Bone Anchor Fixation in the Repair of Blunt Traumatic Abdominal Wall Hernias: A Western Trauma Association Multicenter Study.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWHs) are rare but require a variety of operative techniques to repair including bone anchor fixation (BAF) when tissue tears off bony structures. This study aimed to provide a descriptive analysis of BAF technique for blunt TAWH repair. Bone anchor fixation and no BAF repairs were compared, hypothesizing increased hernia recurrence with BAF repair. METHODS: A secondary analysis of the WTA blunt TAWH multicenter study was performed including all patients who underwent repair of their TAWH. Patients with BAF were compared to those with no BAF with bivariate analyses. RESULTS: 176 patients underwent repair of their TAWH with 41 (23.3%) undergoing BAF. 26 (63.4%) patients had tissue fixed to bone, with 7 of those reinforced with mesh. The remaining 15 (36.6%) patients had bridging mesh anchored to bone. The BAF group had a similar age, sex, body mass index, and injury severity score compared to the no BAF group. The time to repair (1 vs 1 days, P = .158), rate of hernia recurrence (9.8% vs 12.7%, P = .786), and surgical site infection (SSI) (12.5% vs 15.6%, P = .823) were all similar between cohorts. CONCLUSIONS: This largest series to date found nearly one-quarter of TAWH repairs required BAF. Bone anchor fixation repairs had a similar rate of hernia recurrence and SSI compared to no BAF repairs, suggesting this is a reasonable option for repair of TAWH. However, future prospective studies are needed to compare specific BAF techniques and evaluate long-term outcomes including patient-centered outcomes such as pain and quality of life.

Effect of Routine Child Physical Abuse Screening Tool on Emergency Department Efficiency.

OBJECTIVES: Physical abuse is a significant cause of morbidity and mortality for children. Routine screening by emergency nurses has been proposed to improve recognition, but the effect on emergency department (ED) workflow has not yet been assessed. We sought to evaluate the feasibility of routine screening and its effect on length of stay in a network of general EDs. METHODS: A 2-question child physical abuse screening tool was deployed for children <6 years old who presented for care in a system of 27 general EDs. Data were compared for the 6 months before and after screening was deployed (4/1/2019-10/2/2019 vs 10/3/2019-3/31/2020). The main outcome was ED length of stay in minutes. RESULTS: There were 14,133 eligible visits in the prescreening period and 16,993 in the screening period. Screening was completed for 13,404 visits (78.9%), with 116 (0.7%) screening positive. The mean ED length of stay was not significantly different in the prescreening (95.9 minutes) and screening periods (95.2 minutes; difference, 0.7 minutes; 95% CI, -1.5, 2.8). Among those who screened positive, 29% were reported to child protective services. On multivariable analysis, implementation of the screening tool did not impact overall ED length of stay. There were no significant differences in resource utilization between the prescreening and screening periods. CONCLUSIONS: Routine screening identifies children at high risk of physical abuse without increasing ED length of stay or resource utilization. Next steps will include determining rates of subsequent serious physical abuse in children with or without routine screening.

Detection of Postpartum Hemorrhage Using Compensatory Reserve Index in Patients Undergoing Cesarean Delivery.

BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. Early recognition and management are imperative for improved outcomes. The compensatory reserve index (CRI) is a novel physiological parameter that trends changes in intravascular volume, by continuously comparing extracted photoplethysmogram waveforms to a reference model that was derived from a human model of acute blood loss. This study sought to determine whether the CRI pattern was differential between those who do and do not experience PPH during cesarean delivery and compare these results to the American Society of Anesthesiologists (ASA) standards for noninvasive monitoring. METHODS: Parturients undergoing cesarean delivery were enrolled between February 2020 and May 2021. A noninvasive CRI monitor was applied to collect continuous CRI values throughout the intraoperative and immediate postpartum periods. Patients were stratified based on blood loss into PPH versus non-PPH groups. PPH was defined as a quantitative blood loss >1000 mL. Function-on-scalar (FoS) regression was used to compare trends in CRI between groups (PPH versus non-PPH) during the 10 to 60-minute window after delivery. Two subanalyses excluding patients who received general anesthesia and preeclamptics were performed. RESULTS: Fifty-one patients were enrolled in the study. Thirteen (25.5%) patients experienced PPH. Pregnant patients who experienced PPH had, on average, lower postdelivery CRI values (-0.13; 95% CI, -0.13 to -0.12; P < .001) than those who did not experience PPH. This persisted even when adjusting for preeclampsia and administration of uterotonics. The average mean arterial pressure (MAP) measurements were not statistically significant (-1.67; 95% CI, -3.57 to 0.22; P = .09). Similar trends were seen when excluding patients who underwent general anesthesia. When excluding preeclamptics, CRI values remained lower in those who hemorrhaged (-0.18; 95% CI, -0.19 to -0.17; P < .001). CONCLUSIONS: CRI detects changes in central volume status not distinguished by MAP. It has the potential to serve as a continuous, informative metric, notifying providers of acute changes in central volume status due to PPH during cesarean delivery.

