Surgical intervention in pediatric trauma at a level 1 trauma hospital: a retrospective cohort study and report of cost data.

BACKGROUND: Given that the management of severely injured children requires coordinated care provided by multiple pediatric surgical subspecialties, we sought to describe the frequency and associated costs of surgical intervention among pediatric trauma patients admitted to a level 1 trauma centre in southwestern Ontario. METHODS: All pediatric (age < 18 yr) trauma patients treated at the Children's Hospital - London Health Sciences Centre (CH-LHSC) between 2002 and 2013 were included in this study. We compared patients undergoing surgical intervention with a nonsurgical group with respect to demographic characteristics and outcomes. Hospital-associated costs were calculated only for the surgical group. RESULTS: Of 784 injured children, 258 (33%) required surgery, 40% of whom underwent orthopedic interventions. These patients were older and more severely injured, and they had longer lengths of stay than their nonsurgical counterparts. There was no difference in mortality between the groups. Seventy-four surgical patients required intervention within 4 hours of admission; 45% of them required neurosurgical intervention. The median cost of hospitalization was $27 571 for the surgical group. CONCLUSION: One-third of pediatric trauma patients required surgical intervention, of whom one-third required intervention within 4 hours of arrival. Despite the associated costs, the surgical treatment of children was associated with comparable mortality to nonsurgical treatment of less severely injured patients. This study represents the most recent update to the per patient cost for surgically treated pediatric trauma patients in Ontario, Canada, and helps to highlight the multispecialty care needed for the management of injured children.

CONTEXTE: La prise en charge des enfants grièvement blessés nécessite la coordination des soins fournis dans le contexte de plusieurs surspécialités chirurgicales pédiatriques. Dans ce contexte, nous avons cherché à décrire la fréquence et les coûts des interventions chirurgicales chez les patients pédiatriques victimes de trauma admis dans un centre de traumatologie de niveau 1 dans le sud-ouest de l'Ontario. MÉTHODES: Tous les patients pédiatriques (moins de 18 ans) ayant subi un trauma traités à l'Hôpital pour enfants du Centre des sciences de la santé de London entre 2002 et 2013 ont été retenus pour l'étude. Nous avons comparé les caractéristiques démographiques et les résultats cliniques des patients ayant subi une intervention chirurgicale et de ceux n'en ayant pas subi. Les coûts d'hospitalisation n'ont été calculés que pour le premier groupe. RÉSULTATS: Parmi les 784 enfants à l'étude, 258 (33 %) avaient eu besoin d'une intervention chirurgicale; 40 % de ceux-ci avaient subi des interventions orthopédiques. Ces patients étaient plus âgés et plus grièvement blessés que les enfants n'ayant pas subi d'intervention chirurgicale, et leur séjour à l'hôpital était généralement plus long. Nous n'avons relevé aucune différence entre les 2 groupes quant à la mortalité. En outre, 74 des patients ayant subi une intervention chirurgicale ont dû être opérés dans les 4 heures suivant l'admission; 45 % d'entre eux ont eu besoin d'une intervention neurochirurgicale. Le coût médian d'une hospitalisation était de 27 571 $. CONCLUSION: Le tiers des patients pédiatriques victimes de trauma ont eu besoin d'une intervention chirurgicale, et le tiers de ceux-ci ont dû être opérés dans les 4 heures suivant leur arrivée. Malgré les coûts, le traitement chirurgical des enfants était associé à un taux de mortalité comparable à celui du traitement non chirurgical des patients blessés moins grièvement. Cette étude est la source d'information la plus récente sur le coût par patient associé au traitement chirurgical des enfants victimes de trauma en Ontario, et elle met en évidence le besoin de soins de multiples spécialités.

Laparoscopic-assisted percutaneous endoscopic gastrostomy: insertion of a skin-level device using a tear-away sheath.

