Pediatric Trauma Population Research Articles

Universal Health Insurance and its association with long term outcomes in Pediatric Trauma Patients

BackgroundRacial disparities in mortality exist among pediatric trauma patients; however, little is known about disparities in outcomes following discharge. MethodsWe conducted a longitudinal cohort study of children admitted for moderate to severe trauma, covered by TRICARE from 2006 to 2014. Patients were followed up to 90days after discharge. All children <18 years with a primary trauma diagnosis, an Injury Severity Score >9 and 90days of follow-up after discharge were included. Complications, readmissions and utilization of healthcare services up to 90days after discharge were compared between Black and White patients. ResultsOf the 5192 children included, majority were White (74.6%, n=3871), with 15.4% Black (n=800) and 10.0% Other (n=521). Most common injuries involved the extremities or the pelvic girdle followed by the head or neck. Complication and readmission rates were 3.6% and 8.9% within 30days of discharge respectively and 4.4% and 9.3% within 90days of discharge. 99.0% of children had at least one outpatient visit by 90days. After adjusting for patient and injury characteristics no significant differences were detected between Black and White children in outcomes after discharge. ConclusionsUniversal insurance may help mitigate disparities in post discharge care in pediatric trauma populations by increasing access to outpatient services overall and within each racial group. Further studies are required to determine the appropriate timing and frequency of follow up care in order to achieve maximum reduction in use of acute care services after discharge.

Undertriage of Pediatric Major Trauma Patients in the United States.

Although trauma undertriage has been widely discussed in the literature, undertriage in the pediatric trauma population remains understudied. Using the 2009-2013 Nationwide Emergency Department Sample, we assessed the national undertriage rate in pediatric major trauma patients (age ≤16 years and injury severity score [ISS] >15), and identified factors associated with pediatric trauma undertriage. Nationally, 21.7% of pediatric major trauma patients were undertriaged. Children living in rural areas were more likely to be undertriaged ( P = .02), as were those without insurance ( P = .00). Children with life-threatening injuries were less likely to be undertriaged ( P < .0001), as were those with chronic conditions ( P < .0001). Improving access to specialized pediatric trauma care through innovative service delivery models may reduce undertriage and improve outcomes for pediatric major trauma patients.

Abnormalities in fibrinolysis at the time of admission are associated with deep vein thrombosis, mortality and disability in pediatric trauma population: Leeper CM, Neal MD, McKenna C, et al. J Trauma Acute Care Surg. 2017;82:27-34

Abnormalities in fibrinolysis at the time of admission are associated with deep vein thrombosis, mortality and disability in pediatric trauma population: Leeper CM, Neal MD, McKenna C, et al. J Trauma Acute Care Surg. 2017;82:27-34

Damage control laparotomy for abdominal trauma in children.

Damage control laparotomy (DCL) is not well studied in the pediatric trauma population. The purpose of this study was to develop a surrogate definition of DCL compatible with national and administrative data sources so that the rate and outcomes of DCL in pediatric trauma patients could be determined. Using the 2010-2014 National Trauma Data Bank, children ≤18 with an abdominal AIS ≥ 3 who underwent a laparotomy within 3h of arrival were identified (n = 2989). DCL was defined as occurring in children who underwent a second laparotomy within 5-48h from the index laparotomy (n = 360). Children meeting these criteria were compared to those children who had the initial definitive operative management (n = 2174) and those who died prior to 48h (n = 455). DCL occurred in 12% of children with operative abdominal trauma. Children who underwent DCL had a greater median ISS (25 vs 18) and heart rate (112 vs 100), lower systolic blood pressure (104 vs 113), and GCS (12 vs 13), and were more likely to receive a preoperative blood transfusion (19 vs 11%) than those who had definitive initial operative management (all p < .05). Median length of stay (17 vs 8 days) and mortality (9 vs 2%) were greater following DCL than definitive initial operative management (p < .001). No differences in rate of DCL were seen based on ACS pediatric verification (p = .07). Few children with operative abdominal trauma undergo DCL. DCL was associated with worse physiology rather than anatomic injury severity in this study. As expected, outcomes were worse following DCL.

