Pediatric Trauma Center Research Articles

Does the American College of Surgeons New Level I Children's Surgery Center Verification Affect Treatment Efficiency and Narcotic Administration in Treating Pediatric Trauma Patients with Femur Fracture?

In 2015, the American College of Surgeons (ACS) created a new hospital improvement program to enhance the performance of pediatric care in US hospitals. The Children's Surgery Verification (CSV) Quality Improvement Program is predicated on the idea that pediatric surgical patients have improved outcomes when treated at children's hospitals with optimal resources. Achieving ACS level I CSV designation at pediatric trauma centers may lead to greater benefits for pediatric trauma patients; however, the specific benefits have yet to be identified. We hypothesize that achieving the additional designation of ACS level I CSV is associated with decreased narcotic use perioperatively and improved efficiency when managing pediatric patients with femur fractures. This study is a retrospective analysis of traumatic pediatric orthopaedic femur fractures treated at a verified level I pediatric trauma center before and after CSV designation (2010 to 2014 vs 2015 to 2019). Efficiency parameters, defined as time from admission to surgery, duration of surgery, and duration of hospital stay, and narcotic administration in oral morphine equivalents (OMEs) were compared. Of 185 traumatic femur fractures analyzed, 80 occurred before meeting ACS level I CSV criteria, and 105 occurred after. Post-CSV, there was a significant decrease in mean wait time from admission to surgery (16.64 hours pre-CSV, 12.52 hours post-CSV [p < 0.01]) and duration of hospital stay (103.49 hours pre-CSV, 71.61 hours post-CSV [p < 0.01]). Narcotic usage was significantly decreased in both the preoperative period (40.61 OMEs pre-CSV, 23.77 OMEs post-CSV [p < 0.01]) and postoperative period (126.67 OMEs pre-CSV, 45.72 OMEs post-CSV [p < 0.01]). Achieving ACS level I CSV designation is associated with increased efficiency and decreased preoperative and postoperative narcotic use when treating pediatric trauma patients.

662: PROPHYLAXIS FOR THE PREVENTION OF EARLY POSTTRAUMATIC SEIZURES IN TRAUMATIC BRAIN INJURY

Introduction: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children under 18 years of age. Early posttraumatic seizures (EPTS), seizures occurring within 7 days of initial neurologic injury, are a known complication following TBI. The goal of this study is to discern how efficacious prophylaxis with Levetiracetam or Fosphenytoin is in preventing EPTS in moderate to severe TBI in pediatric patients. Methods: A retrospective observational study at a Level 1 Pediatric Trauma Center was conducted with patients 0-5 years with moderate to severe TBI admitted to the PICU from January 1, 2015 – January 1, 2021. Moderate to severe TBI was defined as Glasgow Coma Scale (GCS) < 13. Patients were identified using ICD-9 and ICD-10 codes. Excluded were patients >5 years old, who presented to the ED with seizures, who received anti-epileptic drug (AED) after a seizure, with non-accidental trauma as the cause of TBI, who did not receive 7 days of AED prophylaxis or died within 7 days of hospital stay. The following points were collected and compared: initial GCS, AED dosage, time to 1st AED dose, occurrence of EPTS, and number of days into hospital stay EPTS occurred. Results: Of 244 patients identified with moderate/severe TBI, 50 patients met inclusion criteria. Subdural hematoma was the most common primary diagnosis (48%). 44 patients (88%) received Levetiracetam. 6 patients (12%) received Fosphenytoin. 5 patients (10%) had EPTS, 95% CI [1.8%, 18.2%]. These 5 patients had received Levetiracetam. The 6 patients that received Fosphenytoin did not have EPTS. Seizures were confirmed with electroencephalography and on average occurred 2.6 days into hospital course. Mean data points of the patients who experienced EPTS: Levetiracetam dose 32.6 mg/kg/day, presenting GCS score 7, and time to administration of 1st AED dose 243 minutes. Mean data points of the patients who did not experience EPTS: Levetiracetam dose 29.3 mg/kg/day, presenting GCS score 9, and time to administration of 1st AED dose 366 minutes. Conclusions: Patients who received Levetiracetam prophylaxis had a higher incidence of EPTS compared to patients who received Fosphenytoin prophylaxis. These patients also had a lower presenting GCS, potentially playing a role in the neuropathophysiology of EPTS.

