To give or not to give? Blood for pediatric trauma patients prior to pediatric trauma center arrival.

PURPOSE: This study evaluates the indications, safety and clinical outcomes associated with the administration of blood products prior to arrival at a pediatric trauma center (prePTC). METHODS: Children (≤ 18 years) who were highest level activations at an ACS level 1 pediatric trauma center (PTC) from 2009-2019 were divided into groups:(1) patients with transport times < 4 h who received blood prePTC(preBlood) versus (2) age matched controls with transport times < 4 h who only received crystalloid prePTC (preCrystalloid). RESULTS: Of 1269 trauma activations, 38 met preBlood and 38 met preCrystalloid inclusion criteria. A similar volume of prePTC crystalloid infusion was observed between cohorts (p = 0.311). PreBlood patients evidenced greater hemodynamic instability as demonstrated by higher prePTC pediatric age-adjusted shock index (SIPA) scores. PreBlood patients showed improvement in lactate (p = 0.038) and hemoglobin (p = 0.041) levels upon PTC arrival. PreBlood patients received less crystalloid within 12 h of PTC admission (p = 0.017). No significant differences were found in blood transfusion volumes within six (p = 0.293) and twenty-four (p = 0.575) hours of admission, nor in mortality between cohorts (p = 0.091). CONCLUSIONS: The administration of blood to pediatric trauma patients prior to arrival at a PTC is safe, transiently improves markers of shock, and was not associated with worse outcomes.

Systems Approach Is Needed for In-Hospital Mobility: A Qualitative Metasynthesis of Patient and Clinician Perspectives.

OBJECTIVE: To describe how different key stakeholders (ie, interprofessional clinical care team and patients) perceive their role in promoting in-hospital mobility by systematically synthesizing qualitative literature. DATA SOURCES: PubMed, Ovid MEDLINE, Ovid PsychInfo, and Cumulative Index to Nursing and Allied Health were searched using terms relevant to mobility, hospitalization, and qualitative research. A total of 510 unique articles were retrieved and screened for eligibility. STUDY SELECTION: Eligible qualitative studies included stakeholder perspectives on in-hospital mobility, including patients, nursing staff, rehabilitation staff, and physicians. Eleven articles remained after inclusion/exclusion criteria were applied. DATA EXTRACTION: At least 2 authors independently read, coded, and derived themes from each study. We used a team-based inductive approach to thematic synthesis informed by critical realism and the socioecological model. Reciprocal translation unified convergent and divergent constructs across primary studies. Investigator triangulation enhanced interpretation. DATA SYNTHESIS: Three primary themes emerged: (1) patient, family, and clinician expectations shape roles in in-hospital mobility; (2) stakeholders' role in mobility depends on hospital environment, infrastructure, culture, and resources; and (3) teamwork creates successful in-hospital mobility, but lack of coordination and cooperation leads to delay in mobilizing. Studies suggested that while mobility is an essential construct in the professional role of clinicians and in the personal identity of patients, the ability of stakeholders to realize their role in mobility is highly dependent on the hospital physical and cultural environment, administrative support, clarity in professional roles, and teamwork. CONCLUSIONS: Interventions designed to address the problem of low hospital mobility should take a systems approach and consider allocation of resources, clarity around professional responsibilities, and elevation of patient and clinician expectations surrounding mobility.

It is time for TEG in pediatric trauma: unveiling meaningful alterations in children who undergo massive transfusion.

