Trauma experts versus pediatric experts: comparison of outcomes in pediatric penetrating injuries.

BACKGROUND: While pediatric trauma centers (PTCs) can uniquely care for pediatric patients, adult trauma centers (ATCs) may be more accessible. Evidence is scarce regarding outcomes of pediatric patients with penetrating trauma treated at PTCs versus ATCs. MATERIALS AND METHODS: We performed a retrospective study using the National Trauma Data Bank to identify pediatric patients aged ≤18 y with penetrating injuries from 2007 to 2012, treated at stand-alone PTCs or ATCs. We excluded patients treated at combined PTC or ATC, transferred between hospitals, with gunshot wounds (GSW) to the head, or dead on arrival. Eligible patients numbered 26,276 (PTC, n = 3737; ATC, n = 22,539). The primary outcome was in-hospital mortality. The secondary outcome was discharge location as a potential surrogate for functional outcome. Univariate and multivariate analyses assessed trauma center type as an independent risk factor for outcomes. RESULTS: Patients treated at ATCs were more likely to have Injury Severity Score >15, Glasgow Coma Scale <9, GSW, cardiovascular injuries, and emergent operations (P < 0.001). Adjusted odds ratios (ORs) for mortality favored PTCs but without statistical significance (OR, 0.592; P = 0.054). In subgroup analyses, children with aged ≤12 y, those with GSW injury mechanism, and those who underwent emergent operations at PTCs were more frequently discharged home versus elsewhere (OR, 0.327, 0.483, and 0.394; P values <0.001, <0.001, and 0.004, respectively). CONCLUSIONS: Children with penetrating injuries demonstrated equivalent survival outcomes whether they were treated at PTCs or ATCs. Younger pediatric patients may have superior functional outcomes when treated at PTCs.

The role of simultaneous abdominal surgery and wound classification in ventriculoperitoneal shunt complication.

PURPOSE: To evaluate whether simultaneous abdominal surgery or wound contamination at the time of ventriculoperitoneal (VP) shunt placement are associated with increased shunt complications. METHODS: Pediatric patients who underwent VP shunt placement were identified using the National Surgical Quality Improvement Program Pediatric database. VP shunt complication rates were compared between patients who underwent simultaneous abdominal surgeries at the time of VP shunt placement vs those who did not and between those with clean/clean-contaminated and contaminated/dirty wound classifications. Adjusted analysis was performed using 1:5 case-control matching. RESULTS: Among 2715 patients who underwent VP shunt placement, 21 had simultaneous abdominal procedures and were matched with 105 control patients. No significant difference was found in overall (34.3 vs 14.3%, p = 0.07), infectious (8.6 vs 4.8%, p = 1.000), or non-infectious (25.7 vs 9.5%, p = 0.156) shunt complications in the simultaneous vs non-simultaneous group, respectively. In a separate analysis of wound classification, 12 patients with contaminated/dirty wounds were matched with 60 patients with clean/clean-contaminated wounds. The rates of shunt infections for clean/clean-contaminated and contaminated/dirty cases were 10.0 and 16.7%, respectively (p = 0.613). CONCLUSION: In our matched case-control study, neither simultaneous abdominal surgery nor wound contamination at the time of VP shunt placement demonstrated significant increased risk of 30-day post-operative complication.

Infant head injury in falls and nonaccidental trauma: does injury pattern correlate with mechanism?

OBJECTIVES: Nonaccidental trauma (NAT) is most common and most lethal in infants. Falls are the most frequently given explanation for NAT, and head injuries can result from both mechanisms. We hypothesized that infant head injuries from NAT have a distinct injury profile compared to falls. METHODS: The trauma registry and patient records were reviewed from 2004 to 2008. Infants with at least 1 head computed tomography were included. RESULTS: Ninety-nine infants were identified. Falls (67 patients) and NAT (21 patients) were the most common mechanism of injury. Falls had lower injury severity scores, 5 versus 17 compared to NAT (P < 0.001). Nonaccidental trauma patients had injuries to face, chest, abdomen, or extremities much more frequently, 62% versus 3% in falls (P < 0.001). Isolated intracranial hemorrhage was higher in NAT (60% vs. 23%, P = 0.002), whereas isolated skull fracture was higher in falls (42% vs. 5%, P = 0.005). Outcomes for NAT showed longer intensive care unit stays (4 days vs. 1 day; P < 0.001), longer hospital stays (7 days vs. 1 day; P < 0.001), and more intracranial operations (9 vs. 1; P < 0.001). CONCLUSIONS: We recommend that all children younger than 1 year, with an isolated intracranial hemorrhage, have a full NAT work-up. Injury severity score greater than 20, Glasgow Coma Scale less than 13, and extracranial injuries should also increase suspicion of NAT.