Trauma center variation of head computed tomography utilization in children presenting with mild traumatic brain injury

BackgroundAlthough published clinical decision rules have identified indications for the use of head CT in children with mild traumatic brain injury, practices vary. ObjectiveThis study seeks to evaluate whether the utilization of head CT in pediatric trauma patients presenting with mTBI varies between American College of Surgeons verified pediatric trauma centers (ACS-PTC) and adult-only trauma centers (ACS-AOTC). Material and methodsA retrospective cohort study of 24,104 trauma patients, ≤17, who presented to the emergency department at 337 ACS verified level I/II trauma centers with isolated mTBI was conducted using National Trauma Data Bank records (2011–2015). Multivariable logistic regression was used to compare the odds of a patient receiving a head CT when treated at an ACS-PTC vs. an ACS-AOTC, controlling for demographic, injury, and hospital-level confounders. Effect modification by loss of consciousness was assessed and adjusted head CT odds were recalculated in patients stratified by LOC status. ResultsThere was no significant difference in the adjusted odds of receiving a head CT at an ACS-PTC vs. an ACS-AOTC (odds ratio: 0.98, 95% confidence interval: 0.92–1.04). However, in patients who had a LOC, the adjusted OR of receiving a head CT at an ACS-PTC vs ACS-AOTC was 0.71 (95% confidence interval: 0.65–0.78). ConclusionChildren presenting to the emergency department of an ACS-verified level I or II trauma center with mTBI who had a loss of consciousness are less likely to receive a head CT at an ACS verified pediatric trauma center than at an ACS verified adult-only trauma center.

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.

A Pediatric Cervical Spine Clearance Guideline Leads to Fewer Unnecessary Computed Tomography Scans and Decreased Radiation Exposure.

Physical examination and computed tomography (CT) are useful to rule out cervical spine injury (CSI). Computed tomography scans increase lifetime cancer risk in children from radiation exposure. Most CSI in children occur between the occiput and C4. We developed a cervical spine (C-spine) clearance guideline to reduce unnecessary CTs and radiation exposure in pediatric trauma patients. A pediatric C-spine clearance guideline was implemented in September 2018 at our Level 2 Pediatric Trauma Center. Guidance included CT of C1 to C4 to scan only high-yield regions versus the entire C-spine and decrease radiation dose. A retrospective cohort study was conducted comparing preguideline and postguideline of all pediatric trauma patients younger than 8 years screened for CSI from July 2017 to December 2020. Primary endpoints included the following: number of full C-spine and C1 to C4 CT scans and radiation dose. Secondary endpoints were CSI rate and missed CSI. Results were compared using χ 2 and Wilcoxon rank-sum test with P < 0.05 significant. The review identified 726 patients: 273 preguideline and 453 postguideline. A similar rate of total C-spine CTs were done in both groups (23.1% vs 23.4%, P = 0.92). Full C-spine CTs were more common preguideline (22.7% vs 11.9%, P < 0.001), whereas C1 to C4 CT scans were more common post-guideline (11.5% vs 0.4%, P < 0.001). Magnetic resonance imaging utilization and CSIs identified were similar in both groups. The average radiation dose was lower postguideline (114 vs 265 mGy·cm -1 ; P < 0.001). There were no missed CSI. A pediatric C-spine clearance guideline led to increasing CT of C1 to C4 over full C-spine imaging, reducing the radiation dose in children. Level IV, therapeutic.

Variation in tracheostomy placement and outcomes following pediatric trauma among adult, pediatric, and combined trauma centers.

