RESUMEN
BACKGROUND: Nonoperative management (NOM) is the standard of care for the management of blunt liver and spleen injuries (BLSI) in the stable pediatric patient. Angiography with embolization (AE) is used as an adjunctive therapy in the management of adult BLSI patients, but it is rarely used in the pediatric population. In this planned secondary analysis, we describe the current utilization patterns of AE in the management of pediatric BLSI. METHODS: After obtaining IRB approval at each center, cohort data was collected prospectively for children admitted with BLSI confirmed on CT at 10 Level I pediatric trauma centers (PTCs) throughout the United States from April 2013 to January 2016. All patients who underwent angiography with or without embolization for a BLSI were included in this analysis. Data collected included patient demographics, injury details, organ injured and grade of injury, CT finding specifics such as contrast blush, complications, failure of NOM, time to angiography and techniques for embolization. RESULTS: Data were collected for 1004 pediatric patients treated for BLSI over the study period, 30 (3.0%) of which underwent angiography with or without embolization for BLSI. Ten of the patients who underwent angiography for BLSI failed NOM. For patients with embolized splenic injuries, splenic salvage was 100%. Four of the nine patients undergoing embolization of the liver ultimately required an operative intervention, but only one patient required hepatorrhaphy and no patient required hepatectomy after AE. Few angiography studies were obtained early during hospitalization for BLSI, with only one patient undergoing angiography within 1 hour of arrival at the PTC, and 7 within 3 hours. CONCLUSION: Angioembolization is rarely used in the management of BLSI in pediatric trauma patients with blunt abdominal trauma and is generally used in a delayed fashion. However, when implemented, angioembolization is associated with 100% splenic salvage for splenic injuries. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
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Embolización Terapéutica , Hígado , Bazo , Heridas no Penetrantes , Humanos , Embolización Terapéutica/métodos , Heridas no Penetrantes/terapia , Heridas no Penetrantes/diagnóstico por imagen , Bazo/lesiones , Bazo/irrigación sanguínea , Bazo/diagnóstico por imagen , Niño , Masculino , Femenino , Hígado/lesiones , Hígado/irrigación sanguínea , Hígado/diagnóstico por imagen , Adolescente , Angiografía , Preescolar , Tomografía Computarizada por Rayos X , Centros Traumatológicos , Puntaje de Gravedad del Traumatismo , Traumatismos Abdominales/terapia , Traumatismos Abdominales/diagnóstico por imagen , Resultado del Tratamiento , Estados Unidos , Estudios ProspectivosRESUMEN
Despite advances in the delivery of trauma care, trauma remains the leading cause of death amongst the pediatric population within the United States and is one of the leading causes of death in children worldwide. Accurately triaging pediatric trauma patients is essential to minimize preventable mortality without burdening the system by utilizing unnecessary resources. This article will review the accuracy of current pediatric trauma triage practices and how it will evolve in the future including moving away from mechanism of injury towards physiologic scoring tools such as the pediatric age-adjust shock index, and intervention-based systems including. Need for Surgeon Presence and Need For Trauma Intervention. This paper will also present evidence regarding over-utilization of air transport for pediatric trauma patients and the associated unnecessary costs placed on the trauma system.
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Triaje , Heridas y Lesiones , Niño , Humanos , Estados Unidos , Heridas y Lesiones/diagnóstico , Heridas y Lesiones/terapiaAsunto(s)
Algoritmos , Maltrato a los Niños/diagnóstico , Abuso Físico , Heridas y Lesiones/diagnóstico , Heridas y Lesiones/etiología , Adolescente , Niño , Preescolar , Toma de Decisiones Clínicas , Servicio de Urgencia en Hospital , Humanos , Lactante , Recién Nacido , Medición de Riesgo , Sociedades Médicas , Heridas y Lesiones/terapiaRESUMEN
BACKGROUND: Penetrating injury independently predicts the need for surgeon presence (NSP) upon arrival. Penetrating injury is often used as a trauma triage indicator, however, it includes a wide range of specific mechanisms of injury. We sought to compare firearm-related and non-firearm related pediatric penetrating injuries with respect to NSP, ISS and mortality. METHODS: Patients <18 from the 2016 National Trauma Quality Improvement Program Database were included. Penetrating injury was identified and grouped using ICD-10 mechanism codes into firearm and non-firearm related injury. NSP, ISS, and mortality were compared between the two groups. RESULTS: A total of 1715 (4.2%) patients with penetrating injury were; 832 firearm-related and 883 non-firearm. No deaths occurred among the non-firearm group compared to 94 (11.3%) among firearm-related patients. Among non-firearm patients, 22.7% had a NSP indicator compared to 51.2% of patients injured by a firearm. CONCLUSION: There is a significantly higher proportion of severe injury and mortality with firearm penetrating injury when compared to non-firearm pediatric penetrating injury. Consideration should be given to dividing it into firearm and non-firearm penetrating injury.
