Pediatric Trauma Population Research Articles

The Efficacy of Antifibrinolytic Drugs in Children Undergoing Noncardiac Surgery

Children undergoing major surgery are frequently exposed to a high risk of blood loss often requiring transfusion. Although the risks associated with blood product transfusion have considerably decreased over the last decade, transfusion is still associated with significant morbidity and mortality. Thus, rigorous efforts should be made to decrease surgical bleeding and the need for blood product transfusion. Antifibrinolytic drugs have been shown to be effective when used in both adult and pediatric surgical patients. While there are data in adults to support safety, data remain limited for pediatric patients. Since the restriction of aprotinin use in 2008, the most commonly used antifibrinolytic drugs have been the lysine analogs, tranexamic acid (TXA), and ε-aminocaproic acid, which inhibit the conversion of plasminogen to plasmin and decrease the degree of fibrinolysis. We performed a systematic review of the literature pertaining to the efficacy of antifibrinolytic drugs in children undergoing noncardiac surgery. During spine surgery, both TXA and ε-aminocaproic acid decrease blood loss and transfusion requirements; however, this information comes from small, mainly retrospective trials. Two prospective, randomized, controlled trials have tested the efficacy of TXA in children undergoing craniofacial surgery and have reported that TXA decreases transfusion requirements. Two pharmacokinetic trials were also recently published and are summarized in this review. No data have been published regarding the efficacy of TXA administration in the pediatric trauma population. Further data are still needed in this field of study, and we discuss some perspectives for future research.

Pleural effusion following blunt splenic injury in the pediatric trauma population

BackgroundPleural effusion is a potential complication following blunt splenic injury. The incidence, risk factors, and clinical management are not well described in children. MethodsTen-year retrospective review (January 2000–December 2010) of an institutional pediatric trauma registry identified 318 children with blunt splenic injury. ResultsOf 274 evaluable nonoperatively managed pediatric blunt splenic injures, 12 patients (4.4%) developed left-sided pleural effusions. Seven (58%) of 12 patients required left-sided tube thoracostomy for worsening pleural effusion and respiratory insufficiency. Median time from injury to diagnosis of pleural effusion was 1.5days. Median time from diagnosis to tube thoracostomy was 2days. Median length of stay was 4days for those without and 7.5days for those with pleural effusions (p<0.001) and 6 and 8days for those pleural effusions managed medically or with tube thoracostomy (p=0.006), respectively. In multivariate analysis, high-grade splenic injury (IV–V) (OR 16.5, p=0.001) was associated with higher odds of developing a pleural effusion compared to low-grade splenic injury (I–III). ConclusionsPleural effusion following pediatric blunt splenic injury has an incidence of 4.4% and is associated with high-grade splenic injuries and longer lengths of stay. While some symptomatic patients may be successfully managed medically, many require tube thoracostomy for progressive respiratory symptoms.

Evaluation of facial trauma in pediatric population

Aim: The aim of this study was to retrospectively evaluate the incidence and treatment rendered for fractures in pediatric population over a period of 13 years. Materials and Methods: Surgical data over 13 years were evaluated for age, type of fracture, and treatment rendered. Out of a total of 423 trauma cases operated, a total of 38 pediatric trauma cases were seen, with 30 patients requiring at least some type of surgical intervention. The etiology of most of the fractures was road traffic accidents. Results: The eight cases of dentoalveolar and undisplaced parasymphysis trauma were managed by wiring and four cases of soft tissue injury treated by suturing while 18 cases required surgery in the form of osteosynthesis. Bioresorbable plating system was used in 11 cases while Titanium plates were used in seven patients, which were removed within 3 months.Conclusion: We recommend the use of open reduction internal fixation with bioresorbable plating system in children above 10 years of age and arch bar fixation for dentoalveolar trauma.