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.

Timing of tracheostomy placement among children with severe traumatic brain injury: A propensity-matched analysis.

BACKGROUND: Early tracheostomy has been associated with shorter hospital stay and fewer complications in adult trauma patients. Guidelines for tracheostomy have not been established for children with severe traumatic brain injury (TBI). The purpose of this study was to (1) define nationwide trends in time to extubation and time to tracheostomy and (2) determine if early tracheostomy is associated with decreased length of stay and fewer complications in children with severe TBI. METHODS: Records of children (<15 years) with severe TBI (head Abbreviated Injury Severity [AIS] score ≥3) who were mechanically ventilated (>48 hours) were obtained from the National Trauma Data Bank (2007-2015). Outcomes after early (≤14 days) and late (≥15 days) tracheostomy placement were compared using 1:1 propensity score matching to control for potential confounding by indication. Propensity scores were calculated based on age, race, pulse, blood pressure, Glasgow Coma Scale motor score, injury mechanism, associated injury Abbreviated Injury Severity scores, TBI subtype, craniotomy, and intracranial pressure monitor placement. RESULTS: Among 6,101 children with severe TBI, 5,740 (94%) were extubated or died without tracheostomy, 95% of the time within 18 days. Tracheostomy was performed in 361 children (6%) at a median [interquartile range] of 15 [10, 22] days. Using propensity score matching, we compared 121 matched pairs with early or late tracheostomy. Early tracheostomy was associated with fewer ventilator days (14 [9, 19] vs. 25 [19, 35]), intensive care unit days (19 [14, 25] vs. 31 [24, 43]), and hospital days (26 [19, 41] vs. 39 [31, 54], all p < 0.05). Pneumonia (24% vs. 41%), venous thromboembolism (3% vs. 13%), and decubitus ulcer (4% vs. 13%) occurred less frequently with early tracheostomy (p < 0.05). CONCLUSIONS: Early tracheostomy is associated with shorter hospital stay and fewer complications among children with severe TBI. Extubation without tracheostomy is rare beyond 18 days after injury. LEVEL OF EVIDENCE: Prognostic and epidemiological, retrospective comparative study, level III.

Symptomatic catheter-associated thrombosis in pediatric trauma patients: Choose your access wisely.

BACKGROUND: Traumatic injury and the presence of a central venous catheter are 2 of the strongest risk factors for venous thromboembolism in children. The purpose of this study was to determine the incidence of symptomatic, catheter-associated thrombosis in critically injured children. We hypothesized that femoral venous catheters are associated with a greater rate of thrombotic complications when compared with all other central venous access points. METHODS: We reviewed a retrospective cohort (2006-2016) of injured children (≤18 years) admitted to a pediatric intensive care unit with central access placed ≤7 days from admission. Symptomatic, catheter-associated thrombosis was determined by radiographic evidence. Poisson regression was used to compare the incidence of catheter-associated thrombosis per 1,000 catheter days between femoral and nonfemoral catheters. All comparisons were 2-tailed with α = 0.05. RESULTS: We examined 209 pediatric trauma patients with central access (65% femoral, 19% subclavian, 11% arm vein, and 5% internal jugular). Femoral catheters were removed earlier (median [interquartile range] 4 [2-7] vs 8 [3-12] days, P < .001) and were larger in diameter (5 Fr [4-7] vs 4 Fr [4-4], P < .001) when compared with all other catheters. Catheter-associated thrombosis was more frequent in femoral versus nonfemoral catheters (18.4 vs 3.5 per 1,000 catheter days, P = .01). CONCLUSION: Femoral venous catheters are associated with a greater incidence of symptomatic, catheter-associated thrombosis in pediatric trauma patients. When central venous access is indicated for injured children, the femoral site should be avoided. If a femoral venous catheter is necessary, use of a smaller catheter should be considered.