BACKGROUND: Hemorrhage is the leading cause of preventable death in pediatric trauma patients. In adults, goal-directed thrombelastography (TEG) has been shown to reduce mortality when used to guide massive transfusion (MT) resuscitation. There remains a paucity of data on the utility of TEG in directing resuscitation of pediatric trauma patients. We hypothesize that abnormalities on admission TEG will differ in pediatric trauma patients who undergo MT, compared to those who do not. METHODS: Pediatric patients (≤ 18 years) who were highest level trauma activations at two trauma centers from 2015 to 2018 were analyzed. We included patients who had admission TEGs and excluded those who did not. Patients were stratified into two groups: those who received MT (> 40 cc/kg total blood product within 6 h of admission) and those who did not. We defined TEG abnormalities based on each institution's normative values and compared TEG abnormalities between the groups. RESULTS: Of 117 children included, 39 had MT. MT patients had higher injury severity scores (30 vs. 23, p = 0.0004), lactates levels (7.0 vs. 3.5, p < 0.001), base deficit levels ( - 12.2 vs. - 5.8, p < 0.001), and INR values (1.8 vs. 1.3, p < 0.001). MT patients had significantly shortened alpha-angles (35.9% vs. 15.4%, p = 0.023), maximum amplitude (MA) values (43.6% vs. 10.3%, p < 0.001), and significantly lower platelet counts (165 vs. 281, p < 0.001) compared to those who did not receive MT. There was no difference in the trends in R-time, LY30 (lysis or shutdown), or fibrinogen concentration between the groups. Logistic regression identified a decreased MA as a significant predictor for MT [OR 3.68 (CI 1.29-10.52)] CONCLUSIONS: Pediatric trauma patients who undergo MT are more likely to have lower alpha-angles and MA values, as well as lower platelet counts. These findings support the use of TEG to identify hemorrhaging pediatric trauma patients, who may benefit from cryoprecipitate and/or platelet transfusions. TEG provides real-time information on coagulation status, which may expedite the delivery of specific blood products during trauma resuscitation. LEVEL OF EVIDENCE: LEVEL III: Type of study: Retrospective comparative study.

Pediatric Traumatic Amputations in the United States: A 5-Year Review.

BACKGROUND: Pediatric traumatic amputations are devastating injuries capable of causing permanent physical and psychological sequelae. Few epidemiologic reports exist for guidance of prevention strategies. The objective of this study is to review the recent trends in pediatric traumatic amputations using a national databank. METHODS: A review of all pediatric (age, 0 to 17 y) amputee patients was performed using the National Trauma Data Bank from 2007 to 2011. Data including demographics, location of amputation, and mechanism of injury were analyzed. RESULTS: In the analysis 2238 patients were identified. The majority of amputations occurred in the youngest (0 to 5 y) and oldest (15 to 17 y) age groups with a 3:1 male to female ratio. The most common amputation locations were finger (54%) and toe (20%). A caught between mechanism (16.3%) was most common overall followed by machinery, powered lawn mowers, motor vehicle collisions, firearms, and off-road vehicles. Males were statistically more likely to have an amputation and lawnmower injuries were statistically associated with lower extremity amputations in children 5 years old and below. Motor vehicle injuries were the most common cause of adolescent amputations. Firearm-related amputations occurred predominantly in adolescents, whereas off-road vehicle amputations occurred in all ages. CONCLUSIONS: Common trends in pediatric amputations are relatively unchanged over the last decade. Young children sustain more finger amputations from a caught between objects mechanism, whereas adolescents sustain serious amputations from higher energy mechanisms such as firearms-related and motor vehicle-related injuries. Lawnmower-related amputations continue to most significantly affect younger children despite increased public awareness. Improved prevention strategies targeting age and mechanism-related trends are necessary to prevent these costly and debilitating injuries. LEVEL OF EVIDENCE: Level IV.

Massive transfusion in pediatric trauma-does more blood predict mortality?

BACKGROUND: Treatment of severe hemorrhage focuses on the control of bleeding and intravascular volume expansion through massive transfusion (MT). This study aimed to determine if transfusion volumes in pediatric trauma patients who receive MT is associated with increased risk of death, and to establish if there is a threshold above which further resuscitation with blood products is futile. METHODS: Pediatric patients (2-18 years old) in the 2014-2017 Trauma Quality Improvement Program (TQIP) database with complete age and blood transfusion data who met the MT definition of 40 mL/kg/24 h were included in analysis. Data elements were cleaned to eliminate discrepancies in reporting blood volumes and erroneous values were excluded. Early mortality was defined as death within 24 h. Late mortality was defined as death more than 24 h after hospital admission. Area under the curve (AUC) was calculated from receiver operating characteristic (ROC) curve analyses to determine upper volume thresholds to predict early versus late mortality. RESULTS: There were 633 patients who met the MT definition of 40 mL/kg/24 h. The overall mortality rate was 21.6%. Volume of blood had poor predicting early and late mortality with an AUC of 0.50 [95% CI (0.42, 0.59)] and 0.50 [95% CI (0.43,0.57)], respectively. Regardless of mechanism, no transfusion volume was associated with a predictably high rate of mortality. CONCLUSIONS: There is no upper transfusion volume threshold to predict mortality in pediatric trauma patients who are massively transfused, regardless of mechanism. Severely injured children can tolerate massive amounts of blood products and still survive. LEVEL OF EVIDENCE: III.