Validation of Rules to Predict Emergent Surgical Intervention in Pediatric Trauma Patients

Trauma centers use guidelines to determine when a trauma surgeon is needed in the emergency department (ED) on patient arrival. A decision rule from Loma Linda University identified patients with penetrating injury and tachycardia as requiring emergent surgical intervention. Our goal was to validate this rule and to compare it with the American College of Surgeons' Major Resuscitation Criteria (MRC). We used data from 1993 through 2010 from 2 level 1 trauma centers in Denver, CO. Patient demographics, injury severity, times of ED arrival and surgical intervention, and all variables of the Loma Linda Rule and the MRC were obtained. The outcome, emergent intervention (defined as requiring operative intervention by a trauma surgeon within 1 hour of arrival to the ED or performance of cricothyroidotomy or thoracotomy in the ED), was confirmed using standardized abstraction. Sensitivities, specificities, and 95% confidence intervals were calculated. There were 8,078 patients included, and 47 (0.6%) required emergent intervention. Of the 47 patients, the median age was 11 years (interquartile range [IQR] 7 to 14 years), 70% were male, 30% had penetrating mechanisms, and the median Injury Severity Score (ISS) was 25 (IQR 9 to 41). At the 2 institutions, the Loma Linda Rule had a sensitivity and specificity of 69% (95% CI 45% to 94%) and 76% (95% CI 69% to 83%), respectively, and the MRC had a sensitivity and specificity of 80% (95% CI 70% to 92%) and 81% (95% CI 77% to 85%), respectively. Emergent surgical intervention is rare in the pediatric trauma population. Although precision of predictive accuracies of the Loma Linda Rule and MRC were limited by small numbers of outcomes, neither set of criteria appears to be sufficiently accurate to recommend their routine use.

The Distally Based Superficial Sural Flap for Reconstruction of the Foot and Ankle in Pediatric Patients

The distally based superficial sural flap has been used for coverage of defects in the foot and ankle for years. However, little attention has been received in the pediatric trauma population because of small sample volumes. The current study presents results using distally based superficial sural flaps for reconstruction of soft tissue defects of the foot and ankle in children. A retrospective study was performed to assess outcomes of 32 pediatric patients with defects of the foot and ankle requiring soft tissue coverage using distally based superficial sural flaps. The average patient age was 9 years. The etiology of the soft tissue defects included 31 traumatic events and 1 chronic ulcer with bone, tendon, or joint lesion exposure. Postoperative follow-up of the 32 patients ranged from 11 months to 7 years. All 32 flaps survived successfully. Complications included one wound dehiscence and three slight venous congestions. The distally based superficial sural flap is a good alternative for soft tissue defects of the foot and ankle in children. The surgical techniques in harvesting the flaps are easy to handle.

Theoretical Breast Cancer Induction Risk From Thoracic Spine CT in Female Pediatric Trauma Patients

To quantify the radiation dose received during thoracic spine computed tomography (CT) versus plain radiographs as well as the theoretical risk of breast cancer induction in a pediatric trauma population. A retrospective evaluation of 179 female pediatric trauma patients who received CT or plain radiographs for clearance of the thoracic spine was performed. Subjects were secondarily grouped as children (0-<12 years) or adolescents (≥12-17.9 years). Radiation doses were calculated by using the ImPACT Patient Dosimetry Calculator. Excess absolute risk (EAR) of induction of breast cancer was determined by multiplying the radiation dose by breast cancer induction rates taken from the National Academy's Biological Effects of Ionizing Radiation Committee's seventh report. The average radiation dose to the breast from a thoracic spine CT was 41.1 (SD 11.4) mSv and 1.8 (SD 0.9) mSv for plain radiographs. The EAR for plain radiographs was 2.7 (95% confidence interval [CI] 2.48-2.85) excess cases of breast cancer per 10 000 studies for female children and 1.4 (95% CI 1.14-1.55) for female adolescents. The breast cancer EAR for thoracic spine CT was significantly higher -79.6 (95% CI 58.6-100.5) and 45.8 (95% CI 42.0-49.6) excess cases per 10 000 scans for female children and adolescents, respectively. There was a substantially higher risk of breast cancer induction for children receiving thoracic spine CT compared with adolescents. CT clearance of the thoracic spine in the pediatric trauma patient results in a high dose of radiation and an age-dependent increase in theoretical breast cancer induction.