Tracheostomy placement is much more common in adults than children following severe trauma. We evaluated whether tracheostomy rates and outcomes differ for pediatric patients treated at trauma centers that primarily care for children versus adults. We conducted a retrospective cohort study of patients younger than 18 years in the National Trauma Data Bank from 2007 to 2016 treated at a Level I/II pediatric, adult, or combined adult/pediatric trauma center, ventilated >24 hours, and who survived to discharge. We used multivariable logistic regression adjusted for age, insurance, injury mechanism and body region, and Injury Severity Score to estimate the association between the three trauma center types and tracheostomy. We used augmented inverse probability weighting to model the likelihood of tracheostomy based on the propensity for treatment at a pediatric, adult, or combined trauma center, and estimated associations between trauma center type with length of stay and postdischarge care. Among 33,602 children, tracheostomies were performed in 4.2% of children in pediatric centers, 7.8% in combined centers (adjusted odds ratio [aOR], 1.47; 95% confidence interval [CI], 1.20-1.81), and 11.2% in adult centers (aOR, 1.81; 95% CI, 1.48-2.22). After propensity matching, the estimated average tracheostomy rate would be 62.9% higher (95% CI, 37.7-88.1%) at combined centers and 85.3% higher (56.6-113.9%) at adult centers relative to pediatric centers. Tracheostomy patients had longer hospital stay in pediatric centers than combined (-4.4 days, -7.4 to -1.3 days) or adult (-4.0 days, -7.2 to -0.9 days) centers, but fewer children required postdischarge inpatient care (70.1% pediatric vs. 81.3% combined [aOR, 2.11; 95% CI, 1.03-4.31] and 82.4% adult centers [aOR, 2.51; 95% CI, 1.31-4.83]). Children treated at pediatric trauma centers have lower likelihood of tracheostomy than children treated at combined adult/pediatric or adult centers independent of patient or injury characteristics. Better understanding of optimal indications for tracheostomy is necessary to improve processes of care for children treated throughout the pediatric trauma system. Prognostic and Epidemiological; Level III.

Development of a unified national trauma center database, 2018

ObjectiveTrauma center certifications across the United States (U.S.) are not unified. Participation in the national trauma certification program established through the American College of Surgeons (ACS) is not universal, and many states maintain unique trauma certification systems with varying criteria. We investigated degree of similarity between the ACS national trauma certification program and state trauma certifications, then combined these distinct certifications into a unified national trauma center database. MethodsWe performed a cross-sectional study of all non-specialty, non-federal emergency U.S. departments (EDs) open in 2018 to determine availability and levels of trauma centers. We created a “Standard” definition of trauma levels using ACS criteria as a benchmark. ACS similar trauma levels were then assigned to state levels I-III by comparing trauma receiving protocol, maximum response times, and general surgical coverage; through this process, levels across distinct systems established through different criteria were standardized. ResultsIn 2018, ACS certifications spanned 47 states and DC; 3 states did not participate in ACS (Mississippi, Pennsylvania, and Washington). A distinct, non-ACS state certification system was present in 47 states and DC; 3 states had no ongoing state certification system in 2018 (Maine, Rhode Island, and Vermont). Among 5,514 US EDs open in 2018, we identified 2,132 associated with adult and pediatric trauma centers (39%) holding certification (ACS, state, or both); 1,083 (51%) were certified levels I-III, and the rest (1,049, 49%) were levels IV-V. Of the 1,083 centers with any level I-III certification, 498 (46%) held ACS certification, and 1,059 (98%) held state certification. Applying ACS-similar criteria to centers with state levels I-III (n=1,059) resulted in a level change for 124 centers (12%). Using our “Standard” definition of a trauma level based on ACS criteria, our unified level I-III database included 959 (89%) adult and pediatric centers, with 24 (3%) ACS-certified only, 461 (48%) state-certified only, and 474 (49%) certified by both. ConclusionsDiscrepancies exist between ACS and state trauma certification systems. The differences in level I-III state criteria confirm discrepant standards for a given trauma “level” across the U.S. We combined these certifications into a unified national trauma center database available to researchers and the public.

Complication Rates in Patients With Classic and Radiographic Variants of Seymour Fractures.

At a tertiary-care, level 1 pediatric trauma center, we have observed fractures of the distal phalanx involving the physis, with associated nail bed injuries, that are distinct from the classic description of the Seymour fracture. We investigated the time to definitive management and the associated morbidity of these Seymour fracture variants compared with classically described Seymour fractures. We hypothesize that these Seymour variants are similarly problematic in terms of complications and delays to the definitive treatment and thus warrant increased awareness. A retrospective chart review was performed of all patients with distal phalanx fractures involving the physis and associated nail bed injuries that were treated with operative intervention at a single pediatric specialty institution over a 9-year period. Radiographs and clinical photographs were reviewed to determine if the patient presented with a classic Seymour fracture or variant. Primary outcomes included time from injury to definitive treatment and complication rate. Of the 66 Seymour fractures identified in the chart review, 36 (55%) were identified as classic Seymour fractures and 30 (45%) were identified as variants. The mean time to operative intervention in the classic and variant groups was 7.3 versus 12.7 days (P=0.216). The complication rates in the classic and variant groups were 11.1% versus 23.3% (P=0.185), with infections accounting for nearly all complications identified. Overall infection rates for the classic and variant cohorts were 8.3% and 20.0% (P=0.169), respectively, with the majority presenting preoperatively (5.6% vs. 13.3%, P=0.274). We found that patients with classic Seymour fractures or radiographic variants had statistically similar incidence rates, complication rates, and delays in treatment, with a trend towards higher complication rates and delayed time to treatment in patients with variant-type injuries. We propose a minor expansion of the definition of Seymour fractures to include common variants to increase awareness of these problematic injuries, minimize delays in treatment, and decrease complications. Level III; Retrospective Comparative Study.