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Heridas por Arma de Fuego/clasificación , Heridas por Arma de Fuego/cirugía , Adolescente , Niño , Preescolar , Femenino , Humanos , Clasificación Internacional de Enfermedades , Masculino , Estudios Retrospectivos , Heridas Penetrantes/clasificación , Heridas Penetrantes/cirugíaAsunto(s)
Armas de Fuego/estadística & datos numéricos , Heridas por Arma de Fuego/prevención & control , Comunicación , Humanos , Violencia de Pareja/estadística & datos numéricos , Relaciones Médico-Paciente , Suicidio/estadística & datos numéricos , Estados Unidos , Heridas por Arma de Fuego/mortalidadRESUMEN
BACKGROUND: When to transport pediatric trauma patients directly from scene to a trauma center via helicopter (HT) has been a long debated topic. This study proposes Need for Surgeon Presence (NSP) matrix as an alternative method to assess appropriate utilization of HT of pediatric trauma patients directly from the scene of injury. METHOD: We utilized the 2016 TQIP database. NSP was defined as having one or more of the following: intubation, transfusion, operation for hemorrhage control/craniotomy, vasopressors, interventional radiology, spinal cord injury, tube thoracostomy, emergency thoracotomy, intracranial pressure monitor, or pericardiocentesis. The outcome of interest was the presence or absence of a NSP indicator. RESULTS: The NSP + patients had a: longer LOS, GCS<14, positive SIPA index value, went to OR/ICU from the ED, and had penetrating injury. Among patient with an ISS≥16, mortality for those also NSP+ was 18.8% versus 1.4% among the NSP-. CONCLUSION: The disparity between NSP and traditional ISS thresholds supports NSP as an additional metric to validate pre-hospital triage criteria and may be a better indicator of overall hospital resource utilization.
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Ambulancias Aéreas , Cirugía General , Evaluación de Necesidades , Procedimientos Quirúrgicos Operativos , Transporte de Pacientes , Heridas y Lesiones/cirugía , Adolescente , Niño , Preescolar , Femenino , Humanos , MasculinoRESUMEN
BACKGROUND: Studies spanning the last three decades demonstrated the injury causing capability of air gun (AG) projectiles. Recent studies have suggested the impact and incidence of these injuries may be declining because of edcational efforts. We hypothesize that injuries in the pediatric population resulting from AGs remain a significant health concern. METHODS: A retrospective review (1/1/2007 to 12/31/2016), of AG-injured children < 19 years old, was performed across six level I Pediatric Trauma Centers, part of the ATOMAC research consortium. AG injuries were defined as injuries sustained by ball-bearing or pellet air-powered guns. Paint ball and soft foam AGs were excluded. Following institutional review board approval, patients were identified by ICD code from the trauma registry. Included were demographic data, injury severity scores, length of stay (LOS), outcome at discharge, and overall cost of admission. Descriptive statistics and parametric tests were employed. RESULTS: A total of 499 patients sustained injuries. Mean age 9.5 (±4.0) y; 81% of victims were male; all survived to hospital discharge. 30% (n = 151) required operative intervention. Hospital LOS was 2.3 (±2.2) d; with mean cost of $23,756 (±$34,441). Injury severity score mean of 3.7 (±4.6) on admission. Over 40% of the injuries to the head/thorax that were severe (AIS ≥ 3) required operative intervention (P < 0.001). CONCLUSIONS: AG injuries to the head or thorax seen at trauma centers were likely to require operative management. While no fatalities occurred, the cost was substantial. This study demonstrates pediatric injuries resulting from AG projectiles remain a significant health concern.
