The art and science of pediatric damage control

Clinical Practice Guideline Recommendations For Pediatric Multisystem Trauma Care: A Systematic Review

OBJECTIVE

To systematically review clinical practice guidelines (CPGs) for pediatric multisystem trauma, appraise their quality, synthesize the strength of recommendations and quality of evidence, and identify knowledge gaps.

BACKGROUND

Traumatic injuries are the leading cause of death and disability in children, who require a specific approach to injury care. Difficulties integrating CPG recommendations may cause observed practice and outcome variation in pediatric trauma care.

METHODS

We conducted a systematic review using Medline, Embase, Cochrane Library, Web of Science, ClinicalTrials, and grey literature, from January 2007 to November 2022. We included CPGs targeting pediatric multisystem trauma with recommendations on any acute care diagnostic or therapeutic interventions. Pairs of reviewers independently screened articles, extracted data, and evaluated the quality of CPGs using "Appraisal of Guidelines, Research, and Evaluation II."

RESULTS

We reviewed 19 CPGs, and 11 were considered high quality. Lack of stakeholder engagement and implementation strategies were weaknesses in guideline development. We extracted 64 recommendations: 6 (9%) on trauma readiness and patient transfer, 24 (38%) on resuscitation, 22 (34%) on diagnostic imaging, 3 (5%) on pain management, 6 (9%) on ongoing inpatient care, and 3 (5%) on patient and family support. Forty-two (66%) recommendations were strong or moderate, but only 5 (8%) were based on high-quality evidence. We did not identify recommendations on trauma survey assessment, spinal motion restriction, inpatient rehabilitation, mental health management, or discharge planning.

CONCLUSIONS

We identified 5 recommendations for pediatric multisystem trauma with high-quality evidence. Organizations could improve CPGs by engaging all relevant stakeholders and considering barriers to implementation. There is a need for robust pediatric trauma research, to support recommendations.

Balanced resuscitation: application to the paediatric trauma population

PURPOSE OF REVIEW

Trauma is the leading cause of death in children over 5 years old. Early mortality is associated with trauma-induced coagulopathy (TIC), with balanced resuscitation potentially mitigating the effects of TIC. We review TIC, balanced resuscitation and the best evidence for crystalloid fluid versus early blood products, massive transfusion protocol (MTP) and the optimal ratio for blood products.

RECENT FINDINGS

Crystalloid fluids have been associated with adverse events in paediatric trauma patients. However, the best way to implement early blood products remains unclear; MTP has only shown improved time to blood products without clear clinical improvement. The indications to start blood products are also currently under investigation with several scoring systems and clinical indications being studied. Current studies on the blood product ratio suggest a 1 : 1 ratio for plasma:pRBC is likely ideal, but prospective studies are needed to further support its use.

SUMMARY

Balanced resuscitation strategies of minimal crystalloid use and early administration of blood products are associated with improved morbidity in paediatric trauma patients but unclear mortality benefit. Current evidence suggests that the utilization of MTPs with 1 : 1 plasma:pRBC ratio may improve morbidity, but more research is needed.

Thrombelastography and transfusion patterns in severely injured pediatric trauma patients with blunt solid organ injuries

BACKGROUND

Thrombelastography (TEG) has emerged as a useful tool to diagnose coagulopathy and guide blood product usage during trauma resuscitations. This study sought to evaluate the correlation between TEG-directed blood product administration in severely injured pediatric trauma patients with blunt solid organ injuries (BSOIs).

METHODS

Patients (≤18 years) with severe BSOIs who presented as highest-level trauma activations at two pediatric trauma centers were included. Thrombelastography results were evaluated to determine indications for blood product administration and rates of TEG-directed resuscitation. Tetrachoric correlations and regression modeling were used to correlate TEG-directed resuscitation with clinical outcomes.

RESULTS

Of 64 patients who met the inclusion criteria, 32.8% (21) had elevated R times and 23.4% (15) had shortened α angles. Maximum amplitude was shortened in 29.7% (19), and percent clot lysis 30 minutes after maximum amplitude that is >3% was seen in 17.0% (9). Thrombelastography-directed resuscitation of fresh frozen plasma was followed 54.7% of the time compared with 67.2% and 81.2% for platelets and cryoprecipitate, respectively. Thrombelastography-directed resuscitation with platelets (odds ratio, 0.56; 95% confidence interval, 0.33-0.93; p = 0.03) and/or cryoprecipitate (odds ratio, 0.09; 95% confidence interval, 0.01-0.42, p = 0.003) were associated with decreased hospital length of stay and mortality, respectively.

CONCLUSION

Severely injured pediatric trauma patients with BSOIs were often coagulopathic upon presentation to the emergency department. Thrombelastography-directed resuscitation with platelets and/or cryoprecipitate was followed for the majority of patients and was associated with improved outcomes.

LEVEL OF EVIDENCE

Therapeutic/Care Management, level III.

