Prevalence and Outcomes of High versus Low Ratio Plasma to Red Blood Cell Resuscitation in a Multi-Institutional Cohort of Severely Injured Children.

BACKGROUND: The benefit of targeting high ratio fresh frozen plasma (FFP):red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP:RBC transfusion and the association with outcomes in children presenting in shock. METHODS: A post-hoc analysis of a 24-institution prospective observational study (4/2018-9/2019) of injured children <18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (>1:2) ratio FFP:RBC. Nonparametric Kruskal-Wallis and chi-square were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths. RESULTS: Of 135 children with median (IQR) age 10 (5,14) years and weight 40 (20,64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (MTP; low-38%, high-46%, p = .34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = .01); however, hospital mortality was similar (low-24%, high-20%, p = .65) as was the risk of extended ventilator, ICU, and hospital days (all p > .05). CONCLUSION: Despite increased injury severity, patients who received a high ratio of FFP:RBC had comparable rates of mortality. These data suggest high ratio FFP:RBC resuscitation is not associated with worst outcomes in children who present in shock. MTP activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

Crystalloid volume is associated with short-term morbidity in children with severe traumatic brain injury: An Eastern Association for the Surgery of Trauma multicenter trial post hoc analysis.

OBJECTIVE: This study examined differences in clinical and resuscitation characteristics between injured children with and without severe traumatic brain injury (sTBI) and aimed to identify resuscitation characteristics associated with improved outcomes following sTBI. METHODS: This is a post hoc analysis of a prospective observational study of injured children younger than 18 years (2018-2019) transported from the scene, with elevated shock index pediatric-adjusted on arrival and head Abbreviated Injury Scale score of ≥3. Timing and volume of resuscitation products were assessed using χ 2t test, Fisher's exact t test, Kruskal-Wallis, and multivariable logistic regression analyses. RESULTS: There were 142 patients with sTBI and 547 with non-sTBI injuries. Severe traumatic brain injury patients had lower initial hemoglobin (11.3 vs. 12.4, p < 0.001), greater initial international normalized ratio (1.4 vs. 1.1, p < 0.001), greater Injury Severity Score (25 vs. 5, p < 0.001), greater rates of ventilator (59% vs. 11%, p < 0.001) and intensive care unit (ICU) requirement (79% vs. 27%, p < 0.001), and more inpatient complications (18% vs. 3.3%, p < 0.001). Severe traumatic brain injury patients received more prehospital crystalloid (25% vs. 15%, p = 0.008), ≥1 crystalloid boluses (52% vs. 24%, p < 0.001), and blood transfusion (44% vs. 12%, p < 0.001) than non-sTBI patients. Among sTBI patients, receipt of ≥1 crystalloid bolus (n = 75) was associated with greater ICU need (92% vs. 64%, p < 0.001), longer median ICU (6 vs. 4 days, p = 0.027) and hospital stay (9 vs. 4 days, p < 0.001), and more in-hospital complications (31% vs. 7.5%, p = 0.003) than those who received <1 bolus (n = 67). These findings persisted after adjustment for Injury Severity Score (odds ratio, 3.4-4.4; all p < 0.010). CONCLUSION: Pediatric trauma patients with sTBI received more crystalloid than those without sTBI despite having a greater international normalized ratio at presentation and more frequently requiring blood products. Excessive crystalloid may be associated with worsened outcomes, including in-hospital mortality, seen among pediatric sTBI patients who received ≥1 crystalloid bolus. Further attention to a crystalloid sparing, early transfusion approach to resuscitation of children with sTBI is needed. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Partnering with High-Risk Communities to Successfully Reduce Pediatric Injury Over Time.