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Heridas por Arma de Fuego/epidemiología , Adolescente , Niño , Preescolar , Traumatismos Craneocerebrales/economía , Traumatismos Craneocerebrales/epidemiología , Traumatismos Craneocerebrales/terapia , Femenino , Humanos , Masculino , Estudios Retrospectivos , Estados Unidos/epidemiología , Heridas por Arma de Fuego/economía , Heridas por Arma de Fuego/terapiaRESUMEN
PURPOSE: Firearm injuries continue to be a common cause of injury for American children. This pilot study was developed to evaluate the feasibility of providing guidance about firearm safety to the parents of pediatric patients using a tablet-based module in the outpatient setting. METHODS: A tablet-based questionnaire that included a firearm safety message based on current best practice was administered to parents of pediatric patients at nine centers in 2018. Parents were shown a firearm safety video and then asked a series of questions related to firearm safety. RESULTS: The study was completed by 543 parents from 15 states. More than one-third (37%) of families kept guns in their home. The majority of parents (81%, nâ¯=â¯438) thought it was appropriate for physicians to provide firearm safety counseling. Two-thirds (63%) of gun owning parents who do not keep their guns locked said that the information provided in the module would change the way they stored firearms at home. CONCLUSION: Use of a tablet based firearm safety module in the outpatient setting is feasible, and the majority of parents are receptive to receiving anticipatory guidance on firearm safety. Further data is needed to evaluate whether the intervention will improve firearm safety practices in the home. LEVEL OF EVIDENCE: Level III.
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Armas de Fuego , Promoción de la Salud/métodos , Padres/educación , Seguridad , Grabación en Video , Adolescente , Atención Ambulatoria , Niño , Preescolar , Computadoras de Mano , Consejo Dirigido , Estudios de Factibilidad , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Pediatría , Proyectos Piloto , Encuestas y Cuestionarios , Estados Unidos , Heridas por Arma de Fuego/prevención & control , Adulto JovenRESUMEN
BACKGROUND: Injury Severity Score (ISS) is the primary metric by which triage has been evaluated in trauma activations. We compared ISS to a previously described set of criteria defined as Need for Surgical Presence (NSP). We hypothesize that NSP may serve as a way to augment ISS in predicting mortality and assessing triage in pediatric trauma patients. METHODS: A total of 19,139 pediatric trauma patients in the 2016 National Trauma Quality Improvement Program Database (excluding transfers) had complete data for mortality, mode of transport, age, injury type, ISS, and NSP factors. NSP was defined as having one or more of the following: intubation, transfusion, operation for hemorrhage control/craniotomy, vasopressors, interventional radiology, spinal cord Injury, tube thoracostomy, emergency thoracotomy, intracranial pressure monitor, or pericardiocentesis. RESULTS: Overall mortality was 1.3% and 96% of all patients suffered blunt injury. A total of 2787 (14.6%) patients had an NSP indicator compared to 2036 (10.8%) with an ISS ≥16. NSP was noninferior to ISS in predicting mortality with the AUC of 0.91 (95% CI 0.89-0.92) and 0.90 (95% CI 0.88-0.92) respectively. CONCLUSION: NSP predicts mortality in pediatric trauma patients as well as ISS, and may compliment ISS. NSP status can be assigned shortly after patient arrival. Proper assessment of over and undertriage allows for optimal resource utilization by the medical facility and ultimately benefits the hospital, physician and patient. STUDY TYPE: Retrospective national dataset study. LEVEL OF EVIDENCE: Level II.
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Puntaje de Gravedad del Traumatismo , Cirujanos/estadística & datos numéricos , Triaje , Heridas y Lesiones , Niño , Servicio de Urgencia en Hospital , Humanos , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Triaje/métodos , Triaje/estadística & datos numéricos , Heridas y Lesiones/clasificación , Heridas y Lesiones/epidemiología , Heridas y Lesiones/mortalidad , Heridas y Lesiones/cirugíaRESUMEN
INTRODUCTION: Evidence based variables predicting the need for surgeon presence (NSP) on arrival of an injured child are limited. We sought to identify prehospital factors that best correlate with NSP and highest level of activation in pediatric trauma. A secondary analysis was also performed to determine whether injury severity score (ISS) was predictive of NSP in pediatric trauma. METHODS: This was a retrospective, single institution study of injured patients ageâ¯≤â¯16â¯years delivered from scene to our Pediatric Level I trauma center between January 2016 and June 2017. 526 patients had complete data available for analysis. NSP was previously described as the presence of any of these factors: intubation, transfusion, emergent operation with the trauma team/craniotomy with the neurosurgery team, vasopressors, interventional radiology, spinal cord Injury, chest tube, emergency department thoracotomy, intracranial pressure monitor, pericardiocentesis, or death in the trauma bay. Multivariable analysis was performed with covariates of interest including scene and ED arrival vitals and interventions. RESULTS: Independent predictors of NSP and highest level of activation were GCS of ≤12 (OR 22.3), penetrating trauma (OR 5.4), and hypotension (age adjusted) (OR 10.2). We also found that ISSâ¯≥â¯16 was a poor indicator of NSP with a sensitivity of only 61%. CONCLUSION: A validated model based on these variables may be useful in predicting NSP and highest level of activation prior to arrival of pediatric trauma patients. NSP may augment assessment of over and undertriage in pediatric trauma patients as compared to the ISS/Cribari system alone. Level of evidence Level III, retrospective cohort study.
