Trauma Articles of Interest

Articles

Urine Leaks in Children Sustaining Blunt Renal Trauma [1]. Ghani MOA, et al. J Trauma Acute Care Surg. 2022 Jan 4. Online ahead of print.

Urinary leak occurs in 30-50% of adults with a high-grade renal injury, but the frequency of this complication in pediatric patients is less clear. Observational management is the standard of care, even with high grade injuries. Also, there are no guidelines establishing the criteria for – and optimal timing of – follow up imaging after injury to evaluate for urine leak.

This is a large single-institution retrospective review of 347 patients with blunt renal trauma, 44 (12.4%) of whom developed a urine leak after their injury. The median age of patients studied was 16, but urine leak was more frequent in younger patients (median age 13). The most frequent presenting symptoms were fever (59%) and hematuria (70.5%) on arrival. Admission vitals and injury severity were not significantly different for patients who developed a urine leak. Patients who did not receive on-table delayed CT on presentation were more likely to have a non-diagnostic scan and require repeat imaging later in the hospitalization. Injury patterns associated with leak included: isolated renal trauma, injury to the upper lateral quadrant of the kidney, and grade of injury 3 or above. Based on these results, patients with a blunt renal injury of grade 3 or higher should receive delayed phase CT imaging during the initial workup, which has been implemented into practice at the authors’ institution.

It is time for TEG in pediatric trauma: unveiling meaningful alterations in children who undergo massive transfusion [2]. Phillips R, et al. Pediatr Surg Int. 2021. Nov;37(11):1613-1620. Epub 2021 Sep 17.

Thromboelastography (TEG) initially was used for monitoring coagulation in cardiac surgery and starting in the 1990s was used as a research tool in trauma patients. TEG then was described for use in guiding massive transfusion protocols in adult trauma patients which has allowed for more goal directed resuscitation. Use of TEG to direct massive transfusion in pediatric trauma patients has not been as broadly accepted as in adult trauma patients. There is little information on use of TEG directed pediatric resuscitation and if there are any differences in TEG results that may be of clinical importance.

This study retrospectively reviewed pediatric trauma patients at two pediatric trauma centers who had admission TEGs obtained and they compared those who received massive transfusions versus those who did not. They reviewed differences in the TEG results between these cohorts. Patients that received massive transfusion had TEG findings consistent with low fibrinogen and abnormal platelet function. The authors conclude that using TEG would alter the resuscitation by earlier cryoprecipitate and platelet transfusion. Albeit as a small retrospective study, it does demonstrate how TEG directed resuscitation may impact product usage and ultimately morbidity and mortality in pediatric patients requiring massive transfusion.

The small (14 Fr) percutaneous catheter (P-CAT) versus large (28-32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial [3]. Kulvatunyou N, et al. J Trauma Acute Care Surg. 2021 Nov 1;91(5):809-813.

The traditional treatment of a hemothorax involved open placement of a large-bore (36- or 40-Fr) chest tube in adults or adult-sized teens. Previous studies have shown that smaller tubes are effective for hemothorax evacuation, and recently a single-center randomized trial showed that a 14-Fr percutaneous catheter (PC), or “pigtail” was just as efficacious for evacuation of blood and air in traumatic hemothorax or hemopneumothorax. Previous studies suggest less pain and discomfort for patients in the placement of the PC versus a larger tube. These data are in adults without any similar randomized data in the pediatric population.

The authors organized a multicenter randomized trial to evaluate the use of either 14-Fr PC’s or 28- to 32- Fr chest tubes for patients 18 or older with traumatic hemothorax or hemopneumothorax. 120 patients at 5 institutions were randomized with primary outcome measure of failure rate for catheter drainage (defined as persistent radiographically evident hemothorax requiring additional intervention). Secondary outcome measures included amount of drainage by time interval, ventilator days, hospital and ICU length of stay, and a non-validated insertion perception experience (IPE) score to measure pain and tolerability of procedure. The study found the two arms similar in all but the IPE score, where the PC group had better tolerance of the procedure. While this study was conducted in adults, not children, this may be generalizable to adult-sized teens presenting with hemothorax.