PURPOSE: Injury is the leading cause of childhood morbidity and mortality. Injury prevention (IP) initiatives are often created in isolation from the communities most affected. We hypothesized that the use of a comprehensive approach to injury prevention through community partnerships will result in a measurable reduction in pediatric injuries. METHODS: The IP program at our free-standing level 1 pediatric trauma center developed partnerships within eight targeted high-risk communities. IP coordinators and community partners implemented programs driven by community-specific injury data and community input. Programs focused on home, bike, playground, pedestrian, and child passenger safety. Program components included in-home education with free safety equipment and installation; free bike helmet fittings and distribution; community playground builds; and car seat classes with education, free car seat distribution and installation. Using trauma registry data, we compared injuries rates in targeted communities with non-intervention communities county-wide over an eight-year period. RESULTS: Between 2012 and 2019, nearly 4000 families received home safety equipment and education through community partnerships. Approximately 2000 bike helmets, 900 car/booster seats, in addition to safety messages and education were provided across the intervention communities. Over this 8-year time period, the injury rates significantly decreased by 28.4%, across the eight targeted high-risk communities, compared to a 10.9% reduction in non-intervention communities across the county. CONCLUSIONS: Effective injury prevention can be achieved through partnerships, working in solidarity with community members to address actual areas of concern to them. Sharing data, seeking ongoing community input, continuously reviewing learnings, and implementing identified changes are crucial to the success of such partnerships. LEVEL OF EVIDENCE: Level III.

Children from disadvantaged neighborhoods experience disproportionate injury from interpersonal violence.

BACKGROUND: Disparities in pediatric injury have been widely documented and are driven, in part, by differential exposures to social determinants of health (SDH). Here, we hypothesized that neighborhood socioeconomic deprivation and specific sociodemographic characteristics would be associated with interpersonal violence-related injury admission. METHODS: We conducted a retrospective cohort study of all patients ≤16 years, residing in Hamilton County, admitted to our level 1 pediatric trauma center. Residential addresses were geocoded to link admissions with a census tract-level socioeconomic deprivation index. Admissions were categorized as resulting from interpersonal violence or not - based on a mechanism of injury (MOI) of abuse or assault. The percentage of interpersonal violence-related injury admissions was compared across patient demographics and neighborhood deprivation index tertiles. These factors were then evaluated with multivariable regression analysis. RESULTS: Interpersonal violence accounted for 6.2% (394 of 6324) of all injury-related admissions. Interpersonal violence-related injury admission was associated with older age, male sex, Black race, public insurance, and living in tertiles of census tracts with higher socioeconomic deprivation. Those living in the most deprived tertile experienced 62.2% of all interpersonal violence-related injury admissions but only 36.9% of non-violence related injury admissions (p < 0.001). After adjustment, insurance and neighborhood deprivation accounted for much of the increase in interpersonal violence-related admissions for Black compared to White children. CONCLUSIONS: Children from higher deprivation neighborhoods, who are also disproportionately Black and publicly insured, experience a higher burden of interpersonal violence-related injury admissions. Level of evidence Level III.

Relationships between socioeconomic deprivation and pediatric firearm-related injury at the neighborhood level.

BACKGROUND: Disparities in pediatric injury are widely documented and partly driven by differential exposures to social determinants of health (SDH). Here, we examine associations between neighborhood-level SDH and pediatric firearm-related injury admissions as a step to defining specific targets for interventions to prevent injury. METHODS: We conducted a retrospective review of patients 16 years or younger admitted to our Level I pediatric trauma center (2010-2019) after a firearm-related injury. We extracted patients' demographic characteristics and intent of injury. We geocoded home addresses to enable quantification of injury-related admissions at the neighborhood (census tract) level. Our population-level exposure variable was a socioeconomic deprivation index for each census tract. RESULTS: Of 15,686 injury-related admissions, 140 were for firearm-related injuries (median age, 14 years; interquartile range, 11-15 years). Patients with firearm-related injuries were 75% male and 64% Black; 66% had public insurance. Nearly half (47%) of firearm-related injuries were a result of assault, 32% were unintentional, and 6% were self-inflicted; 9% died. At the neighborhood level, the distribution of firearm-related injuries significantly differed by deprivation quintile ( p < 0.05). Children from the highest deprivation quintile experienced 25% of injuries of all types, 57% of firearm-related injuries, and 70% of all firearm-related injuries from assault. They had an overall risk of firearm-related injury 30 times that of children from the lowest deprivation quintile. CONCLUSION: Increased neighborhood socioeconomic deprivation is associated with more firearm-related injuries requiring hospitalization, at rates far higher than injury-related admissions overall. Addressing neighborhood-level SDH may help prevent pediatric firearm-related injury. LEVEL OF EVIDENCE: Prognostic and epidemiological, Level III.

