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Gorski JK, Chaudhari PP, Spurrier RG, Goldstein SD, Zeineddin S, Martin-Gill C, Sepanski RJ, Stey AM, Ramgopal S. Comparison of Vital Sign Cutoffs to Identify Children With Major Trauma. JAMA Netw Open 2024; 7:e2356472. [PMID: 38363566 PMCID: PMC10873773 DOI: 10.1001/jamanetworkopen.2023.56472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/26/2023] [Indexed: 02/17/2024] Open
Abstract
Importance Vital signs are essential components in the triage of injured children. The Advanced Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS) physiologic criteria are frequently used for trauma assessments. Objective To evaluate the performance of ATLS and PALS criteria vs empirically derived criteria for identifying major trauma in children. Design, Setting, and Participants This retrospective cohort study used 2021 American College of Surgeons Trauma Quality Improvement Program (TQIP) data contributed by US trauma centers. Included encounters involved pediatric patients (aged <18 years) with severe injury, excluding those who experienced out-of-hospital cardiac arrest, were receiving mechanical ventilation, or were transferred from another facility. Data were analyzed between April 9 and December 21, 2023. Exposure Initial hospital vital signs, including heart rate, respiratory rate, and systolic blood pressure (SBP). Main Outcome and Measures Major trauma, determined by the Standard Triage Assessment Tool, a composite measure of injury severity and interventions performed. Multivariable models developed from PALS and ATLS vital sign criteria were compared with models developed from the empirically derived criteria using the area under the receiver operating characteristic curve. Validation of the findings was performed using the 2019 TQIP dataset. Results A total of 70 748 patients (median [IQR] age, 11 [5-15] years; 63.4% male) were included, of whom 3223 (4.6%) had major trauma. The PALS criteria classified 31.0% of heart rates, 25.7% of respiratory rates, and 57.4% of SBPs as abnormal. The ATLS criteria classified 25.3% of heart rates, 4.3% of respiratory rates, and 1.1% of SBPs as abnormal. Among children with all 3 vital signs documented (64 326 [90.9%]), PALS had a sensitivity of 88.4% (95% CI, 87.1%-89.3%) and specificity of 25.1% (95% CI, 24.7%-25.4%) for identifying major trauma, and ATLS had a sensitivity of 54.5% (95% CI, 52.7%-56.2%) and specificity of 72.9% (95% CI, 72.6%-73.3%). The empirically derived cutoff vital sign z scores had a sensitivity of 80.0% (95% CI, 78.5%-81.3%) and specificity of 48.7% (95% CI, 48.3%-49.1%) and area under the receiver operating characteristic curve of 70.9% (95% CI, 69.9%-71.8%), which was similar to PALS criteria (69.6%; 95% CI, 68.6%-70.6%) and greater than ATLS criteria (65.4%; 95% CI, 64.4%-66.3%). Validation using the 2019 TQIP database showed similar performance to the derivation sample. Conclusions and Relevance These findings suggest that empirically derived vital sign criteria strike a balance between the sensitivity of PALS criteria and the specificity of ATLS criteria in identifying major trauma in children. These criteria may help to identify children at greatest risk of trauma-related morbidity and mortality.
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Affiliation(s)
- Jillian K. Gorski
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Department of Pediatrics, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Ryan G. Spurrier
- Division of Pediatric Surgery, Department of Surgery, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Seth D. Goldstein
- Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Suhail Zeineddin
- Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert J. Sepanski
- Department of Quality and Safety, Children’s Hospital of The King’s Daughters, Norfolk, Virginia
- Department of Pediatrics, Eastern Virginia Medical School, Norfolk
| | - Anne M. Stey
- Department of Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Kochar A, Hildebrandt K, Silverstein R, Appavu B. Approaches to neuroprotection in pediatric neurocritical care. World J Crit Care Med 2023; 12:116-129. [PMID: 37397588 PMCID: PMC10308339 DOI: 10.5492/wjccm.v12.i3.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/30/2023] [Accepted: 04/12/2023] [Indexed: 06/08/2023] Open
Abstract
Acute neurologic injuries represent a common cause of morbidity and mortality in children presenting to the pediatric intensive care unit. After primary neurologic insults, there may be cerebral brain tissue that remains at risk of secondary insults, which can lead to worsening neurologic injury and unfavorable outcomes. A fundamental goal of pediatric neurocritical care is to mitigate the impact of secondary neurologic injury and improve neurologic outcomes for critically ill children. This review describes the physiologic framework by which strategies in pediatric neurocritical care are designed to reduce the impact of secondary brain injury and improve functional outcomes. Here, we present current and emerging strategies for optimizing neuroprotective strategies in critically ill children.