Abnormalities in fibrinolysis at the time of admission are associated with deep vein thrombosis, mortality, and disability in a pediatric trauma population.

Abnormalities in fibrinolysis are common and associated with increased mortality in injured adults. While hyperfibrinolysis (HF) and fibrinolysis shutdown (SD) are potential prognostic indicators and treatment targets in adults, these derangements are not well described in a pediatric trauma cohort. This was a prospective analysis of highest level trauma activations in subjects aged 0 to 18 years presenting to our academic center between June 1, 2015, and July 31, 2016, with admission rapid thrombelastograph. Shutdown was defined as LY30 (lysis 30 minutes after the maximum amplitude has been reached) of 0.8% or less and HF defined as LY30 of 3.0% or greater. Variables of interest included demographics, admission vital signs and laboratory values, injuries, incidence of venous thromboembolism under our screening protocol, death, and functional disability (discharge to facility or dependence in functional independence measure category). Youden index determined optimal definition of SD, then Wilcoxon rank-sum, Kruskal-Wallis, and Fisher exact tests were performed. One hundred thirty-three patients are included with median age of 10 years (interquartile range [IQR], 5-13 years); male sex, 5.4%; median Injury Severity Score, 17 (IQR, 10-26); blunt mechanism, 68.4%. Youden analysis defined SD as LY30 of 0.8 or less. In total, 38.3% (n = 51) had SD on admission; 19.6% (n = 26) had HF, and 42.1% (n = 56) were normal. Mortality rate was 9.0% (n = 12), and deep vein thrombosis incidence was 10.7% (n = 13/121 surviving). Shutdown and HF were both associated with mortality (p = 0.014 and p = 0.021) and blood transfusion (p = 0.001 and p < 0.001); SD was also associated with disability (p < 0.001) and deep vein thrombosis (p = 0.002). Blunt mechanism was associated with SD, and penetrating mechanism was associated with HF (p = 0.011). Both SD (p = 0.001) and HF (p = 0.036) were associated with elevated international normalized ratio. LY30 did not differ significantly across age groups. Children demonstrate high rates of inhibition (SD) and overactivation (HF) of fibrinolysis after injury. Shutdown and HF are both associated with poor outcomes. Shutdown is a particularly poor prognostic indicator, accounting for the greatest percentage of death, disability, and patients requiring transfusion, as well as later development of hypercoagulable state. The addition of thrombelastograph to pediatric trauma care protocols should be considered as it contributes important prognostic and clinical information. Prognostic and epidemiologic study, level III.

Utility of plain radiographs and MRI in cervical spine clearance in symptomatic non-obtunded pediatric patients without high-impact trauma.

The optimal imaging modality for evaluating cervical spine trauma and optimizing management in the pediatric population is controversial. In pediatric populations, there are no well-established guidelines for cervical spine trauma evaluation and treatment. Currently, there is virtually no literature regarding imaging and management of symptomatic pediatric patients who present with cervical spine trauma without high-impact mechanism. This study aims to establish an optimal imaging strategy for this subgroup of trauma patients. We performed a retrospective review of pediatric patients (aged below 18years) who were admitted to Monash Medical Centre, Melbourne, Australia between July 2011 and June 2015, who did not suffer a high-impact trauma but were symptomatic for cervical spine injury following cervical trauma. Imaging and management strategies were reviewed and results compared. Forty-seven pediatric patients were identified who met the inclusion criteria. Of these patients, 46 underwent cervical spine series (CSS) plain radiograph imaging. Thirty-four cases underwent magnetic resonance imaging (MRI) and 9 patients underwent CT. MRI was able to detect 4 cases of ligamentous injury, which were not seen in CSS imaging and was able to facilitate cervical spine clearance in a further two patients whose CSS radiographs were abnormal. In this study, MRI has a greater sensitivity and specificity when compared to CSS radiography in a symptomatic pediatric low-impact trauma population. Our data call in to question the routine use of CSS radiographs in children.

