Management of pediatric renal trauma - Results from the American Association for Surgery and Trauma Multi-Institutional Pediatric Acute Renal Trauma Study (Mi-PARTS).

BACKGROUND: Pediatric renal trauma is rare and lacks sufficient population-specific data to generate evidence-based management guidelines. A non-operative approach is preferred and has been shown to be safe. However, bleeding risk assessment and management of collecting system injury is not well understood. We introduce the Multi-institutional Pediatric Acute Renal Trauma Study (Mi-PARTS), a retrospective cohort study designed to address these questions. This manuscript describes the demographics and contemporary management of pediatric renal trauma at Level I trauma centers in the United States. METHODS: Retrospective data were collected at 13 participating Level I trauma centers on pediatric patients presenting with renal trauma between 2010-2019. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Descriptive statistics were used to report on demographics, acute management and outcomes. RESULTS: In total 1216 cases were included in this study. 67.2% were male, and 93.8% had a blunt injury mechanism. 29.3% had isolated renal injuries. 65.6% were high-grade (AAST Grade III-V) injuries. The mean Injury Severity Score (ISS) was 20.5. Most patients were managed non-operatively (86.4%) 3.9% had an open surgical intervention, including 2.7% having nephrectomy. Angioembolization was performed in 0.9%. Collecting system intervention was performed in 7.9%. Overall mortality was 3.3% and was only observed in polytrauma. The rate of avoidable transfer was 28.2%. CONCLUSION: The management and outcomes of pediatric renal trauma lacks data to inform evidence-based guidelines. Non-operative management of bleeding following renal injury is a well-established practice. Intervention for renal trauma is rare. Our findings reinforce differences from the adult population, and highlights opportunities for further investigation. With data made available through Mi-PARTS we aim to answer pediatric specific questions, including a pediatric-specific bleeding risk nomogram, and better understanding indications for interventions for collecting system injuries. LEVEL OF EVIDENCE: IV, Epidemiological (prognostic/epidemiological, therapeutic/care management, diagnostic test/criteria, economic/value-based evaluations, and Systematic Review and Meta-Analysis).

Pediatric Cervical Spine Injury Following Blunt Trauma in Children Younger Than 3 Years: The PEDSPINE II Study.

Importance: There is variability in practice and imaging usage to diagnose cervical spine injury (CSI) following blunt trauma in pediatric patients. Objective: To develop a prediction model to guide imaging usage and to identify trends in imaging and to evaluate the PEDSPINE model. Design, Setting, and Participants: This cohort study included pediatric patients (<3 years years) following blunt trauma between January 2007 and July 2017. Of 22 centers in PEDSPINE, 15 centers, comprising level 1 and 2 stand-alone pediatric hospitals, level 1 and 2 pediatric hospitals within an adult hospital, and level 1 adult hospitals, were included. Patients who died prior to obtaining cervical spine imaging were excluded. Descriptive analysis was performed to describe the population, use of imaging, and injury patterns. PEDSPINE model validation was performed. A new algorithm was derived using clinical criteria and formulation of a multiclass classification problem. Analysis took place from January to October 2022. Exposure: Blunt trauma. Main Outcomes and Measures: Primary outcome was CSI. The primary and secondary objectives were predetermined. Results: The current study, PEDSPINE II, included 9389 patients, of which 128 (1.36%) had CSI, twice the rate in PEDSPINE (0.66%). The mean (SD) age was 1.3 (0.9) years; and 70 patients (54.7%) were male. Overall, 7113 children (80%) underwent cervical spine imaging, compared with 7882 (63%) in PEDSPINE. Several candidate models were fitted for the multiclass classification problem. After comparative analysis, the multinomial regression model was chosen with one-vs-rest area under the curve (AUC) of 0.903 (95% CI, 0.836-0.943) and was able to discriminate between bony and ligamentous injury. PEDSPINE and PEDSPINE II models' ability to identify CSI were compared. In predicting the presence of any injury, PEDSPINE II obtained a one-vs-rest AUC of 0.885 (95% CI, 0.804-0.934), outperforming the PEDSPINE score (AUC, 0.845; 95% CI, 0.769-0.915). Conclusion and Relevance: This study found wide clinical variability in the evaluation of pediatric trauma patients with increased use of cervical spine imaging. This has implications of increased cost, increased radiation exposure, and a potential for overdiagnosis. This prediction tool could help to decrease the use of imaging, aid in clinical decision-making, and decrease hospital resource use and cost.

