Pediatric Traumatic Injury Emergency Department Visits and Management in US Children's Hospitals From 2010 to 2019

Utility of brain imaging in pediatric patients with a suspected accidental spinal injury but no brain injury-related symptoms

PURPOSE

Imaging is the gold standard in diagnosing traumatic brain injury, but unnecessary scans should be avoided, especially in children and adolescents. Clinical decision-making rules often help to distinguish the patients who need imaging, but if spinal trauma is suspected, concomitant brain imaging is often conducted. Whether the co-occurrence of brain and spine injuries is high enough to justify head imaging in patients without symptoms suggesting brain injury is unknown.

OBJECTIVE

This study aims to assess the diagnostic yield of brain MRI in pediatric patients with suspected or confirmed accidental spinal trauma but no potential brain injury symptoms.

METHODS

We retrospectively reviewed the medical and imaging data of pediatric patients (under 18 years old) who have undergone concomitant MRI of the brain and spine because of acute spinal trauma in our emergency radiology department over a period of 8 years. We compared the brain MRI findings in patients with and without symptoms suggesting brain injury and contrasted spine and brain MRI findings.

RESULTS

Of 179 patients (mean age 11.7 years, range 0-17), 137 had symptoms or clinical findings suggesting brain injury, and 42 did not. None of the patients without potential brain injury symptoms had traumatic findings in brain MRI. This finding also applied to patients with high-energy trauma (n = 47) and was unrelated to spinal MRI findings.

CONCLUSION

Pediatric accidental trauma patients with suspected or confirmed spine trauma but no symptoms or clinical findings suggesting brain injury seem not to benefit from brain imaging.

Triage tools for detecting cervical spine injury in paediatric trauma patients

BACKGROUND

Paediatric cervical spine injury (CSI) after blunt trauma is rare but can have severe consequences. Clinical decision rules (CDRs) have been developed to guide clinical decision-making, minimise unnecessary tests and associated risks, whilst detecting all significant CSIs. Several validated CDRs are used to guide imaging decision-making in adults following blunt trauma and clinical criteria have been proposed as possible paediatric-specific CDRs. Little information is known about their accuracy.

OBJECTIVES

To assess and compare the diagnostic accuracy of CDRs or sets of clinical criteria, alone or in comparison with each other, for the evaluation of CSI following blunt trauma in children.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, and six other databases from 1 January 2015 to 13 December 2022. As we expanded the index test eligibility for this review update, we searched the excluded studies from the previous version of the review for eligibility. We contacted field experts to identify ongoing studies and studies potentially missed by the search. There were no language restrictions.

SELECTION CRITERIA

We included cross-sectional or cohort designs (retrospective and prospective) and randomised controlled trials that compared the diagnostic accuracy of any CDR or clinical criteria compared with a reference standard for the evaluation of paediatric CSI following blunt trauma. We included studies evaluating one CDR or comparing two or more CDRs (directly and indirectly). We considered X-ray, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and clinical clearance/follow-up as adequate reference standards.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance, and carried out eligibility, data extraction and quality assessment. A third review author arbitrated. We extracted data on study design, participant characteristics, inclusion/exclusion criteria, index test, target condition, reference standard and data (diagnostic two-by-two tables) and calculated and plotted sensitivity and specificity on forest plots for visual examination of variation in test accuracy. We assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies Version 2 tool. We graded the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included five studies with 21,379 enrolled participants, published between 2001 and 2021. Prevalence of CSI ranged from 0.5% to 1.85%. Seven CDRs were evaluated. Three studies reported on direct comparisons of CDRs. One study (973 participants) directly compared the accuracy of three index tests with the sensitivities of NEXUS, Canadian C-Spine Rule and the PECARN retrospective criteria being 1.00 (95% confidence interval (CI) 0.48 to 1.00), 1.00 (95% CI 0.48 to 1.00) and 1.00 (95% CI 0.48 to 1.00), respectively. The specificities were 0.56 (95% CI 0.53 to 0.59), 0.52 (95% CI 0.49 to 0.55) and 0.32 (95% CI 0.29 to 0.35), respectively (moderate-certainty evidence). One study (4091 participants) compared the accuracy of the PECARN retrospective criteria with the Leonard de novo model; the sensitivities were 0.91 (95% CI 0.81 to 0.96) and 0.92 (95% CI 0.83 to 0.97), respectively. The specificities were 0.46 (95% CI 0.44 to 0.47) and 0.50 (95% CI 0.49 to 0.52) (moderate- and low-certainty evidence, respectively). One study (270 participants) compared the accuracy of two NICE (National Institute for Health and Care Excellence) head injury guidelines; the sensitivity of the CG56 guideline was 1.00 (95% CI 0.48 to 1.00) compared to 1.00 (95% CI 0.48 to 1.00) with the CG176 guideline. The specificities were 0.46 (95% CI 0.40 to 0.52) and 0.07 (95% CI 0.04 to 0.11), respectively (very low-certainty evidence). Two additional studies were indirect comparison studies. One study (3065 participants) tested the accuracy of the NEXUS criteria; the sensitivity was 1.00 (95% CI 0.88 to 1.00) and specificity was 0.20 (95% CI 0.18 to 0.21) (low-certainty evidence). One retrospective study (12,537 participants) evaluated the PEDSPINE criteria and found a sensitivity of 0.93 (95% CI 0.78 to 0.99) and specificity of 0.70 (95% CI 0.69 to 0.72) (very low-certainty evidence). We did not pool data within the broader CDR categories or investigate heterogeneity due to the small quantity of data and the clinical heterogeneity of studies. Two studies were at high risk of bias. We identified two studies that are awaiting classification pending further information and two ongoing studies.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.