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Centros Traumatológicos/normas , Traumatología , Heridas y Lesiones/cirugía , Adolescente , Transfusión Sanguínea , Niño , Preescolar , Estudios de Cohortes , Femenino , Humanos , Hipotensión , Puntaje de Gravedad del Traumatismo , Masculino , Evaluación de Necesidades , Admisión y Programación de Personal , Estudios Retrospectivos , Heridas Penetrantes/cirugíaRESUMEN
Background: Recently, several series have reported the use of laparoscopy in pediatric trauma, most commonly for bowel and pancreatic injury within the first 12 or 24 hours. During a multicenter trial at 10 Level 1 pediatric trauma centers, selective use of laparoscopy in children with blunt liver or spleen injury (BLSI) was noted. A secondary analysis was performed to describe the frequency and application of these procedures to pediatric BLSI. Patients and Methods: Prospective data were collected on all children age ≤18 years with BLSI presenting to 1 of 10 pediatric trauma centers. An unplanned secondary analysis of children who underwent laparoscopy was done. Results: Of 1008 children with BLSI, 59 initially underwent a laparotomy, but 11 underwent a laparoscopic procedure during their index admission; 1 of these was 22 hours postlaparotomy and 2 others were laparoscopy-assisted and converted to laparotomy. Median age of patients undergoing a laparoscopic procedure was 11.5 years (interquartile range [IQR]: 5.8-16.4). Laparoscopy was performed at 7 of the 10 centers. Median time to surgery was 42 hours (IQR: 8-96). Most patients had a liver (n = 6) injury; 4 had spleen and 1 had both. One of the laparoscopies was for pancreatic surgery, and 2 were for bowel injury (but converted to open). Conclusions: Laparoscopy was utilized in 16% of children requiring abdominal surgery after BLSI, with a median time of 42 hours postinjury. Uses included diagnostic laparoscopy, drain placement, laparoscopic pancreatectomy, and washout of hematoma.
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Traumatismos Abdominales/cirugía , Hemorragia/terapia , Laparoscopía/estadística & datos numéricos , Laparotomía/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Bazo/lesiones , Heridas no Penetrantes/cirugía , Traumatismos Abdominales/complicaciones , Adolescente , Niño , Preescolar , Femenino , Estudios de Seguimiento , Hemorragia/etiología , Humanos , Lactante , Recién Nacido , Hígado/lesiones , Hígado/cirugía , Masculino , Estudios Retrospectivos , Bazo/cirugía , Centros Traumatológicos , Estados Unidos , Heridas no Penetrantes/complicacionesRESUMEN
Removal of extracorporeal membrane oxygenation (ECMO) cannulae and discontinuing systemic anticoagulation typically occurs soon after separation from ECMO. We have found, however, that delaying decannulation after terminating ECMO therapy does not predispose to adverse outcomes and may be advantageous. Between January 2014 and June 2016, 36 postcardiotomy patients at the Children's Hospital of Oklahoma required ECMO. In this cohort of 36 patients, there was a need for 42 ECMO runs. Of the 42 ECMO runs, 29 (69%) survived to decannulation. Of those ECMO runs that survived to decannulation, 18 (62%) were cannulated centrally and 11 (38%) were cannulated via the neck. For the runs where the patient survived to decannulation, the mean number of days on ECMO support was 4 ± 2 days. There was an average time interval of 21 ± 14 hours from ECMO termination to decannulation. A single patient failed being separated from ECMO support and required reinstitution of ECMO 18 hours after separation (but did not require recannulation).
