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Herren A, Palmer CS, Landolt MA, Lehner M, Neuhaus TJ, Simma L. Pediatric Trauma and Trauma Team Activation in a Swiss Pediatric Emergency Department: An Observational Cohort Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1377. [PMID: 37628376 PMCID: PMC10453385 DOI: 10.3390/children10081377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/02/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Trauma is one of the most common causes of death in childhood, but data on severely injured Swiss children are absent from existing national registries. Our aim was to analyze trauma activations and the profiles of critically injured children at a tertiary, non-academic Swiss pediatric emergency department (PED). In the absence of a national pediatric trauma database, this information may help to guide the design of infrastructure, processes within organizations, training, and policies. METHODS A retrospective analysis of pediatric trauma patients in a prospective resuscitation database over a 2-year period. Critically injured trauma patients under the age of 16 years were included. Patients were described with established triage and injury severity scales. Statistical evaluation included logistic regression analysis. RESULTS A total of 82 patients matched one or more of the study inclusion criteria. The most frequent age group was 12-15 years, and 27% were female. Trauma team activation (TTA) occurred with 49 patients (59.8%). Falls were the most frequent mechanism of injury, both overall and for major trauma. Road-traffic-related injuries had the highest relative risk of major trauma. In the multivariate analysis, patients receiving medicalized transport were more likely to trigger a TTA, but there was no association between TTA and age, gender, or Injury Severity Score (ISS). Nineteen patients (23.2%) sustained major trauma with an ISS > 15. Injuries of Abbreviated Injury Scale severity 3 or greater were most frequent to the head, followed by abdomen, chest, and extremities. The overall mortality rate in the cohort was 2.4%. Conclusions: Major trauma presentations only comprise a small proportion of the total patient load in the PED, and trauma team activation does not correlate with injury severity. Low exposure to high-acuity patients highlights the importance of deliberate learning and simulation for all professionals in the PED. Our findings indicate that high priority should be given to training in the management of severely injured children in the PED. The leading major trauma mechanisms were preventable, which should prompt further efforts in injury prevention.
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Affiliation(s)
- Anouk Herren
- Department of Pediatrics, Children’s Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
- Department of Pediatrics, University’s Children Hospital Zurich, University of Zurich, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland
| | - Cameron S. Palmer
- Trauma Service, The Royal Children’s Hospital, Melbourne, VIC 3052, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Markus A. Landolt
- Department of Psychosomatics and Psychiatry and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland
- Division of Child and Adolescent Health Psychology, Department of Psychology, University of Zurich, Binzmuehlestrasse 14, CH-8050 Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital of Zurich, University of Zurich, CH-8032 Zurich, Switzerland
| | - Markus Lehner
- Department of Pediatric Surgery, Children’s Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
| | - Thomas J. Neuhaus
- Department of Pediatrics, Children’s Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
| | - Leopold Simma
- Children’s Research Center, University Children’s Hospital of Zurich, University of Zurich, CH-8032 Zurich, Switzerland
- Emergency Department, Children’s Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
- Emergency Department, University’s Children Hospital Zurich, University of Zurich, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland
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Nguyen ATM, Drynan DP, Holland AJA. Paediatric pelvic fractures - an updated literature review. ANZ J Surg 2022; 92:3182-3194. [PMID: 35781759 PMCID: PMC10084350 DOI: 10.1111/ans.17890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 05/07/2022] [Accepted: 06/20/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Pelvic fractures in children are indicative of significant trauma. Patients will often have associated injuries - some of which require urgent intervention to prevent death and disability. Paediatric and adult pelvises respond to traumatic forces differently and distinct approaches are required for each population. Historically, pelvic fractures have been treated conservatively, but this trend is changing with a better understanding of the pelvis' inability to remodel significant deformity, as well as new techniques for operative fixation. METHODS A comprehensive search of the literature was conducted for articles published between 2000 and 2020 on paediatric pelvic fractures using medical databases including PubMed, Embase and the Cochrane Library. RESULTS We included 143 studies in our literature review and summarized the incidence, pathophysiology, assessment, management and complications associated with paediatric pelvic fractures. CONCLUSIONS The rarity of paediatric pelvic fractures corresponds with a paucity of randomized clinical trials covering this topic. Trends such as the screening pelvic x-ray are derived from adult populations but are now questioned in children. Other aspects of assessment and management of these children warrant such levels of scrutiny.
