Anthony Stallion

The New Injury Severity Score and the evaluation of pediatric trauma.

BACKGROUND To compare the effectiveness of the Injury Severity Score (ISS) and New Injury Severity Score (NISS) in predicting mortality in pediatric trauma patients. METHODS NISS, the sum of the squares of a patients three highest Abbreviated Injury Scale scores (regardless of body region), were calculated for 9,151 patients treated at four regional pediatric trauma centers and compared with previously calculated ISS values. The power of the two scoring systems to predict mortality was gauged through comparison of misclassification rates, receiver operating characteristic curves, and Hosmer-Lemeshow goodness-of-fit statistics. RESULTS Although there were significant differences in mean NISS and ISS values for each hospital, differences in the predictive abilities of the two scoring systems were insignificant, even when analysis was restricted to the subgroup of patients with severe or penetrating injuries. CONCLUSION The significant differences in the predictive abilities of the ISS and NISS reported in studies of adult trauma patients were not seen in this review of pediatric trauma patients.

The significant relationship between platelet count and haemorrhagic complications on ECMO

Haemorrhagic complications, which occur in up to 35% of infants during extracorporeal membrane oxygenation (ECMO), often produce devastating sequelae. Although many complex factors interact to control haemostasis, platelet number and function has significant impact on the development of primary haemostasis. The optimum platelet count on ECMO, however, has not been defined. At our institution prior to August 1987, platelet counts were maintained at greater than 100 000/mm3. After August 1987, however, platelet counts of greater than 200 000/mm 3 were maintained. In a retrospective study, patients were randomly chosen from these two treatment periods: group 1 - March 1986 to July 1987; and group 2 - June 1988 to June 1989. The average platelet count, platelets administered, hours on ECMO, and bleeding complications were compared to each other and to the July 1992 ELSO Registry. There was a significant difference in average platelet counts between group 1 and group 2. However, the amount of platelets administered per kg per day was similar. There was a significant difference in overall bleeding complications between Group 2 (12%) and the ELSO Registry (35%) (p < 0.01). There was a trend towards decreased complications in all subgroups, although sample size precluded significance. We conclude that increasing platelet counts to greater than 200 000/mm3 decreases the overall bleeding complication rate. This advantage is achieved without a continuous need for increased platelet administration once the desired level is reached and without an increase in perfusion time, mechanical complications, or mortality.

Extracorporeal membrane oxygenation in the management of cardiac failure secondary to myocarditis

While most patients with viral myocarditis have a relatively uncomplicated clinical course, a small number of patients will present with cardiogenic shock unresponsive to standard medical therapy. We describe the clinical course of three patients who developed profound cardiac failure secondary to a documented viral myocarditis. Each patient was managed using venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support using the right common carotid artery/internal jugular vein for cannulation. While undergoing ECMO support, each patient developed elevated left-sided cardiac chamber pressures with resultant pulmonary edema. This was managed by balloon atrial septostomy in two cases and combined blade/balloon atrial septostomy in one case. Excellent decompression of the left heart was achieved in each patient. Two patients were successfully weaned from ECMO and are currently alive, with one demonstrating residual cardiac dysfunction. One patient developed global myocardial necrosis and ultimately died. This small series demonstrates a role for ECMO in the management of cardiac failure due to acute viral myocarditis unresponsive to medical therapy. Our experience also suggests that balloon atrial septostomy may be useful to decompress the left atrium and ventricle of patients with acute myocarditis while on ECMO.

Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis: A pediatric trauma society collaborative.

