Tag Archives: pediatric trauma

Nursing Tips for Managing Pediatric Orthopedic Trauma

Nurses have a complementary role with physicians in caring for children with orthopedic injuries. Typically, the child will have been evaluated and had some sort of fracture management implemented. In children, nursing management is easer than in adults since a child is less likely to need an invasive surgical procedure. Many fractures can be dealt with using casts and splints alone.

Here are a few tips for providing the best care for your pediatric patients:

  • Ensure adequate splinting / casting. You will have an opportunity to see the child at their usual level of activity. If it appears likely that their activity may defeat the purpose of the cast or splint, inform the surgeon or extender so they can apply a better one.
  • Focus on pain control. Nothing aggravates parents more than seeing their child in pain! Make sure acetominophen or ibuprofen is available prn if pain is very mild, or scheduled if more significant. Ensure that mild narcotics are available if pain levels are higher. Remember, stool softeners are mandatory if narcotics are given.
  • Monitor compartments frequently. If a cast is used, check the distal part of the extremity for pain, unwillingness to move, numbness or swelling. If any are present, call the physician or extender and expect prompt attention to the problem.
  • Always think about the possibility of abuse. Fractures are rarely seen in children under 3, and almost never if less than 1 year old. If you have concerns about the physical findings or parent interactions, let the physician and social workers know immediately.

Vascular Trauma Resources At Pediatric Trauma Centers

There are two types of pediatric trauma centers: freestanding and combined. These adjectives refer to whether an adult trauma center is directly associated with the pediatric one. Over the years, I have come to appreciate that there may be substantial resource and experience differences between the two.

Trauma surgeons at freestanding centers are usually pediatric surgeons. They have managed trauma cases during their surgical residency and pediatric surgical fellowship, but usually have not taken a trauma fellowship. Their experience with complex trauma and advanced concepts like damage control surgery generally comes from their training and on the job experience. Surgeons at combined centers may be pediatric trained, or may be adult surgeons with pediatric experience. The adult surgeons are generally well-versed in advanced trauma concepts, and the pediatric surgeons can take advantage of the adult surgeons’ expertise in advanced trauma cases.

Freestanding pediatric centers may have fewer resources in some key areas, such as fellowship trained specialists in vascular surgery, GI endoscopy, and interventional radiology. A recent study accepted for publication from the University of Arkansas examines differences in surgeon practice patterns and resource availability at freestanding vs combined centers.

Two surveys were sent to 85 pediatric trauma centers around the US. Roughly half were Level I, and half were freestanding. One was sent to 414 pediatric surgeons at those centers inquiring about practice patterns, and the other was sent to the trauma medical directors of each center asking about their resources.

Here are the factoids:

  • 50 of the 85 trauma centers responded, as did 176 of the 414 surgeons. 48% of trauma medical directors responded. These are reasonable response rates for questionnaires.
  • Adult surgeons covered pediatric trauma at 6% of Level I centers, and 33% of Level II
  • During pediatric surgical fellowship, 56% participated in management of vascular trauma, 25% was managed by vascular surgeons, and 19% had no experience
  • At 23% of freestanding centers, vascular surgeons were not always available, and a vascular surgeon was not listed on the call schedule 38% of the time
  • 27% of freestanding facilities indicated that endovascular and stent capabilities were not available, and 18% did not have interventional radiologists (IR) available within 30 minutes
  • All combined centers had vascular and endovascular capabilities, and IR was available within 30 minutes 92% of the time

Bottom line: This is an intriguing paper that looks at a few of the disparities between freestanding and combined pediatric trauma centers. Obviously, it is hampered by the survey format, but does provide some interesting information. The focus was on vascular resources, and shows several of the major differences between the two types of centers.

Fortunately, vascular trauma is relatively rare in the pediatric age group. But it is possible that a child presenting to a freestanding pediatric trauma center may be managed by a pediatric surgeon with little vascular experience, and assistance from a fellowship trained vascular surgeon and/or interventional radiologist may be unavailable.

This paper provides important information regarding resource disparities in pediatric trauma care. Ideally, this should be reviewed and remedied as the Resources for Optimal Care of the Injured Patient (Orange Book) evolves over the coming years.

Reference: Pediatric Vascular Trauma Practice Patterns and Resource Availability: A Survey of ACS-Designated Pediatric Trauma Centers. J Trauma, accepted for publication Jan 12, 2018.

Delayed Diagnoses In Children Revisited

A couple of years ago I wrote about a paper that examined patterns in delayed diagnoses in injured children. It was a single-hospital study of children treated at a Level II pediatric trauma center. In that study, the overall rate of delayed diagnosis was 4%. The orthopedic component looked high but was not really broken down in detail.

A soon-to-be-published study looked at more recent experience with this issue, specifically in pediatric patients with orthopedic injury. They specifically evaluated all pediatric patients with bone, joint, peripheral nerve, and tendon injuries treated at their Level I pediatric trauma center over a nearly 6 year period. Orthopedic surgery consults were obtained at the discretion of the trauma or primary service.