Higher Crystalloid Volume During Initial Pediatric Trauma Resuscitation is Associated With Mortality

BACKGROUND

Historically, aggressive fluid resuscitation has been a cornerstone of management of hemorrhagic shock in pediatrics. Adult data suggest this strategy may be harmful. We sought to determine whether aggressive fluid resuscitation within the first hour of presentation to the emergency department in pediatric patients with trauma is associated with worse clinical outcomes.

MATERIALS AND METHODS

We performed a retrospective cohort study from 2012 to 2017 at a single pediatric level 1 trauma center. We defined three patient cohorts: ≤ 20 cc/kg (reference), 20-40 (20.01 to 39.99) cc/kg, and ≥40 cc/kg of intravenous fluid (IVF) given in the first in-hospital hour. Covariates included age, injury severity score, shock index (adjusted for age), and mechanism of injury and were adjusted for with multivariable regression. The primary outcome was in-hospital mortality.

RESULTS

A total of 1479 consecutive injured children were eligible for inclusion. One hundred ninety-four patients were excluded for missing IVF data, aged ≥16 y, having primary burns, or arriving pulseless. A total of 1285 patients met inclusion criteria (mean age 8.1 ± 5.5 y, male 64.5%). Higher rates of IVF administration were associated with mortality for both the 20-40 cc/kg (adjusted odds ratio (aOR) 2.96; 95% confidence interval (CI) 1.02-8.55; P = 0.045) and ≥40 cc/kg groups (aOR 6.26; 95% CI 1.79-21.83; P = 0.004). The ≥40 cc/kg group was associated with increased pediatric intensive care unit length of stay (aOR 2.20; 95% CI: 1.05-4.61; P = 0.036) and increased need for mechanical ventilation (aOR 3.79; 95% CI 1.62-8.87; P = 0.002).

CONCLUSIONS

Greater than one 20 cc/kg IVF bolus in the first emergency department hour was associated with mortality with a dose-response relationship, even after adjusting for injury severity and initial hemodynamics. These results encourage further investigation into initial resuscitation strategies for injured children.

Association of Blood Component Ratios With 24-Hour Mortality in Injured Children Receiving Massive Transfusion

OBJECTIVES

To determine if higher fresh frozen plasma and platelet to packed RBC ratios are associated with lower 24-hour mortality in bleeding pediatric trauma patients.

DESIGN

Retrospective cohort study using the Pediatric Trauma Quality Improvement Program Database from 2014 to 2016.

SETTING

Level I and II pediatric trauma centers participating in the Trauma Quality Improvement Program PATIENTS:: Injured children (≤ 14 yr old) who received massive transfusion (≥ 40 mL/kg total blood products in 24 hr). Of 123,836 patients, 590 underwent massive transfusion, of which 583 met inclusion criteria.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Ratios of fresh frozen plasma:packed RBC and platelet:packed RBC. Of the 583 patients, 60% were male and the median age was 5 years (interquartile range, 2-10 yr). Overall mortality was 19.7% (95% CI, 16.6-23.2%) at 24 hours. There was 51% (adjusted relative risk, 0.49; 95% CI, 0.27-0.87; p = 0.02) and 40% (adjusted relative risk, 0.60; 95% CI, 0.39-0.92; p = 0.02) lower risk of death at 24 hours for the high (≥ 1:1) and medium (≥ 1:2 and < 1:1) fresh frozen plasma:packed RBC ratio groups, respectively, compared with the low ratio group (< 1:2). Platelet:packed RBC ratio was not associated with mortality (adjusted relative risk, 0.94; 95% CI, 0.51-1.71; p = 0.83).

CONCLUSIONS

Higher fresh frozen plasma ratios were associated with lower 24-hour mortality in massively transfused pediatric trauma patients. The platelet ratio was not associated with mortality. Although these findings represent the largest study evaluating blood product ratios in pediatric trauma patients, prospective studies are necessary to determine the optimum blood product ratios to minimize mortality in this population.

Damage control surgery in neonates: Lessons learned from the battlefield

INTRODUCTION

Mortality for neonates requiring surgery for serious pathology such as NEC, remains high. Damage control surgery (DCS) has evolved as an operative strategy in battlefield trauma that sacrifices the completeness of the initial surgery to address the deadly triad of acidosis, hypothermia and coagulopathy. This approach is now used routinely in sick adults with nontrauma surgical emergencies. Here we describe our experience of using DCS in neonates.

METHOD

Neonates undergoing DCS at our hospital from 1/8/2010 to 30/11/17 had data collected prospectively.

