Surgical outcomes of pancreaticoduodenal injuries in children.

PURPOSE: To examine surgical outcomes of children with pancreaticoduodenal injuries at a Quaternary Level I pediatric trauma center. METHODS: We queried a prospectively maintained trauma database of a level one pediatric trauma center for all cases of pancreatic and/or duodenal injury from 2002 to 2017. Analysis was conducted using JMP 13.1.0. RESULTS: 170 children presented with pancreatic and/or duodenal injury. 13 (7.7%) suffered a combined injury and this group forms the basis for this report with mean ISS of 22.8 (± 15.1), RTS2 of 6.4(± 2.1), and median age of 6.6 (1.3-13.5) years. Child abuse (31%) and bicycle injuries (23%) were the most common mechanisms. 8/13 (61.5%) required operative intervention. Higher AAST pancreatic and duodenal injury grade (2.9 vs. 1.2, p = 0.05 and 3.6 vs. 1.4, p = < 0.01), lower RTS2 (7.84 vs. 5.49, p < 0.01), and lower GCS (9.6 vs. 15, p = 0.03) predicted operative intervention. 6/8 (75%) undergoing surgery survived to discharge with only (2/6) survivors suffering postoperative complications. Both mortalities were secondary to severe traumatic brain injury. CONCLUSION: Surgical management of complex pancreaticoduodenal injury is an uncommon traumatic event that is associated with high injury severity, but survival occurs in most scenarios.

Charge Awareness Affects Treatment Choice: Prospective Randomized Trial in Pediatric Appendectomy.

OBJECTIVE: To determine whether charge awareness affects patient decisions. BACKGROUND: Pediatric uncomplicated appendicitis can be treated with open or laparoscopic techniques. These 2 operations are considered to have clinical equipoise. METHODS: In a prospective, randomized clinical trial, nonobese children admitted to a children's hospital with uncomplicated appendicitis were randomized to view 1 of 2 videos discussing open and laparoscopic appendectomy. Videos were identical except that only one presented the difference in surgical materials charges. Patients and parents then choose which operation they desired. Videos were available in English and Spanish. A postoperative survey was conducted to examine factors that influenced choice. The trial was registered at ClinicalTrials.gov (NCT 01738750). RESULTS: Of 275 consecutive cases, 100 met enrollment criteria. In the group exposed to charge data (n = 49), 63% chose open technique versus 35% not presented charge data (P = 0.005). Patients were 1.8 times more likely to choose the less expensive option when charge estimate was given (95% confidence interval, 1.17-2.75). The median total hospital charges were $1554 less for those who had open technique (P < 0.001) and $528 less for the group exposed to charge information (P = 0.033). Survey found that 90% of families valued having input in this decision and 31% of patients exposed to charge listed it as their primary reason for their choice in technique. CONCLUSIONS: Patients and parents tended to choose the less expensive but equally effective technique when given the opportunity. A discussion of treatment options, which includes charge information, may represent an unrealized opportunity to affect change in health care spending.

Cervical spine imaging in hospitalized children with traumatic brain injury.

OBJECTIVES: The purposes of this study, in children with traumatic brain injury (TBI), to describe cervical spine imaging practice, to assess for recent changes in imaging practice, and to determine whether cervical spine computed tomography (CT) is being used in children at low risk for cervical spine injury. METHODS: The setting was children's hospitals participating in the Pediatric Health Information System database, from January 2001 to June 2011. Participants were children (younger than 18 y) with TBI who were evaluated in the emergency department, admitted to the hospital, and received a head CT scan on the day of admission. The primary outcome measures were cervical spine imaging studies. This study was exempted from institutional review board assessment. RESULTS: A total of 30,112 children met study criteria. Overall, 52% (15,687/30,112) received cervical spine imaging. The use of cervical spine radiographs alone decreased between 2001 (47%) and 2011 (23%), with an annual decrease of 2.2% (95% confidence interval [CI], 1.1%-3.3%), and was largely replaced by an increased use of CT, with or without radiographs (8.6% in 2001 and 19.5% in 2011, with an annual increase of 0.9%; 95% CI, 0.1%-1.8%). A total of 2545 children received cervical spine CT despite being discharged alive from the hospital in less than 72 hours, and 1655 of those had a low-risk mechanism of injury. CONCLUSIONS: The adoption of CT clearance of the cervical spine in adults seems to have influenced the care of children with TBI, despite concerns about radiation exposure.

