Evaluation Of Pediatric Trauma Research Articles

Serial Trauma Abdominal Ultrasound in Children (STAUNCH): A Pilot Study.

Ultrasound has established utility within pediatric emergency medicine and has an added benefit of avoiding excessive radiation exposure. The serial focused assessment with sonography in trauma (sFAST) examination is a potential alternative to improve pediatric trauma evaluation. We sought to evaluate the accuracy of sFAST in pediatric patients with blunt abdominal trauma. We performed a multicenter, retrospective observational study of electronic medical records, trauma registry data, and image archiving records of previous sFAST examinations. Examinations from pediatric patients (18 years or younger) who presented to an emergency department with blunt abdominal trauma were eligible for inclusion as long as the period between the first and second FAST was at least 30 minutes but no more than 24 hours. Demographic data and patient and outcomes were collected. Data collected from 3 institutions found a total of 38 sFAST performed between July 2017 and September 2021 on eligible patients. Of these, there were 6 (15.4%) FAST examinations that were positive after an initial negative or indeterminate interpretation. The overall sensitivity and specificity of sFAST were 66.7% (95% confidence interval 22.3-95.7%) and 93.8% (79.2-99.3%), respectively. This pilot study found that sFAST can enhance blunt trauma evaluation and improve sensitivity and diagnostic accuracy. More data are needed to determine how sFAST can be utilized in pediatric patients with blunt abdominal trauma.

CT scans for pediatric injury in a middle-income country trauma center: Are we repeating past mistakes?

PurposeSustained efforts in high-income countries have decreased the rate of unnecessary computed tomography (CT) among children, aiming to minimize radiation exposure. There are little data regarding CT use for pediatric trauma in low- and middle-income countries. We aimed to assess the pattern and utility of CT performed during evaluation of trauma patients presenting to a middle-income country (MIC) trauma center. MethodsWe reviewed pediatric (age<18) trauma admissions at a single tertiary referral center in South Africa. Patient demographics, injury details, surgical intervention(s), and mortality were abstracted from the medical record. CT indications, results, and necessity were determined by review. ResultsOf 1,630 children admitted to the trauma center, 826 (51%) had CT imaging. Children undergoing imaging were younger (median age 11 [IQR: 6, 16] vs 13 [IQR: 7, 17]) and had higher median ISS [9 [IQR: 4, 13] vs 4 [2, 9]) compared to those without imaging (both p<0.001). Overall, 1,224 scans were performed with normal findings in 609 (50%). A median of 1 scan was performed per patient (range: 1–5). The most common location was CT head (n = 695, 57%). Among patients with positive findings on CT head (n = 443), 31 (7%) underwent either intracranial pressure monitoring or surgery. CT of the cervical spine had positive findings in 12 (7%) with no patients undergoing spine surgery. Of 173 patients with abdominal CT imaging, 83 (48%) had abnormal findings and 18 (10%) required operative exploration. Thirteen (16%) patients with abnormal findings on abdominal CT had exploratory laparotomy. Of 111 children undergoing whole body CT, 8 (7%) underwent thoracic and/or abdominal operations. ConclusionUse of CT during evaluation of pediatric trauma is common in an MIC center. A high rate of normal findings and low rates of intervention following head, cervical spine, and abdominal CT suggest potential overuse of this resource. Level of EvidenceLevel III

Incorporating a Trauma-Informed Care Protocol Into Pediatric Trauma Evaluation: The Pediatric PAUSE Does Not Delay Imaging or Disposition.

Trauma evaluation in the emergency department (ED) can be a stressful event for children. With the goal of minimizing pain, anxiety, and unneeded interventions in stable patients, we implemented the Pediatric PAUSE at our level 1 adult/level 2 pediatric trauma center. The Pediatric PAUSE is a brief protocol performed after the primary survey, which addresses Pain/Privacy, Anxiety/IV Access, Urinary Catheter/Rectal exam/Genital exam, Support from family or staff, and Explain to patient/Engage with PICU team. The aim was to assess whether performing the PAUSE interfered with timeliness of emergent imaging in pediatric patients and their disposition. We identified all patients aged 0 to 18 years evaluated as trauma activations at our institution after the Pediatric PAUSE was implemented (October 1, 2016-March 31, 2017) as well as 2 analogous 6-month pre-PAUSE periods. Patient demographics, time to imaging studies, and time to ED disposition were analyzed. One hundred seventy-two patients met the study criteria, with a mean age of 10.9 years and mean injury severity score of 10.6. One hundred fifteen participants (68.5%) were transferred from other hospitals, and 101 (87.8%) had ≥1 imaging study performed before arrival. The Pediatric PAUSE was performed for 41 (25%) of 163 study participants. There was no difference in time to first imaging study in participants for whom the PAUSE was performed (18.4 vs 15.0 minutes, P = 0.09). The PAUSE is a practice intervention designed to address the psychosocial needs of pediatric trauma patients and their families to help prevent posttraumatic stress symptoms. Implementation did not interfere with the timeliness of first imaging in pediatric trauma patients.

