There’s a lot of debate about if and at what age injured children develop significant risk for venous thromboembolism (VTE). In the adult world, it’s a little more clear cut, and nearly every patient gets some type of prophylactic device or drug. Kids, we’re not so certain about at all.
The Children’s Hospital of Wisconsin tried to tease out these factors to develop and implement a practice guideline for pediatric VTE prophylaxis. They prospectively reviewed over 4000 pediatric patients admitted over a 6 year period.
It looks like the guideline was developed using some or all of this data, then tested using regression models to determine which factors were significant. The guideline was then tweaked and a final model implemented.
Here are the factoids:
- 588 of the patients (14%) were admitted to the ICU, and 199 of these were identified as high risk by the guidelines
- Median age was 10 (this is always important in these studies)
- VTE occurred in 4% of the ICU patients, and 10% of the high risk ones
- Significant risk factors included presence of central venous catheter, use of inotropes, immobilization, and GCS < 9
Bottom line: This abstract confuses me. How were the guidelines developed? What were they, exactly? And the results seem to pertain to the ICU patients only. What about the non-ICU kids? The abstract just can’t convey enough information to do the study justice. Hopefully, the oral presentation will explain all.
I prefer a very nice analysis done at the Oregon Health Science University in Portland. I wrote about this study earlier this year. The authors developed a very useful calculator that includes most of the risk factors in this model, and a few more. Input the specific risks, and out comes a nice score. The only issue is, what is the score threshold to begin prophylaxis and monitoring? Much more practical (and understandable) than this abstract. Check it out at the link below.
- Evaluation of guidelines for injured children at high risk for VTE: a prospective observational study. AAST 2016, Paper 68.
- A Clinical Tool for the Prediction of Venous Thromboembolism in Pediatric Trauma Patients. JAMA Surg 151(1):50-57, 2016.
Pediatric emergency and trauma care is not readily available across a sizable chunk of the US, particularly in rural areas. Couple this with the fact that many rural emergency providers are not necessarily trained in emergency medicine and may have little recent pediatric training fosters the common practice of transferring these injured children to a higher level of care.
And unfortunately, many of these transferred children have relatively simple issues that really don’t actually need a transfer. Some studies have reported that up to 40% of children sent to tertiary pediatric centers are sent home in less than 24 hours.
Most research in this area focuses on single medical center experiences. An article currently in press looks at the experience of the entire state of Iowa over a 10 year period. The authors looked at all claims data for children between ages 8 days and 18 years. Children who were transferred were compared to those who were not.
Here are the factoids:
- 2 million cases were included in the study, and only 1% were transferred (21,319)
- Children in rural areas were transferred 3x more often than those in urban areas
- Only 63% were transferred to a designated children’s hospital, and 45% were sent to an ED rather than direct transfer to an inpatient bed
- 39% were potentially avoidable transfers, meaning that they were discharged from the receiving ED or the hospital within 24 hours of admission
- Two of the top 5 reasons for transfer were trauma related: fracture, and TBI without blood in the head.
- The cost for potentially avoidable transfers in the top 5 categories was $2 million dollars (!)
Bottom line: This is a very comprehensive study that shows the magnitude and cost consequences of potentially inappropriate pediatric transfers. It was not designed to figure out what to do about it, but it provides some insight for the problem solvers out there. Since we know the top 5 transfer diagnoses (seizure, fracture, TBI without bleeding, respiratory infection, and asthma), we can start to work on systems to provide education to rural providers on these topics, as well as real-time interaction to help them determine the 60% that really do need a higher level of care. Telemedicine will eventually be a big part of this, but most areas around the country are still struggling to figure out the details. Stay tuned!
Reference: Potentially Avoidable Pediatric Interfacility Transfer is a Costly Burden for Rural Families: A Cohort Study. Acad Emerg Med 28 March 2016, in press.
Nonaccidental trauma (NAT) in children, a.k.a. child abuse, is a problem that trauma professionals see all too frequently. Much of the time, the abuse is obvious. Sometimes, it is more insidious and occult, and we can be misdirected by the history given by the caregivers. The most frequent story used to cover up obvious injuries child abuse is that the child fell. Unfortunately, the injuries observed from abuse may be very similar to those seen from shaking, grabbing, lifting, and throwing.
A paper that is currently in press from the University of Colorado at Aurora seeks to clarify this a bit, trying to tease out nuances in common injury patterns that may help us distinguish NAT from falls. They performed a retrospective database review at both Denver Health and Children’s Health Colorado over a 15 year period. They specifically looked at children with blunt abdominal trauma. Unfortunately, they chose the age group < 18 years as “children”, which muddies the picture somewhat.