Not as simple as ABC: Tools to trigger massive transfusion in pediatric trauma.

BACKGROUND: Early and accurate identification of pediatric trauma patients who will receive massive transfusion (MT) is not well established. We developed the ABCD (defined as penetrating mechanism, positive focused assessment with sonography for trauma, shock index, pediatric age-adjusted [SIPA], lactate, and base deficit [BD]) and BIS scores (defined as a combination of BD, international normalized ratio [INR], and SIPA) and hypothesized that the BIS score would perform best in the ability to predict the need for MT in children. METHODS: Pediatric trauma patients (≤18 years old) admitted to our trauma center between 2008 and 2019 were identified. Using a receiver operator curve, we defined cutoff points for lactate (≥3.2), BD (≤-6.9), and INR (≥1.4). ABCD scores were calculated by combining penetrating mechanism; positive focused assessment with sonography for trauma examination; SIPA; lactate; and BD. BIS scores were calculated by combining BD, INR, and SIPA. The sensitivity, specificity, and accuracy of each score were calculated based on receiving MT. RESULTS: Seven hundred seventy-two patients were included, of which 59 (7.6%) underwent MT. The best predictor of receiving MT was achieved by a BIS score of ≥2 that was 98% sensitive and 23% specific with an area under the curve of 0.81. The ABCD score of ≥2 was 97% sensitive and 20% specific with an area under the curve of 0.77. CONCLUSION: The BIS score, which takes into account derangements in acidosis, coagulopathy, and SIPA, is accurate and easy to perform and can be incorporated into a simple bedside screening tool for triggering MT in pediatric trauma patients. LEVEL OF EVIDENCE: Diagnostic Tests or Criteria, Level IV.

Elevated pediatric age-adjusted shock-index (SIPA) in blunt solid organ injuries.

BACKGROUND/PURPOSE: Shock index-pediatric age-adjusted (SIPA) is a proven tool to predict outcomes in blunt pediatric trauma. We hypothesized that an elevated SIPA in either the pre-hospital or in the emergency department (ED) would identify children with blunt liver or spleen injury (BLSI) needing a blood transfusion and those at risk for failure of non-operative management (NOM). METHODS: Pediatric patients (1-18 years) in the ACS pediatric-TQIP database (2014-2016) with a BLSI were included. Patients were stratified by the need for a blood transfusion and/or abdominal operation. RESULTS: A total of 3561 patients had BLSI, of which 4% received a blood transfusion, and 4% underwent an abdominal operation. Patients who received blood had higher ISS scores (27.0 vs. 5.0, p < 0.001) and mortality (22% vs. 0.4%, p < 0.001). Those who failed NOM had higher ISS scores (17.0 vs. 5.0, p < 0.001) and mortality (7.9% vs. 0.9%, p < 0.001). On multivariable regression, an elevated SIPA score in either pre-hospital or ED was significantly associated with blood transfusion (odds ratio (OR) 8.2, 95% confidence intervals (CI) 5.8-11.5, p < 0.001) and failure of NOM (OR 2.3, CI 1.5-3.4, p < 0.001). CONCLUSIONS: Hemodynamic instability, represented by an elevated pre-hospital or ED SIPA, accurately identifies children with BLSI who may need blood products or an operative intervention. TYPE OF STUDY: Retrospective Comparative Study. LEVEL OF EVIDENCE: Level III.

Combining Cribari matrix and Need For Trauma Intervention (NFTI) to accurately assess undertriage in pediatric trauma.