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Affiliation(s)
- Alexander T M Nguyen
- Orthopaedics Department, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Division of Surgery, Liverpool Hospital, Liverpool, New South Wales, Australia.,South West Sydney Clinical School, The University of New South Wales, New South Wales, Australia
| | - David P Drynan
- Orthopaedics Department, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Andrew J A Holland
- The Burns Unit, The Children's Hospital at Westmead Burns Research Institute, Westmead, New South Wales, Australia.,Douglas Cohen Department of Paediatric Surgery, The Children's Hospital at Westmead Clinical School, The Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
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Can we reduce CT scan and hospital costs in children with blunt trauma using four parameters? ANNALS OF PEDIATRIC SURGERY 2022. [DOI: 10.1186/s43159-021-00142-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Blunt trauma is one of the most common causes of admission to the emergency service in childhood. Children with trauma are generally evaluated in emergency services where pediatric and adult patients are together, and difficulties are experienced in managing children exposed to trauma. CT is preferred for quick detection and grading of toracoabdominal, skeleton, and neurological injury in high energy trauma. The present study aims to determine the severity of trauma and whether CT exposure can be reduced and patient cost using four parameters.
This study was conducted with 586 pediatric patients exposed to blunt abdominal trauma. The clinical prediction rule consisted of four parameters, including abdominal pain, physical examination findings, aspartate aminotransferase (AST), and chest x-ray (CXR, which was used to predict intraabdominal injury in patients with blunt trauma. Patients with no parameters of the clinical decision rule were considered very low risk, and those with one or more parameters were considered at risk. The hospital cost of the patients with and without clinical decision rule was calculated and compared.
Results
In our study, according to the four-variable clinical prediction rule, 88.1% of the patients had a very low risk of intraabdominal injury and 11.9% of them were at risk. The sensitivity was 97.3%, specificity 98.2%, and accuracy was 97.4% in very low-risk patients with four variables clinical prediction rule. In the very low-risk patients, the abnormal CT rate was 0.3% and conservative treatment was performed. With the use of four variables, 0.17% of solid organ injuries may be overlooked. In the risk of patients, 2.9% of these patients were abnormal CT findings, while tube thoracostomy was performed in four patients with pneumothorax, conservative treatment was performed in other patients.
It was determined that routine computed tomography scan increased the patient cost by 5.5 times.
Conclusion
Patients exposed to blunt trauma with a very low risk of intra-abdominal injury can be identified with a four-variable clinical prediction rule. According to the four-variable clinical prediction rule, very low-risk patients do not require immediate CT. The hospital costs can be reduced by reducing the CT scan. However, it should be kept in mind that a small proportion of intra-abdominal injuries may be overlooked.
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Fonacier FS, Chan HK, Ugalde I. Pediatric scapular fractures and associated injuries following blunt chest trauma. Am J Emerg Med 2021; 52:196-199. [PMID: 34953235 DOI: 10.1016/j.ajem.2021.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 11/22/2021] [Accepted: 12/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Scapular fractures in the pediatric population are rare, and medical literature is lacking regarding these specific injuries in the pediatric population. Prior studies have shown that scapular fractures resulting from blunt chest trauma have been associated with significant morbidities in adults, and that a majority of scapular fractures are missed on chest X-ray (CXR) and seen on computerized tomography only (SOCTO). Further guidance is needed regarding the prevalence of coinciding injuries in the pediatric population and the modality for diagnosis. OBJECTIVES The primary objectives of this study were to assess 1) the frequency of scapular fractures following blunt trauma in the pediatric cohort, 2) the frequency of other associated thoracic injuries, 3) the proportion on scapular fractures SOCTO. METHODS We conducted a retrospective cohort study with data obtained from our study site's Trauma Registry. Patients under 18 years receiving both a CXR and chest CT following blunt trauma or any patient diagnosed with a scapular fracture by any modality from January 2009 to December 2019 were included. Primary outcome variables were the presence of a scapular fracture diagnosed by any modality, absence of scapular fracture, and scapular fractures SOCTO. Charts were also reviewed for the following concurring injuries: 1) contusion/atelectasis, 2) pneumothorax, 3) hemothorax, 4) rib fracture, 5) other fracture, 6) vascular injury, 7) mediastinal injury, 8) diaphragm rupture, 9) foreign body, 10) incidental finding. RESULTS Of 12,826 charts of pediatric patients with blunt chest trauma, 1405 obtained both CXR and chest CT. Sixty (0.47%) were diagnosed with scapular fracture, and 48 (73.3%) of the fractures were SOCTO. The most commonly associated injuries were other fracture (88.3%), lung contusion/atelectasis (78.3%), pneumothorax (58.3%) and rib fracture (58.3%). Patients with scapular fractures had higher injury severity scores (ISS) and more frequently required surgery for other intrathoracic injuries. Only five patients required surgical management of the scapular fracture with the rest managed conservatively. CONCLUSION Pediatric scapular fractures are rare and are often associated with other intrathoracic injury. A majority of scapula fractures are missed on CXR, but identification of the injury did not change management as most were treated conservatively.
