A Decade of Firearm Injuries: Children Caught in the Crossfire.

INTRODUCTION: Firearm injuries (FIs) are the leading cause of preventable morbidity and mortality in pediatric patients. In this study, we aim to define evolving trends and avenues for prevention. METHODS: Following institutional review board approval, medical records of patients presenting to our two State-Designated Level 1 Pediatric Trauma Centers for treatment of FIs from 2010 to 2019 were retrospectively reviewed. Data was analyzed with Chi-Squared and Student's t-test; P-value <0.05 was significant. RESULTS: 1037 FI encounters from 1005 unique patients aged 0-21 y were included. 70.4% (n = 730) were determined to be assaults, 26.1% (n = 271) unintentional, and 1.7% (n = 18) self-inflicted injuries. Overall mortality was 4.5% (n = 45). FI victims were most commonly African American (n = 836, 80.6%), male (n = 869, 83.8%), aged 13-17 (n = 753, 72.6%), and from single-parent families (n = 647, 62.4%). The incidence of FIs increased significantly over the last 5 y of the study (2010-2014, 6.8 FIs/month), compared to 2015-2019 (averaging 10.6 FIs/month, P < 0.0001). Concurrently, FI related fatality increased from an average of 2.6 deaths/year (2010-2014) to 6.4 deaths/year (2015-2019, P = 0.064). Results were subanalyzed for pediatric patients aged 0-14 y. For the entire cohort, 12.1% (n = 116) recidivists were identified. Geographic patterns of injury were identified, with 75% of all FIs clustered in a single urban region. CONCLUSIONS: Incidence of pediatric FIs is increasing in recent years, with high mortality rates. Violence and recidivism are geographically concentrated, offering an opportunity for targeted interventions.

Relationship between the COVID-19 pandemic and structural inequalities within the pediatric trauma population.

BACKGROUND: The COVID-19 pandemic disrupted social, political, and economic life across the world, shining a light on the vulnerability of many communities. The objective of this study was to assess injury patterns before and after implementation of stay-at-home orders (SHOs) between White children and children of color and across varying levels of vulnerability based upon children's home residence. METHODS: A multi-institutional retrospective study was conducted evaluating patients < 18 years with traumatic injuries. A "Control" cohort from an averaged March-September 2016-2019 time period was compared to patients injured after SHO initiation-September 2020 ("COVID" cohort). Interactions between race/ethnicity or social vulnerability index (SVI), a marker of neighborhood vulnerability and socioeconomic status, and the COVID-19 timeframe with regard to the outcomes of interest were assessed using likelihood ratio Chi-square tests. Differences in injury intent, type, and mechanism were then stratified and explored by race/ethnicity and SVI separately. RESULTS: A total of 47,385 patients met study inclusion. Significant interactions existed between race/ethnicity and the COVID-19 SHO period for intent (p < 0.001) and mechanism of injury (p < 0.001). There was also significant interaction between SVI and the COVID-19 SHO period for mechanism of injury (p = 0.01). Children of color experienced a significant increase in intentional (COVID 16.4% vs. Control 13.7%, p = 0.03) and firearm (COVID 9.0% vs. Control 5.2%, p < 0.001) injuries, but no change was seen among White children. Children from the most vulnerable neighborhoods suffered an increase in firearm injuries (COVID 11.1% vs. Control 6.1%, p = 0.001) with children from the least vulnerable neighborhoods having no change. All-terrain vehicle (ATV) and bicycle crashes increased for children of color (COVID 2.0% vs. Control 1.1%, p = 0.04 for ATV; COVID 6.7% vs. Control 4.8%, p = 0.02 for bicycle) and White children (COVID 9.6% vs. Control 6.2%, p < 0.001 for ATV; COVID 8.8% vs. Control 5.8%, p < 0.001 for bicycle). CONCLUSIONS: In contrast to White children and children from neighborhoods of lower vulnerability, children of color and children living in higher vulnerability neighborhoods experienced an increase in intentional and firearm-related injuries during the COVID-19 pandemic. Understanding inequities in trauma burden during times of stress is critical to directing resources and targeting intervention strategies.

Evaluating the Regional Differences in Pediatric Injury Patterns During the COVID-19 Pandemic.