Evaluation of Emergency Department Pediatric Readiness and Outcomes Among US Trauma Centers [4], Newgard CD, et al. JAMA Pediatr. 2021 Sep 1;175(9):947-956.

All pediatric surgeons recognize that trauma is the leading cause of mortality for children. Children receiving post-injury care at pediatric trauma centers are known to have lower mortality rates and lower rates of splenectomy after blunt trauma when compared to non-pediatric centers. Timely access to pediatric trauma centers for all children, however, is geographically limited. Only 43% of children live within a 60-minute drive to a pediatric trauma center, and it is estimated that as high as 80% of children receive initial post-injury care outside of a pediatric trauma center. The National Pediatric Readiness Project (NPRP) is a quality improvement initiative that aims to ensure that emergency departments have the essential guidelines and resources in place to provide effective emergency care to children, regardless of pediatric designation status. Emergency Department Pediatric Readiness scores for individual facilities are measured by facility-level self-reported survey. While pediatric trauma centers have been shown to have high Pediatric Readiness scores, adult trauma centers are known to have pediatric readiness scores that are similar to non-pediatric general hospitals nationally. Mortality outcomes for pediatric critical illness have been shown to be improved at centers with higher Pediatric Readiness scores, but this relationship has not been shown within trauma centers.

This retrospective cohort study of 832 trauma center emergency departments with known pediatric readiness scores derived from the 2013 National Pediatric Readiness Assessment, examined center-specific risk-adjusted mortality as a function of initial receiving center weighted pediatric readiness scores. This study examined in-hospital risk-adjusted mortality of over 370,000 children, and demonstrated that children that were initially treated at an emergency department with weighted pediatric readiness score (wPRS) in the top quartile were less likely to die than children initially treated in EDs with a wPRS in the lowest quartile (adjusted odds ratio 0.58; 95% CI, 0.45-0.75). This study highlights the importance of pediatric trauma centers partnering with outlying referring centers to promote pediatric readiness within community and critical access hospitals, as well as in neighboring adult freestanding centers. As the majority of children receive initial post-injury stabilization outside of pediatric trauma centers, collaborative efforts to improve pediatric readiness in these referring centers have the potential to impact mortality for patients eventually transferred to pediatric trauma centers for definitive care.

Nonaccidental Trauma in Pediatric Patients: Evidence-based Screening Criteria for Ophthalmologic Examination [5], Ip et al J Amer Ass Ped Ophth Strabismus 2020 Aug 18:S1091-8531(20)30158-0.

Ophthalmologic examination is a standard component of the evaluation of nonaccidental trauma (NAT) in children. Previous studies of children being evaluated have demonstrated that intracranial hemorrhage is associated with the presence of retinal hemorrhage (RH) and that retinal hemorrhage is rare in the absence of intracranial hemorrhage.

This single institution, retrospective study reviewed patients who received a NAT evaluation that included an ophthalmologic examination over a four-year period. The study included 192 children between six days and six years of age with neuroimaging obtained in 171 of these evaluations. Only 15 (eight percent) of patients had RH – all of whom had positive neuroimaging (defined as any abnormality other than scalp hematoma). Positive neuroimaging was associated with the presence of RH with odds ratio of 21.0. Other findings associated with RH included subdural hemorrhage (OR=54), extra-axial hemorrhage (OR=28.3), seizures (OR=15.8), altered mental status including seizure (OR=8.3), brain parenchymal hypoxia/ischemia/infarct (OR=10.1) and vomiting (OR=4.4). The authors concluded that neuroimaging is an effective screening tool and that an ophthalmologic examination should not be routinely performed in the absence of abnormal findings on neuroimaging.

Tranexamic Acid in Pediatric Combat Trauma Requiring Massive Transfusions and Mortality [6], Hamele et al J Trauma Acute Care Surg 2020 Aug;89(2S Suppl 2):S242-S245.