Admission maximum amplitude-reaction time ratio: Association between thromboelastography values predicts poor outcome in injured children.

Thromboelastography (TEG)-derived maximum amplitude-reaction time (MA-R) ratio that accounts for both hypocoagulable and hypercoagulable changes in coagulation is associated with poor outcomes in adults. The relationship between these TEG values and outcomes has not been studied in children. In a retrospective cohort study, a level I pediatric trauma center database was queried for children younger than 18 years who had a TEG assay on admission between 2016 and 2020. Demographics, injury characteristics, and admission TEG values were recorded. The MA-R ratio was calculated and divided into quartiles. Main outcomes included mortality, transfusion within 24 hours of admission, and thromboembolism. A logistic regression model was generated adjusting for age, Injury Severity Score, injury mechanism, admission shock, and Glasgow Coma Scale. In total, 657 children were included, of which 70% were male and 75% had blunt mechanism injury. The median (interquartile range) age was 11 (4-14) years, the median (interquartile range) Injury Severity Score was10 (5-22), and in-hospital mortality was 7% (n = 45). Of these patients, 17% (n = 112) required transfusion. Most R and MA values were within normal limits. On unadjusted analysis, the lowest MA-R ratio quartile was associated with increased mortality (15% vs. 4%, 5%, and 4%, respectively; p < 0.001) and increased transfusion need (26% vs. 12%, 16%, and 13%, respectively; p = 0.002) compared with higher quartiles. In the logistic regression models, a low MA-R ratio was independently associated with increased in-hospital mortality (odds ratio [95% confidence interval], 4.4 [1.9-10.2]) and increased need for transfusion within 24 hours of admission (odds ratio [95% confidence interval], 2.0 [1.2-3.4]) compared with higher MA-R ratio. There was no association between MA-R ratio and venous thromboembolic events (venous thromboembolic event rate by quartile: 4%, 2%, 1%, and 3%). Although individual admission TEG values are not commonly substantially deranged in injured children, the MA-R ratio is an independent predictor of poor outcome. Maximum amplitude-reaction time ratio may be a useful prognostic tool in pediatric trauma; validation is necessary. Therapeutic/Care Management; Level III.

Computed tomography rates in pediatric trauma patients among emergency medicine and pediatric emergency medicine physicians

BackgroundPediatric trauma patients undergo fewer computed tomography (CT) scans when evaluated at pediatric trauma centers (PTC) versus adult trauma centers (ATC) with no change in clinical outcome. Factors contributing to this difference are unclear. We sought to identify whether the training background of physicians, specifically emergency medicine (EM) versus pediatric emergency medicine (PEM), affected the CT rate of pediatric trauma patients within one institution. MethodsA single-center retrospective study of CT utilization based on attending physicians’ training in trauma patients <18 years between November 2018 and November 2020. Attendings were categorized into two groups: EM residency with no PEM fellowship, or pediatrics/EM residency with PEM fellowship. Primary outcomes measured were the proportion of patients receiving a CT and CT positivity rate. ResultsOf 463 study patients, CTs were obtained in 145/228 (64%) patients by EM, and 130/235 (55%) by PEM (p=.07). CT positivity rate was 21% and 19% in EM and PEM, respectively (p=.46). The mean number of CTs per patient in EM was 2.8 compared to 2.1 in PEM (p<.01), and for patients with an injury severity score (ISS) >15, mean number of CTs per patient increased to 4.9 in EM versus 2.4 in PEM (p=.01). ConclusionsThe mean number of CTs ordered per patient was statistically higher for EM attendings. The differences between CT rates highlight future opportunities for ongoing development of pediatric trauma imaging guidelines and radiation exposure reduction. Levels of evidenceRetrospective Study, Level III

COVID-19 Pandemic Effects on the Epidemiology and Mortality of Pediatric Firearm Injuries; A Single Center Study