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Affiliation(s)
- Angad Kochar
- Department of Neurosciences, Phoenix Children's Hospital, Phoenix, AZ 85213, United States
| | - Kara Hildebrandt
- Department of Neurosciences, Phoenix Children's Hospital, Phoenix, AZ 85213, United States
| | - Rebecca Silverstein
- Department of Neurosciences, Phoenix Children's Hospital, Phoenix, AZ 85213, United States
| | - Brian Appavu
- Department of Neurosciences, Phoenix Children's Hospital, Phoenix, AZ 85213, United States
- Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ 85016, United States
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3
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Lulla A, Lumba-Brown A, Totten AM, Maher PJ, Badjatia N, Bell R, Donayri CTJ, Fallat ME, Hawryluk GWJ, Goldberg SA, Hennes HMA, Ignell SP, Ghajar J, Krzyzaniak BP, Lerner EB, Nishijima D, Schleien C, Shackelford S, Swartz E, Wright DW, Zhang R, Jagoda A, Bobrow BJ. Prehospital Guidelines for the Management of Traumatic Brain Injury - 3rd Edition. PREHOSP EMERG CARE 2023:1-32. [PMID: 37079803 DOI: 10.1080/10903127.2023.2187905] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Affiliation(s)
- Al Lulla
- Department of Emergency Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Angela Lumba-Brown
- Department of Emergency Medicine, Stanford University, Stanford, California
| | - Annette M Totten
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Patrick J Maher
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Neeraj Badjatia
- Department of Neurocritical Care, Neurology, Anesthesiology, Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Randy Bell
- Uniformed Services University, Bethesda, Maryland
| | | | - Mary E Fallat
- Hiram C. Polk Jr Department of Pediatric Surgery, University of Louisville, Norton Children's Hospital, Louisville, Kentucky
| | - Gregory W J Hawryluk
- Department of Neurosurgery, Cleveland Clinic and Akron General Hospital, Fairlawn, Ohio
| | - Scott A Goldberg
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Halim M A Hennes
- Department of Pediatric Emergency Medicine, UT Southwestern Medical Center, Dallas Children's Medical Center, Dallas, Texas
| | - Steven P Ignell
- Department of Emergency Medicine, Stanford University, Stanford, California
| | - Jamshid Ghajar
- Department of Neurosurgery, Stanford University, Stanford, California
| | | | - E Brooke Lerner
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Daniel Nishijima
- Department of Emergency Medicine, UC Davis, Sacramento, California
| | - Charles Schleien
- Pediatric Critical Care, Cohen Children's Medical Center, Hofstra Northwell School of Medicine, Uniondale, New York
| | - Stacy Shackelford
- Trauma and Critical Care, USAF Center for Sustainment of Trauma Readiness Skills, Seattle, Washington
| | - Erik Swartz
- Department of Physical Therapy and Kinesiology, University of Massachusetts, Lowell, Massachusetts
| | - David W Wright
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | - Rachel Zhang
- University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Andy Jagoda
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bentley J Bobrow
- Department of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
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4
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Raikot SR, Polites SF. Current management of pediatric traumatic brain injury. Semin Pediatr Surg 2022; 31:151215. [PMID: 36399949 DOI: 10.1016/j.sempedsurg.2022.151215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Raees M, Hooli S, von Saint André-von Arnim AO, Laeke T, Otupiri E, Fabio A, Rudd KE, Kumar R, Wilson PT, Aklilu AT, Tuyisenge L, Wang C, Tasker RC, Angus DC, Kochanek PM, Fink EL, Bacha T. An exploratory assessment of the management of pediatric traumatic brain injury in three centers in Africa. Front Pediatr 2022; 10:936150. [PMID: 36061402 PMCID: PMC9428450 DOI: 10.3389/fped.2022.936150] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/22/2022] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). Hospital care practices of pediatric TBI patients in LMICs are unknown. Our objective was to report on hospital management and outcomes of children with TBI in three centers in LMICs. METHODS We completed a secondary analysis of a prospective observational study in children (<18 years) over a 4-week period. Outcome was determined by Pediatric Cerebral Performance Category (PCPC) score; an unfavorable score was defined as PCPC > 2 or an increase of two points from baseline. Data were compared using Chi-square and Wilcoxon rank sum tests. RESULTS Fifty-six children presented with TBI (age 0-17 y), most commonly due to falls (43%, n = 24). Emergency department Glasgow Coma Scale scores were ≤ 8 in 21% (n = 12). Head computed tomography was performed in 79% (n = 44) of patients. Forty (71%) children were admitted to the hospital, 25 (63%) of whom were treated for suspected intracranial hypertension. Intracranial pressure monitoring was unavailable. Five (9%, n = 5) children died and 10 (28%, n = 36) inpatient survivors had a newly diagnosed unfavorable outcome on discharge. CONCLUSION Inpatient management and monitoring capability of pediatric TBI patients in 3 LMIC-based tertiary hospitals was varied. Results support the need for prospective studies to inform development of evidence-based TBI management guidelines tailored to the unique needs and resources in LMICs.
