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Scarponcini TR, Edwards CJ, Rudis MI, Jasiak KD, Hays DP. The role of the emergency pharmacist in trauma resuscitation. J Pharm Pract 2011; 24:146-59. [PMID: 21712210 DOI: 10.1177/0897190011400550] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The clinical pharmacist in the emergency department is now commonly incorporated as a member of the emergency department trauma team. As such, the emergency pharmacist needs to have detailed knowledge of the pharmacotherapy of resuscitation and be able to apply the skills needed to function as a valuable member of this team. In addition to the traditional skills of the discipline of clinical pharmacy, the emergency pharmacist must be familiar with the intricacies of treating life-threatening injuries in an emergent setting and be able to anticipate the direction of the patient's care. The ability to provide valuable pharmacological interventions throughout the resuscitation and stabilization process requires familiarity with the process of resuscitation, including rapid sequence induction, analgesia and sedation, seizure prophylaxis, appropriate antibiotic and tetanus prophylaxis, intracranial pressure control, hemodynamic stabilization, and any other specific drug therapy that the clinical situation demands. This article discusses the aforementioned pharmacotherapeutic topics and describes the role of the Emergency Pharmacist on the ED trauma team.
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Georgiou A, Lockey DJ. The performance and assessment of hospital trauma teams. Scand J Trauma Resusc Emerg Med 2010; 18:66. [PMID: 21144035 PMCID: PMC3017008 DOI: 10.1186/1757-7241-18-66] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 12/13/2010] [Indexed: 11/10/2022] Open
Abstract
The purpose of the trauma team is to provide advanced simultaneous care from relevant specialists to the seriously injured trauma patient. When functioning well, the outcome of the trauma team performance should be greater than the sum of its parts. Trauma teams have been shown to reduce the time taken for resuscitation, as well as time to CT scan, to emergency department discharge and to the operating room. These benefits are demonstrated by improved survival rates, particularly for the most severely injured patients, both within and outside of dedicated trauma centres. In order to ensure the best possible performance of the team, the leadership skills of the trauma team leader are essential and their non-technical skills have been shown to be particularly important. Team performance can be enhanced through a process of audit and assessment of the workings of the team and the evidence currently available suggests that this is best facilitated through the process of video review of the trauma resuscitation. The use of human patient simulators to train and assess trauma teams is becoming more commonplace and this technique offers a safe environment for the future education of trauma team staff. Trauma teams are a key component of most programmes which set out to improve trauma care. This article reviews the background of trauma teams, the evidence for benefit and potential techniques of performance assessment. The review was written after a PubMed, Ovid, Athens, Cochrane and guideline literature review of English language articles on trauma teams and their performance and hand searching of references from the relevant searched articles.
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Physiologically focused triage criteria improve utilization of pediatric surgeon-directed trauma teams and reduce costs. J Pediatr Surg 2010; 45:1315-23. [PMID: 20620338 DOI: 10.1016/j.jpedsurg.2010.02.108] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Accepted: 02/23/2010] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Pediatric surgeon-directed trauma teams (STTs) provide lifesaving treatment but at a high cost. We used physiologically based criteria to improve STT utilization. METHODS We reviewed 152 consecutive STT activations at one center, comparing standard and physiologically focused criteria and 24-hour hospital costs/charges for overtriaged patients vs level 2 (emergency department managed) blunt trauma patients matched for age, Injury Severity Score (ISS), and necessity for operation. RESULTS Our cohort (73.0% male; 86.8% blunt; median age, 8.0 [interquartile range, 4.0-14.0] years) had 10 deaths (6.6%) and 18 (11.8%) emergent operations. Twenty-nine patients met neither standard nor physiologic criteria (group 1), 25 met standard but not physiologic criteria (overtriaged, group 2), and 98 met physiologic criteria (group 3). Group 3 had higher median ISS (19.0 [10.0-33.0] vs 10.0 [4.0-17.0] and 5.5 [5.0-16.75] for groups 1 and 2, P = .001), more intensive care unit admissions (67.2% vs 31.0% and 52.0%, P = .001), longer hospitalization (5.0 [3.0-9.25] days vs 3.0 [1.0-5.0] and 4.0 [2.0-5.0] days, P = .002), and all patients who died or required emergent operation (P < .001). Physiologic criteria maintained 100% sensitivity but improved specificity (49.2% vs 23.0%). Overtriaged patients (n = 18) had 78.2% higher charges ($4700; 95% confidence interval, 13.3%-180.1%; P = .013) and 53.4% higher costs ($800; 95% confidence interval, 1.8%-131.2%; P = .041) than level 2 patients (n = 259) after adjusting for age, ISS, and need for operation, largely because of computed tomography and emergency department charges (66% of overtriaged charges). CONCLUSIONS Physiologic STT activation criteria would have saved 25 activations, $20,000 in costs, and $120,000 in charges annually without compromising patient safety.
