The effect of family presence on the efficiency of pediatric trauma resuscitations.

STUDY OBJECTIVE: Family presence has broad professional organizational support and is gaining acceptance. We seek to determine whether family presence prolonged pediatric trauma team resuscitations as measured by time from emergency department arrival to computed tomographic (CT) scan, and to resuscitation completion. METHODS: A prospective trial offered families of pediatric trauma patients family presence on even days and no family presence on odd days. Primary outcome measures were time from arrival to CT scan and to resuscitation completion (laboratory tests, emergency procedures, portable radiographs, and secondary survey). We evaluated the effect of family presence in an adjusted Cox proportional hazards model. Staff and family experiencing a resuscitation with family presence were asked their opinions of that experience. RESULTS: Of 1,229 pediatric trauma activations, 705 patients were included in the study protocol, 283 with family presence on even days, 422 without family presence on odd days. Median times to CT scan (21 minutes; IQR 16 to 29 minutes) and median resuscitation times (15 minutes; IQR 10 to 20 minutes) were similar with and without family presence. There was no clinically relevant difference in CT time (hazard ratio 1.04; 95% confidence interval [CI] 0.83 to 1.30) or resuscitation time (hazard ratio 0.98; 95% CI 0.83 to 1.15). Families believed that family presence was helpful both to their child and themselves. CONCLUSION: This prospective trial shows that family presence does not prolong time to CT imaging or to resuscitation completion for pediatric trauma patients. Family presence does not negatively affect the time efficiency of the pediatric trauma resuscitation.

The utility of a "trauma 1 OP" activation at a level 1 pediatric trauma center.

PURPOSE: To expedite flow of injured children suspected to require operative intervention, a "trauma 1 OP" (T1OP) activation classification was created. The purpose of this study was to review this strategy at a level 1 pediatric trauma center. METHODS: A retrospective review of T1OP activations between 2003 and 2015 was performed. Children suspected of requiring neurosurgical intervention were classified as trauma 1 OP neuro (T1OP(N)). Comparisons were made to trauma 1 (T1) patients who required emergent operative intervention, excluding orthopedic injuries. RESULTS: Overall, 461 T1OP activations occurred (72% T1OP(N)) compared to 129 T1 activations requiring emergent surgery. Demographics were not significantly different between groups, although T1OP patients were slightly younger and more often experienced falls or were victims of abuse. Compared to T1 activations, T1OP activations had a significantly higher mortality rate (21% vs. 7%, p<0.001). Repeat head imaging was more common in the T1OP(N) group compared to imaged children in the T1 group (20% vs. 37%, p=0.05). T1OP(N) patients more often went directly to the OR (45% vs. 33%, p=0.02) and did so in a significantly faster period of time (32min vs. 53min, p<0.001). CONCLUSIONS: Use of the T1OP activations appropriately triaged surgical patients, resulting in significantly faster transport times to the OR. LEVEL OF EVIDENCE: II, prognosis study.

Factors Associated with Time to Arrival at a Regional Pediatric Trauma Center.

OBJECTIVE: The goal of this study was to test the hypothesis that the prehospital time between injury and arrival at a trauma center for critically injured children is associated with patient injury severity and mode of transport. METHODS: Secondary analysis of prospectively collected data on children 0-17 years of age admitted with traumatic injuries to a designated Level I pediatric trauma center from January 1, 2006 through September 30, 2007 was conducted. Multivariate regression methods were used to assess for factors independently associated with prehospital time. RESULTS: Of 1,175 admissions during the study period, only 355 (30%) had a prehospital time within 60 minutes of injury. Prehospital time within 60 minutes of injury was associated with higher frequency of coma, higher mean injury severity scores (ISS), and greater frequency of admission to the intensive care unit when compared with prehospital time beyond 60 minutes of injury. Children who arrived at the trauma center within 60 minutes versus beyond 60 minutes were 13-fold (odds ratio [OR]: 12.9; 95% Confidence Interval [CI], 7.6-22.0) more likely to be transported via air ambulance than a private vehicle, and had 4.8-fold greater odds (95% CI, 2.2-10.3) of transport via ground ambulance than private vehicle. For each kilometer of distance between the injury zip code and the trauma center, the odds of arrival within 60 minutes versus beyond 60 minutes decreased by 15% (OR: 0.85; 95% CI, 0.79-0.91). CONCLUSION: Field triage and decision making appeared to correlate with severity of patient injury with expeditious transport of the most severely injured children to definitive trauma care. This finding serves as important groundwork that might enable further study into factors that influence triage and overall prehospital care for critically injured children.