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Catéteres , Remoción de Dispositivos/métodos , Oxigenación por Membrana Extracorpórea/instrumentación , Cardiopatías Congénitas/cirugía , Hospitales Pediátricos , Femenino , Cardiopatías Congénitas/mortalidad , Humanos , Lactante , Recién Nacido , Masculino , Oklahoma/epidemiología , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Focused Abdominal Sonography for Trauma (FAST) examination has long been proven useful in the management of adult trauma patients, however, its utility in pediatric trauma patients is not as proven. Our goal was to evaluate the utility of a FAST examination in predicting the success or failure of nonoperative management (NOM) of blunt liver and/or spleen (BLSI) in the pediatric trauma population. METHODS: A retrospective analysis of a prospective observational study of patients younger than 18 years presenting with BLSI to one of ten Level I pediatric trauma centers between April 2013 and January 2016. 1,008 patients were enrolled and 292 had a FAST examination recorded. We analyzed failure of NOM of BLSI in the pediatric trauma population. We then compared FAST examination alone or in combination with the pediatric age adjusted shock index (SIPA) as it relates to success of NOM of BLSI. RESULTS: Focused Abdominal Sonography for Trauma examination had a negative predictive value (NPV) of 97% and positive predictive value (PPV) of 13%. The odds ratio of failing with a positive FAST examination was 4.9 and with a negative FAST was 0.20. When combined with SIPA, a positive FAST examination and SIPA had a PPV of 17%, and an odds ratio for failure of 4.9. The combination of negative FAST and SIPA had an NPV of 96%, and the odds ratio for failure was 0.20. CONCLUSION: Negative FAST is predictive of successful NOM of BLSI. The addition of a positive or negative SIPA score did not affect the PPV or NPV significantly. Focused Abdominal Sonography for Trauma examination may be useful clinically in determining which patients are not at risk for failure of NOM of BLSI and do not require monitoring in an intensive care setting. LEVEL OF EVIDENCE: Prognostic study, level IV; therapeutic/care management, level IV.
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Traumatismos Abdominales/diagnóstico por imagen , Evaluación Enfocada con Ecografía para Trauma/métodos , Heridas no Penetrantes/diagnóstico por imagen , Traumatismos Abdominales/terapia , Adolescente , Arizona/epidemiología , Arkansas/epidemiología , Estudios de Casos y Controles , Niño , Preescolar , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Hígado/lesiones , Masculino , Oklahoma/epidemiología , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Estudios Retrospectivos , Choque/diagnóstico , Choque/terapia , Bazo/lesiones , Texas/epidemiología , Centros Traumatológicos/estadística & datos numéricos , Insuficiencia del Tratamiento , Heridas no Penetrantes/terapiaRESUMEN
BACKGROUND: After NOM for BLSI, APSA guidelines recommend activity restriction for grade of injury +2 in weeks. This study evaluates activity restriction adherence and 60â¯day outcomes. METHODS: Non-parametric tests and logistic regression were utilized to assess difference between adherent and non-adherent patients from a 3-year prospective study of NOM for BLSI (≤18â¯years). RESULTS: Of 1007 children with BLSI, 366 patients (44.1%) met the inclusion criteria of a completed 60â¯day follow-up; 170 (46.4%) had liver injury, 159 (43.4%) had spleen injury and 37 (10.1%) had both. Adherence to recommended activity restriction was claimed by 279 (76.3%) patients; 49 (13.4%) reported non-adherence and 38 (10.4%) patients had unknown adherence. For 279 patients who adhered to activity restrictions, unplanned return to the emergency department (ED) was noted for 35 (12.5%) with 16 (5.7%) readmitted; 202 (72.4%) returned to normal activity by 60â¯days. No patient bled after discharge. There was no statistical difference between adherent patients (nâ¯=â¯279) and non-adherent (nâ¯=â¯49) for return to ED (χ2â¯=â¯0.8 [pâ¯<â¯0.4]) or readmission (χ2â¯=â¯3.0 [pâ¯<â¯0.09]); for 216 high injury grade patients, there was no difference between adherent (nâ¯=â¯164) and non-adherent (nâ¯=â¯30) patients for return to ED (χ2â¯=â¯0.6 [pâ¯<â¯0.4]) or readmission (χ2â¯=â¯1.7 [pâ¯<â¯0.2]). CONCLUSION: For children with BLSI, there was no difference in frequencies of bleeding or ED re-evaluation between patients adherent or non-adherent to the APSA activity restriction guideline. LEVEL OF EVIDENCE: Level II, Prognosis.
