Trauma

This is Todd Ponsky, editor of Stay Current in Pediatric Surgery. In today's podcast, we'll be discussing current concepts in pediatric trauma. But before we get into today's podcast, here's a review of last month's podcast on Hirschprung's disease with Doctor Mark Levitt, Previously on Stay Current. But I can tell you that I personally have changed my practice over the last few years. And I don't do leveling colostomies anymore. I have done permanent biopsies, but a diversion at the at an ileostomy and wait for permanent section, which is much more accurate, and then at some point down the road, do your pull-through. Mark, what pull-through technique do you use now in your practice? More recently, um, I have started to Do trans anal Swensen. You know there's a lot of controversy with the laparoscopic approach. That's the approach that I prefer. What are your thoughts on that? I know there's a lot of controversy. Well, I mean, laparoscopy is a fantastic adjunct to Hirschprung's disease. I think the controversy really becomes, do you apply laparoscopy to all Hirschprung's patients, or are there somewhere in which it's to do transanal only. My feeling about this has definitely changed because I've seen a lot of morbidity that has resulted from an overly aggressive transanal-only approach. So to confirm that you are out of the transition zone, you need your pathologist to tell you that your nerves are less than 40 microns. That's correct. Stay Current is an audio publication designed to keep healthcare professionals up to date with standards of care and new emerging ideas. These podcasts are designed to keep healthcare professionals current while on their commute. Stay Current is created and edited by Todd Ponsky and Nicholas Bruns in partnership with Globalcast MD and is recorded and produced at Akron Children's Hospital in Akron, Ohio. Welcome back to Stay Current in Pediatric Surgery. Today we're going to be talking about one of the more common problems that people face in our field, and that is trauma. And it seems like it's an ever changing field with every day a new, a new standard of care, and we have none better than really one of the experts in the country in the world on pediatric trauma, and that's Dr. Rich Falcone. Who is director of trauma services at Cincinnati Children's Hospital. He's associate professor of surgery at University of Cincinnati. Rich, thanks for joining us today. Yeah, thanks for having me. This is great. Well, let's, let's jump right into it and actually I want to ask you, Rich, can you tell us before we jump into things, can you tell us a little bit about your center, what kind of volumes you're seeing there, and what kind of trauma center you have there in Cincinnati? Yeah, absolutely. So we are, we're a Level 1 pediatric trauma center, freestanding hospital. We've actually been verified since 1993 consistently. We see about we're approaching 2000 patients a year here. That's great. Let me ask you, who runs your traumas down there? Is it the emergency room or the surgical team? Yeah, so we've, we've gone back and forth as a lot of centers I'm sure have done over the years. Right now with our focus on teamwork, we've decided and come to an agreement that actually the ED physician is our team leader role for all of our traumas. Came to that after, you know, several back and forths, but really in the end it was who's there when the patient gets here all the time. That's great. And actually, Here at Akron Children's Hospital we do the same thing. We've now moved it so the emergency department does take the lead, so. Um, well, let's, let's jump right into things here, Rich, and, and this is something that I think is probably the one topic that I really wanted to get a better understanding of, and it seems like it's changing frequently, and that is C-spine clearance. Can you take us through your thoughts on sort of the new standards of care or how you'd sort of summarize C-spine clearance and what is the role of CAT scan? Uh, and how you would go about clearing a child's C-spine. Um, I think there's a couple things that that we've learned. One is the, the ultimate risk of injury is actually pretty low, um, and C-spine, a C collar is often a useful adjunct, um, uh, that gives you time. So if you have a, if you have a kid in a, in a C collar, there's no, there's generally no rush to figure out, do they have an injury. So one of the things that I'll go into some other, you know, some recent literature, but one of the things that we do. Um, not infrequently at all, is leave a kid in nursing collar, and we admit them to the hospital in nursy collar. I would say 90% of those kids the next morning, um, when they're, they're less distracted, they're not in the trauma bay, um, we can, we can clinically clear. The C-spine on rounds the next morning. That's true for young kids, older kids, and these are, we'll talk about first kind of the normal GCS kids or the kids that are at least cooperative enough to do that from a