BACKGROUND Guidelines for nonoperative management (NOM) of high-grade pancreatic injuries in children have not been established, and wide practice variability exists. The purpose of this study was to evaluate common clinical strategies across multiple pediatric trauma centers to develop a consensus-based standard clinical pathway. METHODS A multicenter, retrospective review was conducted of children with high-grade (American Association of Surgeons for Trauma grade III-V) pancreatic injuries treated with NOM between 2010 and 2015. Data were collected on demographics, clinical management, and outcomes. RESULTS Eighty-six patients were treated at 20 pediatric trauma centers. Median age was 9 years (range, 1–18 years). The majority (73%) of injuries were American Association of Surgeons for Trauma grade III, 24% were grade IV, and 3% were grade V. Median time from injury to presentation was 12 hours and median ISS was 16 (range, 4–66). All patients had computed tomography scan and serum pancreatic enzyme levels at presentation, but serial enzyme level monitoring was variable. Pancreatic enzyme levels did not correlate with injury grade or pseudocyst development. Parenteral nutrition was used in 68% and jejunal feeds in 31%. 3Endoscopic retrograde cholangiopancreatogram was obtained in 25%. An organized peripancreatic fluid collection present for at least 7 days after injury was identified in 59% (42 of 71). Initial management of these included: observation 64%, percutaneous drain 24%, and endoscopic drainage 10% and needle aspiration 2%. Clear liquids were started at a median of 6 days (IQR, 3–13 days) and regular diet at a median of 8 days (IQR 4–20 days). Median hospitalization length was 13 days (IQR, 7–24 days). Injury grade did not account for prolonged time to initiating oral diet or hospital length; indicating that the variability in these outcomes was largely due to different surgeon preferences. CONCLUSION High-grade pancreatic injuries in children are rare and significant variability exists in NOM strategies, which may affect outcomes and effective resource utilization. A standard clinical pathway is proposed. LEVEL OF EVIDENCE Therapeutic/care management, level V (case series).BACKGROUND Guidelines for non-operative management (NOM) of high-grade pancreatic injuries in children have not been established, and wide practice variability exists. The purpose of this study was to evaluate common clinical strategies across multiple pediatric trauma centers in order to develop a consensus-based standard clinical pathway. METHODS A multicenter, retrospective review was conducted of children with high-grade (AAST grade III-V) pancreatic injuries treated with NOM between 2010-15. Data was collected on demographics, clinical management, and outcomes. RESULTS Eighty-six patients were treated at 20 pediatric trauma centers. Median age was 9 years (range 1-18). The majority (73%) of injuries were AAST grade III, 24% were grade IV, and 3% were grade V. Median time from injury to presentation was 12 hours and median ISS was 16 (range 4-66). All patients had computed tomography (CT) scan and serum pancreatic enzyme levels at presentation, but serial enzyme level monitoring was variable. Pancreatic enzyme levels did not correlate with injury grade or pseudocyst development. Parenteral nutrition was used in 68% and jejunal feeds in 31%. Endoscopic retrograde cholangiopancreatogram (ERCP) was obtained in 25%. An organized peri-pancreatic fluid collection present for at least 7 days following injury was identified in 59% (42/71). Initial management of these included: observation 64%, percutaneous drain 24%, and endoscopic drainage 10% and needle aspiration 2%. Clear liquids were started at median 6 days (IQR 3-13) and regular diet at median 8 days (IQR 4-20). Median hospitalization length was 13 days (IQR 7-24). Injury grade did not account for prolonged time to initiating oral diet or hospital length; indicating that the variability in these outcomes was largely due to different surgeon preferences. CONCLUSION High-grade pancreatic injuries in children are rare and significant variability exists in NOM strategies, which may affect outcomes and effective resource utilization. A standard clinical pathway is proposed. LEVEL OF EVIDENCE IV (case series). STUDY TYPE Therapeutic/Care Management.

The utility of ERCP in pediatric pancreatic trauma

BACKGROUND/PURPOSE Endoscopic retrograde cholangiopancreatography (ERCP) is an adjunct for pediatric pancreatic injury management, but its use and utility in pediatric patients are unclear. We set out to evaluate the use of ERCP and its effects on outcomes. METHODS A retrospective review was performed for children who had pancreatic injuries at 22 pediatric trauma centers between 2010 and 2015. ERCP details and outcomes were collected. Analysis was performed using descriptive statistics and Wilcoxon rank-sum tests. RESULTS ERCP was used at 14/22 centers for 26 patients. Indications were duct evaluation, duct leak control, pseudocyst, fistula, and stricture. ERCP altered management or improved outcomes in 13/26 (50%), most commonly in patients with ERCP for duct evaluation, stricture, and fistula. In patients managed nonoperatively, those with early endoscopic intervention (within one week of injury) with stent or sphincterotomy (n=9) had similar time to regular diet [median (IQR)]: [10 (7-211) vs 7 (4-12) days; p=0.55], similar hospital days: [12 (8-20) vs 11 (6-19) days, p=0.63], and similar time on parenteral nutrition: [17 (10-40) vs 10 (6-18) days; p=0.19] compared to patients who were only observed. CONCLUSIONS In children with blunt pancreatic injury, ERCP can be useful to diagnose duct injury and for management of late complications such as stricture and fistula. However, early endoscopic intervention for pancreatic duct disruption may not improve outcome or expedite recovery. Further study is needed. STUDY TYPE Retrospective Study; Treatment Study. LEVEL OF EVIDENCE III.

Massive retroperitoneal cystic mass in an adolescent.

Anadolescentgirlpresentedtoherpediatricianreportingabdominaldistention.Shefirstbecameawareofherincreasedabdominalgirthwhenfriendsatschoolaskedwhethershewaspregnant.Shehadnoticedherclothingbecomingtighteroverrecentweeks.Shehadnotexperiencedabdominalpainorothersymptoms,andtherewasnohistoryoftrauma.Physicalexaminationre-vealed a firm, distended abdomen without bowelsounds. Pregnancy test results were negative. Resultsoflaboratorystudies,includingacompletebloodcellcount,basicmetabolicpanel,andliverfunctiontests,werewithinnormallimits.Anabdominalradiographshowedapaucityofbowelgasmarkings(Figure1A).Asubsequentcomputedtomographicscanoftheabdomenandpelvisrevealeda30-cmretroperitonealcysticstructurecausingsignificantmasseffectontheabdominalviscera,displacingtherightkidneysuperiorlyunderthelivercausingmod-eratehydronephrosis(Figure1B).