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Guías como Asunto , Hígado/lesiones , Cooperación del Paciente/estadística & datos numéricos , Bazo/lesiones , Heridas no Penetrantes/terapia , Adolescente , Niño , Servicio de Urgencia en Hospital/estadística & datos numéricos , Ejercicio Físico , Femenino , Estudios de Seguimiento , Humanos , Masculino , Readmisión del Paciente/estadística & datos numéricos , Estudios Prospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: APSA guidelines do not recommend routine reimaging for pediatric blunt liver or spleen injury (BLSI). This study characterizes the symptoms, reimaging, and outcomes associated with a selective reimaging strategy for pediatric BLSI patients. METHODS: A planned secondary analysis of reimaging in a 3-year multi-site prospective study of BLSI patients was completed. Inclusion required successful nonoperative management of CT confirmed BLSI without pancreas or kidney injury and follow up at 14 or 60â¯days. Patients with re-injury after discharge were excluded. RESULTS: Of 1007 patients with BLSI, 534 (55%) met inclusion criteria (median age: 10.18 [IQR: 6, 14]; 62% male). Abdominal reimaging was performed on 27/534 (6%) patients; 3 of 27 studies prompting hospitalization and/or intervention. Abdominal pain was associated with reimaging, but decreased appetite predicted imaging findings associated with readmission and intervention. CONCLUSION: Selective abdominal reimaging for BLSI was done in 6% of patients, and 11% of studies identified radiologic findings associated with intervention or re-hospitalization. A selective reimaging strategy appears safe, and even reimaging symptomatic patients rarely results in intervention. Reimaging after 14â¯days did not prompt intervention in any of the 534 patients managed nonoperatively. LEVEL OF EVIDENCE: Level II, Prognosis.
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Dolor Abdominal/diagnóstico por imagen , Hígado/diagnóstico por imagen , Bazo/diagnóstico por imagen , Heridas no Penetrantes/diagnóstico por imagen , Dolor Abdominal/etiología , Adolescente , Anorexia/etiología , Niño , Preescolar , Femenino , Humanos , Hígado/lesiones , Masculino , Readmisión del Paciente , Estudios Prospectivos , Bazo/lesiones , Heridas no Penetrantes/complicacionesAsunto(s)
Armas de Fuego , Violencia/prevención & control , Heridas por Arma de Fuego/prevención & control , Chicago , Investigación Participativa Basada en la Comunidad , Características Culturales , Armas de Fuego/ética , Armas de Fuego/legislación & jurisprudencia , Armas de Fuego/normas , Política de Salud , Humanos , Salud Mental , Seguridad , Aislamiento Social , Estados Unidos , Violencia/psicología , Heridas por Arma de Fuego/complicaciones , Heridas por Arma de Fuego/mortalidad , Heridas por Arma de Fuego/psicologíaRESUMEN
BACKGROUND: Patients with stable blunt great vessel injury (GVI) can have poor outcomes if the injury is not identified early. With current pediatric trauma radiation reduction efforts, these injuries may be missed. As a known association between scapular fracture and GVI exists in adult blunt trauma patients, we examined whether that same association existed in pediatric blunt trauma patients. METHODS: Bluntly injured patients younger than 18 years old were identified from 2012 to 2014 in the National Trauma Data Bank. Great vessel injury included all major thoracic vessels and carotid/jugular. Demographics of patients with and without scapular fracture were compared with descriptive statistics. The χ test was used to examine this association using SAS Version 9.4 (SAS Institute, Inc, Cary, NC). RESULTS: We found a significant association between pediatric scapular fracture and GVI. Of 291,632 children identified, 1,960 had scapular fractures. Children with scapular fracture were 10 times more likely to have GVI (1.2%) compared to those without (0.12%, p < 0.0001). Most common GVI seen were carotid artery, thoracic aorta, and brachiocephalic or subclavian artery or vein. Children with both scapular fracture and GVI were most commonly injured by motor vehicles (57% collision, 26% struck). CONCLUSIONS: Injured children with blunt scapular fracture have a 10-fold greater risk of having a GVI when compared to children without scapular fracture. Presence of blunt traumatic scapular fracture should have appropriate index of suspicion for a significant GVI in pediatric trauma patients. LEVEL OF EVIDENCE: Epidemiologic and prognostic study, level III; Therapeutic, level IV.