BACKGROUND/PURPOSE: The American College of Surgeons (ACS) Committee on Trauma targets undertriage (UT) rates of <5% to optimize the chances of survival. The Cribari Matrix (CM) has traditionally been employed to identify undertriage, but it likely overestimates actual undertriage. An innovative tool called "Need For Trauma Intervention" (NFTI), demonstrates a more accurate assessment of undertriage in adults. We hypothesized that using the combination of CM and NFTI would more accurately identify UT in pediatric trauma patients, compared to CM alone. METHODS: We reviewed undertriage rates using CM and NFTI criteria. Univariate analysis was used to compare the need for surgical management, transfusion requirements, ventilator days, ICU length of stay (LOS), hospital LOS, and hospital costs between CM, NFTI, and the combination of CM and NFTI. RESULTS: Undertriage rates were 8.2% with CM and 4.6% with NFTI. When CM and NFTI were combined, the UT rate was 2.7%. Pediatric patients categorized as UT by the combination of CM and NFTI had significantly longer ICU Length of Stay (LOS) (p < 0.001), hospital LOS (p < 0.001), higher mortality rates (p = 0.004), and higher hospitalization costs (p < 0.001). CONCLUSIONS: The combination of CM and NFTI identified UT in children, more accurately than CM or NFTI alone. Injured children who are undertriaged had higher mortality, morbidity, and cost of care. The use of CM in combination with NFTI to evaluate undertriage rates led to the identification of risk factors that may modify the activation criteria for highest and modified level trauma team activations. LEVEL OF EVIDENCE: III STUDY TYPE: Retrospective study without negative criteria (Therapeutic/Care Management).

Meaningful viscoelastic abnormalities in abusive and non-abusivepediatric trauma.

BACKGROUND/PURPOSE: There remains a lack of data on the utility of viscoelastic tests in managing abused patients. We hypothesize that abnormalities on admission thrombelastography (TEG) will differ in abused patients compared to those accidentally injured. METHODS: Pediatric trauma patients (≤10 years old) who had an admission TEG at a Level I pediatric trauma center (2010-2020) were included and stratified into two cohorts: abuse versus accidental trauma. TEG abnormalities were based on the institution's normative values and compared between the groups. RESULTS: Of 41 children included, 21 sustained abuse. Five abused patients and three accidentally injured patients died. Abused children showed a hypercoagulable pattern on viscoelastic testing with TEG when compared to those accidentally injured, as demonstrated by a short R-time (67% vs. 30%, p = 0.040) and an increased alpha angle (47% vs. 0%, p = 0.001). There was no significant difference in the MA and LY30 values between the two groups. In a multivariable model, only an abnormal alpha angle remained associated with abuse [odds ratio (OR) 0.17 (confidence intervals (CI) 0.02-0.92)]. In a separate multivariable model, only an abnormal MA was associated with mortality [OR 18.97 (CI 1.93-475.47), p = 0.025]. CONCLUSIONS: Our data suggest that hemostasis is significantly different in abused children relative to those who are accidentally injured. TYPE OF STUDY: Retrospective Comparative Study. LEVEL OF EVIDENCE: Level III.

Why Delay? Early Enteral Nutrition in Pediatric Burn Patients Improves Outcomes.

Children who sustain moderate to large surface area burns present in a hypermetabolic state with increased caloric and protein requirements. A policy was implemented at our institution in 2017 to initiate enteral nutrition (EN) in pediatric burn patients within 4 hours of admission. The authors hypothesize that early EN (initiated within 4 hours of admission) is more beneficial than late EN (initiated ≥ 4 hours from admission) for pediatric burn patients and is associated with decreased rates of pneumonia, increased calorie and protein intake, fewer feeding complications, a shorter Intensive Care Unit (ICU) length of stay (LOS), and a reduced hospital LOS. Children who sustained a total body surface area (TBSA) burn injury ≥ 10% between 2011 and 2018 were identified in a prospectively maintained burn registry at Children's Hospital Colorado. Patients were stratified into two groups for comparison: early EN and late EN. The authors identified 132 pediatric burn patients who met inclusion criteria, and most (60%) were male. Approximately half (48%) of the study patients were in the early EN group. The early EN group had lower rates of underfeeding during the first week (P = .014) and shorter ICU LOS (P = .025). Achieving and sustaining adequate nutrition in pediatric burn patients with moderate to large surface area burn injuries are critical to recovery. Early EN in pediatric burn patients is associated with decreased underfeeding and reduced ICU LOS. The authors recommend protocols to institute feeding for patients with burns ≥ 10% TBSA within 4 hours of admission at all pediatric burn centers.

Rib fracture patterns predict thoracic chest wall and abdominal solid organ injury.