Massive transfusion in pediatric trauma: analysis of the National Trauma Databank

BackgroundMassive transfusion (MT) in pediatric trauma has been described in combat populations and other single institutions studies. We aim to define the incidence of MT in a large US civilian pediatric trauma population, identify predictive parameters of MT, and the mortality associated with MT. MethodsData from the National Trauma Databank (2010-2012), a trauma registry maintained by the American College of Surgeons, were analyzed. We included pediatric trauma patients ≤14 y that underwent MT, as defined by 40 mL/kg of blood products within the first 24 h after admission. We compared the MT group with children receiving any transfusion within the same time frame. Univariate and multivariate analysis were performed. ResultsOf 356,583 pediatric trauma patients, 13,523 (4%) received any transfusion in the first 24 h and 173 (0.04%) had a MT. On multivariate analysis, factors predicting MT were: older patients (5-12: OR 2.71, P = 0.006, and ≥12: OR 5.14, P < 0.001), hypothermic patients (temperature <35: OR 2.48, P < 0.025), low Glasgow Coma Scale (Glasgow Coma Scale <8: OR 2.82, P = 0.009), and Injury Severity Scores ≥25 (OR 2.01, P = 0.03). Overall mortality for the entire group, any transfusion group, and MT group were 2.5%, 13.6%, and 50.6%, respectively (P < 0.001). ConclusionsMT in pediatric trauma is an uncommon event associated with a significant mortality. Patients undergoing MT are older, more likely to be hypothermic and have sustained more severe injuries as measured by traditional trauma scoring systems than transfused trauma patients.

Helicopters and Injured Kids: Improved Survival With Scene Air Medical Transport in the Pediatric Trauma Population: Brown JB, Leeper CM, Sperry JL, et al. J Trauma Acute Care Surgery. 2016;80:702-710

Helicopters and Injured Kids: Improved Survival With Scene Air Medical Transport in the Pediatric Trauma Population: Brown JB, Leeper CM, Sperry JL, et al. J Trauma Acute Care Surgery. 2016;80:702-710

Acute traumatic coagulopathy in a critically injured pediatric population: Definition, trend over time, and outcomes.

While our understanding of acute traumatic coagulopathy (ATC) in adults is advancing, the pediatric literature on ATC is limited. Children have a unique injury profile and physiologic response to trauma; however, the impact of this phenomenon on ATC has not been fully elucidated. We performed a retrospective review of our trauma registry from 2005 to 2014. Level 1 trauma patients age 0 year to 17 years requiring admission to the intensive care unit were included. Variables included admission vital signs and laboratory studies, product transfusion, injuries, and mortality. Youden index was used to determine optimum cutoff point for admission international normalized ratio (INR) as a predictor of mortality. Logistic regression modeling was used to determine independent predictors of mortality adjusting for hypotension, hypothermia, acidosis, injury severity, hemorrhage, and head injury. χ tests were performed evaluating for association between mortality and 24-hour INR as well as between transfusion and INR correction. A total of 776 patients were analyzed: 29.2% (n = 227) had an admission INR of 1.3 or greater, and 13.3% (n = 103) had an admission INR of 1.5 or greater. Youden index demonstrated optimum cutoff at INR of 1.3 or greater to distinguish survivors and nonsurvivors. Overall mortality rate was 11.1% (n = 86). Elevated INR was independently associated with mortality (odds ratio, 3.77; p < 0.001) after controlling for other predictors in regression modeling. Death was also associated with elevated INR at 24 hours and worsening INR trend over time. Patients who received plasma were equally likely to normalize their INR compared with those who were not transfused (p = nonsignificant). Findings were consistent across age groups. INR likely serves as a marker of systemic dysregulation rather than a treatment target in ATC. Elevated admission INR, elevated INR at 24 hours, and overall trend in INR strongly predict mortality in a diverse pediatric trauma population; however, product transfusion did not influence the INR trend or clinical outcome. Further research is warranted to evaluate potential upstream mediators of ATC and targets for intervention in pediatric trauma patients. Prognostic and epidemiologic study, level III.