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Aorta Torácica/lesiones , Venas Yugulares/lesiones , Escápula/lesiones , Lesiones del Sistema Vascular/epidemiología , Lesiones del Sistema Vascular/etiología , Heridas no Penetrantes/complicaciones , Adolescente , Tronco Braquiocefálico/lesiones , Venas Braquiocefálicas/lesiones , Traumatismos de las Arterias Carótidas/epidemiología , Traumatismos de las Arterias Carótidas/etiología , Estudios de Casos y Controles , Niño , Preescolar , Bases de Datos Factuales , Femenino , Humanos , Masculino , Estudios Retrospectivos , Arteria Subclavia/lesiones , Vena Subclavia/lesionesRESUMEN
BACKGROUND: One of the concerns associated with nonoperative management of splenic injury in children has been delayed splenic bleed (DSB) after a period of hemostasis. This study evaluates the incidence of DSB from a multicenter 3-year prospective study of blunt splenic injuries (BSI). METHODS: A 3-year prospective study was done to evaluate nonoperative management of pediatric (≤18years) BSI presenting to one of 10 pediatric trauma centers. Patients were tracked at 14 and 60days. Descriptive statistics were used to summarize patient and injury characteristics. RESULTS: During the study period, 508 children presented with BSI. Median age was 11.6 [IQR: 7.0, 14.8]; median splenic injury grade was 3 [IQR: 2, 4]. Nonoperative management was successful in 466 (92%) with 18 (3.5%) patients undergoing splenectomy at the index admission, all within 3h of injury. No patient developed a delayed splenic bleed. At least one follow-up visit was available for 372 (73%) patients. CONCLUSION: A prior single institution study suggested that the incidence of DSB was 0.33%. Based on our results, we believe that the rate may be less than 0.2%. LEVEL OF EVIDENCE: Level II, Prognosis.
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Hemorragia/etiología , Bazo/lesiones , Enfermedades del Bazo/etiología , Heridas no Penetrantes/complicaciones , Adolescente , Niño , Preescolar , Femenino , Estudios de Seguimiento , Hemorragia/epidemiología , Humanos , Incidencia , Lactante , Recién Nacido , Masculino , Pronóstico , Estudios Prospectivos , Esplenectomía/estadística & datos numéricos , Enfermedades del Bazo/epidemiología , Centros Traumatológicos/estadística & datos numéricos , Resultado del Tratamiento , Heridas no Penetrantes/diagnóstico , Heridas no Penetrantes/terapiaRESUMEN
PURPOSE: Children with blunt liver or spleen injury (BLSI) requiring early transfusion may present without hypotension despite significant hypovolemia. This study sought to determine the relationship between early transfusion in pediatric BLSI and hypotension. METHODS: Secondary analysis of a 10-institution prospective observational study was performed of patients 18years and younger presenting with BLSI. Patients with central nervous system (CNS) injury were excluded. Children receiving blood transfusion within 4h of injury were evaluated. Time to first transfusion, vital signs, and physical exams were analyzed. Patients with hypotension were compared to those without hypotension. RESULTS: Of 1008 patients with BLSI, 47 patients met inclusion criteria. 22 (47%) had documented hypotension. There was no statistical difference in median time to first transfusion for those with or without hypotension (2h vs. 2.5h, p=0.107). The hypotensive group was older (median 15.0 versus 9.5years; p=0.007). Median transfusion volume in the first 24h was 18.2mL/kg (IQR: 9.6, 25.7) for those with hypotension and 13.9mL/kg (IQR: 8.3, 21.0) for those without (p=0.220). Mortality was 14% (3/22) in children with hypotension and 0% (0/25) in children without hypotension. CONCLUSION: Hypotension occurred in less than half of patients requiring early transfusion following pediatric BLSI suggesting that hypotension does not consistently predict the need for early transfusion. TYPE OF STUDY: Secondary analysis of a prospective observational study. LEVEL OF EVIDENCE: Level IV cohort study.