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Au EHK, Holdgate A. Characteristics and outcomes of patients discharged home from the Emergency Department following trauma team activation. Injury 2010; 41:465-9. [PMID: 20015489 DOI: 10.1016/j.injury.2009.11.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Revised: 10/19/2009] [Accepted: 11/23/2009] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Past research on trauma teams has largely focused on the outcomes of severely injured patients. Few studies have looked at patients who have activated the trauma team but are discharged home directly from the Emergency Department. The aim of this study was to examine the characteristics and outcomes of these patients following discharge. METHODS All adult Emergency Department discharged trauma patients who were contactable by telephone 7-14 days post-discharge and spoke English were eligible for the study. A 10-min questionnaire was conducted covering their perceptions of Emergency Department care, return to activities, discharge and follow-up care, missed injuries and pain management. Data were also collected on their age, sex, injuries and length of stay in the Emergency Department. RESULTS Over the 169-day study period, 158 trauma patients were discharged from Liverpool hospital, which formed 30.1% of all patients treated by the trauma team. Of these, 106 patients were contactable and 100 completed the follow-up questionnaire. They suffered mainly minor injuries but stayed a median 341 min in the Department. Most patients (87%) reported that their health had impacted on their daily activities and about half of all full-time workers remained off work for 1 week or more. A small number of patients had missed fractures or other serious injuries. Two-third of patients visited a medical practitioner after discharge and 8 required further specialist and/or in-patient care. CONCLUSION Most trauma patients discharged from the Emergency Department continue to suffer significant morbidity after their departure from hospital and require further medical care. A small number of patients also had significant missed injuries. This suggests that more comprehensive discharge and follow-up care for these patients is warranted.
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Affiliation(s)
- Eric H K Au
- University of New South Wales, Sydney, New South Wales, Australia
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Dudley NC, Hansen KW, Furnival RA, Donaldson AE, Van Wagenen KL, Scaife ER. The Effect of Family Presence on the Efficiency of Pediatric Trauma Resuscitations. Ann Emerg Med 2009; 53:777-84.e3. [DOI: 10.1016/j.annemergmed.2008.10.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2008] [Revised: 09/19/2008] [Accepted: 10/01/2008] [Indexed: 10/21/2022]
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Reducing "cry wolf"--changing trauma team activation at a pediatric trauma centre. ACTA ACUST UNITED AC 2009; 66:698-702. [PMID: 19276740 DOI: 10.1097/ta.0b013e318165b2f7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND To improve utilization of scarce surgical resources, we changed from a single tier trauma paging system (TPS) to a three tiered TPS at a tertiary pediatric trauma center. We investigated if patients were appropriately classified into the three levels of trauma team activation. METHODS Trauma registry data were used to review data 12 months before and after implementation of a three tiered TPS (level I entire team present, level II surgical subspecialties within 10 minutes, level III emergency department team only at patient arrival). We correlated TPS activation with proxies of injury severity (admission status and major/nonmajor trauma). RESULTS There were 192 activations during 12 months of the single tier TPS and 216 during the three tier TPS (33 level I, 49 level II, and 134 level III). The entire team was to attend in all 192 single tier and in 82 (40%) level I and II three tier TPS activations i.e., there were 60% fewer surgical team activations. During single tier TPS, 96% patients were admitted and 23% classified as major trauma. Three tiered TPS level I, II and III were admitted in 97%, 94%, and 81% and classified as major trauma in 58%, 35%, and 15%, respectively. Of the 20 level III patients classified as major trauma, TPS level was deemed appropriate in 18 and inappropriately low in 2, although patient care had not been compromised. CONCLUSION Our results suggest that a three tiered TPS more efficiently utilizes limited surgical resources without leading to major misclassifications.
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Evaluation of a Multidisciplinary Pediatric Mock Trauma Code Educational Initiative: A Pilot Study. ACTA ACUST UNITED AC 2008; 64:761-7. [DOI: 10.1097/ta.0b013e3180341ff8] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Effect of emergency department care on outcomes in pediatric trauma: what approaches make a difference in quality of care? ACTA ACUST UNITED AC 2008; 63:S136-9. [PMID: 18091205 DOI: 10.1097/ta.0b013e31815acd19] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Deriving evidence-based best practice for each phase or setting of trauma care is necessary to maximize best outcomes. There is a paucity of studies examining the association of provider training on pediatric trauma outcomes. Pivotal decisions (whether and where to transfer, diagnostic workup, and initial resuscitation) occur in this setting, yet there is little evidence relating to best practices in those areas. Classic process-performance measures such as time intervals during care (e.g., time to computerized tomography scan, time to operating room, etc.) or utilization measures (American College of Surgeons designation) are commonly used in the trauma center certification process, yet process-outcome links relevant to children are lacking. Although great advances have been made in the trauma care delivered to children, scientific proof is lacking and much more needs to be done to establish the evidence-based need to deliver the highest quality of pediatric trauma care.
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Role of the pediatric intensivist in the management of pediatric trauma. ACTA ACUST UNITED AC 2008; 63:S101-5; discussion S106-12. [PMID: 18091199 DOI: 10.1097/ta.0b013e31815acc59] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
There is a substantial body of evidence supporting the importance of the intensivist, and the importance of active involvement of the intensivist in day-to-day management of patients, although there are much fewer data for pediatric trauma. Postoperative management of the pediatric trauma patient is complex and includes many nonsurgical areas of expertise, such as management of respiratory and renal failure, nutritional support, metabolic support, prevention and management of infection, and sepsis. Collaborative multidisciplinary care of these children should include the active and officially acknowledged involvement of pediatric intensivists side by side with their surgical colleagues.