RESULTS

27 neonates (median age 21 days; gestation 29 weeks; weight 1200 g; M:F 18:9) underwent DCS. Diagnosis (NEC 23, volvulus 2, meconium peritonitis 1, spontaneous perforation 1). Preoperative physiology: median temperature 35.5 °C, lactate 3.7, Activated prothrombin time 49; on a median of 1 inotrope (range 0 to 4); 19 had surgery on the intensive care unit. Surgery involved resection of dead bowel with the ends ligated and the abdomen left open. Operation took 38 min (26-80 min) and crew-resource management techniques were used to optimize efficiency. Second look occurred at 48 h (24-108 h) when the physiology had normalized. There were a total of 32 anastomoses in 18 patients with one leak; 3 patients had stomas for distal rectal disease. Overall mortality was 15% (4/27) or 18% in the NEC group (4/23).

CONCLUSION

Though techniques such as "clip and drop" exist, they have not been routinely incorporated into an operative strategy for sick neonates based on physiological derangement. The two benefits from our DCS approach were a low mortality and an avoidance of stomas. This approach deserves more investigation to see whether it is as effective in babies and children with nontrauma associated abdominal catastrophes as it is in adults.

TYPE OF STUDY

Case controlled study.

LEVEL OF EVIDENCE

Level III.

Damage control orthopedics applied in an 8-year-old child with life-threatening multiple injuries: A CARE-compliant case report

RATIONALE

Damage control is a staged surgical approach to manage polytraumatized patients. The damage control approach comprises three steps. First, bleeding is controlled and fractures are stabilized temporarily; second, vital parameters are stabilized and the child is rewarmed in the intensive care unit; and third, the child is reoperated for definitive repair of injuries. We aimed to describe the feasibility of the damage control orthopedic approach in a child.

PATIENT CONCERNS

An 8-year-old girl fell from the balcony of the 5th floor onto concrete pavement and was admitted to our accident and emergency ward in a stable cardiorespiratory state, but with gross deformity of the lower limbs, left thigh, and forearm.

DIAGNOSES

The child had sustained multiple injuries with severe bilateral lung contusion, pneumothorax, fracture of first rib, liver laceration, stable spine fractures, transforaminal fracture of sacrum, pelvic ring fracture, displaced baso-cervical femoral neck fracture, displaced bilateral multifragmental growth plate fractures of both tibiae, fractures of both fibulae, displaced fracture of left forearm, and displaced supracondylar fracture of the humerus.

INTERVENTION

In the initial operation, we performed closed reduction and K-wire fixation of the right tibia, closed reduction and external fixation of the left tibia, open reduction and screw osteosynthesis of the femoral neck fracture, closed reduction and K-wire fixation of the radius, and closed reduction of the supracondylar fracture. Subsequently, we transferred the girl to the pediatric intensive care unit for hemodynamic stabilization, respiratory therapy, rewarming, and treatment of crush syndrome. In a third step, 10 days after the injury, we managed the supracondylar fracture of the humerus by closed reduction and K-wire fixation.

OUTCOMES

Growth arrest of the left distal tibial growth plate and osteonecrosis of the femoral head and neck, slipped capital femoris epiphysis (SCFE), and coxa vara of the right femur led to balanced leg length inequality 2 years after the injury. The lesion of the left sciatic nerve improved over time and the girl walked without walking aids and took part in school sports but avoided jumping exercises.

LESSONS

We emphasize the importance of damage control principles when managing polytraumatized children.

Pediatric trauma-related coagulopathy: Balanced resuscitation, goal-directed therapy and viscoelastic assays

The improved understanding of trauma-induced coagulopathy in adults has led to an evolution in the strategies of damage-control resuscitation. While its impact on the care of pediatric trauma patients is of tremendous interest, the evidence is sparse, and a great deal of research is still needed in this domain. Areas of particular interest include age-related differences in hemostasis and balanced resuscitation, advances in functional coagulation assays and effective adjunctive medications, such as tranexamic acid, for hemorrhage control. This review examines the available pediatric data, reviews applicable adult data, and introduces areas of investigation that will impact pediatric trauma care in the future.

Damage control resuscitation in pediatric trauma

PURPOSE OF REVIEW

Damage control resuscitation is an overall management strategy used in trauma patients to rapidly restore physiologic stability, while mitigating hypothermia, coagulopathy and acidosis. We review the evidence and current practice of damage control resuscitation in pediatric trauma patients with a specific focus on fluid management.

RECENT FINDINGS

There have been a number of studies over the last several years examining crystalloid fluid resuscitation, balanced blood product transfusion practice and hemostatic agents in pediatric trauma. Excessive fluid resuscitation has been linked to increased number of ICU days, ventilator days and mortality. Balanced massive transfusion (1 : 1 : 1 product ratio) has not yet been demonstrated to have the same mortality benefits in pediatric trauma patients as in adults. Similarly, tranexamic acid (TXA) has strong evidence to support its use in adult trauma and some evidence in pediatric trauma.

SUMMARY

Attention to establishing rapid vascular access and correcting hypothermia and acidosis is essential. A judicious approach to crystalloid resuscitation in the bleeding pediatric trauma patient with early use of blood products in keeping with an organized approach to massive hemorrhage is recommended. The ideal crystalloid volumes and/or blood product ratios in pediatric trauma patients have yet to be determined.