Regional Pediatric Trauma Center Research Articles

1.64 Retrospective Analysis of Substance Use–Related Psychiatric Consultations at a Level 1 Regional Pediatric Trauma Center

1.64 Retrospective Analysis of Substance Use–Related Psychiatric Consultations at a Level 1 Regional Pediatric Trauma Center

Risk of Injury-Related Readmission Varies by Initial Presenting-Hospital Type Among Children at High Risk for Physical Abuse.

Children experiencing physical abuse may initially present to hospitals with underappreciated minor injuries, only to experience more severe injuries in the future. The objectives of this study were to 1) describe young children presenting with high-risk diagnoses for physical abuse, 2) characterize the hospitals to which they initially presented, and 3) evaluate associations of initial presenting-hospital type with subsequent admission for injury. Patients aged younger than 6 years from the 2009-2014 Florida Agency for Healthcare Administration database with high-risk diagnoses (codes previously associated with >70% risk of child physical abuse) were included. Patients were categorized by the hospital type to which they initially presented: community hospital, adult/combined trauma center, or pediatric trauma center. Primary outcome was subsequent injury-related hospital admission within 1 year. Association of initial presenting-hospital type with outcome was evaluated with multivariable logistic regression, adjusting for demographics, socioeconomic status, preexisting comorbidities, and injury severity. A total of 8626 high-risk children met inclusion criteria. Sixty-eight percent of high-risk children initially presented to community hospitals. At 1 year, 3% of high-risk children had experienced subsequent injury-related admission. On multivariable analysis, initial presentation to a community hospital was associated with higher risk of subsequent injury-related admission (odds ratio, 4.03 vs level 1/pediatric trauma center; 95% confidence interval, 1.83-8.86). Initial presentation to a level 2 adult or combined adult/pediatric trauma center was also associated with higher risk for subsequent injury-related admission (odds ratio, 3.19; 95% confidence interval, 1.40-7.27). Most children at high risk for physical abuse initially present to community hospitals, not dedicated trauma centers. Children initially evaluated in high-level pediatric trauma centers had lower risk of subsequent injury-related admission. This unexplained variability suggests stronger collaboration is needed between community hospitals and regional pediatric trauma centers at the time of initial presentation to recognize and protect vulnerable children.

Pediatric Dog Bites: A Review of 1422 Cases Treated at a Level One Regional Pediatric Trauma Center.

Children under the age of 14 account for over 40% of the almost 900,000 annual hospital visits associated with dog bites. Care for dog bites ranges from simple wound irrigation to complex surgical reconstruction. Due to a number of factors, children frequently sustain dog bites to highly vulnerable regions, often necessitating intervention by plastic surgeons. This retrospective study analyzed data from the 1422 pediatric patients who sustained dog bites and presented to the Le Bonheur Children's Hospital Emergency Room from January 2011 to May 2017. The typical pediatric dog bite case was male (63.5%), African-American (57.4%), and less than 10 years old (69.4%). The head and neck were the most commonly affected areas (64.7%). Of the head and neck regions, the cheeks and lips were the most frequently injured structures (34.5%). Hospital admission was required for 188 patients (13.2%) and operative repair was deemed necessary in 16.9% of all cases. Of the patients requiring inpatient operative repair, most (78.3%) were discharged in less than 24 hours. Operative complications occurred in 5.8% of all cases, with infections accounting for the majority (92.9%). No fatal dog bites occurred in this study. Age, bite location, and number of bites sustained are several factors of significance, which may aid the novice plastic surgeon in identifying, which pediatric dog bite cases will require surgical intervention.

Health-related Quality of Life After Fractures of the Lateral Third of the Clavicle in Children and Adolescents.