Interfacility Transport of Children with Traumatic Pneumothorax: Does Elevation Make a Difference?

INTRODUCTION: Traumatic pneumothorax (PTX) remains a source of significant morbidity and mortality in pediatric trauma patients. Management with tube thoracostomy is routinely dictated by symptoms, use of positive pressure ventilation, or plan for air transport. Many patients transferred to our pediatric trauma center (PTC) require transport at considerable elevation. We sought to characterize the effect of transport at elevation in this population to inform management recommendations. METHODS: The trauma registry was queried for pediatric patients transferred to our tertiary referral center with traumatic PTX from 2010 to 2022, yielding 412 charts for analysis. Data abstracted included mechanism of injury, mode of transport, size of pneumothorax, chest tube placement, endotracheal intubation, and estimated elevation change during transport. RESULTS: There were 412 patients included for analysis. Most patients had small pneumothoraces that resolved without chest tube placement (388 patients, 94.1%). No patients experienced acute respiratory decompensation in transport. There were four (0.9%) patients with increased PTX on arrival, however, none experienced acute decompensation as a result. Average elevation gain was 2337 feet. There was no association between elevation change and requirement of post-transport chest tube placement. No patients experienced PTX-related complications after discharge. CONCLUSIONS: In this large patient series, no patient experienced a meaningful increase in the size of their traumatic PTX during or immediately following transport at elevation to our institution. These findings suggest it is safe to transfer a pediatric trauma patient with a small, hemodynamically insignificant PTX without tube thoracostomy despite considerable changes in elevation during transport. LEVELS OF EVIDENCE: II-III, Retrospective Study.

A western trauma association multicenter comparison of mesh versus non-mesh repair of blunt traumatic abdominal wall hernias.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWH) occur in <1 % of trauma patients. Optimal repair techniques, such as mesh reinforcement, have not been studied in detail. We hypothesize that mesh use will be associated with increased surgical site infections (SSI) and not improve hernia recurrence. MATERIALS AND METHODS: A secondary analysis of the Western Trauma Association blunt TAWH multicenter study was performed. Patients who underwent TAWH repair during initial hospitalization (1/2012-12/2018) were included. Mesh repair patients were compared to primary repair patients (non-mesh). A logistic regression was conducted to assess risk factors for SSI. RESULTS: 157 patients underwent TAWH repair during index hospitalization with 51 (32.5 %) having mesh repair: 24 (45.3 %) synthetic and 29 (54.7 %) biologic. Mesh patients were more commonly smokers (43.1 % vs. 22.9 %, p = 0.016) and had a larger defect size (10 vs. 6 cm, p = 0.003). Mesh patients had a higher rate of SSI (25.5 % vs. 9.5 %, p = 0.016) compared to non-mesh patients, but a similar rate of recurrence (13.7 % vs. 10.5%, p = 0.742), hospital length of stay (LOS), and mortality. Mesh use (OR 3.66) and higher ISS (OR 1.06) were significant risk factors for SSI in a multivariable model. CONCLUSION: Mesh was used more frequently in flank TAWH and those with a larger defect size. Mesh use was associated with a higher incidence and risk of SSI but did not reduce the risk of hernia recurrence. When repairing TAWH mesh should be employed judiciously, and prospective randomized studies are needed to identify clear indications for mesh use in TAWH.

Comparison of Pediatric Trauma Scoring Tools That Incorporate Neurological Status for Trauma Team Activation.

