Pediatric Blunt Cerebrovascular Injuries: Approach and Management.

ABSTRACT: The low incidence of blunt cerebrovascular injury (BCVI) reported in pediatric studies (<1%) might be related to an underreporting due to both the absence of current screening guidelines and the use of inadequate imaging techniques. This research is a review of the literature limited to the last 5 years (2017-2022) about the approach and management of BCVI in pediatrics. The strongest predictors for BCVI were the presence of basal skull fracture, cervical spine fracture, intracranial hemorrhage, Glasgow Coma Scale score less than 8, mandible fracture, and injury severity score more than 15. Vertebral artery injuries had the highest associated stroke rate of any injury type at 27.6% (vs 20.1% in carotid injury). The sensitivity of the well-established screening guidelines of BCVI varies when applied to the pediatric population (Utah score - 36%, 17%, Eastern Association for the Surgery of Trauma (EAST) guideline - 17%, and Denver criteria - 2%). A recent metaanalysis of 8 studies comparing early computed tomographic angiogram (CTA) to digital subtraction angiography for BCVI detection in adult trauma patients demonstrated high variability in the sensitivity and specificity of CTA across centers. Overall, CTA was found to have a high specificity but low sensitivity for BCVI. The role of antithrombotic as well as the type and duration of therapy remain controversial. Studies suggest that systemic heparinization and antiplatelet therapy are equally effective.

Who are the trauma team leaders across Canada? A national survey evaluating the profession in adult and pediatric level one trauma centres.

OBJECTIVES: Trauma Team Leaders (TTLs) are critical for coordinating and leading trauma resuscitations. This survey sought to characterize the demographics and professional practices of Canadian TTLs at level one trauma centres. As a secondary objective, this information will be utilized to inform the operational goals of the Trauma Association of Canada (TAC) TTL Committee. METHODS: A detailed survey, developed by the TAC board of directors and TTL committee leads, was sent to 225 TTLs across Canada's level one trauma centres. TTLs were identified via contacting trauma directors at each level one centre, in addition to public registry searches. This survey captured demographics, professional background, resuscitation practices, trauma team composition, and TTL involvement in trauma responses. RESULTS: The response rate was 41.7%. Mean respondent age was 42 (SD 7.4) and 71.0% were male. Most TTLs trained in emergency medicine (53.1%) or general surgery (25.5%); 63.8% underwent TTL training: either via a trauma surgery fellowship or TTL fellowship. All centres have a massive hemorrhage protocol implemented, and there is no large variation between the rates of use of cryoprecipitate and fibrinogen, nor the ratio of blood products transfused (2:1 vs 1:1). Most TTL respondents intend to participate in a TTL group associated with TAC (85.1%). CONCLUSION: The results of this survey will contribute to the recognition of TTLs as a crucial role in the initial phase of care of severely injured trauma patients and serves as the first publication to document professional backgrounds and practices of Canadian TTLs at level one trauma centres. All the information gathered via this survey will be used by the TAC TTL Committee, which will focus on several initiatives such as the dissemination of best practice guidelines and creation of a TTL stream at the TAC Annual Conference.

RéSUMé: OBJECTIFS: Les chefs d'équipe de traumatologie (TTL) sont essentiels pour coordonner et diriger les réanimations traumatiques. Cette enquête visait à caractériser la démographie et les pratiques professionnelles des TTL canadiens dans les centres de traumatologie de niveau 1. À titre d'objectif secondaire, cette information sera utilisée pour éclairer les objectifs opérationnels du Comité TTL de l'Association canadienne de traumatologie (ATC). MéTHODES: Un sondage détaillé, élaboré par le conseil d'administration de l'ATC et les responsables des comités de TTL, a été envoyé à 225 TTL dans les centres de traumatologie de niveau 1 du Canada. Les TTL ont été identifiés en contactant les directeurs de traumatologie de chaque centre de niveau 1, en plus des recherches dans le registre public. Cette enquête a porté sur la démographie, les antécédents professionnels, les pratiques de réanimation, la composition de l'équipe de traumatologie et la participation de la TTL aux réponses traumatologiques. RéSULTATS: Le taux de réponse était de 41,7 %. L'âge moyen des répondants était de 42 ans (ET 7,4) et 71,0 % étaient des hommes. La plupart des TTL ont suivi une formation en médecine d'urgence (53,1%) ou en chirurgie générale (25,5%); 63,8% ont suivi une formation TTL : soit via une bourse en chirurgie traumatologique ou une bourse TTL. Tous les centres ont mis en œuvre un protocole d'hémorragie massive, et il n'y a pas de grande variation entre les taux d'utilisation du cryoprécipité et du fibrinogène, ni entre le rapport des produits sanguins transfusés (2:1 vs 1:1). La plupart des répondants TTL ont l'intention de participer à un groupe TTL associé au TAC ( 85,1 %). CONCLUSION: Les résultats de ce sondage contribueront à la reconnaissance des TTL comme un rôle crucial dans la phase initiale des soins aux patients ayant subi un traumatisme grave et serviront de première publication pour documenter les antécédents et les pratiques professionnelles des TTL canadiens au niveau un centres de traumatologie. Toutes les informations recueillies dans le cadre de cette enquête seront utilisées par le Comité TAC TTL, qui se concentrera sur plusieurs initiatives telles que la diffusion de lignes directrices sur les meilleures pratiques et la création d'un flux TTL à la conférence annuelle TAC.