Guns, Scalpels, and Sutures: The Cost of Gunshot Wounds in Children and Adolescents [7], Phillips et al J Trauma Acute Care Surg 2020; 89(3) 558-564.

Nationwide Use of REBOA in Adolescent Trauma Patients: An Analysis of the AAST AORTA Registry [8], Theodorou et al Injury

Timing of tracheostomy placement among children with severe traumatic brain injury: A propensity-matched analysis [9], McLaughlin et al J Trauma Acute Care Surg 2019;87:818–26.

Adult intensive care has moved towards early performance of tracheostomy in patients requiring prolonged mechanical ventilation as it is associated with less frequent complications and possibly also lower mortality. The timing, necessity and appropriateness of tracheostomy in critically ill children is more complex. There is a natural tendency to wait longer before broaching the subject of tracheostomy with parents. This dilemma is especially relevant for children with traumatic brain injury (TBI) in which the long term neurologic prognosis is frequently uncertain.

The data presented by McLaughlin et al provide more robust support for early timing of tracheostomy in critically injured pediatric patients. Specifically, they focused on 361 children with severe TBI with early tracheostomy defined as sooner than 15 days after injury. Although their data is retrospective (from the National Trauma Data Bank), they attempted to account for critical confounders by matching patients based on propensity scores. While early timing of tracheostomy was not associated with lower mortality, it was significantly associated with fewer ventilator days, time in the intensive care unit, lower odds of pneumonia and higher odds of discharge to home. Finally, this study had a notable finding that 95% of children not receiving tracheostomy were on the ventilator for 18 days or less suggesting that few children with severe TBI will be successfully extubated beyond this point.

Defining Massive Transfusion in Civilian Pediatric Trauma [10], Rosenfeld et al J Pediatr Surg 2019 May;54(5):975-979.

Massive transfusion protocols (MTP) are intended to rapidly deliver predefined volumes of blood products in specific ratios to critically ill patients in hemorrhagic shock. Currently, there is a lack of data validating existing pediatric MTP triggers.

The purpose of this study was to identify an optimal definition of massive transfusion in civilian trauma. Severely injured children (< =18-years old, ISS >=25) in the Trauma Quality Improvement Program research datasets 2014-2015 that received blood products were identified. Children with traumatic brain injury and non-survivable injuries were excluded. Using receiver operator curves and sensitivity and specificity analysis in this cohort of 270 patients, sensitivity and specificity for early mortality was optimized at a 4-hour transfusion volume of 37mL/kg. This threshold predicted the need for a hemorrhage control procedure (OR 8.60; 95% CI 4.25-17.42; p < 0.01) and early mortality (OR 4.24; 95% CI 1.96-9.16; p < 0.01).
The threshold of 37mL/kg/4h for defining massive transfusion in the civilian pediatric trauma population accurately predicts early mortality and the need for hemorrhage control operations. This marker can provide clinicians with a timely prognostic indicator, improve research methodology, and resource utilization.

Rethinking the Definition of Major Trauma: The Need For Trauma Intervention Outperforms InjurySeverity Score and Revised Trauma Score in 38 Adult and Pediatric Trauma Centers [11], Roden-Foreman et al J Trauma Acute Care Surg 2019 Jun 24.

Prevention of Firearm Injuries Among Children and Adolescents Consensus-Driven Research Agenda from the Firearm Safety Among Children and Teens (FACTS) Consortium [12], Cunningham et al JAMA Pediatr. 2019 Jun 10.

High Volume Crystalloid Resuscitation Adversely Affects Pediatric Trauma Patients [13], Coons et al J Pediatr Surg 2018 Jul 24.

Current research in adult trauma resuscitation has emphasized lower volumes of crystalloid fluid in order to decrease adverse outcomes (e.g. ventilator days, intensive care unit (ICU) stay, ongoing hemorrhage, abdominal compartment syndrome). The relationship between volume of crystalloid resuscitation and outcome in pediatric trauma has not been well described.

