Golden Hour or Golden Opportunity: Early Management of Pediatric Trauma

Mobile injury prevention programs for children: a scoping review protocol

OBJECTIVE

The objective of this review is to examine mobile injury prevention programs for children and their families.

INTRODUCTION

Unintentional injuries are the leading cause of death worldwide for children aged one to 18years. Providing injury prevention education to children and their families is a necessary and critical element in health promotion.

INCLUSION CRITERIA

This review will consider studies that include children from birth to 18years of age and their parents or guardians. The concept of this review is mobile or traveling injury prevention education programs for the specified population. Studies conducted in any geographic location or setting that report on how these programs are being utilized, who is providing the education, where education is being provided, who is funding the education, and outcome measures reported with mobile injury prevention programs will be included in the review.

METHODS

This review will follow JBI's guidance for scoping reviews. The key databases to be searched include MEDLINE (PubMed), CINAHL (EBSCO), the Cochrane Library (Wiley), ERIC (EBSCO), Web of Science (Clarivate), and Embase (Elsevier). The search for unpublished studies will consist of OpenGrey ( www.opengrey.eu ) and ProQuest Dissertations and Theses Sciences and Engineering Collection (ProQuest). Studies conducted in English, in any year, will be included. Two independent reviewers will perform title and abstract screening, retrieval and review of full-text studies, and data extraction. The results will be presented in diagrammatic or tabular form that aligns with a narrative summary.

Association of Risk of Mortality in Pediatric Patients Transferred From Scene by Helicopter With Major But Not Minor Injuries

OBJECTIVES

Helicopter emergency medical services (HEMS) are used for 16% of pediatric trauma. National HEMS guidelines advised that triage criteria be standardized for pediatric patients. A national report found pediatric HEMS associated with decreased mortality compared with ground emergency medical services (GEMS) but did not control for transport time. We hypothesized that the rate of HEMS has decreased nationally and the mortality risk for HEMS to be similar when adjusting for transport time compared with GEMS.

METHODS

The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients younger than 16 years transported by HEMS or GEMS. A multivariable logistic regression was used.

RESULTS

From 25,647 patients, 4527 (17.7%) underwent HEMS. The rate of HEMS from scene decreased from 21.2% in 2014 to 18.2% in 2016. The rate of HEMS for minor trauma (Injury Severity Score <15) decreased from 14.9% in 2014 to 13.5% in 2016 and major trauma (Injury Severity Score > 15) from 38.4% in 2014 to 35.9% in 2016. After controlling for predictors of mortality and transport time, HEMS was associated with decreased risk of mortality for only those with major injuries transferred from scene (odds ratio, 0.48; 95% confidence interval, 0.26-0.88; P = 0.01) compared with GEMS.

CONCLUSIONS

The rate of HEMS in pediatric trauma has decreased. However, there is room for improvement as 14% of those with minor trauma are transported by HEMS. Given the similar risk of mortality compared with GEMS, further development of guidelines that avoid the unnecessary use of HEMS appears warranted. However, utilization of HEMS for transport of pediatric major trauma should continue.

Paediatric trauma: experience from the UK's busiest trauma centre

Paediatric major trauma is relatively uncommon (6% of all traumas) and therefore unfamiliar to many radiologists. The indications for and interpretation of imaging are different to those commonly encountered in adults. In a centre that rarely encounters paediatric trauma, there can be trepidation over the best way to image children due to concerns regarding radiation and the injury patterns that occur at various ages. Within paediatric trauma, as per the Royal College of Radiologists "paediatric trauma protocols" guidelines and National Institute for Health and Care Excellence (NICE) guidance, the main reliance is on computed tomography (CT) and plain radiographs. This review of paediatric trauma from a busy UK major trauma centre demonstrates the most appropriate use of different imaging techniques, the extent of imaging, and the types of injuries that occur in a selection of paediatric trauma patients with a variety of trauma mechanisms. Cases include trauma related to road traffic accidents, bicycle handlebar injuries, falls, and even stabbings. Important learning points highlighted include the use of targeted body part imaging in children, the significance of handlebar injuries, and the importance of assessing for underlying injury in paediatric rib fractures and abdominal bruising and tenderness. We hope these examples will help to support and guide radiologists when encountering paediatric trauma within their own centres.