How good was their discretion? Here are the factoids:

  • 1009 trauma activations were reviewed, of which 196 (19%) were eventually diagnosed with an orthopedic injury
  • There were 18 children (9%) with a delayed diagnosis, defined as one discovered 12 hours or longer after admission. Most were missed on initial exam or imaging
  • The injuries were literally all over the place. There was no obvious pattern.
  • Six of these were detected on tertiary survey
  • Average time to discovery was 3 days, and the average age of these children was 11 years
  • Children with a delayed diagnosis tended to be much more seriously hurt (ISS 21 vs 9), and more likely to have a significant head injury (GCS 12 vs 14)
  • One child required surgery for the delayed diagnosis, the rest were managed with splinting/casting or observation

Bottom line: Delayed diagnoses happen in children, too. And typically, they are due to a failure in the physical exam. Sometimes there is nothing to discover on the exam. But often times, if the mechanism is fully taken into account and a really good  exam is performed, these injuries may be found early.

I don’t consider an injury found on tertiary exam to be a delayed diagnosis, as long as it is performed within a reasonable time frame (24-48 hours max). It’s a well established fact that some injuries will not manifest as pain or bruising until the next day, or longer. So pick a maximum time interval (but don’t make it too early either) and do a tertiary survey on all children who are trauma activations, have multiple injuries, or have a significant mechanism. 

Related posts:

Reference: Incidence of delayed diagnosis of orthopaedic injury in pediatric trauma patients. J Ortho Trauma epub ahead of print, April 29, 2017.

Potentially Avoidable Pediatric Transfers

Pediatric emergency and trauma care is not readily available across a sizable chunk of the US, particularly in rural areas. Couple this with the fact that many rural emergency providers are not necessarily trained in emergency medicine and may have little recent pediatric training fosters the common practice of transferring these injured children to a higher level of care.

And unfortunately, many of these transferred children have relatively simple issues that really don’t actually need a transfer. Some studies have reported that up to 40% of children sent to tertiary pediatric centers are sent home in less than 24 hours.

Most research in this area focuses on single medical center experiences. An article currently in press looks at the experience of the entire state of Iowa over a 10 year period. The authors looked at all claims data for children between ages 8 days and 18 years. Children who were transferred were compared to those who were not.

Here are the factoids:

  • 2 million cases were included in the study, and only 1% were transferred (21,319)
  • Children in rural areas were transferred 3x more often than those in urban areas
  • Only 63% were transferred to a designated children’s hospital, and 45% were sent to an ED rather than direct transfer to an inpatient bed
  • 39% were potentially avoidable transfers, meaning that they were discharged from the receiving ED or the hospital within 24 hours of admission
  • Two of the top 5 reasons for transfer were trauma related: fracture, and TBI without blood in the head.
  • The cost for potentially avoidable transfers in the top 5 categories was $2 million dollars (!)

Bottom line: This is a very comprehensive study that shows the magnitude and cost consequences of potentially inappropriate pediatric transfers. It was not designed to figure out what to do about it, but it provides some insight for the problem solvers out there. Since we know the top 5 transfer diagnoses (seizure, fracture, TBI without bleeding, respiratory infection, and asthma), we can start to work on systems to provide education to rural providers on these topics, as well as real-time interaction to help them determine the 60% that really do need a higher level of care. Telemedicine will eventually be a big part of this, but most areas around the country are still struggling to figure out the details. Stay tuned!

Reference: Potentially Avoidable Pediatric Interfacility Transfer is a Costly Burden for Rural Families: A Cohort Study. Acad Emerg Med 28 March 2016, in press.

How To Predict Venous Thromboembolism In Pediatric Trauma

As with adults a decade ago, the incidence of venous thromboembolism (VTE) in children is now on the rise. Whereas adult VTE occurs in more than 20% of adult trauma patients without appropriate prophylaxis, it is only about 1% in kids, but increasing. There was a big push in the early 2000′s to develop screening criteria and appropriate methods to prevent VTE. But since the incidence in children was so low, there was no impetus to do the same for children.

The group at OHSU in Portland worked with a number of other US trauma centers, and created some logistic regression equations based on a large dataset from the NTDB. The authors developed and tested 5 different models, each more complex than the last. They ultimately selected a model that provided the best fit with the fewest number of variables.

The tool consists of a list of risk factors, each with an assigned point value. The total point value is then identified on a chart of the regression equation, which shows the risk of VTE in percent.

Here are the factors:

Note that the highest risk factors are age >= 13, ICU admission, and major surgery.

And here is the regression chart:

Bottom line: This is a nice tool, and it’s time for some clinical validation. So now all we have to do is figure out how much risk is too much, and determine which prophylactic tools to use at what level. The key to making this clinically usable is to have a readily available “VTE Risk Calculator” available at your fingertips to do the grunt work. Hmm, maybe I’ll chat with the authors and help develop one!

Reference: A Clinical Tool for the Prediction of Venous Thromboembolism in Pediatric Trauma Patients. JAMA Surg 151(1):50-57, 2016.