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Carreras González E, Rey Galán C, Concha Torre A, Cañadas Palaz S, Serrano González A, Cambra Lasaosa FJ. Asistencia al paciente politraumatizado. Realidad actual desde la perspectiva de las unidades de cuidados intensivos. An Pediatr (Barc) 2007; 67:169-76. [PMID: 17692264 DOI: 10.1016/s1695-4033(07)70579-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To study the epidemiology and management of pediatric trauma patients as well as the organizational, human and technical resources dedicated to these children from the perspective of the pediatric intensive care unit (PICU). MATERIAL AND METHODS A standardized data collection form was sent to 43 PICUs in Spain. Items inquired about the existence of training courses, trauma clinical practice guidelines and trauma registers, and which physician was in charge of trauma patients. Data on casuistics, the age of trauma patients, and the availability of human and technical resources, were also recorded. RESULTS Twenty-four PICUs completed the questionnaire. The PICU physician was responsible for trauma patient care in 66% of the hospitals. No training courses were available in 59% of the hospitals. No trauma register was available in 62% of the hospitals. Trauma patients represented 11% of PICU admissions, and most patients were aged up to 14 years old. An anesthetist was always at the hospital in 100% of the hospitals. A radiologist and traumatologist were always at the hospital in 91%, a neurosurgeon in 66% and a pediatric surgeon in 50%. The remaining surgical and medical specialties were on call. Continuous intracranial pressure monitoring was available in 87% of the PICUs, jugular venous saturation monitoring in 54% and continuous electroencephalogram and transcranial Doppler ultrasound in 50%. Computed tomography and ultrasound were available at all times in all hospitals. Magnetic nuclear resonance and echocardiography were available at all times in 44% of the hospitals, and arteriography in 42%. CONCLUSION In Spain, the organization of pediatric trauma management is based on pediatric teams under the supervision of a PICU physician. Some hospitals show a lack of technical and human resources. Therefore, the minimum criteria required to consider a hospital as a pediatric trauma center should be established. Trauma training courses are required.
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Bernhard M, Becker TK, Nowe T, Mohorovicic M, Sikinger M, Brenner T, Richter GM, Radeleff B, Meeder PJ, Büchler MW, Böttiger BW, Martin E, Gries A. Introduction of a treatment algorithm can improve the early management of emergency patients in the resuscitation room. Resuscitation 2007; 73:362-73. [PMID: 17287064 DOI: 10.1016/j.resuscitation.2006.09.014] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Revised: 08/24/2006] [Accepted: 09/28/2006] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Successful management of emergency patients with multiple trauma in the hospital resuscitation room depends on the immediate diagnosis and rapid treatment of the most life-threatening injuries. In order to reduce the time spent in the resuscitation room, an in-hospital algorithm was developed in an interdisciplinary team approach with respect to local structures. The aim of the study was to analyse whether this algorithm affects the interval between hospital admission and the completion of diagnostic procedures and the start of life-saving interventions. Moreover, in-hospital mortality was investigated before and after the algorithm was introduced. MATERIAL AND METHODS In this prospective study, all consecutive trauma patients in the resuscitation room were investigated before (group I, 01/04-10/04) and after (group II, 01/05-11/05) introduction of the algorithm. The times between hospital admission and the end of the diagnostic procedures (ultrasound [sono], chest X-ray [CF], and cranial computed tomography [CCT]), and between hospital admission and the start of life-saving interventions were registered and in-hospital mortality analysed. RESULTS In the study period, 170 patients in group I and 199 patients in group II were investigated. Injury severity score (ISS) were comparable between the two groups. The intervals between admission and completion of diagnostic procedures were significantly lower after the algorithm was introduced (mean+/-S.D.): sono (11 +/- 10 min versus 7 +/- 6 min, p < 0.05), CF (21 +/- 12 min versus 12 +/- 9 min, p < 0.01), and CCT (55 +/- 27 min versus 32 +/- 14 min, p < 0.01). Moreover, the interval to the start of life-saving interventions was significantly shorter (126 +/- 90 min versus 51 +/- 20 min, p < 0.01). After introducing the algorithm, in-hospital mortality was reduced significantly from 33.3% to 16.7% (p < 0.05) in the most severely injured patients (ISS>or=25). CONCLUSION The introduction of an algorithm for early management of emergency patients significantly reduced the time spent in the resuscitation room. The periods to completion of sono, CF, and CCT, respectively, and the start of life-saving interventions were significantly shorter after introduction of the algorithm. Moreover, introduction of the algorithm reduced mortality in the most severely injured patients. Although further investigations are needed to evaluate the effects of the Heidelberg treatment algorithm in terms of outcome and mortality, the time reduction in the resuscitation room seems to be beneficial.
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Affiliation(s)
- Michael Bernhard
- Department of Anesthesiology and Emergency Medicine, University of Heidelberg, 110, Im Neuenheimer Feld, D-69120 Heidelberg, Germany
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Nasr A, Mikrogianakis A, McDowall D, Wales P. External Validation and Modification of a Pediatric Trauma Triage Tool. ACTA ACUST UNITED AC 2007; 62:606-9. [PMID: 17414335 DOI: 10.1097/ta.0b013e31802ee56f] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Simon et al. developed a simple secondary triage tool (mPTS) based on physiologic parameters and physical findings to identify pediatric trauma patients who had a low likelihood of serious injury. Such patients could be treated in the emergency room without full trauma team activation. Our objective was to evaluate the mPTS on the trauma population at our institution, a Level I pediatric trauma center. METHODS This was a retrospective cohort study of all trauma team activations at The Hospital for Sick Children (Sick Kids) (1999-2002), excluding penetrating trauma and burns. Patients were stratified into high-risk (Injury Severity Score [ISS] >or=12) and low-risk (ISS <12) groups. The mPTS evaluates airway integrity, open wounds, neurologic status, hemodynamics, and skeletal integrity and applies a score of 1 point to each criterion. RESULTS There were 628 trauma patients (382 boys, mean age of 8 +/- 3.8 years). The mPTS had a sensitivity of 92% and a positive predictive value (PPV) of 47% when applied to our population. The mPTS missed 21 patients with significant injuries, many were intra-abdominal. We modified the mPTS to include contusions to head and/or torso and a history of loss of consciousness and a 7-point score was developed. After modification the sensitivity was 99%, specificity 21%, and PPV of 46% with a 20% reduction in unnecessary trauma team activations. CONCLUSIONS The original mPTS by Simon et al. was not sensitive enough when applied to our population. The Sick Kids modification to the score improved the sensitivity to 99%. The PPV of 46% indicates a safe level of overtriage is maintained. The Sick Kids mPTS remains easy to apply and would have reduced trauma team activation by 20%.
