Tag Archives: pediatric

Performance Improvement

Mainstem Intubation In Pediatric Patients: How Common?

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Mainstem intubation in the pediatric patient is a common problem. There are two major issues: the trachea is shorter than in an adult, and the angles are different making intubation of the right mainstem bronchus much easier. Frequently, the intubator watches the balloon slide between the cords, then pushes the tube in “just a little further.”

Unfortunately, that “little bit” can vary significantly. An abstract from my hospital was presented at the Pediatric Trauma Society in 2016. Subjectively, we noticed that mainstem intubation was occurring with some regularity in our pediatric trauma patients.  It seemed as though insufficient attention was being paid to the depth of the tube.

A major difference between adult and pediatric intubations is that in adults, optimal tube depth is locked into a relatively narrow range. In children, the depth varies considerably based upon child age and size. And small variances in depth can have major implications for tube position.

We decided to implement a PI project to change our intubation policy. In order to focus the entire team on tube depth, a color coded card was attached to each size of endotracheal tube. This card listed the optimal depth for insertion. Once the provider inserted the tube, the final depth was called out for the team and documentation scribe to hear. This had the added advantage of allowing multiple team members confirm the appropriateness of tube depth. A chest x-ray was immediately obtained to confirm position.

We retrospectively reviewed our seven year experience with pediatric intubations, from 2009-2015. Here are the factoids:

  • Nearly 2,000 pediatric trauma patients were admitted during the study period
  • 94 patients (5%) required intubation in the ED
  • Prior to implementation of the new protocol, 6 of 68 patients (8.8%) had confirmed right mainstem intubation 
  • After the change, only one further mainstem intubation occurred in 26 procedures (3.8%)

Bottom line: Unfortunately, this series is too small to determine statistical significance. There is a definite trend toward fewer mainstem intubations. It appears that by calling more attention to the proper tube depth, fewer deep placements occur. Our numbers  have remained low since this change.

Are there other methods to ensure proper ET tube placement in small patients? In my next post, I’ll review a paper that compares three additional different techniques that can be used.

Reference: Eliminating the Preventable Occurrence of Right Mainstem Intubation in the Pediatric Trauma Patient: A Quality Performance Improvement (PI) Initiative. Pediatric Trauma Society Poster Abstract #1, 2016.

Abdomen, Abstracts

AAST 2019 #3: Delayed Splenectomy In Pediatric Splenic Injury

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Nonoperative management of the blunt injured spleen is now routine in patients who are hemodynamically and have no evidence of other significant intra-abdominal injury.  The trauma group at the University of Arizona – Tucson scrutinized the failure rate of this procedure in children because it is not yet well established.

They reviewed 5 years of data from the National Readmission Database. This is actually a collection of software and databases maintained by the federal government that seeks to provide information on a difficult to track patient group: those readmitted to hospitals after their initial event.

Patients who had sustained an isolated spleen injury who were less than 18 years old and who had either nonoperative management (NOM), angioembolization (AE), or splenectomy were analyzed. Outcome measures included readmission rate, blood transfusion, and delayed splenectomy. Common statistical techniques were used to analyze the data.

Here are the factoids:

  • About 9500 patients were included, with an average age of 14
  • Most (77%) underwent NOM, 16% had splenectomy, and 7% had AE (no combo therapies?)
  • Significantly more patients with high grade injury (4-5) had splenectomy or AE than did the NOM patients (as would be expected)
  • A total of 6% of patients were readmitted within 6 months of their initial injury: 12% of NOM *, 8% of AE *, and 5% of those with splenectomy (* = statistically significant)
  • The NOM and AE patients were also more likely to receive blood transfusions during their first admission
  • Delayed splenectomy occurred in 15% of cases (7% NOM and 5% AE) (these numbers don’t add up, see below)
  • Statistical analysis showed that delayed splenectomy was predicted by high grade injury (of course), blood transfusion (yes), and nonoperative management (huh?)
  • In patients who were readmitted and splenectomized, it occurred after an average of 14 days for the NOM group and 58 days for AE (huh?)

The authors concluded that “one in seven children had failure of conservative management and underwent delayed splenectomy within 6 months of discharge.” They stated that NOM and AE demonstrated only a temporary benefit and that we need to be better about selecting patients for nonoperative management.

Hmm, there are several loose ends here. First, what is the quality of the study group? Was it possible to determine if these patients had been treated in a trauma center? A pediatric vs adult trauma center? We know that there are outcome disparities in spleen trauma care at different types of trauma centers. 

Next, are they really pediatric patients? Probably not, since age < 18 were included and the average age was 14. Injured spleens in pre-pubescent children behave much better than adolescents, which are more adult-like.

And what about the inherent bias in the “readmission data set?” You are looking only at patients who were readmitted! By definition, youare looking at a dataset of poorer outcomes. What if you had identified 9,500 initial patient admissions from trauma registries and then tried to find them in the readmission set. I know it’s not possible to do that, but if it were I would bet the readmission and delayed splenectomy numbers would be far, far lower.

And what about those delayed splenectomy numbers? I can’t get the percentages to match up. If 15% of the 7965 patients who didn’t have an initial splenectomy  had it done later, how does 7.2% of the 7318 NOM patients and 5.3% of the 1541 AE patients add up?