Blunt trauma patients with rib fractures were studied to determine whether the number of rib fractures or their patterns were more predictive of abdominal solid organ injury and/or other thoracic trauma. Rib fractures were characterized as upper zone (ribs 1 to 4), midzone (ribs 5 to 8), and lower zone (ribs 9 to 12). Findings of sternal and scapular fractures, pulmonary contusions, and solid organ injures (liver, spleen, kidney) were characterized by the total number and predominant zone of ribs fractured. There were 296 men and 14 women. There were 38 patients with scapular fracture and 19 patients with sternal fractures. There were 90 patients with 116 solid organ injuries: liver (n = 42), kidney (n = 27), and spleen (n = 47). Lower rib fractures, whether zone-limited or overlapping, were highly predictive of solid organ injury when compared with upper and midzones. Scapular and sternal fractures were more common with upper zone fractures and pulmonary contusions increased with the number of fractured ribs. Multiple rib fractures involving the lower ribs have a high association with solid organ injury, 51 per cent in this series. The increasing number of rib fractures enhanced the likelihood of other chest wall and pulmonary injuries but did not affect the incidence of solid organ injury.

The true cost of child abuse at a level 1 pediatric trauma center.

BACKGROUND: Child physical abuse (CPA) is a significant cause of morbidity and mortality. Children who sustain CPA consume significant healthcare resources. We hypothesized that the costs to care for children who sustain for children with CPA-type injuries are greater than the costs to care for children who sustain accidental injuries. METHODS: All confirmed CPA patients between the ages of 0 and 19 years old, who were admitted to a level 1 pediatric trauma center between January 2010 and September 2018, were retrospectively reviewed. We compared outcomes, including mortality, length of stay (LOS), diagnostic work-up, and overall cost using propensity matching between CPA and accidentally injured trauma patients. Patients were matched based on injury severity score (ISS). RESULTS: The CPA cohort (n = 595) was younger (1.31 +/- 1.96 years, p < 0.0001) than the accidental trauma patients (8.6 +/-5.54 years). The majority of the CPA patients had Medicaid coverage (75.1%), when compared to accidental trauma patients (37.5%; p < 0.0001). CPA patients had longer ICU LOS (2.43 days; p < 0.0001), increased ventilation days (2.57 days; p < 0.0001), and longer hospital LOS (6.56 days; p = 0.0004). The overall mortality rate for CPA patients was higher than accidental trauma patients (9.9% vs. 1.2%; p < 0.0001). The median hospital cost was significantly higher for those with CPA ($18,000) than accidental trauma ($10,100; p < 0.0001). CONCLUSION: The costs to care for children who sustain CPA-type injuries are significantly greater than the costs to care for children who sustain accidental trauma. Better screening tools, more provider education and broader community outreach efforts are needed to reduce the societal and economic costs associated with child physical abuse. STUDY TYPE: Treatment. LEVEL OF EVIDENCE: Level III.

The shock index, pediatric age-adjusted (SIPA) enhanced: Prehospital and emergency department SIPA values forecast transfusion needs for blunt solid organ injured children.

BACKGROUND: The elevated shock index, pediatric age-adjusted (SIPA) has been found to accurately predict the need for blood transfusion in severely injured children. We sought to determine the utility of monitoring sequential SIPA values from the prehospital setting through the emergency department to identify children with a blunt liver or spleen injury who will require a blood transfusion. METHODS: We conducted a retrospective review of children 1 to 18 years old admitted to a level-1 pediatric trauma center with any grade blunt liver or spleen injury between 2009 and 2019. Cohorts were stratified into those who received a blood transfusion within the first 24 hours after injury and those who did not. RESULTS: A total of 477 children had a blunt liver or spleen injury during the study period, of which 20% (95 of 477) received a blood transfusion within 24 hours of trauma center arrival. Of those who received a blood transfusion, 75% (71 of 95) were transfused within 6 hours of arrival at our center. Nearly 90% (84 of 95) of patients who received blood had at least 1 elevated SIPA score in either setting (prehospital or emergency department). Based on multivariable regression, an elevated SIPA score in either setting was significantly associated with blood transfusion (odds ratio 7.8 (confidence interval 4.7-12.9, P = .002). CONCLUSION: Elevated SIPA values in the prehospital setting and on emergency department arrival are associated with early blood transfusion. The importance of this finding is that after serial SIPA values may assist in the early identification of children with blunt liver or spleen injury who will require a blood transfusion.

Pain Management for Pediatric Burns in the Outpatient Setting: A Changing Paradigm?

