Paediatric Major Trauma Centre Research Articles

188. Review of a regional paediatric trauma service

Sheffield Children’s NHS Foundation Trust (SCH) is a paediatric major trauma centre, covered by a regional on-call oral and maxillofacial surgery (OMFS) team. Referrals are taken from across South Yorkshire and North Derbyshire. We carried out a retrospective review of all emergency referrals to OMFS to establish indications for referral and review management.

Interventional radiology and open surgery: An effective partnership for solid organ trauma

BackgroundManagement algorithms of paediatric blunt abdominal solid organ injury (BASOI) are evolving to include interventional radiology, but there are few studies documenting the application and clinical outcomes of cases in children. MethodsA retrospective case note review of all paediatric BASOI at a single Paediatric Major Trauma Centre was completed. CT scans and injuries have been retrospectively graded according to AAST guidelines. ResultsIn the period February 2012 - October 2019, there were 106 children (median age 10.6 years (range 10 days – 16 years)) with BASOI. Of these, 71% (n = 75) suffered liver injuries, 29% (n = 31) spleen, and 27% (n = 29) renal. 95 children (89.6%) were treated with non-operative management, of which 15% (n = 14) went on to require secondary operative management (surgery, n = 1 & interventional radiology, n = 14). There were no deaths or loss of organ in the group which required secondary operative management, regardless of the grade of injury. ConclusionThe majority of BASOI can be successfully treated conservatively, but IR is a useful additional tool in management for all grades of injury and is complementary to open surgery. Level of EvidenceLevel IV Case Series

Adaptations to practice and resilience in a paediatric major trauma centre during a mass casualty incident

BackgroundInnovation and human adaptation in the face of unfolding catastrophe is the cornerstone of an effective systemwide response. Capturing, analysing, and disseminating this is fundamental in developing resilience for future events. The aim of this study was to understand the characteristics of adaptations to practice early in a paediatric major trauma centre during a mass casualty incident. MethodsA qualitative interview study of 40 healthcare staff at a paediatric major trauma centre in the immediate aftermath of a terrorist bombing was conducted. An inductive thematic analysis approach was used, followed by a deductive analysis of the identified adaptations informed by constructs of resilience engineering. ResultsFive themes of adaptations to practice that enhanced the resilient performance of the hospital were identified: teamworking; psychologically supporting patients, families, and staff; reconfiguring infrastructure; working around the hospital electronic systems; and maintaining hospital safety. Examples of resilience potential in terms of respond, monitor, anticipate, and learn are presented. ConclusionsOur study shows how adaptations to practice sustained the resilient performance of a paediatric major trauma centre during a mass casualty incident. Rapid, early capture of these data during a mass casualty incident provides key insights into enhancing future emergency preparedness, response, and resilience planning.

Orthoplastic management of open tibial fractures in children : a consecutive five-year series from a paediatric major trauma centre.

Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date. Data were extracted from medical records and databases for patients with an open tibial fracture aged < 16 years who presented between 1 May 2014 and 30 April 2019. Patients who were transferred from elsewhere were excluded, yielding 44 open fractures in 43 patients, with a minimum follow-up of one year. Management was reviewed from the time of injury to discharge. Primary outcome measures were the rate of deep infection, time to union, and the Modified Enneking score. The mean age of the patients was 9.9 years (2.8 to 15.8), and 28 were male (64%). A total of 30 fractures (68%) involved a motor vehicle collision, and 34 (77%) were classified as Gustilo Anderson (GA) grade 3B. There were 17 (50%) GA grade 3B fractures, which were treated with a definitive hexapod fixator, and 33 fractures (75%) were treated with a free flap, of which 30 (91%) were scapular/parascapular or anterolateral thigh (ALT) flaps. All fractures united at a median of 12.3 weeks (interquartile range (IQR) 9.6 to 18.1), with increasing age being significantly associated with a longer time to union (p = 0.005). There were no deep infections, one superficial wound infection, and the use of 20 fixators (20%) was associated with a pin site infection. The median Enneking score was 90% (IQR 87.5% to 95%). Three patients had a bony complication requiring further surgery. There were no flap failures, and eight patients underwent further plastic surgery. The timely and comprehensive orthoplastic care of open tibial fractures in this series of patiemts aged < 16 years resulted in 100% union and 0% deep infection, with excellent patient-reported functional outcomes. Cite this article: Bone Joint J2021;103-B(6):1160-1167.