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Affiliation(s)
- Madiha Raees
- Division of Critical Care Medicine, Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Critical Care Medicine, University of Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Shubhada Hooli
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Amélie O von Saint André-von Arnim
- Division of Pediatric Critical Care, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, WA, United States.,Department of Global Health, University of Washington, Seattle, WA, United States
| | - Tsegazeab Laeke
- Division of Neurosurgery, Department of Surgery, College of Health Science, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway.,National Institute for Health Care and Research (NIHR) Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Easmon Otupiri
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Anthony Fabio
- Epidemiology Data Center, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kristina E Rudd
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (CRISMA), University of Pittsburgh, Pittsburgh, PA, United States
| | - Rashmi Kumar
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Patrick T Wilson
- Department of Pediatrics, Columbia University Medical Center, New York, NY, United States
| | - Abenezer Tirsit Aklilu
- Division of Neurosurgery, Department of Surgery, College of Health Science, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway.,National Institute for Health Care and Research (NIHR) Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Lisine Tuyisenge
- Department of Paediatrics, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Chunyan Wang
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Robert C Tasker
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (CRISMA), University of Pittsburgh, Pittsburgh, PA, United States
| | - Patrick M Kochanek
- Department of Critical Care Medicine, University of Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, United States
| | - Ericka L Fink
- Department of Critical Care Medicine, University of Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, United States
| | - Tigist Bacha
- Department of Pediatrics and Child Health, St. Paul Millennium Medical College, Addis Ababa, Ethiopia
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Alberto EC, McKenna E, Amberson MJ, Tashiro J, Donnelly K, Thenappan AA, Tempel PE, Ranganna AS, Keller S, Marsic I, Sarcevic A, O’Connell KJ, Burd RS. Metrics of shock in pediatric trauma patients: A systematic search and review. Injury 2021; 52:3166-3172. [PMID: 34238538 PMCID: PMC8560576 DOI: 10.1016/j.injury.2021.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Shock-index (SI) and systolic blood pressure (SBP) are metrics for identifying children and adults with hemodynamic instability following injury. The purpose of this systematic review was to assess the quality of these metrics as predictors of outcomes following pediatric injury. MATERIALS AND METHODS We conducted a literature search in Pubmed, SCOPUS, and CINAHL to identify studies describing the association between shock metrics on the morbidity and mortality of injured children and adolescents. We used the data presented in the studies to calculate the sensitivity and specificity for each metric. This study was registered with Prospero, protocol CRD42020162971. RESULTS Fifteen articles met the inclusion criteria. seven studies evaluated SI or SIPA score, an age-corrected version of SI, as predictors of outcomes following pediatric trauma, with one study comparing SIPA score and SBP and one study comparing SI and SBP. The remaining eight studies evaluated SBP as the primary indicator of shock. The median sensitivity for predicting mortality and need for blood transfusion was highest for SI, followed by SIPA, and then SBP. The median specificity for predicting these outcomes was highest for SBP, followed by SIPA, and then SI. CONCLUSIONS Common conclusions were that high SIPA scores were more specific than SI and more sensitive than SBP. SIPA score had better discrimination for severely injured children compared to SI and SBP. An elevated SIPA was associated with a greater need for blood transfusion and higher in-hospital mortality. SIPA is specific enough to exclude most patients who do not require a blood transfusion.
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Affiliation(s)
- Emily C. Alberto
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington D.C., United States
| | - Elise McKenna
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington D.C., United States
| | - Michael J. Amberson
- Department of Pediatrics, Children’s National Hospital, Washington D.C., United States
| | - Jun Tashiro
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington D.C., United States
| | - Katie Donnelly
- Division of Emergency Medicine, Children’s National Hospital, Washington D.C., United States
| | - Arunachalam A. Thenappan
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington D.C., United States
| | - Peyton E. Tempel
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington D.C., United States
| | - Adesh S. Ranganna
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington D.C., United States
| | - Susan Keller
- Department of Nursing Science Professional Practice and Quality, Children’s National Hospital, Washington D.C., United States
| | - Ivan Marsic
- Department of Electrical and Computer Engineering, Rutgers University, Piscataway, NJ, United States
| | - Aleksandra Sarcevic
- College of Computing and Informatics, Drexel University, Philadelphia, PA, United States
| | - Karen J. O’Connell
- Division of Emergency Medicine, Children’s National Hospital, Washington D.C., United States
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington D.C., United States,Corresponding author at: Division of Trauma and Burn Surgery, Children’s National Hospital, 111 Michigan Ave NW, Washington D.C. 20010, United States. (R.S. Burd)
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7