Injury Pattern and Outcomes Following All-Terrain Vehicle Accidents in Kentucky Children: A Retrospective Study.

PURPOSE: All-terrain vehicles (ATVs) pose a significant risk for morbidity and mortality amongst children. We hypothesize that current vague legislation regarding helmet use impacts injury patterns and outcomes in pediatric ATV accidents. METHODS: The institutional trauma registry was queried for pediatric patients involved in ATV accidents from 2006 to 2019. Patient demographics and helmet wearing status were identified in addition to patient outcomes, such as injury pattern, injury severity score, mortality, length of stay, and discharge disposition. These elements were analyzed for statistical significance. RESULTS: 720 patients presented during the study period, which were predominantly male (71%, n = 511) and less than 16 years old (76%, n = 543). Most patients were not wearing a helmet (82%, n = 589) at time of injury. Notably, there were 7 fatalities. A lack of helmet use is positively associated with head injury (42% vs 23%, P < .01), intracranial hemorrhage (15% vs 7%, P = .03), and associated with lower Glasgow Coma Scale (13.9 vs 14.4, P < .01). Children 16 years and older were least likely to wear a helmet and most likely to incur injuries. Patients over 16 years had longer lengths of stay, higher mortality, and higher need for rehabilitation. CONCLUSION: Not wearing a helmet is directly correlated with injury severity and concerning rates of head injury. Children 16 years and older are at greatest risk for injury, but younger children are still at risk. Stricter state laws regarding helmet use are necessary to reduce pediatric ATV-related injury burden. LEVEL OF EVIDENCE: level III retrospective comparative study.

Evaluation of the learning curve for laparoscopic pyloromyotomy.

BACKGROUND: Laparoscopic pyloromyotomy is the preferred surgical management of hypertrophic pyloric stenosis at most centers. We aimed to analyze the learning curve for laparoscopic pyloromyotomy using the experience of five fellowship-trained pediatric surgeons. METHODS: A retrospective review of consecutive patients undergoing laparoscopic pyloromyotomy was performed. All cases were performed with general surgery residents. Cumulative sum (CUSUM) analysis for operating time was performed for up to the first 150 consecutive cases for individual surgeons. Outcomes were compared to identify different phases of the learning curve for operative competency. RESULTS: A total of 414 patients were included in the analysis as not all surgeons had reached 150 cases at time of analysis. The mean operating time was 29.2 min for all cases across the 5 surgeons. CUSUM analysis for mean operating time revealed three phases of learning: Learning Phase (cases 1-16), Plateau Phase (cases 17-87), and a Proficiency Phase (cases 88-150). The mean operating time during the three phases was 34.1, 29.0, and 28.3 min, respectively (P = 0.005). There were no differences in complications, reoperations, length of stay, or readmissions across the three phases. CONCLUSION: Three distinct phases of learning for laparoscopic pyloromyotomy were identified with no differences in outcomes across the phases. The operating time differed only for the Learning Phase, suggesting that some degree of proficiency occurs after 16 cases.

Reducing Emergency Department Length of Stay in Critically Injured Pediatric Trauma Patients: A Quality Improvement Initiative.