The health-related quality of life after pediatric fractures of the lateral third of the clavicle is unknown. Given the trend in the literature toward surgical management of clavicular fractures in adults, we frequently receive referrals for surgical management of lateral clavicular fractures in children.Therefore, we examined (1) the health-related quality of life of patients who sustained a fracture of the lateral third of the clavicle in childhood and who were treated at a large regional pediatric trauma center, (2) if the health-related quality of life was associated with the age at the time of the injury, and (3) whether fracture and displacement patterns were associated with health-related qualify of life. This is a retrospective case series. We were able to identify 69 patients (21 girls and 48 boys) who sustained a fracture of the lateral third of the clavicle between the period spanning from January 2004 to June 2015. These patients were asked to fill in a questionnaire that included the Quick version of the Disability of Arm, Shoulder, and Hand (DASH) (primary outcome) and the Pediatric Quality of Life Inventory (Peds-QL). Until July 2017, we were able to get a response from 56 of these patients, resulting in a follow-up of 81%. Treatment was conservative in all cases but one. In these cases, after a mean follow-up of 6.5 years (range, 1 to 13.2 y), the mean Quick-DASH was 1.2 (SD, 4.4) at a scale of 0 to 100, with lower values representing better quality of life. The mean physical function score of the Peds-QL was 97.8 (SD, 4.4), and the mean psychosocial function score was 91.8 (SD, 10.8), both at a scale of 0 to 100, with higher values representing better quality of life.There was no statistically significant association of age at the time of injury on the primary outcome Quick-DASH.There were no statistically significant associations between fracture or displacement patterns with regard to health-related quality of life. Conservative treatment of lateral clavicular fractures in children and adolescents is associated with excellent health-related quality of life, as measured with the disease-specific Quick-DASH and the non-disease-specific Peds-QL at a mean follow-up of 6.5 years (range, 1 to 13.2 y). There was no effect of age at the time of injury, and we were unable to identify associations to commonly analyzed risk factors, such as displacement patterns.As the conservative treatment of this type of fracture in children and adolescents is associated with such a good health-related quality of life, it is unlikely that these results could be further improved by surgical interventions. Level IV-case series.

Seasonal, Weather, and Temporal Factors in the Prediction of Admission to a Pediatric Trauma Center.

Our objective is to identify seasonal and weather trends associated with pediatric trauma admissions. We reviewed all trauma activations leading to admission in patients ≤18years admitted to a regional pediatric trauma center from January 1, 2000, to December 31, 2015. We reviewed climatologic measures of the mean temperature, mean visibility, and precipitation for each admission in the 6h prior to each presentation in addition to time of arrival, weekday/weekend presentation, and season. We used a negative binomial regression model with multivariable analysis to estimate associations between weather and rate of trauma admissions. Results were presented as incidence rate ratios (IRR) with 95% confidence intervals (CI). In total, 3856 encounters [2539 males (65.8%), mean age 10.2years ± SD 5.1years] were included. Results from multivariable analysis (IRR, 95% CI) suggested an association of admissions with rain (0.82, 0.75-0.90) and overnight hours (23:51-05:50; 0.69, 0.58-0.82) as compared to morning (05:51-11:50). The IRR of trauma increased during the afternoon (11:51-17:50; 4.05, 3.57-4.61), night periods (17:51-23:50; 5.59, 4.94-6.33), and weekends (1.24, 1.15-1.32), and with every 1°C increase in temperature (1.04, 1.03-1.04). After accounting for other variables, season was not found to be independently predictive of trauma admission. Trauma admissions had a higher rate during afternoon, evening hours, and weekends. The presence of rain lowered the rate of pediatric trauma admission. Each degree increase in temperature increased the rate of trauma admissions by 4%. The findings provide information from the perspective of emergency preparedness, resource utilization, and staffing to pediatric trauma centers.

"Perimortem" total body CT-scan examination in severely injured children: an informative insight into the causes of death.