Admission for Isolated Low-Grade Solid Organ Injury May Not Be Necessary in Pediatric Patients.

BACKGROUND: Recent publications indicate that blunt solid organ injuries can be safely managed with reduced length of stay using pathways focused on hemodynamics. We hypothesized that pediatric patients with isolated blunt Grade I or II solid organ injuries may be safely discharged after brief observation with appropriate outpatient follow-up. OBJECTIVE: The purpose of this study is to evaluate the need for admission of pediatric trauma patients with isolated low-grade solid organ injury resulting from blunt trauma. METHODS: We performed a retrospective cohort study of trauma registry data from 2011 to 2018 to identify isolated blunt Grade I or II solid organ injuries among children younger than 19 years. "Complication or intervention" was defined as transfusions, transfer to the intensive care unit, repeat imaging, decrease in Hgb greater than 2 g/dl, fluid bolus after initial resuscitation, operation or interventional radiology procedure, or readmission within 1 week. RESULTS: A total of 51 patients were admitted to the trauma service with isolated Grade I or II blunt solid organ injuries during the 8-year study period. The average age was 11 years. Among isolated Grade I or II injuries, seven (14%) had "complication or intervention" including greater than 2 g/dl drop in Hgb in four patients (8%), follow-up ultrasonography for pain in one patient (2%), readmission for pain in one patient (2%), or a fluid bolus in two patients (4%). None required transfusion or surgery. The most common mechanism of injury was sports related (45%), and the average length of stay was 1 day. CONCLUSION: Among a cohort of 51 patients with isolated blunt Grade I or II solid organ injuries, none required a significant intervention justifying need for admission. All "complication or intervention" patients observed were of limited clinical significance. We recommend that hemodynamically stable patients with isolated low-grade solid organ injuries may be discharged from the emergency department after a brief observation along with appropriate instructions and pain management.

Catching the red eye: A retrospective review of factors associated with retinal hemorrhage in child physical abuse.

BACKGROUND/PURPOSE: Accurate identification of child physical abuse is crucial during the evaluation of injured children. Retinal hemorrhages (RH) are used for diagnosis, but clear criteria for screening with direct fundoscopic exam are lacking. We sought to identify key factors associated with RH to guide evaluations. METHODS: Electronic medical records for patients <1 year of age presenting to a Level I Pediatric Trauma Center with unwitnessed head injury from January 2015 to December 2018 were retrospectively reviewed. Multivariable logistic regression was used to identify factors associated with RH. RESULTS: Two hundred and seventy-six patients were included; 63% underwent direct fundoscopic examination, of which 23% were positive and 77% were negative for RH. Unscreened patients tended to be older and have isolated skull fractures. Multivariable regression analysis revealed that abnormal GCS and subdural hemorrhage were positively associated with a diagnosis of retinal hemorrhage, while isolated skull fracture was negatively associated. CONCLUSIONS: Children under 1 year of age with subdural hemorrhage have a greater risk of associated RH and should undergo routine screening with direct fundoscopic examination. Conversely, those with isolated skull fractures may not require an ophthalmology consultation. Standardized screening protocols may help reduce the risk of missing child physical abuse. LEVEL OF EVIDENCE: III (Diagnostic Test).

Timing and volume of crystalloid and blood products in pediatric trauma: An Eastern Association for the Surgery of Trauma multicenter prospective observational study.