Incorporating a Trauma-Informed Care Protocol into Pediatric Trauma Evaluation: The Pediatric PAUSE© Does Not Delay Imaging or Disposition

Background: Trauma evaluation in the Emergency Department (ED) can be a stressful event for children. With the goal of minimizing pain, anxiety, and unneeded interventions in stable patients, we implemented a Pediatric PAUSE© at our Level 1 Adult/Level 2 Pediatric Trauma Center. The Pediatric PAUSE© is a brief protocol performed after the primary survey, which addresses Pain/Privacy, Anxiety/IV Access, Urinary Catheter/Rectal exam/Genital exam, Support from family or staff, and Explain to patient/Engage with PICU team. The aim was to assess whether performing the PAUSE© interfered with timeliness of emergent imaging in pediatric patients and their disposition. Methods: We identified all patients aged 0-18 years evaluated as trauma activations at our institution after the Pediatric PAUSE© was implemented (10/1/16-3/31/17) as well as two analogous 6-month pre-PAUSE© time periods. Patient demographics, time to imaging studies, and time to ED disposition were analyzed. Findings: One hundred and seventy-two patients met study criteria, with a mean age of 10.9 years and mean Injury Severity Score of 10.6. One hundred fifteen participants (68.5 %) were transferred from other hospitals, and 101 (87.8%) had ≥1 imaging study performed prior to arrival. The Pediatric PAUSE© was performed for 41/163 (25%) study participants. There was no difference in time to first imaging study in participants for whom the PAUSE© was performed (18.4 min vs 15.0 min, p=0.09). Interpretation: The PAUSE© is a practice intervention designed to address the psychosocial needs of pediatric trauma patients and their families to help prevent PTS symptoms. Implementation did not interfere with the timeliness of first imaging in pediatric trauma patients. Funding Statement: The authors state: No funding to disclose. Declaration of Interests: The authors declare: No conflicts of interests.' Ethics Approval Statement: The study protocol was approved by the Committee for the Protection of Human Subjects at our institution, granting access to our institution’s existing trauma database and the electronic health records of study patients (Dartmouth College Committee for the Protection of Human Subjections: Study #00030129).

A novel streamlined trauma response team training improves imaging efficiency for pediatric blunt abdominal trauma patients

Background/purposeThe morbidity and mortality of children with traumatic injuries are directly related to the time to definitive management of their injuries. Imaging studies are used in the trauma evaluation to determine the injury type and severity. The goal of this project is to determine if a formal streamlined trauma response improves efficiency in pediatric blunt trauma by evaluating time to acquisition of imaging studies and definitive management. MethodsThis study is a chart review of patients <18 years who presented to a pediatric trauma center following blunt trauma requiring trauma team activation. 413 records were reviewed to determine if training changed the efficiency of CT acquisition and 652 were evaluated for FAST efficiency. The metrics used for comparison were time from ED arrival to CT image, FAST, and disposition. ResultsTime from arrival to CT acquisition decreased from 37 (SD 23) to 28 (SD27) min (p < 0.05) after implementation. The proportion of FAST scans increased from 315 (63.5%) to 337 (80.8%) and the time to FAST decreased from 18 (SD15) to 8 (SD10) min (p < 0.05). The time to operating room (OR) decreased after implementation. ConclusionThe implementation of a streamlined trauma team approach is associated with both decreased time to CT, FAST, OR, and an increased proportion of FAST scans in the pediatric trauma evaluation. This could result in the rapid identification of injuries, faster disposition from the ED, and potentially improve outcomes in bluntly injured children. Type of studyTherapeutic Level of evidenceLevel III

