A Protocol Driven Approach to Reduce Lengths of Stay for Pediatric Blunt Liver and Spleen Injury Patients.

BACKGROUND: Our institution updated blunt liver and spleen injury (BLSI) protocols in 2019 in adherence to updated American Pediatric Surgery Association (APSA) recommendations. This retrospective study compares resource utilization for pediatric BLSI patients treated under old and updated guidelines. METHODS: BLSI patients without severe non-abdomen injuries aged under 18 treated with prior (04/2015-06/2019) and updated (06/2019-12/2022) guidelines were retrospectively reviewed and compared. Each patient received an adjusted injury severity score (ISS) to control for non-BLSI injuries. Multivariate analysis examined protocol group differences while controlling for adjusted ISS and BLSI grades. Primary outcomes were ICU length of stay (LOS), hospital LOS (analyzed using Cox regression), and patient costs (linear regression). Secondary outcomes include readmission in two weeks and death rates (logistic regression). RESULTS: 176 and 170 BLSI patients were treated with old and updated protocols, respectively. Patient demographics, average BLSI grade, and adjusted ISS were similar in both groups. Patients treated with old protocols indicate decreased hazard, showing significantly more days before ICU discharge (coefficient = -0.3868, p < .0009) and hospital discharge (coefficient = -0.5507, p < .0001). Patient costs (coefficient = 0.0921, p = 0.1874) trend towards being lower in the new protocol. Readmission rates were significantly higher in the new protocol (coefficient = -1.1731, p = 0.0465), and death rates (coefficient = 0.0519, p = 0.9710) were comparable. CONCLUSIONS: BLSI patients treated under new APSA guidelines compared to old guidelines had significant decreases in ICU and hospital LOS, a decreasing trend in costs, comparable death rates, but higher readmission rates. Future studies with larger sample sizes and detailed cost analysis would explore whether updated guidelines reduce patient costs and help elucidate the veracity or potential cause of the increased readmission rates. LEVEL OF EVIDENCE: Level III, Therapeutic/Care Management.

Pediatric spinal injury patterns and management in all-terrain vehicle and dirt bike crashes, 2010-2019.

OBJECTIVE: Pediatric spinal injuries in all-terrain vehicle (ATV) and dirt bike crashes are relatively uncommon but may be associated with significant morbidity. There are no recent studies examining these injuries, their management, and outcomes. Therefore, a retrospective study was performed to characterize pediatric spinal injuries related to ATV and dirt bike crashes over the last decade. METHODS: Data on all patients involved in ATV or dirt bike crashes evaluated at a regional level 1 pediatric trauma center over a 10-year period (2010-2019) were analyzed. Descriptive statistics were analyzed and chi-square, Fisher exact, and Mann-Whitney U-tests were performed comparing the demographics, injury characteristics, and clinical outcomes in patients with versus those without spinal injuries. RESULTS: Of 680 patients evaluated, 35 (5.1%) were diagnosed with spinal injuries. Over the study period, both spinal injuries and emergency department visits related to ATV or dirt bike crashes increased in frequency. All spinal injuries were initially diagnosed on CT scans, and 57.9% underwent spinal MRI. Injuries were most commonly thoracic (50%), followed by cervical (36.8%). The injuries of most patients were classified as American Spinal Injury Association (ASIA) grade E on presentation (86.8%), while 2 (5.3%) had complete spinal cord injuries (ASIA grade A) and 3 patients (8.6%) were ASIA grade B-D. Operative management was required for 13 patients (28.9%). Nonoperative management was used in 71.1% of injuries, including bracing in 33% of all injuries. Patients with spinal injuries were older than those without (13.4 ± 3.35 vs 11.5 ± 3.79 years, p = 0.003). Spinal injuries occurred via similar crash mechanisms (p = 0.48) and in similar locations (p = 0.29) to nonspinal injuries. Patients with spinal injuries more frequently required admission to the intensive care unit (ICU; 34.2% vs 14.6%, p = 0.011) and had longer hospital stays (mean 4.7 ± 5.5 vs 2.7 ± 4.0 days, p = 0.0025). CONCLUSIONS: Although infrequent among young ATV and dirt bike riders, spinal injuries are associated with longer hospital stays, increased ICU use, and required operative intervention in 29%. Increasing awareness among ATV and dirt bike riders about the severity of riding-related injuries may encourage safer riding behaviors.