from a head injury standpoint. But most of those kids we can do. We also have gone with our emergency room. Of sending some sending kids home in their collar, follow up in our trauma clinic with our nurse practitioners in a week, and they clear them, um, clinically there. So we've, we've really through that practice really minimized our use of CT. OK, Rich, so what I'm hearing you basically say is that when in doubt, it's great to leave the C collar on these children. Correct. OK, so can you go a little more into when you would be using CT to evaluate the C-spine in children? The, the kids that can cooperate, I mean, we very rarely now will do a C-spine CT, um, but that, that's really supported more and more by the literature, as you know, and we want to minimize. radiation in these in these kids and they're really kind of two recent papers that I think have talked to us and become a little more of our go to standard. One was done by the Trauma Association of Canada Pediatric Subcommittee. And they published this in the journal of Trauma 2 or 3 years ago now, but they did an evidence-based review of of spine clearance in children and really came out with some recommendations, the best best you can with the current evidence. Uh, essentially they do, uh, what I'm, what I'm kind of describing to you already is, is rely heavily on your, your clinical exam, number one, and they kind of go through an algorithm which is, are you able to clinically clear the C-spine? That's your first test if you're able to do that. You don't need any other, you know, you don't need any other imaging. You can, can clear them right there if you're not, then they go on recommending your, your normal lateral, um, kind of more standard AP and lateral X-rays, um, if you have those, they're normal and you have a normal neurologic exam. Um, and the kids greater than 8, their recommendation fits pretty much with what I've been describing, which is what we do is reexamine them. If you have a normal X-ray and you're able to re-examine them and their exam is now normal, you clear them. If they have an abnormal neurologic exam, that's really the only branch point there that goes to consider CT or MRI. So they have an abnormal neuro exam, they, they're going to get. It, you know, a CT or an MRI and get your spine surgeons, whether they're neurosurgeons or orthopedic surgeons involved in their, their, uh, care. OK, so I would like to repeat this cause I think this is an important point. If they have any tenderness at all, or you don't think you can trust your exam, then you get an AP and lateral film to make sure there's no bony injuries. And going along with that theme you said before, keep them in the collar and re-examine them the next day. And that the only time you should be getting a CAT scan if there are hard signs of a spinal cord injury or any neurologic spinal deficits, is that right? Correct. What if they have tenderness on exam? If they have an abnormal exam where they just have tenderness but not neurologic findings, those are kids that you can go on and get a flexion, you know, consider your flexion extension in or in our environment, most of the time we'll, those are the kids we'll leave in the collar and reevaluate them. A day or or up to a week later, but if you can do that because sometimes you try to do those flexion extensions early and the kid's too tender, too scared, and you get inadequate films anyway, um, and the same with CT if you get a CT early and the kid's still having tenderness, you're not gonna feel comfortable, um, taking them out of that collar um with just that image. You wanna have both the imaging and and some uh clinical findings that say they're not having tenderness anymore so we found that. Getting that CT early in kids with the normal neurologic exam really wasn't useful and that's what their evidence-based data would say. So let me see, make sure I understand, uh, and so let's, let me just take some examples and you'll guide me through it now so. A 10 year old motor vehicle crash comes in. He was at a sea power place just because that, that's how, just because of the mechanism. And, uh, he comes in. He's got no real obvious distracting injuries. He's looking at you. He's talking normal. He's got nothing obvious. Can you just clear him clinically without getting any films right there in the trauma bay? Yes, I think you have to be, you have to trust your clinical exam and you have to trust, you know, your comfort level with that. It's not point, not midline tenderness, I think, and sorting midline versus some lateral tenderness or stuff that's less, you know, more musculoskeletal. But I think if you have a true, truly awake kid with Distracting injuries. There's, there's enough evidence now that you don't need to get an X-ray on it, even a plain X-ray on every one of those. OK, so, so that patient we could considerably, you know, consider if he's that kind of patient doing just a clinical exam and clearing him and. Maybe even sending him home