Adherence behavior in an acute pediatric hand trauma population: A pilot study of parental report of adherence levels and influencing factors

IntroductionDescriptive and cross-sectional study. Purpose of the StudyThe hand is a common site of injury in children; however, little is known regarding adherence to hand trauma management in this population. PurposeThis pilot study aimed to describe adherence to plaster slab immobilization, advice regarding return to sport, appointment attendance, and the factors influencing nonadherence. MethodForty-seven parents of children with hand trauma completed an online questionnaire reporting their child's adherence to the initial medical management. ResultsParents reported that 34% (16 of 47) of children were adherent to all aspects of management. Nonadherence with plaster slab immobilization was reported by 38% (18 of 47), and 45% (21 of 47) reported nonadherence with advice regarding return to sport. Hygiene, discomfort, and restriction were the most common reasons for plaster removal. Belief that sport would not cause harm and social factors influenced return to sport against medical advice. ConclusionNonadherence behavior is commonly reported in children with acute hand trauma. Level of evidence4.

Incidence of Deep Vein Thrombosis and Pulmonary Embolism in the Elective Pediatric Orthopaedic Patient.

Although venous thromboembolism (VTE) has been well studied in the pediatric trauma population, rates of VTE associated with elective pediatric orthopaedic procedures have not been addressed in current literature. The purpose of this retrospective study was to identify the incidence of VTE in the elective pediatric orthopaedic surgical population and delineate subsets of this population at greatest risk. This study may provide valuable data to begin the process of resolving the controversy surrounding deep vein thrombosis prophylaxis in the pediatric orthopaedic population. The Pediatric Health Information System was queried for patients admitted on an ambulatory or inpatient basis, aged below 18 years, from January 2006 to March 2011 during which an elective orthopaedic surgery was the principal procedure performed. Patients with diagnoses or procedures related to infection, trauma, malignancy, or coagulopathies were excluded. Patients admitted through the emergency department or whose orthopaedic procedure was not performed on the admission date were excluded. Age, sex, ethnicity, race, admission year, and all procedures/diagnoses were recorded. The presence of VTE at the index admission or any subsequent readmission within 90 days was recorded. All criteria were coded using ICD-9-CM codes. Generalized logistic regression analyses were used to identify factors related to VTE. A total of 143,808 admissions (117,676 patients) matched the inclusion criteria. Thirty-three had a VTE during the index admission with an additional 41 at subsequent readmissions, for a total incidence of 0.0515% by admission and 0.0629% by patient. In the multivariable model, variables significantly (P<0.05) related to VTE included increasing age, admission type, diagnosis of metabolic conditions, obesity, and/or syndromes, and complications of implanted devices and/or surgical procedures. No procedure variables were significantly related to VTE in the multivariable model. The incidence of VTE in this cohort of pediatric patients undergoing elective orthopaedic surgery was 0.0515%. In children, underlying diagnosis seems to be a stronger predictor of VTE than procedures performed. Diagnosis with a metabolic condition, syndrome, and/or obesity, complications of implanted devices and/or surgical procedures, older age, and admission as an inpatient were significantly related to the development of a VTE. Level IV—case series.

Indication Bias Explains Some of the Observed Increased Mortality Associated With Use of Prehospital Intravenous Fluids in a Pediatric Trauma Population.

