Jonathan I. Groner

Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma

BACKGROUND Focused abdominal sonography for trauma (FAST) has been well reported in adults, but its applicability in children is less well established. We decided to test the hypothesis that FAST and computed tomography (CT) are equivalent imaging studies in the setting of pediatric blunt abdominal trauma. METHODS One hundred seven hemodynamically stable children undergoing CT for blunt abdominal trauma were prospectively investigated using FAST. The ability of FAST to predict injury by detecting free intraperitoneal fluid was compared with CT as the imaging standard. RESULTS Thirty-two patients had CT documented injuries. There were no late injuries missed by CT. FAST detected free fluid in 12 patients. Ten patients had solid organ injury but no free fluid and, thus, were not detected by FAST. The sensitivity of FAST relative to CT was only 0.55 and the negative predictive value was only 0.50. CONCLUSION FAST has insufficient sensitivity and negative predictive value to be used as a screening imaging test in hemodynamically stable children with blunt abdominal trauma.

Clinical manifestations of appendiceal pinworms in children: an institutional experience and a review of the literature

The association of Enterobius vermicularis infestation with acute appendicitis varies from 0.2–41.8% worldwide. Our purpose was to determine the significance of Enterobius-associated appendicitis by retrospective review of appendectomies performed during a 5-year period at a major children’s hospital. The Surgical Pathology database at Children’s Hospital, Columbus, Ohio, was reviewed for appendiceal specimens found to have Enterobius infestation. Corresponding patient charts were evaluated for age, gender, presenting symptoms, laboratory data, operative findings, and clinical course. Of the 1,549 appendectomies performed from January 1998 through January 2003, 21 specimens (1.4%) were found to contain Enterobius vermicularis. Fifteen of the appendectomies were performed for symptoms of acute appendicitis; the remaining six were incidental appendectomies in conjunction with other operations. The mean age was 8.9 years. Ten patients were male; 11 were female. Of the 15 symptomatic children, nine presented with fever >99.0ºF, and 11 had a WBC count >10,000. Intra-operative appearance of the appendix ranged from normal to perforation. Pathologic evaluation showed neutrophil or eosinophil infiltration in 15 of the 21 specimens. Enterobius infestation is an uncommon cause of acute appendicitis in children in the United States. It may be associated with acute appendicitis, “chronic appendicitis,” ruptured appendicitis, or with no significant clinical symptoms.

Acute care clinical indicators associated with discharge outcomes in children with severe traumatic brain injury.

Objective:The effect of the 2003 severe pediatric traumatic brain injury (TBI) guidelines on outcomes has not been examined. We aimed to develop a set of acute care guideline–influenced clinical indicators of adherence and tested the relationship between these indicators during the first 72 hours after hospital admission and discharge outcomes. Design:Retrospective multicenter cohort study. Setting:Five regional pediatric trauma centers affiliated with academic medical centers. Patients:Children under 18 years with severe traumatic brain injury (admission Glasgow Coma Scale score ⩽ 8, International Classification of Diseases, 9th Edition, diagnosis codes of 800.0–801.9, 803.0–804.9, 850.0–854.1, 959.01, 950.1–950.3, 995.55, maximum head abbreviated Injury Severity Score ≥ 3) who received tracheal intubation for at least 48 hours in the ICU between 2007 and 2011 were examined. Interventions:None. Measurements and Main Results:Total percent adherence to the clinical indicators across all treatment locations (prehospital, emergency department, operating room, and ICU) during the first 72 hours after admission to study center were determined. Main outcomes were discharge survival and Glasgow Outcome Scale score. Total adherence rate across all locations and all centers ranged from 68% to 78%. Clinical indicators of adherence were associated with survival (adjusted hazard ratios, 0.94; 95% CI, 0.91–0.96). Three indicators were associated with survival: absence of prehospital hypoxia (adjusted hazard ratios, 0.20; 95% CI, 0.08–0.46), early ICU start of nutrition (adjusted hazard ratios, 0.06; 95% CI, 0.01–0.26), and ICU PaCO2 more than 30 mm Hg in the absence of radiographic or clinical signs of cerebral herniation (adjusted hazard ratios, 0.22; 95% CI, 0.06–0.8). Clinical indicators of adherence were associated with favorable Glasgow Outcome Scale among survivors (adjusted hazard ratios, 0.99; 95% CI, 0.98–0.99). Three indicators were associated with favorable discharge Glasgow Outcome Scale: all operating room cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.61; 95% CI, 0.58–0.64), all ICU cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.73; 95% CI, 0.63–0.84), and no surgery (any type; adjusted relative risk, 0.68; 95% CI, 0.53– 0.86). Conclusions:Acute care clinical indicators of adherence to the Pediatric Guidelines were associated with significantly higher discharge survival and improved discharge Glasgow Outcome Scale. Some indicators were protective, regardless of treatment location, suggesting the need for an interdisciplinary approach to the care of children with severe traumatic brain injury.

