Ronald A. Furnival

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.

Prehospital intranasal midazolam for the treatment of pediatric seizures.

Background: The local emergency medical services (EMS) council implemented a new pediatric treatment protocol using a Mucosal Atomization Device (MAD) to deliver intranasal (IN) midazolam for seizure activity. Methods: We sought to compare outcomes in seizing pediatric patients treated with IN midazolam using a MAD (IN-MAD midazolam) to those treated with rectal (PR) diazepam, 18 months before and after the implementation of the protocol. Results: Of 857 seizure patients brought by EMS to our emergency department (ED), 124 patients (14%) had seizure activity in the presence of EMS and were eligible for inclusion in this study. Of the 124 patients eligible for this study, 67 patients (54%) received no medications in the prehospital setting, 39 patients (32%) were treated with IN-MAD midazolam, and 18 patients (15%) were treated with PR diazepam. Median seizure time noted by EMS was 19 minutes longer for PR diazepam (30 minutes) when compared with IN-MAD midazolam (11 minutes, P = 0.003). Patients treated with PR diazepam in the prehospital setting were significantly more likely to have a seizure in the ED (odds ratio [OR], 8.4; confidence interval [CI], 1.6-43.7), ED intubation (OR, 12.2; CI, 2.0-75.4), seizure medications in the ED to treat ongoing seizure activity (OR, 12.1; CI, 2.2-67.8), admission to the hospital (OR, 29.3; CI, 3.0-288.6), and admission to the pediatric intensive care unit (OR, 53.5; CI, 2.7-1046.8). Conclusions: The IN-MAD midazolam controlled seizures better than PR diazepam in the prehospital setting and resulted in fewer respiratory complications and fewer admissions.

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.

The clinical presentation of pediatric pelvic fractures

Background Few studies have addressed the presentation and clinical impact of pediatric pelvic fractures. We sought to describe pediatric blunt trauma patients with pelvic fracture (PF) and to evaluate the sensitivity and specificity of physical examination at presentation for diagnosis. Methods Retrospective analysis of all PF and control (NPF) patients from our pediatric institution over an 8-year period. Results A total of 174 patients (88 PF, 86 NPF) were included. Median patient age was 8 years (range, 3 months to 18 years), with 54% males. The most common mechanisms of injury for PF patients were automobile-related accidents (75%). There were 140 patients (87%) who were transported by air or ground medical services. At presentation, approximately 16% of PF patients had a Glasgow Coma score of <15, a mean Revised Trauma Score of 7.49, and a median Injury Severity Score (ISS) of 9. Thirty-one PF patients (35%) had an ISS of >15 indicating severe, multiple injuries. Sixty-eight PF patients (77%) had severe isolated injuries (Abbreviated Injury Scale 1990 value of >3); 11% of PF patients required transfusions, and 2% died. Fifteen PF patients (17% ) had no pelvic ring disruption; 39 (43%) had a single pelvic ring fracture, 22 (2%) had two pelvic ring fractures, 2 (2%) had acetabular fractures, and 10 (11%) had a combination of pelvic fractures. An abnormal physical examination of the pelvis was noted in 81 patients with PF (92% sensitivity, 95% confidence interval [CI] = 0.89–0.95), 15 NPF patients had an abnormal examination (79% specificity, 95% CI = 0.74–0.84). The positive predictive value of the pelvis examination was 0.84, and the negative predictive value was 0.89. The most common abnormal pelvis examination finding was pelvic tenderness in 65 PF patients (73%). A total of seven PF patients had a normal examination of the pelvis; four had a depressed level of consciousness (defined as GCS <15), and six patients had a distracting injury. Conclusions Pediatric blunt trauma patients with pelvic fracture represent a severely injured population but generally have lower transfusion rates and mortality than noted in adult studies. The pelvis examination appears to be sensitive and specific in this retrospective study. However, an altered level of consciousness and/or distracting injuries may affect examination sensitivity and specificity. Based on this retrospective study, we cannot advocate eliminating pelvic radiographs in the severely injured, blunt trauma patient. Prospective studies are recommended.

ABCs of scoring systems for pediatric trauma.