Traditionally, in both pediatric and adult trauma patients, management of hemorrhage and shock has included early rapid intravenous fluid (IVF) replacement at the scene or during transport to a definitive care facility. Because prehospital resuscitation can be considered as a lifesaving intervention, severely injured patients are more likely to receive IVF. Observational studies not adequately adjusting for this confounding by indication (indication bias) while evaluating the impact of prehospital IVF on mortality in clinically heterogeneous patient populations are likely to find an increased mortality associated with the use of prehospital IVF, an association that may be spurious even after traditional multivariable risk adjustment. Propensity scores can be used to mitigate the impact of this selection bias on the estimated effect. The authors hypothesized that the effect of IVF on mortality will differ based on whether propensity scores (based on a set of prehospital indications for IVF) are adjusted for in a multivariable outcome model. This was a retrospective cohort study of severely injured pediatric (<18 years) patients consecutively evaluated and treated between January 1, 2008, and June 30, 2011, at Oklahoma's only Level I pediatric trauma center. Patients were divided into those receiving 250mL or more (GE250 group) and those receiving less (LT250 group) of prehospital IVF based on area under curve (AUC) analysis (AUC=0.7, 95% confidence interval [CI]=0.6 to 0.80, sensitivity=0.81 and specificity=0.56). Propensity scores were used to minimize confounding by indication of the mortality estimate and were calculated based on measurable prehospital factors. Using Cox's regression to minimize survival bias, the independent effect of prehospital IVF on the risk of 30-day in-hospital mortality was evaluated with and without adjusting for the propensity to receive 250mL of prehospital IVF. A total of 482 patients met study criteria. Of these, 46.3% (223 of 449) were in the GE250 group. After adjusting for Injury Severity Score, presence of a severe head injury, shock, and a penetrating injury, all of which were significant predictors of mortality, receiving 250mL or more of prehospital IVF was significantly associated with an almost threefold increase in the risk of 30-day in-hospital mortality (hazard ratio [HR]= 2.96, 95% CI=1.1 to 8.2). However, further adjusting for the propensity to be in the GE250 group, in addition to the aforementioned variables, attenuated the effect estimate and resulted in a nonsignificant (p=0.3408), more precise association between prehospital IVF and mortality (HR= 1.9, 95% CI=0.6 to 6.6). Propensity-adjusted survival analysis suggests that the observed increased risk in mortality associated with use of prehospital IVF replacement may be a spurious association resulting from inadequate control of confounding by indication inherent in observational studies. In the absence of patient subgroup-specific results from well-controlled studies, IVF resuscitation should not be a reason to delay patient transport to a definitive care facility. Randomized trials evaluating the effect of prehospital fluids are warranted in the pediatric trauma population, as such studies have shown clinical significance in the adult trauma population.

Heart rate in pediatric trauma: rethink your strategy

BackgroundThe optimal heart rate (HR) for children after trauma is based on values derived at rest for a given age. As the stages of shock are based in part on HR, a better understanding of how HR varies after trauma is necessary. Admission HRs of pediatric trauma patients were analyzed to determine which ranges were associated with lowest mortality. Materials and methodsThe National Trauma Data Bank was used to evaluate all injured patients ages 1–14 years admitted between 2007 and 2011. Patients were stratified into eight groups based on age. Clinical characteristics and outcomes were recorded, and regression analysis was used to determine mortality odds ratios (ORs) for HR ranges within each age group. ResultsA total of 214,254 pediatric trauma patients met inclusion criteria. The average admission HR and systolic blood pressure were 104.7 and 120.4, respectively. Overall mortality was 0.8%. The HR range associated with lowest mortality varied across age groups and, in children ages 7–14, was narrower than accepted resting HR ranges. The lowest risk of mortality for patients ages 5–14 was captured at HR 80–99. ConclusionsThe HR associated with lowest mortality after pediatric trauma frequently differs from resting HR. Our data suggest that a 7y old with an HR of 115 bpm may be in stage III shock, whereas traditional HR ranges suggest that this is a normal rate for this child. Knowing when HR is critically high or low in the pediatric trauma population will better guide treatment.

