Pediatric Trauma Resuscitation Research Articles

Whole blood: Total blood product ratio impacts survival in injured children.

Some studies in both children and adults have shown a mortality benefit for the use of low titer group O whole blood (LTOWB) compared with component therapy for traumatic resuscitation. Although LTOWB is not widely available at pediatric trauma centers, its use is increasing. We hypothesized that in children who received whole blood after injury, the proportion of whole blood in relation to the total blood product resuscitation volume would impact survival. The trauma database from a single academic pediatric Level I trauma center was queried for pediatric (age <18 years) recipients of LTOWB after injury (years 2015-2022). Weight-based blood product (LTOWB, red blood cells, plasma, and platelet) transfusion volumes during the first 24 hours of admission were recorded. The ratio of LTOWB to total transfusion volume was calculated. The primary outcome was in-hospital mortality. Multivariable logistic regression model adjusted for the following variables: age, sex, mechanism of injury, Injury Severity Score, shock index, and Glasgow Coma Scale score. Adjusted odds ratio representing the change in the odds of mortality by a 10% increase in the LTOWB/total transfusion volume ratio was reported. There were 95 pediatric LTOWB recipients included in the analysis, with median (interquartile range [IQR]) age of 10 years (5-14 years), 58% male, median (IQR) Injury Severity Score of 26 (17-35), 25% penetrating mechanism. The median (IQR) volume of LTOWB transfused was 17 mL/kg (15-35 mL/kg). Low titer group O whole blood comprised a median (IQR) of 59% (33-100%) of the total blood product resuscitation. Among patients who received LTOWB, there was a 38% decrease in in-hospital mortality for each 10% increase in the proportion of WB within total transfusion volume ( p < 0.001) after adjusting for age, sex, mechanism of injury, Injury Severity Score, shock index, and Glasgow Coma Scale score. Increased proportions of LTOWB within the total blood product resuscitation was independently associated with survival in injured children. Based on existing data that suggests safety and improved outcomes with whole blood, consideration may be given to increasing the use of LTOWB over CT resuscitation in pediatric trauma resuscitation. Therapeutic/Care Management; Level III.

Multidisciplinary Simulation for Blunt and Penetrating Pediatric Trauma Utilizing Standard and Rapid Cycle Deliberate Practice Models.

Pediatric trauma resuscitations are low-frequency, high-stakes events that require skilled multidisciplinary teams with strong medical knowledge and communication skills. This pediatric trauma simulation training session included two cases and formats. The first case was designed in a traditional format and featured a 12-month-old child with inflicted blunt head and abdominal trauma. The second case was organized in successive rounds utilizing the rapid cycle deliberate practice (RCDP) model and featured an 18-month-old with gunshot wounds to the abdomen and chest. Educational objectives included effective communication in a multidisciplinary team, timely completion of primary and secondary surveys, awareness of systems and processes related to trauma care, and increasing competency with low-frequency pediatric trauma skills. Necessary equipment included high-fidelity toddler-sized mannequins, chest tube task trainer or applicable mannequin and equipment, intubation equipment and supplies, intraosseous access, and blood products with rapid delivery infusers. This training session was designed for learners in a multidisciplinary team including physician trainees, nurses, and advanced practice providers; adjustments could be made to the team members as desired. Quantitative and qualitative evaluations demonstrated high learner satisfaction and engagement, particularly in the RCDP style of learning. Multidisciplinary team practice of pediatric trauma scenarios, particularly utilizing the RCDP simulation model, provides the opportunity to improve teamwork and communication, practice procedural skills, and deepen team members' understanding of and comfort with trauma resuscitations.

Prevalence and outcomes of high versus low ratio plasma to red blood cell resuscitation in a multi-institutional cohort of severely injured children.