BackgroundThe COVID-19 pandemic has been associated with increased firearm injuries amongst adults, though the pandemic's effect on children is less clearly understood. MethodsThis cross-sectional study was performed at a Level 1 Pediatric Trauma Center and included youths 0–19 years. The trauma registry was retrospectively queried for firearm injuries occurring pre-COVID-19 pandemic (March 2015-February 2020). Baseline data was compared to prospectively collected data occurring during the COVID-19 pandemic (March 2020-March 2022). Fischer's exact, Pearson's Chi-square and/or correlation analysis was used to compare pre and post-COVID-19 firearm injury rates and intent, victim demographics and disposition. Temporal relationships between firearm injury rates and local COVID-19 death rates were also described. Results413 pre-COVID-19 firearm injuries were compared to 259 pandemic firearm injuries. Victims were mostly Black males with a mean age of 13.4 years. Compared to the 5 years pre-pandemic, monthly firearm injury rates increased 51.5% (6.8 vs 10.3 shootings/month), including a significant increase (p = 0.04) in firearm assaults/homicides and a relative decrease in unintentional shootings. Deaths increased 29%, and there were significantly fewer ED discharges and more admissions to OR and/or PICU (p = 0.005). There was a significant increase in Black victims (p = 0.01) and those having Medicaid or self-pay (p<0.001). Firearm injury spikes were noted during or within the 3 months following surges in local COVID-19 death rates. ConclusionsThe COVID-19 pandemic was associated with an increase in the frequency and mortality of pediatric firearm injuries, particularly assaults amongst Black children following surges in COVID death rates. Increased violence-intervention services are needed, particularly amongst marginalized communities. Level of evidenceThis is a prognostic study, evaluating the effects of the COVID-19 pandemic on pediatric firearm injuries, including victim demographics, injury intent and mortality. This study is retrospective and observational, making it Oxford Level III evidence.

Predictive Factors for Delayed Surgical Intervention in Children With Epidural Hematomas.

Optimal treatment of children with traumatic intracranial epidural hematomas (EDHs) is unknown. We sought to identify clinical and radiographic predictors of delayed surgical intervention among children with EDH admitted for observation. We retrospectively identified patients younger than 15 years with acute traumatic EDHs evaluated at our level 1 pediatric trauma center. We excluded patients with penetrating head injuries, recent surgical evacuation of EDH, or depressed skull fracture requiring surgical repair and assigned the remaining subjects to the immediate surgery group if they underwent immediate surgical evacuation, to the supportive-therapy-only group if they underwent observation only, and to the delayed surgery group if they underwent surgery after observation. We abstracted clinical and laboratory findings, surgical interventions, and neurological outcome and measured EDH dimensions and volumes, adjusting for cranial size. We compared clinical and radiographic characteristics among groups and performed receiver-operator characteristic analyses of predictors of delayed surgery. Of 172 patients with EDH, 103 patients met the inclusion criteria, with 6 (6%) in the immediate surgery group, 87 (84%) in the supportive-therapy-only group, and 10 (10%) in the delayed surgery group. Headache, prothrombin time of >14 seconds, EDH maximal thickness of ≥1.1 cm, volume of ≥14 mL, EDH thickness/cranial width index of ≥0.08 and EDH volume/cranial volume index of ≥0.18, and mass effect were associated with delayed surgical intervention. There was no difference in length of stay or functional impairment between the immediate and delayed surgery groups. However, patients in delayed surgery group were more likely to have subjective symptoms at discharge than those in immediate surgery group. Among patients with EDH admitted for observation, larger EDH, mass effect, headaches, and prothrombin time of >14 seconds were associated with delayed surgical intervention. A larger-scale study is warranted to identify independent predictors of delayed surgery in children under observation for EDH.

No Difference in Mortality and Outcomes After Addition of a Nearby Pediatric Trauma Center.

Previous studies demonstrate that higher volume pediatric trauma centers (PTCs) offer improved outcomes. This study evaluated pediatric trauma volume and outcomes at an existing level I (L-I) adult and level II (L-II) PTC after the addition of a new children's hospital L-II PTC within a 2-mile radius, hypothesizing no difference in mortality and complications. A retrospective review of patients aged 14 years or younger presenting to a single adult L-I and L-II PTC was performed. Patients from 2015-2016 (PRE) were compared with patients from 2018-2019 (POST) for mortality and complications using bivariate analyses. Compared with the PRE cohort, there were less patients in the POST cohort (277 vs 373). Patients in the POST cohort had higher rates of insurance coverage (91.3% vs 78.8%, P < 0.001), self-transportation (7.2% vs 2.7%, P < 0.01), and hospital admission (72.6% and 46.1%, P < 0.001). There was no difference in all complications and mortality (all P > 0.05) between the 2 cohorts. After opening a second L-II PTC within a 2-mile radius, there was an increase in the rate of admissions and self-transportation to the preexisting L-II PTC. Despite a nearly 26% decrease in pediatric trauma volume, there was no difference in length of stay, hospital complications, or mortality.