Non-accidental Trauma Injury Patterns and Outcomes: A Single Institutional Experience

Non-accidental trauma (NAT) victims account for a significant percentage of our pediatric trauma population. We sought to better understand the injury patterns and outcomes of NAT victims who were treated at our level I pediatric trauma center. Trauma registry data were used to identify NAT victims between January 2008 and December 2012. Demographic data, injury severity, hospital course, and outcomes were evaluated. One hundred and eighty-eight cases of suspected NAT were identified. Children were mostly male and white. The median age was 1.1 years; the median Injury Severity Score was 9. Traumatic brain injuries, lower extremity fractures, and skull fractures were the most common injuries. Twenty-seven per cent required medical procedures; most were performed by orthopedic surgery. Twenty-four per cent required admission to the pediatric intensive care unit. The median length of stay was two days. The mortality rate was 9.6 per cent. We generated a hot spot map of our catchment area and identified areas of our state where NAT occurs at increased rates. NAT victims sustain significant morbidity and mortality. Due to the severity of injuries, pediatric trauma surgeons should be involved in the evaluation and management of these children. Much work is needed to prevent the death and disability incurred by victims of child abuse.

Assessing the Relationship Between BMI and Resource Utilization in a Pediatric Trauma Population.

In 2000, 15.5% of children surpassed the BMI for age at the 95th percentile; in 2010, this percentage increased to 16.9%.1,2 Children with higher BMIs are at an increased risk for developing cardiovascular, endocrine, and mental disorders3 and may suffer more from diseases such as asthma and obstructive sleep apnea.4–7 Even more concerning is that approximately one-half of obese school-aged children become obese adults who are then at risk for diseases associated with adulthood obesity.8–10 The cost of treating adult obesity and its related comorbidities is significant, with estimates approaching $94 billion per year in 2002.11 Data related to health care utilization for overweight children are limited; 1 estimate suggests that obesity-associated inpatient hospitalization costs have risen threefold, from $35 million in 1979–1981 to $127 million in 1997–1999.12 Trauma is the leading cause of morbidity and mortality for pediatric patients,13 typically requiring extensive resources and expensive hospital-based health care.14 Multiple studies have reviewed the association between obesity and trauma outcomes (eg, ICU and hospital length of stay [LOS], mortality), with varied results.15–20 Single institutional studies have concluded that obese patients experiencing traumatic injuries have a higher incidence of complications,15 increased risk for ventilator support,20 and longer hospitalizations15,20 for comparable injury severity scores (ISS) than those with normal BMIs.15 In contrast, other studies have determined that there are no differences in total ventilation days or PICU LOS18 and found no association with mortality15,19 after adjusting for ISS17 in obese pediatric patients. Because hospital resources are finite, current health care economics demand optimal patient care at the lowest cost; appropriate utilization is therefore crucial. For the purposes of hospital planning and management, patient populations …

Alcohol consumption and interpersonal injury in a pediatric oral and maxillofacial trauma population: a retrospective review of 1,192 trauma patients.

The social, financial, and health implications of adult alcohol-related oral and maxillofacial trauma have been recognized for several years. Affordability and widespread accessibility of alcohol and issues of misuse in the pediatric trauma population have fostered concerns alcohol may be similarly implicated in young patients with orofacial trauma. The aim of this study was to review data of pediatric facial injuries at a regional maxillofacial unit, assess the prevalence of alcohol use, and review data of patients sustaining injury secondary to interpersonal violence. This study is a retrospective, 3-year review of a Regional Maxillofacial Unit (RMU) trauma database. Inclusion criterion was consecutive facial trauma patients under 16 years of age, referred to RMU for further assessment and/or management. Alcohol use and injuries sustained were reviewed. Of 1,192 pediatric facial trauma patients, 35 (2.9%) were associated with alcohol intake. A total of 145 (12.2%) alleged assault as the mechanism of injury, with older (12-15 years) (n = 129; 88.9%), male (n = 124; 85.5%) (p < 0.001) patients commonly involved and alcohol use implicated in 26 (17.9%) presentations. A proportion of vulnerable adolescents misuse alcohol to the risk of traumatic facial injury, and prospective research to accurately determine any role of alcohol in the pediatric trauma population is essential.