Errors in cervical spine immobilization during pediatric trauma evaluation

BackgroundThe purpose of this study was to identify factors during trauma evaluation that increase the likelihood of errors in cervical spine immobilization (‘lapses’). Materials and methodsMultivariate analysis was used to identify the associations between patient characteristics, event features, and tasks performed in proximity to the head and neck and the occurrence and duration of a lapse in maintaining cervical spine immobilization during 56 pediatric trauma evaluations. ResultsLapses in cervical spine immobilization occurred in 71.4% of patients (n = 40), with an average of 1.2 ± 1.3 lapses per patient. Head and neck tasks classified as oxygen manipulation occurred an average of 12.2 ± 9.7 times per patient, whereas those related to neck examination and cervical collar manipulation occurred an average of 2.7 ± 1.7 and 2.1 ± 1.2 times per patient, respectively. More oxygen-related tasks were performed among patients who had than those who did not have a lapse (27.3 ± 16.5 versus 11.5 ± 8.0 tasks, P = 0.001). Patients who had cervical collar placement or manipulation had a two-fold higher risk of a lapse than those who did not have these tasks performed (OR 1.92, 95% CI 0.56, 3.28, P = 0.006). More lapses occurred during evaluations on the weekend (P = 0.01), when more tasks related to supplemental oxygen manipulation were performed (P = 0.02) and when more tasks associated with cervical collar management were performed (P < 0.001). ConclusionsErrors in cervical spine immobilization were frequently observed during the initial evaluation of injured children. Strategies to reduce these errors should target approaches to head and neck management during the primary and secondary phases of trauma evaluation.

The radiation footprint on the pediatric trauma patient

BackgroundThe actual baseline of radiation exposure used in evaluating pediatric trauma is not known and has relied on estimates in the literature that may not reflect clinical reality. Our objectives were to determine the baseline amount of radiation delivered in a pediatric trauma evaluation and correlate radiation exposure with trauma activation status to identify the cohort most at risk.MethodsWe retrospectively evaluated trauma patients (N = 1050) at an independent Level I children’s hospital for each level of trauma activation (consults, alerts, stats) from June 2010 to January 2011. Those patients with full dosimetry (N = 215) were analyzed for demographics, mechanism of injury, Injury Severity Score, imaging modalities, and total effective radiation dosages during the full trauma assessment from the time of injury to discharge.ResultsDemographics included gender (143 males, 72 females) and average age (5.5 years [range < 1–16]). The most radiation was conferred from CTs and greatest in trauma stats, followed by alerts, then consults (p < 0.001 for stat and alert doses compared to consults). Repeated imaging was common: 35% of stats had 2–3 CTs and 40% had 4–10 CTs (range 0–10 CTs). The average non-accidental trauma consult utilized four times as many CTs as the average consult (p = 0.002). Most outside hospital CTs (66%) delivered more radiation: 50.0% were at least double the standard pediatric dosage.ConclusionsThis study is the first to identify the actual baseline of radiation exposure for one trauma evaluation and correlate radiation exposure with trauma activation status. Factors associated with highest radiation include stat activations, suspected non-accidental traumas (NAT), and outside hospital system imaging.

Limiting thoracic CT: a rule for use during initial pediatric trauma evaluation

BackgroundDespite increases in imaging guidelines for other body-regions during initial trauma assessment and the demonstrated utility of chest radiographs (CXR), guidelines for use of thoracic computed-tomography (TCT) are lacking. We hypothesized that TCT utilization had not decreased relative to other protocolized CTs, and mechanism and CXR could together predict significant injury independent of TCT. MethodsWe performed a retrospective review of blunt trauma patients ≤18 y.o. (2007–2015) at two level-1 trauma centers who received chest imaging. Baseline characteristics and incidences of body region-specific CT were compared. Injury mechanism, intrathoracic pathology, and interventions among other data were examined (significance: p<0.05). ResultsAlthough other body-region CT incidence decreased (p<0.05), TCT incidence did not change (p=0.65). Of the 2951 patients, 567 had both CXR and TCT, 933 received TCT-only, and 1451 had CXR-only. TCT altered management in 17 patients: 2 operations, 1 stent-placement, 1 medical management, 9 thoracostomy tube placements, and 4 negative diagnostic workups. All clinically significant changes were predicted by vehicle-related mechanism and abnormal CXR findings. ConclusionsTCT utilization has not decreased over time. All meaningful interventions were predicted by CXR and mechanism of injury. We propose a rule, for prospective validation, reserving TCT for patients with abnormal CXR findings and severe vehicle-related trauma. Level of evidenceDiagnostic study, Level III.