Sledding while towed behind motorized vehicles associates with more severe and lethal injuries☆.

INTRODUCTION: Our institution has recently experienced an increase in sledding-related injuries, particularly when towed behind motorized vehicles. The purpose of this study was to characterize injury severity and clinical outcomes between pediatric patients who sustain injuries owing to motorized sledding accidents to aid in injury prevention messaging. METHODS: This retrospective study queried all patients who presented with a sledding-related injury to a single ACS-verified Level 1 Pediatric Trauma Center located in the Southeastern United States between 01/2015 and 01/2022. Demographics, injury details, and clinical outcomes were compared between two groups: patients towed behind a motorized vehicle (MOTOR) and those who were not (GRAVITY). RESULTS: Of the 67 patients included in our analysis, 15 (22%) were in the MOTOR group. Patients in the MOTOR group presented with significantly higher injury severity (ISS) and lower Glasgow coma scale (GCS) scores. Additionally, patients in this MOTOR group more often received a blood transfusion and intubation, had longer intensive care and overall hospital lengths of stay, and incurred higher hospital costs. In a multivariate analysis, the use of a motorized vehicle to sled was independently associated with increased ISS (OR: 9.7, 95% CI 1.9-17.5; p = 0.02). Two deaths occurred after sledding while being towed behind a motorized vehicle. CONCLUSION: Children experiencing sledding accidents while being towed by motorized vehicles sustain significantly more severe injuries and require more intensive treatments that together lead to increased hospital costs. These findings provide the framework for community educational initiatives and injury prevention measures to mitigate risk among children engaged in sledding. LEVEL OF EVIDENCE: IV retrospective cohort study.

Socioeconomic factors associated with helmet use in pediatric ATV and dirt bike trauma.

Objectives: Recreational off-road vehicle crashes can produce severe injury and death among children, often from head trauma sustained while riding unhelmeted. Although required for competition, recreational riders commonly forego helmets. This study aimed to identify socioeconomic factors associated with unhelmeted injuries among children riding all-terrain vehicles (ATVs) and dirt bikes recreationally, thus informing injury prevention efforts. Methods: A retrospective review was completed of patients younger than 18 years who presented after recreational ATV or dirt bike crash to a single American College of Surgeons-verified level 1 pediatric trauma center (2010-2019). Demographic, injury, and outcome data were collected. US Census data regarding median and per capita income, poverty prevalence, and scholastic graduation rates were recorded for each patient's home county. Relationships between helmet use at the time of injury, demographics, and socioeconomic variables were examined. Results: The cohort comprised 680 injured recreational ATV (n=510; 75%) and dirt bike (170; 25%) riders. Unhelmeted riders (n=450) were significantly older (median age 13 vs 11 years; p=0.008) and more often rode ATVs (n=399). Significantly greater percentages of females (77.9%; p<0.001) and passengers (89.5%; p<0.001) were unhelmeted at the time of injury. Residents of counties with lower median and per capita income, higher poverty prevalence, and lower high school and college graduation rates were significantly more likely to be unhelmeted at the time of their crash (p=0.003). In multivariable analysis, unhelmeted injuries were independently associated with ATV use (OR=6.757; p<0.0001), passenger status (OR=6.457; p<0.0001), and older age (OR=1.219; p<0.0001). Conclusion: In children, ATV use, passenger status, and older age associated independently with unhelmeted riding in recreational vehicle crash. Residence in a county with both lower median income and scholastic graduation rates associated with unhelmeted crashes, and lower median income significantly predicted unhelmeted crashes. This study revealed socioeconomic factors that identify communities with greatest need for injury prevention initiatives. Level of evidence: III-retrospective comparative epidemiological study.