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Affiliation(s)
- Frances Sparks Fonacier
- UTHealth Science Center Houston, 6431 Fannin Street, Houston, TX 77030, United States of America.
| | - Hei Kit Chan
- UTHealth Science Center Houston, 6431 Fannin Street, Houston, TX 77030, United States of America
| | - Irma Ugalde
- UTHealth Science Center Houston, 6431 Fannin Street, Houston, TX 77030, United States of America
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Ugalde IT, Prater S, Cardenas-Turanzas M, Sanghani N, Mendez D, Peacock J, Guvernator G, Koerner C, Allukian M. Chest x-ray vs. computed tomography of the chest in pediatric blunt trauma. J Pediatr Surg 2021; 56:1039-1046. [PMID: 33051082 DOI: 10.1016/j.jpedsurg.2020.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/03/2020] [Accepted: 09/06/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Chest x-ray (CXR) has been shown to be an effective detection tool for clinically significant trauma. We evaluated differences in findings between CXR and computed tomography of the chest (CCT), their impact on clinical management and the performance of the CXR. METHODS This retrospective study examined children (less than 18 years) who received a CXR and CCT between 2009 and 2015. We compared characteristics of children by conducting univariate analysis, reporting the proportion of additional diagnoses captured by CCT, and using it to evaluate the sensitivity and specificity of the CXR. Outcome variables were diagnoses made by CCT as well as the ensuing changes in the clinical management attributable to the diagnoses reported by the CCT and not observed by the CXR. RESULTS In 1235 children, CCT was associated with diagnosing higher proportions of contusion or atelectasis (60% vs 31%; p < .0001), pneumothorax (23% vs 9%; p < .0001), rib fracture (18% vs 7%; p < .0001), other fracture (20% vs 10%; p < .0001), diaphragm rupture (0.2% vs 0.1%; p = .002), and incidental findings (7% vs 2%; p < .0001) as compared to CXR. CCT findings changed the management of 107 children (8.7%) with 32 (2.6%) of the changes being surgical procedures. The overall sensitivity and specificity of the CXR were 57.9% (95% CI: 54.5-61.2) and 90.2% (95% CI: 86.8-93.1), respectively. The positive predictive value and negative predictive value were 93.1% and 48.6%, respectively. CONCLUSION CXR is a useful initial screening tool to evaluate pediatric trauma patients along with clinical presentation in the Emergency Department in children. LEVEL OF EVIDENCE Level III, diagnostic test.
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Affiliation(s)
- Irma T Ugalde
- Department of Emergency Medicine, McGovern Medical School at UT Health Sciences Center, Houston, TX.