BACKGROUND: The purpose of this study was to determine the relationship between timing and volume of crystalloid before blood products and mortality, hypothesizing that earlier transfusion and decreased crystalloid before transfusion would be associated with improved outcomes. METHODS: A multi-institutional prospective observational study of pediatric trauma patients younger than 18 years, transported from the scene of injury with elevated age-adjusted shock index on arrival, was performed from April 2018 to September 2019. Volume and timing of prehospital, emergency department, and initial admission resuscitation were assessed including calculation of 20 ± 10 mL/kg crystalloid boluses overall and before transfusion. Multivariable Cox proportional hazards and logistic regression models identified factors associated with mortality and extended intensive care, ventilator, and hospital days. RESULTS: In 712 children at 24 trauma centers, mean age was 7.6 years, median (interquartile range) Injury Severity Score was 9 (2-20), and in-hospital mortality was 5.3% (n = 38). There were 311 patients(43.7%) who received at least one crystalloid bolus and 149 (20.9%) who received blood including 65 (9.6%) with massive transfusion activation. Half (53.3%) of patients who received greater than one crystalloid bolus required transfusion. Patients who received blood first (n = 41) had shorter median time to transfusion (19.8 vs. 78.0 minutes, p = 0.005) and less total fluid volume (50.4 vs. 86.6 mL/kg, p = 0.033) than those who received crystalloid first despite similar Injury Severity Score (median, 22 vs. 27, p = 0.40). On multivariable analysis, there was no association with mortality (p = 0.51); however, each crystalloid bolus after the first was incrementally associated with increased odds of extended ventilator, intensive care unit, and hospital days (all p < 0.05). Longer time to transfusion was associated with extended ventilator duration (odds ratio, 1.11; p = 0.04). CONCLUSION: Resuscitation with greater than one crystalloid bolus was associated with increased need for transfusion and worse outcomes including extended duration of mechanical ventilation and hospitalization in this prospective study. These data support a crystalloid-sparing, early transfusion approach for resuscitation of injured children. LEVEL OF EVIDENCE: Therapeutic, level IV.

Comparison of diagnostic imaging modalities for the evaluation of pancreatic duct injury in children: a multi-institutional analysis from the Pancreatic Trauma Study Group.

PURPOSE: Determining the integrity of the pancreatic duct is important in high-grade pancreatic trauma to guide decision making for operative vs non-operative management. Computed tomography (CT) is generally an inadequate study for this purpose, and magnetic resonance cholangiopancreatography (MRCP) is sometimes obtained to gain additional information regarding the duct. The purpose of this multi-institutional study was to directly compare the results from CT and MRCP for evaluating pancreatic duct disruption in children with these rare injuries. METHODS: Retrospective study of data obtained from eleven pediatric trauma centers from 2010 to 2015. Children up to age 18 with suspected blunt pancreatic duct injury who had both CT and MRCP within 1 week of injury were included. Imaging findings of both studies were directly compared and analyzed using descriptive statistics, Chi square, Wilcoxon rank-sum, and McNemar's tests. RESULTS: Data were collected for 21 patients (mean age 7.8 years). The duct was visualized more often on MRCP than CT (48 vs 5%, p < 0.05). Duct disruption was confirmed more often on MRCP than CT (24 vs 0%), suspected based on secondary findings equally (38 vs 38%), and more often indeterminate on CT (62 vs 38%). Overall, MRCP was not superior to CT for determining duct integrity (62 vs 38%, p = 0.28). CONCLUSIONS: In children with blunt pancreatic injury, MRCP is more useful than CT for identifying the pancreatic duct but may not be superior for confirmation of duct integrity. Endoscopic retrograde cholangiogram (ERCP) may be necessary to confirm duct disruption when considering pancreatic resection. LEVEL OF EVIDENCE: III.

Routine surveillance imaging following mild traumatic brain injury with intracranial hemorrhage may not be necessary.