A faster approach to ECG analysis in emergency situations

Every day, a substantial number of people need to be treated in emergencies and these situations imply a short timeline. Especially concerning heart abnormalities, the time factor is very important. Therefore, we propose a full-stack system for faster and cheaper ECG taking aimed at paramedics, to enhance Emergency Medical Service (EMS) response time. To stick with the golden hour rule, and reduce the cost of the current devices, the system is capable of enabling the detection and annotation of anomalies during ECG acquisition. Our system combines Machine Learning and traditional Signal Processing techniques to analyze ECG tracks to use it in a glove-like wearable. Finally, a graphical interface offers a dynamic view of the whole procedure.

Association Between Prearrival Notification Time and Advanced Trauma Life Support Protocol Adherence

BACKGROUND

Prearrival notification of injured patients facilitates preparation of personnel, equipment, and other resources needed for trauma evaluation and treatment. Our purpose was to determine the impact of prearrival notification time on adherence to Advanced Trauma Life Support (ATLS) protocols.

MATERIALS AND METHODS

Pediatric trauma activations of admitted patients were analyzed by video review to determine activities performed before and after patient arrival. Using an expert model based on ATLS, fitness scores were calculated that represented model adherence, ranging from "0" (noncompliant) to "100" (completely compliant). Multivariate regression was used to determine the association between fitness values of the evaluation phases and the length of prearrival notification time and injury profiles.

RESULTS

Ninety-four patients met study criteria. The average overall fitness was 89.0 ± 7.3, with similar fitness values being observed for the primary and secondary surveys (91.5 ± 13.4 and 88.6 ± 7.7, respectively). Prearrival notification time ranged from 67.3 min before to 4.8 min after patient arrival. Longer prearrival notification time was associated with improved completion of prearrival tasks, overall resuscitation performance, and secondary survey performance. The positive association of overall and secondary survey fitness with notification time was no longer observed when notification time was <5 min and <10 min, respectively. Notification time was correlated with a higher percentage of required team members when the patient arrived (Pearson correlation coefficient 0.46, P < 0.001).

CONCLUSIONS

Prearrival notification time has a significant impact on adherence to ATLS protocol. Strategies for improving notification time or improving performance when adequate notification cannot be achieved are needed.

Determining the Education and Research Priorities in Pediatric Trauma Nursing: A Delphi Study

Trauma has a greater impact on morbidity and mortality than all other disease processes in the pediatric population; yet, there is a gap in the literature related to the scientific basis for educating and researching future practice. The purpose of this research study was to utilize the Delphi technique to identify the current education and research priorities for pediatric trauma nursing as described by the members of the Society of Trauma Nurses. Consensus on the education and research priorities was derived from a sample (n = 25) of trauma nursing experts. The pediatric trauma nursing education priorities are the following: (1) initial resuscitation; (2) assessment; and (3) evidence-based practice. The pediatric trauma nursing research priorities are the following: (1) impact of nursing care on outcomes; (2) initial resuscitation; and (3) critical care. Future efforts in educational program development and research study should focus on these priorities.

Direct Air Versus Ground Transport Predictors for Rural Pediatric Trauma

OBJECTIVE

Traumatic injury is the leading cause of mortality in children and the most common cause of emergency medical services transport in pediatric populations. We aimed to identify what factors are currently associated with selection for helicopter transport (HEMS) over ground ambulance (GEMS) in a primarily rural state.

METHODS

We performed a retrospective case-control study of trauma patients younger than 18 years old reported to the Oklahoma State Trauma Registry between 2005 and 2014 who received direct transport from the scene of injury to a tertiary trauma center within the state. Factors associated with HEMS transport over GEMS were identified by multivariate regression analysis.

RESULTS

Of the 1,700 patients in the study group, 50.8% were transported by HEMS. Increased distance (odds ratio [OR] = 6.1-18.6), lower Glasgow Coma Scale (OR = 2.5), multisystem injury (OR = 1.5), intubation (OR = 2.7), motor vehicle collision-related injuries (OR = 2.1), and elevated heart rate (OR = 1.8) were all associated with increased odds of HEMS transport, with distance being the strongest factor.

CONCLUSION

This study found that the principal determinants of triage to HEMS transport in the case of pediatric trauma in a rural state were primarily distance to a major trauma center and clinical factors relating to the type and severity of injury.