Urine leaks in children sustaining blunt renal trauma.

BACKGROUND: Few consensus statements exist to guide the timely diagnosis and management of urine leaks in children sustaining blunt renal trauma (BRT). The aims of this study were to characterize kidney injuries among children who sustain BRT, evaluate risk factors for urine leaks, and describe the negative impact of urinoma on patient outcomes and resource consumption. METHODS: A retrospective review was performed of 347 patients, younger than 19 years, who presented with BRT to a single American College of Surgeons-verified Level I Pediatric Trauma Center between 2005 and 2020. Frequency of and risk factors for urine leak after BRT were evaluated, and impact on patient outcomes and resource utilization were analyzed. RESULTS: In total, 44 (12.7%) patients developed urine leaks, which exclusively presented among injury Grade 3 (n = 5; 11.4%), Grade 4 (n = 27; 61.4%), and Grade 5 (n = 12; 27.3%). A minority of urine leaks (n = 20; 45.5%) were discovered on presenting CT scan but all within 3 days. Kidney-specific operative procedures (nephrectomy, cystoscopy with J/ureteral stent, percutaneous nephrostomy) were more common among urine leak patients (n = 17; 38.6%) compared with patients without urine leaks (n = 3; 1.0%; p = 0.001). Patients with urine leak had more frequent febrile episodes during hospital stay (n = 24; 54.5%; p = 0.001) and showed increased overall 90-day readmission rates (n = 14; 33.3%; p < 0.001). Independent risk factors that associated with urine leak were higher grade (odds ratio [OR], 7.9; 95% confidence interval [CI], 2.6-24.3; p < 0.001), upper-lateral quadrant injuries (OR, 2.9; 95% CI, 1.2-7.1; p = 0.02), and isolated BRT (OR, 2.6; 95% CI, 1.0-6.5; p = 0.04). CONCLUSION: In a large cohort of children sustaining BRT, urine leaks result in considerable morbidity, including more febrile episodes, greater 90-day readmission rates, and increased operative or image-guided procedures. This study is the first to examine the relationship between kidney quadrant injury and urine leaks. Higher grade (Grade 4-5) injury, upper lateral quadrant location, and isolated BRT were independently predictive of urine leaks. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

The impact of helmet use on neurosurgical care and outcomes after pediatric all-terrain vehicle and dirt bike crashes: a 10-year single-center experience.

