Tag Archives: pediatric

Solid organ

Phlebotomy And Pediatric Solid Organ Injury

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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!

Related posts:

Reference: Reducing scheduled phlebotomy in stable pediatric patients with liver or spleen injury. J Ped Surg 49(5):759-762, 2014.

Abdomen

Best of: Blunt Duodenal Injury In Children

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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.

Abdomen

Do Children With Low Grade Solid Organ Injury Need To Transfer To A Pediatric Trauma Center?

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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.

General

Vascular Trauma Resources At Pediatric Trauma Centers

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There are two types of pediatric trauma centers: freestanding and combined. These adjectives refer to whether an adult trauma center is directly associated with the pediatric one. Over the years, I have come to appreciate that there may be substantial resource and experience differences between the two.

Trauma surgeons at freestanding centers are usually pediatric surgeons. They have managed trauma cases during their surgical residency and pediatric surgical fellowship, but usually have not taken a trauma fellowship. Their experience with complex trauma and advanced concepts like damage control surgery generally comes from their training and on the job experience. Surgeons at combined centers may be pediatric trained, or may be adult surgeons with pediatric experience. The adult surgeons are generally well-versed in advanced trauma concepts, and the pediatric surgeons can take advantage of the adult surgeons’ expertise in advanced trauma cases.

Freestanding pediatric centers may have fewer resources in some key areas, such as fellowship trained specialists in vascular surgery, GI endoscopy, and interventional radiology. A recent study accepted for publication from the University of Arkansas examines differences in surgeon practice patterns and resource availability at freestanding vs combined centers.

Two surveys were sent to 85 pediatric trauma centers around the US. Roughly half were Level I, and half were freestanding. One was sent to 414 pediatric surgeons at those centers inquiring about practice patterns, and the other was sent to the trauma medical directors of each center asking about their resources.

Here are the factoids:

  • 50 of the 85 trauma centers responded, as did 176 of the 414 surgeons. 48% of trauma medical directors responded. These are reasonable response rates for questionnaires.
  • Adult surgeons covered pediatric trauma at 6% of Level I centers, and 33% of Level II
  • During pediatric surgical fellowship, 56% participated in management of vascular trauma, 25% was managed by vascular surgeons, and 19% had no experience
  • At 23% of freestanding centers, vascular surgeons were not always available, and a vascular surgeon was not listed on the call schedule 38% of the time
  • 27% of freestanding facilities indicated that endovascular and stent capabilities were not available, and 18% did not have interventional radiologists (IR) available within 30 minutes
  • All combined centers had vascular and endovascular capabilities, and IR was available within 30 minutes 92% of the time

Bottom line: This is an intriguing paper that looks at a few of the disparities between freestanding and combined pediatric trauma centers. Obviously, it is hampered by the survey format, but does provide some interesting information. The focus was on vascular resources, and shows several of the major differences between the two types of centers.

Fortunately, vascular trauma is relatively rare in the pediatric age group. But it is possible that a child presenting to a freestanding pediatric trauma center may be managed by a pediatric surgeon with little vascular experience, and assistance from a fellowship trained vascular surgeon and/or interventional radiologist may be unavailable.

This paper provides important information regarding resource disparities in pediatric trauma care. Ideally, this should be reviewed and remedied as the Resources for Optimal Care of the Injured Patient (Orange Book) evolves over the coming years.

Reference: Pediatric Vascular Trauma Practice Patterns and Resource Availability: A Survey of ACS-Designated Pediatric Trauma Centers. J Trauma, accepted for publication Jan 12, 2018.

Abstracts

EAST 2018 #5: Predicting Absence Of Pediatric Abdominal Injury

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More on prediction systems today! The authors of this abstract used good old mathematics, albeit very fancy math, instead of a machine learning algorithm. The specifics of this tool were described in an article published in JACS earlier this year (see reference).

The authors were interested in finding a way to decrease the use of CT scan for evaluating blunt abdominal trauma in children. After developing the model using prospectively collected data from 14 Level I pediatric trauma centers, they sought to validate it using a public dataset from the Pediatric Emergency Care Applied Research Network (PECARN). This dataset contained more than 2,400 records, and included 10% of patients who had an intra-abdominal injury (IAI), and 2.5% with an IAI that required intervention (IAI-I).

Here are the factoids:

  • There were five prediction rule variables: complaint of abdominal pain, tenderness / distension / or contusion on exam, abnormal chest x-ray, AST > 200, elevated pancreatic enzymes)
  • Prediction rule sensitivity was 98% and specificity was 37% for IAI, and 100% / 35% for IAI-I
  • The negative predictive value for finding any abdominal injury was 99.3%, and for injury requiring intervention was 100%
  • Unfortunately, nearly half of the very low risk children underwent CT scanning anyway!

Bottom line: This is a nice validation study for a well-designed prediction tool. It builds on previous work published earlier this year. The variables make clinical sense. Although the number of patients with injury were relatively small, I believe these results should be considered for incorporation in our blunt pediatric trauma evaluation protocols now!

Here are some questions for the authors to consider before their presentation:

  • The liver function and pancreatic enzyme tests results take some time to perform. How much do they contribute to the negative predictive value, since they are relatively uncommon injuries?
  • What are considered abnormal chest x-ray findings?
  • How do you recommend incorporating this into the care of trauma activation patients? Wait for 30 minutes in the trauma bay for the lab tests to come back? Evaluation in patients undergoing a more routine evaluation for abdominal trauma would not be unduly delayed.
  • Be prepared to explain how you derived the decision rule in very simple language.

References:

  • EAST 2018 Podium paper #7.
  • Identifying Children at Very Low Risk for Blunt Intra-Abdominal Injury in Whom CT of the Abdomen Can Be Avoided Safely. JACS 224(4):449-458.