Tag Archives: pediatric trauma

General

Contrast Blush in Children

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A contrast blush is occasionally seen on abdominal CT in patients with solid organ injury. This represents active arterial extravasation from the injured organ. In most institutions, this is grounds for call interventional radiology to evaluate and possibly embolize the problem. The image below shows a typical blush.

Splenic contrast blush

This thinking is fairly routine and supported by the literature in adults. However, it cannot be generalized to children!

Children have more elastic tissue in their spleen and tend to do better with nonoperative management than adults. The same holds true for contrast blushes. The vast majority of children will stop bleeding on their own, despite the appearance of a large blush. In fact, if children are taken to angiography, it is commonplace for no extravasation to be seen!

Angiography introduces the risk of local complications in the femoral artery as well as more proximal ones. That, coupled with the fact that embolization is rarely needed, should keep any prudent trauma surgeon from ordering the test. A recently released paper confirms these findings.

The only difficult questions is “when is a child no longer a child?” Is there an age cutoff at which the spleen starts acting like an adult and keeps on bleeding? Unfortunately, we don’t know. I recommend that you use the “eyeball test”, and reserve angiography for kids with contrast extravasation who look like adults (size and body habitus).

Reference: What is the significance of contrast “blush” in pediatric blunt splenic trauma? Davies et al. J Pediatric Surg 2010 May; 45(5):916-20.

General

Pediatric Trauma Mortality and Pediatric Trauma Centers

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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.