BACKGROUND: Two novel pediatric trauma scoring tools, SIPAB+ (defined as elevated SIPA with Glasgow Coma Scale ≤8) and rSIG (reverse Shock Index multiplied by Glasgow Coma Scale and defined as abnormal using cutoffs for early outcomes), which combine neurological status with Pediatric Age-Adjusted Shock Index (SIPA), have been shown to predict early trauma outcomes better than SIPA alone. We sought to determine if one more accurately identifies children in need of trauma team activation. METHODS: Patients 1 to 18 years old from the 2014-2018 Pediatric Trauma Quality Improvement Program database were included. Sensitivity and specificity for SIPAB+ and rSIG were calculated for components of pediatric trauma team activation, based on criteria standard definitions. RESULTS: There were 11,426 patients (1.9%) classified as SIPAB+ and 235,672 (39.0%) as having an abnormal rSIG. SIPAB+ was consistently more specific, with specificities exceeding 98%, but its sensitivity was poor (<30%) for all outcomes. In comparison, rSIG was a more sensitive tool, with sensitivities exceeding 60%, and specificity values exceeded 60% for all outcomes. CONCLUSIONS: Trauma systems must determine their priorities to decide how best to incorporate SIPAB+ and rSIG into practice, although rSIG may be preferred as it balances both sensitivity and specificity. LEVEL OF EVIDENCE: Level III.

Use of prehospital reverse shock index times Glasgow Coma Scale to identify children who require the most immediate trauma care.

BACKGROUND: Appropriate prehospital trauma triage ensures transport of children to facilities that provide specialized trauma care. There are currently no objective and generalizable scoring tool for emergency medical services to facilitate such decisions. An abnormal reverse shock index times Glasgow Coma Scale (rSIG), which is calculated using readily available parameters, has been shown to be associated with severely injured children. This study sought to determine if rSIG could be used in the prehospital setting to identify injured children who require the highest levels of care. METHODS: Patients (1-18 years old) transferred from the scene to a level 1 pediatric trauma center from 2010 to 2020 with complete prehospital and emergency department vital signs, and Glasgow Coma Scale (GCS) scores were included. Reverse shock index times GCS was calculated as previously described ((systolic blood pressure/heart rate) × GCS), and the following cutoffs were used: ≤13.1, ≤16.5, and ≤20.1 for 1- to 6-, 7- to 12-, and 13- to 18-year-old patients, respectively. Trauma activation level and clinical outcomes upon arrival to the pediatric trauma center were collected. RESULTS: There were 247 patients included in the analysis; 66.0% (163) had an abnormal prehospital rSIG. Patients with an abnormal rSIG had a higher rate of highest-level trauma activation compared with those with a normal rSIG (38.7% vs. 20.2%, p = 0.013). Patients with an abnormal prehospital rSIG also had higher rates of intubation (28.8% vs. 9.52%, p < 0.001), intracranial pressure monitor (9.20 vs. 1.19%, p = 0.032), need for blood (19.6% vs. 8.33%, p = 0.034), laparotomy (7.98% vs. 1.19%, p = 0.039), and intensive care unit admission (54.6% vs. 40.5%, p = 0.049). CONCLUSION: Reverse shock index times GCS may assist emergency medical service providers in early identification and triage of severely injured children. An abnormal rSIG in the emergency department is associated with higher rates of intubation, need for blood transfusion, intracranial pressure monitoring, laparotomy, and intensive care unit admission. Use of this metric may help to speed the identification, care, and treatment of any injured child. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Risk factors for recurrence in blunt traumatic abdominal wall hernias: A secondary analysis of a Western Trauma association multicenter study.

BACKGROUND: Few studies have investigated risk factors for recurrence of blunt traumatic abdominal wall hernias (TAWH). METHODS: Twenty trauma centers identified repaired TAWH from January 2012 to December 2018. Logistic regression was used to investigate risk factors for recurrence. RESULTS: TAWH were repaired in 175 patients with 21 (12.0%) known recurrences. No difference was found in location, defect size, or median time to repair between the recurrence and non-recurrence groups. Mesh use was not protective of recurrence. Female sex, injury severity score (ISS), emergency laparotomy (EL), and bowel resection were associated with hernia recurrence. Bowel resection remained significant in a multivariable model. CONCLUSION: Female sex, ISS, EL, and bowel resection were identified as risk factors for hernia recurrence. Mesh use and time to repair were not associated with recurrence. Surgeons should be mindful of these risk factors but could attempt acute repair in the setting of appropriate physiologic parameters.