| | - Samuel Prater
- Department of Emergency Medicine, McGovern Medical School at UT Health Sciences Center, Houston, TX
| | - Marylou Cardenas-Turanzas
- School of Biomedical Informatics and McGovern Medical School at UT Health Sciences Center, Houston, TX
| | - Nipa Sanghani
- Department of Emergency Medicine, McGovern Medical School at UT Health Sciences Center, Houston, TX
| | - Donna Mendez
- Department of Emergency Medicine, McGovern Medical School at UT Health Sciences Center, Houston, TX
| | - John Peacock
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Grace Guvernator
- Department of Anesthesiology, McGovern Medical School at UT Health Sciences Center, Houston, TX
| | - Christine Koerner
- Department of Emergency Medicine, McGovern Medical School at UT Health Sciences Center, Houston, TX
| | - Myron Allukian
- Division of Pediatric, General, Thoracic, and Fetal Surgery and the Trauma Center at the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Shinn K, Gilyard S, Chahine A, Fan S, Risk B, Hanna T, Johnson JO, Hawkins CM, Xing M, Duszak R, Newsome J, Kokabi N. Contemporary Management of Pediatric Blunt Splenic Trauma: A National Trauma Databank Analysis. J Vasc Interv Radiol 2021; 32:692-702. [PMID: 33632588 DOI: 10.1016/j.jvir.2020.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/17/2020] [Accepted: 11/29/2020] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To quantify changes in the management of pediatric patients with isolated splenic injury from 2007 to 2015. MATERIALS AND METHODS Patients under 18 years old with registered splenic injury in the National Trauma Data Bank (2007-2015) were identified. Splenic injuries were categorized into 5 management types: nonoperative management (NOM), embolization, splenic repair, splenectomy, or a combination therapy. Linear mixed models accounting for confounding variables were used to examine the direct impact of management on length of stay (LOS), intensive care unit (ICU) days, and ventilator days. RESULTS Of included patients (n = 24,128), 90.3% (n = 21,789), 5.6% (n = 1,361), and 2.7% (n = 640) had NOM, splenectomy, and embolization, respectively. From 2007 to 2015, the rate of embolization increased from 1.5% to 3.5%, and the rate of splenectomy decreased from 6.9% to 4.4%. Combining injury grades, NOM was associated with the shortest LOS (5.1 days), ICU days (1.9 days), and ventilator days (0.5 day). Moreover, splenectomy was associated with longer LOS (10.1 days), ICU days (4.5 days), and ventilator days (2.1 days) than NOM. The average failure rate of NOM was 1.5% (180 failures/12,378 cases). Average embolization failure was 1.3% (6 failures/456 cases). Splenic artery embolization was associated with lower mortality than splenectomy (OR: 0.10, P <.001). No statistically significant difference was observed in mortality between embolization and NOM (OR: 0.96, P = 1.0). CONCLUSIONS In pediatric splenic injury, NOM is the most utilized and associated with favorable outcomes, most notably in grades III to V pediatric splenic injury. If intervention is needed, embolization is effective and increasingly utilized most significantly in lower grade injuries.
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Affiliation(s)
- Kaitlin Shinn
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Shenise Gilyard
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Amanda Chahine
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Sijian Fan
- Department of Biostatistics & Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Benjamin Risk
- Department of Biostatistics & Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Tarek Hanna
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Jamlik-Omari Johnson
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - C Matthew Hawkins
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Minzhi Xing
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Richard Duszak
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Janice Newsome
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Nima Kokabi
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia.
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Weber B, Lackner I, Braun CK, Kalbitz M, Huber-Lang M, Pressmar J. Laboratory Markers in the Management of Pediatric Polytrauma: Current Role and Areas of Future Research. Front Pediatr 2021; 9:622753. [PMID: 33816396 PMCID: PMC8010656 DOI: 10.3389/fped.2021.622753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 02/19/2021] [Indexed: 11/13/2022] Open
Abstract
Severe trauma is the most common cause of mortality in children and is associated with a high socioeconomic burden. The most frequently injured organs in children are the head and thorax, followed by the extremities and by abdominal injuries. The efficient and early assessment and management of these injuries is essential to improve patients' outcome. Physical examination as well as imaging techniques like ultrasound, X-ray and computer tomography are crucial for a valid early diagnosis. Furthermore, laboratory analyses constitute additional helpful tools for the detection and monitoring of pediatric injuries. Specific inflammatory markers correlate with post-traumatic complications, including the development of multiple organ failure. Other laboratory parameters, including lactate concentration, coagulation parameters and markers of organ injury, represent further clinical tools to identify trauma-induced disorders. In this review, we outline and evaluate specific biomarkers for inflammation, acid-base balance, blood coagulation and organ damage following pediatric polytrauma. The early use of relevant laboratory markers may assist decision making on imaging tools, thus contributing to minimize radiation-induced long-term consequences, while improving the outcome of children with multiple trauma.
