Screening for alcohol and drug use in pediatric trauma.

BACKGROUND: Level 1 pediatric trauma centres should screen all trauma patients aged 12 years and older for alcohol use and provide substance use interventions as a means to minimize relapse. We aimed to approximate the rate of alcohol and drug use screening in Canadian pediatric patients admitted for trauma in our centre, determine the prevalence of intoxication on admission and compare the injury characteristics and morbidity of patients with and without concomitant substance use. METHODS: We conducted a single-centre retrospective review of the Stollery Children's Hospital's medical records abstracted from the Alberta Trauma Registry database of patients aged 12-17 years who were admitted for trauma (Injury Severity Score ≥ 12) between Jan. 1, 2012, and Dec. 31, 2021. RESULTS: Of the 543 patients included in the analysis, 380 (70.0%) received screening for alcohol as a part of their trauma panel; meanwhile, only 5 (0.9%) patients were screened for drug use. Among the patients who were screened for alcohol, 47 (12.4%) had a positive blood alcohol level (BAC). Nine (7%) of 129 screened patients aged 12-14 years were found to have positive BACs compared with 38 (15.1%) of 251 screened patients aged 15-17 years. Patient age and mechanism of injury significantly affected rates of screening. Among patients with positive BACs on admission, the 3 most prevalent mechanisms of injury were motor vehicle accident (26 [55.3%]), assault (13 [27.7%]) and recreational vehicle accidents (4 [8.5%]). Patients with a positive BAC sustained significantly more severe injuries (p = 0.003). CONCLUSION: These results provide evidence of the importance of standardized screening to identify pediatric patients admitted for trauma who are in need of treatment for alcohol and drug use. The Screening, Brief Intervention and Referral to Treatment model is the primary approach used to fulfill substance use identification and intervention recommendations. The Alcohol Use Disorders Identification Test and the Car, Relax, Alone, Forget, Friends, Trouble questionnaire are most suitable for adolescent populations.

The right treatment at the right time in the right place: a population-based, before-and-after study of outcomes associated with implementation of an all-inclusive trauma system in a large Canadian province.

OBJECTIVE: To evaluate the implementation of an all-inclusive philosophy of trauma care in a large Canadian province. BACKGROUND: Challenges to regionalized trauma care may occur where transport distances to level I trauma centers are substantial and few level I centers exist. In 2008, we modified our predominantly regionalized model to an all-inclusive one with the hopes of increasing the role of level III trauma centers. METHODS: We conducted a population-based, before-and-after study of patient admission and transfer practices and outcomes associated with implementation of an all-inclusive provincial trauma system using multivariable Poisson and linear regression and Cox proportional hazard models. RESULTS: In total, 21,772 major trauma patients were included. Implementation of the all-inclusive model of trauma care was associated with a decline in transfers directly to level I trauma centers [risk ratio (RR) = 0.91; 95% confidence interval (CI): 0.88-0.94; P < 0.001] and an increase in transfers from level III to level I centers (RR = 1.10; 95% CI: 1.00-1.21; P = 0.04). These changes in trauma care occurred in conjunction with a 12% reduction in the hazard of mortality (hazard ratio = 0.88; 95% CI: 0.84-0.98; P = 0.003) and a decrease in mean trauma patient hospital length of stay by 1 day (95% CI: 1.02-1.11; P = 0.02) after adjustment for differences in case mix. CONCLUSIONS: In this study, introduction of an all-inclusive provincial trauma system was associated with an increased number of injured patients cared for in their local systems and improved trauma patient mortality and hospital length of stay.

Occult pneumothoraces in ventilated pediatric trauma patients: a review.