Effect of Family Presence on Advanced Trauma Life Support Task Performance During Pediatric Trauma Team Evaluation.

In many hospitals, family members are separated from their children during the early phases of trauma care. Including family members during this phase of trauma care varies by institution and is limited by concerns for adverse effects on clinical care. The aim of this study is to evaluate the effect of family presence (FP) on advanced trauma life support primary and secondary survey task performance by pediatric trauma teams. We hypothesized that trauma care with FP would be noninferior to care when families were absent. We performed a retrospective video review of consecutive pediatric trauma evaluations. Family presence status was determined by availability of the family. The study was conducted at an American College of Surgeons-designated level I pediatric trauma center that serves the Washington, DC, metropolitan area. Participants included patients younger than 16 years of age who met trauma activation criteria and were evaluated by the trauma team in our emergency department. We compared task performance between patients with and without FP. Video recordings of 135 trauma evaluations were reviewed. Family was present for 88 (65%) evaluations. Patients with FP were younger (mean age, 6.4 years [SD = 4.1] vs 9.0 years [SD = 4.9]; P < 0.001) and more likely to have sustained blunt injuries (95% vs 85%, P = 0.03). Noninferiority of frequency and timeliness of completion of all primary survey tasks were confirmed for evaluations with FP. Noninferiority of frequencies of secondary survey task completion was confirmed for most tasks except for examination of the neck, pelvis, and upper extremities. Family members did not directly interfere with patient care in any case. Performance of most advanced trauma life support tasks during pediatric trauma evaluation was not worsened by FP. Our data provide additional evidence supporting FP during the acute management of injured children.

Computed Tomography in the Evaluation of Pediatric Trauma

The objective of this article is to review the use of computed tomography (CT) for the purpose of injury evaluation in pediatric trauma patients. The relative risk of radiation-induced cancer mortality is discussed. Evidence-based indications for obtaining CT and optimization of CT scanner protocols are provided. CT use specific to pediatric trauma is discussed for the following anatomic regions: thorax, abdomen, head, spine, vascular, and musculoskeletal. Limiting unnecessary CT use by understanding when and how to order an appropriate scan in order to adequately diagnose and treat a specific injury is the most practical way for clinicians to help reduce patients’ risk of radiation.

The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation

PurposeWith increasing concerns about radiation exposure, we questioned whether a structured program of FAST might decrease CT use. MethodsAll pediatric trauma surgeons in our level 1 pediatric trauma center underwent formal FAST training. Children with potential abdominal trauma and no prior imaging were prospectively evaluated from 10/2/09 to 7/31/11. After physical exam and FAST, the surgeon declared whether the CT could be eliminated. ResultsOf 536 children who arrived without imaging, 183 had potential abdominal trauma. FAST was performed in 128 cases and recorded completely in 88. In 48% (42/88) the surgeon would have elected to cancel the CT based on the FAST and physical exam. One of the 42 cases had a positive FAST and required emergent laparotomy; the others were negative. The sensitivity of FAST for injuries requiring operation or blood transfusion was 87.5%. The sensitivity, specificity, PPV, and NPV in detecting pathologic free fluid were 50%, 85%, 53.8%, and 87.9%. ConclusionsTrue positive FAST exams are uncommon and would rarely direct management. While the negative FAST would have potentially reduced CT use due to practitioner reassurance, this reassurance may be unwarranted given the test's sensitivity.

Pediatric Trauma Interprofessional Simulation: 5-Year-Old Pedestrian Struck by a Motor Vehicle