A randomized double-blind trial of intranasal dexmedetomidine versus intranasal esketamine for procedural sedation and analgesia in young children

BACKGROUND

Procedural sedation and analgesia are commonly used in the Emergency Departments. Despite this common need, there is still a lack of options for adequate and safe analgesia and sedation in children. The objective of this study was to evaluate whether intranasal dexmedetomidine could provide more effective analgesia and sedation during a procedure than intranasal esketamine.

METHODS

This was a double-blind equally randomized (1:1) superiority trial of 30 children aged 1-3 years presenting to the Emergency Department with a laceration or a burn and requiring procedural sedation and analgesia. Patients were randomized to receive 2.0 mcg/kg intranasal dexmedetomidine or 1.0 mg/kg intranasal esketamine. The primary outcome measure was highest pain (assessed using Face, Legs, Activity, Cry, Consolability scale (FLACC)) during the procedure. Secondary outcomes were sedation depth, parents' satisfaction, and physician's assessment. Comparisons were done using Mann-Whitney U test (continuous variables) and Fisher's test (categorical variables).

RESULTS

Adequate analgesia and sedation were reached in 28/30 patients. The estimated sample size was not reached due to changes in treatment of minor injuries and logistical reasons. The median (IQR) of highest FLACC was 1 (0-3) with intranasal dexmedetomidine and 5 (2-6.75) with intranasal esketamine, (p-value 0.09). 85.7% of the parents with children treated with intranasal dexmedetomidine were "very satisfied" with the procedure and sedation compared to the 46.2% of those with intranasal esketamine, (p-value 0.1). No severe adverse events were reported during this trial.

CONCLUSIONS

This study was underpowered and did not show any difference between intranasal dexmedetomidine and intranasal esketamine for procedural sedation and analgesia in young children. However, the results support that intranasal dexmedetomidine could provide effective analgesia and sedation during procedures in young children aged 1-3 years with minor injuries.

TRIAL REGISTRATION

Eudra-CT 2017-00057-40, April 20, 2017. https://eudract.ema.europa.eu/.

ECMO in trauma care: What you need to know

ABSTRACT

Over the past 10 years, extracorporeal membrane oxygenation (ECMO) use in trauma patients has increased significantly. This includes adult and pediatric trauma patients and even combat casualties. Most ECMO applications are in a venovenous (VV ECMO) configuration for acute hypoxemic respiratory failure or anatomic injuries that require pneumonectomy or extreme lung rest in a patient with insufficient respiratory reserve. In this narrative review, we summarize the most common indications for VV ECMO and other forms of ECMO support used in critically injured patients, underscore the importance of early ECMO consultation or regional referral, review the technical aspects of ECMO cannulation and management, and examine the expected outcomes for these patients. In addition, we evaluate the data where it exists to try to debunk some common myths surrounding ECMO management.