Changes in emergency department blood product use for major paediatric trauma following the implementation of a major haemorrhage protocol.

Fixed ratio blood product administration may improve outcomes in trauma patients with massive blood loss. The present study aimed to describe the impact of a major haemorrhage protocol (MHP) on the ratio of blood products administered for paediatric major trauma. Retrospective observational study in a state-designated paediatric major trauma centre in Melbourne, Australia. Children with major trauma who received blood products in the ED were identified from a hospital trauma registry. Blood product ratios before, during and after implementation of a hospital MHP were compared in consecutive 2 year blocks. Over a 6 year period, 767 major trauma patients were identified, of whom 47 received blood products in the ED and were included in the analysis; 14 pre-MHP implementation, 24 during-MHP implementation and nine post-MHP implementation. No patients received blood products at a ratio of 1:1:1 for red blood cells:fresh frozen plasma:platelets, respectively, during any time period. In this cohort of predominantly blunt trauma, blood products were infrequently administered in the ED because of the low prevalence of massive blood loss. Coagulopathy and hypofibrinogenaemia were commonly observed, nearly half of included patients were managed operatively and one quarter did not survive their injuries. The implementation of a MHP did not change the ratio of blood product administration in this cohort of patients because of the infrequency of massive blood loss. Future studies may focus on the impact of treating coagulopathy and hypofibrinogenaemia on patient-centred outcomes.

Major trauma centre Lead Clinicians: An evaluation of current practice in major trauma centres in England

Background NHS England requires there to be a clinical consultant with managerial responsibility for the Major Trauma Centre (MTC) service, who holds the title of MTC Lead Clinician. The objective of this study was to investigate the role of MTC Lead Clinician in England. Firstly, identifying the parent speciality of the current cohort and their background and training. Further aims were to ascertain what attracted clinicians to the position and to explore ideas about how to train the next generation of MTC Lead Clinicians. Methods Survey-based data collection was performed. Included were current MTC Lead Clinicians, or those with equivalent job descriptions, for adult major trauma. Paediatric MTCs and Trauma Units were excluded. Fixed choice questions were analysed using descriptive statistics. Open-ended questions were interpreted using thematic analysis. Results The response rate for the survey was 81.81%. The largest proportion of respondents were Emergency Medicine Physicians (38.9%). Previous senior leadership roles were identified as valuable previous experience. Regular attendance at conferences was deemed to be of more importance than specific training courses. Leadership, management, and financial skills were identified as key areas for further training. There was variance in both the job role and the time allocated for these duties between centres. Conclusion Currently there is variation in the parent specialty, role responsibilities and preparation for MTC Lead Clinicians in England. Our findings suggest that guidance on appropriate training, clarity in responsibilities and fostering leadership and managerial skills are important as the role develops for the future.

Pattern of injuries and management of adolescent trauma in a combined adult and paediatric major trauma centre in United Kingdom