Childhood burns are common and distressing for children and their parents. Pain is the most common complaint and often thought to be undertreated, which can negatively influence the child's care and increase the risk of posttraumatic stress disorder. There is limited literature on the role of opioids and multimodal therapy in the treatment of pediatric outpatient burns. We sought to evaluate the current use of opioids (including the use of multimodal therapies), storage, and disposal of opioids in this patient population. Parents of burn-injured children 8 months to 18 years old, who were seen in an outpatient setting within 2 weeks of their burn injury, were queried from April to December 2019 regarding their child's pain control, opioid medication use, over-the-counter pain medication use, opioid storage, and disposal. A total of 142 parents of burn-injured children and their parents were surveyed. The median age of the burn-injured children was 2.7 years old and the majority (54.2%; 77/142) were male. The mean total body surface area (TBSA) was 1.8% and half sustained burn injuries to one or both hands. The most frequently used regimens for constant and/or breakthrough pain control were acetaminophen (62.7%) and nonsteroidal anti-inflammatory drugs (NSAIDs; 68.3%). Less than one fifth (26/142;18%) of patients were prescribed opioids and 88% filled their prescription. The median number of doses of opioids prescribed was eight doses, with a median of four doses of opioids unused. Only three patients used all of their prescribed opioids and no patient ≥12 years old used their entire prescription. Burns greater than 3% TBSA, irrespective of burn injury location, were associated with opioid prescription (P = .003). Approximately 40% (10/26) of parents who filled their child's opioid prescription stored the opioid in a locked area. Fewer than one third (7/26) of patients were educated on how to dispose of excess opioid pain medication. Overall, most pediatric outpatient burn injuries can be successfully managed with over-the-counter medications. Providers, who care for burn-injured children ≤ 12 years old with burns that cover ≥3% TBSA in the outpatient setting, should consider no more than four opioid doses for initial pain control. This guideline, coupled with family and provider-centered education on multimodal therapy at the time of initial presentation and safe use of opioids, are important first steps to minimizing the use of opioids in the management of small area burns in children.

Guns, scalpels, and sutures: The cost of gunshot wounds in children and adolescents.

BACKGROUND: Firearm injuries are the second leading cause of death among US children. While injury prevention has been shown to be effective for blunt mechanisms of injury, the rising incidence of accidental gunshot wounds, school shootings, and interpersonal gun violence suggests otherwise for firearm-related injuries. The purpose of the study is to describe the incidence, injury severity, and institutional costs of pediatric gun-related injuries in Colorado. METHODS: Pediatric patients (≤18 years), who sustained firearm injuries between 2008 and 2018, were identified from the trauma registries of three pediatric trauma centers in Colorado. Patients were stratified based on age: those younger than 14 years were defined as children and those 15 years to 18 years as adolescents. RESULTS: Our cohort (n = 308) was predominantly male (87%), with a median age of 14 years. The overall mortality rate was 11% (34/308), with significantly fewer children (5%) dying from their injuries when compared with adolescents (14%; p = 0.04). Sixty-five (21%) patients required blood product transfusions, with 23 (7.4%) patients receiving a massive transfusion. Overall, 52% (161/308) required a major operation, with 15% undergoing an exploratory laparotomy. One third (4/13) of the patients who had a thoracotomy in the emergency department survived to hospital discharge. Overall, 14.0% of patients had psychiatric follow-up at both 30 days and 1 year. The readmission rate for complications was 11.6% at 30 days and 14% at 1 year. The total cost of care for all pediatric firearm-related injuries was approximately US $26 million. CONCLUSION: The survivors of pediatric firearm injuries experience high operative and readmission rates, sustain long-term morbidities, and suffer from mental health sequelae. Combining these factors with the economic impact of these injuries highlights the immense burden of disease. This burden may be palliated by a multipronged approach, which includes the development and dissemination of injury prevention strategies and better follow-up care for these patients. LEVEL OF EVIDENCE: Epidemiological, Level III.

Anti-coagulation management in pediatric traumatic vascular injuries.