Alternative model for a pediatric trauma center: efficient use of physician manpower at a freestanding children's hospital.

BACKGROUND: Freestanding children's hospitals may lack resources, especially surgical manpower, to meet American College of Surgeons trauma center criteria, and may organize trauma care in alternative ways. MATERIALS AND METHODS: At a tertiary care children's hospital, attending trauma surgeons and anesthesiologists took out-of-hospital call and directed initial care for only the most severely injured patients, whereas pediatric emergency physicians directed care for patients with less severe injuries. Survival data were analyzed using TRISS methodology. RESULTS: A total of 903 trauma patients were seen by the system during the period 10/1/96-6/30/01. Median Injury Severity Score was 16, and 508 of patients had Injury Severity Score > or =15. There were 83 deaths, 21 unexpected survivors, and 13 unexpected deaths. TRISS analysis showed that z-score was 4.39 and W-statistic was 3.07. CONCLUSIONS: Mortality outcome from trauma in a pediatric hospital using this alternative approach to trauma care was significantly better than predicted by TRISS methodology.

Significant reduction in delayed diagnosis of injury with implementation of a pediatric trauma service.

BACKGROUND: The occurrence of delayed diagnosis of injury (DDI) among pediatric trauma patients represents a breakdown in trauma care. Although some DDI may be unavoidable, the rate of DDI may be used as a measure of quality improvement. OBJECTIVE: We sought to investigate DDI in admitted pediatric trauma patients while a designated pediatric trauma response team was used and compare this with the prior incidence of DDI (4.3%) before initiation of the response team. METHODS: Primary Children's Medical Center (PCMC) is a regional tertiary pediatric trauma center. This analysis used the prospectively gathered PCMC Trauma Database, and included all hospitalized pediatric trauma patients from 1997 through 2000. RESULTS: A total of 3265 patients were included; no patients were excluded. A DDI occurred in 15 (0.46%; 95% CI: 0.31, 0.79) trauma patients. The DDI patients were more severely injured with significantly higher Injury Severity Scores, lower TRISS Probability of Survival values, longer hospitalizations (P < or = 0.05, Mann-Whitney U), and were more frequently admitted to the PICU (P < or = 0.05, chi2) than the non-DDI patient population. In a previous study, our incidence of missed injury was 4.3% (50/1175; 95% CI: 3.3, 5.6); with implementation of a designated trauma response team and trauma service, the incidence of DDI was reduced nearly 10-fold to 0.46% (15/3265; 95% CI: 0.31, 0.79). CONCLUSIONS: Implementation of an effective trauma team and trauma service was associated with a significant reduction in DDI.

Infant car safety seats and risk of head injury.

BACKGROUND/PURPOSE: We observed a high incidence of traumatic brain injuries (TBI) in properly restrained infants involved in higher speed motor vehicle crashes (MVCs). We hypothesized that car safety seats are inadequately protecting infants from TBI. METHODS: We retrospectively queried scene crash data from our State Department of Transportation (2007-2011) and State Department of Public Health data (2000-2011) regarding infants who presented to a trauma center after MVC. RESULTS: Department of Transportation data revealed 94% of infants in MVCs were properly restrained (782/833) with average speed of 44.6 miles/h when there was concern for injury. Department of Public Health data showed only 67/119 (56.3%) of infants who presented to a trauma center after MVC were properly restrained. Properly restrained infants were 12.7 times less likely to present to a trauma center after an MVC (OR=12.7, CI 95% 5.6-28.8, p<0.001). TBI was diagnosed in 73/119 (61.3%) infants; 42/73 (57.5%) properly restrained, and 31/73 (42.5%) improperly/unrestrained (p=0.34). Average head abbreviated injury scale was similar for properly restrained (3.2±0.2) and improperly/unrestrained infants (3.5±0.2, p=0.37). CONCLUSION: Car safety seats prevent injuries. However, TBI is similar among properly restrained and improperly/unrestrained infants involved in higher speed MVCs who present to a trauma center.