BACKGROUND: Currently there is no clinical consensus on how to treat occult pneumothoraces in adults, and even less research has been done in children. We sought to understand the outcomes of severely injured, ventilated children with occult pneumothoraces. METHODS: Using the Alberta Trauma Registry, we retrospectively reviewed the charts of all ventilated pediatric patients at a children's hospital from 2001 to 2011 who had an injury severity score greater than 12 and a diagnosis of occult pneumothorax (seen on computed tomography scan but not on supine chest radiograph). RESULTS: There were 1689 severely injured children, with 496 admitted to the pediatric intensive care unit (PICU) and ventilated. A total of 130 children were found to have pneumothoraces, and of those, 96 were admitted to the PICU. Of those, 15 children had a total of 19 occult pneumothoraces, and all were successfully treated without chest tubes. The average age was 13.4 (range 2.0-17.0) years, and 54% of these children were male. The average time spent on the ventilator was 2.3 (range 0-13) days, and 7 children had at least 1 operation. CONCLUSION: In our institution, occult pneumothoraces occur in very few severely injured, ventilated pediatric trauma patients. Our study adds to the increasing evidence in the adult and pediatric literature suggesting that occult pneumothoraces may be safely observed even while under positive-pressure ventilation.

CONTEXTE: À l'heure actuelle, il n'existe pas de consensus clinique sur la façon de traiter le pneumothorax occulte chez les adultes et encore moins de recherches ont porté sur les enfants. Nous avons voulu comprendre comment évoluent les enfants grièvement blessés porteurs d'un pneumothorax occulte placés sous respirateur. MÉTHODES: À partir du registre de traumatologie de l'Alberta, nous avons analysé de manière rétrospective les dossiers de tous les patients pédiatriques sous respirateur dans un hôpital pour enfants entre 2001 et 2011; ces enfants présentaient un score de gravité des blessures supérieur à 12 et un diagnostic de pneumothorax occulte (révélé par la tomodensitométrie mais non par la radiographie pulmonaire en décubitus dorsal). RÉSULTANTS: Nous avons dénombré 1689 enfants grièvement blessés, dont 496 ont été admis dans une unité de soins intensifs pédiatriques (USIP) et placés sous respirateur. En tout, 130 enfants présentaient un pneumothorax et 96 d'entre eux ont été admis à l'USIP. Parmi ceux-ci, 15 présentaient en tout 19 pneumothorax occultes, et tous ont été traités avec succès sans drains thoraciques. L'âge moyen était de 13,4 (entre 2,0 et 17,0) ans et 54 % de ces enfants étaient de sexe masculin. La durée moyenne de la ventilation assistée a été de 2,3 (entre 0 et 13) jours et 7 enfants ont dû subir au moins une intervention chirurgicale. CONCLUSION: Dans notre établissement, le pneumothorax occulte s'observe chez très peu de grands blessés pédiatriques placés sous respirateur. Notre étude vient étayer les preuves présentées dans la littérature sur les adultes et sur les enfants selon lesquelles les patients atteints de pneumothorax occulte peuvent être placés en observation en toute sécurité, même sous ventilation en pression positive.

Use of paralysis in silo-assisted closure of gastroschisis.

OBJECTIVE: To examine the association between pre-closure neuromuscular paralysis and time to final surgical closure for infants with gastroschisis undergoing silo reduction. STUDY DESIGN: This study was an exploratory review of observational variables obtained from the Canadian Pediatric Surgery Network database. The focus was on the subset of infants with gastroschisis undergoing silo reduction between May 2005 and March 2009. Of the 186 infants, paralysis use could be ascertained for 167 infants (79 received pre-closure paralysis and 88 received none). Groups were compared by using statistical tests, with relationships explored using regression analysis. RESULTS: Infants receiving paralysis took longer to achieve closure by an average of 3 days (8 versus 5 days; P < .001) and had greater mean number of ventilation days (12 versus 7 days; P < .001). The relationship between paralysis and days to closure remained after adjusting for other variables. CONCLUSIONS: In infants with gastroschisis undergoing silo reduction, use of paralysis was associated with longer time to closure. Pre-closure paralysis should be carefully weighed in this population.

Pediatric surgery telehealth: patient and clinician satisfaction.