The Diagnostic and Clinical Value of Computed Tomography of the Facial Bones in Pediatric Trauma Patients at a Level 2 Pediatric Trauma Center

The Diagnostic and Clinical Value of Computed Tomography of the Facial Bones in Pediatric Trauma Patients at a Level 2 Pediatric Trauma Center

Evaluation of activation criteria in paediatric multi-trauma.

To explore the optimal set of trauma activation criteria predicting paediatric patients' need for acute care following multi-trauma, with particular attention to Glasgow Coma Scale (GCS) cut-off value. A retrospective cohort study of paediatric multi-trauma patients aged 0 to 16 years, performed at a Level 1 paediatric trauma centre. Trauma activation criteria and GCS levels were examined with respect to patients' need for acute care, defined as: direct to operating room disposition, intensive care unit admission, need for acute interventions in the trauma room, or in-hospital death. We enrolled 436 patients (median age 8.0 years). The following predicted need for acute care: GCS <14 (adjusted odds ratio [aOR] 23.0, 95% confidence interval [CI]: 11.5 to 45.9, P < 0.001), hemodynamic instability: (aOR 3.7, 95% CI: 1.2-8.1, P = 0.01), open pneumothorax/flail chest (aOR: 20.0, 95% CI: 4.0 to 98.7, P < 0.001), spinal cord injury (aOR 15.4, 95% CI; 2.4 to 97.1, P = 0.003), blood transfusion at the referring hospital (aOR: 7.7, 95% CI: 1.3 to 44.2, P = 0.02) and GSW to the chest, abdomen, neck, or proximal extremities (aOR 11.0, 95% CI; 1.7 to 70.8, P = 0.01). Using these activation criteria would have decreased over- triage by 10.7%, from 49.1% to 37.2% and under-triage by 1.3%, from 4.7% to 3.5%, in our cohort of patients. Using GCS<14, hemodynamic instability, open pneumothorax/flail chest, spinal cord injury, blood transfusion at the referring hospital, and GSW to the chest, abdomen, neck of proximal extremities, as T1 activation criteria could decrease over- and under-triage rates. Prospective studies are needed to validate the optimal set of activation criteria in paediatric patients.

The clinical characteristics and management of paediatric pelvic fractures: a changing landscape based on skeletal maturity

IntroductionPaediatric pelvic fractures (PPFs) are uncommon but signify serious trauma. A comprehensive multidisciplinary approach is needed due to a high number of associated injuries. This study aims to retrospectively analyse PPFs over a 5-year period and evaluate how advancing skeletal maturity changes fracture patterns and management plans.MethodsThe trauma database was retrospectively reviewed for pelvic fractures in patients aged ≤ 18 years. Radiographs and CT scans were used to classify pelvic injuries according to the modified Torode classification and determine the status of the triradiate cartilage (open: skeletally immature; closed: skeletally mature). Data collected also included the mechanism of injury, clinical and functional outcomes, and associated injuries. Logistic regression analysis was performed to identify risk factors for associated abdominal injuries.Results65 PPFs (2.8% of paediatric trauma admissions during the study period) were classified as type I (3.1%), type II (7.7%), type IIIa (32.3%), type IIIb (38.5%), type IV (18.5%) according to the modified Torode classification. The mean age was 13.41 ± 3.82. Skeletally immature children were more likely to be hit by a motor vehicle as a pedestrian (p < 0.001), be intubated (p = 0.009), acquire Torode type II (p = 0.047) and rami fractures (p = 0.037), and receive chest (p = 0.005) and head injuries (p = 0.046). Skeletally immature children were also less likely to acquire Torode type IV fractures (p = 0.018), receive surgical treatment for their pelvic injuries (p = 0.036), and had a faster time to full weight bearing (p = 0.013). Pelvis AIS score ≥ 4 (OR 5.3; 95% CI 1.3–22.6; p = 0.023) and a pedestrian accident (OR 4.9; 95% CI 1.2–20.7; p = 0.030) were risk factors for associated abdominal injuries. There was a strong association between a higher pelvic fracture grade and the proportion of patients with closed triradiate cartilage (p = 0.036), hospital length of stay (p = 0.034), mean pelvic AIS score (p = 0.039), a pelvis AIS score of ≥ 4 (p = 0.022), mean ISS (p = 0.003), an ISS score between 25 and 75 (p = 0.004), average time to FWB (p = 0.001), requirement of blood products (p = 0.015), and a motor vehicle accident (p = 0.037).ConclusionPPFs occurring in skeletally mature and immature patients are significantly different in terms of mechanism of injury, fracture severity, fracture pattern, and management strategy. There is a high rate of associated injuries, necessitating an integrated multidisciplinary approach in paediatric trauma centres.

