Impact of intra-abdominal insufflation pressure on gas leakage occurring during laparoscopy.

INTRODUCTION: The advent of the COVID-19 pandemic led to recommendations aimed at minimizing the risk of gas leaks at laparoscopy. As this has continuing relevance including regarding operating room pollution, we empirically quantified carbon dioxide (CO2) leak jet velocity (important for particle propulsion) occurring with different instruments inserted into differing trocars repeated across a range of intra-abdominal pressures (IAPs) and modern insufflators in an experimental model. METHOD: Laparoscopic gas plume leak velocity (metres/second) was computationally enumerated from schlieren optical flow videography on a porcine cadaveric laparoscopic model with IAPs of 4-5, 7-8, 12-15 and 24-25 mmHg (repeated with 5 different insufflators) during simulated operative use of laparoscopic clip appliers, scissors, energy device, camera and staplers as well as Veres needle (positive control) and trocar obturator (negative control) in fresh 5 mm and 12 mm ports. RESULTS: Close-fitting solid instruments (i.e. cameras and obturators) demonstrated slower gas leak velocities in both the 5 mm and 12 mm ports (p = 0.02 and less than 0.001) when compared to slimmer instruments, however, hollow instrument designs were seen to defy this pattern with the endoscopic linear stapler visibly inducing multiple rapid jests even when compared to similarly sized clip appliers (p = 0.03). However, on a per device basis the operating instrumentation displayed plume speeds which did not vary significantly when challenged with varying post size, IAP and a range of insufflators. CONCLUSION: In general, surgeon's selection of instrument, port or pressure does not usefully mitigate trocar CO2 leak velocity. Instead better trocar design is needed, helped by a fuller understanding of trocar valve mechanics via computational fluid dynamics informed by relevant surgical modelling.

Pre-hospital Tourniquet Use in Adolescent and Pediatric Traumatic Hemorrhage: A National Study.

BACKGROUND: Tourniquet placement (TP) is a crucial intervention to control hemorrhage, but limited literature exists for use in children. This study aimed to evaluate the effectiveness of tourniquet application by different providers (Emergency Medical Services (EMS), first responder (FR), and bystanders), hypothesizing equivalent impact on outcomes for pediatric trauma patients for all providers. METHODS: Data from the National EMS Information Systems (NEMSIS) 2017-2020 was used to examine patients 0-19 years old and assess the outcomes of tourniquet application. We considered demographics, procedure success, timing of TP relative to EMS arrival, revised trauma score (RTS), and improvement in acuity. Multivariable logistic regression models were employed to predict initial acuity and likelihood of acuity improvement after TP, while accounting for patient and provider-related variables. RESULTS: 301 patients were included with a median age of 17 and 86.7 % male. TP by any provider before EMS transport arrival was associated with reduced odds of critical acuity upon EMS arrival (OR = 0.84, CI = 0.76-0.94, p = 0.003). After EMS arrival, bystander- and FR-placed tourniquets were associated with increased odds of improved acuity compared to EMS-placed tourniquets (OR = 1.90, CI = 1.06-3.41, p = 0.03). There was only one TP failure (0.43 %) in the EMS group. TP failure was associated with decreased odds of acuity improvement (OR = 0.62, CI = 0.44-0.86, p = 0.005). CONCLUSION: Early TP for pediatric traumatic hemorrhage is crucial. Failures were rare. Placement by bystanders and FR were associated with improved acuity when controlling for other factors including RTS and EMS arrival time. These findings emphasize the importance of training on TP for all providers in prehospital settings. LEVEL OF EVIDENCE: IV.

Child Maltreatment Education: Utilizing an Escape Room Activity to Engage Learners on a Sensitive Topic.