A pediatric massive transfusion protocol

BACKGROUND Pediatric massive blood transfusions occur widely at hospitals across the nation; however, there are limited data on pediatric massive transfusion protocols (MTPs) and their impact. We present a pediatric MTP and examine its impact on morbidity and mortality as well as identify factors that may prompt protocol initiation. METHODS Using a prospective cohort, we collected data on all pediatric patients who required un–cross-matched blood from January 1, 2009, through January 1, 2011. This captured patients who received blood products according to the protocol as well as patients who were massively transfused at physician discretion. Outcomes between groups were compared. RESULTS A total of 55 patients received un–cross-matched blood, with 22 patients in the MTP group and 33 patients receiving blood at physician discretion (non–MTP group). Mortality was not significantly different between groups. Injury Severity Score for the MTP group was 42 versus 25 for the non–MTP group (p ⩽ 0.01). Thromboembolic complications occurred more exclusively in the non–MTP group (p ⩽ 0.04). Coagulopathy, evidenced by partial thromboplastin time (PTT) greater than 36, was associated with initiation of the MTP. CONCLUSION MTPs have been widely adopted by hospitals to minimize the coagulopathy associated with hemorrhage. Blood transfusion via MTP was associated with fewer thromboembolic events. Coagulopathy was associated with initiation of the MTP. These results support the institution of pediatric MTPs and suggest a need for further research on the protective relationship between MTP and thromboembolic events and on identifying objective factors associated with MTP initiation. LEVEL OF EVIDENCE Therapeutic study, level IV.

Undertriage of major trauma patients in the US emergency departments

BACKGROUND There is evidence that regionalized trauma care and appropriate triage of major trauma patients improve patient outcomes. However, the national rate of undertriage and diagnoses of undertriaged patients are unknown. METHODS We used the 2010 Nationwide Emergency Department Sample to estimate the national rate of undertriage, identify the prevalent diagnoses, and conduct a simulation analysis of the capacity increase required for level I and II trauma centers (TCs) to accommodate undertriaged patients. Undertriaged patients were those with major trauma, injury severity score ≥ 16, who received definitive care at nontrauma centers (NTCs), or level III TCs. The rate of undertriage was calculated with those receiving definitive care at an NTC center or level III center as a fraction of all major trauma patients. RESULTS The estimated number of major trauma patient discharges in 2010 was 232448. Level of care was known for 197702 major trauma discharges, and 34.0% were undertriaged in emergency departments (EDs). Elderly patients were at a significantly higher risk of being undertriaged. Traumatic brain injury (TBI) was the most common diagnosis, 40.2% of the undertriaged patient diagnoses. To accommodate all undertriaged patients, level I and II TCs nationally would have to increase their capacity by 51.5%. CONCLUSIONS We found that more than one-third of US ED major trauma patients were undertriaged, and more than 40% of undertriaged diagnoses were TBIs. A significant capacity increase at level I and II TCs to accommodate these patients appears not feasible.

