Category Archives: General

Pediatric Trauma Mortality and Pediatric Trauma Centers

There are only about 45 Pediatric Trauma centers in the United States. They are clustered in the Northeast, in the central Midwest, and along the west coast. This poses a problem for parents located in the rest of the country.

In contrast, there are nearly 500 adult trauma centers, scattered much more evenly across the country. All adult centers that treat more than 100 children per year are required to have basic pediatric trauma resources, such as a pediatric ICU and intensivists to man it. 

A growing body of research shows that adults and children with major trauma do better if treated at an adult trauma center. Is there an advantage to having your child treated at a pediatric trauma center?

The answer is yes! A paper published in 2008 looked at children admitted to hospitals in Florida over a 10 year period. They found that children and young adults did better when admitted to a trauma center when compared to a non-trauma hospital, although the effect was less in younger children. The overall survival improvement was about 3%. 

When treated at a pediatric trauma center, survival increased an additional 4%! The reasons are not entirely clear, because these studies do not have the ability to discern specifics. However, it appears that a combination of resource availability (present in all Level I and II trauma centers) and specialty capabilities (only present in hospitals with pediatric resources) is key.

Most children with injuries serious enough to require hospitalization can be treated at any trauma center. Those who have critical injuries that require considerable aftercare (severe brain injury, complex orthopedic/pelvic injuries) are best treated at a designated pediatric trauma center if one is available.

Reference: Do pediatric patients with trauma in Florida have reduced mortality rates when treated in designated trauma centers? Tepas, Flint et al. J Pediatric Surgery, 43, 212-221, 2008.

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Initial Management of Blunt Bladder Injury

Bladder injury is uncommon after blunt trauma. It is typically seen after high energy events, most commonly a motor vehicle crash with a lap belt in place. During the initial evaluation, the patient may complain of abdominal pain, but this is not universal. 

FAST results are also inconsistent. Free fluid may be seen, and an irregular bladder outline may also be appreciated. The key to diagnosis is placement of a urinary catheter. Bloody urine is found nearly 100% of the time. 

The character of the bloody urine suggests what type of injury is present. Faint hematuria, primarily shades of pink, is usually associated with renal injury or a bladder contusion. A moderate amount of darkly bloody urine is frequently associated with extraperitoneal bladder injury. A small amount of very dark, bloody urine may mean an intraperitoneal bladder injury. Finally, scant and very dark blood in the catheter suggests a urethral injury or a catheter balloon inflated in the urethra.

Examination of the urine is suggestive but not diagnostic of the type of injury. Determining the real diagnosis requires imaging, and evaluation of the entire GU tract is essential. CT scan is used to evaluate the kidneys, ureters, and to some degree, the bladder. Cystogram is required to fully evaluate the bladder, and a CT technique may be used. Bladder imaging using passive filling by clamping the catheter is accurate only 50% of the time. The bladder must be pressurized using contrast instilled into the bladder by gravity. When performed in this manner, the CT cystogram is 97% accurate.

Once a diagnosis of bladder injury is made, the treatment is usually straightforward. Extraperitoneal injuries usually do not require repair and will heal on their own. However, if the symphysis pubis needs instrumentation to restore anatomic position, concomitant repair of the bladder is frequently necessary to keep the hardware from being contaminated by urine. 

Intraperitoneal injuries require operative repair. If possible, the injured area should be opened and the inside visually inspected. If the injury extends anywhere near the trigone, a urology consult should be obtained. Most repairs are simple two layer closures. The mucosal layer must be made with absorbable suture; the outer layer is surgeon’s choice. 

For either type of bladder injury, the urinary catheter should be left in place for about 10 days. A cystogram should be obtained, and in most cases there will not be any leakage of urine and the catheter can be removed. In the event of a leak, another 7 days with the catheter is in order and the cystogram can be repeated.

The vast majority of bladder injuries can be easily handled by the trauma surgeon and are healed completely within two weeks.

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National Standards for Teen Drivers?

During a single week in April, there were 18 driving deaths in Minnesota, most of them involving teens. In at least one crash, the driver was in violation of several of the state’s graduated driver license provisions. Graduated licensing is increasingly popular across the country, and incidents like this are prompting our legislators to tighten them.

One big problem is that each state sets its own licensing standards. And since most states insist on reinventing their own wheel, a patchwork of state standards has been enacted. Some have higher age minimums for obtaining a license. Others limit night driving or number of underage passengers. Most states have addressed phoning and texting while driving.

There is now a push in the US Senate to standardize graduated licensing rules in all states so there is a more even playing field.  The proposed legislation would:

  •  Make getting a driver’s license a 3 step process, including a learner’s permit, a restricted license, and finally an unrestricted license.
  • Prohibit nighttime driving without an unrestricted license.
  • Prohibit cell phone use without an unrestricted license.

The proposed law makes sense. Accident research has shown that states that adopt a more restrictive licensing policy see a significant reduction in crashes, and a reduction in injury crashes of nearly 40%. Fatal crashes in young drivers was reduced by a whopping 75% in these states!

The major problem with the proposed legislation is that the penalties for states not complying are rather heavy-handed. Such states would face losing some of their federal highway construction funding. Many states would face this issue soon if the law was enacted as it is now written.

Concerned parents should communicate with their legislators and support these efforts to protect their children. More immediately, though, parents need to be involved in the driving decisions of their children. Don’t allow them to drive after dark. Limit the number of passengers they can carry. Require them to use their seatbelts. And make sure they understand the consequences if they choose to break these rules: immediate and non-negotiable loss of driving privileges for a set period of time.

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Trauma 20 Years Ago: Chance Fractures

Centers that take care of blunt trauma are familiar with the spectrum on injury that is directly attributable to seat belt use. Although proper restraint significantly decreases mortality and serious head injury, seat belts can cause visceral injury, especially to small bowel.

Lap belt use has been associated with Chance fracture (flexion distraction injury to the lumbar spine) since 1982. The association between seat belts and intra-abdominal injury, especially with an obvious “seat belt sign” was first described in 1987. 

Twenty years ago, orthopedic surgeons in Manitoba finally put two and two together and reported a series of 7 cases of Chance fractures. They noted that 6 of the fractures were associated with restraint use. Seat belt sign was also present in 5 of the 6 patients with fractures and three of the six had bowel injuries.

The authors noted that many provinces were mandating seatbelt use at the time, and they predicted that the number of Chance fractures, seat belt signs and hollow viscus injuries would increase. On the positive side, the number of deaths and serious head injuries would be expected to decline.

Although this was a small series, it finally cemented the unusual Chance fracture, seat belt sign, and bowel injury after motor vehicle trauma.

Reference: Pediatric Chance Fractures: Association with Intra-abdominal Injuries and Seatbelt Use. Reid et al. J Trauma 30(4) 384-91, 1990.

Chance fracture

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