Child physical abuse and COVID-19: Trends from nine pediatric trauma centers.

BACKGROUND: Economic, social, and psychologic stressors are associated with an increased risk for abusive injuries in children. Prolonged physical proximity between adults and children under conditions of severe external stress, such as witnessed during the COVID-19 pandemic with "shelter-in-place orders", may be associated with additional increased risk for child physical abuse. We hypothesized that child physical abuse rates and associated severity of injury would increase during the early months of the pandemic as compared to the prior benchmark period. METHODS: We conducted a nine-center retrospective review of suspected child physical abuse admissions across the Western Pediatric Surgery Research Consortium. Cases were identified for the period of April 1-June 30, 2020 (COVID-19) and compared to the identical period in 2019. We collected patient demographics, injury characteristics, and outcome data. RESULTS: There were no significant differences in child physical abuse cases between the time periods in the consortium as a whole or at individual hospitals. There were no differences between the study periods with regard to patient characteristics, injury types or severity, resource utilization, disposition, or mortality. CONCLUSIONS: Apparent rates of new injuries related to child physical abuse did not increase early in the COVID-19 pandemic. While this may suggest that pediatric physical abuse was not impacted by pandemic restrictions and stresses, it is possible that under-reporting, under-detection, or delays in presentation of abusive injuries increased during the pandemic. Long-term follow-up of subsequent rates and severity of child abuse is needed to assess for unrecognized injuries that may have occurred.

Traumatic brain injury: preferred methods and targets for resuscitation.

PURPOSE OF REVIEW: Severe traumatic brain injury (TBI) is the most common cause of death and disability in pediatric trauma. This review looks at the strategies to treat TBI in a temporal fashion. We examine the targets for resuscitation from field triage to definitive care in the pediatric ICU. RECENT FINDINGS: Guidelines for the management of pediatric TBI exist. The themes of contemporary clinical research have been compliance with these guidelines and refinement of treatment recommendations developing a more sophisticated understanding of the pathophysiology of the injured brain. In the field, the aim has been to achieve routine compliance with the resuscitation goals. In the hospital, efforts have been directed at improving our ability to monitor the injured brain, developing techniques that limit brain swelling, and customizing brain perfusion. SUMMARY: As our understanding of pediatric TBI evolves, the ambition is that age-specific and perhaps individual brain injury strategies based upon feedback from continuous monitors will be defined. In addition, vogue methods such as hypothermia, hypertonic saline, and aggressive surgical decompression may prove to impact brain swelling and outcomes.

Adrenocortical tumors in children.

Adrenocortical neoplasms are rare in childhood. Unlike their adult counterparts, they are often hormonally active and malignant. Despite being uncommon, adrenocortical neoplasms in children have significant associated morbidity and require complete surgical resection for effective management. Furthermore, the clinical overlap between adrenocortical neoplasms, adrenal medullary neoplasms, and functional disorders of the adrenal cortex requires that the practicing pediatric surgeon have a solid working knowledge of the presentation, diagnostic workup, and management of these anatomically related yet disparate pathologies.

The effect of family presence on the efficiency of pediatric trauma resuscitations.