INTRODUCTION: Reports of pediatric injury patterns during the COVID-19 pandemic are conflicting and lack the granularity to explore differences across regions. We hypothesized there would be considerable variation in injury patterns across pediatric trauma centers in the United States. MATERIALS AND METHODS: A multicenter, retrospective study evaluating patients <18 y old with traumatic injuries meeting National Trauma Data Bank criteria was performed. Patients injured after stay-at-home orders through September 2020 ("COVID" cohort) were compared to "Historical" controls from an averaged period of equivalent dates in 2016-2019. Differences in injury type, intent, and mechanism were explored at the site level. RESULTS: 47,385 pediatric trauma patients were included. Overall trauma volume increased during the COVID cohort compared to the Historical (COVID 7068 patients versus Historical 5891 patients); however, some sites demonstrated a decrease in overall trauma of 25% while others had an increase of over 33%. Bicycle injuries increased at every site, with a range in percent change from 24% to 135% increase. Although the greatest net increase was due to blunt injuries, there was a greater relative increase in penetrating injuries at 7/9 sites, with a range in percent change from a 110% increase to a 69% decrease. CONCLUSIONS: There was considerable discrepancy in pediatric injury patterns at the individual site level, perhaps suggesting a variable impact of the specific sociopolitical climate and pandemic policies of each catchment area. Investigation of the unique response of the community during times of stress at pediatric trauma centers is warranted to be better prepared for future environmental stressors.

Pediatric Injury Transfer Patterns During the COVID-19 Pandemic: An Interrupted time Series Analysis.

INTRODUCTION: With the expected surge of adult patients with COVID-19, the Children's Hospital Association recommended a tiered approach to divert children to pediatric centers. Our objective was understanding changes in interfacility transfer to Pediatric Trauma Centers (PTCs) during the first 6 mo of the pandemic. METHODS: Children aged < 18 y injured between January 1, 2016 and September 30, 2020, who met National Trauma Databank inclusion criteria from 9 PTCs were included. An interrupted time-series analysis was used to estimate an expected number of transferred patients compared to observed volume. The "COVID" cohort was compared to a historical cohort (historical average [HA]), using an average across 2016-2019. Site-based differences in transfer volume, demographics, injury characteristics, and hospital-based outcomes were compared between cohorts. RESULTS: Twenty seven thousand thirty one/47,382 injured patients (57.05%) were transferred to a participating PTC during the study period. Of the COVID cohort, 65.4% (4620/7067) were transferred, compared to 55.7% (3281/5888) of the HA (P < 0.001). There was a decrease in 15-y-old to 17-y-old patients (10.43% COVID versus 12.64% HA, P = 0.003). More patients in the COVID cohort had injury severity scores ≤ 15 (93.25% COVID versus 87.63% HA, P < 0.001). More patients were discharged home after transfer (31.80% COVID versus 21.83% HA, P < 0.001). CONCLUSIONS: Transferred trauma patients to Level I PTC increased during the COVID-19 pandemic. The proportion of transferred patients discharged from emergency departments increased. Pediatric trauma transfers may be a surrogate for referring emergency department capacity and resources and a measure of pediatric trauma triage capability.

A Multi-institutional Study Evaluating Pediatric Burn Injuries During the COVID-19 Pandemic.

During the COVID-19 pandemic, children were out of school due to Stay-at-Home Orders. The objective of this study was to investigate how the COVID-19 pandemic may have impacted the incidence of burn injuries in children. Eight Level I Pediatric Trauma Centers participated in a retrospective study evaluating children <18 years old with traumatic injuries defined by the National Trauma Data Bank. Patients with burn injuries were identified by ICD-10 codes. Historical controls from March to September 2019 ("Control" cohort) were compared to patients injured after the start of the COVID-19 pandemic from March to September 2020 ("COVID" cohort). A total of 12,549 pediatric trauma patients were included, of which 916 patients had burn injuries. Burn injuries increased after the start of the pandemic (COVID 522/6711 [7.8%] vs Control 394/5838 [6.7%], P = .03). There were no significant differences in age, race, insurance status, burn severity, injury severity score, intent or location of injury, and occurrence on a weekday or weekend between cohorts. There was an increase in flame burns (COVID 140/522 [26.8%] vs Control 75/394 [19.0%], P = .01) and a decrease in contact burns (COVID 118/522 [22.6%] vs Control 112/394 [28.4%], P = .05). More patients were transferred from an outside institution (COVID 315/522 patients [60.3%] vs Control 208/394 patients [52.8%], P = .02), and intensive care unit length of stay increased (COVID median 3.5 days [interquartile range 2.0-11.0] vs Control median 3.0 days [interquartile range 1.0-4.0], P = .05). Pediatric burn injuries increased after the start of the COVID-19 pandemic despite Stay-at-Home Orders intended to optimize health and increase public safety.