To report routine practice of "perimortem" CT-scan imaging to determine the causes of death in children dying from severe accidental injuries within the first hours following hospital admission. Trauma center of a University Pediatric Hospital. A retrospective study was conducted in children (0 to 15years old) referred for severe trauma (GCS ≤ 8) to a regional pediatric trauma center, presenting with at least spontaneous cardiac rhythm and dying within the first 12h after admission. "Perimortem" CT-scan consisted in high-resolution, contrast-enhanced, full-body CT-scan imaging, performed whatever child's clinical status. Lethal and associated lesions found were analyzed and classified according to validated scales. The comparison between clinical and radiological examinations and CT-scan findings evaluated the accuracy of clinical examination to predict lethal lesions. CT-scan performed in 73 children detected 132 potentially lethal lesions, at least 2 lesions in 63%, and 1 in 37% of the cases. More frequent lethal lesions were brain (43%), and chest injuries (33%), followed by abdominal (12%), and cervical spine injuries (12%). Clinical and minimal radiological examinations were poorly predictive for identifying abdominal/chest lesions. Clinical and imaging data provided to the medical examiner were considered sufficient to identify the cause of death, and to deliver early burial certificates in 70 children. Only three legal autopsies were commanded. Perimortem CT imaging could provide an insight into the causes of death in traumatized children. Performed on an emergency basis near death, it eliminates the difficulties encountered in forensic radiology. It could be a possible alternative to full-scale forensic examination, at least regarding elucidation of the potential, or highly probable causes of death.

Postconcussion Academic Support in Children Who Attend a Primary Care Provider Follow-up Visit after Presenting to the Emergency Department

To examine whether a primary care provider (PCP) follow-up visit after emergency department evaluation of concussion improved the children's likelihood of receiving academic support. This was a prospective cohort study. Concussed children, aged 8-18years, presenting to a regional pediatric trauma center emergency department (n=160) were contacted 7 and 30days after injury to gather data on PCP follow-up, symptoms, quality of life, and receipt of academic support instituted after and because of the concussion. Bivariate comparisons of demographics, concussion characteristics, quality of life, and symptoms were made between children who did and did not receive support using independent samples ttests, Wilcoxon rank sum tests, or χ2 tests. ORs and 95% CIs were calculated using multivariable logistic regression with backwards elimination to test the association between attending an outpatient follow-up visit and the receipt of academic support for variables where P<.2 in bivariate comparisons. Overall, 51.3% (n=82) received academic support; of these, 84.2% attended a follow-up visit compared with 71.8% of 78 children who attended a follow-up visit but did not receive support (P=.06). Children who received support were more likely to have commercial insurance; experience a sports-related injury mechanism; have parents whose primary language was English; suffer from learning disabilities and migraines; and be non-Hispanic (P<.05). There was no association between attending a follow-up visit and receipt of academic support (adjusted OR 1.83; 95% CI 0.75-4.45). Although the majority of children received academic support postconcussion, accommodations were associated with several demographic, medical history, and injury characteristics, but not attending a PCP follow-up visit.

A Qualitative Study of Multidisciplinary Providers' Experiences With the Transfer Process for Injured Children and Ideas for Improvement.

Most injured children initially present to a community hospital, and many will require transfer to a regional pediatric trauma center. The purpose of this study was 1) to explore multidisciplinary providers' experiences with the process of transferring injured children and 2) to describe proposed ideas for process improvement. This qualitative study involved 26 semistructured interviews. Subjects were recruited from 6 community hospital emergency departments and the trauma and transport teams of a level I pediatric trauma center in New Haven, Conn. Participants (n = 34) included interprofessional providers from sending facilities, transport teams, and receiving facilities. Using the constant comparative method, a multidisciplinary team coded transcripts and collectively refined codes to generate recurrent themes across interviews until theoretical saturation was achieved. Participants reported that the transfer process for injured children is complex, stressful, and necessitates collaboration. The transfer process was perceived to involve numerous interrelated components, including professions, disciplines, and institutions. The 5 themes identified as areas to improve this transfer process included 1) Creation of a unified standard operating procedure that crosses institutions/teams, 2) Enhancing 'shared sense making' of all providers, 3) Improving provider confidence, expertise, and skills in caring for pediatric trauma transfer cases, 4) Addressing organization and environmental factors that may impede/delay transfer, and 5) Fostering institutional and personal relationships. Efforts to improve the transfer process for injured children should be guided by the experiences of and input from multidisciplinary frontline emergency providers.

Timely Hemodynamic Resuscitation and Outcomes in Severe Pediatric Traumatic Brain Injury: Preliminary Findings.