STUDY OBJECTIVE: Family presence has broad professional organizational support and is gaining acceptance. We seek to determine whether family presence prolonged pediatric trauma team resuscitations as measured by time from emergency department arrival to computed tomographic (CT) scan, and to resuscitation completion. METHODS: A prospective trial offered families of pediatric trauma patients family presence on even days and no family presence on odd days. Primary outcome measures were time from arrival to CT scan and to resuscitation completion (laboratory tests, emergency procedures, portable radiographs, and secondary survey). We evaluated the effect of family presence in an adjusted Cox proportional hazards model. Staff and family experiencing a resuscitation with family presence were asked their opinions of that experience. RESULTS: Of 1,229 pediatric trauma activations, 705 patients were included in the study protocol, 283 with family presence on even days, 422 without family presence on odd days. Median times to CT scan (21 minutes; IQR 16 to 29 minutes) and median resuscitation times (15 minutes; IQR 10 to 20 minutes) were similar with and without family presence. There was no clinically relevant difference in CT time (hazard ratio 1.04; 95% confidence interval [CI] 0.83 to 1.30) or resuscitation time (hazard ratio 0.98; 95% CI 0.83 to 1.15). Families believed that family presence was helpful both to their child and themselves. CONCLUSION: This prospective trial shows that family presence does not prolong time to CT imaging or to resuscitation completion for pediatric trauma patients. Family presence does not negatively affect the time efficiency of the pediatric trauma resuscitation.

A standard pediatric trauma laboratory panel: a plea for a minimalist approach.

BACKGROUND: Optimizing patient outcomes has promoted a protocol-driven environment within the trauma bay. No standardized laboratory panel exists during the initial evaluation of injured children. METHODS: In 2004, we implemented a standard trauma panel consisting of an i-STAT analysis (electrolytes, hematocrit, and blood gas), and type and cross. We reviewed the experience of this protocol 1 year prior (T1) and after (T2) its implementation. RESULTS: During T1, 23% of patients underwent a traditional trauma panel compared with T2 where 43.5% received the new standard trauma panel. Neither the mean number of laboratory draws per patient (T1 = 4.6 vs. T2 = 4.3, p = 0.77) nor the mean number of laboratory tests obtained (T1 = 15.0 vs. T2 = 12.7, p = 0.99) were significantly different between the two groups. The mean amount of blood drawn within the trauma bay was significantly more in T1 compared with T2 (10 mL vs. 3.8 mL, respectively, p < 0.0001). The initial laboratory costs were $307.97 during T1 and $177.51 during T2, although the mean total laboratory charges were not significantly different between the two groups (T1 = $2,119.97 vs. T2 = $2,143.77, p = 0.62). CONCLUSIONS: The implementation of a standard laboratory panel increased the uniformity of care without compromising quality. We limited the volume and initial cost of blood drawn which is advantageous in small children.

Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: a multi-center study of the american association for the surgery of trauma.

BACKGROUND: Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years. METHODS: The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by univariate and multivariate analysis. A weighted score was calculated by assigning 1, 2, or 3 points to each independent predictor according to its magnitude of effect. The score was established on two thirds of the population and validated using the remaining one third. RESULTS: Of 12,537 patients younger than 3 years, CSI was identified in 83 patients (0.66%), eight had spinal cord injury. Four independent predictors of CSI were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a negative predictive value of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study. CONCLUSIONS: CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.

Report of 52nd annual meeting of the pacific association of pediatric surgeons.

This is the report of the 52nd Annual Association of Pediatric Surgeons held in Christchurch, New Zealand, March 10-March 14, 2019.

Use of ECMO support in pediatric patients with severe thoracic trauma.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has been used in the non-trauma setting for over 30 years. However, the use of ECMO in trauma remains a difficult question, as the risk of bleeding must be weighed against the benefits of cardiopulmonary support. METHODS: Retrospective review of children who sustained severe thoracic trauma (chest abbreviated injury score ≥3) and required ECMO support between 2009 and 2016. RESULTS: Of the 425 children who experienced severe thoracic trauma, 6 (1.4%) underwent ECMO support: 67% male, median age 4.8 years, median ISS 36, median GCS 3, and overall survival 83%. The median hospital day of ECMO initiation was 2 with a median ECMO duration of 7 days. All cannulations occurred through the right neck regardless of the size of the child. Five initially had veno-venous support with 1 requiring conversion to veno-arterial (VA) support. Both children on VA support suffered devastating cerebrovascular accidents, one of which ultimately led to withdrawal of care and death. Complications in the cohort included: paraplegia (1), neurocognitive defects/dysphonia (1), infected neck hematoma (1), deep femoral venous thrombosis (1), bilateral lower extremity spasticity (1). CONCLUSION: This small cohort supports the use of ECMO in children with severe thoracic injuries as a potentially lifesaving intervention, however, not without significant complication. LEVEL OF EVIDENCE: IV.