PURPOSE: The Stollery Children's Hospital serves a very large geographic region of over at least 650,000 km² with patients from outside of Edmonton accounting for approximately 50% of the service population. The aim of this study is to document the experience and opinion of the patient and clinician satisfaction with telehealth encounter for various pediatric surgical consultations and follow-up as a way to bridge the distance gap. METHODS: We observe our experience with recent telehealth implementation from 2008 to 2009. Qualitative data were collected through questionnaires aimed at patients and clinicians. RESULTS: There were 259 pediatric surgical telehealth encounters, of which 37% were from outside the province. There were 42 antenatal multidisciplinary, 13 chronic pain, 103 general surgery, 2 orthopedic, 63 urology, 33 head and shape nurse practioner clinic, and 3 neurosurgery consults. 83 patient and 12 clinician questionnaires were completed. 97% of patients and 73% of clinicians reported satisfaction with having a telehealth session. 97% of the patients reside more than 200 km from the city and 77% live more than 400 km away. 48% reported a cost saving >$500-$700. CONCLUSION: Telehealth for pediatric surgical services is an alternative as an acceptable, effective, and appropriate way to consult and follow-up pediatric patients who live in significantly remote areas with great clinician and patient satisfaction.

Attention to small details: big deal for gastrostomies.

Gastrostomy tubes are used in the pediatric population when long-term enteral feeding is needed. A common method of placement is percutaneously with endoscopy (PEG, percutaneous endoscopic gastrostomy). Although PEG placement is a straightforward procedure most of the time, it can be associated with a significant rate of minor complications and a smaller but significantly important rate of major complications. Some of these complications may also occur after any type of gastrostomy. We will present representative case studies outlining major complications and discuss how we may be able to prevent them at the time of PEG insertion or during PEG to low-profile button gastrostomy exchange. The proposed guidelines apply to all types of gastrostomies.

Canadian Association of Pediatric Surgeons' state of wellness.

The following is a summary of the fourth Ein Panel Debate Session from the 50th Annual Meeting of the Canadian Association of Pediatric Surgeons (CAPS) held in Toronto, ON, from September 26-29, 2018. The session focused on surgeon well-being at different stages of career: role of mentorship at the start of career, second victim syndrome, litigation stress syndrome, and retirement. Using Maslach Burnout Inventory Survey, CAPS members were presented their wellness scores as a group compared to other health care providers. The power of surgical culture in influencing decision making and judgment was explored. A culture shift toward vulnerability and transparency is possible and more suitable to expert practice and surgeon wellness.

Oral feeding outcomes in infants with esophageal atresia and tracheoesophageal fistula.

PURPOSE: The purpose of this study was to explore oral feeding outcomes in infants born with type-C esophageal atresia and tracheoesophageal fistula (EA/TEF). METHODS: A retrospective cohort study of all infants born between January 2005 and December 2015 undergoing surgery for type-C EA/TEF at the University of Alberta Hospital was performed. RESULTS: Fifty-seven infants were identified, of which 61.4% were exclusively orally feeding at discharge home. Variables anticipated to predict oral feeding were explored. Only 46% of babies with a structural cardiac anomaly had exclusive oral feeding compared to 79% without cardiac anomaly, p=0.055. Logistic regression identified the presence of structural cardiac anomaly and corrected gestational age at discharge as significant negative predictor variables for exclusive oral feeding at discharge home. Additional regression analyses found early transanastomotic feeding to be a significant positive predictor for the discontinuation of PN. CONCLUSION: We report the rate of oral feeding at discharge for infants born with type-C EA/TEF and identify predictor variables. This information is important for health care professionals and the families of children born with EA/TEF, because a significant number will go home with supplemental nutrition by gavage tube or other routes. LEVEL OF EVIDENCE: Level 2.

Refractory tension pneumothorax as a result of an internally displaced thoracoamniotic shunt in an infant with a congenital pulmonary airway malformation.

Antenatally, congenital pulmonary airway malformation (CPAM) causing fetal hydrops can be palliated with thoracoamniotic shunts, which may become displaced in utero. We report a case of an infant born at 34 weeks gestational age with an antenatally diagnosed macrocystic lung lesion, fetal hydrops and an internally displaced thoracoamniotic shunt. The infant suffered refractory pneumothoraces despite multiple chest drains, and stabilised only after surgical resection of the lesion. Intraoperatively, the shunt was noted to form a connection between a type I CPAM and the pleural space. As the shunt was displaced internally, this complication was not immediately obvious during the initial resuscitation. In infants with large cystic lung lesions, clinicians should be aware that internally displaced thoracoamniotic shunts could contribute to refractory tension pneumothoraces and anticipate the need for advanced neonatal resuscitation, including early thoracocentesis or chest drain insertion. Furthermore, displaced shunts may require early surgical intervention.