Computed Tomography Findings in Patients With Pediatric Blunt Renal Trauma in Whom Expectant (Nonoperative) Management Failed

To determine whether the features on a computed tomography (CT) scan can predict the need for urologic intervention in a pediatric blunt renal trauma population initially treated with expectant management. A review of a prospective database of pediatric patients sustaining renal trauma from 1991 to 2003 was performed. The data reviewed included the mechanism of injury, injury grade, CT findings, operative intervention, and complications. Parametric statistical analysis was used to compare the CT findings and outcomes. A total of 72 children presented with blunt renal injury, of whom 61 met the study criteria. Of the 61 patients, 50 had grade I-III, 10 had grade IV, and 1 had grade V injuries. No children with grade I-III injuries required operative intervention. Of the 10 patients with grade IV injuries, 4 had medial contrast extravasation from the collecting system on their original CT scan, 3 of whom required intervention. Intervention initially consisted of delayed endoscopic procedures at 3, 9, and 33 days after injury. All 3 patients (100%) developed complications in their management, and 2 (66%) required open surgical intervention. The 1 patient with grade V injury underwent nephrectomy because of hemodynamic instability. Grade IV renal injuries with medial contrast extravasation are associated with urologic intervention at greater rates than those without extravasation. Delayed treatment of this finding could be associated with greater than expected complication rates and renal loss, and early/aggressive treatment should be considered. This knowledge could improve the specificity of "expectant" nonoperative management of pediatric renal injury.

Can a pediatric trauma center improve the response to a mass casualty incident?

Recent events including the 2001 terrorist attacks on New York; Hurricane Katrina; the 2010 Haitian and Chilean earthquakes; and the 2011 earthquake, tsunami, and nuclear disaster in Japan have reminded disaster planners and responders of the tremendous scale of mass casualty disasters and their resulting human devastation. Although adult disaster medicine is a well-developed field with roots in wartime medicine, we are increasingly recognizing that children may comprise up to 50% of disaster victims, and response mechanisms are often designed without adequate preparation for the number of pediatric victims that can result. In this short educational review, we explore the differences between the pediatric and adult disaster and trauma populations, the requirements for designation of a site as a pediatric trauma center (PTC), and the magnitude of the problem of pediatric disaster patients as described in the literature, specifically as it pertains to the availability and use of designated PTCs as opposed to trauma centers in general. We also review our own experience in planning and simulating pediatric mass casualty events and suggest strategies for preparedness when there is no PTC available. We aim to demonstrate from this brief survey that the availability of a designated PTC in the setting of a mass casualty disaster event is likely to significantly improve the outcome for the pediatric demographic of the affected population. We conclude that the relative scarcity of disaster data specific to children limits epidemiologic study of the pediatric disaster population and offer suggestions for strategies for future study of our hypothesis. Systematic review, level III.

Intrapericardial Foreign Bodies in the Pediatric Trauma Population

Intrapericardial Foreign Bodies in the Pediatric Trauma Population

Drug Use and Screening in Pediatric Trauma

There is a paucity of research on substance use in the pediatric trauma population. This study aims to describe trends in substance use and screening in the Canadian pediatric trauma population. A retrospective review of the London Health Sciences Centre trauma database from April 1999 to January 2009 identified patients less than 18 years old admitted after major trauma [injury severity score (ISS) > 12]. Data extracted included age, gender, ISS, blood alcohol concentration (BAC), and results of toxicology screens. BAC data were available for 799 patients and toxicology screens for 761 patients. BAC testing was completed in 30% (21% positive). Toxicology screens were completed in 7% (44% positive). Increasing age was associated with screening for alcohol (odds ratio = 1.4; 95% confidence interval 1.3-1.5). Screening for drug use had a bimodal distribution, with no children aged 4-10 years screened. Those screened for drugs and alcohol had a significantly higher ISS than those not tested (BAC 28 versus 23, P < 0.001, toxin screening 29 versus 24, P = 0.003). The most common ingestions were alcohol, benzodiazepines, cannabinoids, and opiates. Screening for drugs and alcohol is sporadic in the pediatric trauma population. Further study utilizing a universal approach to drug and alcohol screening is needed to further delineate the true prevalence of substance use in this population.