The authors retrospectively evaluated outcomes of pediatric trauma patients associated with differing volumes of crystalloid resuscitation. They analyzed patient cohorts based on volume of crystalloid resuscitation at 24 and 48 hrs: less than 20 mL/kg/day, 20 to 40 mL/kg/day, 40 to 60 mL/kg/day and greater than 60 mL/kg/day. They evaluated the incidence of adverse outcomes in each of these cohorts. They discovered that administration of high volumes of crystalloid fluid (i.e. greater than 60 mL/kg/day) in the first 48 hours was associated with significantly increased ICU length of stay, overall length of stay, days on the ventilator and time spent NPO. These findings held true when adjusting for patient age, weight, Glascow coma scale and Injury Severity Score.

Critically injured children should receive judicious fluid resuscitation with crystalloid, as high volume fluid resuscitation (i.e. greater than 60 mL/kg/day) is associated with worse pulmonary outcome and length of stay.

Implementation of Clinical Effectiveness Guidelines for Solid Organ Injury after Trauma: 10-year Experience at a Level 1 Pediatric Trauma Center [14], Leeper et al J Pediatr Surg 2018 Apr;53(4):775-779.

U.S. Pediatric Burn Patient 30-Day Readmissions [15], Wheeler et al J Burn Care Res 2018 Jan 1;39(1):73-81.

Indications and Outcomes of Extracorporeal Life Support in Trauma Patients [16], Swol et al. J Trauma Acute Care Surg 2018 Jun;84(6):831-837.

Consistent Screening of Admitted Infants with Head Injuries Reveals High Rate of Non-Accidental Trauma [17], Kim et al J Pediatr Surg 2017.

Use of a screening guideline has eliminated screening disparities in evaluating for NAT in infants admitted with an unwitnessed head injury. Retrospective review of 563 infants admitted with an unwitnessed head injury and screened for NAT had an overall rate of NAT of 25.6% (n = 144). Screening for NAT was consistent across race and insurance status in this patient population. Logistic regression analysis showed that NAT was associated with a higher ISS (p < 0.0001), positive skeletal survey (p< 0.0001), and no insurance or government insurance (p = 0.0047). Age, race and sex did not correlate with NAT.
There is a high rate of NAT in infants admitted after a head injury not witnessed in a public situation. Victims of NAT admitted with an unwitnessed head injury have a higher ISS, positive skeletal survey and no insurance or government insurance than those with accidental injury.

Acute Procedural Interventions after Pediatric Blunt Abdominal Trauma: A Prospective Multicenter Evaluation [18], Arbra et al J Trauma Acute Care Surg 2017 Oct;83(4):597-602.

This is a secondary analysis of a 14 center prospective evaluation of pediatric patients presenting to the emergency center with suspected blunt abdominal trauma. Of 2,188 patients, 261 had abdominal injury identified on CT. 17% of these received an acute intervention (surgery or angioembolization). The most common reason for surgery was hollow viscus injury (59%). Patients who required acute intervention were more commonly hypotensive, had a lower GCS, and abnormal abdominal physical exam at presentation than those that did not require intervention.

A Cohort Study of Blunt Cerebrovascular Injury Screening in Children: Are They Just Little Adults? [19], Cook et al J Trauma Acute Care Surg 2018 Jan;84(1):50-57.

To evaluate the efficacy of blunt cerebrovascular injury (BCVI) screening criteria in children, the Denver criteria (DC), EAST guidelines, and Utah score (US) were retrospectively applied to 558 children (age less than 18 years) who sustained blunt trauma at a single center from 2005 through 2015 and received neck imaging (96% CTA; 4% MRA). The primary outcome was the false-negative rate (Type II error) of the screening tests.