Pediatric injury trends and relationships with social vulnerability during the COVID-19 pandemic: A multi-institutional analysis.

BACKGROUND: The impact of the COVID-19 pandemic on pediatric injury, particularly relative to a community's vulnerability, is unknown. The objective of this study was to describe the change in pediatric injury during the first 6 months of the COVID-19 pandemic compared with prior years, focusing on intentional injury relative to the social vulnerability index (SVI). METHODS: All patients younger than 18 years meeting inclusion criteria for the National Trauma Data Bank between January 1, 2016, and September 30, 2020, at nine Level I pediatric trauma centers were included. The COVID cohort (children injured in the first 6 months of the pandemic) was compared with an averaged historical cohort (corresponding dates, 2016-2019). Demographic and injury characteristics and hospital-based outcomes were compared. Multivariable logistic regression was used to estimate the adjusted odds of intentional injury associated with SVI, moderated by exposure to the pandemic. Interrupted time series analysis with autoregressive integrated moving average modeling was used to predict expected injury patterns. Volume trends and observed versus expected rates of injury were analyzed. RESULTS: There were 47,385 patients that met inclusion criteria, with 8,991 treated in 2020 and 38,394 treated in 2016 to 2019. The COVID cohort included 7,068 patients and the averaged historical cohort included 5,891 patients (SD, 472), indicating a 20% increase in pediatric injury ( p = 0.031). Penetrating injuries increased (722 [10.2%] COVID vs. 421 [8.0%] historical; p < 0.001), specifically firearm injuries (163 [2.3%] COVID vs. 105 [1.8%] historical; p = 0.043). Bicycle collisions (505 [26.3%] COVID vs. 261 [18.2%] historical; p < 0.001) and collisions on other land transportation (e.g., all-terrain vehicles) (525 [27.3%] COVID vs. 280 [19.5%] historical; p < 0.001) also increased. Overall, SVI was associated with intentional injury (odds ratio, 7.9; 95% confidence interval, 6.5-9.8), a relationship which increased during the pandemic. CONCLUSION: Pediatric injury increased during the pandemic across multiple sites and states. The relationship between increased vulnerability and intentional injury increased during the pandemic. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

COVID-19 Pandemic Effects on the Epidemiology and Mortality of Pediatric Firearm Injuries; A Single Center Study.

BACKGROUND: The COVID-19 pandemic has been associated with increased firearm injuries amongst adults, though the pandemic's effect on children is less clearly understood. METHODS: This cross-sectional study was performed at a Level 1 Pediatric Trauma Center and included youths 0-19 years. The trauma registry was retrospectively queried for firearm injuries occurring pre-COVID-19 pandemic (March 2015-February 2020). Baseline data was compared to prospectively collected data occurring during the COVID-19 pandemic (March 2020-March 2022). Fischer's exact, Pearson's Chi-square and/or correlation analysis was used to compare pre and post-COVID-19 firearm injury rates and intent, victim demographics and disposition. Temporal relationships between firearm injury rates and local COVID-19 death rates were also described. RESULTS: 413 pre-COVID-19 firearm injuries were compared to 259 pandemic firearm injuries. Victims were mostly Black males with a mean age of 13.4 years. Compared to the 5 years pre-pandemic, monthly firearm injury rates increased 51.5% (6.8 vs 10.3 shootings/month), including a significant increase (p = 0.04) in firearm assaults/homicides and a relative decrease in unintentional shootings. Deaths increased 29%, and there were significantly fewer ED discharges and more admissions to OR and/or PICU (p = 0.005). There was a significant increase in Black victims (p = 0.01) and those having Medicaid or self-pay (p<0.001). Firearm injury spikes were noted during or within the 3 months following surges in local COVID-19 death rates. CONCLUSIONS: The COVID-19 pandemic was associated with an increase in the frequency and mortality of pediatric firearm injuries, particularly assaults amongst Black children following surges in COVID death rates. Increased violence-intervention services are needed, particularly amongst marginalized communities. LEVEL OF EVIDENCE: This is a prognostic study, evaluating the effects of the COVID-19 pandemic on pediatric firearm injuries, including victim demographics, injury intent and mortality. This study is retrospective and observational, making it Oxford Level III evidence.