Fractures of the clivus and traumatic diastasis of the central skull base in the pediatric population

Fractures of the clivus and traumatic diastases of the clival synchondroses are rare in the pediatric population. The incidence, outcome, and biomechanics associated with these fractures have been difficult to ascertain secondary to the lack of literature pertaining to their occurrence. A Boolean search of the electronic medical record database at the Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, was performed to identify patients with fractures of the clivus that were diagnosed using CT of the head. A retrospective review of the chart and radiographic imaging was then performed to assess data regarding patient demographics, mechanism of injury, and skull and brain parenchymal injuries, as well as outcomes. Between May 2002 and November 2007, 16 patients with fractures of the clivus were identified. The mean age of these patients was 9 years (range 1-16 years). Eleven (68.8%) of the 16 patients had an associated traumatic diastasis of the central skull base. Five (31.3%) of the 16 patients died. However, of the 11 patients who survived, all had a good outcome with a Glasgow Outcome Scale score of 4 or 5 at the time of discharge. The incidence of clival fractures among patients with head injuries was 0.33%. Clival fractures occur with a similar incidence in both the pediatric and adult trauma population. Outcome is not correlated directly with the extent of clival fracture, but rather with the presenting Glasgow Coma Scale score and concomitant brain parenchymal injuries. The identification of traumatic diastases in patients with clival fractures suggests that static loading forces are a significant factor in the biomechanics producing these types of fractures.

Percutaneous versus Open Tracheostomy in the Pediatric Trauma Population

Percutaneous versus Open Tracheostomy in the Pediatric Trauma Population

Substance use in paediatric trauma: setting the stage for an injury prevention programme

Injury prevention initiatives provide education to increase awareness of high-risk behaviours and teach strategies to prevent injury. To be successful, these initiatives must identify at risk populations and understand how...

Alcohol Interventions for Trauma Patients Are Not Just for Adults: Justification for Brief Interventions for the Injured Adolescent at a Pediatric Trauma Center

Research on the rates of alcohol and drug misuse as well as developmentally appropriate screening and intervention approaches in a hospitalized pediatric trauma population are lacking. The purpose of this study was to identify the rate of alcohol misuse in an admitted trauma population of adolescents aged 11 years to 17 years and to identify key correlates of alcohol misuse in this population including age, gender, and injury severity. A prospective clinical study of 230 injured youth (aged 11-17 years) comprising both hospitalized and emergency department (ED) population was performed, and the patients were screened for the Alcohol Use Disorders Identification Test (AUDIT), blood alcohol levels (BALs), and drinking and driving index. The main outcome measures were rates of alcohol misuse characterized by a positive BAL or a positive AUDIT. Thirty percent hospitalized trauma patients screened positive for alcohol misuse. Five patients had a positive BAL without a positive AUDIT score. Binge drinking was the most commonly positive domain of the AUDIT tool. In hospitalized trauma patients who are older than 14 years (p = 0.005), it was significantly associated with a positive AUDIT score, but the injury severity score, gender, mechanism of injury, or positive BAL were not significant predictors. In the ED sample, 15.8% of patients had a positive AUDIT score. One-way analysis of variance among the ED group showed that age >or=14 was the single predictor of a positive AUDIT score. Twenty-three percent of hospitalized patients had been in a car, where the driver had been drinking. The average AUDIT scores in this group was 5.3 versus 1.0 (p < 0.001), compared with those who had not ridden in a car with a driver who had been drinking. Injured youth admitted to a pediatric trauma center are a high-risk population. Alcohol misuse is a significant cofactor for trauma for these patients, and effective developmentally appropriate interventions are justified and needed.

Assessment of termination of trauma resuscitation guidelines: are children small adults?

Background Guidelines for termination of resuscitation in prehospital traumatic cardiopulmonary arrest (TCPA) have recently been published for adults. Clinical criteria for termination of care include absent pulse, unorganized electrocardiogram (ECG), fixed pupils (all at the scene), and cardiopulmonary resuscitation (CPR) greater than 15 minutes. The goal of this study was to evaluate these guidelines in a pediatric trauma population. Methods Pediatric trauma patients with documented arrest were included in the study. Data assessed were duration of CPR, ECG rhythm, pulse assessment, pupil response, transport times, and standard injury criteria (eg, mechanism of injury). Survivors were compared to nonsurvivors using descriptive statistics, χ 2, and Pearson correlation. Results Between 2000 and 2009, 30 patients were identified as having had a TCPA. Of the 30 with a prehospital TCPA, there were 9 females and 21 males (0.2-18 years old). The average (SD) injury severity score was 35.4 (20.6). Twenty-four patients (80%) did not survive. Severe traumatic brain injury was associated with nonsurvivors in 78%. One-way analysis of variances demonstrated that CPR greater than 15 minutes ( P = .011) and fixed pupils ( P = .022) were significant variables to distinguish between survivors and nonsurvivors, whereas ECG rhythm ( P = .34) and absent pulse ( P = .056) did not, 42 ± 28 minutes for nonsurvivors and 7 ± 3 minutes for survivors. Conclusion Criteria for termination of resuscitation correctly predicted 100% of those who died when all the criteria were met. More importantly, no survivors would have had resuscitation stopped. Duration of CPR seems to be a strong predictor of mortality in this study.