The benefit of targeting high ratio fresh frozen plasma (FFP)/red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP/RBC transfusion and the association with outcomes in children presenting in shock. A post hoc analysis of a 24-institution prospective observational study (April 2018 to September 2019) of injured children younger than 18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (≥1:2) ratio FFP/RBC. Nonparametric Kruskal-Wallis and χ 2 were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths. Of 135 children with median (interquartile range) age 10 (5-14) years and weight 40 (20-64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (low-38%, high-46%, p = 0.34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = 0.01); however, hospital mortality was similar (low-24%, high-20%, p = 0.65) as was the risk of extended ventilator, intensive care unit, and hospital days (all p > 0.05). Despite increased injury severity, patients who received a high ratio of FFP/RBC had comparable rates of mortality. These data suggest high ratio FFP/RBC resuscitation is not associated with worst outcomes in children who present in shock. Massive transfusion protocol activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers. Therapeutic/Care Management; Level III.

Use of pediatric trauma simulations to facilitate exposure to pediatric trauma resuscitations during training

BackgroundPediatric traumas are often high-acuity but are low-frequency compared to adult trauma activations. This is reflected in the relatively limited experience with these events during training. Although some principles of trauma resuscitation are similar between adults and children, there are also important differences in physiology, injury patterns, and presentation. Therefore, simulation can be used to supplement trainee exposure and enhance their ability to respond to these high-stakes events. MethodsWe developed a multidisciplinary pediatric trauma resuscitation simulation curriculum to increase exposure to pediatric traumas at our institution. The intervention includes monthly sessions in the pediatric resuscitation bays, during which multidisciplinary teams complete 2 full pediatric trauma resuscitation simulations. This is supplemented with formal debriefing, simulation-specific teaching, and standardized trauma cognitive aids. The comprehensiveness of trauma evaluations and resuscitation efforts are evaluated using our institutional structured trauma resuscitation observation tool, and post-simulation surveys are used to assess the impact of the teaching interventions. ResultsNine simulation sessions were conducted with more than 100 participants, including surgical residents, emergency medicine residents, nursing staff, respiratory therapists, and medical students. Completeness of resuscitation efforts improved from 55% to 82% (P < .01) between initial and repeat simulations. Surveyed participants reported improvement in overall team performance on the Team Emergency Assessment Measure (P < .01). ConclusionImplementing a multidisciplinary pediatric trauma simulation curriculum with structured teaching interventions and standardized trauma scripts promotes teamwork and strengthens trainees’ ability to conduct comprehensive evaluations required for high-acuity pediatric traumas.

A National Comparison of Volume and Acuity for Adult and Pediatric Trauma: A Trauma Quality Improvement Program Cohort Study

IntroductionMost injured children receive trauma care outside of a pediatric trauma center. Differences in physiology, dosing, and injury pattern limit extrapolation of adult trauma principles to pediatrics. We compare US trauma center experience with pediatric and adult trauma resuscitation. Materials and MethodsWe queried the 2019 Trauma Quality Improvement Program to describe the experience of US trauma centers with pediatric (<15 y) and adult trauma. We quantified blunt, penetrating, burn, and unspecified traumas and compared minor, moderate, severe, and critical traumas (ISS 1-8 Minor, ISS 9-14 Moderate, ISS 15-24 Severe, ISS 25+ Critical). We estimated center-level volumes for adults and children. Institutional identifiers were generated based on unique center specific factors including hospital teaching status, hospital type, verification level, pediatric verification level, state designation, state pediatric designation, and bed size. ResultsA total of 755,420 adult and 76,449 pediatric patients were treated for traumatic injuries. There were 21 times as many critical or major injuries in adults compared to children, 17 times more moderate injuries, and 6 times more minor injuries. Children and adults presented with similar rates of blunt trauma, but penetrating injuries were more common in adults and burn injuries were more common in children. Comparing center-level data, adult trauma exceeded pediatric for every severity and mechanism. ConclusionsThere is relatively limited exposure to high-acuity pediatric trauma at US centers. Investigation into pediatric trauma resuscitation education and simulation may promote pediatric readiness and lead to improved outcomes.

