commentary

Commentary

Cyclists' injury epidemiology based on a road trauma registry

IntroductionCycling is increasing in some cities. Bicycle injuries are often overlooked, partly because police crash data largely under-report them.MethodA road trauma registry in a French area (Rhne county, population=1.6 Million)...

Quality of child abuse information for measurement and surveillance: linking hospital and child welfare data

National estimates of the prevalence of child abuse-related injuries are obtained from a variety of sectors including welfare, justice and health resulting in inconsistent estimates across sectors. The International Classification...