A Single Institution's Recent Experience With Pediatric Hand Burns.

Children are at risk for sustaining hand burns due to their innate curiosity, slow withdrawal reflexes, and thin palmar epidermis. We sought to summarize our recent experience managing pediatric hand burns, focusing on injuries that required surgical management. This was a retrospective review of children with burn-injured hands managed at a quaternary referral children's hospital between 2016 and 2020. Demographics and mechanisms of injury were collected for all patients. Initial management of all wounds included pain control, deflation of blisters, and mechanical debridement. Wounds were then dressed, and a plaster-backed soft cast was applied for positioning if the swelling was controlled. Wounds were reassessed in 4-7 days, at which time a nonadherent dressing with antifungal ointment or a bismuth dressing was applied to partial-thickness wounds, vs an active silver dressing for deep partial-thickness burns. For patients who underwent split-thickness or full-thickness skin grafting, additional wound care, operative, and short-term outcomes data were collected. A total of 3715 children were seen for burn injuries during the study period, of which 2100 (56.5%) were seen for hand burns. In total, 123 (5.8%) required a skin graft an average of 11.7 days from the date of their burn injury. Surgical complications were minimal with 5 (4.1%) incomplete graft takes, though none required reoperation, and 1 (0.8%) experiencing a postoperative wound infection. Pediatric hand burns are common. A multidisciplinary treatment approach, including standardized wound care and adept therapeutic interventions, will lead to spontaneous healing in approximately 95% of patients.

Use of reverse shock index times Glasgow coma scale (rSIG) to determine need for transfer of pediatric trauma patients to higher levels of care.

INTRODUCTION: Most children in the US live more than one hour from a Level 1 PTC. The Need For Trauma Intervention (NFTI) score was developed to assess trauma triage criteria and is dependent on whether someone requires one of six urgent interventions (NFTI+). We sought to determine if a novel scoring tool, rSIG, could predict NFTI and facilitate the transfer decision making process. METHODS: Children 1-18 years old transferred to our level 1 PTC from 2010 - 2020 with complete vital signs and Glasgow Coma Scale (GCS) score at the transferring facility were included. rSIG was calculated as previously described [(SBP/HR) x GCS], and the following cutoffs were used for each age group: ≤13.1, ≤16.5, and ≤20.1 for 1-6, 7-12, and 13-18 years, respectively. Clinical outcomes upon arrival to the PTC were collected to determine if patients met any NTFI criteria. RESULTS: A total of 456 patients met inclusion criteria. The proportion of patients with an abnormal rSIG was 60.1% (274) and 37.0% (169) were NFTI+. Patients with an abnormal rSIG had an odds ratio of 6.18 (95% CI: 3.90, 10.07), p < 0.001 of being NFTI+ compared to those with a normal rSIG. CONCLUSION: Children with an abnormal rSIG are more likely to be NFTI+ and require higher levels of care, indicating this scoring tool can identify pediatric trauma patients who may benefit from expedited transfer. Incorporating rSIG into initial evaluation and triage of traumatically injured children may expedite the transfer decision making process and limit delays in transport to a PTC. TYPE OF STUDY: Retrospective Comparative Study LEVEL OF EVIDENCE: III.

A precision-designed gastrostomy button securement device.