BACKGROUND: This study describes our experience with the placement of a skin-level gastrostomy device (MIC-KEY) in a single procedure. METHODS: We identified infants, children and young adults who underwent laparoscopic-assisted percutaneous endoscopic gastrostomy (LAPEG) tube insertion between October 2009 and June 2013. The steps of this procedure include upper endoscopy, single-port laparoscopy, gastropexy via percutaneous T-fasteners and placement of a skin-level gastrostomy device (MIC-KEY) using a "push" technique with a tear-away sheath. RESULTS: We included 92 patients in our study. Mean age was 3.7 years (range 3 wk-5 yr), and mean weight was 11.2 (range 2.8-54) kg. Median procedural time was 20 (range 12-76) minutes. Total median duration for the most recent 25 procedures was lower than that of the first 25 (62 v. 79 min, p = 0.004). There were no intraoperative complications or conversions to open surgery. Postoperative complications were observed in 6 (6.5%) patients. Three retained T-fasteners were assessed endoscopically (n = 1) or removed via local excision (n = 2). Two patients experienced early dislodged feeding tubes that were replaced via interventional radiology (n = 1) or repeat LAPEG (n = 1). There was also 1 intra-abdominal fluid collection that was drained percutaneously but ultimately required a laparotomy and washout. There were no major complications in the most recent 50 procedures. CONCLUSION: Our results suggest that LAPEG is a safe, minimally invasive procedure for infants, children and young adults. This approach allows for immediate use of a skin-level gastrostomy device without the need for postoperative tube exchanges.

CONTEXTE: Cette étude décrit notre expérience avec la pose d'un dispositif de gastrostomie au niveau de la peau (MIC-KEY) en une seule intervention. MÉTHODES: Nous avons recensé les nourrissons, enfants et jeunes adultes ayant subi l'insertion d'un tube de gastrostomie par voie endoscopique percutanée sous laparoscopie (GEPL) entre octobre 2009 et juin 2013. Les étapes de cette intervention incluent une endoscopie haute, une laparoscopie à trocart unique, une gastropexie avec ancres en T percutanées et la pose d'un dispositif de gastrostomie au niveau de la peau (MIC-KEY) à l'aide de la technique « push ¼ et d'une pellicule amovible. RÉSULTATS: Nous avons inclus 92 patients dans notre étude. L'âge moyen était de 3,7 ans (de 3 semaines à 5 ans) et le poids moyen était de 11,2 (de 2,8 à 54) kg. La durée médiane de l'intervention a été de 20 minutes (entre 12 et 76 minutes). La durée totale médiane des 25 plus récentes interventions a été plus brève que celle des 25 premières (62 c. 79 minutes, p = 0,004). On n'a observé aucune complication peropératoire ni conversion vers une chirurgie ouverte. Des complications postopératoires ont été observées chez 6 (6,5 %) patients. Trois ancres en T persistantes ont été évaluées par voie endoscopique (n = 1) ou extraites par excision locale (n = 2). Les tubes d'alimentation se sont déplacés tôt chez 2 patients et ont été replacés en radiologie interventionnelle (n = 1) ou avec une nouvelle GEPL (n = 1). On a également noté un cas d'épanchement de liquide intra-abdominal qui a pu être drainé par voie percutanée, mais qui a finalement nécessité une laparotomie et un lavage. Aucune complication majeure n'a été signalée lors des 50 plus récentes interventions. CONCLUSION: Selon nos résultats, la GEPL est une intervention sécuritaire et minimalement effractive pour les nourrissons, les enfants et les jeunes adultes. Cette approche permet l'utilisation immédiate d'un dispositif de gastrostomie au niveau de la peau sans nécessiter de changements de sondes après l'intervention.

Acute gastric volvulus in a six-year-old: a case report and review of the literature.

BACKGROUND: First described in the pediatric population in 1899 by Oltmann, pediatric gastric volvulus is a rare disease, but carries a high mortality rate. Due to vague signs and symptoms it can easily be mistaken for gastroenteritis or appendicitis, but unique radiographic findings can help illuminate the diagnosis. The pathophysiology of gastric volvulus is related to an abnormality in the attachment of at least one of the gastric ligaments, which can occur either primarily or secondarily. The abnormality in these ligaments allows the stomach to freely rotate, eventually causing an obstruction. We describe a unique case occurring in a 6-year-old with no pre-exiting medical conditions as well as the associated radiographic images. OBJECTIVES: Our aim is to discuss the presentation and management of a potentially lethal intra-abdominal process that mimics far more benign disease entities and to highlight the pertinent radiographic findings. CASE REPORT: A previously healthy 6-year-old female presented to the emergency department in the middle of the night after sudden onset of vomiting and abdominal pain. On exam her heart rate was mildly elevated but all other vital signs were within normal limits. She was assessed with an abdominal x-ray and given ondansetron. After settling with her parents and having no further bouts of emesis she was sent home. She returned that afternoon febrile with increasing abdominal pain and emesis. Abdominal x-ray revealed a massively distended stomach and left diaphragmatic eventration. She underwent operative intervention and improved over the course of the following week. CONCLUSION: Acute gastric volvulus presents a diagnostic challenge. In patients with vague abdominal complaints knowledge of the typical x-ray findings is essential in early identification and treatment.

