Eric R. Scaife

Hyperglycemia and outcomes from pediatric traumatic brain injury.

BACKGROUND The clinical significance of hyperglycemia after pediatric traumatic brain injury is controversial. This study addresses the relationship between hyperglycemia and outcomes after traumatic brain injury in pediatric patients. METHODS We identified trauma patients admitted during a single year to our regional pediatric referral center with head regional Abbreviated Injury Scale scores > or = 3. We studied identified patients for admission characteristics potentially influencing their outcomes. The primary outcome measure was Glasgow Outcome Scale score. RESULTS Patients who died had significantly higher admission serum glucose values than those patients who survived (267 mg/dL vs. 135 mg/dL; p = 0.000). Admission serum glucose > or = 300 mg/dL was uniformly associated with death. Admission Glasgow Coma Scale score (odds ratio, 0.560; 95% confidence interval, 0.358-0.877) and serum glucose (odds ratio, 1.013; 95% confidence interval, 1.003-1.023) are independent predictors of mortality in children with traumatic head injuries. CONCLUSION Hyperglycemia and poor neurologic outcome in head-injured children are associated. The pathophysiology of hyperglycemia in neurologic injury after head trauma remains unclear.

The Effect of Family Presence on the Efficiency of Pediatric Trauma Resuscitations

STUDY OBJECTIVE Family presence has broad professional organizational support and is gaining acceptance. We seek to determine whether family presence prolonged pediatric trauma team resuscitations as measured by time from emergency department arrival to computed tomographic (CT) scan, and to resuscitation completion. METHODS A prospective trial offered families of pediatric trauma patients family presence on even days and no family presence on odd days. Primary outcome measures were time from arrival to CT scan and to resuscitation completion (laboratory tests, emergency procedures, portable radiographs, and secondary survey). We evaluated the effect of family presence in an adjusted Cox proportional hazards model. Staff and family experiencing a resuscitation with family presence were asked their opinions of that experience. RESULTS Of 1,229 pediatric trauma activations, 705 patients were included in the study protocol, 283 with family presence on even days, 422 without family presence on odd days. Median times to CT scan (21 minutes; IQR 16 to 29 minutes) and median resuscitation times (15 minutes; IQR 10 to 20 minutes) were similar with and without family presence. There was no clinically relevant difference in CT time (hazard ratio 1.04; 95% confidence interval [CI] 0.83 to 1.30) or resuscitation time (hazard ratio 0.98; 95% CI 0.83 to 1.15). Families believed that family presence was helpful both to their child and themselves. CONCLUSION This prospective trial shows that family presence does not prolong time to CT imaging or to resuscitation completion for pediatric trauma patients. Family presence does not negatively affect the time efficiency of the pediatric trauma resuscitation.

Early resuscitation of children with moderate-to-severe traumatic brain injury.

OBJECTIVES: Traumatic brain injury is a leading cause of death and disability in children. Guidelines have been established to prevent secondary brain injury caused by hypotension or hypoxia. The purpose of this study was to identify the prevalence, monitoring, and treatment of hypotension and hypoxia during “early” (prehospital and emergency department) care and to evaluate their relationship to vital status and neurologic outcomes at hospital discharge. METHODS: This was a retrospective study of 299 children with moderate-to-severe traumatic brain injury presenting to a level 1 pediatric trauma center. We recorded vital signs and medical provider response to hypotension and/or hypoxia during all portions of early care. RESULTS: Blood pressure (31%) and oxygenation (34%) were not recorded during some portion of “early care.” Documented hypotension occurred in 118 children (39%). An attempt to treat documented hypotension was made in 48% (57 of 118 children). After adjusting for severity of illness, children who did not receive an attempt to treat hypotension had an increased odds of death of 3.4 and were 3.7 times more likely to suffer disability compared with treated hypotensive children. Documented hypoxia occurred in 131 children (44%). An attempt to treat hypoxia was made in 92% (121 of 131 children). Untreated hypoxia was not significantly associated with death or disability, except in the setting of hypotension. CONCLUSIONS: Hypotension and hypoxia are common events in pediatric traumatic brain injury. Approximately one third of children are not properly monitored in the early phases of their management. Attempts to treat hypotension and hypoxia significantly improved outcomes.

Elimination of soybean lipid emulsion in parenteral nutrition and supplementation with enteral fish oil improve cholestasis in infants with short bowel syndrome.