Children's injury database: development of an injury surveillance system in a pediatric emergency department

BACKGROUND

Injuries are the leading cause of death in children and are also a leading cause of all emergency department (ED) visits for children. Obtaining epidemiologic data to define the wide range of childhood injuries for individual communities is challenging. The Children's Injury Database (CID) is an injury surveillance system developed to collect data from injury-related visits to our tertiary care pediatric emergency department.

RESULTS

During 2021, a total of 15,168 injury visits were analyzed representing 22% of total ED visits (68,834). A total of 2053 injury visits (13.5%) resulted in hospital admission. The 10 leading injury types included: falls, poisonings, motor vehicle collision (MVC), assault, dog bite, burns, sports, pedestrian, bicycle, and all-terrain vehicle (ATV). Admission rates varied by age group with children ages 13 years and older having the highest rate of admission (18.4%). The median length of stay (LOS) for all injured children requiring admission was 2 days while the median LOS for preschoolers was 1 day, the median LOS for school-age children was 2 days, and the median LOS for teenagers was 3 days. While MVCs were the most common cause of vehicle-related injuries, ATV-related injuries had the highest rate of admission (51%).

CONCLUSIONS

In this study, teenagers had significantly higher admission rates, lengths of stay, and hospital charges. Black and Hispanic children were under-represented in the number of visits for injuries compared to all ED visits. Further research should focus on disparities in injury-related visits based on race as well as gender. CID has demonstrated that injury surveillance systems can assist with reporting new injury patterns while also acting as a stimulus for new research ideas, planning interventions targeting the most at-risk populations, and evaluating the effectiveness of injury prevention interventions.

Functional status of pediatric patients with trauma and risk factors for mortality from a single center in China

Introduction

The influence of reduced functional status has become increasingly relevant because of the gradual decline in mortality rate over the recent years. Nonetheless, only a few studies investigating the functional status of patients with trauma at hospital discharge have been conducted. This study aimed to identify the risk factors influencing the mortality rate in pediatric trauma survivors at a pediatric intensive care unit and analyze their functional status using the Functional Status Scale (FSS).

Methods

A retrospective analysis was conducted at Shengjing Hospital of China Medical University. Children admitted to the pediatric intensive care unit between January 2015 and January 2020 who met the trauma diagnostic criteria were included. The FSS score and the Injury Severity Score (ISS) were recorded upon admission and discharge, respectively. Clinical data were compared between the survival and non-survival groups to identify the risk factors for poor prognosis. The risk factors for mortality were identified using multivariate and univariate analyses.

Results

A total of 246 children {59.8%, male; median [interquartile range (IQR)] age: 3 [1-7] years} were diagnosed with trauma (including head trauma, chest trauma, abdominal trauma, and extremity trauma). Of these patients, 207 were discharged, 11 dropped out mid-treatment, and 39 died (hospital mortality rate, 15.9%). Upon admission, the median FSS and trauma scores were 14 (IQR, 11-18) and 22 (IQR, 14-33) points, respectively. At discharge, the FSS score was 8 (IQR, 6-10) points. The patient clinical status improved with a ΔFSS score of -4 (IQR, -7, 0) points. At hospital discharge, 119 (48.3%), 47 (19.1%), 27 (11.0%), 12 (4.8%), and 2 (0.9%) survivors had good, mildly abnormal, moderately abnormal, severely abnormal, and very severely abnormal function, respectively. Reduced functional status in patients was categorized as follows: motor, 46.4%; feeding, 26.1%; sensory, 23.2%; mental, 18.4%; and communication, 17.9%. In the univariate analysis, ISS >25 points, shock, respiratory failure, and coma were independently associated with the mortality rate. Multivariate analysis revealed that the ISS was an independent risk factor for mortality.

Conclusion

The mortality rate of patients with trauma was high. ISS was an independent risk factor for mortality. Mildly reduced functional status remained at discharge and was reported in nearly half of the discharged patients. Motor and feeding functions were the most severely impacted domains.