Delay in diagnosis and treatment of blunt intestinal perforation does not adversely affect prognosis in the pediatric trauma patient.

Blunt intestinal injury (BII) requiring surgical intervention in the pediatric trauma population remains difficult to diagnose. We sought to analyze whether delay in treatment in the event of perforation had an adverse affect on patient outcome. A multi-institutional retrospective chart review by the members of the American Pediatric Surgical Association Committee on Trauma was initiated after the approval of Institutional Review Board at each of the 18 institutions. All children <or=15 years of age diagnosed with a BII were identified and only those with BII noted during surgery or autopsy from January, 2002, through December, 2007, were included. The data form was designed and approved before chart review and all data were combined into one database. Three hundred fifty-eight patients were accrued into the study. Two hundred fourteen patients had sufficient data to analyze the interval between injury and operation. These were divided into six groups (<6 hours, 6-12 hours, and >12 hours) based on time from injury to intervention and whether they had perforation or not. Early and late complications as well as hospital days, injury severity score, and time to full feeds were compared in each group. There were two deaths from an abdominal source in the <6-hour nonperforation group, one in the 6-hour perforation group, and one in the 6-hour to 12-hour nonperforation group. Injury severity score was significantly greater in the <6-hour intervention group regardless of perforation status. There was no correlation between time to surgery and complication rate nor was there a significant increase in hospital days. These data suggest that delay in operative intervention does not have a significant effect on prognosis after pediatric blunt intestinal perforation. Appropriate observation and serial examination rather than repeat computed tomography and/or urgent exploration would appear adequate when the diagnosis is in question.

Percutaneous versus Open Tracheostomy in the Pediatric Trauma Population

The purpose of this study was to determine the safety and efficacy of percutaneous versus open tracheostomy in the pediatric trauma population. A retrospective chart review was conducted of all tracheostomies performed on trauma patients younger than 18 years for an 8-year period. There was no difference in the incidence of brain, chest, or facial injury between the open and percutaneous tracheostomy groups. However, the open group had a significantly lower age (14.2 vs. 15.5 years; P < 0.01) and higher injury severity score (26 vs. 21; P = 0.015). Mean time from injury to tracheostomy was 9.1 days (range, 0 to 16 days) and was not different between the two methods. The majority of open tracheostomies were performed in the operating room and, of percutaneous tracheostomies, at the bedside. Concomitant feeding tube placement did not affect complication rates. There was not a significant difference between complication rates between the two methods of tracheostomy (percutaneous one of 29; open three of 20). Percutaneous tracheostomy can be safely performed in the injured older child.

Impact of hypothermia in the rural, pediatric trauma patient*

Hypothermia is an independent predictor of mortality in adult trauma studies. However, the impact of hypothermia on the pediatric trauma population has not been described. The purpose of this study is to evaluate hypothermia as a cofactor to mortality, complications, and among survivors, hospital length of stay parameters in the pediatric trauma population. Retrospective review of a prospectively collected database (National Trauma Registry of the American College of Surgeons) over a 5-yr period (July 2002 to June 2007). A rural, level I trauma center. One thousand six hundred twenty-nine pediatric patients admitted with a traumatic injury. None. Multivariate regression models were used to evaluate the association of hypothermia with mortality, infectious complications, organ dysfunction, and among survivors, hospital length of stay parameters. Of 1,629 pediatric trauma patients admitted, 182 (11.1%) patients were hypothermic (temperature below 36 degrees C) on admission. Hypothermia had an adjusted odds ratio (AOR) of 2.41 (95% confidence interval [CI], 1.12-5.22, p = .025) for mortality. After controlling for covariates, hypothermia had associations with developing pneumonia (AOR, 0.185, 95% CI, 0.040-0.853; p = .031) and a bleeding diathesis (AOR, 3.14, 95% CI, 1.04-9.44; p = .042). The median days in the hospital, intensive care unit (ICU), and ventilator were longer in the hypothermic cohort; however, after controlling for covariates, hypothermia was not associated with differences in hospital days, ICU days, or ventilator days. Hypothermia is a common problem at admission among pediatric trauma patients. Hypothermia is associated with an increase in the odds of death and the development of a bleeding diathesis, while having decreased odds for developing pneumonia. While the length of stay indicators were longer in the hypothermic cohort among survivors, no significant association was noted with hypothermia for hospital, ICU, or ventilator days after controlling for confounders.