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Affiliation(s)
- Ahmed Nasr
- Department of General Surgery, The Hospital for Sick Children, University of Toronto, Canada
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Ducrocq SC, Meyer PG, Orliaguet GA, Blanot S, Laurent-Vannier A, Renier D, Carli PA. Epidemiology and early predictive factors of mortality and outcome in children with traumatic severe brain injury: experience of a French pediatric trauma center. Pediatr Crit Care Med 2006; 7:461-7. [PMID: 16885795 DOI: 10.1097/01.pcc.0000235245.49129.27] [Citation(s) in RCA: 138] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To describe the results of an integrated pre- and in-hospital approach to critical care in a large population of children with severe traumatic brain injury and to identify the early predictors of their outcome. DESIGN A 9-yr retrospective review of the data of a trauma data bank. SETTING Level III pediatric trauma center. PATIENTS All children (1 month to 15 yrs) with severe traumatic brain injury (Glasgow Coma Scale </=8) hospitalized in our trauma center and followed until death or for >/=6 months after discharge. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Univariate and further multivariate analyses were performed to determine independent predictive factors of death and outcome at discharge and 6 months later. The Glasgow Outcome Scale was used to evaluate outcome; a poor outcome referred to Glasgow Outcome Scale >/=3. Receiver operating characteristic curves were drawn to determine the threshold values of predictors of death and outcome. Analysis concerned 585 children (67% male and 33% female). Mean age was 7 +/- 5 yrs. Predominant mechanisms of injury were road traffic accidents and falls. Mean values for Glasgow Coma Scale, Pediatric Trauma Score, and Injury Severity Score were 6 (3-8), 3 (-4,10), and 28 (4-75), respectively. Mortality rate was 22%; Glasgow Outcome Scale was <3 in 53% of the cases at discharge and 60% at 6 months. Multivariate analysis identified Glasgow Coma Scale, Injury Severity Score, and hypotension on arrival as independent predictors of death and poor outcome at discharge and at 6 months. Threshold values for death were 28 for Injury Severity Score and 5 for Glasgow Coma Scale. The same values were found for poor outcome, except for outcome at 6 months where threshold value for the Glasgow Coma Scale was 6. CONCLUSIONS Initial hypotension, Glasgow Coma Scale, and Injury Severity Score are independent predictors of outcome in children with traumatic brain injury. Threshold values can be calculated for predicting poor outcome. These variables can be easily and detected early in this population and used for quality assessment.
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Affiliation(s)
- Sarah C Ducrocq
- Division of Pediatric Anesthesia and Neurocritical Care Unit, Hôpital Necker-Enfants Malades, Université René Descartes Paris 5, France
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Willson DF, Dean JM, Newth C, Pollack M, Anand KJS, Meert K, Carcillo J, Zimmerman J, Nicholson C. Collaborative Pediatric Critical Care Research Network (CPCCRN). Pediatr Crit Care Med 2006; 7:301-7. [PMID: 16738501 DOI: 10.1097/01.pcc.0000227106.66902.4f] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Pediatric critical care was formally recognized as a separate subspecialty in pediatrics in 1987. Since that time the numbers of pediatric intensivists, pediatric intensive care units, and pediatric intensive care beds in the United States have increased dramatically. Research efforts have lagged behind, however, as this new discipline has struggled to identify the necessary time, funding, and other resources to pursue clinical and laboratory investigation. In April 2004, the National Center for Medical Rehabilitation Research of the National Institute for Child Health and Human Development issued a request for applications to establish the Collaborative Pediatric Critical Care Research Network (CPCCRN). The CPCCRN provides an infrastructure to pursue collaborative clinical trials and descriptive studies in pediatric critical care medicine. Six pediatric centers involving seven intensive care units and a data-coordinating center were identified through a competitive application process. Network goals include the support of collaborative clinical trials otherwise impracticable in single institutions and the establishment of a framework for developing the scientific basis for pediatric critical care practice. This article describes how the CPCCRN was established, its organization, and its goals and future plans.