Early resuscitation may improve outcomes in pediatric traumatic brain injury (TBI). We examined the association between timely treatment of hypotension and hypoxia during early care (prehospital or emergency department locations) and discharge outcomes in children with severe TBI. Hypotension was defined as systolic blood pressure less than 70 + 2 (age in years), and hypoxia was defined as PaO2 less than 60 mm Hg or oxygen saturation less than 90% in accordance with the 2003 Brain Trauma Foundation guidelines. Timely treatment of hypotension and hypoxia during early care was defined as the treatment within 30 minutes of a documented respective episode. Two hundred thirty-six medical records of children younger than 18 years with severe TBI from 5 regional pediatric trauma centers were examined. Main outcomes were in-hospital mortality and discharge Glasgow Outcome Scale (GOS) score. Hypotension occurred in 26% (60/234) during early care and was associated with in-hospital mortality (23.3% vs 8.6%; P = 0.01). Timely treatment of hypotension during early care occurred in 92% (55/60) by use of intravenous fluids, blood products, or vasopressors and was associated with reduced in-hospital mortality [adjusted relative risk (aRR), 0.46; 95% confidence interval, 0.24-0.90] and less likelihood of poor discharge GOS (aRR, 0.54; 95% confidence interval, 0.39-0.76) when compared to children with hypotension who were not treated in a timely manner. Early hypoxia occurred in 17% (41/236) and all patients received timely oxygen treatment. Timely resuscitation during early care was common and associated with lower in-hospital mortality and favorable discharge GOS in severe pediatric TBI.

Variation in seizure prophylaxis in severe pediatric traumatic brain injury.

OBJECTIVE Posttraumatic seizure is a major complication following traumatic brain injury (TBI). The aim of this study was to determine the variation in seizure prophylaxis in select pediatric trauma centers. The authors hypothesized that there would be wide variation in seizure prophylaxis selection and use, within and between pediatric trauma centers. METHODS In this retrospective multicenter cohort study including 5 regional pediatric trauma centers affiliated with academic medical centers, the authors examined data from 236 children (age < 18 years) with severe TBI (admission Glasgow Coma Scale score ≤ 8, ICD-9 diagnosis codes of 800.0-801.9, 803.0-804.9, 850.0-854.1, 959.01, 950.1-950.3, 995.55, maximum head Abbreviated Injury Scale score ≥ 3) who received tracheal intubation for ≥ 48 hours in the ICU between 2007 and 2011. RESULTS Of 236 patients, 187 (79%) received seizure prophylaxis. In 2 of the 5 centers, 100% of the patients received seizure prophylaxis medication. Use of seizure prophylaxis was associated with younger patient age (p < 0.001), inflicted TBI (p < 0.001), subdural hematoma (p = 0.02), cerebral infarction (p < 0.001), and use of electroencephalography (p = 0.023), but not higher Injury Severity Score. In 63% cases in which seizure prophylaxis was used, the patients were given the first medication within 24 hours of injury, and 50% of the patients received the first dose in the prehospital or emergency department setting. Initial seizure prophylaxis was most commonly with fosphenytoin (47%), followed by phenytoin (40%). CONCLUSIONS While fosphenytoin was the most commonly used medication for seizure prophylaxis, there was large variation within and between trauma centers with respect to timing and choice of seizure prophylaxis in severe pediatric TBI. The heterogeneity in seizure prophylaxis use may explain the previously observed lack of relationship between seizure prophylaxis and outcomes.