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Affiliation(s)
- Birte Weber
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
| | - Ina Lackner
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
| | - Christian Karl Braun
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany.,Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Miriam Kalbitz
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
| | - Markus Huber-Lang
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany
| | - Jochen Pressmar
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
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Abstract
INTRODUCTION Given the concern for radiation-induced malignancy in children and the fact that risk of severe chest injury in children is low, the risk/benefit ratio must be considered in each child when ordering a computed tomography (CT) scan after blunt chest trauma. METHODS The study included pediatric blunt trauma patients (age, <15 years) with chest radiograph (CR) before chest CT on admission to our adult and pediatric level I trauma center. Surgeons were asked to view the blinded images and reads and indicate if they felt CT was warranted based on CR findings, if their clinical management change based on additional findings on chest CT, and how they might change management. RESULTS Of the 127 patients identified, 64.6% had no discrepancy between their initial CR and chest CT and 35.4% of the children's imaging contained a discrepancy. The majority of the pediatric and general trauma surgeons felt CT was indicated in 6 of 45 patients based on CR. In 87% of patients with a discrepancy in findings on CR and CT, the majority of surgeons agreed that their management would not change based on the additional information. In the 6 patients in which the CT was considered indicated, 4 of the 6 would have triggered a management change. CONCLUSIONS Our study suggests that chest CT scans frequently serve as confirmatory diagnostic tools and in the pediatric blunt chest trauma patient and can be withheld in many cases without hindering the management of an injured child.
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Kerr H, Bowen B, Light D. Thoracoabdominal Injuries. CONTEMPORARY PEDIATRIC AND ADOLESCENT SPORTS MEDICINE 2018. [PMCID: PMC7123492 DOI: 10.1007/978-3-319-56188-2_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Trauma to the thorax and abdomen can occur during participation in sports. This chapter reviews some of the more common presentations of such injuries and how such injuries should be best managed. Thoracic injuries reviewed include internal injuries such as pneumothorax, pulmonary contusion, hemothorax, commotio cordis, and cardiac contusion. Chest wall injuries are also reviewed such as rib fractures, costochondritis, and slipping rib syndrome plus sternal and scapular fractures. Abdominal injuries reviewed are focused on internal organ trauma to the spleen and liver, kidney, pancreas, and bowel. There is attention to the effect of Epstein-Barr virus and infectious mononucleosis, seen very frequently in high school and collegiate athletes. Finally, groin pain and athletic pubalgia are described. In addition to anatomy and clinical presentation, imaging modalities that characterize such trauma are reviewed for each diagnosis. Prevention of thoracoabdominal injuries and return-to-play decisions are described at the chapter conclusion.
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Braungart S, Beattie T, Midgley P, Powis M. Implications of a negative abdominal CT in the management of pediatric blunt abdominal trauma. J Pediatr Surg 2017; 52:293-298. [PMID: 27912976 DOI: 10.1016/j.jpedsurg.2016.11.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 11/08/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND No consensus exists on management of children with a negative trauma CT following blunt abdominal trauma (BAT). Asymptomatic children are frequently "admitted for observation" following negative CT owing to concerns about missing an intraabdominal injury (IAI) without evidence for this practice. We aimed to investigate the feasibility of discharge following a negative CT scan in children sustaining blunt abdominal trauma. METHODS Retrospective audit at a UK paediatric major trauma center and review of the literature. RESULTS 108 patients were included (median age 11y; 60% male). Commonest mechanisms of injury: road traffic collisions (61 patients; 56%) and falls from a height (37; 34%). 40 (37%) had a normal CT scan, of whom 6 (15%) were discharged from ED. The remaining 34 patients were admitted, of whom 14 (41%) were discharged within 24h. The other 20 children were admitted for other specialty input. None of the 108 children had a missed IAI or reattended with suspicion of IAI. The NPV for CT to detect IAI was 100% (95% CI: 96%-100%). The literature search identified 3 observational cohort studies and 2 patient groups contained in a systematic review (total of 9149 patients with normal CT abdomen after BAT). Only 9 (<0.1%) patients required operative intervention for missed IAI. The NPV for CT to detect IAI was 99.6%-99.8% (95% CI 99%-100%). CONCLUSION Our study and literature review demonstrate that asymptomatic children with a normal abdominal CT scan in the ED are very unlikely to have IAI and that the NPV of CT is very high (96%-100%). Direct discharge from the ED is possible for asymptomatic children with a negative CT following blunt abdominal trauma, as long as no other reasons for admission exist and should be accompanied by safety-net advice. LEVEL OF EVIDENCE STATEMENT This is a level II evidence study. In itself it is a retrospective study, with the literature review including one large, high-quality prospective cohort study, and further prospective cohort studies of ordinary quality.