Implementation of a North American pediatric emergency medicine simulation curriculum using the virtual resuscitation room.

Background: Simulation provides consistent opportunities for residents to practice high-stakes, low-frequency events such as pediatric resuscitations. To increase standardization across North American residency programs, the Emergency Medicine Resident Simulation Curriculum for Pediatrics (EM ReSCu Peds) was developed. However, access to high-quality simulation/pediatric expertise is not uniform. As the concurrent COVID-19 pandemic necessitated new virtual simulation methods, we adapted the Virtual Resus Room (VRR) to teach EM ReSCu Peds. VRR is an award-winning, low-resource, open-access distance telesimulation platform we hypothesize will be effective and scalable for teaching this curriculum. Methods: EM residents completed six VRR EM ReSCu Peds simulation cases and received immediate facilitator-led teledebriefing. Learners completed retrospective pre-post surveys after each case. Learners and facilitators completed end-of-day surveys. Primary outcomes were learning effectiveness measured by a composite of the Simulation Effectiveness in Teaching Modified (SET-M) tool and self-reported changes in learner comfort with case objectives. Secondary outcome was VRR scalability to teach EM ReSCu Peds using a composite outcome of net promoter scores (NPS), resource utilization, open-text feedback, and technical issues. Results: Learners reported significantly increased comfort with 95% (54/57) of EM ReSCu Peds-defined case objectives (91% cognitive, 9% psychomotor), with moderate (Cohen's d 0.71, 95% CI 0.67-0.76) overall effect size. SET-M responses indicated simulation effectiveness, particularly with debriefing. Ninety EM residents from three North American residency programs were taught by 59 pediatric faculty from six programs over 4 days-more than possible if simulations were conducted in person. Learners (39) and faculty (68) NPS were above software industry benchmarks (13). Minor, quickly resolved, technical issues were reported by 18% and 29% of learners and facilitators, respectively. Conclusions: Learners and facilitators report that the VRR is an effective and scalable platform to teach EM ReSCu Peds. This low-cost, accessible distance simulation intervention could increase equitable, global access to high-quality pediatric emergency education.

Trauma Care During the COVID-19 Pandemic: A Canadian Survey.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has placed major limitations on trauma health care systems. This survey aims to identify how Canadian trauma centres altered their processes to care for injured patients and protect their staff during the pandemic. METHODS: A survey was distributed to trauma directors at level 1 Canadian adult trauma centres in July 2020. Questions included changes made to the trauma service in preparation for the pandemic, modification to clinical practice and expected lasting modifications after the pandemic. RESULTS: The response rate was 68.4%. All trauma centres modified their treatment and investigation protocols for the pandemic. Most respondents adopted online platforms for meetings and educational activities and used simulation to prepare for COVID-19-infected trauma patients. The approach to who would intubate trauma patients, which trauma patients should be tested for COVID-19 and who should use N95 ventilators, varied among the sites surveyed. CONCLUSION: All centres modified some of their treatment and investigation protocols for the pandemic but not all modifications were adopted universally. Knowing these steps and comparing them with other global centres will help organize disaster plans for the current and future pandemics.

The Effect of a Multidisciplinary Trauma Team Leader Paradigm at a Tertiary Trauma Center: 10-Year Experience.

BACKGROUND: To illustrate the impact of the implementation of a multidisciplinary TTL program in 2005 on the mortality of trauma patients in a level 1 trauma center as well as admission rates and length of stay. METHODS: Retrospective observational study of all trauma patients included in the provincial trauma database at the Montreal General Hospital between 1998 and 2015. The primary outcome studied was in-hospital mortality. The secondary outcomes studied were hospital and intensive care unit (ICU) rates of admission and hospital and ICU length of stay. RESULTS: 24,107 patients were included. We observed a statistically significant reduction in mortality of 1.25% or a relative reduction of 16% (p value = 0.0058; rate ratio 0.844 (95% CI 0.747-0.952)). ICU admissions were also significantly reduced where we observed a statistically significant absolute reduction of 4.46% or a relative reduction of 14% (p value = 8.38 × 10-7; rate ratio 0.859 (95% CI 0.808-0.912)). The ICU length of stay was increased by 0.91 days or 19.03% (p value = 0.016 (95% CI 0.167-1.655)). There was no observed change in overall length of stay (13.97 days pre-TTL and 12.91 post-TTL (p value = 0.13; estimate -1.053 (95% CI -2.424-0.318))). CONCLUSIONS: This article suggests that multidisciplinary TTL model may be beneficial in the care of trauma patients. Further subgroup analysis may help determine which patients could benefit more.