Slipping Rib Syndrome in Children: Natural History and Outcomes Following Costal Cartilage Excision.

INTRODUCTION: Slipping rib syndrome (SRS) or subluxation of the medial aspect of the lower rib costal cartilages is an underdiagnosed cause of debilitating pain in otherwise healthy children. Costal cartilage excision may provide definitive symptom relief. However, limited data exist on the natural history, difficulty in diagnosis, and patient-reported outcomes for SRS in children. METHODS: We performed a single-institution descriptive study using chart review and a patient-focused survey for patients who underwent surgery for SRS from 2012 to 2020. Data regarding demographics, symptoms, diagnostic workup, and patient-reported outcomes were collected. RESULTS: Surgical resection was performed in 13 children. The median age at symptom onset was 12.5 y [IQR 9.7, 13.9], with a preponderance of girls (10, 77%). Eight patients participated in competitive athletics at the time of symptom onset. Prior to diagnosis, patients were seen by a median 3 [IQR 2, 5] providers with a median of 4 [IQR 3, 6] non-diagnostic imaging exams performed. The children included in the study underwent surgery for left (8), bilateral (4), and right (1) SRS. Two were lost to follow-up. At median post-op follow-up of 3.5 mo [IQR 1.2, 9.6], 73% (8/11) had returned to full activity. One reported non-limiting persistent pain symptoms. CONCLUSIONS: Lack of knowledge regarding SRS may result in delayed diagnosis, excessive testing, and limitation of physical activity. Operative treatment appears to provide durable relief and should be considered for children with SRS. The challenge remains to decrease the number of non-diagnostic exams and time to diagnosis.

The COVID-19 pandemic and associated rise in pediatric firearm injuries: A multi-institutional study.

BACKGROUND: Firearm sales in the United States (U.S.) markedly increased during the COVID-19 pandemic. Our objective was to determine if firearm injuries in children were associated with stay-at-home orders (SHO) during the COVID-19 pandemic. We hypothesized there would be an increase in pediatric firearm injuries during SHO. METHODS: This was a multi institutional, retrospective study of institutional trauma registries. Patients <18 years with traumatic injuries meeting National Trauma Data Bank (NTDB) criteria were included. A "COVID" cohort, defined as time from initiation of state SHO through September 30, 2020 was compared to "Historical" controls from an averaged period of corresponding dates in 2016-2019. An interrupted time series analysis (ITSA) was utilized to evaluate the association of the U.S. declaration of a national state of emergency with pediatric firearm injuries. RESULTS: Nine Level I pediatric trauma centers were included, contributing 48,111 pediatric trauma patients, of which 1,090 patients (2.3%) suffered firearm injuries. There was a significant increase in the proportion of firearm injuries in the COVID cohort (COVID 3.04% vs. Historical 1.83%; p < 0.001). There was an increased cumulative burden of firearm injuries in 2020 compared to a historical average. ITSA showed an 87% increase in the observed rate of firearm injuries above expected after the declaration of a nationwide emergency (p < 0.001). CONCLUSION: The proportion of firearm injuries affecting children increased during the COVID-19 pandemic. The pandemic was associated with an increase in pediatric firearm injuries above expected rates based on historical patterns.

Impact of "Stay-at-Home" orders on non-accidental trauma: A multi-institutional study.

BACKGROUND: It is unclear how Stay-at-Home Orders (SHO) of the COVID-19 pandemic impacted the welfare of children and rates of non-accidental trauma (NAT). We hypothesized that NAT would initially decrease during the SHO as children did not have access to mandatory reporters, and then increase as physicians' offices and schools reopened. METHODS: A multicenter study evaluating patients <18 years with ICD-10 Diagnosis and/or External Cause of Injury codes meeting criteria for NAT. "Historical" controls from an averaged period of March-September 2016-2019 were compared to patients injured March-September 2020, after the implementation of SHO ("COVID" cohort). An interrupted time series analysis was utilized to evaluate the effects of SHO implementation. RESULTS: Nine Level I pediatric trauma centers contributed 2064 patients meeting NAT criteria. During initial SHO, NAT rates dropped below what was expected based on historical trends; however, thereafter the rate increased above the expected. The COVID cohort experienced a significant increase in the proportion of NAT patients age ≥5 years, minority children, and least resourced as determined by social vulnerability index (SVI). CONCLUSIONS: The COVID-19 pandemic affected the presentation of children with NAT to the hospital. In times of public health crisis, maintaining systems of protection for children remain essential. LEVEL OF EVIDENCE: III.

