Kristine W. Hansen

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.

Effect of a Pediatric Trauma Response Team on Emergency Department Treatment Time and Mortality of Pediatric Trauma Victims

Objective. Delay in the provision of definitive care for critically injured children may adversely effect outcome. We sought to speed care in the emergency department (ED) for trauma victims by organizing a formal trauma response system. Design. A case-control study of severely injured children, comparing those who received treatment before and after the creation of a formal trauma response team. Setting. A tertiary pediatric referral hospital that is a locally designated pediatric trauma center, and also receives trauma victims from a geographically large area of the Western United States. Subjects. Pediatric trauma victims identified as critically injured (designated as “trauma one”) and treated by a hospital trauma response team during the first year of its existence. Control patients were matched with subjects by probability of survival scores, and were chosen from pediatric trauma victims treated at the same hospital during the year preceding the creation of the trauma team. Interventions. A trauma response team was organized to respond to pediatric trauma victims seen in the ED. The decision to activate the trauma team (designation of patient as “trauma one”) is made by the pediatric emergency medicine (PEM) physician before patient arrival in the ED, based on data received from prehospital care providers. Activation results in the notification and immediate travel to the ED of a pediatric surgeon, neurosurgeon, emergency physician, intensivist, pharmacist, radiology technician, phlebotomist, and intensive care unit nurse, and mobilization of an operating room team. Most trauma one patients arrived by helicopter directly from accident scenes. Outcome Measures. Data recorded included identifying information, diagnosis, time to head computerized tomography, time required for ED treatment, admission Revised Trauma Score, discharge Injury Severity Score, surgical procedures performed, and mortality outcome. Trauma Injury Severity Score methodology was used to calculate the probability of survival and mortality compared with the reference patients of the Major Trauma Outcome Study, by calculation ofz score. Results. Patients treated in the ED after trauma team initiation had statistically shorter times from arrival to computerized tomography scanning (27 ± 2 vs 21 ± 4 minutes), operating room (63 ± 16 vs 623 ± 27 minutes) and total time in the ED (85 ± 8 vs 821 ± 9 minutes). Calculation ofz score showed that survival for the control group was not different from the reference population (z = −0.8068), although survival for trauma-one patients was significantly better than the reference population (z = 2.102). Conclusion. Before creation of the trauma team, relevant specialists were individually called to the ED for patient evaluation. When a formal trauma response team was organized, time required for ED treatment of severe trauma was decreased, and survival was better than predicted compared with the reference Major Trauma Outcome Study population.

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.

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.

A Prospective Evaluation of the Clinical Presentation of Pediatric Pelvic Fractures

BACKGROUND We sought to describe pediatric, blunt trauma patients with pelvic fracture (PF) and to evaluate pelvis examination sensitivity and specificity. METHODS We conducted a prospective study of blunt trauma patients at a Level I pediatric trauma center. A pediatric emergency medicine physician attempted to diagnose a PF, solely on the basis of the history and pelvis examination. Patients with blunt trauma but no pelvic fracture (NPF) were used as controls. RESULTS We enrolled 140 patients (16 PF, 124 NPF), and no significant differences were found regarding median age, gender, injury mechanism, acuity, and medical outcome. Approximately 25% of PF patients had iliac-wing fractures; 37%, single pelvic ring; 25%, double pelvic ring; and 13%, acetabular fractures. Eleven patients with PF had an abnormal pelvis examination (69% sensitivity), compared with six NPF patients (95% specificity, negative predictive value 0.91). CONCLUSION Pediatric patients with PF have low mortality and few complex fractures. The pelvis examination appears to have both high specificity and negative predictive value.

Significant reduction in delayed diagnosis of injury with implementation of a pediatric trauma service.