Background Major trauma is a leading cause of death and disability in 16–18-year olds in the UK. Since the launch of major trauma centres (MTCs) in 2012 in UK, survival rates have improved on the whole. The aim of this study was to look at the pathways of 16–18-year olds through one MTC and patterns of rehabilitation provision. Material and methods A retrospective case notes review of all trauma patients aged between 16 and 18 years admitted to one MTC between October 2012 and May 2018. Results One hundred forty-seven young people were identified. 67.3% were male with a mean age of 17.1 years. Motor vehicle accidents were the most common cause of injury (59.2%). Thirty-nine percent had a Glasgow Coma Scale at scene &gt;13. Sixty-three percent were admitted to an adult intensive care unit (ICU), 5.4% to paediatric ICU and 31.3% directly to a ward. Admissions to rehabilitation ward came through adult services with no commissioned equivalent in those admitted to paediatrics. Mean length of stay was 18.1 days. 75.5% of patients were discharged home from the MTC. Discussion The majority of young people were admitted on to adult wards and were able to access commissioned services. However, such services do not provide for the specialist needs of young people, with no access to schooling or parent’s accommodation. Those who were admitted to children’s services missed out on commissioned rehabilitation pathways. Conclusion Young people of transition age often fall between services. For the first time, we illustrate injury patterns and the fragmented services seen in this vulnerable patient group.

The effects of a UK lockdown on orthopaedic trauma admissions and surgical cases

Aims The current global pandemic due to COVID-19 is generating significant burden on the health service in the UK. On 23 March 2020, the UK government issued requirements for a national lockdown. The aim of this multicentre study is to gain a greater understanding of the impact lockdown has had on the rates, mechanisms and types of injuries together with their management across a regional trauma service. Methods Data was collected from an adult major trauma centre, paediatric major trauma centre, district general hospital, and a regional hand trauma unit. Data collection included patient demographics, injury mechanism, injury type and treatment required. Time periods studied corresponded with the two weeks leading up to lockdown in the UK, two weeks during lockdown, and the same two-week period in 2019. Results There was a 55.7% (12,935 vs 5,733) reduction in total accident and emergency (A&amp;E) attendances with a 53.7% (354 vs 164) reduction in trauma admissions during lockdown compared to 2019. The number of patients with fragility fractures requiring admission remained constant (32 patients in 2019 vs 31 patients during lockdown; p &gt; 0.05). Road traffic collisions (57.1%, n = 8) were the commonest cause of major trauma admissions during lockdown. There was a significant increase in DIY related-hand injuries (26% (n = 13)) lockdown vs 8% (n = 11 in 2019, p = 0.006) during lockdown, which resulted in an increase in nerve injuries (12% (n = 6 in lockdown) vs 2.5% (n = 3 in 2019, p = 0.015) and hand infections (24% (n = 12) in lockdown vs 6.2% (n = 8) in 2019, p = 0.002). Conclusion The national lockdown has dramatically reduced orthopaedic trauma admissions. The incidence of fragility fractures requiring surgery has not changed. Appropriate provision in theatres should remain in place to ensure these patients can be managed as a surgical priority. DIY-related hand injuries have increased which has led to an increased in nerve injuries requiring intervention.

The effects of a UK lockdown on orthopaedic trauma admissions and surgical cases: A multicentre comparative study.

AimsThe current global pandemic due to COVID-19 is generating significant burden on the health service in the UK. On 23 March 2020, the UK government issued requirements for a national lockdown. The aim of this multicentre study is to gain a greater understanding of the impact lockdown has had on the rates, mechanisms and types of injuries together with their management across a regional trauma service.MethodsData was collected from an adult major trauma centre, paediatric major trauma centre, district general hospital, and a regional hand trauma unit. Data collection included patient demographics, injury mechanism, injury type and treatment required. Time periods studied corresponded with the two weeks leading up to lockdown in the UK, two weeks during lockdown, and the same two-week period in 2019.ResultsThere was a 55.7% (12,935 vs 5,733) reduction in total accident and emergency (A&E) attendances with a 53.7% (354 vs 164) reduction in trauma admissions during lockdown compared to 2019. The number of patients with fragility fractures requiring admission remained constant (32 patients in 2019 vs 31 patients during lockdown; p > 0.05). Road traffic collisions (57.1%, n = 8) were the commonest cause of major trauma admissions during lockdown. There was a significant increase in DIY related-hand injuries (26% (n = 13)) lockdown vs 8% (n = 11 in 2019, p = 0.006) during lockdown, which resulted in an increase in nerve injuries (12% (n = 6 in lockdown) vs 2.5% (n = 3 in 2019, p = 0.015) and hand infections (24% (n = 12) in lockdown vs 6.2% (n = 8) in 2019, p = 0.002).ConclusionThe national lockdown has dramatically reduced orthopaedic trauma admissions. The incidence of fragility fractures requiring surgery has not changed. Appropriate provision in theatres should remain in place to ensure these patients can be managed as a surgical priority. DIY-related hand injuries have increased which has led to an increased in nerve injuries requiring intervention.