Bottom line: The usual success rate tossed around for well-selected nonoperative management is around 93% when optional adjunctive AE is part of the algorithm. That’s a 1 in 14 failure rate, and it generally occurs during the initial hospitalization. In my experience, readmissions are very rare. And that’s for adults; children tend to behave even better!

I wouldn’t consider changing my practice yet based on these findings, but the devil will probably be in the details!

Here are some questions for the presenter and authors:

  • Please provide some detail on the data set. We really need to know an age breakdown and the types of centers they were treated at, if available.
  • Discuss the potential data set bias working backwards from a database that includes only readmitted patients.
  • Please clarify the delayed splenectomy statistics to help match up the numbers.

I’m anticipating a great presentation at the meeting!

Reference: Delayed splenectomy in pediatric splenic injuries: is conservative management overused? AAST 2019 Oral abstract #8.

Mechanism

Button Batteries: Part 2 – Getting Them Out

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In my last post, I detailed how to suspect and image a button battery ingestion. In this one, I’ll describe how to extract them, and how quickly it’s necessary.

When batteries come to rest and are surrounded by moist mucosal tissue, a current arc is generated around the two sides of the button. This releases heat, which coagulates the surrounding tissue. Depending on the location, closeness of contact, and the duration, these burn injuries may extend into underlying tissue. This is of particular significance in the esophagus, which is in close proximity to the thoracic aorta.

Here’s a simple demonstration you can do at home with some lunch meat:

Here are guidelines for what to do when you encounter pediatric patients who have ingested a button battery:

  • If the child is experiencing bleeding from the upper GI tract, activate your trauma team. The child may have an aorto-esophageal fistula. If there is no active bleeding, obtain a chest x-ray to assess the battery’s position. If there is active bleeding, proceed to the OR (preferably a hybrid room if you have one) and use fluoro to locate the battery. If bleeding persists, call appropriate pediatric surgical specialists (surgery, CV surgery, GI), activate your massive transfusion protocol, and consider tamponade with a Blakemore tube (remember those?) or a urinary catheter if you don’t have one.
  • No bleeding from the upper GI tract? If the battery is large (>20mm) and/or the child is small (<5 years), and is lodged in the esophagus, proceed immediately to OR and remove endoscopically.
  • Batteries in the stomach are of less concern. They will generally pass if <20mm. A repeat x-ray after 48 hours should be obtained for larger batteries. If still in the stomach, they should be removed endoscopically. Smaller batteries will usually pass, and should be re-imaged after two weeks to confirm this.

References:

  • Button battery and magnet ingestions in the pediatric patient.  Curr Opin Pediatrics 30:653-659, 2018.
  • Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. J Pediatric Gastroenterol Nutr 60:562-574, 2015.
Mechanism

Button Batteries: Part 1

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I know what you are saying. Button batteries? Trauma? Not too many adult trauma professionals have seen or heard of this. But those who care for pediatric patients should be very familiar. If the importance of this seemingly minor problem is ignored, the results can be catastrophic.

Kids eat stuff, and not just food. The smaller ones always seem to be putting things in their mouths. Foreign body ingestion (or insertion into other orifices) is a common presentation at pediatric emergency departments. Unfortunately, the fact that a battery has been eaten may not be appreciated by the parents.  The child may be brought in with  nonspecific GI or respiratory symptoms.

As soon as a battery ingestion is known or suspected, a two-view chest x-ray is needed. This should show both chest and upper abdomen in order to visualize both esophagus and stomach. Separate chest and abdominal images may be required if the child is too large for a single shot. Two views (AP and lateral) are important because the nature of the foreign body may not be appreciated if the battery is seen edge-on.

If you are fortunate enough to image the battery “face-on”, you may see a telltale halo sign. Because of the way these batteries are put together, there are two metal sides that have a slight difference in overlap.

You’ve made the diagnosis! So now what? And how quickly? I’ll deal with this in my next post.

CNS, General

GCS At 40: Pediatric Glasgow Coma Scale

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I’ve been discussing the Glasgow Coma Scale (GCS), but only the adult version so far. The pediatric GCS was created about 10 years after the classic adult scale after it was recognized that several of the scores were not appropriate for younger non-verbal children, typically less than one year of age. It has been validated several times over the ensuing years and has been integrated into our trauma practices.

So what is different about the pediatric GCS scale? It has the same three main components, eye opening, best verbal response, and best motor response. The number of scores under each remains the same as well. The major changes occurred in the verbal response scores. Here’s the breakdown; I’ve highlighted the differences.

Eye Opening

  • All components are the same as for adults

Best Verbal Response

  1. No response to stimuli
  2. Inconsolable, agitated
  3. Inconsistently inconsolable, moaning
  4. Cries but consolable. Has appropriate interactions.
  5. The child smiles, orients to sounds, follows objects, and interacts with adults

Best Motor Response

  1. No response to stimuli
  2. Decerebrate posturing (extension to stimulation, see the adult post for details)
  3. Decorticate posturing (flexion to stimulation, see the adult post for details)
  4. Withdraws from pain
  5. Withdraws from touch
  6. Spontaneous, purposeful movement

In my next post in the series, I’ll review what’s new with the GCS-40 score.

Reference: Neurologic evaluation and support in the child with an acute brain insult. Pediatric Annals 15(1):16-22, 1986.