BACKGROUND: Efficient transfer of adult trauma patients to the intensive care unit (ICU) is associated with decreased emergency department (ED) length of stay (ED LOS) and improved patient outcomes. While well studied in adults, quality improvement (QI) initiatives focused on the rapid transfer of pediatric trauma patients are lacking. We report the effect of institutional system changes directed at expediting the transfer of pediatric trauma patients to the pediatric ICU (PICU). METHODS: This initiative commenced in 2013. Preliminary data regarding ED LOS for pediatric trauma patients were collected from January through December 2012 as the pre-implementation cohort. Using the plan-do-study-act (PDSA) framework of QI, the first PDSA cycle was implemented in January 2013. In subsequent PDSA cycles, we implemented the mandatory attendance of the PICU charge nurse and the PICU attending physician to all highest-level pediatric trauma activations. Throughout, ED LOS was collected and mapped on a run chart. ED LOS and variance were compared between all cycles of implementation. RESULTS: One hundred and fifty-one pediatric patients arrived or were upgraded to the highest-level pediatric trauma activation and admitted to the PICU from 2012 through 2019. We observed a decrease in median ED LOS of 105 minutes between the pre- and post-implementation groups. With each PDSA cycle, we observed a decrease in median ED LOS and variation. CONCLUSION: The inclusion of the PICU charge nurse and attending physician at highest-level pediatric trauma activations facilitated more rapid access to the PICU with decreased ED LOS.

A parent-led intervention to promote recovery following pediatric injury: study protocol for a randomized controlled trial.

BACKGROUND: Injury is one of the most prevalent potentially emotionally traumatic events that children experience and can lead to persistent impaired physical and emotional health. There is a need for interventions that promote full physical and emotional recovery and that can be easily accessed by all injured children. Based on research evidence regarding post-injury recovery, we created the Cellie Coping Kit for Children with Injury intervention to target key mechanisms of action and refined the intervention based on feedback from children, families, and experts in the field. The Cellie Coping Kit intervention is parent-guided and includes a toy (for engagement), coping cards for children, and a book for parents with evidence-based strategies to promote injury recovery. This pilot research trial aims to provide an initial evaluation of the impact of the Cellie Coping Kit for Children with Injury on proximal targets (coping, appraisals) and later child health outcomes (physical recovery, emotional health, health-related quality of life). METHOD / DESIGN: Eighty children (aged 8-12 years) and their parents will complete a baseline assessment (T1) and then will be randomly assigned to an immediate intervention group or waitlist group. The Cellie Coping Kit for Injury Intervention will be introduced to the immediate intervention group after the T1 assessment and to the waitlist group following the T3 assessment. Follow-up assessments of physical and emotional health will be completed at 6 weeks (T2), 12 weeks (T3), and 18 weeks (T4). DISCUSSION: This will be one of the first randomized controlled trials to examine an intervention tool intended to promote full recovery after pediatric injury and be primarily implemented by children and parents. Results will provide data on the feasibility of the implementation of the Cellie Coping Intervention for Injury as well as estimations of efficacy. Potential strengths and limitations of this design are discussed. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03153696 . Registered on 15 May 2017.

Pediatric blunt renal trauma practice management guidelines: Collaboration between the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society.

BACKGROUND: Injury to the kidney from either blunt or penetrating trauma is the most common urinary tract injury. Children are at higher risk of renal injury from blunt trauma than adults, but no pediatric renal trauma guidelines have been established. The authors reviewed the literature to guide clinicians in the appropriate methods of management of pediatric renal trauma. METHODS: Grading of Recommendations Assessment, Development and Evaluation methodology was used to aid with the development of these evidence-based practice management guidelines. A systematic review of the literature including citations published between 1990 and 2016 was performed. Fifty-one articles were used to inform the statements presented in the guidelines. When possible, a meta-analysis with forest plots was created, and the evidence was graded. RESULTS: When comparing nonoperative management versus operative management in hemodynamically stable pediatric patient with blunt renal trauma, evidence suggests that there is a reduced rate of renal loss and blood transfusion in patients managed nonoperatively. We found that in pediatric patients with high-grade American Association for the Surgery of Trauma grade III-V (AAST III-V) renal injuries and ongoing bleeding or delayed bleeding, angioembolization has a decreased rate of renal loss compared with surgical intervention. We found the rate of posttraumatic renal hypertension to be 4.2%. CONCLUSION: Based on the completed meta-analyses and Grading of Recommendations Assessment, Development and Evaluation profile, we are making the following recommendations: (1) In pediatric patients with blunt renal trauma of all grades, we strongly recommend nonoperative management versus operative management in hemodynamically stable patients. (2) In hemodynamically stable pediatric patients with high-grade (AAST grade III-V) renal injuries, we strongly recommend angioembolization versus surgical intervention for ongoing or delayed bleeding. (3) In pediatric patients with renal trauma, we strongly recommend routine blood pressure checks to diagnose hypertension. This review of the literature reveals limitations and the need for additional research on diagnosis and management of pediatric renal trauma. LEVEL OF EVIDENCE: Guidelines study, level III.