Delay in diagnosis and treatment of blunt intestinal injury does not adversely affect prognosis in the pediatric trauma patient

Background Blunt intestinal injury (BII) requiring surgical intervention in the pediatric trauma population remains difficult to diagnose. We sought to determine whether delay in treatment had an adverse affect on patient outcome. Methods A multi-institutional retrospective chart review using the American Pediatric Surgical Association Committee on Trauma was initiated after Institutional Review Board approval was obtained at each of the 18 institutions. All children younger than 15 years diagnosed with a BII were identified, and only those with BII noted during surgery or autopsy from January 2002 through December 2007 were included. The data form was designed and approved before chart review, and all data were combined into one database. Results Three hundred fifty-eight patients were accrued into the study. Two hundred fourteen patients had sufficient data to determine the interval between injury and operation. These were divided into 4 groups (<6, 6-12, 12-24, and >24 hours) based on time from injury to intervention. Early and late complications, as well as hospital days, were compared in each group. There were 3 deaths from an abdominal source in the less-than-6-hour group and 2 in the 6-to-12-hour group. Injury Severity Score was significantly greater in the less-than-6-hour intervention group. There was no correlation between time to surgery and complication rate, nor was there a significant increase in hospital days. Conclusions These data suggest that delay in operative intervention does not have a significant effect on prognosis after pediatric BII. Appropriate observation and serial examination rather than repeated computed tomography and/or urgent exploration would appear adequate when the diagnosis is in question.

Childhood obesity: a risk factor for injuries observed at a level-1 trauma center

Purpose Obesity is an independent risk factor in trauma-related morbidity in adults. The purpose of this study was to investigate the effect of obesity in the pediatric trauma population. Methods All patients (6-20 years) between January 2004 and July 2007 were retrospectively reviewed and defined as non-obese (body mass index [BMI] <95th percentile for age) or obese (BMI ≥95th percentile for age). Groups were compared for differences in demographics, initial vital signs, mechanisms of injury, length of stay, intensive care unit stay, ventilator days, Injury Severity Score, operative procedures, and clinical outcomes. Results Of 1314 patients analyzed, there were 1020 (77%) nonobese patients (mean BMI = 18.8 kg/m 2) and 294 (23%) obese patients (mean BMI = 29.7 kg/m 2). There was no significant difference in sex, heart rate, length of stay, intensive care unit days, ventilator days, Injury Severity Score, and mortality between the groups. The obese children were significantly younger than the nonobese children (10.9 ± 3.3 vs 11.5 ± 3.5 years; P = .008) and had a higher systolic blood pressure during initial evaluation (128 ± 17 vs 124 ± 16 mm Hg, P < .001). In addition, the obese group had a higher incidence of extremity fractures (55% vs 40%; P < .001) and orthopedic surgical intervention (42% vs 30%; P < .001) but a lower incidence of closed head injury (12% vs 18%; P = .013) and intraabdominal injuries (6% vs 11%; P = .023). Evaluation of complications showed a higher incidence of decubitus ulcers ( P = .043) and deep vein thrombosis ( P = .008) in the obese group. Conclusion In pediatric trauma patients, obesity may be a risk factor for sustaining an extremity fracture requiring operative intervention and having a higher risk for certain complications (ie, deep venous thrombosis [DVT] and decubitus ulcers) despite having a lower incidence of intracranial and intraabdominal injuries. Results are similar to reports examining the effect(s) of obesity on the adult population.