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Alberto EC, Harvey AR, Amberson MJ, Zheng Y, Thenappan AA, Oluigbo C, Marsic I, Sarcevic A, O'Connell KJ, Burd RS. Assessment of Non-Routine Events and Significant Physiological Disturbances during Emergency Department Evaluation after Pediatric Head Trauma. Neurotrauma Rep 2021; 2:39-47. [PMID: 33748812 PMCID: PMC7962792 DOI: 10.1089/neur.2020.0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Outcomes following pediatric traumatic brain injury (TBI) are dependent on initial injury severity and prevention of secondary injury. Hypoxia, hypotension, and hyperventilation following TBI are associated with increased mortality. The purpose of this study was to determine the association of non-routine events (NREs) during the initial resuscitation phase with these physiological disturbances. We conducted a video review of pediatric trauma resuscitations of patients with suspected TBI and Glasgow Coma Scale (GCS) scores <13. NREs were rated as "momentary" if task progression was delayed by <1 min and "moderate" if delayed by >1 min. Vital sign monitor data were used to identify periods of significant physiological disturbances. We calculated the association between the rate of overall and moderate NREs per case and the proportion of cases with abnormal vital signs using multi-variate linear regression, controlling for GCS score and need for intubation. Among 26 resuscitations, 604 NREs were identified with a median of 23 (interquartile range [IQR] 17-27.8, range 5-44) per case. Moderate delay NREs occurred in 19 resuscitations (n = 32, median 1 NRE/resuscitation, IQR 0.3-1, range 0-5). Oxygen desaturation and respiratory depression were associated with a greater rate of moderate NREs (p = 0.008, p < 0.001, respectively). We observed no association between duration of hypotension, desaturation, and respiratory depression and overall NRE rate. NREs are common in the initial resuscitation of children with moderate to severe TBI. Episodes of hypoxia and respiratory depression are associated with NREs that cause a moderate delay in task progression. Conformance with resuscitation guidelines is needed to prevent physiological events associated with adverse outcomes following pediatric TBI.
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Affiliation(s)
- Emily C. Alberto
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington DC, USA
| | - Allison R. Harvey
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington DC, USA
| | | | - Yinan Zheng
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington DC, USA
| | | | - Chima Oluigbo
- Division of Neurosurgery, Children's National Hospital, Washington DC, USA
| | - Ivan Marsic
- Department of Electrical and Computer Engineering, Rutgers University, Piscataway, New Jersey, USA
| | - Aleksandra Sarcevic
- College of Computing and Informatics, Drexel University, Philadelphia, Pennsylvania, USA
| | - Karen J. O'Connell
- Division of Emergency Medicine, Children's National Hospital, Washington DC, USA
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington DC, USA
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8
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Sumann G, Moens D, Brink B, Brodmann Maeder M, Greene M, Jacob M, Koirala P, Zafren K, Ayala M, Musi M, Oshiro K, Sheets A, Strapazzon G, Macias D, Paal P. Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel. Scand J Trauma Resusc Emerg Med 2020; 28:117. [PMID: 33317595 PMCID: PMC7737289 DOI: 10.1186/s13049-020-00790-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments. Objective To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments. Eligibility criteria All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms. Sources of evidence PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles. Charting methods Evidence was searched according to clinically relevant topics and PICO questions. Results Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland. Conclusions Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.
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Affiliation(s)
- G Sumann
- Austrian Society of Mountain and High Altitude Medicine, Emergency physician, Austrian Mountain and Helicopter Rescue, Altach, Austria
| | - D Moens
- Emergency Department Liège University Hospital, CMH HEMS Lead physician and medical director, Senior Lecturer at the University of Liège, Liège, Belgium
| | - B Brink
- Mountain Emergency Paramedic, AHEMS, Canadian Society of Mountain Medicine, Whistler Blackcomb Ski Patrol, Whistler, Canada
| | - M Brodmann Maeder
- Department of Emergency Medicine, University Hospital and University of Bern, Switzerland and Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - M Greene
- Medical Officer Mountain Rescue England and Wales, Wales, UK
| | - M Jacob
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Hospitallers Brothers Saint-Elisabeth-Hospital Straubing, Bavarian Mountain Rescue Service, Straubing, Germany
| | - P Koirala
- Adjunct Assistant Professor, Emergency Medicine, University of Maryland School of Medicine, Mountain Medicine Society of Nepal, Kathmandu, Nepal
| | - K Zafren
- ICAR MedCom, Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA, USA.,Alaska Native Medical Center, Anchorage, AK, USA
| | - M Ayala
- University Hospital Germans Trias i Pujol, Badalona, Spain
| | - M Musi
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - K Oshiro
- Department of Cardiovascular Medicine and Director of Mountain Medicine, Research, and Survey Division, Hokkaido Ohno Memorial Hospital, Sapporo, Japan
| | - A Sheets
- Emergency Department, Boulder Community Health, Boulder, CO, USA
| | - G Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.,The Corpo Nazionale Soccorso Alpino e Speleologico, National Medical School (CNSAS SNaMed), Milan, Italy
| | - D Macias
- Department of Emergency Medicine, International Mountain Medicine Center, University of New Mexico, Albuquerque, NM, USA
| | - P Paal
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria.