Guideline Adherence and Hospital Costs in Pediatric Severe Traumatic Brain Injury*

Adherence to pediatric traumatic brain injury guidelines has been associated with improved survival and better functional outcome. However, the relationship between guideline adherence and hospitalization costs has not been examined. To evaluate the relationship between adherence to pediatric severe traumatic brain injury guidelines, measured by acute care clinical indicators, and the total costs of hospitalization associated with severe traumatic brain injury. Retrospective cohort study. Five regional pediatric trauma centers affiliated with academic medical centers. Demographic, injury, treatment, and charge data were included for pediatric patients (17 yr) with severe traumatic brain injury. Percent adherence to clinical indicators was determined for each patient. Cost-to-charge ratios were used to estimate ICU and total hospital costs for each patient. Generalized linear models evaluated the association between healthcare costs and adherence rate. Cost data for 235 patients were examined. Estimated mean adjusted hospital costs were $103,485 (95% CI, 98,553-108,416); adjusted ICU costs were $82,071 (95% CI, 78,559-85,582). No association was found between adherence to guidelines and total hospital or ICU costs, after adjusting for patient and injury characteristics. Adjusted regression model results provided cost ratio equal to 1.01 for hospital and ICU costs (95% CI, 0.99-1.03 and 0.99-1.02, respectively). Adherence to severe pediatric traumatic brain injury guidelines at these five leading pediatric trauma centers was not associated with increased hospitalization and ICU costs. Therefore, cost should not be a factor as institutions and providers strive to provide evidence-based guideline driven care of children with severe traumatic brain injury.

Factors Associated with Time to Arrival at a Regional Pediatric Trauma Center.

The goal of this study was to test the hypothesis that the prehospital time between injury and arrival at a trauma center for critically injured children is associated with patient injury severity and mode of transport. Secondary analysis of prospectively collected data on children 0-17 years of age admitted with traumatic injuries to a designated Level I pediatric trauma center from January 1, 2006 through September 30, 2007 was conducted. Multivariate regression methods were used to assess for factors independently associated with prehospital time. Of 1,175 admissions during the study period, only 355 (30%) had a prehospital time within 60 minutes of injury. Prehospital time within 60 minutes of injury was associated with higher frequency of coma, higher mean injury severity scores (ISS), and greater frequency of admission to the intensive care unit when compared with prehospital time beyond 60 minutes of injury. Children who arrived at the trauma center within 60 minutes versus beyond 60 minutes were 13-fold (odds ratio [OR]: 12.9; 95% Confidence Interval [CI], 7.6-22.0) more likely to be transported via air ambulance than a private vehicle, and had 4.8-fold greater odds (95% CI, 2.2-10.3) of transport via ground ambulance than private vehicle. For each kilometer of distance between the injury zip code and the trauma center, the odds of arrival within 60 minutes versus beyond 60 minutes decreased by 15% (OR: 0.85; 95% CI, 0.79-0.91). Field triage and decision making appeared to correlate with severity of patient injury with expeditious transport of the most severely injured children to definitive trauma care. This finding serves as important groundwork that might enable further study into factors that influence triage and overall prehospital care for critically injured children.

Pediatric abdominal injury patterns caused by “falls”: A comparison between nonaccidental and accidental trauma

Background/PurposeFalling from a low height is the most common history given by caregivers of pediatric nonaccidental trauma (NAT) victims evaluated for blunt abdominal trauma (BAT). The purpose of this study is to compare the patterns of injuries seen in children with BAT who are victims of NAT with those seen after a fall-related incident. MethodsTrauma database query from regional pediatric trauma centers identified patients were who were evaluated for BAT resulting from either NAT or a fall. Study groups included patients younger than five years who were (1) victims or NAT, or (2) fall casualties. ResultsSixty-five NATs and 115 fall casualties were identified. NAT victims had higher ISS, had more severe head injuries according to AIS scores, had more hollow viscus injuries, and had more pancreatic injuries. Fall casualties were more likely to have solid organ injuries. ConclusionsWhen evaluating children with a history of blunt abdominal trauma caused by a fall, suspicion for NAT is warranted if the child is younger than five years, has a hollow viscus, pancreatic, and/or severe head injury and has a high ISS. Likewise, isolated splenic or renal injury allays suspicion for NAT.

Six years beyond pediatric trauma: child and parental ratings of children's health-related quality of life in relation to parental mental health.