Longboard injuries treated at a level 1 pediatric trauma center.

INTRODUCTION: Recreation on longboards is gaining in popularity. The purpose of this study is to detail the injury patterns, treatment and management of children with longboarding injuries seen at a level 1 pediatric trauma center. METHODS: A retrospective review using our trauma registry from 2006 to 2016 of pediatric patients who sustained injuries while riding a longboard. RESULTS: Of 12,920 injured children, 64 (0.5%) were treated for injuries that occurred while riding a longboard. Median age was 14.5 years (IQR 13.6, 15.4) and 84% were male. Fifty-one (80%) suffered a traumatic brain injury (TBI) including 32 intracranial hemorrhages (ICH), 17 concussions, and 31 skull fractures. Seven (11%) were wearing helmets. Three patients required neurosurgical intervention. Extremity fractures were the most common reason for surgery. Ninety-six percent of patients were admitted to the hospital with a median length of stay of 1 day (IQR 1, 3). All children survived to discharge. Compared with skateboard injuries during the same period, TBI, ICH, concussion, and skull fractures were all greater. CONCLUSIONS: TBI ranging from concussion to ICH requiring craniotomy is common in children injured while riding a longboard, and greater than rates after skateboarding injuries. Extremity fracture was the most common reason for operative intervention. LEVEL OF EVIDENCE: III.

Reduction of resource utilization in children with blunt solid organ injury.

BACKGROUND/PURPOSE: Nonoperative management of blunt solid organ injuries continues to progress and improve cost-effective utilization of resources while maximizing patient safety. The purpose of this study is to compare resource utilization and patient outcomes after changing admission criteria from a grade-based protocol to one based on hemodynamic stability. METHODS: A retrospective review of isolated liver and spleen injuries was done using prospectively collected trauma registry data from 2013 to 2017. The 2 years preceding the change were compared to the 2 years after protocol change. All analyses were performed using SAS 9.4. RESULTS: There were 121 patients in the preprotocol cohort and 125 patients in the postprotocol cohort. Baseline demographics were similar along with injury mechanisms and severity. The ICU admission rate decreased from 40% to 22% (p = 0.002). There were no adverse events on the floor and no patient needed to be transferred to the ICU. CONCLUSIONS: A protocol for ICU admission based on physiologic derangement versus solely on radiologic grade significantly reduced admission rates to the ICU in children with solid organ injury. The protocol was safe and effectively reduced resource utilization. LEVEL OF EVIDENCE: Level II, prospective comparison study.

Report of PAPS meeting.

This is a report of the Pacific Association of Pediatric Surgeons Fifty-First Scientific Meeting held in Sapporo, Japan, from May 13to May 17, 2018.

Helmet under-utilization by children during equestrian events is associated with increased traumatic brain injury.

PURPOSE: Awareness of equestrian related injury remains limited. Studies evaluating children after equestrian injury report under-utilization of safety equipment and rates of operative intervention as high as 33%. METHODS: We hypothesized that helmets are underutilized during equestrian activity and lack of use is associated with increased traumatic brain injury. We queried the trauma database of a level one pediatric trauma center for all cases of equestrian and rodeo related injury from 2005 to 2015. Analysis was conducted using SAS 9.4. RESULTS: Of 312 children identified, 142 were assessed for use of a helmet. Only 28 children (19.7%) had documented use of a helmet. Most injuries occurred while riding a horse (83%) or bull (13%) with traumatic brain injury being the most common injury (51%). Helmet use was associated with decreased ISS (7.1 vs. 11.3, p<0.01), TBI (32.4% vs. 55.3%, p=0.03), and ICU admission (10.7% vs. 29%, p=0.05). Multivariable analysis reveals lack of helmet use to be an independent predictor of TBI (OR 2.5, 95% CI 1.1-6.3). CONCLUSION: Helmets are underutilized by children during equestrian related activity. Increased awareness of TBI and education encouraging helmet use may decrease morbidity associated with equestrian activities. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Longitudinal analysis of hospital charges following injury in a level 1 pediatric trauma system.