BACKGROUND: Gastrostomy buttons (g-buttons) are commonly placed in children to facilitate weight gain, correct nutritional deficiencies, and provide hydration and/or medication delivery. At our institution, parents are taught to place a gauze sponge under their child's g-button and secure it with strips of tape; however, the g-button still moves in the tract, which delays wound healing and leads to a variety of tract-related complications. We viewed this universal problem as a challenge and a prime opportunity for innovation. METHODS: In 2016, a pediatric surgeon and a team of graduate engineering students outlined the problem, created a list of design requirements, and began to iterate on a variety of device designs. RESULTS: Over 400 design ideas were iterated upon to various degrees. The first prototype was studied in a small clinical trial, in which 80% of caregivers reported satisfaction with the design, but 90% noted difficulty connecting the extension feeding tube. A second-generation prototype was developed, which included a reusable lid and disposable base layer. Third- generation prototypes added "edge-grippers" to facilitate attaching the extension tubing, plus pre-cut absorbent, sterile gauze pads to fit around the stem of the g-button. Finally, in 2020, the design was finalized with the addition of a childproof hinge between the lid and base layer. CONCLUSIONS: An intuitive g-button securement device was created to simplify daily gauze replacement, reduce tract-related complications, and lower the cost of care. A randomized controlled trial comparing the securement device to the "tic-tac-toe" dressing will begin in early 2022 with results available later this year.

Factors associated with new mental health diagnoses and resource utilization among pediatric patients following trauma admission.

PURPOSE: Injured children are at risk for a variety of physical and emotional sequelae that may impair their ability to return to prior function. The effect of traumatic injury on mental health in children is not well characterized or understood. We sought to determine factors associated with new mental health diagnoses and/or mental health resource utilization following admission to a Level 1 pediatric trauma center for traumatic injury. METHODS: A retrospective chart review of patients admitted for accidental trauma between 2016 and 2019 was performed. Demographic data, injury characteristics, new mental health diagnoses and/or mental health resource utilization following hospitalization were extracted. Patients with prior mental health diagnosis, psychotropic prescription(s), or resource utilization were excluded from this cohort. A multivariable logistic regression model was used to examine predictors of new mental health diagnoses and/or resource utilization. RESULTS: The prevalence of new mental health diagnoses or resources utilization was 9.5% (363/3828). The most common diagnoses were anxiety disorders and nonbipolar depression. The most common psychotropic medication prescribed was antidepressants. Patients with new mental illness were older (odds ratio [OR] 1.1 [95% CI: 1.06, 1.12]), more likely to sustain burn injuries (OR 6.3 [4.2, 9.5]), have non-sports related injuries (OR 3.5 [2.1, 6.0]), and be pedestrian struck (OR 2.7 [1.5, 4.8]). They additionally were more likely to sustain head, neck, and spine injuries (OR 3.8 [2.9, 5.1], 2.4 [1.1, 5.5], and 2.1 [1.3, 3.3], respectively). CONCLUSIONS: There are a variety of demographic and injury specific factors associated with new mental health diagnoses and/or resource utilization in children following admission for trauma. Knowledge of these risk factors may ensure patients are allocated adequate resources to promote timely access to appropriate mental health services after hospitalization. TYPE OF STUDY: Retrospective comparative study LEVEL OF EVIDENCE: III.

National trends in pediatric firearm and automobile fatalities.

BACKGROUND: Successful public health policies and injury prevention efforts have reduced pediatric automobile fatalities across the United States. In 2019, firearm injuries exceeded motor vehicle crashes (MVC) as the leading cause of childhood death in Colorado. We sought to determine if similar trends exist nationally and if state gun laws impact firearm injury fatality rates. METHODS: Annual pediatric (≤19 years-old) fatality rates for firearm injuries and MVCs were obtained from the CDC WONDER database (1999-2020). State gun law scores were based on the 2014-2020 Gifford's Annual Gun Law Scorecard and strength was categorized by letter grades A-F. Poisson generalized linear mixed models were used to model fatality rates. Rates were estimated for multiple timepoints and compared between grade levels. RESULTS: In 1999, the national pediatric fatality rate for MVCs was 248% higher than firearm injuries (Incidence Rate Ratio (IRR) 95% Confidence Interval (CI): 2.25-2.73, p<0.0001). By 2020, the fatality rate for MVCs was 16% lower than that of firearm injuries (IRR 95% CI: 0.75- 0.93, p = 0.0014). For each increase in letter grade for gun law strength there was an 18% reduction in the firearm fatality rate (IRR 95%CI: 0.78-0.86, p<0.0001). States with the strongest gun laws (A) had a 55% lower firearm fatality rate compared to those with the weakest laws (F). CONCLUSION: Firearm injuries are the leading cause of death in pediatric patients across the United States. State gun law strength has a significant impact on pediatric firearm injury fatality rates. New public health policies, political action, media attention and safer guns are urgently needed to curb this national crisis. LEVEL OF EVIDENCE/STUDY TYPE: Level III, retrospective.