Transitioning Cognitive Aids into Decision Support Platforms: Requirements and Design Guidelines.

Digital cognitive aids have the potential to serve as clinical decision support platforms, triggering alerts about process delays and recommending interventions. In this mixed-methods study, we examined how a digital checklist for pediatric trauma resuscitation could trigger decision support alerts and recommendations. We identified two criteria that cognitive aids must satisfy to support these alerts: (1) context information must be entered in a timely, accurate, and standardized manner, and (2) task status must be accurately documented. Using co-design sessions and near-live simulations, we created two checklist features to satisfy these criteria: a form for entering the pre-hospital information and a progress slider for documenting the progression of a multi-step task. We evaluated these two features in the wild, contributing guidelines for designing these features on cognitive aids to support alerts and recommendations in time- and safety-critical scenarios.

Discovering interpretable medical process models: A case study in trauma resuscitation

Understanding the actual work (i.e., “work-as-done”) rather than theorized work (i.e., “work-as-imagined”) during complex medical processes is critical for developing approaches that improve patient outcomes. Although process mining has been used to discover process models from medical activity logs, it often omits critical steps or produces cluttered and unreadable models. In this paper, we introduce a TraceAlignment-based ProcessDiscovery method called TAD Miner to build interpretable process models for complex medical processes. TAD Miner creates simple linear process models using a threshold metric that optimizes the consensus sequence to represent the backbone process, and then identifies both concurrent activities and uncommon-but-critical activities to represent the side branches. TAD Miner also identifies the locations of repeated activities, an essential feature for representing medical treatment steps. We conducted a study using activity logs of 308 pediatric trauma resuscitations to develop and evaluate TAD Miner. TAD Miner was used to discover process models for five resuscitation goals, including establishing intravenous (IV) access, administering non-invasive oxygenation, performing back assessment, administering blood transfusion, and performing intubation. We quantitively evaluated the process models with several complexity and accuracy metrics, and performed qualitative evaluation with four medical experts to assess the accuracy and interpretability of the discovered models. Through these evaluations, we compared the performance of our method to that of two state-of-the-art process discovery algorithms: Inductive Miner and Split Miner. The process models discovered by TAD Miner had lower complexity and better interpretability than the state-of-the-art methods, and the fitness and precision of the models were comparable. We used the TAD process models to identify (1) the errors and (2)the best locations for the tentative steps in knowledge-driven expert models. The knowledge-driven models were revised based on the modifications suggested by the discovered models. The improved modeling using TAD Miner may enhance understanding of complex medical processes.

The Use of Blood in Pediatric Trauma Resuscitation

The Use of Blood in Pediatric Trauma Resuscitation

Association of blood product ratios with early mortality in pediatric trauma resuscitation: A time-dependent analysis from the National Trauma Databank.

Injured children with severe hemorrhage often receive blood product transfusions with ratios of plasma and platelets to packed red blood cells (PRBCs) approaching 1:1:1. Whether blood product ratios vary during pediatric resuscitation is unknown. This study (1) described precise timing of pediatric blood product administration, (2) characterized changes in blood product ratios over time, and (3) evaluated the association of blood products with early mortality while incorporating time-varying factors. Pediatric (younger than 18 years) trauma patients receiving high-volume transfusion (>40 mL/kg total products or >2 U PRBC or whole blood, during first 4 hours) were obtained from the 2017 to 2019 Trauma Quality Improvement Program database. The time of each individual product transfusion was recorded, along with demographics, injury details, and times of death. Patients were assigned to blood product groups at 15-minute intervals: high plasma/PRBC ratio (>1:1) with platelets, high plasma/PRBC ratio (>1:1) without platelets, low plasma/PRBC ratio (<1:1), PRBC only, and whole blood. Cox proportional hazards modeling for 24-hour mortality was performed, including blood product group as a time-varying variable and adjusting for relevant covariates. Of 1,152 included patients (median age, 15 years; 32% penetrating, 28% severe traumatic brain injury [sTBI]), 18% died within 24 hours. During the resuscitation period, the number of patients in high-ratio groups increased over time, and patients switched blood product groups up to six times. There was no significant difference in mortality by blood product group. Among patients with sTBI, there was a strong trend toward lower mortality among high plasma/PRBC without platelets versus high plasma/PRBC with platelets (hazard ratio, 0.55; p = 0.07). No significant association of high ratios or whole blood with mortality was seen when time-varying factors were incorporated. The impact of balanced resuscitation strategies, particularly platelet transfusion, may be greatest among patients with sTBI. Optimizing balanced resuscitation for children requires appropriately designed prospective studies. Therapeutic/Care Management; Level IV.