Expectant parents' understanding of the implications and management of fever in the neonate.

OBJECTIVE: We estimated the extent to which Canadian expectant parents would seek medical care in a febrile neonate (age 30 days or less). We also evaluated expectant parents' knowledge of signs and symptoms of fever in a neonate, and explored the actions Canadian expectant parents would take to optimize the health of their child. METHODS: We conducted a cross-sectional survey of a sample of expectant parents from a large urban center in Canada. We recruited participants from waiting rooms in an obstetrical ultrasound clinic located in an urban tertiary care hospital in Montreal, Canada. We asked participants nine questions about fever in neonates including if, and how, they would seek care for their neonate if they suspected he/she were febrile. RESULTS: Among the 355 respondents, (response rate 87%) we found that 75% of parents reported that they would take their febrile neonate for immediate medical assessment, with nearly one fifth of the sample reporting that they would not seek medical care. We found no significant associations between the choice to seek medical care and expectant parents socio-demographic characteristics. CONCLUSIONS: Despite universal access to high quality health care in Canada, our study highlights concerning gaps in the knowledge of the care of the febrile infant in one fifth of expectant parents. Physicians and health providers should strive to provide early education to expectant parents about how to recognize signs of fever in the neonate and how best to seek medical care. This may improve neonatal health outcomes in Canada.

Emergency airway management: the difficult airway.

Patients requiring airway management in the emergency department present an enormous challenge. It requires not only a firm concept of techniques for securing the airway but also of dealing with the potential difficult airway (DA) in which establishing a definite airway is not possible with techniques routinely used. This article highlights the importance of recognition and management of the DA in emergent situations. Both awake and nonawake intubation are discussed, and indications and guidelines are given for the use of nonsurgical and surgical airway interventions.

The prevalence of hypoglycemia in children with vomiting or decreased oral intake and irritability.

OBJECTIVE: This study aimed to estimate the prevalence of hypoglycemia in children younger than 5 years presenting to the emergency department with vomiting or decreased oral intake and irritability. METHODS: Children aged 1 month to 5 years presenting to the emergency department with vomiting (twice or more) or decreased oral intake (>50%) during the past 24 hours and irritability as part of the history of present illness were enrolled. Capillary blood glucose was obtained at triage. Patients with glucose level higher than 3.0 mmol/L were considered normoglycemic. Patients with glucose level of 3.0 mmol/L or lower were re-triaged (acuity level increased by 1), and sent to a treatment room with the recommendation that our institution's hypoglycemia protocol be applied. RESULTS: Of the 145 enrolled patients, 2 were hypoglycemic, for an estimated prevalence of 1.4%. The mean capillary blood glucose level was 5.4 mmol/L, and the range was 2.8 to 11.8 mmol/L. The average age of participants was 21 months, and 48.3% were female. Most were triaged category 4 or 5, and the most common discharge diagnoses were gastroenteritis, viral illness, and vomiting not yet diagnosed. CONCLUSIONS: Hypoglycemia is a rare occurrence in all-comers younger than 5 years with vomiting or decreased oral intake, even with early signs of neuroglycopenia. Measuring the capillary glucose is better left to the discretion of the physician than as part of triage.

Bedside emergency department ultrasonography availability and use for blunt abdominal trauma in Canadian pediatric centres.

OBJECTIVES: To quantify the current availability and use of bedside emergency department ultrasonography (EDUS) for blunt trauma at Canadian pediatric centres and to identify any perceived barriers to the use of bedside EDUS in such centres. METHODS: An electronic survey was sent to 162 pediatric emergency physicians and 12 site directors from the 12 pediatric emergency departments across Canada. RESULTS: Ninety-two percent (11 of 12) of centres completed the survey. The individual physician response rate was 65% (106 of 162), with 100% of site directors responding. Ultrasound machines were available in 45% (5 of 11) of centres. Forty-two percent (32 of 77) of emergency physicians working in equipped pediatric centres used bedside EDUS to evaluate blunt abdominal trauma (BAT). In the subgroup of staff who also worked at adults sites, the frequency of ultrasonography use for the evaluation of pediatric BAT was 75%. In the 55% (6 of 11) of centres without ultrasonography, 88% of staff intend to incorporate its use in the future and 81% indicated that they believed the incorporation of ultrasonography would have a positive impact on patient care. The main perceived barriers to the use of ultrasonography in the evaluation of BAT were a lack of training (41%) and a lack of equipment (26%). CONCLUSION: Bedside EDUS is currently used in almost half of pediatric trauma centres, a frequency that is significantly lower than adult centres. Physicians in pediatric centres who use ultrasonography report that it has a high utility, and a great majority of physicians at pediatric centres without EDUS plan to incorporate it in the future. The main reported barriers to its use are a lack of training and a lack of equipment availability.