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Affiliation(s)
- Sarah Braungart
- Department of Paediatric Surgery, Leeds Teaching Hospitals NHS Trust, UK; Child Life and Health, University of Edinburgh, UK
| | | | | | - Mark Powis
- Department of Paediatric Surgery, Leeds Teaching Hospitals NHS Trust, UK.
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11
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McNamara C, Mironova I, Lehman E, Olympia RP. Predictors of Intrathoracic Injury after Blunt Torso Trauma in Children Presenting to an Emergency Department as Trauma Activations. J Emerg Med 2016; 52:793-800. [PMID: 27998635 DOI: 10.1016/j.jemermed.2016.11.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 11/10/2016] [Accepted: 11/19/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Thoracic injuries are a major cause of death associated with blunt trauma in children. Screening for injury with chest x-ray study, compared with chest computed tomography (CT) scan, has been controversial, weighing the benefits of specificity with the detriment of radiation exposure. OBJECTIVE To identify predictors of thoracic injury in children presenting as trauma activations to a Level I trauma center after blunt torso trauma, and to compare these predictors with those previously reported in the literature. METHODS We performed a retrospective chart review of pediatric patients (<18 years of age) who presented to the Emergency Department of a Level I trauma center between June 2010 and June 2013 as a trauma activation after sustaining a blunt torso trauma and who received diagnostic imaging of the chest as part of their initial evaluation. RESULTS Data analysis was performed on 166 patients. There were 33 patients (20%) with 45 abnormalities detected on diagnostic imaging of the chest, with the most common abnormalities being lung contusion (36%), pneumothorax (22%), and rib fracture (13%). Statistically significant predictors of abnormal diagnostic imaging of the chest included Glasgow Coma Scale score (GCS) < 15 (27% with abnormality vs. 13% without abnormality), hypoxia (22% vs. 5%), syncope/loss of consciousness (55% vs. 35%), cervical spine tenderness (12% vs. 3%), thoraco-lumbar-sacral spine tenderness (41% vs. 17%), and abdominal/pelvic tenderness (12% vs. 3%). CONCLUSIONS Based on our data, predictors of thoracic injury in children after blunt torso trauma include GCS < 15, hypoxia, syncope/dizziness, cervical spine tenderness, thoraco-lumbar-sacral spine tenderness, and abdominal/pelvic tenderness.
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Affiliation(s)
| | | | - Erik Lehman
- Department of Public Health Sciences, Penn State University College of Medicine, Hershey, PA
| | - Robert P Olympia
- Department of Emergency Medicine, Penn State Hershey Medical Center, Hershey, PA
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12
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Limiting chest computed tomography in the evaluation of pediatric thoracic trauma. J Trauma Acute Care Surg 2016; 81:271-7. [DOI: 10.1097/ta.0000000000001110] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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de la Morandiere K. Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET: Is CT thorax necessary to exclude significant injury in paediatric patients with blunt chest trauma? Emerg Med J 2016. [PMID: 26195475 DOI: 10.1136/emermed-2015-205158.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
A shortcut review was carried out to establish if CXR had sufficient sensitivity to rule out significant thoracic injury in haemodynamically stable, paediatric patients with a significant mechanism of trauma. No studies were found that directly answered the three-part question, but 13 studies were found which were considered relevant. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that important thoracic injuries may not be clinically apparent and that CT scans have a significantly higher sensitivity than CXR in detecting such injuries.