Pediatric spinal injury patterns and management in all-terrain vehicle and dirt bike crashes, 2010-2019.

Pediatric spinal injuries in all-terrain vehicle (ATV) and dirt bike crashes are relatively uncommon but may be associated with significant morbidity. There are no recent studies examining these injuries, their management, and outcomes. Therefore, a retrospective study was performed to characterize pediatric spinal injuries related to ATV and dirt bike crashes over the last decade. Data on all patients involved in ATV or dirt bike crashes evaluated at a regional level 1 pediatric trauma center over a 10-year period (2010-2019) were analyzed. Descriptive statistics were analyzed and chi-square, Fisher exact, and Mann-Whitney U-tests were performed comparing the demographics, injury characteristics, and clinical outcomes in patients with versus those without spinal injuries. Of 680 patients evaluated, 35 (5.1%) were diagnosed with spinal injuries. Over the study period, both spinal injuries and emergency department visits related to ATV or dirt bike crashes increased in frequency. All spinal injuries were initially diagnosed on CT scans, and 57.9% underwent spinal MRI. Injuries were most commonly thoracic (50%), followed by cervical (36.8%). The injuries of most patients were classified as American Spinal Injury Association (ASIA) grade E on presentation (86.8%), while 2 (5.3%) had complete spinal cord injuries (ASIA grade A) and 3 patients (8.6%) were ASIA grade B-D. Operative management was required for 13 patients (28.9%). Nonoperative management was used in 71.1% of injuries, including bracing in 33% of all injuries. Patients with spinal injuries were older than those without (13.4 ± 3.35 vs 11.5 ± 3.79 years, p = 0.003). Spinal injuries occurred via similar crash mechanisms (p = 0.48) and in similar locations (p = 0.29) to nonspinal injuries. Patients with spinal injuries more frequently required admission to the intensive care unit (ICU; 34.2% vs 14.6%, p = 0.011) and had longer hospital stays (mean 4.7 ± 5.5 vs 2.7 ± 4.0 days, p = 0.0025). Although infrequent among young ATV and dirt bike riders, spinal injuries are associated with longer hospital stays, increased ICU use, and required operative intervention in 29%. Increasing awareness among ATV and dirt bike riders about the severity of riding-related injuries may encourage safer riding behaviors.

Metaphyseal Fracture Displacement is Predictive of Intra-Articular Displacement in Adolescent Triplane Ankle Fractures