Expert Perspectives on Time Sensitivity and a Related Metric for Children Involved in Motor Vehicle Crashes

OBJECTIVE

Advanced Automatic Crash Notification (AACN) uses vehicle telemetry data to predict risk of serious injury among motor vehicle crash occupants and can thus improve the accuracy with which injured children are triaged by first responders. To better define serious injury for AACN systems (which typically use Abbreviated Injury Scale [AIS] metrics), an age-specific approach evaluating severity, time sensitivity (TS), and predictability of injury has been developed. This study outlines the development of the TS score.

METHODS

The 95% most frequent AIS 2+ injuries in a national motor vehicle crash data set spanning 2000 to 2011 were determined for the following age groups: 0 to 4, 5 to 9, 10 to 14, and 15 to 18 years. For each age-specific injury, clinicians with pediatric trauma expertise were asked if treatment at a trauma center was required and were asked about the urgency of treatment. A TS score (range 0-1) was calculated by combining the mean trauma center decision and urgency scores.

RESULTS

A total of 30 to 32 responses were obtained for each age-specific injury. The most frequent motor vehicle crash-induced injuries in the younger groups received significantly higher scores than those in the older groups (median TS score 0 to 4 years: 0.89, 5-9 years: 0.87, 10-14 years: 0.82, 15-18 years: 0.72, P < .001). Large variations in TS existed within each AIS severity level; for example, scores among AIS 2 injuries in 0- to 4-year-olds ranged from 0.12 to 0.98.

CONCLUSIONS

The TS of common pediatric injuries varies on the basis of age and may not be accurately reflected by AIS metrics. AIS may not capture all aspects of injury that should be considered by AACN systems.

Paediatric trauma systems and their impact on the health outcomes of severely injured children: protocol for a mixed methods cohort study

BACKGROUND

Injury is a leading cause of death and disability for children. Regionalised trauma systems have improved outcomes for severely injured adults, however the impact of adult orientated trauma systems on the outcomes of severely injured children remains unclear. The objective of this study is to review the processes of care and describe the impacts of a regionalised trauma system on the outcomes of severely injured children.

METHODS

This article describes the design of a mixed methods cohort study evaluating the paediatric trauma system in New South Wales (NSW), the most populous state in Australia. Recommendations and an implementation strategy will be developed for aspects of the paediatric trauma care system that require change. All injured children (aged <16 years) requiring intensive care, or with an Injury Severity Score (ISS) ≥ 9 treated in NSW, or who died following injury in NSW in the 2015-16 financial year, will be eligible for participation. Injury treatment and processes will be examined via retrospective medical record review. Quality of care will be measured via peer review and staff interviews, utilising a human factors framework. Health service and cost outcomes will be calculated using activity based funding data provided by the Ministry of Health. Health-related quality of life (HRQoL) proxy measures will occur at baseline, 6 and 12 months to measure child HRQoL and functional outcomes.

DISCUSSION

This will be the first comprehensive analysis undertaken in Australia of the processes and systems of care for severe paediatric injury. The collaborative research method will encourage clinician, consumer and clinical networks to lead the clinical reform process and will ultimately enable policy makers and service providers to ensure that children seriously injured in Australia have the best opportunity for survival, improved functional outcome and long-term quality of life.

Paediatric trauma systems and their impact on the health outcomes of severely injured children: An integrative review

BACKGROUND

Injury is a leading cause of death and disability for children. Regionalised trauma systems have improved outcomes for severely injured adults, however the impact of adult orientated trauma systems on the outcomes of severely injured children remains unclear.

AIMS

This research aims to identify the impact of trauma systems on the health outcomes of children following severe injury.

METHODS

Integrative review with data sourced from Medline, Embase, CINAHL, Scopus and hand searched references. Abstracts were screened for inclusion/exclusion criteria with fifty nine articles appraised for quality, analysed and synthesised into 3 main categories.

RESULTS

The key findings from this review include: (1) a lack of consistency of prehospital and inhospital triage criteria for severely injured children leading to missed injuries, secondary transfer and poor utilisation of finite resources; (2) severely injured children treated at paediatric trauma centres had improved outcomes when compared to those treated at adult trauma centres, particularly younger children; (3) major causes of delays to secondary transfer are unnecessary imaging and failure to recognise the need for transfer; (4) a lack of functional or long term outcomes measurements identified in the literature.

CONCLUSIONS

Research designed to identify the best processes of care and describe the impacts of trauma systems on the long term health outcomes of severely injured children is required. Ideally all phases of care including prehospital, paediatric triage trauma criteria, hospital type and interfacility transfer should be included, focusing on timeliness and appropriateness of care. Outcome measures should include long term functional outcomes in addition to mortality.