Tranexamic Acid Administration to Pediatric Trauma Patients in a Combat Setting: The Pediatric Trauma and Tranexamic Acid Atudy (PED-TRAX): Eckert MJ, Wertin TM, Tyner SD, et al. J Trauma Acute Care Surg 2014;77:852–8.

Early administration of tranexamic acid (TXA) in adult trauma patients has been associated with decreased mortality and blood product administration. Limited data are available on the use of TXA in pediatric trauma. The goal of this study was to evaluate the use and efficacy of TXA in pediatric combat patients. The authors conducted a retrospective cohort study of all pediatric trauma admissions to the North Atlantic Treaty Organization Role 3 hospital, Camp Bastion, Afghanistan, from 2008 to 2012. All pediatric trauma patients < 18 years of age were included. The primary outcome for the study was mortality. Secondary outcomes included factors associated with TXA use and complications of TXA use. TXA administration was used at adult dosing, with a single fixed bolus dose of 1 g TXA administered within 3 h of injury. In total, 766 admitted pediatric trauma patients were included in the study, of which 10% received TXA. Overall injury severity score (ISS) for those treated with TXA was significantly higher than average (15 vs. 10, p < 0.05). Significant independent predictors of TXA administration were severe abdominal or extremity injury and severe metabolic acidosis, with base deficit > 5. However, the propensity analysis model showed significant unexplained variance in the decision to administer TXA with an R-squared value of .47. Unadjusted mortality was higher in patients who received TXA (15% vs. 9%), but this difference was not statistically significant (P = 0.06). After controlling for confounding factors including mechanism, injury severity, base deficit, hypotension, and Glasgow Coma Scale score, TXA administration was associated with reduced mortality (P = 0.03). There were nonstatistically significant trends toward improved survival in those patients receiving TXA in subpopulation analysis of those who received transfusions and those severely injured, with an ISS > 15. Analysis of additional outcomes besides mortality studied in propensity-matched groups of TXA vs. no TXA administration demonstrated advantage to the TXA group, with significantly improved neurologic status at the time of discharge or transfer, a higher likelihood of a near-normal GCS score, fewer patients with severe brain injury, and a lower likelihood of requiring mechanical ventilation at the time of discharge or transfer. There were no adverse outcomes associated with the administration of TXA. The authors concluded that the same favorable association of survival advantage and safety profile as seen in the adult trauma population held true in a pediatric trauma population, and furthermore, there may be added benefit of improved neurologic and pulmonary outcomes in patients treated with TXA. Limitations acknowledged by the authors included the retrospective nature of the study, and no information on blood loss or coagulation/thromboelastometry data, which limits the ability to directly measure the effects of TXA on blood loss or coagulation; and lack of data on timing of TXA administration of subsequent dosing. Another limitation noted was that the relatively small population might significantly limit safety conclusions.