BACKGROUND: Pediatric traumatic vascular injuries are rare. Given the paucity of data to guide anti-coagulation (AC) management of these injuries in children, who have a lower overall risk for thrombosis compared to their adult counterparts, we sought to examine and summarize our recent experience. METHOD: We conducted a retrospective review of all patients (<18 years old) who sustained traumatic vascular injuries between 2010-2018 at a Level 1 and Level 2 Pediatric Trauma Center. RESULTS: Ninety-nine patients had traumatic vascular injuries. Eighty-four patients sustained a major arterial injury, 26 had a major venous injury, and 11 had both arterial and venous injuries. The arterial injury cohort had a median age of 13.3 years. Most of the arterial injury patients (65/84, 77%) required vascular repair. In-hospital AC management for the arterial injury patients consisted of a post-operative heparin drip (18%, 15/84), aspirin (39%, 26/84), enoxaparin (23%, 19/84), or none (42%, 43/84). Approximately one-half of the patients with arterial injuries (54%, 45/84) were discharged home on AC therapy, most commonly aspirin. Fifty-six patients (66%) followed up post-injury, of which 25% (14/56) had experienced complications. CONCLUSION: Pediatric traumatic arterial injuries that require surgical intervention other than ligation should be considered for discharge AC - most commonly aspirin - in the absence of contraindications. Pediatric patients with vascular injuries to the aorta, carotid artery, inferior vena cava, portal vein, or lower extremities that are managed non-operatively should also be considered for AC. The preferred AC for pediatric venous injuries is enoxaparin, in the absence of contraindications. STUDY TYPE: Treatment Study LEVEL OF EVIDENCE: IV.

The ABC-D score improves the sensitivity in predicting need for massive transfusion in pediatric trauma patients.

PURPOSE: Early and accurate identification of pediatric trauma patients who will require massive transfusion (MT) remains difficult, and MT activation criteria are not well established. In children, the addition of shock index-pediatric age-adjusted (SIPA) to the ABC score (ABC-S) only modestly improves the sensitivity of the ABC score. We hypothesized that the discriminate ability of the ABC-S score would improve with the addition of elevated serum lactate and base deficit (ABCD score). METHODS: We identified children between 1 and 18 years old who received a pRBC transfusion between 2008 and 2018 from our trauma registry. We calculated sensitivity, specificity, and accuracy of the ABC, ABC-S, and ABCD scores to determine the need for MT. RESULTS: We included 211 children, of which 66 required MT. The best predictor of MT was achieved by adding BD and lactate to the ABC-S score, with an AUC of 0.805. An ABCD score of 3 or greater was 77.4% sensitive and 78.8% specific at predicting the need for MT. Pediatric trauma patients that required MT had higher injury severity score (p = 0.005), lactate (p = 0.002), base deficit (p = <0.0001). Mortality was higher in the MT group (45.5% vs 15.3%, p = 0.0004). CONCLUSIONS: The ABCD score improves the sensitivity of activating MT in pediatric trauma patients. STUDY TYPE: Treatment Study. LEVEL OF EVIDENCE: Level III.

Antibiotic ointment versus a silver-based dressing for children with extremity burns: A randomized controlled study.

INTRODUCTION: Antibiotic or silver-based dressings are widely used in burn wound care. Our standard method of dressing pediatric extremity burn wounds consists of an antibiotic ointment or nystatin ointment-impregnated nonadherent gauze (primary layer), followed by rolled gauze, soft cast pad, plaster and soft casting tape (3M™ Scotchcast™, St. Paul, MN). The aim of this study was to compare our standard ointment-based primary layer versus Mepitel Ag® (Mölnlycke Health Care, Gothenburg, Sweden) in the management of pediatric upper and lower extremity burn wounds. METHODS: Children with a new burn injury to the upper or lower extremities, who presented to the burn clinic were eligible. Eligible children were enrolled and randomized, stratified by burn thickness, to be dressed in an ointment-based dressing or Mepitel Ag®. Study personnel and participants were not blinded to the dressing assignment after randomization. Dressings were changed approximately once or twice per week, until the burn wound was healed or skin-grafted. The primary outcome was time to wound healing and p-value < 0.05 was considered significant. RESULTS: Ninety-six children with 113 upper or lower extremity burns were included in the analysis. Mepitel Ag® (hazard ratio [HR] 0.57 (95% Confidence Interval (CI) 0.40-0.82); p = 0.002) significantly reduced the rate of wound healing, adjusting for burn thickness and fungal wound infection. The incidence of fungal wound infections and skin grafting was similar between the two groups. Children randomized to standard ointment dressings were significantly less likely to require four or more burn clinic visits than those in the Mepitel Ag® (4% versus 27%; p = 0.004). CONCLUSION: Our study shows that our standard ointment-based dressing significantly increases the rate of wound healing compared to Mepitel Ag® for pediatric extremity burn injuries. LEVEL OF EVIDENCE: Treatment study; Level 1.