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Abstract
Purpose of review In the last decade, video-assisted thoracoscopic surgery (VATS) has become a popular method in diagnosis and treatment of acute chest injuries. Except for patients with unstable vital signs who require larger surgical incisions to check bleeding, this endoscopic surgery could be employed in the majority of thoracic injury patients with stable vital signs. Recent findings In the past, VATS was used to evacuate traumatic-retained hemothorax. Recent study has revealed further that lung repair during VATS could decrease complications after trauma. Management of fractured ribs could also be assisted by VATS. Early VATS intervention within 7 days after injury can decrease the rate of posttraumatic infection and length of hospital stay. In studies of the pathophysiology of animal models, N-acetylcysteine and methylene blue were used in animals with blunt chest trauma and found to improve clinical outcomes. Summary Retained hemothorax derived from blunt chest trauma should be managed carefully and rapidly. Early VATS intervention is a well tolerated and reliable procedure that can be applied to manage this complication cost effectively.
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15
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The use of an institutional pediatric abdominal trauma protocol improves resource use. J Trauma Acute Care Surg 2016; 80:57-63. [DOI: 10.1097/ta.0000000000000712] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Zundel S, Szavay P. Konservative vs. chirurgische Therapie des Bauchtraumas. Monatsschr Kinderheilkd 2015. [DOI: 10.1007/s00112-015-3472-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Marin JR, Wang L, Winger DG, Mannix RC. Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits. J Pediatr 2015; 167:897-904.e3. [PMID: 26233603 PMCID: PMC4881390 DOI: 10.1016/j.jpeds.2015.06.052] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 05/21/2015] [Accepted: 06/25/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess variation in the use of computed tomography (CT) for pediatric injury-related emergency department (ED) visits. STUDY DESIGN This was a retrospective cohort study of visits to 14 network-affiliated EDs from November 2010 through February 2013. Visits were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Primary outcome was CT use. We used descriptive statistics and performed multivariable logistic regression to evaluate the association of patient and ED covariates on any and body region-specific CT use. RESULTS Of the 80 868 injury-related visits, 11.4% included CT, and 28.4% of those involved more than 1 CT. Across EDs, CT use ranged from 7.6% to 25.5% of visits and did not correlate with institutional Injury Severity Score (P = .33) or admission/transfer rates (P = .07). In multivariable analysis of nonpediatric EDs, trauma centers and nonacademic EDs were associated with CT use. Higher pediatric volume was associated with any CT use; however, there was an inverse relationship between volume and nonhead CT use. When the pediatric ED was included in multivariable modeling, the effect of level 1-3 trauma center designation remained, and the pediatric level 1 trauma center was less likely to use most body region-specific CTs. CONCLUSION There is wide variation in CT imaging for pediatric injury-related visits not attributable solely to case mix. Future work to optimize CT utilization should focus on additional factors contributing to imaging practices and interventions.
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Affiliation(s)
- Jennifer R Marin
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Li Wang
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Daniel G Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Rebekah C Mannix
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
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18
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Hershkovitz Y, Naveh S, Kessel B, Shapira Z, Halevy A, Jeroukhimov I. Elevated white blood cell count, decreased hematocrit and presence of macrohematuria correlate with abdominal organ injury in pediatric blunt trauma patients: a retrospective study. World J Emerg Surg 2015; 10:41. [PMID: 26379763 PMCID: PMC4570506 DOI: 10.1186/s13017-015-0034-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 08/19/2015] [Indexed: 11/21/2022] Open
Abstract
Introduction Computerized tomography (CT) has become an important diagnostic modality in trauma patients. Pediatric patients are particularly susceptible to ionized radiation making liberal CT use in this age group unacceptable. We aimed to identify parameters that might predict abnormal findings on abdominal CT leading to patient management changes. Methods Data on blunt trauma patients up to 15 years of age admitted to Assaf Harofeh Medical Center from January 2007 to October 2014 was retrospectively collected. All patients with abdominal CT scan as part of initial assessment were included. Medical and surgical data were extracted from the medial charts. Patients were divided into two groups. Group I: patients whose management was changed solely based on abdominal CT findings and Group II: patients with normal abdominal CT. The groups were compared by all the data parameters. Results Overall, 182 patients were included in the study. The groups were comparable by age and mechanism of injury. Management changes based on CT findings were found in 68 (37.4 %) patients. White blood cell count >14000, abnormally low hematocrit level and macrohematuria were associated with a diagnosis of intra-abdominal injury requiring patient management changes (p < 0.05). Group I patients had longer LOS. Fifteen patients (22 %) required active intervention based solely on CT findings. Physical examination, arterial blood gases and initial radiology examinations results did not correlate with abdominal CT findings. Conclusions Elevated WBC, decreased hematocrit and presence of macrohematuria strongly correlate with abdominal CT findings and lead to changes in patient management.