OBJECTIVE: All-terrain vehicle (ATV) and dirt bike crashes frequently result in traumatic brain injury. The authors performed a retrospective study to evaluate the role of helmets in the neurosurgical outcomes of pediatric patients involved in ATV and dirt bike crashes who were treated at their institution during the last decade. METHODS: The authors analyzed data on all pediatric patients involved in ATV or dirt bike crashes who were evaluated at a single regional level I pediatric trauma center between 2010 and 2019. Patients were excluded if the crash occurred in a competition (n = 70) or if helmet status could not be determined (n = 18). Multivariable logistic regression was used to analyze the association of helmet status with the primary outcomes of 1) neurosurgical consultation, 2) intracranial injury (including skull fracture), and 3) moderate or severe traumatic brain injury (MSTBI) and to control for literature-based, potentially confounding variables. RESULTS: In total, 680 patients were included (230 [34%] helmeted patients and 450 [66%] unhelmeted patients). Helmeted patients were more frequently male (81% vs 66%). Drivers were more frequently helmeted (44.3%) than passengers (10.5%, p < 0.001). Head imaging was performed to evaluate 70.9% of unhelmeted patients and 48.3% of helmeted patients (p < 0.001). MSTBI (8.0% vs 1.7%, p = 0.001) and neurosurgical consultation (26.2% vs 9.1%, p < 0.001) were more frequent among unhelmeted patients. Neurosurgical injuries, including intracranial hemorrhage (16% vs 4%, p < 0.001) and skull fracture (18% vs 4%, p < 0.001), were more common in unhelmeted patients. Neurosurgical procedures were required by 2.7% of unhelmeted patients. One helmeted patient (0.4%) required placement of an intracranial pressure monitor, and no other helmeted patients required neurosurgical procedures. After adjustment for age, sex, driver status, vehicle type, and injury mechanism, helmet use significantly reduced the odds of neurosurgical consultation (OR 0.250, 95% CI 0.140-0.447, p < 0.001), intracranial injury (OR 0.172, 95% CI 0.087-0.337, p < 0.001), and MSTBI (OR 0.244, 95% CI 0.079-0.758, p = 0.015). The unadjusted absolute risk reduction provided by helmet use equated to a number-needed-to-helmet of 6 riders to prevent 1 neurosurgical consultation, 4 riders to prevent 1 intracranial injury, and 16 riders to prevent 1 MSTBI. CONCLUSIONS: Helmet use remains problematically low among young ATV and dirt bike riders, especially passengers. Expanding helmet use among these children could significantly reduce the rates of intracranial injury and MSTBI, as well as the subsequent need for neurosurgical procedures. Promoting helmet use among recreational ATV and dirt bike riders must remain a priority for neurosurgeons, public health officials, and injury prevention professionals.

Measuring the effects of institutional pediatric traumatic brain injury volume on outcomes for rural-dwelling children.

OBJECTIVE: Rural-dwelling children may suffer worse pediatric traumatic brain injury (TBI) outcomes due to distance from and accessibility to high-volume trauma centers. This study aimed to compare the impacts of institutional TBI volume and sociodemographics on outcomes between rural- and urban-dwelling children. METHODS: This retrospective study identified patients 0-19 years of age with ICD-9 codes for TBI in the 2012-2015 National Inpatient Sample database. Patients were characterized as rural- or urban-dwelling using United States Census classification. Logistic and linear (in log scale) regressions were performed to measure the effects of institutional characteristics, patient sociodemographics, and mechanism/severity of injury on occurrence of medical complications, mortality, length of stay (LOS), and costs. Separate models were built for rural- and urban-dwelling patients. RESULTS: A total of 19,736 patients were identified (median age 11 years, interquartile range [IQR] 2-16 years, 66% male, 55% Caucasian). Overall, rural-dwelling patients had higher All Patient Refined Diagnosis Related Groups injury severity (median 2 [IQR 1-3] vs 1 [IQR 1-2], p < 0.001) and more intracranial monitoring (6% vs 4%, p < 0.001). Univariate analysis showed that overall, rural-dwelling patients suffered increased medical complications (6% vs 4%, p < 0.001), mortality (6% vs 4%, p < 0.001), and LOS (median 2 days [IQR 1-4 days ] vs 2 days [IQR 1-3 days], p < 0.001), but multivariate analysis showed rural-dwelling status was not associated with these outcomes after adjusting for injury severity, mechanism, and hospital characteristics. Institutional TBI volume was not associated with medical complications, disposition, or mortality for either population but was associated with LOS for urban-dwelling patients (nonlinear beta, p = 0.008) and cost for both rural-dwelling (nonlinear beta, p < 0.001) and urban-dwelling (nonlinear beta, p < 0.001) patients. CONCLUSIONS: Overall, rural-dwelling pediatric patients with TBI have worsened injury severity, mortality, and in-hospital complications, but these disparities disappear after adjusting for injury severity and mechanism. Institutional TBI volume does not impact clinical outcomes for rural- or urban-dwelling children after adjusting for these covariates. Addressing the root causes of the increased injury severity at hospital arrival may be a useful path to improve TBI outcomes for rural-dwelling children.

Changes in Pediatric Emergency Department Visits During the COVID-19 Pandemic.