Pediatric trauma-associated acute respiratory distress syndrome: Incidence, risk factors, and outcomes.

BACKGROUND/PURPOSE: Acute Respiratory Distress Syndrome (ARDS) results in significant morbidity and mortality in pediatric trauma victims. The objective of this study was to determine risk factors and outcomes specifically related to pediatric trauma-associated ARDS (PT-ARDS). METHODS: A retrospective cohort (2007-2014) of children ≤18 years old from the American College of Surgeons National Trauma Data Bank (NTDB) was used to analyze incidence, risk factors, and outcomes related to PT-ARDS. RESULTS: PT-ARDS was identified in 0.5% (2660/488,381) of the analysis cohort, with an associated mortality of 18.6% (494/2660). Mortality in patients with PT-ARDS most commonly occurred in the first week after injury. Risk factors associated with the development of PTARDS included nonaccidental trauma, near drowning, severe injury (AIS ≥ 3) to the head or chest, pneumonia, sepsis, thoracotomy, laparotomy, transfusion, and total parenteral nutrition use. After adjustment for age, injury complexity, injury mechanism, and physiologic variables, PT-ARDS was found to be independently associated with higher mortality (adjusted OR 1.33, 95% CI 1.18-1.51, p < 0.001). CONCLUSIONS: PT-ARDS is a rare complication in pediatric trauma patients, but is associated with substantial mortality within 7 days of injury. Recognition and initiation of lung-protective measures early in the postinjury course may represent the best opportunity to change outcomes. LEVEL OF EVIDENCE: Level 3 - Epidemiologic.

The rate of PD catheter complication does not increase with simultaneous abdominal surgery.

INTRODUCTION: Children with kidney failure requiring PD catheter placement often require additional intraabdominal surgery. However, the risk of complication related to simultaneous abdominal surgery at time of catheter placement is unknown. METHODS: Patients (0-18years) who underwent PD catheter placement (2012-2015) in the NSQIP-P database were reviewed. Complication rates between patients who underwent additional abdominal surgery at the time of PD catheter placement and those that did not were evaluated. One to one case control matching was performed for additional adjusted analysis. RESULTS: Of 563 patients who met inclusion criteria, 82 underwent simultaneous abdominal surgery at time of PD catheter placement. Patients in the simultaneous group had a higher rate of wound contamination but there was no difference in rates of SSI, 30-day PD catheter complication, or 30-day mortality compared with the nonsimultaneous group. There was no difference when overall simultaneous abdominal surgery or gastrointestinal surgery was evaluated. In our 1:1 adjusted analysis, there was a higher rate of PD catheter complication (11.3% vs. 2.8%, p=0.049) and SSI (31.0% vs. 4.2%, p<0.001) in the nonsimultaneous group. CONCLUSIONS: Thirty-day PD catheter complication and SSI in patients who underwent simultaneous abdominal surgery at time of catheter placement were noninferior to outcomes in the nonsimultaneous. LEVEL OF EVIDENCE: Level III, Treatment study, Retrospective comparative study.

Comparison of outcomes in severe pediatric trauma at adult trauma centers with different trauma case volumes.

BACKGROUND: In addition to trauma center levels and types, trauma volume may be an important factor impacting outcomes in severe pediatric trauma. METHODS: All severely injured pediatric patients treated at adult trauma centers were identified from the National Trauma Data Bank. All qualifying centers were stratified into four groups based on the cumulative pediatric trauma case volumes with ISS >15: lowest (group 1), lower (group 2), higher (group 3), and highest (group 4) volume centers. Mortality rates among the groups were compared. RESULTS: A total of 3747 patients were stratified into group 1 (n=2122, median annual pediatric trauma volume 3 cases/year), group 2 (n=842, 15 cases/year), group 3 (n=494, 24 cases/year), and group 4 (n=289, 43 cases/year). In the hierarchical logistic regression analysis, the highest volume centers (group 4) were shown to have improved mortality (odds ratio 0.474, 95% confidence interval [CI] 0.301-0.747) compared to the lowest volume centers (group 1). Odds ratios of group 4 against group 1 for subgroups were 0.634 (age<10, 95% CI 0.335-1.198), 0.491 (blunt injury, 95% CI 0.310-0.777), and 0.495 (level 1 center, 95% CI 0.312-0.785). CONCLUSIONS: In severe pediatric trauma treated at adult trauma centers, higher volume centers were associated with improved mortality in comparison to the lower volume centers. LEVEL OF EVIDENCE: Level III, therapeutic/care management, retrospective comparative study without negative criteria.