This review presents an overview of scoring systems used in pediatric and adult trauma. Triage scoring systems, using readily available physical examination, physiologic, and/or mechanism of injury parameters, are used to determine appropriate prehospital referral patterns. The Trauma Score, Revised Trauma Score, Circulation/Respiration/Abdomen/Motor/Speech Scale, Prehospital Index, and Trauma Triage Rule were reviewed. Injury scoring systems based upon anatomic descriptions of all identified injuries, are retrospectively used to analyze trauma populations. The Abbreviated Injury Scale, Injury Severity Score, Modified Injury Severity Score, Organ Injury Scaling, and Anatomic Profile were discussed. The two trauma outcome analysis systems presented, TRISS and ASCOT, allow for reproducible quantification of trauma severity, and survival comparison between trauma populations. Many of these triage, injury severity, and outcome analysis systems were developed with patient survival as the major outcome variable. Although subsequent studies may have found them to have some predictive value for measures of trauma morbidity, these scoring systems do not specifically address long-term risk of impairment, and therefore overlook one of the most crucial elements of pediatric trauma care. The last 2 decades have seen considerable development of scoring systems and analysis methods applicable to the trauma patient. As presented, this trend includes both the elaboration of increasingly simple, field-oriented triage tools, and more complex mathematical techniques for trauma outcome analysis. Although not all systems were designed specifically with the pediatric patient in mind, validation or modification of these systems for the pediatric patient will likely occur in the future. It is anticipated that this field will continue to evolve with greater mathematical sophistication; a baseline familiarity of the early stages of this evolution may be of benefit to those caring for the pediatric trauma patient.

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.

Evaluating state capacity to collect and analyze emergency medical services data.

Background. Centralized emergency medical services (EMS) data collection is critical to evaluating EMS system effectiveness, yet a general lack of EMS data persists at local, state, andnational levels. Objective. To assess state capacity to collect, analyze, andutilize EMS data. Methods. Information was gathered through state site visits andsurveys from 54 states andU.S. territories in spring 2003 regarding EMS data-collection systems. Survey results were used to create 11 broad indicators that assess state data system infrastructure, collection methods, compliance with data standards, anddata uses. Results. States andterritories on average met 59% of the EMS data system indicators, with four states meeting all 11 indicators andtwo states meeting none. Seventy-six percent of the states reported having state-level EMS data-collection systems, and78% reported having authority to collect EMS data. However, most state EMS data sets were not capturing information on all EMS incidents, andonly 46% of the states had data dictionaries containing at least three-fourths of nationally recommended EMS data elements. In addition, only 33% of the states had linked EMS data with other health data sets to analyze EMS system operations andpatient outcomes. Conclusion. While EMS data systems exist in the majority of states, continued attention andresources are needed for state-level EMS data system development to improve capacity for evaluation of emergency medical services.

Pediatric care recommendations for freestanding urgent care facilities

Treatment of children at freestanding urgent care facilities has become common in pediatric health care. Well-managed freestanding urgent care facilities can improve the health of the children in their communities, integrate into the medical community, and provide a safe, effective adjunct to, but not a replacement for, the medical home or emergency department. Recommendations are provided for optimizing freestanding urgent care facilities’ quality, communication, and collaboration in caring for children.

Controversies in pediatric thoracic and abdominal trauma

Abstract The majority of pediatric thoracic and abdominal injuries are successfully treated with nonoperative management: thus, the role and clinical responsibility of the pediatric emergency physician or intensivist are increased. This review addresses some of the ongoing controversies in pediatric trauma care for the patient with truncal injury. The value of pediatric thoracic injury as a marker for overall severity. recent advances in diagnostic imaging for thonicic injuries, current recommendations for the evaluation of pediatric cardiac injury, and the potential benefits of minimally invasive thoracoscopy are discussed in detail. Recognition of pediatric intra-abdominal organ injury, often thought to be difficult in the acute care setting, can be quite accurate with the use of clinical information from physical examination. laboratory testing, and diagnostic imaging in the emergency department. A knowledge of the current trauma literature is required for effective care of the child with thoracoabdominal injury.