Outcomes in Pediatric Trauma Patients Who Receive Blood Transfusion.

INTRODUCTION: Increased blood volumes, due to massive transfusion (MT), are known to be associated with both infectious and noninfectious adverse outcomes. The aim of this study was to assess the association between MT and outcomes in pediatric trauma patients, and, secondarily, determine if these outcomes are differential by age once MT is reached. METHODS: Pediatric patients (ages 1-18 y old) in the ACS pediatric Trauma Quality Improvement Program (TQIP) database (2015-2018) who received blood were included. Patients were stratified by MT status, which was defined as blood product volume of 40 mL/kg within 24 h of admission (MT+) and compared to children who received blood products but did not meet the MT threshold (MT-). Defined MT + patients were matched 1:1 to MT-patients via propensity score matching of characteristics before comparisons. Adjusted logistic regression was performed on univariably significant outcomes of interest. RESULTS: There were 2318 patients in the analytic cohort. Patients who received MT had higher rates of deep venous thrombosis (DVT) (2.5% versus 1.0%, P < 0.001), acute kidney injury (AKI) (1.5% versus 0.0%, P = 0.022), CLABSI (4.0% versus 2.0% P = 0.008), and severe sepsis (2.3% versus. 1.1%, P = 0.02). On logistic regression MT was an independent risk factor for these outcomes. There was no differential effect of MT on these outcomes based on age. CONCLUSIONS: Outcomes associated with blood transfusion in pediatric trauma patients are low overall, but rates of DVT, AKI, CLABSI, and sepsis are higher in those who receive MT+ with no differences based on age.

Discreet Values of Shock Index Pediatric Age-Adjusted (SIPA) to Predict Intervention in Children With Blunt Organ Injuries.

INTRODUCTION: Elevated shock index pediatric age-adjusted (SIPA) has been shown to be associated with the need for both blood transfusion and intervention in pediatric patients with blunt liver and spleen injuries (BLSI). SIPA has traditionally been used as a binary value, which can be classified as elevated or normal, and this study aimed to assess if discreet values above SIPA cutoffs are associated with an increased probability of blood transfusion and failure of nonoperative management (NOM) in bluntly injured children. MATERIALS AND METHODS: Children aged 1-18 y with any BLSI admitted to a Level-1 pediatric trauma center between 2009 and 2020 were analyzed. Blood transfusion was defined as any transfusion within 24 h of arrival, and failure of NOM was defined as any abdominal operation or angioembolization procedure for hemorrhage control. The probabilities of receiving a blood transfusion or failure of NOM were calculated at different increments of 0.1. RESULTS: There were 493 patients included in the analysis. The odds of requiring blood transfusion increased by 1.67 (95% CI 1.49, 1.90) for each 0.1 unit increase of SIPA (P < 0.001). A similar trend was seen initially for the probability of failure of nonoperative management, but beyond a threshold, increasing values were not associated with failure of NOM. On subanalysis excluding patients with a head injury, increased 0.1 increments were associated with increased odds for both interventions. CONCLUSIONS: Discreet values above age-related SIPA cutoffs are correlated with higher probabilities of blood transfusion in pediatric patients with BLSI and failure of NOM in those without head injury. The use of discreet values may provide clinicians with more granular information about which patients require increased resources upon presentation.

The compensatory reserve index predicts recurrent shock in patients with severe dengue.