Resting energy expenditure in children following major operative procedures

Resting energy expenditure (REE) is reported to increase by 24% in adults following elective operations; however, similar data are not available for children. We studied REE in 12 children (14 operative procedures) to test the hypothesis that children experience a similar rise in REE as adults following operation. The operations included endorectal pull-through, gastric resection, ileostomy closure, and other major abdominal procedures. REE was measured daily by indirect calorimetry using a computerized bedside metabolic cart. All subjects (7 males, 5 females; age range, 8 to 19 years; mean age, 14.7 years) were measured supine, in bed, and after an overnight fast. REE was expressed as kilocalories per unit body surface area (BSA) per day. In addition, respiratory quotient (RQ) was calculated for each patient. Contrary to adults, these children did not demonstrate a significant increase in REE following major operative procedures. Furthermore, there was no change in RQ postoperatively. These data demonstrate that children might have a different response to surgical stress than adults. We theorize that children are able to convert energy expended on growth to energy spent on wound repair and healing, thus avoiding the overall increase in energy expenditure seen in the adult population.

Mortality increases with recurrent episodes of nonaccidental trauma in children

BACKGROUND Nonaccidental trauma (NAT) is a leading cause of childhood traumatic injury and death. Our objectives were to compare the mortality rates of children who experience recurrent episodes of NAT (rNAT) with children who experience a single episode of NAT and to identify factors associated with rNAT and increased mortality from rNAT. METHODS Patients of NAT and rNAT in the Ohio State Trauma Registry were identified by matching date of birth, race, and sex between records of patients younger than 16 years between 2000 and 2010 with an DRG International Classification of Diseases—9th Rev. e-code for child abuse (E967–E967.9). Statistical comparisons were made using Fisher’s exact and Wilcoxon rank-sum tests. RESULTS A total of 1,572 patients of NAT were identified, with 53 patients meeting criteria for rNAT. Compared with patients with single-episode NAT, patients with rNAT were more commonly male (66% vs. 52%, p = 0.05), were white (83% vs. 65%, p = 0.02), were evaluated at a pediatric trauma center (87% vs. 69%, p = 0.008), and had higher mortality (24.5% vs. 9.9%, p = 0.002). Compared with rNAT patients who did not die, those who died with rNAT had a longer interval from initial episode to second episode (median [interquartile range], 527 days [83–1,099] vs. 166 days [52–502]; p = 0.07) and were older during their second episode (1 year [<6 months to 3 years] vs. <6 months [<6 months to 1 year]; p = 0.06). At initial presentation, lower-extremity fractures (p = 0.09) and liver injuries (p = 0.06) were reported more commonly in nonsurvivors of rNAT. CONCLUSION Mortality is significantly higher in children who experience rNAT. Therefore, it is critically important to effectively intervene with appropriate resources and follow-up after a child’s initial episode of NAT to prevent a future catastrophic episode. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level IV.

Pediatric All-Terrain Vehicle–Related Injuries in Ohio From 1995 to 2001: Using the Injury Severity Score to Determine Whether Helmets Are a Solution

OBJECTIVE. The goal was to identify regions in Ohio with severe pediatric all-terrain vehicle–related injuries and to determine whether helmet usage was associated with lower injury severity scores. METHODS. We performed a retrospective review of data for all patients entered into the registries of Ohio’s major pediatric trauma centers for the period of January 1, 1995, to December 31, 2001. RESULTS. Seven hospitals participated. A total of 285 children were admitted; 2 patients died, and 13 required rehabilitation. The mean age was 11.1 years, with 76.1% of patients being male and 88.1% white. Most patients came from the central and southwestern regions of Ohio. An average of 30 admissions per year occurred from 1995 to 1998, but the number increased to 55 admissions per year from 1999 to 2001. Among the 285 injured children, 869 injuries were sustained; 57% of patients sustained multiple injuries. The most commonly injured body parts were the head (22.3%) and lower extremities (12.6%). The most common injuries sustained were fractures (31.4%) and contusions/abrasions (22.2%). Of patients for whom documentation was available, 72.2% (171 of 237 patients) were not helmeted. There was no significant difference in mean injury severity scores between helmeted and nonhelmeted riders (9.58 vs 9.12). Helmet usage was not associated with a reduction in head/facial injuries. CONCLUSIONS. All-terrain vehicle–related injuries to children nearly doubled between 1995 to 1998 and 1999 to 2001. Fewer than 30% of injured children were wearing helmets at the time of injury. With the injury severity score as an indicator, helmets provided no significant protection for all-terrain vehicle riders in this pediatric population.

