John Recicar

Blunt cerebrovascular injury in children: Underreported or underrecognized?: A multicenter atomac study

BACKGROUND Blunt cerebrovascular injury (BCVI) has been well described in the adult trauma literature. The risk factors, proper screening, and treatment options are well known. In pediatric trauma, there has been very little research performed regarding this injury. We hypothesize that the incidence of BCVI in children is lower than the 1% reported incidence in adult studies and that many children at risk are not being screened properly. METHODS This is a multi-institutional retrospective cohort study of pediatric patients (<15 years) admitted with blunt trauma to six American College of Surgeons–verified Level 1 pediatric trauma centers between October 2009 and June 2011. All patients with head, neck, or face injuries who were high risk for BCVI based on Memphis criteria were analyzed. RESULTS Of 5,829 blunt trauma admissions, 538 patients had at least one of the Memphis criteria. Only 89 (16.5%) of these patients were screened (16 patients had more than one test) by angiography (64 by computed tomography angiography, 39 by magnetic resonance angiography, and 2 by conventional angiography), while 459 (83.5%) were not screened. Screened patients differed from unscreened patients in Injury Severity Score (ISS) (22.6 ± 13.3 vs. 13.3 ± 9.9, p < 0.0001) and head and neck Abbreviated Injury Scale (AIS) score (3.7 ± 1.2 vs. 2.8 ± 1.2, p < 0.0001). The incidence of BCVI in our total population was 0.4% (23 patients). Of the 23 patients with BCVI, 3 (13%) had no risk factors for the injury. The odds of having sustained BCVI in a patient with one or more of the risk factors was 4.0 (95% confidence interval, 1.1–14.2). CONCLUSION BCVI in Level 1 pediatric trauma centers is diagnosed less frequently than in adult centers. However, screening was performed in a minority of high-risk patients who may explain the reported lower incidence of BCVI in children. Pediatric surgeons need to become more vigilant about screening pediatric patients with high-risk criteria for BCVI. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Duodenal injuries in the very young: Child abuse?

BACKGROUND Duodenal injuries in children are uncommon but have been specifically linked with child abuse in case reports. Owing to the rarity of the diagnosis, few studies to date have looked at the association between duodenal injuries and mechanism in younger child. We hypothesize that duodenal injuries in the very young are significantly associated with child abuse. METHODS This investigation is a retrospective cohort study of patients admitted with duodenal injuries at one of six Level I pediatric trauma centers. All institutions had institutional review board approval. The trauma registries were used to identify children aged 0 year to 5 years from 1991 to 2011. Multiple variables were collected and included age, mechanism of injury, type of duodenal injury, additional injuries, mortality, and results of abuse investigation if available. Relationships were analyzed using Fischer’s exact test. RESULTS We identified 32 patients with duodenal injuries with a mean age of 3 years. Duodenal injuries included duodenal hematomas (44%) and perforations/transections (56%). Of all duodenal injuries, 53% resulted in operation, 53% had additional injuries, and 12.5% resulted in death. Of the 32 children presenting with duodenal injuries, 20 were child abuse patients (62.5%). All duodenal injuries in children younger than 2 years were caused by child abuse (6 of 6, p = 0.06) and more than half of the duodenal injuries in children older than 2 years were caused by child abuse (14 of 26). Child abuse–related duodenal injuries were associated with delayed presentation (p = 0.004). There was a significant increase in child abuse–related duodenal injuries during the time frame of the study (p = 0.002). CONCLUSION Duodenal injuries are extremely rare in the pediatric population. This multi-institutional investigation found that child abuse consistently associated with duodenal injuries in children younger than 2 years. The evidence supports a child abuse investigation on children younger than 2 years with duodenal injury. LEVEL OF EVIDENCE Epidemiological study, level III.

The effectiveness of a statewide trauma call center in reducing time to definitive care for severely injured patients.