BACKGROUND: Dengue shock syndrome (DSS) is one of the major clinical phenotypes of severe dengue. It is defined by significant plasma leak, leading to intravascular volume depletion and eventually cardiovascular collapse. The compensatory reserve Index (CRI) is a new physiological parameter, derived from feature analysis of the pulse arterial waveform that tracks real-time changes in central volume. We investigated the utility of CRI to predict recurrent shock in severe dengue patients admitted to the ICU. METHODS: We performed a prospective observational study in the pediatric and adult intensive care units at the Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam. Patients were monitored with hourly clinical parameters and vital signs, in addition to continuous recording of the arterial waveform using pulse oximetry. The waveform data was wirelessly transmitted to a laptop where it was synchronized with the patient's clinical data. RESULTS: One hundred three patients with suspected severe dengue were recruited to this study. Sixty-three patients had the minimum required dataset for analysis. Median age was 11 years (IQR 8-14 years). CRI had a negative correlation with heart rate and moderate negative association with blood pressure. CRI was found to predict recurrent shock within 12 h of being measured (OR 2.24, 95% CI 1.54-3.26), P < 0.001). The median duration from CRI measurement to the first recurrent shock was 5.4 h (IQR 2.9-6.8). A CRI cutoff of 0.4 provided the best combination of sensitivity and specificity for predicting recurrent shock (0.66 [95% CI 0.47-0.85] and 0.86 [95% CI 0.80-0.92] respectively). CONCLUSION: CRI is a useful non-invasive method for monitoring intravascular volume status in patients with severe dengue.

Pediatric cardiac and great vessel injuries: Recent experience at two pediatric trauma centers.

BACKGROUND: Cardiac injuries are rare in pediatric trauma patients and data regarding this type of injury is limited. There is even less data on traumatic great vessel injuries. This study sought to examine and summarize our recent experience at two pediatric trauma centers, which serve a major metropolitan area and large geographic region. METHODS: This is a retrospective review of pediatric (<18 years) patients who sustained cardiac or great vessel injuries and were managed at a Level 1 or Level 2 pediatric trauma center between January 1, 2010 and June 30, 2020. Demographic and clinical characteristics were compared using two-sample t-tests, Wilcoxon Rank-Sum tests, Fisher's exact tests and chi-squared tests for continuous, non-normally distributed continuous, and categorical variables, respectively. RESULTS: A total of 53 patients sustained cardiac and/or great vessel injuries. Of these, 37 (70%) sustained cardiac, 9 (17%) sustained great vessel, and 7 (13%) sustained both types of injuries. The median age was 14.9 years and 74% (n = 39) were male. The median injury severity score (ISS) was 36.0 and the injury mechanism was blunt in 31 (58%) patients. The most common cardiac and great vessel injury locations were left ventricle (n = 9) and thoracic aorta (n = 11), respectively. The overall mortality rate was 53% (n = 28). Mortality was highest among those who sustained great vessel injuries (89%). CONCLUSIONS: There is substantial heterogeneity in cardiac and great vessel injuries. Regardless, they are highly morbid and lethal, despite aggressive surgical and catheter-based interventions.

Thrombelastography and transfusion patterns in severely injured pediatric trauma patients with blunt solid organ injuries.

BACKGROUND: Thrombelastography (TEG) has emerged as a useful tool to diagnose coagulopathy and guide blood product usage during trauma resuscitations. This study sought to evaluate the correlation between TEG-directed blood product administration in severely injured pediatric trauma patients with blunt solid organ injuries (BSOIs). METHODS: Patients (≤18 years) with severe BSOIs who presented as highest-level trauma activations at two pediatric trauma centers were included. Thrombelastography results were evaluated to determine indications for blood product administration and rates of TEG-directed resuscitation. Tetrachoric correlations and regression modeling were used to correlate TEG-directed resuscitation with clinical outcomes. RESULTS: Of 64 patients who met the inclusion criteria, 32.8% (21) had elevated R times and 23.4% (15) had shortened α angles. Maximum amplitude was shortened in 29.7% (19), and percent clot lysis 30 minutes after maximum amplitude that is >3% was seen in 17.0% (9). Thrombelastography-directed resuscitation of fresh frozen plasma was followed 54.7% of the time compared with 67.2% and 81.2% for platelets and cryoprecipitate, respectively. Thrombelastography-directed resuscitation with platelets (odds ratio, 0.56; 95% confidence interval, 0.33-0.93; p = 0.03) and/or cryoprecipitate (odds ratio, 0.09; 95% confidence interval, 0.01-0.42, p = 0.003) were associated with decreased hospital length of stay and mortality, respectively. CONCLUSION: Severely injured pediatric trauma patients with BSOIs were often coagulopathic upon presentation to the emergency department. Thrombelastography-directed resuscitation with platelets and/or cryoprecipitate was followed for the majority of patients and was associated with improved outcomes. LEVEL OF EVIDENCE: Therapeutic/Care Management, level III.