Serious impact of handlebar injuries.

BACKGROUND: Injuries from bicycles is a leading cause of trauma in children. We sought to investigate the epidemiology of bicycle handlebar injuries. METHODS: A retrospective analysis of bicycle trauma treated at our institution was preformed. RESULTS: A total of 462 children younger than 17 years had bicycle trauma. Abdominal handlebar injuries, representing 9% of bicycle injuries, contributed to 19% of all internal organ injuries, and 45.4% of solid, 87.5% of hollow, 66.6% of vascular or lymphatic, and 100% of pancreatic injuries. Handlebar injuries were 10 times more likely to cause severe injury, yet more than half of the children were misdiagnosed at their initial presentation. Delayed diagnosis and longer hospital stays were observed in handlebar injuries to the abdomen. CONCLUSION: Physicians should be aware of the serious impact of bicycle handlebar injury to the abdomen. The mechanism alone should raise the suspicion of internal organ injury, and timely imaging and surgical consultation.

The impact of fatal pediatric trauma on aboriginal children.

BACKGROUND/PURPOSE: Injuries are the leading cause of death in young people. Our aim is to examine the differences between aboriginal and non-aboriginal pediatric trauma mortality as a means to focus on prevention strategies. METHODS: The records for all traumatic pediatric (0-18 years) deaths between 1996 and 2010 were reviewed from the regional Medical Examiner's office. RESULTS: The majority of the total 932 pediatric deaths were the result of non-intentional injuries (640) followed by suicide (195), homicide (65), child abuse (15), and undetermined (17). Despite being only 3.3% of the provincial population, Aboriginals represented 30.9% of pediatric trauma fatalities. Aboriginal fatalities occurred most commonly in the home, with males and females equally affected. Road related events were the main causes of injury overall. Up to three-quarters of Aboriginal children who died in a non-pedestrian road related event did not wear an indicated protective device. Pedestrian deaths were over-represented in Aboriginal children. The second most common cause of death was suicide for both non-Aboriginal and Aboriginal children. Almost half of all of the suicides were Aboriginal. Homicide and child abuse had similar proportions for both non-Aboriginal and Aboriginal children. CONCLUSION: Pediatric Aboriginal injury prevention should be a priority and tailored for Aboriginal communities.

Focus on pediatric intentional trauma.

BACKGROUND: Based on our previous study, pediatric intentional trauma injuries with Injury Severity Scores (ISS) ≥ 12 were more commonly observed in the urban than the rural setting (15.2% vs. 5.5%) in Alberta from 1996 to 2006. We wish to understand differences between urban and rural pediatric intentional trauma to plan for prevention and supportive strategies. METHODS: Data were extracted from the Alberta Trauma Registry on pediatric patients (0-17 years) with ISS ≥ 12, treated from 1996 to 2010 at the Stollery Children's Hospital. Statistical analysis was made comparing urban versus rural groups using t test and χ2 with p < 0.05 considered significant. RESULTS: There were 170 pediatric patients who suffered intentional injury (urban = 58.3%; rural = 41.8%; not significant), with a majority of males (72.4%). Two groups were predominant: the very young (<1 year) at 17.1% of all injuries and the teens (≥ 15 years) at 54.1%. The cause of intent injury was child abuse (31.2%), assault with blunt object (24.6%), assault with a sharp object (22.9%), and suicide (18.2%). The mean ISS was 22.9 ± 7.8 standard deviation. Tragically, 29 patients (17.1%) died. There were no differences between urban and rural pediatric trauma in terms of age, gender, cause of injury, ISS, survival, length of stay, pediatric intensive care unit length of stay, number of operations needed, or alcohol. CONCLUSION: An important pattern of intentional injuries can be seen where preventative efforts can be strengthened regardless of urban or rural area: the very young as shaken baby cases and the teens, who unfortunately, accounted for the majority of suicidal attempts.