Index Admission Cholecystectomy and Recurrence of Pediatric Gallstone Pancreatitis: Multicenter Cohort Analysis.

BACKGROUND: We aim to evaluate recurrence rates of gallstone pancreatitis in children undergoing early vs interval cholecystectomy. STUDY DESIGN: A multicenter, retrospective review of pediatric patients admitted with gallstone pancreatitis from 2010 through 2017 was performed. Children were evaluated based on timing of cholecystectomy. Early cholecystectomy was defined as surgery during the index admission, whereas the delayed group was defined as no surgery or surgery after discharge. Outcomes, recurrence rates, and complications were evaluated. RESULTS: Of 246 patients from 6 centers with gallstone pancreatitis, 178 (72%) were female, with mean age 13.5 ± 3.2 years and a mean body mass index of 28.9 ± 15.2. Most (90%) patients were admitted with mild pancreatitis (Atlanta Classification). Early cholecystectomy was performed in 167 (68%) patients with no difference in early cholecystectomy rates across institutions. Delayed group patients weighed less (61 kg vs. 72 kg, p = 0.003) and were younger (12 vs. 14 years, p = 0.001) than those who underwent early cholecystectomy. However, there were no differences in clinical, radiological, or laboratory characteristics between groups. There were 4 (2%) episodes of postoperative recurrent pancreatitis in the early group compared with 22% in the delayed group. More importantly, when cholecystectomy was delayed more than 6 weeks from index discharge, recurrence approached 60%. There were no biliary complications in any group. CONCLUSIONS: Cholecystectomy during the index admission for children with gallstone pancreatitis reduces recurrent pancreatitis. Recurrence proportionally increases with time when patients are treated with a delayed approach.

Racial disparities in triage of adolescent patients after bullet injury.

BACKGROUND: While pediatric trauma centers (PTCs) and adult trauma centers (ATCs) exhibit equivalent trauma mortality, the optimal care environment for traumatically injured adolescents remains controversial. Race has been shown to effect triage within emergency departments (EDs) with people of color receiving lower acuity triage scores. We hypothesized that African-American adolescents were more likely triaged to an ATC than a PTC compared with their White peers. METHODS: Institutional trauma databases from a neighboring, urban Level I PTC and ATC were queried for gunshot wounds in adolescents (15-18 years) presenting to the ED from 2015 to 2017. The PTC and ATC were compared in terms of demographics, services, and outcomes. Results were analyzed using univariate analysis and logistic regression. RESULTS: Among 316 included adolescents, 184 were treated in an ATC versus 132 in a PTC. Patients at the PTC were significantly more likely to be younger (16.1 vs. 17.5 years; p < 0.001), White (16% vs. 5%; p = 0.001), and privately insured (41% vs. 30%; p = 0.002). At each age, the proportion of Whites treated at the PTC exceeded the proportion of African-Americans. At the PTC, patients were more likely to receive inpatient and outpatient social work follow-up (89% vs. 1%, p < 0.001). Adolescents treated at the PTC were less likely to receive opioids (75% vs. 56%, p = 0.001) at discharge and to return to ED within 6 months (25% vs. 11%, p = 0.005). On multivariate logistic regression, African-American adolescents were less likely to be treated at a PTC (odds ratio, 0.30; 95% confidence interval, 0.10-0.85; p = 0.02) after controlling for age and Injury Severity Score. CONCLUSION: Disparities in triage of African-American and White adolescents after bullet injury lead to unequal care. African-Americans were more likely to be treated at the ATC, which was associated with increased opioid prescription, decreased social work support, and increased return to ED. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level IV.

Implementation of a clinical guideline for nonoperative management of isolated blunt renal injury in children.