Ninety-six patients with 128 BCVIs for an incidence of 1.3%. The patient population were primarily adolescent, male, were injured following a motor vehicle crash and were severely injured. In-hospital mortality was 9% and the overall incidence of CVA in children with a diagnosis of a BCVI was 18%. Aspirin was most common treatment used (59%). With respect to the primary outcome, the false-negative rates for the DC was 2%, EAST was 17%, and US was 17% and the difference was statistically significant. With respect to the clinically meaningful false-negative rate (patients who did not meet clinical screening criteria and developed a CVA); the DC was 0%, EAST was 12%, and US was 6%; the differences were not statistically significant. The authors comment that under their current practice 6 CTAs of the neck would need to be order to identify 1 BCVI and 33 CTAs to identify 1 patient with neurologic sequelae of their BCVI. The study has several limitations including a significantly higher incidence of BCVI in their cohort as well as limitations associated with a retrospective cohort design, particularly with respect to the fact that clinically silent injuries were not identified and additional screening test characteristics such as sensitivity, specificity, or the negative and positive predictive values could bot be evaluated.

The 3 most commonly used clinical screening criteria have a sizeable false-negative rate, although the most liberal criteria, the DC, performed the best. These findings support the recommendations to screen children according to adult guidelines and support the use of a liberal approach to clinical screening and imaging for BCVI

Variability of Child Access Prevention Laws and Pediatric Firearm Injuries [20], Hamilton et al J Trauma Acute Care Surg 2017 Dec 28.

Child access prevention (CAP) laws impart criminal liability to adults who allow children access to firearms. CAP laws are not federally mandated and therefore there is variability in the laws across states. Strong CAP laws require safe storage of firearms while weak CAP laws only impose criminal liability if a child gains access to a gun. This study utilized the KID (Kids’ Inpatient Database) to find that strong CAP laws were associated with a significant reduction in all (70%), self-inflicted (46%) and unintentional (56%0 pediatric firearm injuries. There was no association with intentional firearm injuries, which were more common in teenagers (14-17 years) and may not be related to gun access in the home.

Focused assessment with sonography for trauma in children after blunt abdominal trauma: A multi-institutional analysis [21], Calder et al J Trauma Acute Care Surg 2017 Aug;83(2):218-224.

The value of the injury severity score in pediatric trauma: Time for a new definition of severe injury? [22], Brown et al J Trauma Acute Care Surg 2017 Jun;82(6):995-1001.

Evaluation of guidelines for injured children at high risk for venous thromboembolism: A prospective observational study [23], Landisch et al J Trauma Acute Care Surg 2017 May;82(5):836-844

The association of non-accidental trauma with historical factors, exam findings and diagnostic testing during the initial trauma evaluation [24], et al J Trauma Acute Care Surg 2017 Jun 23;82(6):1147-57

The Sensitivity and Negative Predictive Value of a Pediatric Cervical Spine Clearance Algorithm that Minimizes Computerized Tomography [25], Arbuthnot et al J Pediatr Surg 2017 Jan;52(1):130-135.

Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents [26], Grool et al JAMA Pediatr 2016 Dec 20; 316(23):2504-2514

Prophylaxis Against Venous Thromboembolism in Pediatric Trauma: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society [27], Mahajerin et al J Trauma Acute Care Surg 2016 Dec 23.

Development and Implementation of a Standardized Pathway in the Pediatric Intensive Care Unit for children with Severe Traumatic Brain Injuries [28], Rakes et al BMJ Qual Improv Rep 2016 Nov 22;5(1).

Abnormalities in Fibrinolysis at the Time of Admission are Associated with Deep Vein Thrombosis, Mortality, and Disability in a Pediatric Trauma Population [14], Leeper et al J Trauma Acute Care Surg 2017 Jan;82(1):27-34.

Recommendations for venous thromboembolism prophylaxis in pediatric trauma patients: A national, multidisciplinary consensus study [29], Hanson et al J Trauma Acute Care Surg 2016 May;80(5):695-701.

Management of pediatric blunt renal trauma: A systematic review [30], LeeVan et al J Trauma Acute Care Surg 2016 Mar;80(3):519-28.