Determining the Association Between Emergency Department Crowding and Debriefing After Pediatric Trauma Resuscitations.

Debriefing in the pediatric emergency department (PED) is an invaluable tool to improve team well-being, communication, and performance. Despite evidence, surveys have reported heavy workload as a barrier to debriefing leading to missed opportunities for improvement in an already busy ED. The study aims to determine the association between the incidence of debriefing after pediatric trauma resuscitations and PED crowding. A total of 491 Trauma One activations in Riley Children's Hospital Pediatric Emergency Department that presented between April 2018 to December 2019 were included in the study. Debriefing documentations, patient demographics, time and date of presentation, mechanism of injury, injury severity score, disposition from PED, and length of stay (LOS) were collected and analyzed. The National Emergency Department Overcrowding Scale score at arrival, Average LOS, total PED census, total PED waiting room census, and rates of left without being seen were compared between groups. Of 491 Trauma One activations presented to our PED, 50 (10%) trauma evaluations had documented debriefing. The National Emergency Department Overcrowding Scale score at presentation was significantly lower in those with debriefing versus without debriefing. In addition, the PED hourly census, waiting room census, average LOS, and left without being seen were also significantly lower in the group with debriefing. In addition, trauma cases with debriefing had a higher proportion of patients with profound injuries and discharges to the morgue. Pediatric emergency department crowding is a significant barrier to debriefing after trauma resuscitations. However, profound injuries and traumatic pediatric deaths remain the strongest predictors in conducting debriefing regardless of PED crowding status.

Impact of COVID-19 on emergency medicine resident procedure performance.

As a result of the COVID-19 pandemic, patterns of patient presentations and medical education have changed, potentially resulting in fewer and different types of patient encounters. Procedural proficiency is a cornerstone of emergency medicine (EM) training, and residents must meet Accreditation Council for Graduate Medical Education (ACGME) requirements to graduate. It is feared there may have been a pandemic-induced decrease in opportunities for residents to perform procedures. This study investigates the change in procedures performed by EM residents during the initial year of the pandemic. This study utilized a multicenter retrospective design. Across three EM residency programs, logs of 14 ACGME-required procedures performed by residents were reviewed. For each procedure, counts were compared prepandemic year (March 2019 to February 2020) to during pandemic year (March 2020 to February 2021). Procedures were further grouped into 4-month periods: March to June, July to October, and November to February. A total of 113 EM resident physicians were included in this study. Procedures performed by EM residents tended to decrease during the COVID-19 pandemic. There were statistically significant decreases in number of annual cricothyrotomies (2.4 vs. 0.9, p < 0.001) and pediatric trauma resuscitations (5.7 vs. 3.9, p=0.024). Comparing the first 4-month periods of each year, there were significant decreases in cardiac pacing (6.3 vs. 5.4, p=0.038), chest tubes (2.2 vs. 1.0, p < 0.001), cricothyrotomies (0.6 vs. 0.1, p=0.001), intubations (8.2 vs. 4.4, p=0.002), and pericardiocenteses (1.7 vs. 0.2, p < 0.001). The COVID-19 pandemic has led to a decrease in the number of procedures performed per EM resident in many of the domains required by the ACGME. Although only some procedures had statically significant decreases, it remains to be seen if this will lead to decreased resident procedural competency. Further research may be required in this area to determine any such effect.