BACKGROUND The state of Arkansas developed and implemented a comprehensive inclusive trauma system in July 2010. The Arkansas Trauma Communication Center (ATCC) is a central component in the system, designed to facilitate both scene transports and interfacility transfers within the state. The first 18 months of operations were examined to evaluate the relationship between ATCC use and emergency department (ED) length of stay (LOS) at sending facilities for patients who require urgent care. METHODS ATCC data were linked to the Arkansas Trauma Registry using unique identifiers. Patients younger than 15 years were excluded from the analysis. Patients older than 15 years with significant injury requiring interfacility transfer were the study population. Significant injury was defined as those with hypotension (systolic blood pressure < 90 mm Hg) or Glasgow Coma Scale (GCS) score less than 9 at the sending facility or Injury Severity Score (ISS) of 16 or greater at the definitive care facility. This cohort was stratified by the use of the ATCC, and ED LOS was determined. RESULTS The study population who met the inclusion criteria was 856; 632 (74%) of whom used the ATCC and 224 (26%) did not use the ATCC for interfacility transfers. There were no statistically significant differences noted between these two groups regarding ISS, systolic blood pressure, and GCS score. The ATCC was associated with a 21-minute reduction in the ED LOS at the sending facility when controlling for all other factors. (p = 0.005). CONCLUSION In the first 18 months following inception, the ATCC has been effective in expediting the transfer process and thus reducing the time to definitive care for severely injured patients. ATCC use has improved since inception and is now a contract deliverable for trauma hospitals based on these early results. LEVEL OF EVIDENCE Therapeutic study, level III.

Focused assessment with sonography for trauma in children after blunt abdominal trauma: A multi-institutional analysis

Introduction The utility of focused assessment with sonography for trauma (FAST) in children is poorly defined with considerable practice variation. Our purpose was to investigate the role of FAST for intra-abdominal injury (IAI) and IAI requiring acute intervention (IAI-I) in children after blunt abdominal trauma (BAT). Methods We prospectively enrolled children younger than 16 years after BAT at 14 Level I pediatric trauma centers over a 1-year period. Patients who underwent FAST were compared with those that did not, using descriptive statistics and univariate analysis; p value less than 0.05 was considered significant. FAST test characteristics were performed using computed tomography (CT) and/or intraoperative findings as the gold standard. Results Two thousand one hundred eighty-eight children (age, 7.8 ± 4.6 years) were included. Eight hundred twenty-nine (37.9%) received a FAST, 340 of whom underwent an abdominal CT. Ninety-seven (29%) of these 340 patients had an IAI and 27 (7.9%) received an acute intervention. CT scan utilization after FAST was 41% versus 46% among those who did not receive FAST. The frequency of FAST among centers ranged from 0.84% to 94.1%. There was low correlation between FAST and CT utilization (r = −0.050, p < 0.001). Centers that performed FAST at a higher frequency did not have improved accuracy. The test performance of FAST for IAI was sensitivity, 27.8%; specificity, 91.4%; positive predictive value, 56.2%; negative predictive value, 76.0%; and accuracy, 73.2%. There were 81 injuries among the 70 false-negative FAST. The test performance of FAST for IAI-I was sensitivity, 44.4%; specificity, 88.5%; positive predictive value, 25.0%; negative predictive value, 94.9%; and accuracy, 85.0%. Fifteen children with a negative FAST received acute interventions. Among the 27 patients with true positive FAST examinations, 12 received intervention. All had an abnormal abdominal physical examination. No patient underwent intervention before CT scan. Conclusion As currently used, FAST has a low sensitivity for IAI, misses IAI-I and rarely impacts management in pediatric BAT. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level II; diagnostic tests or criteria study, level II; therapeutic/care management study, level III.

Pediatric Traumatic Amputations in the United States: A 5-Year Review.

Background: Pediatric traumatic amputations are devastating injuries capable of causing permanent physical and psychological sequelae. Few epidemiologic reports exist for guidance of prevention strategies. The objective of this study is to review the recent trends in pediatric traumatic amputations using a national databank. Methods: A review of all pediatric (age, 0 to 17 y) amputee patients was performed using the National Trauma Data Bank from 2007 to 2011. Data including demographics, location of amputation, and mechanism of injury were analyzed. Results: In the analysis 2238 patients were identified. The majority of amputations occurred in the youngest (0 to 5 y) and oldest (15 to 17 y) age groups with a 3:1 male to female ratio. The most common amputation locations were finger (54%) and toe (20%). A caught between mechanism (16.3%) was most common overall followed by machinery, powered lawn mowers, motor vehicle collisions, firearms, and off-road vehicles. Males were statistically more likely to have an amputation and lawnmower injuries were statistically associated with lower extremity amputations in children 5 years old and below. Motor vehicle injuries were the most common cause of adolescent amputations. Firearm-related amputations occurred predominantly in adolescents, whereas off-road vehicle amputations occurred in all ages. Conclusions: Common trends in pediatric amputations are relatively unchanged over the last decade. Young children sustain more finger amputations from a caught between objects mechanism, whereas adolescents sustain serious amputations from higher energy mechanisms such as firearms-related and motor vehicle–related injuries. Lawnmower-related amputations continue to most significantly affect younger children despite increased public awareness. Improved prevention strategies targeting age and mechanism-related trends are necessary to prevent these costly and debilitating injuries. Level of Evidence: Level IV.