BACKGROUND: Mild traumatic brain injury (mTBI) comprises the majority of pediatric traumatic brain injury. Children with mTBI even with traumatic intracranial hemorrhage (tICH) rarely experience a clinically significant neurologic decline (CSND). The utility of routine surveillance imaging in the pediatric population also remains controversial, especially owing to concerns about the risks of radiation exposure at a young age. This study aims to identify demographic or injury-related characteristics that may facilitate recognition of children at risk of progression with mTBI. METHODS: We performed a retrospective review of patients <16 years old with mTBI (GCS 13-15) and tICH admitted to a Level I pediatric trauma center between 2009 and 2014. Management of these patients was directed by the Cincinnati Children's Hospital Medical Center Minor Head Injury Algorithm. We reviewed each chart with emphasis on patient demographics, injury specific data, and radiographic or clinical progression. RESULTS: 154 patients met inclusion criteria with mean age of 4 [0-16]; 116 sustained an tICH and 38 patients had isolated skull fractures. Repeat neuroimaging was obtained in 68 patients (59%). Only 9 patients (13%) with tICH had radiographic progression, none of which resulted in CSND. In addition, 9 patients experienced CSND, leading to neurosurgical intervention in 6 patients. Notably, none of these patients had repeat imaging prior to their neurologic changes. Both CSND and need for intervention were significantly higher in patients with epidural hematomas than other types of tICH (19.2% vs. 1.1%, p = 0.002). Of 154 patients, 19 did not have documented follow-up, 135 were seen as outpatients and 65 (48%) had follow up neuroimaging. All patients who had surveillance imaging in the outpatient setting had stable or resolved tICH. CONCLUSION: Few children with mTBI and tICH experience clinical decline. Importantly, all patients that required neurosurgical intervention were identified by clinical changes rather than via repeat imaging. Our study suggests that in the vast majority of cases, clinical monitoring alone is safe and sufficient in patients in order to avoid exposure to repeat radiographic imaging. LEVEL OF EVIDENCE: Level III, prognostic and epidemiological.

Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis: A pediatric trauma society collaborative.

BACKGROUND: Guidelines for nonoperative management (NOM) of high-grade pancreatic injuries in children have not been established, and wide practice variability exists. The purpose of this study was to evaluate common clinical strategies across multiple pediatric trauma centers to develop a consensus-based standard clinical pathway. METHODS: A multicenter, retrospective review was conducted of children with high-grade (American Association of Surgeons for Trauma grade III-V) pancreatic injuries treated with NOM between 2010 and 2015. Data were collected on demographics, clinical management, and outcomes. RESULTS: Eighty-six patients were treated at 20 pediatric trauma centers. Median age was 9 years (range, 1-18 years). The majority (73%) of injuries were American Association of Surgeons for Trauma grade III, 24% were grade IV, and 3% were grade V. Median time from injury to presentation was 12 hours and median ISS was 16 (range, 4-66). All patients had computed tomography scan and serum pancreatic enzyme levels at presentation, but serial enzyme level monitoring was variable. Pancreatic enzyme levels did not correlate with injury grade or pseudocyst development. Parenteral nutrition was used in 68% and jejunal feeds in 31%. 3Endoscopic retrograde cholangiopancreatogram was obtained in 25%. An organized peripancreatic fluid collection present for at least 7 days after injury was identified in 59% (42 of 71). Initial management of these included: observation 64%, percutaneous drain 24%, and endoscopic drainage 10% and needle aspiration 2%. Clear liquids were started at a median of 6 days (IQR, 3-13 days) and regular diet at a median of 8 days (IQR 4-20 days). Median hospitalization length was 13 days (IQR, 7-24 days). Injury grade did not account for prolonged time to initiating oral diet or hospital length; indicating that the variability in these outcomes was largely due to different surgeon preferences. CONCLUSION: High-grade pancreatic injuries in children are rare and significant variability exists in NOM strategies, which may affect outcomes and effective resource utilization. A standard clinical pathway is proposed. LEVEL OF EVIDENCE: Therapeutic/care management, level V (case series).

Pediatric trauma undertriage in Ohio.