Improving Follow-up Skeletal Survey Compliance in Suspected Nonaccidental Trauma Patients: What's the FUSS About?

INTRODUCTION: Nonaccidental trauma (NAT) victims account for a significant percentage of our pediatric trauma population. The skeletal survey (SS) and follow-up skeletal survey (FUSS) are essential in the evaluation of selected NAT patients. We identified that our clinically indicated FUSS completion rate was suboptimal. We hypothesized that implementing an intervention of postdischarge follow-up in our pediatric surgery clinic would improve FUSS completion rates. METHODS: A follow-up clinic for NAT patients was established in July 2013. A retrospective review was performed of all suspected NAT cases younger than 2 years old seen at Kentucky Children's Hospital between November 2012 and February 2014. The study population was divided into pre (Group 1) and postintervention (Group 2). Bivariate analysis was performed. RESULTS: Group 1 consisted of 50 patients (58% male; median age, 9 months). Forty-7 (94%) had an SS; fractures were identified in 37 (74%) patients. Only 20 patients (40%) had FUSS; of those, 4 had newly identified fractures. Group 2 consisted of 52 patients (54% male; median age, 7 months). All 52 children (100%) had an SS; fractures were identified in 35 (67%) patients. Forty-seven patients (90%) had FUSS. Of those, 6 had new radiographic findings. Thirty-five patients (67%) were seen in our clinic. This improvement in FUSS (40% versus 90%) was statistically significant, P < 0.001. CONCLUSION: The decision to follow NAT patients in our clinic had significantly increased our rates of FUSS completion. This additional clinic follow-up also provided more evidence for NAT evaluation.

Bicycle Helmets Save More than Heads: Experience from a Pediatric Level I Trauma Hospital.

We studied pediatric bicycle accident victims (age ≤ 15 years) who were treated at our pediatric Level I trauma center during a 10-year period. Demographic data, injury severity, hospital course, and hospital cost data were collected. We compared the children who were helmeted to those who were unhelmeted. Our study cohort consisted of 516 patients. Patients were mostly male (70.2%) and white (84.7%); the median age was nine years. There were 101 children in the helmet group and 415 children in the unhelmeted group. Helmeted children were more likely to have private insurance (68.3% vs 35.9%, P < 0.001). Unhelmeted children were more likely to sustain multiple injuries (40% vs 25.7%, P = 0.008), meet our trauma activation criteria (45.5% vs 16.8%, P < 0.001), and be admitted to the hospital (42.4% vs 14.9%, P < 0.001). Helmeted children were less likely to sustain brain injuries (15.8% vs 25.8%, P = 0.037), skull fractures (1% vs 10.8%, P = 0.001), and facial fractures (1% vs 6%, P = 0.040). Median hospital costs were more expensive in the unhelmeted group. Helmet usage was suboptimal. Although most children sustained relatively minor injuries, the unhelmeted children had more injuries and higher costs than those who used helmets. Injury prevention programs are warranted.

A Multidisciplinary Child Protection Team Improves the Care of Nonaccidental Trauma Patients.