OBJECTIVES: Community mitigation measures were implemented to decrease the spread of severe acute respiratory syndrome coronavirus 2. In this study, we aimed to evaluate changes in pediatric emergency department (ED) visits, secondary to acute respiratory illnesses (ARIs) and trauma, before and during the pandemic. We hypothesized that the numbers of ED visits and ARIs would decrease, whereas the proportion of trauma visits would increase. METHODS: A retrospective study from 2018 to 2020 was performed on children 18 years and younger presenting to the ED either for ARI or trauma at a high-volume comprehensive pediatric hospital between March and May each year. International Classification of Diseases, 10th Revision, Clinical Modification admission diagnosis codes were used to identify ARI, trauma, and injury mechanisms. Pearson's χ2 test was used to compare proportions between categorical variables. RESULTS: Overall, 6393 total ED visits occurred in 2020, compared with 11 758 and 12 138 in 2018 and 2019, respectively. In 2020, the total ARI number declined by 58%, and ARI frequency decreased significantly, whereas the total trauma number declined by 34%, and the proportion of trauma visits significantly increased. In addition, the number and proportion of recreational vehicle crashes increased, whereas the number and proportion decreased for all intentional and animal-related traumas. CONCLUSIONS: The total number of pediatric ED visits dropped precipitously in 2020, but the proportion of trauma visits increased significantly in 2020, accounting for greater than one-quarter of all ED visits. Injury mechanism varied significantly compared to previous years. Future studies are needed to confirm these findings and evaluate the benefits of community mitigation to decrease ARIs and strategies directed to reduce mechanism-specific trauma.

Therapeutic laparoscopy for pediatric abdominal trauma.

BACKGROUND: For the surgical treatment of traumatic hollow viscus injuries, laparoscopy offers a potentially less morbid approach to open exploration among appropriately selected patients. This study aimed to evaluate utilization trends and efficacy of laparoscopy in the management of pediatric abdominal trauma. STUDY DESIGN: To gain both study granularity and power, our institutional trauma registry (2005-2017) and the National Trauma Data Bank (NTDB; 2010-2015) identified patients ≤18 years who required celiotomy for abdominal trauma. Injury mechanisms, patient characteristics, and hospital courses were compared between open and laparoscopic approaches. Unadjusted and adjusted statistical analyses were performed. RESULTS: Overall, data were similar among 393 institutional and 11,399 NTDB patients undergoing laparoscopic (n = 88, 22%; n = 1663, 16%) or open (n = 305, 78%; n = 9736, 85%) surgery for abdominal trauma. In both registries, laparoscopy was more commonly employed in younger (institutional p = 0.026; NTDB p < 0.001) female (p = 0.019; p < 0.001) patients having lower injury severity (p < 0.001) and blunt injuries (p = 0.031; p < 0.001). Laparoscopy was associated with fewer complications overall when adjusting for demographics and injury severity [institutional OR 0.25 (0.08-0.75), p = 0.013; NTDB OR 0.69 (0.55-0.88), p = 0.002]. An increase in utilization of MIS for pediatric abdominal trauma was detected over time (NTDB: r = 0.88, p = 0.02). CONCLUSION: For the management of pediatric abdominal trauma, laparoscopy was employed typically in younger, more stable, and female patients sustaining blunt injuries. Appropriately selected patients have similar or better outcomes to patients treated with laparotomy, with no increase in adverse events or missed injuries. Increased utilization of laparoscopy to manage abdominal trauma in children suggests greater acceptance of this approach. LEVEL OF EVIDENCE: Level III.

Evolution of a level I pediatric trauma center: Changes in injury mechanisms and improved outcomes.