Association between pediatric blunt splenic injury volume and the splenectomy rate.

BACKGROUND/PURPOSE: While pediatric trauma centers are shown to have lower splenectomy rate as compared to adult trauma centers, it remains unknown whether other institutional factors such as case volumes would have an impact on the splenectomy rate in pediatric blunt splenic injury (BSI). METHODS: Pediatric patients who sustained BSI were identified from the National Trauma Data Bank 2007-2014. A hierarchical logistic regression model was built to evaluate differences in risk-adjusted splenectomy rate and in-hospital mortality in between trauma centers with different pediatric BSI case volumes. RESULTS: A total of 7621 children who met criteria were treated at trauma centers with different pediatric BSI case volumes (0-60, 61-120, 121-180, 181-240 cases during 2007-2014 for Group 1, 2, 3, and 4, respectively). High volume centers were shown to have decreased splenectomy rates (odds ratios [OR] 0.50 and 0.64, 95% confidence intervals [CI] 0.30-0.83, 0.44-0.95 for Groups 3 and 4, respectively) with an additional survival benefit in Group 4 (OR 0.452, 95%CI 0.257-0.793) when compared to the lowest volume centers (Group 1). CONCLUSIONS: Higher pediatric BSI case volume was associated with lower splenectomy rate with an additional survival benefit. Trauma centers' volume in pediatric BSI may be an important factor for the improved splenic preservation. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

A gastrointestinal stromal tumor found in perforated Meckel's diverticulum.

BACKGROUND: Meckel's diverticulum is the most common anomaly of the gastrointestinal tract. It is usually asymptomatic, but approximately 4 % present with complications such as bleeding, intestinal obstruction, and inflammation, while perforation is rare. Carcinoid or gastrointestinal stromal tumors are occasionally found in the resected specimens of Meckel's diverticulum, particularly in the context of perforation. CASE PRESENTATION: A 62-year-old male with a recent history of admission and evaluation for hematochezia presented with abdominal pain. His physical examination was consistent with peritonitis. Results of laboratory testing were significant for white blood cell count of 32,000/µL. CT scan of the abdomen revealed pneumoperitoneum. During the exploratory laparotomy, perforated Meckel's diverticulum was encountered and segmental bowel resection was performed. Histological examination findings were compatible with gastrointestinal stromal tumor within Meckel's diverticulum. CONCLUSIONS: While gastrointestinal stromal tumor is a rare finding in Meckel's diverticula, the potential for the coexistence of this and other tumors suggests that segmental resection of the small bowel should be considered in the treatment of perforated Meckel's diverticulum.

Operative outcomes of infantile hypertrophic pyloric stenosis in patients with congenital heart disease.

PURPOSE: This study aims to compare the outcomes of pyloromyotomy for infantile hypertrophic pyloric stenosis (IHPS) in children with and without congenital heart disease (CHD). METHODS: A retrospective, single pediatric center, case-control, matched cohort study was performed over 10years. A case of IHPS with CHD was paired with control patients of IHPS without CHD, matched by age and gender. Perioperative morbidity, 30-day mortality, length of hospital stay, and hospital cost were compared. Subgroups were analyzed based on the severity of CHD and the reason for admission. RESULTS: Twenty-six patients who underwent pyloromyotomy for IHPS with CHD (CHD group) were matched with 78 patients with IHPS without CHD (Non-CHD group). No 30-day mortality was identified in either group. Overall perioperative complications were not significantly different between groups (11.5% vs 5.2%, p=0.163). However, postoperative length of stay was longer in CHD group (6 vs 1days, p<0.001) and any subgroups of CHD as compared to Non-CHD group. CHD group patients admitted only for IHPS had short postoperative LOS, whereas those who developed pyloric stenosis during a hospital admission stayed longer postoperatively (1.5 vs 26.5days, p<0.001). Mean hospital costs in patients admitted for IHPS were $16,270 and $3591 for CHD group and Non-CHD group, respectively (p<0.001). CONCLUSIONS: IHPS patients with CHD have prolonged postpyloromyotomy course, especially when inpatients with CHD incidentally develop IHPS.