The process of treating pediatric appendicitis.

BACKGROUND: A large service and distant geographical area can make the process of diagnosing and treating appendicitis a challenge. METHODS: Hospital records of children treated for appendicitis between 2007 and 2009 were retrospectively analyzed, including time from emergency (ER) to operating room (OR), diagnostic imaging (DI) utilization, preoperative antibiotic usage, operating time, length of stay (LOS), and perforation rate. RESULTS: The perforation rate was 34%, with longer LOS. Transfer time to the children's hospital between ER inside and outside the city was not different. ER to OR time was significantly shorter for patients assessed at the children's hospital directly. Ultrasound remained the most used DI modality (55%). Preoperative antibiotics were only fully administered in 42% of the cases. CONCLUSION: A clinical pathway for pediatric appendicitis may address the challenges of the process of pre-ER, ER to OR, and OR care to maintain an acceptable perforation rate.

Incidence and predictors of gastrocutaneous fistula in the pediatric patient.

Background/Purpose. To determine the incidence, predictors, and outcomes of repair of gastrocutaneous fistulae (GCF) in pediatric patients. Methods. Patients were identified through a medical records search of all gastrostomy insertions performed from 1997-2007. Results. Of 1083 gastrostomies, 49 had GCF closure. Gastrostomy indications were reflux/aspiration (30/43 [70%]) and feeding intolerance/failure to thrive (7/43 [16%]). Gastrostomies were performed as open surgical procedures (84%) with fundoplication (66% of all cases) at an age of 0.5 ± 0.57 (median ± inter-quartile range) years. Gastrostomies were removed in outpatient settings when no longer used and were present for 2.3 ± 2.2 years, and GCF persisted for 2.0 ± 3.0 months. GCF were closed by laparotomy and stapling. GCF closure length of stay was 2.0 ± 3.3 days. Complications occurred in 6/49 patients and included infection/fever (4/6) and localized skin redness/breakdown (2/6). Conclusions. From our collected data, GCFs occur at a frequency of 4.5% and persist for 2.0 ± 3.0 months until closed. Given the complicated medical histories of patients and relatively high rate of postoperative infection/reaction (12.2%), GCF closure is not a benign, "uncomplicated" procedure. Further information describing factors determining which patients develop GCF requiring closure is needed.

Urban vs rural pediatric trauma in Alberta: where can we focus on prevention?

PURPOSE: Understanding differences between rural and urban pediatric trauma is important in establishing preventative strategies specific to each setting. METHODS: Data were extracted from a Provincial Pediatric Trauma Registry on pediatric patients (0-17 years) with Injury Severity Scores (ISS) 12 or more, treated from 1996 to 2006 at 5 major trauma centers in the province. Urban and rural patients were compared with respect to demographic data, as well as injury type and severity. Statistical analysis was made using SPSS software (SPSS Inc, Chicago, Ill) by chi(2), Fisher's Exact test, or t test with P < .05 considered significant. RESULTS: Of n = 2660, 63.3% rural patients predominate; mean ISS was 22.5. However, rural patients had more severe injuries (ISS, 23.2 vs 21.8; P < .0001). Blunt trauma was the most common mechanism overall (urban, 89.6%; rural, 93.2%), with most being motor vehicle accidents (MVAs). Significantly, more penetrating trauma occurred in the urban setting (5.4% vs 2.6%; P < .0001). Intent injuries were more common in the urban setting (15.2% vs 5.5%). Of the patients, 89.2% survived the trauma. However, urban patients had a higher rate of death than rural ones (13.0% vs 10.5%; P < .05). CONCLUSION: Despite the finding that rural patients sustained more severe injuries, overall survival was actually better when compared with urban patients. Most injuries were blunt trauma, suggesting road safety should be the main target in prevention strategies. Intent injuries were much higher in the urban group, thus, a need to target violence in urban prevention strategies.

Pediatric appendicitis rupture rate: disparities despite universal health care.