BACKGROUND: Trauma is the leading cause of mortality among children, underscoring the need for specialized child-centered care. The impact on presenting mechanisms of injury and outcomes during the evolution of independent pediatric trauma centers is unknown. The aim of this study was to evaluate the impact of our single center transition from an adult to American College of Surgeons-verified pediatric trauma center. METHODS: A retrospective analysis was performed of 1,190 children who presented as level I trauma activations between 2005 and 2016. Patients were divided into 3 chronological treatment eras: adult trauma center, early pediatric trauma center, and late pediatric trauma center after American College of Surgeons verification review. Comparisons were made using Pearson χ2, Wilcoxon rank sum, and Kruskal-Wallis tests. RESULTS: The predominant mechanism of injury was motor vehicle crash, with increases noted in assault/abuse (2% adult trauma center, 11% late pediatric trauma center). A decrease in intensive care admissions was identified during late pediatric trauma center compared with early pediatric trauma center and adult trauma center (51% vs 62.4% vs 67%, P < .001), with concomitant increases in admissions to the floor and immediate operative interventions, but overall mortality was unchanged. CONCLUSION: Transition to a verified pediatric trauma center maintains the safety expected of the American College of Surgeons certification, but with notable changes identified in mechanism of injury and improvements in resource utilization.

Standardizing ICU management of pediatric traumatic brain injury is associated with improved outcomes at discharge.

OBJECT The goal of critical care in treating traumatic brain injury (TBI) is to reduce secondary brain injury by limiting cerebral ischemia and optimizing cerebral blood flow. The authors compared short-term outcomes as defined by discharge disposition and Glasgow Outcome Scale scores in children with TBI before and after the implementation of a protocol that standardized decision-making and interventions among neurosurgeons and pediatric intensivists. METHODS The authors performed a retrospective pre- and postprotocol study of 128 pediatric patients with severe TBI, as defined by Glasgow Coma Scale (GCS) scores < 8, admitted to a tertiary care center pediatric critical care unit between April 1, 2008, and May 31, 2014. The preprotocol group included 99 patients, and the postprotocol group included 29 patients. The primary outcome of interest was discharge disposition before and after protocol implementation, which took place on April 1, 2013. Ordered logistic regression was used to assess outcomes while accounting for injury severity and clinical parameters. Favorable discharge disposition included discharge home. Unfavorable discharge disposition included discharge to an inpatient facility or death. RESULTS Demographics were similar between the treatment periods, as was injury severity as assessed by GCS score (mean 5.43 preprotocol, mean 5.28 postprotocol; p = 0.67). The ordered logistic regression model demonstrated an odds ratio of 4.0 of increasingly favorable outcome in the postprotocol cohort (p = 0.007). Prior to protocol implementation, 63 patients (64%) had unfavorable discharge disposition and 36 patients (36%) had favorable discharge disposition. After protocol implementation, 9 patients (31%) had unfavorable disposition, while 20 patients (69%) had favorable disposition (p = 0.002). In the preprotocol group, 31 patients (31%) died while 6 patients (21%) died after protocol implementation (p = 0.04). CONCLUSIONS Discharge disposition and mortality rates in pediatric patients with severe TBI improved after implementation of a standardized protocol among caregivers based on best-practice guidelines.

Identifying Characteristics in Abusive Head Trauma: A Single-Institution Experience.

Abusive head trauma (AHT) is a significant cause of childhood morbidity and mortality. The purpose of this study was to better understand the trends centered on AHT patients treated at Vanderbilt Children's Hospital. A retrospective study of 139 children undergoing treatment and management for traumatic brain injury due to abuse between January 2006 and April 2013 at Vanderbilt Children's Hospital was conducted. Caucasian males made up 61% and the youngest sibling represented 86.3% of our cohort. The median age was 5 months with injuries occurring during summertime and on weekdays, 31 and 63%, respectively. Seventy-nine percent were diagnosed with subdural hematomas, and 42% had a Glasgow Coma Scale (GCS) of 8 or less. A total of 25 patients, median age 8.6 months, died during our study period. The results of this study describe the AHT population at Vanderbilt Children's Hospital. Future studies should prospectively assess this population to better understand social factors involved in AHT.