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.
- All components are the same as for adults
Best Verbal Response
- No response to stimuli
- Inconsolable, agitated
- Inconsistently inconsolable, moaning
- Cries but consolable. Has appropriate interactions.
- The child smiles, orients to sounds, follows objects, and interacts with adults
Best Motor Response
- No response to stimuli
- Decerebrate posturing (extension to stimulation, see the adult post for details)
- Decorticate posturing (flexion to stimulation, see the adult post for details)
- Withdraws from pain
- Withdraws from touch
- 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.
Anyone who reads this blog already knows I am a big believer in well-crafted and focused practice guidelines. And by focused I mean directed toward a clinical problem that typically sees a lot of variability between care providers. Use of imaging is one of these clinical problems. A surgeon may order a certain set of studies for a major blunt trauma patient, and their emergency medicine colleague might order a somewhat different set for someone with the exact same history, physical exam, and injury pattern. Who is right? Neither!
And the variability is even greater when we throw a pediatric patient into the mix. Trauma professionals tend to be even more “generous” when ordering studies on children because they are afraid they might miss something. Unfortunately, this has the potential for overuse of imaging and exposure to unnecessary radiation.
Avery Nathens and a consortium of pediatric trauma centers used the Trauma Quality Improvement Database (TQIP) to review CT imaging practices on children age < 18 over a four year period. Only blunt trauma patients were studied, and the Abbreviated Injury Scale had to be at least 2 for a minimum of one organ system. Transfer patients were excluded because there is no data on imaging for the referring hospital in the TQIP database for them. Comparisons were made between practices at adult trauma centers treating children (ATC), mixed adult/pediatric centers (MTC) and pediatric only trauma centers (PCT).
Here are the factoids:
- Over 59,000 pediatric trauma patients were identified in the data, and about half (31,081) received at least one CT scan
- The distribution among the three types of trauma centers was even, with roughly a third seen at each
- Of the study group 46% had a head CT, 17% a chest CT, and 26% underwent abdominal CT
- Injured children were more likely to undergo CT if they were older, had a higher ISS, lower motor GCS, were involved in a car crash, or had severe injuries to head or torso
- Overall CT rates were about the same across the three types of centers (56% ATC, 57% MTC, 43% PTC)
- Chest CT was performed 8x as much at ATC/MTC vs PTC (!)
- Abdominal CT was performed 2x as much at ATC/MTC vs PTC
- Lesser injured children received relatively more CT scans at ATC/MTC when compared to PTC
- Using standard estimates of cancer risk from all CT scans received, children treated at adult or mixed trauma centers received enough radiation to cause 17 additional lifetime cancers per 100,000 patients
- About 35 additional lifetime cancers per 100,000 would be caused by the chest and abdominal scans performed at the ATC/MTC centers when compared to pediatric-only centers
Bottom line: This is yet another reason to adopt a well-designed pediatric imaging guideline. Not only are adult centers using CT scanning much more that pediatric-only centers, but they are unnecessarily adding to the lifetime risk for cancer of our children!
As I always recommend, find a well-designed imaging guideline from an established pediatric center and “borrow” it. Sure, it may need a few minor tweaks to fit well with your hospital. That’s okay. Just get it done so your team can begin to order the initial imaging studies consistently and intelligently.
Reference: Computed tomography rates and estimated radiation-associated cancer risk among injured children treated at different trauma center types. Injury 2018, in press. https://doi.org/10.1016/j.injury.2018.09.036
A pediatric trauma paper published a while back tried to focus on reducing the rate of phlebotomy in children who were being observed for solid organ injury. I was more excited about the overall protocol being used to manage liver and spleen injury, as it was a great advance over the original APSA guideline. But let’s look at the phlebotomy part as well.
This is an interestingly weird study, and you’ll see what I mean shortly. Two New York trauma hospitals that take care of pediatric patients pooled 4 years of registry records on children with isolated blunt liver and/or spleen injuries. Then they did a tabletop excercise, looking at “what if” they had applied the APSA guideline, and “what if” they had applied their new, proposed guideline.
Interestingly, this implies that they were using neither! I presume they are trying to justify (and push all their partners) to move to the new protocol from (probably) random, individual choice.
Here are the factoids:
- 120 records were identified across the 2 hospitals that met criteria
- Late presentation to the hospital, contrast extravasation, comorbidities, lack of imaging, operative intervention at an outside hospital excluded 59 patients, leaving 61 for analysis. Three of those patients became unstable and were also excluded.
- None of the remaining patients required operation or angioembolization
- Use of the “new” (proposed) protocol would reduce ICU admissions by 65%, reduce blood draws by 70%, and reduce hospital stay by 37%
- Conclusion: use of the protocol would eliminate the need for serial phlebotomy (huh?)