PurposeTo examine the relationship between child self-report and parent proxy report of health-related quality of life (HRQL) and how parents’ mental health status relates to the HRQL ratings 6 years after minor to severe injury of the child.Materials and methodsThis cross-sectional cohort study was performed at a regional pediatric trauma center in Stockholm, Sweden. The PedsQL 4.0 versions for ages 5–7, 8–12, and 13–18 years were completed by 177 child–parent dyads 6 years after injury to the child. The parents also rated their own mental health through the mental health domain (MH) in the SF-36 Health Survey.ResultsThe children’s median age was 13 years (IQR 10–16 years), 54 % were males, and the median ISS was 5 (IQR 2–9). Most of the parents were female (77 %), born in Sweden (79 %), and half had university degrees. There was no statistically significant difference between child self-report and parent proxy report in any of the PedsQL 4.0 scales or summary scales. The levels of agreement between child self-report and parent proxy reports were excellent (ICC ≥ 0.80) for all scales with the exception of emotional functioning (ICC 0.53) which also was the scale with the lowest internal consistency in child self-report (α 0.60). Multiple regression analyses showed that worse parental mental health status correlated with worse child self-report and parent proxy report of children’s HRQL. ConclusionsChildren and their parents’ reports on child’s HRQL were in agreement. Decreased mental health in parents was associated with lower scores on parent proxy reports and child self-reports of HRQL after injury. The current investigation highlights the possible relationship between parent’s mental health status and children’s HRQL long after an injury, which should be considered in future investigations and in clinical care.

Acute care clinical indicators associated with discharge outcomes in children with severe traumatic brain injury.

The effect of the 2003 severe pediatric traumatic brain injury (TBI) guidelines on outcomes has not been examined. We aimed to develop a set of acute care guideline-influenced clinical indicators of adherence and tested the relationship between these indicators during the first 72 hours after hospital admission and discharge outcomes. Retrospective multicenter cohort study. Five regional pediatric trauma centers affiliated with academic medical centers. Children under 18 years with severe traumatic brain injury (admission Glasgow Coma Scale score ≤ 8, International Classification of Diseases, 9th Edition, diagnosis codes of 800.0-801.9, 803.0-804.9, 850.0-854.1, 959.01, 950.1-950.3, 995.55, maximum head abbreviated Injury Severity Score ≥ 3) who received tracheal intubation for at least 48 hours in the ICU between 2007 and 2011 were examined. None. Total percent adherence to the clinical indicators across all treatment locations (prehospital, emergency department, operating room, and ICU) during the first 72 hours after admission to study center were determined. Main outcomes were discharge survival and Glasgow Outcome Scale score. Total adherence rate across all locations and all centers ranged from 68% to 78%. Clinical indicators of adherence were associated with survival (adjusted hazard ratios, 0.94; 95% CI, 0.91-0.96). Three indicators were associated with survival: absence of prehospital hypoxia (adjusted hazard ratios, 0.20; 95% CI, 0.08-0.46), early ICU start of nutrition (adjusted hazard ratios, 0.06; 95% CI, 0.01-0.26), and ICU PaCO2 more than 30 mm Hg in the absence of radiographic or clinical signs of cerebral herniation (adjusted hazard ratios, 0.22; 95% CI, 0.06-0.8). Clinical indicators of adherence were associated with favorable Glasgow Outcome Scale among survivors (adjusted hazard ratios, 0.99; 95% CI, 0.98-0.99). Three indicators were associated with favorable discharge Glasgow Outcome Scale: all operating room cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.61; 95% CI, 0.58-0.64), all ICU cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.73; 95% CI, 0.63-0.84), and no surgery (any type; adjusted relative risk, 0.68; 95% CI, 0.53- 0.86). Acute care clinical indicators of adherence to the Pediatric Guidelines were associated with significantly higher discharge survival and improved discharge Glasgow Outcome Scale. Some indicators were protective, regardless of treatment location, suggesting the need for an interdisciplinary approach to the care of children with severe traumatic brain injury.