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9
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Erickson SL, Killien EY, Wainwright M, Mills B, Vavilala MS. Mean Arterial Pressure and Discharge Outcomes in Severe Pediatric Traumatic Brain Injury. Neurocrit Care 2020; 34:1017-1025. [PMID: 33108627 DOI: 10.1007/s12028-020-01121-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND OBJECTIVE Optimizing blood pressure is an important target for intervention following pediatric traumatic brain injury (TBI). The existing literature has examined the association between systolic blood pressure (SBP) and outcomes. Mean arterial pressure (MAP) is a better measure of organ perfusion than SBP and is used to determine cerebral perfusion pressure but has not been previously examined in relation to outcomes after pediatric TBI. We aimed to evaluate the strength of association between MAP-based hypotension early after hospital admission and discharge outcome and to contrast the relative strength of association of hypotension with outcome between MAP-based and SBP-based blood pressure percentiles. METHODS We examined the association between lowest age-specific MAP percentile within 12 h after pediatric intensive care unit admission and poor discharge outcome (in-hospital death or transfer to a skilled nursing facility) in children with severe (Glasgow Coma Scale score < 9) TBI who survived at least 12 h. Poisson regression results were adjusted for maximum head Abbreviated Injury Scale (AIS) severity score, maximum nonhead AIS, and vasoactive medication use. We also examined the ability of lowest MAP percentile during the first 12 h to predict discharge outcomes using receiver operating curve characteristic analysis without adjustment for covariates. We contrasted the predictive ability and the relative strength of association of blood pressure with outcome between MAP and SBP percentiles. RESULTS Data from 166 children aged < 18 years were examined, of whom 20.4% had a poor discharge outcome. Poor discharge outcome was most common among patients with lowest MAP < 5th percentile (42.9%; aRR 5.3 vs. 50-94th percentile, 95% CI 1.2, 23.0) and MAP 5-9th percentile (40%; aRR 8.5, 95% CI 1.9, 38.7). Without adjustment for injury severity or vasoactive medication use, lowest MAP percentile was moderately predictive of poor discharge outcome (AUC: 0.75, 95% CI 0.66, 0.85). In contrast, lowest SBP was associated with poor discharge outcome only for the < 5th percentile (50%; aRR 5.4, 95% CI 1.3, 22.2). Lowest SBP percentile was moderately predictive of poor discharge outcome (AUC: 0.82, 95% CI 0.74, 0.91). CONCLUSIONS In children with severe TBI, a single MAP < 10th percentile during the first 12 h after Pediatric Intensive Care Unit admission was associated with poor discharge outcome. Lowest MAP percentile during the first 12 h was moderately predictive of poor discharge outcome. Lowest MAP percentile was more strongly associated with outcome than lowest SBP percentile but had slightly lower predictive ability than SBP.
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Affiliation(s)
- Scott L Erickson
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA.,Department of Epidemiology, University of Washington, Seattle, USA
| | - Elizabeth Y Killien
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA. .,Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA.
| | - Mark Wainwright
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, USA
| | - Brianna Mills
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA.,Department of Epidemiology, University of Washington, Seattle, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA
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10
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Hanna K, Hamidi M, Vartanyan P, Henry M, Castanon L, Tang A, Zeeshan M, Kulvatunyou N, Joseph B. Non-neurologic organ dysfunction plays a major role in predicting outcomes in pediatric traumatic brain injury. J Pediatr Surg 2020; 55:1590-1595. [PMID: 32081358 DOI: 10.1016/j.jpedsurg.2020.01.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 12/02/2019] [Accepted: 01/24/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Nonneurological organ dysfunction (NNOD) occurs after traumatic brain injury (TBI) and is associated with mortality. The aim of our study was to evaluate the prevalence of NNOD and its association with outcomes in pediatric patients with TBI. We hypothesized that NNOD is associated with worse outcomes in pediatric patients with severe TBI. METHODS We performed a 4-year (2013-16) analysis of our prospectively maintained TBI database. All patients (age < 18) with an isolated-severe TBI (head-abbreviated injury scale: AIS ≥ 3 & extracranial-AIS < 3) were included. NNOD was measured using the pediatric multiple organ dysfunction (P-MOD) score. Outcomes were in-hospital mortality, Glasgow Outcome Scale-Extended (GOS-E), and adverse discharge disposition: rehabilitation or skilled nursing facility (SNF). Regression analysis was performed. RESULTS We analyzed 292 patients. Mean age was 11 ± 6 years, 57% were male and the mortality rate was 18.1%. The incidence of NNOD was 35%. The most common dysfunctional organ system was the respiratory (25%) followed by the cardiovascular (12%). On regression analysis, the presence of at least one NNOD was independently associated with in-hospital mortality (OR 2.1 [1.7-2.9]; p < 0.01), low GOS-E (OR 1.8 [1.5-2.3]; p < 0.01), and SNF disposition (OR 1.7 [1.2-2.1]; p < 0.01). CONCLUSION NNOD develops in one of every three severe TBI pediatric patients and is independently associated with adverse outcomes. Identification of NNOD in pediatric TBI and focusing on management of NNOD could improve outcomes. LEVEL OF EVIDENCE III Prognostic.