BACKGROUND: The aim was to evaluate the impact of a standardized nonoperative management protocol by comparing patients with isolated blunt renal injury before and after implementation. METHODS: We retrospectively reviewed the trauma registry at our Level 1 pediatric trauma center. We compared consecutive patients (≤ 18 years) managed nonoperatively for blunt renal injury Pre (1/2010-9/2014) and Post (10/2014-3/2020) implementation of a clinical guideline. Outcomes included length of stay, intensive care unit admission, urinary catheter use, and imaging studies. RESULTS: We included 48 patients with isolated blunt renal injuries (29 Pre, 19 Post). There were no differences in age, sex, injury grade, or mechanism (P > .05). Postprotocol had decreased length of stay (P = .040), intensive care unit admissions (P = .015), urinary catheter use (P = .031), and ionizing radiation imaging (P < .001). CONCLUSION: These data suggest improved outcomes and resource utilization following implementation of a nonoperative management protocol of pediatric isolated blunt renal injuries.

Extended sternotomy with lateral neck incision: An alternative approach for children with large apical chest masses with thoracic inlet involvement.

Pediatric tumors in the apex of the thoracic cavity are often diagnosed late due to the absence of symptoms. These tumors can be quite large at presentation with involvement of the chest wall, sympathetic chain, spine, and aortic arch. The tumors can also extend into the thoracic inlet and encircle the brachial plexus. Depending on the diagnosis, treatment may involve chemotherapy with subsequent surgery or require primary resection. Optimal exposure to resect large apical tumors with thoracic inlet extension is a surgical challenge. To date, several surgical techniques have been described to resect these tumors - including both anterior and posterior thoracic approaches. Each of these techniques can be limited by inadequate exposure of the mass. We describe an alternative approach to surgical resection of these masses that employs an extended sternotomy with a lateral neck incision. This report details two successful resections of large left apical masses with thoracic inlet involvement in children using this technique (Level of evidence 4).

Case report of mesenteric strangulation secondary to longstanding ventriculoperitoneal shunt catheter.

BACKGROUND: Ventriculoperitoneal (VP) shunts are the most common treatment for hydrocephalus in both pediatric and adult patients. Complications resulting from the abdominal portion of shunts include tube disconnection, obstruction of the shunt tip, catheter migration, infection, abdominal pseudocysts, and bowel perforation. However, other less common complications can occur. The authors present a unique case of a patient with a longstanding VP shunt presenting with an acute abdomen secondary to knotting of the peritoneal portion of the catheter tubing. CASE DESCRIPTION: A 13-year-old male with past medical history significant for myelomeningocele, requiring ventriculoperitoneal shunt placement at 18 months of age, presented to an outside hospital with chief complaint of abdominal pain. Cross-sectional imaging revealed spontaneous knot formation within the shunt tubing around the base of the small bowel mesentery. He was then transferred to our facility for general and neurosurgical evaluation. His abdominal exam was notable for diffuse distension in addition to tenderness to palpation with guarding and rebound. Given his tenuous clinical status and peritonitis, he was emergently booked for abdominal exploration. He underwent bowel resection, externalization of his shunt, with later re-anastomosis and shunt internalization. He eventually made a full recovery. DISCUSSION: Given the potential for significant bowel loss with this and other shunt-related complications, this case serves as a reminder that even longstanding VP shunts should be considered in the differential diagnosis of abdominal pain in any patient with a shunt.

North American survey on the post-neuroimaging management of children with mild head injuries.

OBJECTIVEThere remains uncertainty regarding the appropriate level of care and need for repeating neuroimaging among children with mild traumatic brain injury (mTBI) complicated by intracranial injury (ICI). This study's objective was to investigate physician practice patterns and decision-making processes for these patients in order to identify knowledge gaps and highlight avenues for future investigation.METHODSThe authors surveyed residents, fellows, and attending physicians from the following pediatric specialties: emergency medicine; general surgery; neurosurgery; and critical care. Participants came from 10 institutions in the United States and an email list maintained by the Canadian Neurosurgical Society. The survey asked respondents to indicate management preferences for and experiences with children with mTBI complicated by ICI, focusing on an exemplar clinical vignette of a 7-year-old girl with a Glasgow Coma Scale score of 15 and a 5-mm subdural hematoma without midline shift after a fall down stairs.RESULTSThe response rate was 52% (n = 536). Overall, 326 (61%) respondents indicated they would recommend ICU admission for the child in the vignette. However, only 62 (12%) agreed/strongly agreed that this child was at high risk of neurological decline. Half of respondents (45%; n = 243) indicated they would order a planned follow-up CT (29%; n = 155) or MRI scan (19%; n = 102), though only 64 (12%) agreed/strongly agreed that repeat neuroimaging would influence their management. Common factors that increased the likelihood of ICU admission included presence of a focal neurological deficit (95%; n = 508 endorsed), midline shift (90%; n = 480) or an epidural hematoma (88%; n = 471). However, 42% (n = 225) indicated they would admit all children with mTBI and ICI to the ICU. Notably, 27% (n = 143) of respondents indicated they had seen one or more children with mTBI and intracranial hemorrhage demonstrate a rapid neurological decline when admitted to a general ward in the last year, and 13% (n = 71) had witnessed this outcome at least twice in the past year.CONCLUSIONSMany physicians endorse ICU admission and repeat neuroimaging for pediatric mTBI with ICI, despite uncertainty regarding the clinical utility of those decisions. These results, combined with evidence that existing practice may provide insufficient monitoring to some high-risk children, emphasize the need for validated decision tools to aid the management of these patients.