Comparison of Outcomes for Children With Cervical Spine Injury Based on Destination Hospital From Scene of Injury

Pediatric cervical spine injury is rare. As a result, evidence-based guidance for prehospital triage of children with suspected cervical spine injuries is limited. The effects of transport time and secondary transfer for specialty care have not previously been examined in the subset of children with cervical spine injuries. The primary objective was to determine if prehospital destination choice affects outcomes for children with cervical spine injuries. The secondary objectives were to describe prehospital and local hospital interventions for children ultimately transferred to pediatric trauma centers for definitive care of cervical spine injuries. The authors searched the Pediatric Emergency Care Applied Research Network (PECARN) cervical spine injury data set for children transported by emergency medical services (EMS) from scene of injury. Neurologic outcomes in children with cervical spine injuries transported directly to pediatric trauma centers were compared with those transported to local hospitals and later transferred to pediatric trauma centers, adjusting for injury severity, indicated by altered mental status, focal neurologic deficits, and substantial comorbid injuries. In addition, transport times and interventions provided in the prehospital, local hospital, and pediatric trauma center settings were compared. Multiple imputation was used to handle missing data. The PECARN cervical spine injury cohort contains 364 patients transported from scene of injury by EMS. A total of 321 met our inclusion criteria. Of these, 180 were transported directly to pediatric trauma centers, and 141 were transported to local hospitals and later transferred. After adjustments for injury severity, odds of a normal outcome versus death or persistent neurologic deficit were higher for patients transported directly to pediatric trauma centers (odds ratio [OR]= 1.89, 95% confidence interval [CI]=1.03 to 3.47). EMS transport times to first hospital did not differ and did not affect outcomes. Prehospital analgesia was very infrequent. Initial destination from scene (pediatric trauma center vs. local hospital) appears to be associated with neurologic outcome of children with cervical spine injuries. Markers of injury severity (altered mental status and focal neurologic findings) are important predictors of poor outcome in children with cervical spine injuries and should remain the primary guide for prehospital triage to designated trauma centers.

A community return-to-play mTBI clinic: Results of a pilot program and survey of high school athletes

BackgroundHigh school athletes who sustain a mild traumatic brain injury (mTBI) or concussion are required to be removed from play until clearance by a provider. A regional pediatric trauma center offered an mTBI clinic to evaluate students for return to play (RTP). MethodsAn mTBI clinic was developed in collaboration with a high school district containing three schools. This program evaluated students suffering from sports-related head trauma, specifically football injuries. Community mTBI education was performed, a standardized RTP algorithm was developed, and a postseason survey was administered to football players. ResultsTwenty-eight students playing football were seen by the mTBI clinic. The average time until RTP for clinic patients was 16.9 days. Four hundred five players were surveyed. Of players responding to the survey, 40 (15%) reported sustaining an mTBI during the football season. Of those sustaining an mTBI, 9 (22.5%) did not report their symptoms. ConclusionAlthough the mTBI rate is similar to reported rates, the unreported mTBI episodes were lower (22.5%) than previously published self-reported mTBI rates. The RTP algorithm was successful in returning athletes in 16.9 days. The algorithm and data can be utilized by other organizations in establishment of an mTBI clinic and RTP program.

Age-related Patterns of Spine Injury in Children Involved in All-Terrain Vehicle Accidents

With increases in use and power of all-terrain vehicles (ATVs), there have been dramatic increases in both the number and severity of ATV-related injuries. The KIDS database showed a 240% increase in the number of children admitted to a hospital for an ATV-related injury between 1997 and 2006. Over the same time period, there was a 476% increase in the number of children with ATV-related spine injuries. To better understand the nature of these injuries, a series of pediatric ATV-related spine fractures at a regional pediatric trauma center were analyzed. Records and radiographs of children and adolescents who presented to a regional pediatric trauma center with a spine injury as a result of an ATV accident were reviewed. In addition to demographic data, information was collected regarding length of stay, Glasgow Coma Score, Pediatric Trauma Score, treatment type, associated injuries, and hospital charges. Patients were divided into 2 groups based on age and American Academy of Orthopaedic Surgeons guidelines for ATV use: younger children (age, 0 to 15 y) and older children (age, 16 to 18 y). Fifty-three spine injuries were identified in 29 children (mean, 1.8 injuries/child) with an average age of 15.7 years; 16 (55%) had associated nonspine injuries and 13 had multiple spine injuries, contiguous in 9 and noncontiguous in 4. Four patients, all in the younger age group, had neurological injuries. Children older than 16 years had significantly lower Pediatric Trauma Scores and were more likely to have a thoracic spine fracture than younger children, who were more likely to have a lumbar fracture. Fourteen patients required surgery for their injuries, 7 for spine injuries and 7 for nonspine injuries; the mean hospital charge was almost $75,000 per patient. ATV-related spine injuries in children and adolescents are high-energy injuries with a high rate of associated spine and nonspine injuries. ATV-related spine injuries are different from other ATV-related injuries in children in that they are more common in older children and in females. As musculoskeletal injuries are the most common ATV-related injuries in children, orthopaedic surgeons need to be aware of these differences, and have a high index of suspicion for associated injuries, including additional and often noncontiguous spine injuries.