Category: Trauma; Ankle Introduction/Purpose: Triplane ankle fractures are a commonly encountered pediatric injury with potential long-term sequelae if not appropriately managed. Computed tomography (CT) imaging is frequently obtained in the workup of a triplane fracture, however the radiation and cost associated with CT imaging is not benign. We aim to determine the utility of a novel and simple plain radiographic measurement as a predictor of intra-articular displacement in adolescent triplane ankle fractures. Methods: An IRB approved, retrospective review of all adolescent triplane ankle fractures from 2003-2013 was performed at a single level 1 pediatric trauma center. Plain radiographs (XR) and CT imaging obtained at initial presentation were independently reviewed by three orthopaedic surgeons. Maximum articular displacement and step off were measured using digital calipers on AP, mortise and lateral XRs as well as on axial, coronal, and sagittal CT imaging. In addition, maximal metaphyseal fracture displacement was recorded on lateral XR. Articular displacement and step off were compared between the two imaging modalities using student's t-test. Pearson and Spearman coefficients were used to identify correlations between XR and CT measurements. Results: 87 triplane ankle fractures were identified to meet inclusion criteria with a mean age of 12.9 years old (10-16 years old). XR was found to underestimate fracture displacement by 233% in the sagittal plane (1mm vs.3.3mm on sagittal CT; p&lt;0.05). XR underestimated displacement by 24% in the coronal plane (2.3mm on AP XR vs. 2.9mm on coronal CT; p&lt;0.05), and articular step off by 184% in the coronal plane and 177% in the sagittal plane (p&lt;0.05). Axial CT demonstrated a significantly greater amount of articular displacement (4.2mm, range 0-19mm) when compared to coronal (2.9mm, range 0-18.7mm) and sagittal (3.3mm, range 0- 11mm) cuts (p&lt;0.05). 65 patients demonstrated metaphyseal fracture displacement &gt;=1mm on lateral XR, of whom 61 demonstrated articular displacement of &gt;2.5mm on CT (positive predictive value of 94%). Conclusion: Plain radiographs appear to underestimate the articular displacement of triplane fractures. Maximal metaphyseal fracture displacement is easily measured on XR and appears to correlate with articular displacement. Maximal metaphyseal fracture displacement &gt;= 1mm is strongly predictive of articular displacement above the commonly accepted threshold for operative intervention. This finding should raise suspicion for significant articular displacement that may not be appreciated on XR and should prompt consideration of a CT before a decision is made on definitive treatment.

Complete Neurological Recovery After Emergency Burr Hole Placement Utilizing EZ-IO® for Epidural Hematoma

BackgroundPost-traumatic epidural hematoma (EDH) accounts for 1–3% of pediatric closed head injury admissions. There is a 2.5:1 male predominance. Etiology varies by age; motor vehicle collisions are the primary cause of EDH in adolescents. Post-traumatic EDH accompanies up to 4% of adult head injuries, and is associated with 10% mortality in adults and 5% mortality in children. In North America, standard of care for post-traumatic EDH includes decompressive craniotomy or trepanation via burr hole. Such lifesaving care is typically provided in the operating room by consulting neurosurgery teams or other personnel trained in the use of burr hole equipment. Case ReportThe case of a 17-year-old female patient who presented to a community emergency department (ED) after being involved in a motor vehicle collision is discussed. At the scene of the accident, she refused emergency medical services transport and was brought to the ED via private vehicle. She quickly decompensated in the ED and required intubation. Neurosurgical services were not available and transport to the nearest pediatric trauma center was delayed due to weather. Decompression and drainage of her EDH was accomplished with an EZ-IO® driver and intraosseous needle under virtual guidance of a pediatric neurosurgeon until definitive care could be obtained. The patient made a full neurologic recovery. Why Should an Emergency Physician Be Aware of ThisEDHs have high morbidity and mortality. In settings without access to neurosurgical services, and where ED access to or familiarity with burr hole equipment is limited, the EZ-IO® device may be a temporizing and lifesaving intervention until definitive neurosurgical care can be obtained.

Pre-hospital CPR after traumatic arrest: Outcomes at a level 1 pediatric trauma center

BackgroundThe survival of traumatic cardiopulmonary arrest (TCA) requiring pre-hospital cardiopulmonary resuscitation (P-CPR) is abysmal across age groups. We aim to describe the mechanisms of injury and outcomes of children suffering from TCA leading to P-CPR at our institution. MethodsA retrospective review was conducted to identify children ages 0-17 years who suffered TCA leading to P-CPR at our institution between 5/2009 and 3/2020. For analysis, patients were stratified into those still undergoing CPR at arrival and those who attained pre-hospital return of spontaneous circulation (ROSC). Primary outcome was discharge alive from the hospital. ResultsP-CPR was initiated for 48 patients who had TCA; 23 had pre-hospital ROSC. Of the 25 children undergoing CPR at presentation, none survived to discharge. The median duration of CPR, from initiation to time of death declaration was 34 min [29,50]. Seventeen patients died after resuscitation attempts in the ED, while 8 died after admission to the PICU. Of the 23 patients who attained pre-hospital ROSC, 6 survived to discharge. All survivors required intensive rehabilitation services at discharge and at most recent follow-up, 5 had residual deficits requiring medical attention. ConclusionThere are poor outcomes in children with pre-hospital traumatic cardiopulmonary arrest, particularly in those without pre-hospital ROSC. These data further support the need for standardized guidelines for resuscitation in children with traumatic cardiopulmonary arrest.