Innate immune function predicts the development of nosocomial infection in critically injured children.

ABSTRACT Background: Critical injury has been associated with reduction in innate immune function in adults, with infection risk being related to degree of immune suppression. This relationship has not been reported in critically injured children. Hypothesis: Innate immune function will be reduced in critically injured children, and the degree of reduction will predict the subsequent development of nosocomial infection. Methods: Children (⩽18 years old) were enrolled in this longitudinal, prospective, observational, single-center study after admission to the pediatric intensive care unit following critical injury, along with a cohort of outpatient controls. Serial blood sampling was performed to evaluate plasma cytokine levels and innate immune function as measured by ex vivo lipopolysaccharide-induced tumor necrosis factor &agr; (TNF-&agr;) production capacity. Results: Seventy-six critically injured children (and 21 outpatient controls) were enrolled. Sixteen critically injured subjects developed nosocomial infection. Those subjects had higher plasma interleukin 6 and interleukin 10 levels on posttrauma days 1–2 compared with those who recovered without infection and outpatient controls. Ex vivo lipopolysaccharide-induced TNF-&agr; production capacity was lower on posttrauma days 1–2 (P = 0.006) and over the first week following injury (P = 0.04) in those who went on to develop infection. A TNF-&agr; response of less than 520 pg/mL at any time in the first week after injury was highly associated with infection risk by univariate and multivariate analysis. Among transfused children, longer red blood cell storage age, not transfusion volume, was associated with lower innate immune function (P < 0.0001). Trauma-induced innate immune suppression was reversible ex vivo via coculture of whole blood with granulocyte-macrophage colony-stimulating factor. Conclusions: Trauma-induced innate immune suppression is common in critically injured children and is associated with increased risks for the development of nosocomial infection. Potential exacerbating factors, including red blood cell transfusion, and potential therapies for pediatric trauma-induced innate immune suppression are deserving of further study.

Management of Penetrating Colon and Rectal Injuries in the Pediatric Patient

PURPOSE:Management of civilian penetrating colon injuries in the adult has evolved from the universal use of fecal diversion to the highly selective use of colostomy. We hypothesized that a similar management approach was appropriate for the pediatric population.METHODS:A retrospective review of pediatric patients (age <17 years) with a penetrating colorectal injury was performed at six Level I trauma centers for the period January 1990 through June 2001.RESULTS:For the period of review, 53 children with a penetrating colorectal injury were identified. Firearms caused 89 percent of the injuries. The colon was injured in 83 percent (n = 44) of patients and the rectum in 17 percent (n = 9) of patients. The colorectal injury was managed without colostomy in 62 percent (n = 33) and with colostomy in 38 percent (colon = 11, rectum = 9). All rectal injuries were treated with colostomy. The hospital length of stay was longer in the colostomy group (17.6 days vs. 11.4 days). The complication rate was higher in the colostomy group (55 percent vs. 27 percent), which included two patients with stoma-related complications. There was no mortality in this series.CONCLUSIONS:Primary repair was used safely in most cases of civilian penetrating colon injuries in the pediatric population. All rectal injuries were treated with colostomy in this series. Fecal diversion was used selectively. Colostomy was performed for selected cases of colon wounds associated with shock, multiple blood transfusions, multiple other injuries, extensive contamination, and high-velocity weapons. In the absence of these associated factors, primary repair appears justified.