We initiated a multidisciplinary Child Protection Team (CPT) as a subgroup of our pediatric multidisciplinary trauma peer review committee. Meetings are held monthly. Nonaccidental trauma (NAT) patients from the preceding month are reviewed. The meeting has two parts. During the open part, detectives and child protective services (CPS) workers are invited to discuss specific cases. The closed part focuses on improvement of specific processes and future outcomes. Attendance is recorded and minutes are kept. We sought to review accomplishments of this group. We retrospectively reviewed the minutes from our CPT meetings conducted between February 2014 and April 2015. We tracked attendance, cases reviewed, process improvement projects, and corrective action plans. Meeting attendance was very good-78 per cent. During the 15-month study period, we had 141 suspected NAT patients; 96 were reviewed at our meetings. CPS workers attended 53 per cent of the meetings; 13 investigations were discussed. We established a clinical practice guideline for the evaluation of NAT patients. We created a mechanism to improve compliance with follow-up skeletal surveys. Six corrective letters were sent to individuals notifying them of care concerns and opportunities for improvement. Equipment needs were identified, and we obtained a digital camera and speaker phone. We have conducted multiple educational sessions to increase awareness. Our CPT meeting has improved the care of our NAT patients and provided better communication between our hospital staff and CPS workers. We have improved inhospital processes for our NAT patients. We have provided educational opportunities to outside care providers.

Non-accidental Trauma Injury Patterns and Outcomes: A Single Institutional Experience.

Non-accidental trauma (NAT) victims account for a significant percentage of our pediatric trauma population. We sought to better understand the injury patterns and outcomes of NAT victims who were treated at our level I pediatric trauma center. Trauma registry data were used to identify NAT victims between January 2008 and December 2012. Demographic data, injury severity, hospital course, and outcomes were evaluated. One hundred and eighty-eight cases of suspected NAT were identified. Children were mostly male and white. The median age was 1.1 years; the median Injury Severity Score was 9. Traumatic brain injuries, lower extremity fractures, and skull fractures were the most common injuries. Twenty-seven per cent required medical procedures; most were performed by orthopedic surgery. Twenty-four per cent required admission to the pediatric intensive care unit. The median length of stay was two days. The mortality rate was 9.6 per cent. We generated a hot spot map of our catchment area and identified areas of our state where NAT occurs at increased rates. NAT victims sustain significant morbidity and mortality. Due to the severity of injuries, pediatric trauma surgeons should be involved in the evaluation and management of these children. Much work is needed to prevent the death and disability incurred by victims of child abuse.

Intussusception clinical pathway: a survey of pediatric surgery practices.

Therapeutic reduction of intussusception by air or contrast enema may require surgery if the bowel is irreducible or perforates. There is no standard for the involvement of a pediatric surgeon in the workup of the condition. A regional survey of clinical practices was therefore undertaken to attempt to establish a consensus as to when the presence of a pediatric surgeon is required. Distributed to pediatric surgeons at 32 institutions, a questionnaire asked the process of imaging and reduction of infants with intussusception and the extent of pediatric surgical involvement. Surgeons at 29 institutions responded (91%). Ultrasound was used in diagnosis in 16 (55%), 13 (45%) requiring a positive ultrasound diagnosis of intussusception before attempting reduction. Three-fourths (22 [76%]) required surgeon notification that enema reduction was taking place, and one-fourth (seven [24%]) required prior surgical consultation. Only three (10%) required the presence of a surgery team member. Most (21 [72%]) did not demand one, and five (18%) indicated that surgical presence was desirable but not a necessity. There is no consensus for pediatric surgical involvement before and during reduction of an intussusception.

Peritoneal drainage as the initial management of intestinal perforation in premature infants.

Complicated necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) are major causes of mortality. We hypothesized that peritoneal drainage (PD) is more efficacious in SIP. Newborn infants with intestinal perforation treated with PD at our institution between 2007 and 2012 were divided into two groups: Group 1, infants with complicated NEC (n = 19), and Group 2, infants with SIP (n = 15). In Group 1, median birth weight was 705 g; median gestational age was 25.9 weeks. Median age at PD was 24 days. Six required laparotomy. Median time from PD to enteral feeds was 22.5 days. In Group 2, median birth weight was 685 g; median gestational age was 25.3 weeks. Median age at PD was 5 days. Two required laparotomy. Median time from PD to enteral feeds was 16 days. In Group 1, eight patients survived to discharge; median length of hospital stay (LOS) was 104.5 days. In Group 2, eight survived; median LOS was 109.5 days. Neither outcome was statistically significant (P = 0.73 and 0.878, respectively). Management of premature infants with intestinal perforation remains challenging. Mortality is high. Between our cohorts, there were no differences in regard to PD as definitive therapy, survival, and LOS.