A Pilot Study of Viscoelastic Monitoring in Pediatric Trauma: Outcomes and Lessons Learned.

BACKGROUND: Examine the characteristics and outcomes of pediatric trauma patients at risk for coagulopathy following implementation of viscoelastic monitoring. MATERIALS AND METHODS: Injured children, aged <18 years, from September 7, 2014, to December 21, 2015, at risk for trauma-induced coagulopathy were identified from a single, level-1 American College of Surgeons verified pediatric trauma center. Patients were grouped by coagulation assessment: no assessment (NA), conventional coagulation testing alone (CCT), and conventional coagulation testing with rapid thromboelastography (rTEG). Coagulation assessment was provider preference with all monitoring options continuously available. Groups were compared and outcomes were evaluated including blood product utilization, Intensive Care Unit (ICU) utilization, duration of mechanical ventilation, and mortality. RESULTS: A total of 155 patients were identified (NA = 78, CCT = 54, and rTEG = 23). There was no difference in age, gender, race, or mechanism. In practice, rTEG patients were more severely injured, more anemic, and received more blood products and crystalloid (P < 0.001). rTEG patients also had increased mortality with fewer ventilator and ICU-free days. Multivariate logistic regression and covariance analysis indicated that while rTEG use was not associated with mortality, it was associated with increased use of blood products, duration of mechanical ventilation, and ICU length of stay. CONCLUSIONS: Viscoelastic monitoring was infrequently performed, but utilized in more severely injured patients. Well-designed prospective studies in patients at high risk of coagulopathy are needed to evaluate goal-directed hemostatic resuscitation strategies in children.

Development of the CIDSS2 Score for Children with Mild Head Trauma without Intracranial Injury.

While most children with mild traumatic brain injury (mTBI) without intracranial injury (ICI) can be safely discharged home from the emergency department, many are admitted to the hospital. To support evidence-based practice, we developed a decision tool to help guide hospital admission decisions. This study was a secondary analysis of a prospective study conducted in 25 emergency departments. We included children under 18 years who had Glasgow Coma Scale score 13-15 head injuries and normal computed tomography scans or skull fractures without significant depression. We developed a multi-variable model that identified risk factors for extended inpatient management (EIM; defined as hospitalization for 2 or more nights) for TBI, and used this model to create a clinical risk score. Among 14,323 children with mTBI without ICI, 20% were admitted to the hospital but only 0.76% required EIM for TBI. Key risk factors for EIM included Glasgow Coma Scale score less than 15 (odds ratio [OR] = 8.1; 95% confidence interval [CI] 4.0-16.4 for 13 vs. 15), drug/alcohol Intoxication (OR = 5.1; 95% CI 2.4-10.7), neurological Deficit (OR = 3.1; 95% CI 1.4-6.9), Seizure (OR = 3.7; 95% CI 1.8-7.8), and Skull fracture (odds ratio [OR] 24.5; 95% CI 16.0-37.3). Based on these results, the CIDSS2 risk score was created. The model C-statistic was 0.86 and performed similarly in children less than (C = 0.86) and greater than or equal to 2 years (C = 0.86). The CIDSS2 score is a novel tool to help physicians identify the minority of children with mTBI without ICI at increased risk for EIM, thereby potentially aiding hospital admission decisions.

Traumatic colorectal injuries in children: The National Trauma Database experience.