Low Plasma d-Dimer Concentration Predicts the Absence of Traumatic Brain Injury in Children

Head Computerized Tomography (CT) has significant risks, especially in children. To reduce this burden, we sought to develop a biomarker panel that predicts the absence of traumatic brain injury (TBI) on head CT. We conducted a prospective cohort observational study followed by validation in a retrospective cohort at a regional pediatric trauma center. The prospective cohort included 57 consecutive children evaluated for TBI in the emergency department between September 2007 and March 2008. At the time of initial evaluation, blood was obtained to measure electrolytes, coagulation markers, complete blood count, and plasma levels of s100beta, D-dimer, and matrix metalloproteinase-9. We conducted routine statistical analysis to determine which predicted TBI on head CT. The independent retrospective cohort included 57 consecutive patients evaluated for the same indication. All patients generally met common clinical criteria (such as the CHALICE criteria 4) for head CT after trauma. Plasma levels of D-dimer were associated with TBI on head CT by univariate analysis (p < 0.001). Other markers including prothrombin time, partial thromboplastin time, and s100beta were not. D-dimer also had the strongest association in multivariate analysis (p = 0.02). This association was independent of and stronger than the baseline Glascow Coma Scale (p = 0.08). A D-dimer level cut-off of 500 pg/microl had 94% negative predictive value (p < 0.001) for brain injury on head CT. The discriminatory capacity of this D-dimer level was confirmed in the independent retrospective cohort. In children who meet clinical criteria for a head CT scan after trauma, low plasma d-dimer suggests the absence of significant brain injury.

Correlates of Reinjury Risk in Sibling Groups: A Prospective Observational Study

The objective of this study was to identify child, parent, and family characteristics that are associated with short-term recurrence of injury within sibling groups. A prospective cohort study was conducted of 92 children who were aged 0 to 15 years and treated for injury at a regional pediatric trauma center and their 166 siblings. The outcome of interest was a second or subsequent injury in the sibling group, occurring within 3 months of the index injury event. Explanatory variables included injury variables, child factors (age, gender, previous injury experience, behavior problems, and traumatic stress symptoms), parental factors (age, education, social support, depressive symptoms, and traumatic stress symptoms), and family factors (socioeconomic status, family function, family structure, and life events). Poisson regression was used in multivariable models with statistical adjustment for clustering within sibling groups. More than 19% of families had at least 1 child injured or reinjured during 3 months of follow-up. The rate of reinjury to index children (8.7%) was similar to that in siblings (7.2%). Controlling for age, gender, and race, the risk for reinjury during follow-up was increased with single-parent family structure (relative risk [RR]: 3.39 [95% confidence interval (CI): 1.69-6.80]), receipt of public assistance (RR: 3.65 [95% CI: 1.61-8.28]), and clinically significant posttraumatic stress disorder arousal symptoms in the child (RR: 3.76 [95% CI: 1.51-9.33]). Along with their siblings, children who receive treatment for injury are at short-term risk for additional injury. Children in single-parent households, in families who receive public assistance, and those with posttraumatic stress disorder arousal symptoms 1 month after injury to themselves or a sibling are at highest risk. These associations could be used to develop interventions to identify and support families through periods of high injury risk.