Evaluation of a population health strategy to reduce distracted driving: Examining all "Es" of injury prevention.

BACKGROUND: Cell phone use while driving (CPWD) increases the risk of crashing and is a major contributor to injuries and deaths. The objective of this study was to describe the evaluation of a multifaceted, evidence-based population health strategy for the reduction of distracted driving. METHODS: A multipronged campaign was undertaken from 2014 to 2016 for 16- to 44-year-olds, based on epidemiology, focused on personal stories and consequences, using the "Es" of injury prevention (epidemiology, education, environment, enforcement, and evaluation). Education consisted of distracted driving videos, informational cards, a social media AdTube campaign, and a movie theater trailer, which were evaluated with a questionnaire regarding CPWD attitudes, opinions, and behaviors. Spatial analysis of data within a geographic information system was used to target advertisements. A random sample telephone survey evaluated public awareness of the campaign. Increased CPWD enforcement was undertaken by police services and evaluated by ARIMA time series modeling. RESULTS: The AdTube campaign had a view rate of >10% (41,101 views), slightly higher for females. The top performing age group was 18- to 24-year-olds (49%). Our survey found 61% of respondents used handheld CPWD (14% all of the time) with 80% reporting our movie trailer made them think twice about future CPWD. A stakeholder survey and spatial analysis targeted our advertisements in areas of close proximity to high schools, universities, near intersections with previous motor vehicle collisions, high traffic volumes, and population density. A telephone survey revealed that 41% of the respondents were aware of our campaign, 17% from our print and movie theater ads and 3% from social media. Police enforcement campaign blitzes resulted in 160 tickets for CPWD. Following campaign implementation, there was a statistically significant mean decrease of 462 distracted driving citations annually (p = 0.001). CONCLUSION: A multifaceted, evidence-based population health strategy using the Es of injury prevention with interdisciplinary collaboration is a comprehensive method to be used for the reduction of distracted driving. LEVEL OF EVIDENCE: Therapeutic, level IV.

A 15 year cohort review of in-hospital pediatric trauma center mortality: A catalyst for injury prevention programming.

BACKGROUND: The objective of our study was to identify the most common mechanisms of injury leading to death in our pediatric population. METHODS: A retrospective cohort of fatally injured children 0-17 years old treated at our trauma center during 2000-2015. RESULTS: The mortality rate in our population was 8% (n = 103). Fifty-five percent were male. The majority (76%) of fatal injuries were blunt. Overall, motor vehicle collisions (MVCs) were the most common mechanism of injury (61%), followed by assault/abuse (9%). Of the deaths caused by MVCs, 37 (59%) were occupants, 11 (17%) were pedestrians, and 6 (10%) were cyclists. In the infant sub-population, assault/abuse was the most common mechanism of injury. CONCLUSION: MVCs were the leading cause of death in this population. In the infant subpopulation (<1 year), abusive head trauma emerged as the leading mechanism. Injury prevention programming should target abusive head trauma in infants and teen road safety.

Early coagulopathy and metabolic acidosis predict transfusion of packed red blood cells in pediatric trauma patients.

BACKGROUND: Severely injured pediatric trauma patients often present to hospital with early coagulopathy and metabolic acidosis. These derangements are associated with poor outcomes, but it is unclear to what degree they predict transfusion of packed red blood cells (pRBC). METHODS: We retrospectively identified pediatric trauma patients from a level 1 trauma center from 2006 to 2013. Inclusion criteria were age less than 18years, Injury Severity Score greater than 12, and pRBC transfusion within 24h of admission. RESULTS: We identified 96 pediatric trauma patients who underwent pRBC transfusion within 24h of presentation to hospital. On admission, 43% of these patients had one or more signs of coagulopathy, and 81% had metabolic acidosis. Size of pRBC transfusion in the first 24h ranged from 3 to 177mL/kg (mean 29mL/kg), and nineteen patients (20%) underwent massive transfusion (>40ml/kg in 24h). Univariate analysis indicated that size of pRBC transfusion was associated with initial base excess (r=0.46), international normalized ratio (r=0.35), partial thromboplastin time (r=0.41), fibrinogen (r=0.46), and BIG score (Base deficit, INR, Glasgow Coma Scale (GCS), r=0.36). Platelet count, age, GCS, and direct versus referred presentation were not predictive. Multivariable linear regression confirmed that coagulopathy and metabolic acidosis remained predictive after adjusting for direct versus referred presentation (R(2)=0.30). CONCLUSIONS: Early coagulopathy and metabolic acidosis predict size of pRBC transfusion among pediatric trauma patients. Further research is needed to develop massive transfusion protocols and guidelines for activation.