PURPOSE: We sought to utilize a nationwide database to characterize colorectal injuries in pediatric trauma. METHODS: The National Trauma Database (NTDB) was queried for all patients (age≤14years) with colorectal injuries from 2013 to 2014. We stratified patients by demographics and measured outcomes. We analyzed groups based on mechanism, colon vs rectal injury, as well as colostomy creation. Statistical analysis was conducted using t-test and ANOVA for continuous variables as well as chi-square for continuous variables. RESULTS: There were 534 pediatric patients who sustained colorectal trauma. The mean ISS was 15.6±0.6 with an average LOS of 8.5±0.5days. 435 (81.5%) were injured by blunt mechanism while 99 (18.5%) were injured by penetrating mechanism. There were no differences between age, ISS, complications, mortality, LOS, ICU LOS, and ventilator days between blunt and penetrating groups. Significantly more patients in the penetrating group had associated small intestine and hepatic injuries as well as underwent colostomies. Patients with rectal injuries (25.7%) were more likely to undergo colonic diversion (p<0.0001), but also had decreased mortality (p=0.001) and decreased LOS (p=0.01). Patients with colostomies (9.9%) had no differences in age, ISS, GCS, transfusion of blood products, and complications compared to patients who did not receive a colostomy. Despite this, colostomy patients had significantly increased hospital LOS (12.1±1.8 vs 8.2±0.5days, p=0.02) and ICU LOS (9.0±1.7 vs 5.4±0.3days, p=0.02). CONCLUSION: Although infrequent, colorectal injuries in children are associated with considerable morbidity regardless of mechanism and may be managed without fecal diversion. LEVEL OF EVIDENCE: III. STUDY TYPE: Epidemiology.

Development and Internal Validation of a Clinical Risk Score for Treating Children With Mild Head Trauma and Intracranial Injury.

Importance: The appropriate treatment of children with mild traumatic brain injury (mTBI) and intracranial injury (ICI) on computed tomographic imaging remains unclear. Evidence-based risk assessments may improve patient safety and reduce resource use. Objective: To derive a risk score predicting the need for intensive care unit observation in children with mTBI and ICI. Design, Setting, and Participants: This retrospective analysis of the prospective Pediatric Emergency Care Applied Research Network (PECARN) head injury cohort study included patients enrolled in 25 North American emergency departments from 2004 to 2006. We included patients younger than 18 years with mTBI (Glasgow Coma Scale [GCS] score, 13-15) and ICI on computed tomography. The data analysis was conducted from May 2015 to October 2016. Main Outcomes and Measures: The primary outcome was the composite of neurosurgical intervention, intubation for more than 24 hours for TBI, or death from TBI. Multivariate logistic regression was used to predict the outcome. The C statistic was used to quantify discrimination, and model performance was internally validated using 10-fold cross-validation. Based on this modeling, the Children's Intracranial Injury Decision Aid score was created. Results: Among 15 162 children with GCS 13 to 15 head injuries who received head computed tomographic imaging in the emergency department, 839 (5.5%) had ICI. The median ages of those with and without a composite outcome were 7 and 5 years, respectively. Among those patients with ICI, 8.7% (n = 73) experienced the primary outcome, including 8.3% (n = 70) who had a neurosurgical intervention. The only clinical variable significantly associated with outcome was GCS score (odds ratio [OR], 3.4; 95% CI, 1.5-7.4 for GCS score 13 vs 15). Significant radiologic predictors included midline shift (OR, 6.8; 95% CI, 3.4-13.8), depressed skull fracture (OR, 6.5; 95% CI, 3.7-11.4), and epidural hematoma (OR, 3.4; 95% CI, 1.8-6.2). The model C statistic was 0.84 (95% CI, 0.79-0.88); the 10-fold cross-validated C statistic was 0.83. Based on this modeling, we developed the Children's Intracranial Injury Decision Aid score, which ranged from 0 to 24 points. The negative predictive value of having 0 points (ie, none of these risk factors) was 98.8% (95% CI, 97.3%-99.6%). Conclusions and Relevance: Lower GCS score, midline shift, depressed skull fracture, and epidural hematoma are key risk factors for needing intensive care unit-level care in children with mTBI and ICI. Based on these results, the Children's Intracranial Injury Decision Aid score is a potentially novel tool to risk stratify this population, thereby aiding management decisions.