BACKGROUND/PURPOSE: Significant socioeconomic disparities have been observed in the rates of perforated appendicitis among children in private health care. We seek to explore if, in the Canadian system of public, universal health care access, pediatric appendicitis rupture rates are an indicator of health disparities. METHODS: Using the Population Health Research Data Repository housed at Manitoba Centre for Health Policy, a retrospective analysis over a 20-year period (1983-2003) examined all patients aged less than 18 years with International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes for appendicitis (N = 7475). Multivariate logistic regression analysis was used to calculate odds ratios in the association between appendiceal rupture rates and the patient's socioeconomic status (SES) based upon average household income of the census area adjusted for age, sex, area of residence, and treating hospital. RESULTS: The overall appendiceal rupture rate was 28.8%. Significant positive predictors of appendiceal rupture were lower rural SES, lower urban SES, younger age, northern area of residence, and receiving treatment at the province's only pediatric tertiary care hospital. CONCLUSION: Despite free, universal access health care, children from lower SES areas have increased appendiceal rupture rates. Seeking and accessing medical attention can be complicated by social, behavioral, and geographical problems.

Foregut duplications: is there an advantage to thoracoscopic resection?

PURPOSE: Thoracoscopy has an expanding role in the treatment of FD cysts (bronchogenic cysts and esophageal duplications). We examined this trend in our patients and reviewed our overall experience. METHODS: All charts of children undergoing surgery for foregut duplications (FDs) in 2 pediatric hospitals between 1992 and 2003 were retrospectively reviewed. Data gathered included age, weight, symptoms, diagnostic tests, operative technique, postoperative course, complications, and outcome. RESULTS: There were 39 children, with FD resected by thoracotomy in 21 patients, thoracoscopy in 11 patients (no conversions to open), cervical incision in 6 patients, and laparotomy in 1 patient for an FD near the gastroesophageal junction. Diagnosis was made by antenatal ultrasound in 7 cases. Four of these neonates had tachypnea or cough, and the rest were asymptomatic. Seventy-five percent of patients diagnosed postnatally presented with respiratory symptoms. Excision of isolated FD (without lung resection) was compared between those who had a thoracotomy (n = 16) vs thoracoscopy (n = 11). The age, weight, operating time, and anesthesia time were not different between the 2 groups. However, the thoracoscopy group had significantly fewer chest tube days (1.6 vs 3.3 days) and a shorter hospital stay (2.6 vs 6.6 days). Intraoperative complications consisted of tracheal injury in 3 patients (2 thoracotomy, 1 thoracoscopy) and esophageal mucosal injury in 2 patients (both thoracotomy), which were all recognized and repaired. CONCLUSION: Foregut duplications may present in a variety of ways and locations. Thoracoscopy is advantageous for isolated intrathoracic FDs.

Effect of temporary tracheal occlusion on the endothelin system in experimental cases of diaphragmatic hernia.

Previously, the authors have shown that tracheal occlusion (TO) partially reverses the onset of congenital diaphragmatic hernia (CDH)-induced pulmonary hypertension (PH) and abnormal pulmonary vascular development whereas release of the occlusion (TR) abolishes these clinical benefits. As a consequence of their mitogenic and vasoactive properties, the authors hypothesize that the expression of endothelin (ET)-1 and ET receptor (ETA) genes is increased in lungs of CDH lambs, and that this increase is abolished partially in CDH + TO but not in CDH + TO + TR. A surgical left-sided CDH was created in fetal lambs at 80 days of gestation (gd), followed by TO at 108 gd, and by TR at 129 gd. Four groups were compared: CDH, CDH + TO, CDH + TO + TR, and nonoperated controls (C). Assessment of mRNA expression by Northern blot showed significantly lower ET-1 and ETA levels in the CDH group than in the CDH + TO +/- TR groups (P < .05). Endothelin protein expression levels were lower in CDH +/- TO +/- TR groups when compared with controls for airways and vessels (P < .05) with the exception of endothelial cells. In contrast, ETA protein expression levels were higher in CDH +/- TO +/- TR groups compared with controls for airways and blood vessels smooth muscles (P < .05). These results suggest that involvement of the endothelin system in the pulmonary hypertension associated with CDH is limited. However, the endothelin system appears to be modulated during development.