Here are the factoids:
- Of the 1,005 blunt abdominal trauma cases identified, 65 were confirmed to be due to NAT, and 115 were actually from falls
- 63 of the 65 NAT victims were less than 5 years old, but only 35 of the falls were
- Average ISS for the NAT kids was 20, vs only 12 for falls
- There were more hollow viscus injuries in NAT kids (25 vs 2), and more pancreatic injuries (16 vs 2)
- If a head injury was present, it was more severe with NAT
- Hospital LOS was longer after NAT, which makes sense given the ISS and head info above
Bottom line: Unfortunately, the authors could accumulate only a small amount of data over 15 years, but it paints a clear picture. Injured children presenting with a history of falls, particularly young children who can’t engage in the high energy pursuits of adolescents, should arouse suspicion. If multiple injuries are found, especially visceral or deep solid organ abdominal injury (pancreas), suspect foul play. Similarly, if the head injury is more severe, be suspicious. All trauma professionals need to keep the possibility of NAT in the back of their minds on every injured child they see!
Reference: Pediatric abdominal injury patterns caused by “falls”: A comparison between nonaccidental and accidental trauma. J Ped Surg, in press, Feb 2, 2016.
Nurses have a complementary role with physicians in caring for children with orthopedic injuries. Typically, the child will have been evaluated and had some sort of fracture management implemented. In children, nursing management is easer than in adults since a child is less likely to need an invasive surgical procedure. Many fractures can be dealt with using casts and splints alone.
Here are a few tips for providing the best care for your pediatric patients:
- Ensure adequate splinting / casting. You will have an opportunity to see the child at their usual level of activity. If it appears likely that their activity may defeat the purpose of the cast or splint, inform the surgeon or extender so they can apply a better one.
- Focus on pain control. Nothing aggravates parents more than seeing their child in pain! Make sure acetominophen or ibuprofen is available prn if pain is very mild, or scheduled if more significant. Ensure that mild narcotics are available if pain levels are higher. Remember, stool softeners are mandatory if narcotics are given.
- Monitor compartments frequently. If a cast is used, check the distal part of the extremity for pain, unwillingness to move, numbness or swelling. If any are present, call the physician or extender and expect prompt attention to the problem.
- Always think about the possibility of abuse. Fractures are rarely seen in children under 3, and almost never if less than 1 year old. If you have concerns about the physical findings or parent interactions, let the physician and social workers know immediately.
Delayed or missed diagnoses happen. It’s a reflection on the state of technology and our own diagnostic acumen. Unfortunately, a few cases of delayed diagnosis result in morbidity, potential lawsuits, and rarely, death.
How often does delayed diagnosis occur? A few spot check type articles were published about 15 years ago, but little has been done to slice and dice the data. And as usual, the old data ranged widely in its assessment of the incidence of this problem (1-18% !). However, I managed to find a (somewhat) more recent one that gives a little clearer picture of this issue.
A single pediatric hospital in Indiana reported its experience from 1997 to 2006. This interval included the time that it was verified as a Level II Trauma Center (2000 onwards). They included children 0-14 who had sustained “major trauma.” This was defined as multiple system injuries, high-energy impacts, and gunshots. In this study, delayed diagnosis was defined as one found after a stable patient was admitted to their room. In patients taken directly to OR, it was one found after the patient left the recovery room.
Here are the factoids:
- 1100 patients met study criteria. 98% were blunt trauma.
- Only 44 patients had delayed diagnoses of 47 injuries
- Average time to diagnosis was 4 days (range 8 hours to 28 days)
- 34% of diagnoses were made within 24 hours
- 3 diagnoses were made at a followup visit, all for upper extremity/should fractures
- 80% of delayed diagnoses required a change in therapy, most commonly a sling or cast. 15% required surgery.
- The long-term delayed diagnosis rate was 4%
Bottom line: Delayed diagnosis remains an issue in patient of all ages. The reported 4% rate subjectively seems about right to me. The most important lesson from this study is the extremely high percentage of delayed diagnoses that required further therapy. This is why it is so important to implement a specific system (the tertiary survey) to seek out these diagnoses.
A tertiary survey is a repeat head-to-toe physical exam and a review of all radiographic imaging performed to date. The trauma center should define the time interval from admission, and I recommend no more than 24-48 hours. We do not count any diagnoses found during this exam as being delayed. However, if a tertiary exam was not performed, or injuries are found after it was completed, we do consider it delayed an run it through our performance improvement process.
Reference: Ten-Year Retrospective Study of Delayed Diagnosis of Injury in Pediatric Trauma Patients at a Level II Trauma Center. Pediatric Emerg Care 25(8)-489-493, 2009.