Audience: Emergency medical service (EMS) providers and other health care professionals. Introduction: In 2019 alone, 656,000 children in the United States were victims of child abuse and neglect.1 The medical community has historically struggled with the identification of child maltreatment. In one study, 33% of abused children had a previous visit with a medical provider in which the abuse was found to have been missed.2 Many voices in the healthcare community have advocated for the implementation of routine screening, and studies have demonstrated the implementation of such screening in the emergency department (ED) increases the detection of child maltreatment.3-7 Child maltreatment screening tools are increasingly utilized in primary care and ED settings, but one has yet to be adapted or designed for universal use by emergency medical services (EMS) professionals in the prehospital care context. Because EMS providers are uniquely positioned to assess for maltreatment, they have traditionally been the only provider to interact with families in the home environment. Unfortunately, EMS rates of documentation of maltreatment is quite low. A recent study using the National Emergency Medical Services Information System database to evaluate EMS documentation of child maltreatment in patients ≤3 years of age compared to the national incidence of known maltreatment found an almost 15-fold discrepancy.8 There have been several attempts to elucidate the difficulties of and barriers to reporting by EMS providers. Markenson et al and Tiyyagura et al outlined several areas that potentially contribute to a lack of reporting: minimal continuing medical education (CME) on child maltreatment, knowledge of physical and historical details suspicious for abuse, knowledge of child development, limited clinical evaluation time in a fast-paced work environment, understanding of how to appropriately interact with families, and fear of being wrong.9,10 This class/escape room activity was developed to directly address several of these areas. Emergency medical service providers participate in traditional didactics (in the form of a short lecture), followed by an escape room activity in which they further explore and reinforce learning in a fun and memorable environment. This activity also promotes teamwork, an especially important skill in potentially complex and difficult situations such as those surrounding suspected child maltreatment. Educational Objectives: By the end of the escape room, the learner should be able to: 1) understand the national and local prevalence of child maltreatment; 2) understand the different types of child maltreatment and common associated presentations; 3) know the local EMS agency reporting requirements; 4) understand when to make base hospital contact with respect to concern for maltreatment; 5) collaborate effectively as a team. Educational Methods: Child maltreatment can be a sensitive and challenging topic. In this class, we presented learners with a short, 15-minute lecture (see Pre-Escape Room Lecture PowerPoint) followed by an escape room activity. The Pre-Escape Room Lecture PowerPoint includes suggestions on the type of image and/or statistics to include on each slide, which can be taken from your site's available de-identified photos and information. The lecture included material describing national and local statistics on child maltreatment, definitions of abuse, and techniques to help identify concern for maltreatment. Learners were free to ask questions following lecture. They were then divided into their assigned crews/teams for the escape room activity. The puzzles in the escape room served to reinforce concepts and details presented in lecture. We held a debrief after the escape room activity to discuss puzzle answers and address any follow-up questions. Research Methods: Learners completed a program evaluation after the activity. These questions assessed the learners' perception of the importance and applicability of the content presented, the escape room format, and what they felt was the most significant and helpful to their practice. Results: Learners reported enjoying the activity and felt the escape room-based approach allowed for deeper engagement with the topic since the serious nature of child maltreatment can sometimes make this difficult. Discussion: Pediatric abuse and neglect is a serious and often heavy topic to present to healthcare providers. While we took into consideration that presenting a sensitive topic such as child abuse in an escape room format may be perceived as insensitive or display a lack of insight or respect for the topic, we also understood that the way we built out the clues and puzzles would be important in how the game was perceived by the participants. By building the puzzles to be factual and not overly excessive, we allowed the learners to interact with the information and practice identifying possible cases of abuse and how and when to report suspicions in a manner that did not trivialize the seriousness of the topic or take away from the fact that they were competing in a game. We used a PowerPoint lecture to present the foundation of the content and then lightened the learning session with the use of the escape room activity. The level of competition and comradery lightened the overall mood, and the learners left the class on a high note. Topics: Child abuse recognition, escape room activity, small-group activity, prehospital, neglect, physical abuse, emotional abuse, sexual abuse, mandated reporter.

Distribution of injury in inflatable jumping amusements in the U.S. over the last 20 years.

PURPOSE: To describe the distribution of injuries attributed to inflatable bounce house devices in children 2-18 years old in the United States from 2000 to 2019. METHODS: The National Electronic Injury Surveillance System (NEISS) was used to identify patients <18 years of age with injuries from activities classified as amusements (NEISS Code 1293 and 3219) during the period from 2000 to 2019. RESULTS: A weighted estimate of 159,569 injuries was obtained using NEISS statistical weights. Injury estimates and rate of estimated injury per year showed a continued linear increase from 2000-2019 (p<0.0001). Bounce house-related injuries were more common in males (53.9%) than in females (46.1%). The injuries reported most commonly were fracture (25.8%), muscle strain (25.7%), and contusion (14.5%). The factors associated with bounce house-related injury were compared between "younger" patients ≤6 years of age and "older" patients >6 years of age. In both age groups, the patient's residence was the most prevalent location of injury (≤6 yr, 95.6%; >6 yr, 97.2%), and the lower extremity was the most prevalent anatomic site of injury (≤6 yr, 34.6%, >6 yr 35.3%). Concussion was rare in both groups (≤6 yr, 1.6%; >6 yr, 2.9%); however, concussion was 86% more prevalent in those >6 years of age (p<0.0001). CONCLUSIONS: The frequency and rate of pediatric bounce house injuries has increased steadily since 2000. The most severe injuries occur disproportionately in children > 6 years old.