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Hunt EA, Hohenhaus SM, Luo X, Frush KS. Simulation of pediatric trauma stabilization in 35 North Carolina emergency departments: identification of targets for performance improvement. Pediatrics 2006; 117:641-8. [PMID: 16510642 DOI: 10.1542/peds.2004-2702] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Trauma is the leading cause of death in children. Most children present to community hospital emergency departments (EDs) for initial stabilization. Thus, all EDs must be prepared to care for injured children. The objectives of this study were to (1) characterize the quality of trauma stabilization efforts in EDs and (2) identify targets for educational interventions. METHODS This was a prospective observational study of simulated trauma stabilizations, that is, "mock codes," at 35 North Carolina EDs. An evaluation tool was created to score each mock code on 44 stabilization tasks. Primary outcomes were (1) interrater reliability of tool, (2) overall performance by each ED, and (3) performance per stabilization task. RESULTS Evaluation-tool interrater reliability was excellent. The median number of stabilization tasks that needed improvement by the EDs was 25 (57%) of 44 tasks. Although problems were numerous and varied, many EDs need improvement in tasks uniquely important and/or complicated in pediatric resuscitations, including (1) estimating a child's weight (17 of 35 EDs [49%]), (2) preparing for intraosseous needle placement (24 of 35 [69%]), (3) ordering intravenous fluid boluses (31 of 35 [89%]), (4) applying warming measures (34 of 35 [97%]), and (5) ordering dextrose for hypoglycemia (34 of 35 [97%]). CONCLUSIONS This study used simulation to identify deficiencies in stabilization of children presenting to EDs, revealing that mistakes are ubiquitous. ED personnel were universally receptive to feedback. Future research should investigate whether interventions aimed at improving identified deficiencies can improve trauma stabilization performance and, ultimately, the outcomes of children who present to EDs.
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Affiliation(s)
- Elizabeth A Hunt
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
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Abstract
A three-part analysis was undertaken to assess pediatric trauma mortality in a nonacademic Level II trauma center at Parkview Hospital in Fort Wayne, Indiana. Part I was a comparison of Parkview trauma registry data collected from 1999 through 2003 with those of pediatric and adult trauma centers in Pennsylvania. The same methodology used in Pennsylvania was used for the initial evaluation of pediatric deaths from trauma in our trauma center. Part II was a formal in-depth analysis of all individual pediatric deaths as well as surgical cases with head, spleen, and liver injuries from the same time frame. Part III proposes a new methodology to calculate a risk-adjusted mortality rate based on the TRISS model for the evaluation of a trauma system. The use of specific mortality and surgical intervention rates was not an accurate reflection of trauma center outcome. The proposed risk-adjusted mortality rate calculation is perhaps an effective outcome measure to assess patient care in a trauma system.
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Affiliation(s)
- Mary O. Aaland
- From Parkview Hospital, Trauma Services, Fort Wayne, Indiana
| | - Thein Hlaing
- From Parkview Hospital, Trauma Services, Fort Wayne, Indiana
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Ban KM, Mannelli F, Messineo A, Frassineti M, Barkin R, Mooney DP, Shannon M, Gensini GF. Building a trauma center and system in Tuscany, Italy. Intern Emerg Med 2006; 1:302-4. [PMID: 17217153 DOI: 10.1007/bf02934765] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Growing evidence supports the premise that adult trauma centers lower the risk of death for severely injured patients. The same principles have been applied to the pediatric population and mounting research suggests that, as in the adult population, gravely injured children have better outcomes at pediatric trauma centers where personnel trained and experienced in the specific needs and unique physiology of injured children provide care. As in the United States, acute traumatic injury represents an important public healthcare concern to the Tuscan regional government whose goal is to maximize clinical outcomes within available resources. In order to address this problem, the Tuscan regional government has created a new and innovative collaboration between the Meyer Pediatric Hospital/University of Florence School of Medicine and the Children's Hospital Boston/Harvard Medical School to build a pediatric trauma center and regional pediatric trauma referral system. GOALS AND OBJECTIVES This long-term international initiative will seek to develop a demonstration model for pediatric trauma care that may later be replicated elsewhere. The initial goals of the project will focus on expanding the role of the pediatricians working in the emergency department to include the acute care of medical, surgical, orthopedic and multiple trauma patients. This new configuration will closely resemble the single provider model of emergency medical care commonly utilized in the United States. During this transition period to a more broadly trained emergency physician, a multi-disciplinary trauma team will be created and pediatric trauma clinical practice guidelines will be introduced into the emergency department and inpatient care units. Systems measurements will be achieved through a comprehensive quality improvement and risk management program. Ultimately, all Tuscan regional pediatric major trauma will be consolidated at the Meyer Pediatric Hospital in Florence.
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Affiliation(s)
- Kevin M Ban
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, One Deaconess Road, West CC2, 2nd Floor, Boston, MA 02215, USA.
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Perno JF, Schunk JE, Hansen KW, Furnival RA. Significant reduction in delayed diagnosis of injury with implementation of a pediatric trauma service. Pediatr Emerg Care 2005; 21:367-71. [PMID: 15942513 DOI: 10.1097/01.pec.0000166726.84308.cf] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The occurrence of delayed diagnosis of injury (DDI) among pediatric trauma patients represents a breakdown in trauma care. Although some DDI may be unavoidable, the rate of DDI may be used as a measure of quality improvement. OBJECTIVE We sought to investigate DDI in admitted pediatric trauma patients while a designated pediatric trauma response team was used and compare this with the prior incidence of DDI (4.3%) before initiation of the response team. METHODS Primary Children's Medical Center (PCMC) is a regional tertiary pediatric trauma center. This analysis used the prospectively gathered PCMC Trauma Database, and included all hospitalized pediatric trauma patients from 1997 through 2000. RESULTS A total of 3265 patients were included; no patients were excluded. A DDI occurred in 15 (0.46%; 95% CI: 0.31, 0.79) trauma patients. The DDI patients were more severely injured with significantly higher Injury Severity Scores, lower TRISS Probability of Survival values, longer hospitalizations (P < or = 0.05, Mann-Whitney U), and were more frequently admitted to the PICU (P < or = 0.05, chi2) than the non-DDI patient population. In a previous study, our incidence of missed injury was 4.3% (50/1175; 95% CI: 3.3, 5.6); with implementation of a designated trauma response team and trauma service, the incidence of DDI was reduced nearly 10-fold to 0.46% (15/3265; 95% CI: 0.31, 0.79). CONCLUSIONS Implementation of an effective trauma team and trauma service was associated with a significant reduction in DDI.