BACKGROUND Parenteral nutrition-associated liver disease (PNALD) is a potentially fatal complication for children with intestinal failure. Fish oil-based lipid emulsions have shown promise for the treatment of PNALD but are not readily available. Six cases are presented in which cholestasis resolved after soybean lipid emulsion (SLE) was removed from parenteral nutrition (PN) and enteral fish oil was given. METHODS A retrospective review at a tertiary childrens hospital (July 2003 to August 2008) identified 6 infants with intestinal failure requiring PN for >6 months who developed severe hepatic dysfunction that was managed by eliminating SLE and providing enteral fish oil. RESULTS Twenty-three infants with short bowel syndrome requiring prolonged PN developed cholestasis. SLE was removed in 6 of these patients, and 4 of the 6 received enteral fish oil. Standard PN included 2-3 g/kg/d SLE with total PN calories ranging from 57 to 81 kcal/kg/d at the time of SLE removal. Hyperbilirubinemia resolved after elimination of SLE within 1.8-5.4 months. Total PN calories required to maintain growth generally did not change. CONCLUSIONS Temporary elimination of SLE and supplementation with enteral fish oil improved cholestasis in PN-dependent infants. Further trials are needed to evaluate this management strategy.

Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: A multi-center study of the american association for the surgery of trauma

BACKGROUND Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years. METHODS The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by univariate and multivariate analysis. A weighted score was calculated by assigning 1, 2, or 3 points to each independent predictor according to its magnitude of effect. The score was established on two thirds of the population and validated using the remaining one third. RESULTS Of 12,537 patients younger than 3 years, CSI was identified in 83 patients (0.66%), eight had spinal cord injury. Four independent predictors of CSI were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a negative predictive value of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study. CONCLUSIONS CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.

Cervical spine clearance after trauma in children

OBJECT Currently, no diagnostic or procedural standards exist for clearing the cervical spine in children after trauma. The establishment of protocols has been shown to reduce the time required to accomplish clearance and reduce the number of missed injuries. The purpose of this study was to determine if reeducation and initiation of a new protocol based on the National Emergency X-Radiography Utilization Study criteria could safely increase the number of pediatric cervical spines cleared by nonneurosurgical personnel. METHODS The authors collected and reviewed data regarding cervical spine clearance in children (age range 0-18 years) who presented to the emergency department at Primary Childrens Medical Center in Salt Lake City, Utah, between 2001 and 2006 after sustaining significant trauma. Radiographic and clinical methods of clearing the cervical spine, as well as the type and management of injuries, were determined for two periods: Period I (January 2001-December 2003) and Period II (January 2004-February 2006). Between 2001 and 2003, 95% of 936 cervical spines were cleared by the neurosurgical service. Twenty-one ligamentous injuries (2.2%) and 12 fracture/dislocations (1.3%) were detected, and five patients (0.5%) required operative stabilization. Since January 2004, 585 (62.4%) of 937 cervical spines have been cleared by nonneurosurgical personnel. Twelve ligamentous injuries (1.3%) and 14 fracture/dislocations (1.5%) were identified, and four patients (0.4%) required operative stabilization. No late injuries were detected in either time period. CONCLUSIONS The protocol outlined in the paper has been effective in detecting cervical spine injuries in children after trauma and has increased the number of cervical spines cleared by nonneurosurgical personnel by nearly 60%. Reeducation with the establishment of protocols can safely facilitate clearance of the cervical spine after trauma by nonneurosurgical personnel.

Utility of a cervical spine clearance protocol after trauma in children between 0 and 3 years of age.

OBJECT Cervical spine clearance after trauma in children 0-3 years of age is deceptively difficult. Young children may not be able to communicate effectively, and severe injuries may require intubation and sedation. Currently, no published guidelines are available to aid in decision-making in these complex situations. The purpose of this study was to determine whether a safe and effective protocol-driven system could be developed for clearance of the cervical spine in noncommunicative children between 0 and 3 years of age. METHODS Children 0-3 years of age, including intubated patients, who were admitted after trauma activation at Primary Childrens Medical Center in Salt Lake City or the Childrens Hospital of New York from 2002 to 2006 were managed according to a cervical spine clearance protocol. Data were collected in a prospective fashion. Radiographic and clinical methods of clearing the cervical spine, as well as the type and management of injuries, were recorded. RESULTS A total of 2828 pediatric trauma activations required cervical spine clearance during the study period. Of these, 575 (20%) were children <or= 3 years of age who were admitted to the hospital. To facilitate clearing the cervical spine in these children, plain radiographs (100%), CT studies (14%), and MR images (10%) were obtained. Nineteen ligamentous injuries (3.3%) and 9 fractures/dislocations (1.5%) were detected, with 4 patients requiring operative stabilization (0.7%). No late injuries have been detected. CONCLUSIONS The protocol used has been effective in detecting cervical spine injuries in noncommunicative children after trauma. The combination of clinical information and radiographic studies is essential for safely clearing the cervical spine in these complex situations. Clearance of the cervical spine without CT or MR imaging studies is possible in the majority of cases, even in very young patients.