BACKGROUND: The treatment of injured children contributes substantially to the financial burden of a health care system. The purpose of this study was to characterize these charges at a level-1 pediatric trauma center. METHODS: Financial data for children (<14 years) admitted for traumatic injury from 1/2009 to 12/2014 were analyzed. The charges of the index admission and first two years following discharge were evaluated. RESULTS: 5853 trauma patients were included with average annual charges of $11,128,730. The most common mechanisms of injury were fall (44%), sports (12%), and bike (9%). The median ISS was 6 (IQR 4-10) with a mortality rate of 1.8% and Z-score of 13.04 (p<0.001). The overall total charges per patient during the index admission were $9513. Spinal cord and major abdominal injuries had the greatest charges per patient ($55,560 and $23,618 respectively) primarily owing to hospital LOS. During the first year after discharge, the total charges per patient were $1733, of which spinal cord injury resulted in highest overall ($19,426), owing to inpatient rehabilitation. For all other injury patterns, mean total charges per patient were $2376 (range $791-$3573). CONCLUSIONS: The value proposition in health care requires us to define outcomes relative to costs. Injury severity, major injury location, and hospital length of stay are the highest contributors for the financial burden of pediatric traumatic injury, while inpatient readmissions and inpatient rehabilitation drove higher charges in the years following discharge. TYPE OF STUDY: Clinical Research Paper. LEVEL OF EVIDENCE: II - Cohort Study.

Clearance of tunneled central venous catheter associated blood stream infections in children.

BACKGROUND: The optimal time to reinsert central venous catheters (tCVC) after a documented central line associated blood stream infection (CLABSI) is unclear. The goal of this study is to identify risk factors for children who develop persistent bacteremia after tCVC removal due to CLABSI. METHODS: We performed a retrospective cohort study from a tertiary children's hospital. Children who underwent removal of a tCVC due to CLABSI were included in our analysis. Our primary outcome was persistent bacteremia after tCVC removal defined by a persistently positive blood culture. Salient patient demographic and clinical factors were extracted from the medical record. RESULTS: A total of 140 patients met inclusion criteria and 27 (19%) had a persistent CLABSI after removal of the tCVC. There were no significant differences between the patients who cleared their bacteremia and those who develop persistent bacteremia. The median (IQR) time to positive blood culture after tCVC removal was 2.7 days (1.7- 4.0). CONCLUSIONS: We did not identify any patient risk factors distinguishing between a child who will clear a CLABSI versus develop a persistent CLABSI after tCVC removal. Blood stream infection clearance was rapid after tCVC removal, supporting a brief line holiday prior to tCVC reinsertion. LEVEL OF EVIDENCE: Level III Retrospective Case-Control Study.

Pediatric blunt abdominal injury: age is irrelevant and delayed operation is not detrimental.

BACKGROUND: During the past 40 years, management of solid organ injury in pediatric trauma patients has shifted to highly successful nonoperative management. Our purpose was to characterize children requiring operative intervention. We hypothesized that older children would be more likely to require operative intervention. In particular, we wanted to examine potential outcome disparities between children who were operated upon immediately and those in whom attempted nonoperative management failed. Additionally, we asked whether attempted nonoperative management, when failed, put children at higher risk for mortality or morbidities such as increased blood product transfusions or lengths of stays. METHODS: Retrospective cohorts from seven Level I pediatric trauma centers were identified. Blunt splenic, hepatic, renal, or pancreatic injuries were documented in 2,944 children <1 to 19 years of age from January 1993 to December 2002. Data collected included demographics, hemodynamics, blood transfusions, Glasgow Coma Scale score, Injury Severity Score, hospital length of stay (LOS), intensive care unit (ICU) LOS, and mortality. Analysis involved 140 (4.8%) of 2,944 patients requiring operation. Two cohorts were characterized: (1) immediate operation (IO), defined as laparotomy 3 hours after arrival (n = 59; 42%). RESULTS: Comparing the two cohorts, no age differences were found. Compared with F-NOM, IO had significantly worse hemodynamics, Injury Severity Score, and Glasgow Coma Scale score and was associated with liver injuries. Pancreatic injuries were significantly associated with F-NOM. While controlling for injury severity to compare IO versus F-NOM, linear regression revealed equivalent blood transfusions, ICU LOS, hospital LOS, and mortality rates. CONCLUSION: IO and F-NOM are rare events and independent of age. When operated upon for appropriate physiology, the timing of operation in pediatric solid organ injury is irrelevant and not detrimental with respect to blood transfusion, mortality, ICU and hospital LOS, and resource utilization.