Restraint status improves the predictive value of motor vehicle crash criteria for pediatric trauma team activation

BACKGROUND Most trauma centers incorporate mechanistic criteria (MC) into their algorithm for trauma team activation (TTA). We hypothesized that characteristics of the crash are less reliable than restraint status in predicting significant injury and the need for TTA. METHODS We identified 271 patients (age, <15 y) admitted with a diagnosis of motor vehicle crash. Mechanistic criteria and restraint status of each patient were recorded. Both MC and MC plus restraint status were evaluated as separate measures for appropriately predicting TTA based on treatment outcomes and injury scores. RESULTS Improper restraint alone predicted a need for TTA with an odds ratios of 2.69 (P = .002). MC plus improper restraint predicted the need for TTA with an odds ratio of 2.52 (P = .002). In contrast, the odds ratio when using MC alone was 1.65 (P = .16). When the 5 MC were evaluated individually as predictive of TTA, ejection, death of occupant, and intrusion more than 18 inches were statistically significant. CONCLUSIONS Improper restraint is an independent predictor of necessitating TTA in this single-institution study.

Acute procedural interventions after pediatric blunt abdominal trauma: A prospective multicenter evaluation

BACKGROUND Pediatric intra-abdominal injuries (IAI) from blunt abdominal trauma (BAT) rarely require emergent intervention. For those children undergoing procedural intervention, our aim was to understand the timing and indications for operation and angiographic embolization. METHODS We prospectively enrolled children younger than 16 years after BAT at 14 Level I Pediatric Trauma Centers over a 1-year period. Patients with IAI who received an intervention (IAI-I) were compared with those who did not receive an intervention using descriptive statistics and univariate analysis; p less than 0.05 was considered significant. RESULTS Two hundred sixty-one (11.9%) of 2,188 patients had IAI. Forty-five (17.2%) IAI patients received an acute procedural intervention (38 operations, seven angiographic embolization). The mean age for patients requiring intervention was 7.1 ± 4.1 years and not different from the population. Most patients (88.9%) with IAI-I were normotensive. IAI-I patients were significantly more likely to have a mechanism of motor vehicle collision (66.7% vs. 38.9%), more likely to present as a Level I activation (44.4% vs. 26.9%), more likely to have a Glascow Coma Scale less than 14 (31.1% vs. 15.5%), and more likely to have an abnormal abdominal physical examination (93.3% vs. 65.7%) than patients that did not require acute intervention. All patients underwent computed tomography scan before intervention. Operations consisted of laparotomy (n = 21), laparoscopy converted to open (n = 11), and laparoscopy alone (n = 6). The most common surgical indications were hollow viscus injury (HVI) (11 small bowel, 10 colon, 6 small bowel/colon, 2 duodenum). All interventions for solid organ injury, including seven angioembolic procedures, occurred within 8 hours of arrival; many had hypotension and received a transfusion. Procedural interventions were more common for HVI than for solid organ injury (59.2% vs. 7.6%). Postoperative mortality from IAI was 2.6%. CONCLUSION Acute procedural interventions for children with IAI from BAT are rare, predominantly for HVI, are performed early in the hospital course and have excellent clinical outcomes. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; therapeutic study, level IV.BACKGROUND Pediatric intraabdominal injuries (IAI) from blunt abdominal trauma (BAT) rarely require emergent intervention. For those children undergoing procedural intervention, our aim was to understand the timing and indications for operation and angiographic embolization. METHODS We prospectively enrolled children <16 years following BAT at 14 Level-One Pediatric Trauma Centers over a 1-year period. Patients with IAI who received an intervention (IAI-I) were compared to those who did not receive an intervention using descriptive statistics and univariate analysis; p < 0.05 was considered significant. RESULTS 261 of 2188 patients (11.9%) had IAI. 45 IAI patients (17.2%) received an acute procedural intervention (38 operations, 7 angiographic embolization). The mean age for patients requiring intervention was 7.1+/-4.1 years and not different from the population. The majority of patients with IAI-I were normotensive (88.9%). IAI-I patients were significantly more likely to have a mechanism of MVC (66.7% vs. 38.9%), more likely to present as a level I activation (44.4% vs. 26.9%), more likely to have a GCS < 14 (31.1% vs. 15.5%), and more likely to have an abnormal abdominal physical exam (93.3% vs. 65.7%) than patients that did not require acute intervention. All patients underwent CT scan before intervention. Operations consisted of laparotomy (n=21), laparoscopy converted to open (n=11), and laparoscopy alone (n=6). The most common surgical indications were hollow viscus injury (HVI) (11 small bowel, 10 colon, 6 small bowel/colon, 2 duodenum). All interventions for solid organ injury (SOI), including 7 angioembolic procedures, occurred within 8 hours of arrival; many had hypotension and received a transfusion. Procedural interventions were more common for HVI than for SOI (59.2% vs. 7.6%). Post-operative mortality from IAI was 2.6%. CONCLUSIONS Acute procedural interventions for children with IAI from BAT are rare, predominantly for HVI, are performed early in the hospital course, and have excellent clinical outcomes. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Antibiotic ointment versus a silver-based dressing for children with extremity burns: A randomized controlled study