Epidemiology and aetiology of paediatric traumatic cardiac arrest in England and Wales

ObjectiveTo describe the epidemiology and aetiology of paediatric traumatic cardiac arrest (TCA) in England and Wales.DesignPopulation-based analysis of the UK Trauma Audit and Research Network (TARN) database.Patients and settingAll paediatric...

Paediatric traumatic cardiac arrest: a Delphi study to establish consensus on definition and management

AimsPaediatric traumatic cardiac arrest (TCA) is associated with low survival and poor outcomes. The mechanisms that underlie TCA are different from medical cardiac arrest; the approach to treatment of TCA...

Heterogeneity in cervical spine assessment in paediatric trauma: A survey of physicians' knowledge and application at a paediatric major trauma centre.

Evidence-based decision-making tools are widely used to guide cervical spine assessment in adult trauma patients. Similar tools validated for use in injured children are lacking. A paediatric-specific approach is appropriate given important differences in cervical spine anatomy, mechanism of spinal injury and concerns over ionising radiation in children. The present study aims to survey physicians' knowledge and application of cervical spine assessment in injured children. A cross-sectional survey of physicians actively engaged in trauma care within a paediatric trauma centre was undertaken. Participation was voluntary and responses de-idenitified. The survey comprised 20 questions regarding initial assessment, imaging, immobilisation and perioperative management. Physicians' responses were compared with available current evidence. Sixty-seven physicians (28% registrars, 17% fellows and 55.2% consultants) participated. Physicians rated altered mental state, intoxication and distracting injury as the most important contraindications to cervical spine clearance in children. Fifty-four per cent considered adequate plain imaging to be 3-view cervical spine radiographs (anterior-posterior, lateral and odontoid), whereas 30% considered CT the most sensitive modality for detecting unstable cervical spine injuries. Physicians' responses reflected marked heterogeneity regarding semi-rigid cervical collars and what constitutes cervical spine 'clearance'. Greater consensus existed for perioperative precautions in this setting. Physicians actively engaged in paediatric trauma care demonstrate marked heterogeneity in their knowledge and application of cervical spine assessment. This is compounded by a lack of paediatric-specific evidence and definitions, involvement of multiple specialties and staff turnover within busy departments. A validated decision-making tool for cervical spine assessment will represent an important advance in paediatric trauma.

PP06.3 – 3029: Tertiary paediatric major trauma centre cohort experience of neurocognitive symptoms post head injury

Objective The objective of this study was to identify the incidence of neurocognitive symptoms experienced post-TBI in children returning to school and to inform future improvements in the major trauma care pathway. Methods In April 2012 our hospital was designated as a major trauma centre receiving patients from across the region with major trauma including head injury. Since this time 169 paediatric trauma patients have been admitted, including 66 traumatic brain injuries (TBI). All paediatric TBI patients are offered a review at 6–8 weeks post discharge in the neurology nurse outpatient clinic. Results Data were collected on 58 patients (39 male) who were admitted during April 2012-June 2014 as major trauma with mild (n=27), moderate (n=19) and severe (n=11) TBI. Patients were aged 15 months–7 years (median age 9.5 years). Patients had a total length of stay of 1–224 days (median 5 days). 34 patients were admitted to PICU and 23 received neurosurgery. Patients Conclusion Neurocognitive symptoms are commonly present in early follow-up. Further assessment and longitudinal follow up is required to establish duration and severity of these cognitive symptoms. Neurocognitive testing at 6 months post TBI would also further define the nature of these difficulties and direct cognitive rehabilitation and school support.