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Affiliation(s)
- Yehuda Hershkovitz
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin 70300, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sergei Naveh
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin 70300, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boris Kessel
- Trauma Unit, Hillel Yaffe Medical Center, Hadera, 38100 Israel
| | - Zahar Shapira
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin 70300, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ariel Halevy
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin 70300, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Igor Jeroukhimov
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin 70300, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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19
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Ham PB, Poorak M, King RG, Mentzer CJ, Walters KC, Pipkin WL, Hatley RM. Occult Injury in the Context of Selective Use of Computed Tomography (CT) in Pediatric Thoracic Trauma. Am Surg 2015. [DOI: 10.1177/000313481508100909] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- P. Benson Ham
- Department of Surgery Children's Hospital of Georgia, Medical College of Georgia Georgia Regents University Augusta, Georgia
| | - Mitra Poorak
- Department of Surgery Children's Hospital of Georgia, Medical College of Georgia Georgia Regents University Augusta, Georgia
| | - Ray G. King
- Department of Surgery Children's Hospital of Georgia, Medical College of Georgia Georgia Regents University Augusta, Georgia
| | - Caleb J. Mentzer
- Department of Surgery Children's Hospital of Georgia, Medical College of Georgia Georgia Regents University Augusta, Georgia
| | - K. Christian Walters
- Department of Surgery Children's Hospital of Georgia, Medical College of Georgia Georgia Regents University Augusta, Georgia
| | - Walter L. Pipkin
- Department of Surgery Children's Hospital of Georgia, Medical College of Georgia Georgia Regents University Augusta, Georgia
| | - Robyn M. Hatley
- Department of Surgery Children's Hospital of Georgia, Medical College of Georgia Georgia Regents University Augusta, Georgia
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20
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Trends in CT Utilization for Pediatric Fall Patients in US Emergency Departments. Acad Radiol 2015; 22:898-903. [PMID: 25957501 DOI: 10.1016/j.acra.2015.02.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 01/27/2015] [Accepted: 02/18/2015] [Indexed: 11/22/2022]
Abstract
RATIONALE AND OBJECTIVES Falls are a common cause of emergency department (ED) visits in the United States. We evaluated trends in computed tomography (CT) utilization for pediatric fall victims in the United States from 2001 to 2010. MATERIALS AND METHODS Using the National Hospital Ambulatory Medical Care Survey from 2001 to 2010, we identified all visits of pediatric (aged <18 years) patients presenting to EDs after falls. This database surveys approximately 500 EDs per year for 4 weeks providing national estimates on ED resource utilization and outcomes. We studied trends in CT utilization and proportion of visits with life-threatening conditions after falls. We also studied the association between CT utilization rates and demographic characteristics and admission status. RESULTS A total of 9763 unweighted observations for a total of 32,432,686 pediatric fall patients were seen in US EDs from 2001 to 2010. The proportion of pediatric fall patients receiving CT increased from 5.3% in 2001 to a peak of 16.6% in 2009 and decreased to 11.3% in 2010, whereas the proportion of pediatric fall patients with life-threatening conditions fluctuated between 1.2% and 3.3% during this period. In multivariate logistic regression analysis, each increasing year was independently associated with CT utilization (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.14-1.16). Patients aged 0-1 years had higher odds of CT utilization than patients aged 13-17 years (OR, 2.27; 95% CI, 2.26-2.27). CONCLUSIONS There was a twofold increase in CT utilization among pediatric fall visits from 2001 to 2010. When controlling for demographic and clinical variables, increasing year was independently associated with CT utilization. These findings suggest that CT may be overutilized among pediatric fall patients.
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