Acute traumatic coagulopathy in a critically injured pediatric population: Definition, trend over time, and outcomes [31], Leeper et al J Trauma Acute Care Surg 2016 Jul;81(1):34-41.

Operative vs Nonoperative Management of Pediatric Blunt Pancreatic Trauma: Evaluation of the National Trauma Data Bank [32], Mora et al J Am Coll Surg 2016 Jun;222(6):977-82.

Return on investment: Thirty years of commitment to the injured child has become a pathway to success [33], Tepas J Trauma Acute Care Surg 2016 May;80(5):689-94.

Post-traumatic liver and splenic pseudoaneurysms in children: Diagnosis, management, and follow-up screening using contrast enhanced ultrasound (CEUS) [34], Durkin et al J Pediatr Surg 2016 Feb;51(2):289-92.

The value of official reinterpretation of trauma computed tomography scans from referring hospitals [35], Onwubiko et al J Pediatr Surg 2016 Mar;51(3):486-9.

Risk factors for venous thromboembolism after pediatric trauma [36], Allen et al J Pediatr Surg 2016 Jan;51(1):168-71.

A Clinical Tool for the Prediction of Venous Thromboembolism in Pediatric Trauma Patients [37], Connelly et al JAMA Surg 2016 Jan 1;151(1):50-7.

The use of an institutional pediatric abdominal trauma protocol improves resource use [38], Fallon et al J Trauma Acute Care Surg. 2016 Jan;80(1):57-63.

Implementation of pediatric cervical spine clearance guidelines at a combined trauma center: Twelve-month impact [39], Rosati et al J Trauma Acute Care Surg 2015 Jun;78(6):1117-21.

Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger [40], Hale et al J Trauma Acute Care Surg 2015 May;78(5):943-8.

Benchmarks for splenectomy in pediatric trauma: How are we doing? [41], Polites et al J Pediatr Surg 2015 Feb;50(2):339-42.

Managing moderately injured pediatric patients without immediate surgeon presence: 10 years later [42], Boomer et al J Pediatr Surg 2015 Jan;50(1):182-5.

Pediatric emergency department thoracotomy: A large case series and systematic review [43], Allen et al J Pediatr Surg 2015 Jan;50(1):177-81.

Pediatric trauma and the Pediatric Trauma Society: Our time has come [44], Gaines J Trauma Acute Care Surg 2015 Jun;78(6):1111-6.

Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma andtranexamic acid study (PED-TRAX) [45], Eckert et al J Trauma Acute Care Surg 2014 Dec;77(6):852-8.

Validation of a clinical prediction rule for pediatric abusive head trauma [46], Hymel et al Pediatrics 2014 Dec;134(6):e1537-44.

Operative vs nonoperative management for blunt pancreatic transection in children: multi-institutional outcomes [47], Iqbal et al J Am Coll Surg 2014 Feb;218(2):157-62.

Children are safer in states with strict firearm laws: a National Inpatient Sample study. [48], Safavi et al J Trauma Acute Care Surg 2014 Jan;76(1):146-50.

Improving ATLS performance in simulated pediatric trauma resuscitation using a checklist [49], Parsons et al Ann Surg 2014 Apr;259(4):807-13.

National trends in pediatric blunt spleen and liver injury management and potential benefits of an abbreviated bed rest protocol [50], Dodgion et al J Pediatr Surg 2014 Jun;49(6):1004-8.

Management of children with mild traumatic brain injury and intracranial hemorrhage [51], Greenberg et al J Trauma Acute Care Surg 2014 Apr;76(4):1089-95.

Trauma remains a surgical disease from cradle to grave [52], Acker et al J Trauma Acute Care Surg 2014 Aug;77(2):219-25.

Routine repeat brain computed tomography in all children with mild traumatic brain injury may result in unnecessary radiation exposure [53], Howe et al J Trauma Acute Care Surg 2014 Feb;76(2):292-5.

References

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Last updated: March 1, 2022