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Affiliation(s)
- Kamil Hanna
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ.
| | - Mohammad Hamidi
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ.
| | - Phillip Vartanyan
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ.
| | - Marion Henry
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ.
| | - Lourdes Castanon
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ.
| | - Andrew Tang
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ.
| | - Muhammad Zeeshan
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ.
| | - Narong Kulvatunyou
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ.
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ.
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11
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Simulation of the Emergency Department Care Process for Pediatric Traumatic Brain Injury. J Healthc Qual 2019; 40:110-118. [PMID: 29271801 DOI: 10.1097/jhq.0000000000000119] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The treatment of patients in the emergency department (ED) with severe pediatric traumatic brain injury (TBI) is challenging, and treatment process strategies that facilitate good outcomes are not well documented. The overall objective of this study was to identify factors that can affect the care process associated with pediatric TBI. This objective was achieved using a discrete-event simulation model of patients with TBI as they progress through the ED treatment process of a Level I trauma center. This model was used to identify areas where the ED length of stay can be reduced. The number of patients arriving at any given time was also varied in the simulation model to observe the impact to bed allocation policies and changes in staff and equipment. The findings showed that implementing changes in the ED (i.e., availability of two computerized tomography scanners, formation of resuscitation teams that included eight staff personnel, and modifying the bed allocation policy) could result in a 17% reduction in the mean ED length of stay. The study outcomes would be of interest to those (e.g., health administrators, health managers, and physicians) who can make decisions related to the treatment process in an ED.
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12
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Lovett ME, O'Brien NF, Leonard JR. Children With Severe Traumatic Brain Injury, Intracranial Pressure, Cerebral Perfusion Pressure, What Does it Mean? A Review of the Literature. Pediatr Neurol 2019; 94:3-20. [PMID: 30765136 DOI: 10.1016/j.pediatrneurol.2018.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 11/28/2018] [Accepted: 12/06/2018] [Indexed: 11/18/2022]
Abstract
Severe traumatic brain injury is a leading cause of morbidity and mortality in children. In 2003 the Brain Trauma Foundation released guidelines that have since been updated (2010) and have helped standardize and improve care. One area of care that remains controversial is whether the placement of an intracranial pressure monitor is advantageous in the management of traumatic brain injury. Another aspect of care that is widely debated is whether management after traumatic brain injury should be based on intracranial pressure-directed therapy, cerebral perfusion pressure-directed therapy, or a combination of the two. The aim of this article was to provide an overview and review the current evidence regarding these questions.
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Affiliation(s)
- Marlina E Lovett
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio.
| | - Nicole F O'Brien
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Jeffrey R Leonard
- Division of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
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13
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Presenting Characteristics Associated With Outcome in Children With Severe Traumatic Brain Injury: A Secondary Analysis From a Randomized, Controlled Trial of Therapeutic Hypothermia. Pediatr Crit Care Med 2018; 19:957-964. [PMID: 30067578 PMCID: PMC6170689 DOI: 10.1097/pcc.0000000000001676] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To identify injury patterns and characteristics associated with severe traumatic brain injury course and outcome, within a well-characterized cohort, which may help guide new research and treatment initiatives. DESIGN A secondary analysis of a phase 3, randomized, controlled trial that compared therapeutic hypothermia versus normothermia following severe traumatic brain injury in children. SETTING Fifteen sites in the United States, Australia, and New Zealand. PATIENTS Children (< 18 yr old) with severe traumatic brain injury. MEASUREMENTS AND MAIN RESULTS Baseline, clinical, and CT characteristics of patients (n = 77) were examined for association with mortality and outcome, as measured by the Glasgow Outcome Scale-Extended Pediatric Revision 3 months after traumatic brain injury. Data are presented as odds ratios with 95% CIs. No demographic, clinical, or CT characteristic was associated with mortality in bivariate analysis. Characteristics associated with worse Glasgow Outcome Scale-Extended Pediatric Revision in bivariate analysis were two fixed pupils (14.17 [3.38-59.37]), abdominal Abbreviated Injury Severity score (2.03 [1.19-3.49]), and subarachnoid hemorrhage (3.36 [1.30-8.70]). Forward stepwise regression demonstrated that Abbreviated Injury Severity spine (3.48 [1.14-10.58]) and midline shift on CT (8.35 [1.05-66.59]) were significantly associated with mortality. Number of fixed pupils (one fixed pupil 3.47 [0.79-15.30]; two fixed pupils 13.61 [2.89-64.07]), hypoxia (5.22 [1.02-26.67]), and subarachnoid hemorrhage (3.01 [1.01-9.01]) were independently associated with worse Glasgow Outcome Scale-Extended Pediatric Revision following forward stepwise regression. CONCLUSIONS Severe traumatic brain injury is a clinically heterogeneous disease that can be accompanied by a range of neurologic impairment and a variety of injury patterns at presentation. This secondary analysis of prospectively collected data identifies several characteristics associated with outcome among children with severe traumatic brain injury. Future, larger trials are needed to better characterize phenotypes within this population.