Factors Affecting Peripheral Intravenous Catheter Placement During Pediatric Trauma Resuscitation

IntroductionIntravenous access is required for resuscitation of injured patients but may be delayed in children because of challenges associated with peripheral intravenous (PIV) catheter placement. Early identification of factors predisposing patients to difficult PIV placement can assist in deciding strategies for timely intravenous access. MethodsWe conducted a retrospective, video-based review of injured children and adolescents treated between April 2018 and May 2019. Patient demographic, physiological, injury, and resuscitation characteristics were obtained from the patient record, including age, race, weight, injury type, Injury Severity Score, initial systolic blood pressure, initial Glasgow Coma Score, intubation status, activation level, and presence of prearrival notification. Video review was used to determine the time to PIV placement, the number of attempts required, the purpose for additional access, and the reason for abandonment of PIV placement. Multivariable regressions were used to determine factors associated with successful placement. ResultsDuring the study period, 154 consented patients underwent attempts at PIV placement in the trauma bay. Placement was successful in 139 (90.3%) patients. Older patients (OR [odds ratio]: 0.9, 95% confidence interval [CI]: 0.9, 0.9) and patients who required the highest level activation response (OR: 0.0, 95% CI: 0.0, 0.3) were less likely to have an attempt at PIV placement abandoned. Children with nonblunt injuries (OR: 11.6, 95% CI: 1.3, 119.2) and pre-existing access (OR: 39.6, 95% CI: 7.0, 350.6) were more likely to have an attempt at PIV placement abandoned. Among patients with successful PIV placement, the time required for establishing PIV access was faster as age increased (−0.5 s, 95% CI: −1.1, −0.0). ConclusionsYounger age was associated with abandonment of PIV attempts and, when successful, increased time to placement. Strategies to improve successful PIV placement and alternate routes of access should be considered early to prevent treatment delays in younger children.

Pediatric Trauma Resuscitation Practices

Pediatric Trauma Resuscitation Practices

The regional whole blood program in San Antonio, TX: A 3‐year update on prehospital and in‐hospital transfusion practices for traumatic and non‐traumatic hemorrhage

AbstractLow titer type O Rh‐D + whole blood (LTO + WB) has become a first‐line resuscitation medium for hemorrhagic shock in many centers around the World. Showing early effectiveness on the battlefield, LTO + WB is used in both the pre‐hospital and in‐hospital settings for traumatic and non‐traumatic hemorrhage resuscitation. Starting in 2018, the San Antonio Whole Blood Collaborative has worked to provide LTO + WB across Southwest Texas, initially in the form of remote damage control resuscitation followed by in‐hospital trauma resuscitation. This program has since expanded to include pediatric trauma resuscitation, obstetric hemorrhage, females of childbearing potential, and non‐traumatic hemorrhage. The objective of this manuscript is to provide a three‐year update on the successes and expansion of this system and outline resuscitation challenges in special populations.