INTRODUCTION Antibiotic or silver-based dressings are widely used in burn wound care. Our standard method of dressing pediatric extremity burn wounds consists of an antibiotic ointment or nystatin ointment-impregnated nonadherent gauze (primary layer), followed by rolled gauze, soft cast pad, plaster and soft casting tape (3M™ Scotchcast™, St. Paul, MN). The aim of this study was to compare our standard ointment-based primary layer versus Mepitel Ag® (Mölnlycke Health Care, Gothenburg, Sweden) in the management of pediatric upper and lower extremity burn wounds. METHODS Children with a new burn injury to the upper or lower extremities, who presented to the burn clinic were eligible. Eligible children were enrolled and randomized, stratified by burn thickness, to be dressed in an ointment-based dressing or Mepitel Ag®. Study personnel and participants were not blinded to the dressing assignment after randomization. Dressings were changed approximately once or twice per week, until the burn wound was healed or skin-grafted. The primary outcome was time to wound healing and p-value < 0.05 was considered significant. RESULTS Ninety-six children with 113 upper or lower extremity burns were included in the analysis. Mepitel Ag® (hazard ratio [HR] 0.57 (95% Confidence Interval (CI) 0.40-0.82); p = 0.002) significantly reduced the rate of wound healing, adjusting for burn thickness and fungal wound infection. The incidence of fungal wound infections and skin grafting was similar between the two groups. Children randomized to standard ointment dressings were significantly less likely to require four or more burn clinic visits than those in the Mepitel Ag® (4% versus 27%; p = 0.004). CONCLUSION Our study shows that our standard ointment-based dressing significantly increases the rate of wound healing compared to Mepitel Ag® for pediatric extremity burn injuries. LEVEL OF EVIDENCE Treatment study; Level 1.

Does restraint status in motor vehicle crash with rollover predict the need for trauma team presence on arrival? An ATOMAC study

PURPOSE Restraint status has not been combined with mechanistic criteria for trauma team activation. This study aims to assess the relationship between motor vehicle crash rollover (MVC-R) mechanism with and without proper restraint and need for trauma team activation. METHODS Patients <16years old involved in an MVC-R between November 2007 and November 2012 at 6 Level 1 pediatric trauma centers were included. Restraint status, the need for transfusion or intervention in the emergency department (ED), hospital and intensive care length of stay and mortality were assessed. RESULTS Of 690 cases reviewed, 48% were improperly restrained. Improperly restrained children were more likely to require intubation (OR 10.24; 95% CI 2.42 to 91.69), receive blood in the ED (OR 4.06; 95% CI 1.43 to 14.17) and require intensive care (ICU) (OR; 3.11; 95% CI 1.96 to 4.93) than the properly restrained group. The improperly restrained group had a longer hospital length of stay (p<0.001), and a higher mortality (3.4% vs. 0.8%; OR 4.09; 95% CI 1.07 to 23.02) than the properly restrained group. CONCLUSION Unrestrained children in MVC-R had higher injury severity and were significantly more likely to need urgent interventions compared to properly restrained children. This supports a modification to include restraint status with the rollover criterion for trauma team activation.