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14
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Yumoto T, Naito H, Yorifuji T, Maeyama H, Kosaki Y, Yamamoto H, Tsukahara K, Osako T, Nakao A. Cushing's sign and severe traumatic brain injury in children after blunt trauma: a nationwide retrospective cohort study in Japan. BMJ Open 2018; 8:e020781. [PMID: 29502094 PMCID: PMC5855168 DOI: 10.1136/bmjopen-2017-020781] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE We tested whether Cushing's sign could predict severe traumatic brain injury (TBI) requiring immediate neurosurgical intervention (BI-NSI) in children after blunt trauma. DESIGN Retrospective cohort study using Japan Trauma Data Bank. SETTING Emergency and critical care centres in secondary and tertiary hospitals in Japan. PARTICIPANTS Children between the ages of 2 and 15 years with Glasgow Coma Scale motor scores of 5 or less at presentation after blunt trauma from 2004 to 2015 were included. A total of 1480 paediatric patients were analysed. PRIMARY OUTCOME MEASURES Patients requiring neurosurgical intervention within 24 hours of hospital arrival and patients who died due to isolated severe TBI were defined as BI-NSI. The combination of systolic blood pressure (SBP) and heart rate (HR) on arrival, which were respectively divided into tertiles, and its correlation with BI-NSI were investigated using a multiple logistic regression model. RESULTS In the study cohort, 297 (20.1%) exhibited BI-NSI. After adjusting for sex, age category and with or without haemorrhage shock, groups with higher SBP and lower HR (SBP ≥135 mm Hg; HR ≤92 bpm) were significantly associated with BI-NSI (OR 2.84, 95% CI 1.68 to 4.80, P<0.001) compared with the patients with normal vital signs. In age-specific analysis, hypertension and bradycardia were significantly associated with BI-NSI in a group of 7-10 and 11-15 years of age; however, no significant association was observed in a group of 2-6 years of age. CONCLUSIONS Cushing's sign after blunt trauma was significantly associated with BI-NSI in school-age children and young adolescents.
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Affiliation(s)
- Tetsuya Yumoto
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama, Japan
- Department of Emergency and Critical Care Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiromichi Naito
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama, Japan
| | - Takashi Yorifuji
- Department of Human Ecology, Okayama University Graduate School of Environmental and Life Science, Okayama, Japan
| | - Hiroki Maeyama
- Department of Emergency and Critical Care Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshinori Kosaki
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama, Japan
| | - Hirotsugu Yamamoto
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama, Japan
| | - Kohei Tsukahara
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama, Japan
| | - Takaaki Osako
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama, Japan
| | - Atsunori Nakao
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama, Japan
- Department of Emergency and Critical Care Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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15
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Abstract
Shock, a state of inadequate oxygen delivery to tissues resulting in anaerobic metabolism, lactate accumulation, and end-organ dysfunction, is common in children in emergency department. Shock can be divided into 4 categories: hypovolemic, distributive, cardiogenic, and obstructive. Early recognition of shock can be made with close attention to historical clues, physical examination and vital sign abnormalities. Early and aggressive treatment can prevent or reverse organ dysfunction and improve morbidity and mortality.
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Affiliation(s)
- Jenny Mendelson
- Pediatrics, Division of Pediatric Critical Care Medicine, University of Arizona College of Medicine, Banner-University Medical Center, 1501 North Campbell Avenue, PO Box 245073, Tucson, AZ 85724-5073, USA; Emergency Medicine, University of Arizona College of Medicine, Banner-University Medical Center, 1501 North Campbell Avenue, Tucson, AZ 85724-5073, USA.
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16
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Gardner MT, O’Meara AMI, Miller Ferguson N. Pediatric Traumatic Brain Injury: an Update on Management. CURRENT PEDIATRICS REPORTS 2017. [DOI: 10.1007/s40124-017-0144-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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17
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Caprarola SD, Kudchadkar SR, Bembea MM. Neurologic Outcomes Following Care in the Pediatric Intensive Care Unit. ACTA ACUST UNITED AC 2017; 3:193-207. [PMID: 29218262 DOI: 10.1007/s40746-017-0092-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Purpose of review With increasing survival of children requiring admission to pediatric intensive care units (PICU), neurodevelopmental outcomes of these patients are an area of increased attention. Our goal was to systematically review recently published literature on neurologic outcomes of PICU patients. Recent Findings Decline in neurofunctional status occurs in 3%-20% of children requiring PICU care. This proportion varies based on primary diagnosis and severity of illness, with children admitted for primary neurologic diagnosis, children who suffer cardiac arrest or who require invasive interventions during the PICU admission, having worse outcomes. Recent research focuses on early identification and treatment of modifiable risk factors for unfavorable outcomes, and on long-term follow-up that moves beyond global cognitive outcomes and is increasingly including tests assessing multidimensional aspects of neurodevelopment. Summary The pediatric critical care research community has shifted focus from survival to survival with favorable neurologic outcomes of children admitted to the PICU.