Cervical spine clearance after trauma in children.

OBJECT: Currently, no diagnostic or procedural standards exist for clearing the cervical spine in children after trauma. The establishment of protocols has been shown to reduce the time required to accomplish clearance and reduce the number of missed injuries. The purpose of this study was to determine if reeducation and initiation of a new protocol based on the National Emergency X-Radiography Utilization Study criteria could safely increase the number of pediatric cervical spines cleared by nonneurosurgical personnel. METHODS: The authors collected and reviewed data regarding cervical spine clearance in children (age range 0-18 years) who presented to the emergency department at Primary Children's Medical Center in Salt Lake City, Utah, between 2001 and 2006 after sustaining significant trauma. Radiographic and clinical methods of clearing the cervical spine, as well as the type and management of injuries, were determined for two periods: Period I (January 2001-December 2003) and Period II (January 2004-February 2006). Between 2001 and 2003, 95% of 936 cervical spines were cleared by the neurosurgical service. Twenty-one ligamentous injuries (2.2%) and 12 fracture/dislocations (1.3%) were detected, and five patients (0.5%) required operative stabilization. Since January 2004, 585 (62.4%) of 937 cervical spines have been cleared by nonneurosurgical personnel. Twelve ligamentous injuries (1.3%) and 14 fracture/dislocations (1.5%) were identified, and four patients (0.4%) required operative stabilization. No late injuries were detected in either time period. CONCLUSIONS: The protocol outlined in the paper has been effective in detecting cervical spine injuries in children after trauma and has increased the number of cervical spines cleared by nonneurosurgical personnel by nearly 60%. Reeducation with the establishment of protocols can safely facilitate clearance of the cervical spine after trauma by nonneurosurgical personnel.

The use of angiography in pediatric blunt abdominal trauma patients.

BACKGROUND: Angiography is a common treatment used in adults with blunt abdominal trauma and/or severe pelvic fractures. The Committee on Trauma of the American College of Surgeons has recently advocated for this resource to be urgently available at pediatric trauma centers; however, its usefulness in the pediatric setting is unclear. The purpose of this study was to determine the incidence of angiography in the treatment of blunt abdominal trauma among injured children. METHODS: An analysis was performed using an established public use data set of children (younger than 18 years) treated at 20 participating trauma centers for blunt torso trauma through the Pediatric Emergency Care Applied Research Network. Patients who underwent angiography of the abdomen or pelvis were identified and analyzed. RESULTS: Of the 12,044 children evaluated for blunt abdominal trauma included within the data set, 973 sustained abdominopelvic injuries. Of these, only 26 (3%) underwent angiography. The median age was 14 years, 65% were males, with a mortality rate of 19%. Overall, 29 angiographic procedures were performed: 21 abdominal, 8 pelvic, with 3 patients undergoing both abdominal and pelvic. Eleven patients underwent embolization of a bleeding vessel, all of which were related to the spleen. No hepatic, renal, or pelvic vessels required embolization. The median time to angiography from emergency department evaluation was 7.3 hours. In addition to angiography, 50% also required surgical intervention, of which 31% underwent a laparotomy. Thirty-five percent of these patients required blood product transfusion, and 42% were admitted to the intensive care unit. CONCLUSION: The emergent use of angiography with embolization is uncommon in pediatric patients with blunt abdominal injuries. The requirement that pediatric trauma centers have access to interventional radiology within 30 minutes may be unnecessary. LEVEL OF EVIDENCE: Epidemiologic study, level III; therapeutic study, level IV.