if he had nothing else going on. What about the patient who is either frantic or has a distracting injury? That's the one where you might wait, you might get, I think I understood that you would get maybe your lateral film and then wait till the next day to do anything further, correct? Yeah. So our general practice in those would be we'd get, we'd probably end up getting an A. And lateral and let the kid go to the floor because generally those are kids that are going to get admitted anyway, leave them in their collar, and most of those kids we can they're now calmed down the next morning, get a good exam, and get them out of the collar the following morning, OK? And the, so then tell me again of all those criteria you explained, which is the group of patients that would get a CAT scan. So the kids that have abnormal neuro neurologic findings, when you say neurologic findings, you mean spinal neurologic problems, correct? Correct, OK, correct. So and those have become pretty clear, are the kids that truly have point, you know, point tenderness along their midline of their C spine would have a higher chance of going down. Now the suspicion, so the high suspicion. You're going to get a CAT scan. Yeah, I think the bottom line is trust your clinical exam, and I think we've, you know, across all pediatric surgery, probably in all adult surgery, have gone away from trusting your clinical exam and falling to imaging. So I think it's the same rules for pediatric traumas. I mean, these kids can give you a reliable exam no matter how, you know, anxious and distract them and as Pete. Surgeons, we do that all the time for appendicitis, you know, distract the kid and get a good exam. We can do the same with our trauma patients. And just to clarify, the CAT scan is really only looking at the bony abnormalities, correct? Yeah, correct. And for the patients that you're going to either get your plain films and observe and you examine them the next day and they are tender. That's the patient that with no neurologic findings. That's the patient you would maybe get a flexion extension or send home with a C collar, correct? Yeah, so we'll send them home with the C, we'll almost more commonly as an inpatient, send them home with that C collar before doing the flex because if they still have muscle tenderness and they're tender, we know they're going to give us an inadequate. You know it's going to be an inadequate flexion extension, and our radiologists are not going to be comfortable giving us a definitive answer, so we actually will send them home with some pain control and then have them see him back and if we at that point we can't clinically clear him, we'll usually get the flexion extension, OK, and you see them back in about 1 week, about 1 week, yeah, and that's our nurse practitioner clinic. Perfect. And I've spoken to some people that are much more liberal with getting MRIs. Do you incorporate that into your practice? We, we have only used, so we'll use MRIs for pundits. Our severe TBI patients will move to an MRI, will get an MRI before we clear those kids, because, and those are the kids that you're, you're not going to have a normal exam to be able to clinically clear them within a few days or a week even. And those kids will end up getting a CT of their C-spine to make sure there's no bony abnormalities. If that's clear, we actually move on to an MRI, and that's what most of the pediatric literature would say. It's not 100% clear, but most, I think most centers are doing it that way. The adult literature, they're getting a little more away, and East recently published a guideline that said you can clear even those a ton of patients with just the CT. Um, but I think most pediatric folks, and I don't even know that most adult folks are really following that protocol yet, OK, so an MRI would be there. So, so in that patient who has a bad head injury, they come in with their C collar, you're going to probably get the CT MRI combo, CT for bone, MRI for soft tissue and cord, and ligaments. And if you see nothing on either of those, you'll go ahead and take that collar off on that patient, correct? We'll take the collar off. And the other thing that we do. Um, and I think this works from a, you know, efficiency in getting them to the, the severe TBIs, getting them to the ICUs. We actually don't, we don't even bother even though we know there might be a high likelihood that we're going to be scanning their C-spine at some point. We don't do that during the initial resuscitation. We'll scan their head and probably C1 and C2 as part of their head scan. Um, and then get them to the ICU and manage their head injury because we know that almost all of those kids are going to go back down for a follow-up head CT in the next 24 hours when they're usually a little more stable, you know what's going on, and then we spend that little bit of extra time to scan their neck, OK. Um, so for the purpose of bullet points at the end of this discussion, I just want to make sure we