Interprofessional Pediatric Trauma Resuscitation Simulation

IntroductionSuccessful resuscitation of pediatric trauma patients requires a team of individuals to come together to provide coordinated, efficient care to the injured child. Lack of specific education in team dynamics and trauma resuscitation skills, combined with a constantly changing membership of pediatric trauma teams, creates barriers to excellence in care delivery. Therefore, it is essential for teams to practice these high-risk, low-volume skills to establish and maintain competency.MethodsAn online educational program consisting of team dynamic training, hospital-specific trauma roles/responsibilities, and exposure to a trauma resuscitation checklist was delivered to 40 interprofessional participants who were representative of the pediatric trauma team. Team members then attended an in-situ simulation of two pediatric trauma resuscitation scenarios.ResultsForty interprofessional team members participated in the program. Education and simulations were well received by the overwhelming majority of participants, with mean scores for achievement of program objectives ranging from 4.75 to 4.85 based on a Likert scale from 1 to 5. Logistical details such as scheduling, equipment setup and takedown, stakeholder buy-in, and validation for continued program funding were determined to be sustainable in that the overall program was not labor intensive, the scheduling system was user friendly, and the financial impact was minimal.DiscussionThis project provided participants with a baseline of education and the opportunity to practice pediatric trauma resuscitation using simulated scenarios that allowed for assessment of team functioning and clinical performance. The results reinforced the acceptance of interprofessional education and identified subject matter for future educational programs.

Alerts as Coordination Mechanisms

In this study, we explore how clinical decision support features can be designed to aid teams in caring for patients during time-critical medical emergencies. We interviewed 12 clinicians with experience in leading pediatric trauma resuscitations to elicit design requirements for decision support alerts and how these alerts should be designed for teams with shared leadership. Based on the interview data, we identified three types of decision support alerts: reminders to perform tasks, alerts to changes in patient status, and suggestions for interventions. We also found that clinicians perceived alerts in this setting as coordination mechanisms and that some alert preferences were associated with leader experience levels. From these findings, we contribute three perspectives on how alerts can aid coordination and discuss implications for designing decision support alerts for shared leadership in time-critical medical processes.

Exploring the Design of Streaming Data Interfaces for Emergency Medical Contexts.

In this late-breaking work, we describe the design of an interface for displaying streaming vital sign data on a digital checklist used in the emergency medical setting of pediatric trauma resuscitation. We used feedback from interviews and participatory design workshops with clinicians to develop two prototypes of the streaming vital sign interface. We evaluated these prototypes in design-walkthroughs, finding that clinicians preferred the design displaying trend graphs for all four vital signs at once. We discuss how streaming data interfaces on interactive mobile devices can be used to provide situational awareness while unobtrusively supporting different levels of clinical experience.

Whole blood hemostatic resuscitation in pediatric trauma: A nationwide propensity-matched analysis.

Whole blood (WB) has shown promise in pediatric trauma resuscitation following its prominent role in the resuscitation of adult trauma patients. Although WB in children has been shown to be feasible, its effectiveness has yet to be explored. The aim of this study was to examine the outcomes of WB transfusion as an adjunct to component therapy (CT) compared with CT only as early resuscitation for pediatric trauma patients. Children aged 1 to 17 years, who were transfused within 4 hours of presentation, were identified in the Trauma Quality Improvement Program 2017 database. Patients were stratified into those receiving WB-CT versus CT alone. Propensity score matching in a 1:2 ratio was performed based on patient demographics, injury characteristics, hemorrhage control interventions, and trauma center level. The primary outcome measure was patient transfusion requirement. Secondary outcome measures were mortality, hospital length of stay, ventilation days, and major complications. A total of 135 children receiving WB-CT were matched to 270 patients receiving CT only. Mean (SD) age was 12 (5) years, 66% were male, and the median Injury Severity Score was 32 (range, 20-43). A total of 51% of patients were in shock, 34% had penetrating injuries, and 41% required surgical intervention for hemorrhage control. Total blood products transfused were significantly decreased in children receiving WB, both at 4 hours (35 [22-73] vs. 48 [33-95] mL/kg; p = 0.013) and 24 hours (39 [24-97] vs. 53 [36-119] mL/kg; p < 0.001). Mortality rate at 24 hours (19.3% vs. 21.9%; p = 0.546) and in-hospital mortality (31.1% vs. 34.4%; p = 0.502) were not different. Similarly, no difference in hospital length of stay and rates of major complications was found. Patients in the WB group required significantly less ventilation days (2 [2-6] vs. 3 [2-8] days; p = 0.021). Using WB as an adjunct to CT was associated with decreased transfusion requirements and ventilation days in pediatric trauma patients. Therapeutic, level III.