Febrile Illness in an Infant With an Intracardiac Inflammatory Myofibroblastic Tumor.

We report a case of a child with a right ventricular inflammatory myofibroblastic tumor (IMT) who presented with fever, viral symptoms, and abdominal discomfort. Including this case, 49 intracardiac tumors have been previously reported in all age groups. The majority of intracardiac IMTs occur in pediatric patients, with approximately half presenting in children aged <12 months. Intracardiac IMTs are generally described as benign tumors; however, depending on their location, the initial presentation may involve heart failure or sudden death.(1) In addition to cardiac signs and symptoms, the clinical presentation of IMTs may also include constitutional signs such as fever, anemia, and elevated inflammatory markers. This case report reviews the diagnosis and management of IMTs, as well as the histopathologic features of this rare tumor type. Clinicians should be aware of their clinical presentation because early diagnosis and treatment can significantly reduce morbidity and mortality.

From focus groups to production of a distracted driving video: Using teen input to drive injury prevention programming.

BACKGROUND: The Impact program is an adolescent, injury prevention program with both school- and hospital-based components aimed at decreasing high-risk behaviors and preventing injury. The objective of this study was to obtain student input on the school-based component of Impact, as part of the program evaluation and redesign process, to ensure that the program content and format were optimal and relevant, addressing injury-related issues important for youth in our region. METHODS: Secondary schools were selected in various geographic regions with students varying in language, religion, and socioeconomic status. A mixed-methods questionnaire was developed and pretested on program content, format, relevance, quality, and effectiveness. Attitude and opinion questions on issues facing teens today were ranked on a 7-point Likert scale. Open-ended, qualitative questions were included in the focus groups, with responses themed. RESULTS: There were 167 respondents in the nine geographically, socioeconomically, and culturally diverse focus groups with a mean age of 16 years, 52% were male, and 69% were in Grade 11. Ninety-three percent of respondents rated the content of Impact as comprehensive (median, 6 of 7, with 7 being very comprehensive), and 29% rated the format a 5 of 7. Impact was rated relevant (89%), addressing issues for teens (median, 6 of 7). Issues suggested to highlight included texting and driving, drugs, partying, self-harm, and abusive relationships. Texting while driving was perceived as a significantly more common (81%) injury issue for adolescents compared with other driving risk factors (p < 0.001), with one student commenting, "If you don't (text and drive), you either don't have a phone or don't have a driver's license." CONCLUSION: Injury prevention programs must be continually evaluated to ensure they are relevant, addressing issues important for youth, and presented in a format that resonates with the audience. Student focus groups identified motor vehicle collisions and texting as important issues as well as a desire for teens to hear personal stories with a visual element. This provided the information needed to develop the next logical direction for our program, the production of a distracted driving video ("Distracted Driving: Josh's Story," http://youtu.be/BFPke9gBybc) to be incorporated into school presentations. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Analgesia in the management of paediatric and adolescent trauma during the resuscitative phase: the role of the pediatric trauma centre.

BACKGROUND: The objective of this study was to evaluate the use of analgesia in the resuscitative phase of severely injured children and adolescents. METHODS: A retrospective cohort of paediatric (age<18 years), severely injured (ISS≥12) patients were identified from the London Health Sciences Centre's Trauma Registry from 2007 to 2010. Variables were compared between Analgesia and Non-analgesia groups with Pearson Chi-square and Mann-Whitney U tests. Resuscitative analgesia use was assessed through multivariable logistic regression controlling for age, gender, mechanism, arrival and Trauma Team Activation (TTA). RESULTS: Analgesia was used in 32% of cases. Univariate analysis did not reveal any differences in gender, age, injury type, injury profile and arrival patterns. Significant differences were found with analgesia used more frequently in patients injured in a motor vehicle collision (58% vs. 42%, p=0.026) and having parents in the resuscitation room (17% vs. 6%, p=0.01). Analgesia patients were more injured (median ISS 22 vs. 17, p=0.027) and had 2.25 times more TTA (39% vs. 17%). Logistic regression revealed patients arriving directly to a trauma centre had a higher incidence of receiving analgesia (OR 2.01, 95% CI: 1.03-3.93), as did TTA (OR 2.18, 95% CI: 1.01-4.73) and having parents in resuscitation room (3.56, 95% CI: 1.23-10.33). Narcotics were most commonly used (85%), followed by benzodiazepines (16%), with 66% given during the primary survey. CONCLUSION: Use of analgesia is important in the acute management of paediatric trauma. Direct presentation to a level I trauma centre, TTA and the presence of parents lead to higher appropriate use of analgesia in paediatric trauma resuscitation.