OPEN ACCESSJanuary 28, 2013Pediatric Trauma Interprofessional Simulation: 5-Year-Old Pedestrian Struck by a Motor Vehicle Joanne Baerg, MD, Kent Denmark, MD, Shannon Longshore, MD Joanne Baerg, MD Loma Linda University Children's Hospital Google Scholar More articles by this author , Kent Denmark, MD Loma Linda University Children's Hospital Google Scholar More articles by this author , Shannon Longshore, MD Loma Linda University Children's Hospital Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.9323 SectionsAbout ToolsDownload Citations ShareFacebookTwitterEmail AbstractAbstractThis resource is a pediatric trauma interprofessional human simulation. It is designed for general and pediatric surgery programs to utilize for their trainees. This simulation provides residents with experience in a scenario that will probably occur in practice but rarely occurs during residency. In it, the learner must assume the leadership role and manage a trauma in the emergency department after a child is struck by a motor vehicle. The patient rapidly loses blood volume from a retro-hepatic injury and requires a trauma thoracotomy to manage hypotension. A difficult airway is also incorporated into the scenario. This resource contains the scenario details, an instructional guide, and radiographs to support implementation. The instructional guide lists references for the learners to review prior to attending the simulation. The main learner is intended to be a senior pediatric surgery trainee or general surgery resident. Other learners include an anesthesia resident and nurses. The learners must overcome professional barriers to ask for help; demonstrate the correct sequence of steps to perform a trauma evaluation, resuscitation, and thoracotomy; and use situation, background, assessment, and recommendation (SBAR) communication between team members. We utilized videotaping when we implemented this resource, with a review of the tape by our learners prior to a debriefing discussion. Although videotaping is recommended, it is not necessary as the resource contains a list of debriefing questions that facilitate discussion, self-assessment, and learning after the scenario has been implemented. After participation, the learner will be better prepared to lead a complicated pediatric trauma resuscitation. This simulation is distinct in its interprofessional focus, in the learner group it targets, and in the complexity of leadership, communication, and technical skill it requires. Educational Objectives By the end of this resource, learners should be able to: Demonstrate the correct sequence of steps to perform a pediatric trauma evaluation, resuscitation, and thoracotomy.Manage cardiac arrest secondary to hemorrhage in a trauma scenario.Delegate tasks appropriately so they maintain their role as decision maker.Recognize a difficult airway and overcome professional barriers to ask for help.Communicate utilizing the situation, background, assessment, and recommendation (SBAR) communication method between team members. Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: Instructional guide 5 yr old ped struck baerg.doc Scenario 5 yr old ped struck baerg.doc ped sim cspine.jpg ped sim cxr.jpg ped sim liver injury.jpg ped sim pelvis.jpg To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. Copyright & Permissions© 2013 Baerg et al. This is an open-access article distributed under the terms of the Creative Commons Attribution license.KeywordsWounds and InjuriesThoracotomyTrauma Disclosures None to report. Funding/Support None to report. Loading ...

Is the Broselow Tape a Reliable Indicator for Use in All Pediatric Trauma Patients?

The purpose of this study was to determine the effectiveness of the Broselow tape in the evaluation of pediatric trauma patients. The trauma registry of a rural level I trauma center was examined. All pediatric trauma patients 16 years or younger were reviewed from 2002 to 2006, totaling 2358 patients. The Broselow tape measures to 146.5 cm. Patients whose height correlated with the tape and had their heights and weights in the medical record were included. The constant variable was the heights by which the estimated weights of the Broselow tape were compared with the actual weights of the patients. A total of 657 patients matched this height and had both heights and weights in their record. Most children (349/657; 53.1%) fell outside the predicted weight range, and of these, 77.1% of the actual weights were greater than those predicted by the Broselow scale. This is observed across all age groups. In patients with heights less than 75 cm, two thirds of patients' weights correlated with the Broselow estimated weight; however, those that deviated did so by 2 to 3 color intervals larger. This deviation was statistically significant in all groups. In our population, the Broselow tape is an ineffective tool to predict weight in more than 50% of pediatric trauma patients. This may lead to the underdosing of emergency medications and blood products.

The New Injury Severity Score and the Evaluation of Pediatric Trauma

To compare the effectiveness of the Injury Severity Score (ISS) and New Injury Severity Score (NISS) in predicting mortality in pediatric trauma patients. NISS, the sum of the squares of a patient's three highest Abbreviated Injury Scale scores (regardless of body region), were calculated for 9,151 patients treated at four regional pediatric trauma centers and compared with previously calculated ISS values. The power of the two scoring systems to predict mortality was gauged through comparison of misclassification rates, receiver operating characteristic curves, and Hosmer-Lemeshow goodness-of-fit statistics. Although there were significant differences in mean NISS and ISS values for each hospital, differences in the predictive abilities of the two scoring systems were insignificant, even when analysis was restricted to the subgroup of patients with severe or penetrating injuries. The significant differences in the predictive abilities of the ISS and NISS reported in studies of adult trauma patients were not seen in this review of pediatric trauma patients.