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Affiliation(s)
- Joseph F Perno
- Division of Pediatric Emergency Medicine, Department of Pediatrics, All Children's Hospital, St. Petersburg, FL, USA.
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69
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Abstract
BACKGROUND Trauma teams have been associated with improved survival probability of paediatric trauma patients. The present study seeks to estimate the use of trauma teams in Australian paediatric tertiary referral centres and describe their medical composition, leadership and criteria for activation. METHODS Australian paediatric tertiary referral centres were identified. A structured questionnaire assessing the presence, composition and means of activation of a trauma team was mailed to the 'Director, Emergency Department' of all identified hospitals. Three months later, all hospitals were contacted by telephone to complete and verify data collection. RESULTS Questionnaires were distributed to eight hospitals. Seventy-five per cent had an established trauma team. Hospitals without a trauma team claimed to have insufficient doctors to form a team and insufficient trauma caseload to justify a team. All trauma teams were potentially activated by prehospital paramedic data (field triage) and required a combination of anatomical, physiological and mechanistic criteria for activation. The two methods of mobilizing a trauma team were by dispatching a common call onto individual pagers (66%) or a specific trauma pager (33%) carried by trauma team members. Fifty per cent of hospitals had a two-tier, stratified trauma team response. All teams consisted of emergency, surgical and intensive care unit registrars. Trauma team leaders were emergency medicine specialists/registrars (33%), surgical registrars (33%) and non-defined (33%). Consultant surgeons were not members of any trauma team. Eighty-three per cent of trauma teams consisted of more junior members after hours. Fifty per cent of hospitals did not have a surgical registrar on site outside of business hours. Eighty-eight per cent of hospitals engaged in some form of trauma audit. CONCLUSIONS Trauma teams are utilized by most Australian paediatric tertiary referral centres, with fairly uniform medical composition and criteria for activation. Paediatric surgeons presently have limited leadership roles and membership of Australian paediatric trauma teams.
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Affiliation(s)
- Kenneth Wong
- Department of Trauma, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
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70
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Kühne CA, Ruchholtz S, Sauerland S, Waydhas C, Nast-Kolb D. [Personnel and structural requirements for the shock trauma room management of multiple trauma. A systematic review of the literature]. Unfallchirurg 2005; 107:851-61. [PMID: 15459805 DOI: 10.1007/s00113-004-0813-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The aim of the study was the description of personal and structural preconditions essential for adequate diagnostic requirements and treatment in severely injured patients. Herein we give detailed information regarding both the composition and qualification of the trauma team and the activation criteria as well as instructions for the design of the emergency room and technical requirements. Clinical trials were systematically collected (MEDLINE, Cochrane, and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system). The trauma team should consist of (trauma) surgeons, anesthesiologists, radiologists, and one to two nursing staff members of each department. The attending physician should be present within 20 min. Trauma team activation criteria are among others: high energy/velocity trauma, penetrating injuries, GCS < or =14, and intubation. The emergency room should be integrated in the emergency department with all technical equipment being permanently available for optimal diagnostic and therapeutic management. A CT scanner should be positioned nearby.Adequate management of severely injured patients requires optimal personal and structural conditions. High costs and additional personnel are justified by improved quality of treatment.
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Affiliation(s)
- C A Kühne
- Klinik für Unfallchirurgie, Universitätsklinikum, Essen.
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71
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Chen LE, Snyder AK, Minkes RK, Dillon PA, Foglia RP. Trauma stat and trauma minor: are we making the call appropriately? Pediatr Emerg Care 2004; 20:421-5. [PMID: 15232239 DOI: 10.1097/01.pec.0000132213.19858.bf] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Trauma accounts for a significant number of pediatric emergency room visits and is the leading cause of death in pediatric patients over 1 year of age. To provide quality care, protocols are used to mobilize personnel to treat injured patients. We reviewed our experience at a level 1 pediatric trauma center, where a 2-tiered trauma activation protocol is used in treating children with significant injuries. METHODS We analyzed data in our trauma registry from 1994 to 1999 of patients with Injury Severity Score > or = 9 in whom trauma activations were called. Data reflected demographics, severity of injury, hospital course and outcome. Trauma activations were based on standard protocols that took physiologic status, anatomic area of injury, and mechanism of injury into account. Nineteen personnel were notified in a Trauma Stat Activation, and 8 were notified in a Trauma Minor Activation. RESULTS There were 470 trauma activations: Trauma Stat = 220 and Trauma Minor = 250. As a group, Trauma Stat patients were more hemodynamically unstable, had a lower GCS and a higher Injury Severity Score than Trauma Minor patients. Patients in the Trauma Stat group were also more likely to require intensive care and have a prolonged hospitalization. The Trauma Stat group had a mortality rate of 20%. There were no deaths in the Trauma Minor group. CONCLUSIONS Trauma activations result in heavy resource utilization and must be appropriate. The 2 trauma activation levels were associated with differences in injury severity, medical resource utilization, and outcome. With no deaths in the Trauma Minor group and a 20% mortality rate in the Trauma Stat group, we conclude that the protocol used was neither too conservative, nor too liberal.