Decompressive laparotomy for abdominal compartment syndrome in children: before it is too late

PURPOSE Abdominal compartment syndrome (ACS) in children is an infrequently reported, rapidly progressive, and often lethal condition underappreciated in the pediatric population. This underrecognition can result in a critical delay in diagnosis causing increased morbidity and mortality. This study examines the clinical course of patients treated for ACS at our institution. METHODS A review of children requiring an emergency laparotomy (n = 264) identified 26 patients with a diagnosis of ACS. ACS was defined as sustained intraabdominal hypertension (bladder pressure >12 mm Hg) that was associated with new onset organ dysfunction or failure. RESULTS Patients ranged in age from 3 months to 17 years old and were cared for in the pediatric intensive care unit (PICU). Twenty-seven percent (n = 7) were transferred from referring hospitals, 50% (n = 13) were admitted directly from the emergency department, and 23% (n = 6) were inpatients before being transferred to PICU. Admission diagnoses included infectious enterocolitis (n = 12), postsurgical procedure (n = 10), and others (n = 4). Patients progressed to ACS rapidly, with most requiring decompressive laparotomy within 8 hours of PICU admission (range, <1-96 hours). Preoperatively, all patients had maximum ventilatory support and oliguria, 85% (n = 22) required vasopressors/inotropes, and 31% (n = 8) required hemodialysis. Mean bladder pressure was 25 mm Hg (range, 12-44 mm Hg). In 42% (n = 11), cardiac arrest preceeded decompressive laparotomy. All patients showed evidence of tissue ischemia before decompressive laparotomy with an average preoperative lactate of 8 (range, 1.2-20). Decompressive laparotomy was done at the bedside in the PICU in 13 patients and in the operating room in 14 patients. Abdominal wounds were managed with open vacuum pack or silastic silo dressings. Physiologic data including fluid resuscitation, oxygen index, mean airway pressure, vasopressor score, and urine output were recorded at 6-hour intervals beginning 12 hours before decompressive laparotomy and extending 12 hours after operation. The data demonstrate improvement of all physiologic parameters after decompressive laparotomy except for urine output, which continued to be minimal 12 hours post intervention. Mortality was 58% (n = 15) overall. The only significant factor related to increased mortality was bladder pressure (P = .046; odds ratio, 1.258). Cardiac arrest before decompressive laparotomy, need for hemodialysis, and transfer from referring hospital also trended toward increased mortality but did not reach significance. CONCLUSION Abdominal compartment syndrome in children carries a high mortality and may be a consequence of common childhood diseases such as enterocolitis. The diagnosis of ACS and the potential need for emergent decompressive laparotomy may be infrequently discussed in the pediatric literature. Increased awareness of ACS may promote earlier diagnosis, treatment, and possibly improve outcomes.

Neurologically intact children with an isolated skull fracture may be safely discharged after brief observation

PURPOSE The management of children presenting with an isolated skull fracture (ISF) posttrauma is highly variable. We sought to estimate the risk of neurologic deterioration in children with a Glasgow coma score (GCS) 15 and ISF to reduce unnecessary hospital admissions. METHODS A retrospective review at a level I pediatric trauma referral center was conducted for patients with ISF on head computed tomography from 2003 to 2008. Patients were excluded for injury greater than 24 hours prior, GCS less than 15, intracranial pathology, significant fracture depression, or complex fractures involving facial bones or skull base. RESULTS A total of 235 patients were identified with an ISF. The median age was 11 months, with falls accounting for 87% of the injuries. One hundred seventy-seven patients were admitted, and 58 patients were discharged from the emergency department after a period of observation (median, 3.3 hours). Median length of stay for those admitted to the hospital was 18.2 hours. One patient developed vomiting following overnight observation and a repeat computed tomography scan demonstrated a small extra-axial hematoma that required no intervention. The mean total costs for patients discharged from the emergency department were

The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation.

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