A pediatric patient with Cushing syndrome caused by ectopic ACTH syndrome and concomitant pituitary incidentalomas.

Ectopic ACTH syndrome is a rare but important cause of pediatric Cushing syndrome, for which management by a multidisciplinary team is required. Although diagnostic evaluation is similar to that in adults, the variation in epidemiology may sway investigations, leading to inappropriate and/or incomplete diagnostic interventions. We present a case of 15-year-old girl with symptoms of severe ACTH-dependent Cushing syndrome and two pituitary adenomas. The ectopic source of ACTH production was confirmed after petrosal venous sampling was performed. Diagnostics and perioperative management of a pulmonary carcinoid tumor producing ectopic ACTH is reviewed. In pediatric patients, as in adult patients, a pituitary lesion <6 mm on MRI is not sufficient confirmation of Cushing's disease, and appropriate diagnostic work-up should be performed to assess the source of the ACTH overproduction.

Radiation from CT scans in paediatric trauma patients: Indications, effective dose, and impact on surgical decisions.

OBJECTIVES: The purpose of this study was to determine the effective dose of radiation due to computed tomography (CT) scans in paediatric trauma patients at a level 1 Canadian paediatric trauma centre. We also explored the indications and actions taken as a result of these scans. PATIENTS AND METHODS: We performed a retrospective review of paediatric trauma patients presenting to our centre from January 1, 2007 to December 31, 2008. All CT scans performed during the initial trauma resuscitation, hospital stay, and 6 months afterwards were included. Effective dose was calculated using the reported dose length product for each scan and conversion factors specific for body region and age of the patient. RESULTS: 157 paediatric trauma patients were identified during the 2-year study period. Mean Injury Severity Score was 22.5 (range 12-75). 133 patients received at least one CT scan. The mean number of scans per patient was 2.6 (range 0-16). Most scans resulted in no further action (56%) or additional imaging (32%). A decision to perform a procedure (2%), surgery (8%), or withdrawal of life support (2%) was less common. The average dose per patient was 13.5mSv, which is 4.5 times the background radiation compared to the general population. CT head was the most commonly performed type of scan and was most likely to be repeated. CT body, defined as a scan of the chest, abdomen, and/or pelvis, was associated with the highest effective dose. CONCLUSIONS: CT is a significant source of radiation in paediatric trauma patients. Clinicians should carefully consider the indications for each scan, especially when performing non-resuscitation scans. There is a need for evidence-based treatment algorithms to assist clinicians in selecting appropriate imaging for patients with severe multisystem trauma.

Nested stromal epithelial tumor of the liver in Beckwith-Wiedemann syndrome.

ABSTRACT Beckwith-Wiedemann syndrome (BWS) is an imprinting disorder characterized by overgrowth, congenital malformation, and tumor predisposition. Children with BWS have a higher incidence of tumors, commonly intra-abdominal tumors such as Wilms tumor, hepatoblastoma, and adrenal cortical carcinoma. Here, we describe the first case of a rare hepatic malignancy of nested stromal epithelial tumor (NSET) of the liver in a child with BWS. A 22-month old girl with BWS had a new incidental liver mass. Her alpha-fetoprotein levels were normal. She underwent a liver segmentectomy. Histopathologic features combined with immunohistochemistry results (positivity for pankeratin [AE1/3], CD56, CK19, CD117, CD99 [weak membranous pattern], ß-catenin, and WT1-COOH [focal]), were diagnostic of NSET of the liver. This is the first case of NSET of the liver associated with BWS. Its occurrence at such an early age is consistent with the tumor predisposition of BWS.