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Affiliation(s)
- Sherrill D Caprarola
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, 6621 Fannin St, Houston, TX, United States, 77030
| | - Sapna R Kudchadkar
- Departments of Anesthesiology and Critical Care Medicine, and Pediatrics, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, United States, 21287
| | - Melania M Bembea
- Departments of Anesthesiology and Critical Care Medicine, and Pediatrics, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, United States, 21287
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18
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Vavilala MS, Lujan SB, Qiu Q, Petroni GJ, Ballarini NM, Guadagnoli N, Depetris MA, Faguaga GA, Baggio GM, Busso LO, García ME, González Carrillo OR, Medici PL, Sáenz SS, Vanella EE, Fabio A, Bell MJ. Benchmarking Prehospital and Emergency Department Care for Argentine Children with Traumatic Brain Injury: For the South American Guideline Adherence Group. PLoS One 2016; 11:e0166478. [PMID: 28005912 PMCID: PMC5179077 DOI: 10.1371/journal.pone.0166478] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 10/29/2016] [Indexed: 12/27/2022] Open
Abstract
Objective There is little information on the type of early care provided to children with traumatic brain injury (TBI) in low middle income countries. We benchmarked early prehospital [PH] and emergency department [ED] pediatric TBI care in Argentina. Methods We conducted a secondary analysis of data from patients previously enrolled in a prospective seven center study of children with TBI. Eligible participants were patients 0–18 years, and had diagnosis of TBI (admission Glasgow Coma scale score [GCS] < 13 or with GCS 14–15 and abnormal head CT scan within 48 hours of admission, and head AIS > 0). Outcomes were transport type, transport time, PH and ED adherence to best practice, and discharge Pediatric Cerebral Performance Category Scale (PCPC) and Pediatric Overall Performance category Scale (POPC). Results Of the 366 children, mean age was 8.7 (5.0) years, 58% were male, 90% had isolated TBI and 45.4% were transported by private vehicle. 50 (34.7%) of the 144 children with severe TBI (39.3% of all TBI patients) were transported by private vehicle. Most (267; 73%) patients received initial TBI care at an index hospital prior to study center admission, including children with severe (81.9%) TBI. Transport times were shorter for those patients who were directly transported by ambulance to study center than for the whole cohort (1.4 vs.5.5 hours). Ambulance blood pressure data were recorded in 30.9%. ED guideline adherence rate was higher than PH guideline adherence rate (84.8% vs. 26.4%). For patients directly transferred from scene to study trauma centers, longer transport time was associated with worse discharge outcome (PCPC aOR 1.10 [1.04, 1.18] and (POPC aOR 1.10 [1.04, 1.18]). There was no relationship between PH or ED TBI guideline adherence rate and discharge POPC and PCPC. Conclusion This study benchmarks early pediatric TBI care in Argentina and shows that many critically injured children with TBI do not receive timely or best practice PH care, that PH guideline adherence rate is low and that longer transport time was associated with poor discharge outcomes for patients with direct transfer status. There is an urgent need to improve the early care of children with TBI in Argentina, especially timely transportation to a hospital.
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Affiliation(s)
- Monica S. Vavilala
- Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, United States of America
- * E-mail:
| | - Silvia B. Lujan
- Centro de Informática e Investigación Clínica, Rosario, Santa Fe, Argentina
- Hospital de emergencias Dr. Clemente Álvarez, Rosario, Santa Fe, Argentina
| | - Qian Qiu
- Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, United States of America
| | - Gustavo J. Petroni
- Centro de Informática e Investigación Clínica, Rosario, Santa Fe, Argentina
- Hospital de emergencias Dr. Clemente Álvarez, Rosario, Santa Fe, Argentina
| | | | - Nahuel Guadagnoli
- Centro de Informática e Investigación Clínica, Rosario, Santa Fe, Argentina
| | | | | | | | | | - Mirta E. García
- Hospital de Niños Sor María Ludovica, La Plata, Buenos Aires, Argentina
| | | | - Paula L. Medici
- Hospital Interzonal Especializado Materno Infantil Dr. Vitorio Tetamanti, Mar del Plata, Buenos Aires, Argentina
| | - Silvia S. Sáenz
- Hospital de Niños de la Santísima Trinidad, Córdoba, Cordoba, Argentina
| | - Elida E. Vanella
- Hospital Pediátrico Dr. Humberto Notti, Mendoza, Mendoza, Argentina
| | - Anthony Fabio
- Graduate School of Public Health, Epidemiology Data Coordinating Center, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Michael J. Bell
- Neurological Surgery and Pediatrics, Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
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