Higher Crystalloid Volume During Initial Pediatric Trauma Resuscitation is Associated With Mortality

BackgroundHistorically, aggressive fluid resuscitation has been a cornerstone of management of hemorrhagic shock in pediatrics. Adult data suggest this strategy may be harmful. We sought to determine whether aggressive fluid resuscitation within the first hour of presentation to the emergency department in pediatric patients with trauma is associated with worse clinical outcomes. Materials and methodsWe performed a retrospective cohort study from 2012 to 2017 at a single pediatric level 1 trauma center. We defined three patient cohorts: ≤ 20 cc/kg (reference), 20-40 (20.01 to 39.99) cc/kg, and ≥40 cc/kg of intravenous fluid (IVF) given in the first in-hospital hour. Covariates included age, injury severity score, shock index (adjusted for age), and mechanism of injury and were adjusted for with multivariable regression. The primary outcome was in-hospital mortality. ResultsA total of 1479 consecutive injured children were eligible for inclusion. One hundred ninety-four patients were excluded for missing IVF data, aged ≥16 y, having primary burns, or arriving pulseless. A total of 1285 patients met inclusion criteria (mean age 8.1 ± 5.5 y, male 64.5%). Higher rates of IVF administration were associated with mortality for both the 20-40 cc/kg (adjusted odds ratio (aOR) 2.96; 95% confidence interval (CI) 1.02-8.55; P = 0.045) and ≥40 cc/kg groups (aOR 6.26; 95% CI 1.79-21.83; P = 0.004). The ≥40 cc/kg group was associated with increased pediatric intensive care unit length of stay (aOR 2.20; 95% CI: 1.05-4.61; P = 0.036) and increased need for mechanical ventilation (aOR 3.79; 95% CI 1.62-8.87; P = 0.002). ConclusionsGreater than one 20 cc/kg IVF bolus in the first emergency department hour was associated with mortality with a dose-response relationship, even after adjusting for injury severity and initial hemodynamics. These results encourage further investigation into initial resuscitation strategies for injured children.

Assessment of Non-Routine Events and Significant Physiological Disturbances during Emergency Department Evaluation after Pediatric Head Trauma.

Outcomes following pediatric traumatic brain injury (TBI) are dependent on initial injury severity and prevention of secondary injury. Hypoxia, hypotension, and hyperventilation following TBI are associated with increased mortality. The purpose of this study was to determine the association of non-routine events (NREs) during the initial resuscitation phase with these physiological disturbances. We conducted a video review of pediatric trauma resuscitations of patients with suspected TBI and Glasgow Coma Scale (GCS) scores <13. NREs were rated as “momentary” if task progression was delayed by <1 min and “moderate” if delayed by >1 min. Vital sign monitor data were used to identify periods of significant physiological disturbances. We calculated the association between the rate of overall and moderate NREs per case and the proportion of cases with abnormal vital signs using multi-variate linear regression, controlling for GCS score and need for intubation. Among 26 resuscitations, 604 NREs were identified with a median of 23 (interquartile range [IQR] 17–27.8, range 5–44) per case. Moderate delay NREs occurred in 19 resuscitations (n = 32, median 1 NRE/resuscitation, IQR 0.3–1, range 0–5). Oxygen desaturation and respiratory depression were associated with a greater rate of moderate NREs (p = 0.008, p < 0.001, respectively). We observed no association between duration of hypotension, desaturation, and respiratory depression and overall NRE rate. NREs are common in the initial resuscitation of children with moderate to severe TBI. Episodes of hypoxia and respiratory depression are associated with NREs that cause a moderate delay in task progression. Conformance with resuscitation guidelines is needed to prevent physiological events associated with adverse outcomes following pediatric TBI.