Impact of a statewide trauma system on the triage, transfer, and inpatient mortality of injured patients.

BACKGROUND: In 2009, Arkansas implemented a statewide trauma system to address the high rates of mortality and morbidity due to trauma. The principal objective of the Arkansas Trauma System is to transport patients to the appropriate facility based on the injuries of the patients. This study evaluated four metrics that were crucial to system health. These measures included: treatment location, scene triage, admission to nondesignated facilities, and inpatient mortality. Furthermore, the authors sought to quantify how the system is selective toward the severely injured regarding triage and treatment location. The authors hypothesized that system implementation should increase the proportion of patients, particularly the severely injured, treated at Level I/II facilities. The system should increase the proportion of patients, especially the severely injured, admitted to Level I/II facilities directly from the scene. The system should result in fewer patients admitted to nondesignated facilities. Lastly, system implementation should result in fewer inpatient deaths. METHODS: A pre-post study design was used for this evaluation. Data from the Arkansas Hospital Discharge data set (2007 through 2012) identified patients who were admitted as a result of their injuries. The ICD-MAP software was used to categorize those with and without severe injuries based on an Injury Severity Score of 16 or greater or head Abbreviated Injury Scale score of 3 or greater. RESULTS: The results indicate that while there was an overall increase in odds of patients being admitted to Level I/II facilities, those with severe injuries were associated with an even greater odds of admission to Level I/II facilities (p < 0.0001). System implementation was also associated with more severely injured patients admitted to Level I/II facilities from the scene. There were also fewer patients admitted to nondesignated hospitals after system implementation (p < 0.0001). System implementation was associated with fewer inpatient deaths (p = 0.02). CONCLUSION: Two years after implementation, the trauma system showed significant progress. The measures evaluated in this study are believed to support the effectiveness of the trauma system. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Acute procedural interventions after pediatric blunt abdominal trauma: A prospective multicenter evaluation.

BACKGROUND: Pediatric intra-abdominal injuries (IAI) from blunt abdominal trauma (BAT) rarely require emergent intervention. For those children undergoing procedural intervention, our aim was to understand the timing and indications for operation and angiographic embolization. METHODS: We prospectively enrolled children younger than 16 years after BAT at 14 Level I Pediatric Trauma Centers over a 1-year period. Patients with IAI who received an intervention (IAI-I) were compared with those who did not receive an intervention using descriptive statistics and univariate analysis; p less than 0.05 was considered significant. RESULTS: Two hundred sixty-one (11.9%) of 2,188 patients had IAI. Forty-five (17.2%) IAI patients received an acute procedural intervention (38 operations, seven angiographic embolization). The mean age for patients requiring intervention was 7.1 ± 4.1 years and not different from the population. Most patients (88.9%) with IAI-I were normotensive. IAI-I patients were significantly more likely to have a mechanism of motor vehicle collision (66.7% vs. 38.9%), more likely to present as a Level I activation (44.4% vs. 26.9%), more likely to have a Glascow Coma Scale less than 14 (31.1% vs. 15.5%), and more likely to have an abnormal abdominal physical examination (93.3% vs. 65.7%) than patients that did not require acute intervention. All patients underwent computed tomography scan before intervention. Operations consisted of laparotomy (n = 21), laparoscopy converted to open (n = 11), and laparoscopy alone (n = 6). The most common surgical indications were hollow viscus injury (HVI) (11 small bowel, 10 colon, 6 small bowel/colon, 2 duodenum). All interventions for solid organ injury, including seven angioembolic procedures, occurred within 8 hours of arrival; many had hypotension and received a transfusion. Procedural interventions were more common for HVI than for solid organ injury (59.2% vs. 7.6%). Postoperative mortality from IAI was 2.6%. CONCLUSION: Acute procedural interventions for children with IAI from BAT are rare, predominantly for HVI, are performed early in the hospital course and have excellent clinical outcomes. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III; therapeutic study, level IV.