Yesterday, I wrote about using ultrasound in place of CT for initial diagnosis of blunt abdominal injury in children. Although it looks good for identification of solid organ injury and free fluid, it may miss injury to the intestine. Is that bad?
Lets look at a recent study that examined the consequences of delayed laparotomy for blunt intestinal injury. The American Pediatric Surgical Association conducted an 18-center study of the management of intestinal injuries in children less than 16 years of age. They were stratified by time to treatment. There were 214 patients with complete data records for review.
The majority of the patients were involved in a motor vehicle crash or a bicycle accident. Demographics were similar in all time to treatment groups. Half were resuscitated at a referring hospital and then transferred to a pediatric trauma center, on average after 6 hours.
The only deaths occurred in the 0-6hr and 6-12hr groups. The average Injury Severity Score of the children who died was significantly higher than survivors.
Children operated on in the 0-6hr group had significantly higher ISS as well.
There was no difference in early or late complications across all groups.
Time to beginning oral intake and time in hospital were the same in all groups.
The authors concluded that observation and serial exam rather than urgent exploration or repeated CT scans is appropriate.
Bottom line: If you combine this study with the ultrasound study I reviewed yesterday, it seems appropriate to modify the usual (read: adult) way of evaluating blunt trauma to the abdomen. In place of automatically getting a CT scan of the abdomen in children, obtain a complete abdominal ultrasound to detect solid organ injury or free fluid. This will determine the degree of monitoring needed (e.g. ICU for higher grade liver or spleen injuries). Follow this with serial abdominal exam. If the child becomes symptomatic, it’s probably time to proceed to the OR.Note: I generally do not make children npo during the observation phase. They need to eat, and if they don’t want to, that tells you something.
Pediatric blunt abdominal trauma is not common, but if present it has the potential to cause significant morbidity or mortality. Evaluation of the abdomen at the trauma center is crucial, and most trauma professionals are aware of the trade-offs in the use of CT scan in children (radiation exposure, need for sedation).
Ultrasound is widely available and allows for imaging of most areas of concern in the abdomen. Could sonography be used in place of CT in specific cases? Pediatric surgeons in Germany (who have been using ultrasound far longer than the US has) published a paper last year looking at their experience with children who were diagnosed with an intra-abdominal organ injury after blunt trauma. Their 7 year experience only produced 35 such children, and they were evaluated with examination and one or more serial FAST ultrasound exams. Equivocal results were scanned with CT.
They found that ultrasound was effective in diagnosing abdominal injury 97% of the time. Although 11 of the 35 children had subsequent CT scanning, it only changed management in one case.
Bottom line: Obviously, this is a very small retrospective series, but it is provocative. The German pediatric surgeons go above and beyond the typical FAST exam in the US, using it for diagnostic purposes as well. Could a complete diagnostic ultrasound take the place of CT in select children in the US? Probably so, as they are very sensitive in detecting free fluid and solid organ injury. But what about blunt intestinal injury? I’ll review that tomorrow and sum up my thoughts on a possible algorithm.
Seatbelt use has increased from 58% in 1994 to a high of 85% last year. We know that seatbelt use saves lives, but trauma professionals are also aware that they can create their own injuries as well. This is a positive trade-off, because belt use prevents injuries that are difficult to treat (e.g. severe brain injury) and produces a higher number of intra-abdominal injuries that are easy to treat.
The spectrum of injuries attributed to seat belt use was finally appreciated in a journal article published 20 years ago this month. The authors wanted to catalog the various injuries seen in belted and unbelted motor vehicle occupants. They reviewed data from the North Carolina Trauma Registry, one of the most sophisticated state registries at the time. Although there were over 21,000 records in the database, only 3,901 involved motor vehicle crashes and had complete data on seatbelt use.
This study found the following:
Mortality was higher in those not wearing their seat belts (7% vs 3.2%)
Unbelted had a much higher incidence of severe head injury (50% vs 33%)
Overall incidence of any abdominal injury was the same for both (14%)
GI tract injuries were more common in the belted group (3.4% vs 1.8%)
Solid organ injury was the same
Bottom line: This study sparked the recognition that seatbelts reduce severe head injury but increase the incidence of some hollow viscus injuries. About 514 severe head injuries were prevented in exchange for 21 additional abdominal injuries that were generally easily repaired. Good tradeoff!
Helicopter EMS (HEMS) transport of trauma patients is used primarily to decrease the amount of time between injury and arrival at the trauma center. Unfortunately, efficacy studies have provided conflicting answers as to whether this is actually true. Last year, the CDC completed a large sample study of this issue using the National Trauma Data Bank (NTDB) in an attempt to determine if HEMS flights are effective.
Using almost 150,000 entries in the NTDB for 2007, they were able to isolate over 56,000 adult records with complete data points. They looked for mortality patterns based on age, injury severity, and revised trauma score, comparing patients who were transported by air vs ground.
They found the following:
Odds of dying in-hospital were 39% lower overall when transported by helicopter
This survival advantaged disappeared for patients age 55 and older, possibly because of decreased reserve, comorbidities, more complications, or medications that interfere with successful resuscitation
Regardless of type of transport, males always fared worse than females
Bottom line: This is a large and intriguing study. About 85% of the US population has access to a Level I or II trauma center within an hour. However, a third of those can only get there in that period of time if transported by air. This mode of transport has a significantly lower mortality rate. However, there are cost and safety considerations as well. The key now is to figure out which patients will have the best outcomes after air transport. This will require more work, looking at more than just mortality (e.g. disability, complications).
Reference: Reduced mortality in injured adults transported by helicopter emergency medical services. Prehospital Emerg Care 15(3):295-302, 2011.
Smart phone programmers are becoming more and more creative! The newest trauma app is geared toward helping the user identify individuals who have suffered a concussion. It can be used by parents, coaches or physicians to help identify a concussion at sporting events.
The app is a portable and convenient system for identifying concussions based on established sports medicine research. It queries the user for common signs of concussion, tallies the results of a simple balance test, and looks for other symptoms that suggestion the injury. The exam can also be administered serially to detect changes from baseline.
To get the most from this free app, the user must purchase an optional module for $4.99 that does a more in-depth physiologic and cognitive evaluation. A report can be emailed automatically to your physician, and he or she can then respond and send a message to your team to approve or deny continuing play.
The app is provided by SportSafety Labs LLC. The basic app is free, and the add-on is $4.99. It is published for the iPhone and iPad.
Bottom line: Expect more trauma-oriented apps geared toward a variety of problems in the near future!