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Affiliation(s)
- Li Ern Chen
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, MO 63110, USA
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72
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Browne GJ, Lam LT, Barker RA. The usefulness of a modified adult protocol for the clearance of paediatric cervical spine injury in the emergency department. Emerg Med Australas 2003; 15:133-42. [PMID: 12675623 DOI: 10.1046/j.1442-2026.2003.00345.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine if the use of a modified adult protocol that uses cervical spine imaging on presentation for the assessment of cervical spine injury in children improves clinical outcome. METHODS This is a case series study on all consecutive trauma patients presenting from April to July 2000 inclusive to the ED of a major paediatric trauma hospital. Children presenting to the ED with potential cervical spine injury (CSI) were identified using standard selection criteria. Patient demographics, mechanism of injury, method and time of presentation, associated injuries, radiological investigation and clinical outcome were recorded. The major outcome measures for this study were: time to clearance of the cervical spine, length of stay in the ED and admission to an in-hospital bed. Data were analysed for compliance to the protocol, this being the standard assessment pathway of cervical spine clearance used by our trauma service. RESULTS The trauma registry identified 1721 trauma presentations during the 4-month study period; 208 presentations representing 200 children with potential CSI were entered into the study. Males represented 72.5% of the study population, having a mean age of 8.32 years, although 29% were less than 5 years of age. The majority of presentations (69%) occurred outside of normal working hours. In 17.8% of cases the cervical spine was cleared based on clinical assessment alone, half less than 5 years of age. Compliance to the protocol occurred in 78% of presentations. However, when examined by age group, children 5 years of age or above were 1.5 times more likely to comply with the protocol as compared with younger children. Adequate plain imaging was not obtained in 18% of presentations, this group almost exclusively less than 5 years of age. There were no missed injuries and no short or long-term neurological sequelae reported during this study. There were no differences in time to clearance, length of stay and admission rate between compliant and non-compliant groups. CONCLUSIONS Modified adult protocols for cervical spine clearance offer guidance in managing the majority of children suffering blunt trauma. However, we recommend caution in rigidly applying such protocols, especially to children of young age.
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Affiliation(s)
- Gary J Browne
- Department of Emergency Medicine, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.
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73
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Browne GJ. Paediatic emergency departments: old needs, new challenges and future opportunities. Emerg Med Australas 2001; 13:409-17. [PMID: 11903425 DOI: 10.1046/j.1035-6851.2001.00254.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- G J Browne
- Department of Emergency Medicine, The Children's Hospital, Westmead, New South Wales, Australia
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74
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Athey J, Dean JM, Ball J, Wiebe R, Melese-d'Hospital I. Ability of hospitals to care for pediatric emergency patients. Pediatr Emerg Care 2001; 17:170-4. [PMID: 11437140 DOI: 10.1097/00006565-200106000-00005] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT The needs of children in emergency situations differ from those of adults and require special attention, yet there has been no study of the ability of U.S. hospitals to care for emergently or critically ill children. OBJECTIVE To estimate the distribution of pediatric services available at U.S. hospitals with emergency departments (EDs). DESIGN Self-report survey of 101 hospital EDs. PARTICIPANTS Stratified probability sample of all U.S. hospitals operating EDs. RESULTS The majority of hospitals that usually admit pediatric patients do not have separate pediatric facilities. Hospitals without a pediatric department, ward, or trauma service usually transfer critically injured pediatric trauma patients; however, nearly 10% of hospitals without pediatric intensive care facilities admit critically injured children to their own facilities. Likewise, 7% of hospitals routinely admit pediatric patients known to require intensive care to their adult intensive care units rather than transferring the patient to a facility with pediatric intensive care facilities. Few hospitals have protocols for obtaining pediatric consultation on pediatric emergencies. Appropriately sized equipment for successful care of infants and children in an emergency situation was more likely to be missing than adult-sized equipment, and significant numbers of hospitals did not have adequate equipment to care for newborn emergencies. CONCLUSION Emergent and critical care of infants and children may not be well integrated and regionalized within our health care system, suggesting that there is room for improvement in the quality of care for children encountering emergent illness and trauma.
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Affiliation(s)
- J Athey
- Health Policy Resources Group, LLC, Brookeville, MD 20833-2233, USA.
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75
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Wachtel TL, Coniglio R, Bourg P, Hawkes A, Knight S, Mayer K, Bensard D. The synergistic relationship between a level I trauma center and a regional pediatric trauma center. Semin Pediatr Surg 2001; 10:38-43. [PMID: 11172573 DOI: 10.1053/spsu.2001.19394] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A regional pediatric trauma center and a level I trauma center with pediatric commitment in the same city developed a synergistic relationship addressing all aspects of care for pediatric trauma patients. Although it is unlikely that this model could be used in its entirety by all similar institutions, the principles may prove helpful in creating guidelines and relationships. Categorization, optimal use of resources, timely transportation of seriously injured children to the appropriate facility, and maintaining urgent care capabilities of each institution to care for seriously injured children are imperative. The combined effort resulted in our level I trauma center being verified by the American College of Surgeons and designated by our state Health Department as meeting all the criteria for pediatric trauma care. This experience should encourage every pediatric trauma center located in a children's hospital to become a regional pediatric trauma center. The real benefit from the relationship is that injured children receive optimal care at both institutions.
