Tag Archives: pediatric

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DVT In Children

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Deep venous thrombosis has been a problem in adult trauma patients for some time. Turns out, it’s a problem in injured children as well although much less common (<1%). However, the subset of kids admitted to the ICU for trauma have a much higher rate if not given prophylaxis (approx. 6%). Most trauma centers have protocols for chemical prophylaxis of adult patients, but not many have similar protocols for children.

The Medical College of Wisconsin looked at trends prior to and after implementation of a DVT protocol for patients < 19 years old. They used the following protocol to assess risk in patients admitted to the PICU and to determine what type of prophylaxis was warranted:

The need for and type of prophylaxis was balanced against the risk for significant bleeding, and this was accounted for in the protocol. The following significant findings were noted:

  • The overall incidence of DVT decreased significantly (65%) after the protocol was introduced, from 5.2% to 1.8%
  • The 1.8% incidence after protocol use is still higher than most other non-trauma pediatric populations 
  • After the protocol was used, all DVT was detected via screening. Suspicion based on clinical findings (edema, pain) only occurred pre-implementation.
  • Use of the protocol did not increase use of anticoagulation, it standardized management in pediatric patients

Bottom line: DVT does occur in injured children, particularly in severely injured ones who require admission to the ICU. Implementation of a regimented system of monitoring and prophylaxis decreases the overall DVT rate and standardizes care in this group of patients. This is another example of how the use of a well thought out protocol can benefit our patients and provide a more uniform way of managing them.

Related posts:

Reference: Effectiveness of clinical guidelines for deep vein thrombosis prophylaxis in reducing the incidence of venous thromboembolism in critically ill children after trauma. J Trauma 72(5):1292-1297, 2012.

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Intracranial Hypertension In Pediatric Head Trauma

This 44 minute video is a good introduction to pediatric head trauma and intracranial hypertension. It covers physiology, diagnosis, as well as management using medications, position, decompression and hypothermia.

Presented at Multidisciplinary Trauma Conference at Regions Hospital on May 3, 2012 by Debbie Song MD, a pediatric neurosurgeon.

(Source: https://player.vimeo.com/)
General

Pediatric CT Scans Before Transfer to a Pediatric Trauma Center

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CT scan is essential in diagnosing injury, although concerns for unnecessary radiation exposure are growing. These concerns are even greater in children, who may be more likely to have long-term effects from it. This makes avoiding duplication of CT scanning extremely important.

Unfortunately, there are only about 50 pediatric trauma centers in the US, so the majority of seriously injured children are seen at another hospital before transfer. Does CT evaluation at the first hospital increase the likelihood that a repeat scan will be needed at the trauma center, increasing radiation exposure and risk?

Rainbow Babies and Children’s Hospital in Cincinnati looked at 3 years of transfers of injured children from community hospitals. They then looked at how many of those children had an initial head and/or abdomen scan at the outside hospital, and whether a repeat scan of those areas was performed within 4 hours or arrival at Rainbow.

Numbers were small, but here are the results:

  • 33 had an outside CT scan, 28 (90%) were repeated
  • 6 had an outside abdominal scan, 2 (33%) were repeated
  • 55 did not have outside scans, none were repeated at Rainbow. (This is a weird thing to look at. I would hope that the trauma center didn’t have to repeat any of their own scans within 4 hours!)

Bottom line: It is critically important for referring hospitals to use radiation wisely! First, if the patient has obvious injuries that require transfer, don’t scan, just send. If you need to scan to decide whether you can keep the patient, use the best ALARA* technique you can. And trauma centers, please send a copy of your CT protocols to your referring hospitals so they can get the best images possible.

*ALARA = As low as reasonably achievable (applied to radiation exposure). Also known as ALARP outside of North America (as low as reasonably practicable). Click here for more info.

Related posts:

Reference: Computed tomography before transfer to a level I pediatric trauma center risks duplication with associated radiation exposure. J Pediatric Surg 43(12): 2268-2272, 2008.

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Delayed Diagnosis of Blunt Intestinal Injury in Children

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Yesterday, I wrote about using ultrasound in place of CT for initial diagnosis of blunt abdominal injury in children. Although it looks good for identification of solid organ injury and free fluid, it may miss injury to the intestine. Is that bad?

Lets look at a recent study that examined the consequences of delayed laparotomy for blunt intestinal injury. The American Pediatric Surgical Association conducted an 18-center study of the management of intestinal injuries in children less than 16 years of age. They were stratified by time to treatment. There were 214 patients with complete data records for review. 

The majority of the patients were involved in a motor vehicle crash or a bicycle accident. Demographics were similar in all time to treatment groups. Half were resuscitated at a referring hospital and then transferred to a pediatric trauma center, on average after 6 hours.

Key points:

  • The only deaths occurred in the 0-6hr and 6-12hr groups. The average Injury Severity Score of the children who died was significantly higher than survivors.
  • Children operated on in the 0-6hr group had significantly higher ISS as well.
  • There was no difference in early or late complications across all groups.
  • Time to beginning oral intake and time in hospital were the same in all groups.

The authors concluded that observation and serial exam rather than urgent exploration or repeated CT scans is appropriate.

Bottom line: If you combine this study with the ultrasound study I reviewed yesterday, it seems appropriate to modify the usual (read: adult) way of evaluating blunt trauma to the abdomen. In place of automatically getting a CT scan of the abdomen in children, obtain a complete abdominal ultrasound to detect solid organ injury or free fluid. This will determine the degree of monitoring needed (e.g. ICU for higher grade liver or spleen injuries). Follow this with serial abdominal exam. If the child becomes symptomatic, it’s probably time to proceed to the OR. Note: I generally do not make children npo during the observation phase. They need to eat, and if they don’t want to, that tells you something.

Related post: Sonography in pediatric abdominal trauma

Reference: Delay in diagnosis and treatment of blunt intestinal injury does not adversely affect prognosis in the pediatric patient. J Pediatric Surg 45(1):161-166, 2010.

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Sonography In Place of CT For Pediatric Abdominal Trauma

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Pediatric blunt abdominal trauma is not common, but if present it has the potential to cause significant morbidity or mortality. Evaluation of the abdomen at the trauma center is crucial, and most trauma professionals are aware of the trade-offs in the use of CT scan in children (radiation exposure, need for sedation).

Ultrasound is widely available and allows for imaging of most areas of concern in the abdomen. Could sonography be used in place of CT in specific cases? Pediatric surgeons in Germany (who have been using ultrasound far longer than the US has) published a paper last year looking at their experience with children who were diagnosed with an intra-abdominal organ injury after blunt trauma. Their 7 year experience only produced 35 such children, and they were evaluated with examination and one or more serial FAST ultrasound exams. Equivocal results were scanned with CT.

They found that ultrasound was effective in diagnosing abdominal injury 97% of the time. Although 11 of the 35 children had subsequent CT scanning, it only changed management in one case. 

Bottom line: Obviously, this is a very small retrospective series, but it is provocative. The German pediatric surgeons go above and beyond the typical FAST exam in the US, using it for diagnostic purposes as well. Could a complete diagnostic ultrasound take the place of CT in select children in the US? Probably so, as they are very sensitive in detecting free fluid and solid organ injury. But what about blunt intestinal injury? I’ll review that tomorrow and sum up my thoughts on a possible algorithm.

Related posts:

Reference: Is sonography reliable for the diagnosis of pediatric blunt abdominal trauma? J Pediatric Surg 45(5):912-915, 2010.