Minimally invasive drainage of subcutaneous abscesses reduces hospital cost and length of stay.

OBJECTIVE: We compared outcomes among pediatric patients managed with minimally invasive (MI) packing techniques with those managed with traditional packing techniques for drainage of subcutaneous abscesses. METHODS: After institutional review board approval, medical records of children requiring drainage of subcutaneous abscesses between January 2010 and June 2011 were reviewed. Data were collected on patient demographics, abscess location, surgical procedure, microbiology cultures, and hospital length of stay (LOS). The hospital accounting system was queried for direct and indirect costs. We compared LOS and cost data among groups managed with MI versus traditional packing techniques. RESULTS: Incision and drainage was performed on 329 children (57.8% girls, 72% white, mean age of 43 months [range <1 to 218]). Of the total abscesses 198 (60.2%) were located in the groin/buttocks/perineum. Methicillin-resistant Staphylococcus aureus was identified in 74% of culture specimens. A total of 202 patients (61.4%) underwent packing and 127 (38.6%) underwent MI drainage. MI drainage ranged from 0% (0/110) in January to June 2010 to 34.6% (44/127) in the July to December 2010 transition period and reached 90.2% (83/92) in 2011 (P < 0.001). Median LOS decreased from 2 days (interquartile range 1-2) in the packing-only period to 1 day (interquartile range 1-2) in the predominantly MI period (P < 0.001). Hospital costs decreased with the transition to the MI technique (P < 0.001). MI drainage was associated with a $520 reduction in median direct costs and a $385 reduction in median indirect costs (P < 0.001). CONCLUSIONS: Soft tissue infections requiring incision and drainage are common in the pediatric population, with the majority caused by methicillin-resistant Staphylococcus aureus. Infections requiring drainage most frequently occurred in the diaper area of girls younger than 3 years old. Changing to an MI technique significantly decreased the hospital costs and LOS in our patient population.

Chondromyxoid fibroma of the second rib.

Chondromyxoid fibromas are benign tumors which are found most frequently in the metaphyses of long bones. They comprise less than 1% of primary bone neoplasms and display a hypermetabolic appearance on PET imaging. Oftentimes, they are misdiagnosed as chondrosarcomas and are excised due to concern for malignancy. We present a case of a condromyxoid fibroma originating from the second rib of a 15-year-old girl.

Primary Closure without Diversion in Management of Operative Blunt Duodenal Trauma in Children.

Background. Operative blunt duodenal trauma is rare in pediatric patients. Management is controversial with some recommending pyloric exclusion for complex cases. We hypothesized that primary closure without diversion may be safe even in complex (Grade II-III) injuries. Methods. A retrospective review of the American College of Surgeons' Trauma Center database for the years 2003-2011 was performed to identify operative blunt duodenal trauma at our Level 1 Pediatric Trauma Center. Inclusion criteria included ages <14 years and duodenal injury requiring operative intervention. Duodenal hematomas not requiring intervention and other small bowel injuries were excluded. Results. A total of 3,283 hospital records were reviewed. Forty patients with operative hollow viscous injuries and seven with operative duodenal injuries were identified. The mean Injury Severity Score was 10.4, with injuries ranging from Grades I-IV and involving all duodenal segments. All injuries were closed primarily with drain placement and assessed for leakage via fluoroscopy between postoperative days 4 and 6. The average length of stay was 11 days; average time to full feeds was 7 days. No complications were encountered. Conclusion. Blunt abdominal trauma is an uncommon mechanism of pediatric duodenal injuries. Primary repair with drain placement is safe even in more complex injuries.