Bottom line: Huh? All this to justify decreasing blood draws? I know, kids hate needles, but the data on decreased length of stay in the hospital and ICU is much more important! We’ve been using a protocol similar to their “new” one at Regions Hospital for almost 10 years, which I’ve shared below. We’ve been enjoying decreased resource utilization, blood draws, and very short lengths of stay for over a decade. And our analysis showed that we save more than $1000 for every patient entering the protocol, compared to the old-fashioned and inefficient way we used to manage them.
In general, kids (and adults) with low grade injuries (I-III) need 2 blood draws, and those with high grade need about 3. Check out our guidelines below to see how it works!
Reference: Reducing scheduled phlebotomy in stable pediatric patients with liver or spleen injury. J Ped Surg 49(5):759-762, 2014.
Blunt injury to hollow organs is rare in adults, but a little more common in children. This is due to their smaller muscle mass and the lack of protection by their more flexible skeleton. Duodenal injury is very rare, and most trauma professionals don’t see any during their career. As with many pediatric injuries, there has been a move toward nonoperative management in selected cases, and duodenal injury is no exception.
What we really need to know is, which child needs prompt operative treatment, and which ones can be treated without it? Children’s Hospital of Boston did a multicenter study of pediatric patients who underwent operation for their injury to try to tease out some answers about who needs surgery and what the consequences were.
A total of 16 children’s hospitals participated in this 4 ½ year study. Only 54 children had a duodenal injury, proven either by operation or autopsy. Some key points identified were:
- The injury was very uncommon, with one child per hospital per year at best
- 90% had tenderness or marks of some sort on their abdomen (seatbelt sign, handlebar mark, other contusions).
- Free air was not universal. Plain abdominal xray showed free air in 36% of cases, while CT showed it only 50% of the time. Free fluid was seen on CT in 100% of cases.
- Contrast extravasation was uncommon, seen in 18% of patients.
- Solid organ injuries were relatively common
- Amylase was frequently elevated
Although laparoscopic exploration was attempted in about 12% of patients, it was universally converted to an open procedure when the injury was confirmed. TPN was used commonly in the postop period. Postop ileus was very common, but serious complications were rare (wound infection <10%, abscess 3%, fistula 4%). There were 2 deaths: one child presented in extremis, the other deteriorated one day after delayed recognition of the injury.
Bottom line: Be alert for this rare injury in children. Marks on the abdomen, particularly the epigastrium, should raise suspicion of a duodenal injury. The best imaging technique is the abdominal CT scan. Contrast is generally not helpful and not tolerated well by children. Duodenal hematoma can be managed nonoperatively. But any evidence of perforation (free fluid, air bubbles in the retroperitoneum, duodenal wall thickening, elevated serum amylase) should send the child to the OR. And laparotomy, not laparoscopy, is the way to go.
Reference: Operative blunt duodenal injury in children: a multi-institutional review. J Ped Surg 47(10):1833-1836, 2012.
Pediatric trauma centers have an excellent reputation when it comes to caring for children when compared to their adult counterparts. Overall mortality for major trauma is lower. Splenectomy rates and the use of angiography are less in children with solid organ injury. And because of this expertise, it is common for surrounding trauma centers of all levels transfer these patients to the nearest pediatric trauma center.
But is this always necessary? Many of these children have relatively minor injury, and the pediatric trauma centers can be few and far between unless you are on one of the coasts. Researchers at the University of Washington, Harborview, and Seattle Children’s looked at their experience with pediatric transfers (or lack thereof) with spleen injury.
They retrospectively looked at 15 years of transfer data. The Seattle hospitals are the catchment area for a huge geographic area in the northwest, and the state trauma system maintains detailed records on all transfers to a higher level of care. Patients 16 years or younger with low grade (I-III) spleen injury were included. In an effort to narrow the focus to relatively isolated spleen injury, patients were excluded if they had moderate injuries in other AIS body regions.
Here are the factoids:
- During the study, over 54,000 patients were admitted to hospitals, but only 1,177 had isolated, low grade spleen injury
- About 20% presented directly to a Level I or II trauma center, 30% presented to a lower level center and were transferred, and 50% stayed put at the lower level center they to which they presented
- 40 patients (3%) underwent an abdominal operation presumably for their spleen, but there was no difference based on which hospital they presented to or whether they were transferred
- The incidence of total splenectomy was not different among the three groups
- Likewise, there was no difference in ICU admission or ICU length of stay
- The only significant difference was that patients who were not transferred to a pediatric center usually spent an extra day in the hospital
Bottom line: Injured children tend to do well, regardless of where they are treated. This study is huge and retrospective, which can cause analysis problems. And even given the size, the total number eligible for the study was relatively small. But it is the best study to date that shows that it is possible to treat select low grade injuries at non-pediatric, non-high level trauma centers. However, before going down this path, it is extremely important to define specific “safe” injuries to manage, and to have an escape valve available in case the patient takes an unexpected turn.