Source of admission and outcomes for critically injured children in the mountain states.

OBJECTIVE: To determine whether mortality and length of stay at a pediatric trauma center differ between patients admitted by interhospital transfer and those admitted directly from the injury scene. DESIGN: Analysis of prospectively collected data from a pediatric trauma center database. SETTING: A designated regional level I pediatric trauma center. PARTICIPANTS: Injured children from birth to 17 years of age hospitalized between January 1, 2006, and September 30, 2007. MAIN EXPOSURE: Incident in-hospital mortality rates and length of stay at the trauma center were compared between patients admitted directly and those admitted by interhospital transfer, controlling for potential confounders. OUTCOME MEASURES: In-hospital mortality and duration of hospitalization. RESULTS: Of 2192 patients admitted to the trauma center, 1175 (53.6%) were admitted directly from the injury scene. Patients admitted by interhospital transfer had higher injury severity and lower Glasgow Coma Scale scores at admission (P < .01). Of 31 deaths during the study period, 26 (83.9%) were among patients admitted by interhospital transfer. These patients had a 7-fold higher unadjusted incident rate of death (incidence rate ratio, 7.16; 95% confidence interval, 2.49-20.58) compared with those admitted directly. This finding remained (incidence rate ratio, 3.01; 95% confidence interval, 1.01-8.98) after adjustment for injury severity and Glasgow Coma Scale scores, elapsed time from injury until admission at the trauma center, and age. Among survivors, patients admitted by interhospital transfer stayed longer in the hospital than those admitted directly. CONCLUSION: Pediatric trauma center mortality rates are lower among children admitted directly from the injury scene compared with those admitted by interhospital transfer.

Utility of a cervical spine clearance protocol after trauma in children between 0 and 3 years of age.

OBJECT: Cervical spine clearance after trauma in children 0-3 years of age is deceptively difficult. Young children may not be able to communicate effectively, and severe injuries may require intubation and sedation. Currently, no published guidelines are available to aid in decision-making in these complex situations. The purpose of this study was to determine whether a safe and effective protocol-driven system could be developed for clearance of the cervical spine in noncommunicative children between 0 and 3 years of age. METHODS: Children 0-3 years of age, including intubated patients, who were admitted after trauma activation at Primary Children's Medical Center in Salt Lake City or the Children's Hospital of New York from 2002 to 2006 were managed according to a cervical spine clearance protocol. Data were collected in a prospective fashion. Radiographic and clinical methods of clearing the cervical spine, as well as the type and management of injuries, were recorded. RESULTS: A total of 2828 pediatric trauma activations required cervical spine clearance during the study period. Of these, 575 (20%) were children

Hyperglycemia and outcomes from pediatric traumatic brain injury.

BACKGROUND: The clinical significance of hyperglycemia after pediatric traumatic brain injury is controversial. This study addresses the relationship between hyperglycemia and outcomes after traumatic brain injury in pediatric patients. METHODS: We identified trauma patients admitted during a single year to our regional pediatric referral center with head regional Abbreviated Injury Scale scores > or = 3. We studied identified patients for admission characteristics potentially influencing their outcomes. The primary outcome measure was Glasgow Outcome Scale score. RESULTS: Patients who died had significantly higher admission serum glucose values than those patients who survived (267 mg/dL vs. 135 mg/dL; p = 0.000). Admission serum glucose > or = 300 mg/dL was uniformly associated with death. Admission Glasgow Coma Scale score (odds ratio, 0.560; 95% confidence interval, 0.358-0.877) and serum glucose (odds ratio, 1.013; 95% confidence interval, 1.003-1.023) are independent predictors of mortality in children with traumatic head injuries. CONCLUSION Hyperglycemia and poor neurologic outcome in head-injured children are associated. The pathophysiology of hyperglycemia in neurologic injury after head trauma remains unclear.