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Affiliation(s)
- T L Wachtel
- St Anthony Central Hospital, Denver, CO, USA
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76
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Abstract
OBJECTIVE Trauma is a diverse disease in which time critical decisions and skills affect patient outcome. This review article examines the methods and assessment of education for the management of the trauma patient. METHOD Literature review. RESULTS Education is a planned experience that leads to a change in behaviour. Adult education methods can be used to improve the knowledge, skills, attitudes and relationships of health care workers. Adult learners need careful consideration of lecture style, small group work, role play and skills stations in order to achieve these aims. These techniques are typically used in short intensive courses such as Advanced Trauma Life Support (ATLS) aimed at the initial care of the trauma patient. There is a relative lack of education directed at definitive care. It is important to assess the impact of trauma education in terms of clinical process, retention of skills/knowledge and the outcome of patients. A generic approach (the ABC approach) is applicable to the care of all critically ill or injured patients. This approach should be taught at junior level. CONCLUSION The care of trauma patients can be improved by educating health care workers using adult educational strategies.
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Affiliation(s)
- S Carley
- Department of Emergency Medicine, Hope Hospital, Stott Lane, Salford, UK.
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77
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Dowd MD, McAneney C, Lacher M, Ruddy RM. Maximizing the sensitivity and specificity of pediatric trauma team activation criteria. Acad Emerg Med 2000; 7:1119-25. [PMID: 11015243 DOI: 10.1111/j.1553-2712.2000.tb01261.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Care of the severely injured child requires the rapid assembly of personnel trained in pediatric trauma care. Trauma team activation criteria, which are highly sensitive and maximally specific for identifying the child who requires resuscitation, are necessary to provide rapid care to all who need it, while using resources efficiently. OBJECTIVE To determine the sensitivity and specificity of the standard trauma team activation (TTA) criteria for identifying patients who receive resuscitation in the emergency department. METHODS A one-year study was conducted of all patients transported by emergency medical out-of-hospital services for a trauma-related complaint. For all patients, out-of-hospital medical control operators recorded whether patients met TTA criteria and, if so, which criteria were met. Criteria included standard physiologic, anatomic, and mechanism parameters. Sensitivity and specificity for the outcome of resuscitation (volume restoration, assisted ventilation or intubation, chest tube insertion/needle decompression, operative intervention) were calculated. RESULTS A total of 492 patients met the case definition. Two-thirds were male, the mean age was 8 years (+/-4.8 SD), and the Injury Severity Score was > or =15 in 9.3%. Trauma team activation criteria were met by 179 patients (36. 4%) and, of these, 107 met mechanism criteria only. A resuscitative intervention was received by 54 (10.9%) of the total and none in the mechanism-only group. Sensitivity and specificity of the TTA criteria for predicting receipt of a resuscitation procedure were 98. 1% and 71.2%, respectively. When mechanism criteria were excluded, the sensitivity remained 98.1% and the specificity increased to 95. 7%. CONCLUSIONS Criteria for TTA that include patients who meet mechanism criteria only are not specific for identifying patients who receive a resuscitative intervention. Use of anatomic and physiologic criteria only results in an increase in specificity, thereby reducing overtriage while retaining a high sensitivity.
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Affiliation(s)
- M D Dowd
- Division of Emergency Medicine, Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Rothrock SG, Green SM, Morgan R. Abdominal trauma in infants and children: prompt identification and early management of serious and life-threatening injuries. Part II: Specific injuries and ED management. Pediatr Emerg Care 2000; 16:189-95. [PMID: 10888461 DOI: 10.1097/00006565-200006000-00015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Evaluation of children with suspected abdominal trauma could be a difficult task. Unique anatomic and physiologic features render vital sign assessment and the physical examination less useful than in the adult population. Awareness of injury patterns and associations will improve the early diagnosis of abdominal trauma. Clinicians must have a complete understanding of common and atypical presentations of children with significant abdominal injuries. Knowledge of the utility and limitations of available laboratory and radiologic adjuncts will assist in accurately identifying abdominal injury. While other obvious injuries (eg, facial, cranial, and extremity trauma) can distract physicians from less obvious abdominal trauma, an algorithmic approach to evaluating and managing children with multisystem trauma will improve overall care and help to identify and treat abdominal injuries in a timely fashion. Finally, physicians must be aware of the capabilities of their own facility to handle pediatric trauma. Protocols must be in place for expediting the transfer of children who require a higher level of care. Knowledge of each of these areas will help to improve the overall care and outcome of children with abdominal trauma.
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Affiliation(s)
- S G Rothrock
- Department of Emergency Medicine, Orlando Regional Medical Center, Arnold Palmer Hospital for Children and Women, FL 37292, USA
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79
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Abstract
Paediatric trauma care is complex and diverse. Paediatric trauma care systems have proven difficult to evaluate, and further work is required to assess their usefulness. Furthermore, head injury is a major component of paediatric trauma and its management is becoming increasingly multifactorial. As its pathophysiology continues to unfold there is much opportunity for ongoing research in this area.
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Affiliation(s)
- R Fairgrieve
- Department of Anaesthesia, Hospital for Sick Children, Toronto, Ontario, Canada.
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