Pediatric vascular injury: experience of a level 1 trauma center

BackgroundOur purpose was to analyze modern major vascular injury (MVI) patterns in pediatric trauma, interventions performed, and outcomes at a level 1 trauma center. Materials and methodsFrom January 2000–December 2012, all pediatric admissions (≤17 y) were reviewed. ResultsOf 1928 pediatric admissions, 103 (5.3%) sustained MVI. This cohort was 85% male, age 15 ± 3 y, 55% black, 58% penetrating, injury severity score of 23 ± 15, with a length of stay of 8 (5) days. Firearm-related injury (47%) was the most common mechanism. Location of injuries included the extremities (50.5%), abdomen/pelvis (29.1%), and chest/neck (20.4%). Operative procedures included repair/bypass (71.4%), ligation (12.4%), amputation (10.5%), or temporary shunt (2.9%). Only three injuries (2.9%) were treated endovascularly. MVI patients had a mortality rate of 19.4%, higher than the overall pediatric trauma population of 3.5% (P < 0.001). After logistic regression, independent risk factors of mortality were vascular injury to the neck (odds ratio [OR]: 6.5; confidence interval (CI): 1.1–39.3), abdomen/pelvis (OR: 16.3; CI: 3.13–80.2), and chest (OR: 49.0; CI: 3.0–794.5). ConclusionsMVI in children more commonly results from firearm-related injury. The mortality rate associated with MVI is profoundly higher than that of the overall pediatric trauma population. These findings underscore the major public health concern of firearm-related injury in children.

Traumatic peripheral nerve injuries in children: epidemiology and socioeconomics.

Despite the negative effects of peripheral nerve injuries (PNIs) on long-term population health, their true prevalence among pediatric trauma patients is under debate. The authors investigated the prevalence of PNIs among children involved in trauma and investigated associations between PNIs and several patient characteristics. The authors performed a retrospective cohort study of pediatric trauma patients who were registered in the National Trauma Data Bank from 2009 through 2011 and who fulfilled the study inclusion criteria. They used regression techniques to investigate the association of demographic and socioeconomic factors with the rate of PNIs among these patients. Of the 245,470 study patients, 50,211 were involved in motor vehicle crashes, 3380 in motorcycle crashes, 20,491 in bicycle crashes, 18,262 in pedestrian accidents, 26,294 in other crashes (mainly involving all-terrain vehicles and snowmobiles), and 126,832 in falls. The respective prevalence of PNIs was 0.66% for motor vehicle crashes, 1% for motorcycle crashes, 0.38% for bicycle crashes, 0.42% for pedestrian accidents, 0.79% for other crashes, and 0.52% for falls. Multivariate logistic regression analysis demonstrated that the following were associated with an increased incidence of PNIs: increased patient age (OR 1.10, 95% CI 1.01-1.20), higher Injury Severity Score (OR 1.10, 95% CI 1.01-1.20), elevated systolic blood pressure at arrival at the emergency room (OR 1.10, 95% CI 1.01-1.20), and increased number of trauma surgeons at the institution (OR 1.10, 95% CI 1.01-1.20). The following were associated with lower incidence of PNIs: female sex (OR 0.94, 95% CI 0.87-1.02), rural hospitals (OR 0.94, 95% CI 0.87-1.02), and urban nonteaching hospitals (OR 0.94, 95% CI 0.87-1.02). PNIs are more common than previously identified for the pediatric trauma population. These injuries are associated with older age and increased severity of the overall injury.

Nuking the radiation: minimizing radiation exposure in the evaluation of pediatric blunt trauma.

Our objective is to highlight recent literature investigating low-radiation diagnostic strategies in the evaluation of pediatric trauma. In the area of minor head injury, research has focused on implementation of validated clinical decision rules into practice to reduce unnecessary computed tomography scans. Clinical observation may also serve as an adjunct to initial assessment and a potential substitute for computed tomography imaging. Subgroups of children with special needs or severe injury mechanisms may also be safely characterized by the clinical decision rule and spared radiation exposure. Physical examination techniques may be useful in diagnosing mandibular fractures. In addition, evidence suggests that plain radiography for evaluation of blunt thoracic trauma may be sufficient in many cases, and computed tomography could be reserved for those with abnormal radiographs, high-risk mechanisms, or abnormal physical findings. Clinical decision rules are able to predict intra-abdominal injury with high sensitivity. Data suggest that skeletal surveys may be modified to limit radiation exposure in the case of suspected nonaccidental trauma. More research is needed in development of pediatric-specific clinical decision rules and risk stratification and in testing low-radiation diagnostic modalities in the pediatric trauma population.