Should All Severely Injured Pediatric Patients be Treated at Pediatric Level I Trauma Centers? A National Trauma Data Bank Study.

The American College of Surgeons Committee on Trauma stratification system for trauma centers presumes that increasing levels of resources will improve patient outcomes. Although some supportive data exist in adult trauma, there is a paucity of evidence demonstrating improved survival in pediatric trauma when patients are treated primarily at Level I versus Level II pediatric trauma centers. We hypothesized that there is no difference in the mortality of comparably injured pediatric patients treated at these two types of facilities. The study population consists of all severely injured pediatric patients (18 years old or younger, injury severity score > 15) registered in the National Trauma Data Bank, treated in designated pediatric trauma centers. A total of 13,803 patients were included in the analysis and were separated into two groups: Pediatric Level I trauma center (n = 9690) and Pediatric Level II trauma center (n = 4113). Although analysis of the clinical characteristics of the unmatched groups showed significant differences including mortality rate (11.7% vs 15.4%, P < 0.001), case matching technique, comparing 2956 pairs, successfully eliminated demographic differences and, when adjusted for injury severity, showed no difference in mortality between center types (10.0% vs 10.1%, P = 0.966, odds ratio of mortality = 0.996 and 95% confidence interval = 0.841-1.180). Subgroup analyses including Glasgow Coma Scale < 9, need for immediate procedures, and ICD-9 (International Classification of Diseases) code groupings indicative of serious injury also failed to demonstrate statistically significant differences in mortality between trauma center types.

Analysis of 29 consecutive thoracoscopic repairs of congenital diaphragmatic hernia in neonates compared to historical controls.

PURPOSE: The applicability of minimally invasive surgical techniques to pediatric surgical diseases continues to grow. Surgeons have hesitated to apply these methods to congenital diaphragmatic hernia (CDH) of Bochdalek because of the disease-associated pulmonary hypertension and patient fragility. We began performing thoracoscopic repair (CDH-T) in 2004 and have since completed 29 sequential repairs. To evaluate feasibility and outcomes, we compared this experience to a historical control group who underwent open repair (CDH-O) at the same institution by the same surgeons from 2001 to 2004. METHODS: From January 2001 through November 2007, 72 neonates were evaluated jointly by the Neonatology and Pediatric Surgical services for CDH. Fifteen infants died before any corrective operation and were excluded from analysis. Demographics including gestational age, birth weight, Apgar scores, percent outborn, usage of extracorporeal life support, and associated anomalies were recorded. End points were complications, additional operative procedures, initial patch closure, recurrence, length of stay in non-extracorporeal membrane oxygenation patients, and postoperative mortality. RESULTS: Demographic characteristics were similar between the 2 groups. There were no statistically significant differences in complications (71.5% vs 55%, P = .28), additional related operative procedures (42.9% vs 34.5%, P = .59), use of prosthetic patch (42.8% vs 51.7%, P = .60), recurrence (6.9% vs 20.7%, P = .25), length of stay (24 vs 34 days, P = .11), or postoperative mortality (21.4% vs 6.9%, P = .14) between the CDH-O and CDH-T groups, respectively. There was one conversion in the CDH-T group (3.4%). CONCLUSIONS: To our knowledge, this is the largest reported series of CDH-T of neonatal CDH of Bochdalek. We have demonstrated the feasibility of performing this procedure thoracoscopically in an unselected population including children who have undergone prior extracorporeal life support. These results compare favorably with CDH-O, although further follow-up is required to determine the durability of the approach.