Background: The occurrence of delayed diagnosis of injury (DDI) among pediatric trauma patients represents a breakdown in trauma care. Although some DDI may be unavoidable, the rate of DDI may be used as a measure of quality improvement. Objective: We sought to investigate DDI in admitted pediatric trauma patients while a designated pediatric trauma response team was used and compare this with the prior incidence of DDI (4.3%) before initiation of the response team. Methods: Primary Childrens Medical Center (PCMC) is a regional tertiary pediatric trauma center. This analysis used the prospectively gathered PCMC Trauma Database, and included all hospitalized pediatric trauma patients from 1997 through 2000. Results: A total of 3265 patients were included; no patients were excluded. A DDI occurred in 15 (0.46%; 95% CI: 0.31, 0.79) trauma patients. The DDI patients were more severely injured with significantly higher Injury Severity Scores, lower TRISS Probability of Survival values, longer hospitalizations (P ≤ 0.05, Mann-Whitney U), and were more frequently admitted to the PICU (P ≤ 0.05, χ2) than the non-DDI patient population. In a previous study, our incidence of missed injury was 4.3% (50/1175; 95% CI: 3.3, 5.6); with implementation of a designated trauma response team and trauma service, the incidence of DDI was reduced nearly 10-fold to 0.46% (15/3265; 95% CI: 0.31, 0.79). Conclusions: Implementation of an effective trauma team and trauma service was associated with a significant reduction in DDI.

Source of Admission and Outcomes for Critically Injured Children in the Mountain States

OBJECTIVE To determine whether mortality and length of stay at a pediatric trauma center differ between patients admitted by interhospital transfer and those admitted directly from the injury scene. DESIGN Analysis of prospectively collected data from a pediatric trauma center database. SETTING A designated regional level I pediatric trauma center. PARTICIPANTS Injured children from birth to 17 years of age hospitalized between January 1, 2006, and September 30, 2007. MAIN EXPOSURE Incident in-hospital mortality rates and length of stay at the trauma center were compared between patients admitted directly and those admitted by interhospital transfer, controlling for potential confounders. OUTCOME MEASURES In-hospital mortality and duration of hospitalization. RESULTS Of 2192 patients admitted to the trauma center, 1175 (53.6%) were admitted directly from the injury scene. Patients admitted by interhospital transfer had higher injury severity and lower Glasgow Coma Scale scores at admission (P < .01). Of 31 deaths during the study period, 26 (83.9%) were among patients admitted by interhospital transfer. These patients had a 7-fold higher unadjusted incident rate of death (incidence rate ratio, 7.16; 95% confidence interval, 2.49-20.58) compared with those admitted directly. This finding remained (incidence rate ratio, 3.01; 95% confidence interval, 1.01-8.98) after adjustment for injury severity and Glasgow Coma Scale scores, elapsed time from injury until admission at the trauma center, and age. Among survivors, patients admitted by interhospital transfer stayed longer in the hospital than those admitted directly. CONCLUSION Pediatric trauma center mortality rates are lower among children admitted directly from the injury scene compared with those admitted by interhospital transfer.

Alternative model for a pediatric trauma center: efficient use of physician manpower at a freestanding children's hospital.

Background: Freestanding childrens hospitals may lack resources, especially surgical manpower, to meet American College of Surgeons trauma center criteria, and may organize trauma care in alternative ways. Materials and Methods: At a tertiary care childrens hospital, attending trauma surgeons and anesthesiologists took out-of-hospital call and directed initial care for only the most severely injured patients, whereas pediatric emergency physicians directed care for patients with less severe injuries. Survival data were analyzed using TRISS methodology. Results: A total of 903 trauma patients were seen by the system during the period 10/1/96-6/30/01. Median Injury Severity Score was 16, and 508 of patients had Injury Severity Score ≥15. There were 83 deaths, 21 unexpected survivors, and 13 unexpected deaths. TRISS analysis showed that z-score was 4.39 and W-statistic was 3.07. Conclusions: Mortality outcome from trauma in a pediatric hospital using this alternative approach to trauma care was significantly better than predicted by TRISS methodology.

Report from the Childress Summit of the Pediatric Trauma Society, April 22–24, 2013

ABSTRACT The summit attendees were divided into four thematically focused work groups as follows: emergency medicine/critical care/resuscitation, general trauma, neurotrauma/traumatic brain injury, and trauma systems. Each work group identified strengths, weaknesses, opportunities, and threats specific to their topic before the summit convened. Once the summit began, each work group met in concurrent breakout sessions to identify challenges and opportunities to improve pediatric trauma care. The groups then reconvened; ideas from each group were shared and discussed among all participants. White papers generated by each group after the summit form the basis of this combined report.