BACKGROUND: Appropriate and timely triage is an essential component of a trauma system. In the state of Ohio, there are 6 verified pediatric trauma centers (PTCs) across 8 state regions. The purpose of this study was to better understand the pediatric undertriage rates in the state. METHODS: We used the Ohio Trauma Registry from 2007 to 2012, consisting of 14,045 records of children younger than 16 years admitted to a hospital for more than 48 hours or who sustained a traumatic death. Pediatric undertriage was defined as not being directly transported to a PTC when one was available within 30 minutes or not being transferred to a PTC within 2 hours of injury. RESULTS: The state pediatric undertriage rate was 52%, only decreasing to 35% when up to a 4-hour transfer time was allowed. Across state trauma regions, undertriage rates varied from 94% to 40%. More than 28% of injured children had access to a PTC within 30 minutes of their home. A trauma center (adult or pediatric) was within 30 minutes for 66% of the children, yet 32% of the children went to a nontrauma center first. Overall, 29% of children never made it to a PTC, and 4% of children remained at a nontrauma center, with regional variation from 5% to 0.5%. Statewide mortality was nearly 3%, with regional variations between 5% and 0.4%. Mortality rate within the appropriately triaged group was 5.3%, while mortality rate in the undertriage group was only 0.7%. Overall, 53% of transferred patients had a more than 2-hour transfer time. CONCLUSIONS: Despite the significant number of PTCs in Ohio, there remains a high undertriage rate with significant regional variations and long transfer times. Continued analysis will be useful in furthering trauma system development for the injured child. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV; epidemiological, level IV.

Consistent screening of admitted infants with head injuries reveals high rate of nonaccidental trauma.

PURPOSE: Implementation of a nonaccidental trauma (NAT) screening guideline for the evaluation of infants admitted with an unwitnessed head injury has eliminated screening disparities. This study sought to determine the overall NAT rate and key predictive factors using this guideline. METHODS: All infants screened via the guideline from 2008 to 2015 were retrospectively reviewed. The overall rate of NAT as determined by our child abuse team was determined. In addition, a logistic regression model was developed to evaluate potential predictors of increased risk of NAT. RESULTS: A total of 563 infants were screened with an overall rate of NAT of 25.6% (n=144). NAT screening was consistent across race and insurance status. By univariate analysis, patients with government insurance or no insurance had a significantly higher rate of NAT, but race was not a factor. Also NAT victims had significantly higher ISS. Skeletal survey showed high positive predictive value of 94%. When regression modeling was performed, ISS, abnormal skeletal survey and having public or no insurance were significantly correlated with NAT, while race showed no correlation. CONCLUSION: One quarter of infants admitted with a head injury not witnessed in a public situation were identified as the victims of NAT. The high rate of abuse among this population supports routine screening in order to avoid missing intentional injuries and preventing future injuries. Race is not a predictor of NAT, but insurance status, as a proxy for socioeconomic status, is correlated, and further investigation is needed. LEVEL OF EVIDENCE: III.

A multicenter prospective analysis of pediatric trauma activation criteria routinely used in addition to the six criteria of the American College of Surgeons.

BACKGROUND: The American College of Surgeons has defined six minimum activation criteria (ACS-6) for the highest level of trauma activations at trauma centers. The verification criteria also allow for the inclusion of additional criteria at the institution's discretion. The purpose of this prospective multicenter study was to evaluate the ACS-6 as well as commonly used activation criteria to evaluate overtriage and undertriage rates for pediatric trauma team activation. METHODS: Data were prospectively collected at nine pediatric trauma centers to examine 29 commonly used activation criteria. Patients meeting any of these criteria were evaluated for the use of high-level trauma resuscitation resources according to an expert consensus list. Patients requiring a resource but not meeting any activation criteria were included to evaluate undertriage rates. RESULTS: During the 1-year study, a total of 656 patients were enrolled with a mean age of 8 years, a median Injury Severity Score of 14, and mortality of 11%. Using all criteria, 55% of patients would have been overtriaged and 9% would have been undertriaged. If only the ACS-6 were used, 24% of patients would have been overtriaged and 16% would have been undertriaged. Among activation criteria with more than 10 patients, those most predictive of using a high-level resource were a gunshot wound to the abdomen (92%), blood given before arrival (83%), traumatic arrest (83%), tachycardia/poor perfusion (83%), and age-appropriate hypotension (77%). The addition of tachycardia/poor perfusion and pretrauma center resuscitation with greater than 40 mL/kg results in eight criteria with an overtriage of 39% and an undertriage of 10.5%. CONCLUSION: The ACS-6 provides a reliable overtriage or undertriage rate for pediatric patients. The inclusion of two additional criteria can further improve these rates while maintianing a simplified triage list for children.