got this. We're talking about, and to say it again, I just said it before, but I'm going to say it again. So a patient over 3 who comes in who has no concerns of distracting injury, they're and they're awake and alert and You examine them, you potentially could do that clinically without radiography radiography. A patient that has any concern or that you could not or may not get a reliable exam, you're going to get an AP and lateral film and likely observe them overnight and more than likely if they're still tender the next day, send them home in a sea cow. For a week follow-up evaluation, correct. And at that point if they're tender, you might get a flexion extension. Exactly, OK. And in the obtunded patient you're going to get likely a CAT scan to evaluate the bones and likely an MRI to evaluate the soft tissues, correct? Now it's easy. And the other group that people get challenged on are the young kids, the under 3 group, and we were part of a kind of a multi-site review, retrospective review. Um, that was done, I think that was published around 2009, um, in the Journal of Trauma also where we, we looked at clinical clearance, uh, for blunt, this is all blunt trauma patients, but those under, under 3 years old. And really kind of came up with some criteria that can help you at least put kids into a higher or lower risk group of where you need to be worried and essentially for that under 3, it gave the system we came up with in that paper was giving them, giving them points um for so you get a you get points, um, 3 points if you had a GCS less than 14, 2 points if you had a GCSI score of 1, 2 points if you were in a motor vehicle collision and 1 point if you were between 2 and 3 years old. And essentially what that found was if you only had 0 or 1 points using that scale, you had a 0.0% chance of having a C spine injury and really didn't need much, much in the way of imaging. On the other hand, they found that if you had a score of 7 or 8 in that, you had about a 21% chance of having an. Injury. Um, and so where, where you each fall as a center and you're experiencing comfort level in those scores between 1 and 7, I think 7 and 8, it's pretty clear they need imaging. Um, they have a high risk of injury, scores less than 10 or 1, pretty clear they don't need much more, but a lot of kids are going to fall in that gray zone. I think that's then where your clinical judgment and following what the Canadian group has described the following, following an algorithm. Um, to minimize that. Interesting in that study that I'm just talking about, they actually also looked at. You know how often CTs of the C-spine were being done and because it was multi-site, it was also multi, you know, there were Level 1 ped centers, there were Level 1 ped centers and adults hospital, freestanding adult trauma centers, and then Level 2 adult trauma centers all contributed data for this. And interestingly, just from a benchmarking standpoint, the PES Level 1 centers were only getting CTs. 17% of that time compared to the adult centers which were anywhere from 24 to 45% of the time depending on their level and their partnership with the PH center or not so clearly if you go benchmarking we're doing a lot too many CTs overall for these kids and I think you have to just take it in a stepwise fashion. Repeat that again for me for the chase. So, so we, so we are pretty, I mean we're pretty comfortable here I think for the most part still if they don't have the head injury, um, clear, even clearing some of those clinically right off the bat if they're, you know, appropriate age appropriate, and, and, you know, doing normal even if it's an infant, um, getting them cleared without, without imaging. But the, the paper that we, we were part of, um, really said if your GCS is less than 14, you've been in a motor vehicle collision, your GCSI score is 1, is is only a 1, you're now in a higher, should be considered in a higher risk group, and it we didn't, weren't able to say in that paper that means you need a CT, but that means you need to be screened more carefully whether that starts. Films or proceeds to CT and the study again, this is the Canadian study that did that stratification. So that's that stratification for the kids under 3 was led by a by a group, the group from Mass General actually led that study, and that was adult and teed centers all combined data, and I think ended up with 12,000 patients younger than 3 to create that. Um, it's, uh, it's clinical clearance of the cervical spine in blunt trauma patients younger than 3 years, Multi-center study of the American Association for the Surgery of Trauma, and that was Journal of Trauma 2009, September 2009. And perfect. And that that that paper for the child that's under 3 helps to stratify them into high or low risk and it helps make a clinical decision, you know, when I go by in the morning and I see these children that are little babies and I go to try to clear their C-spine. I was once told that you can go ahead and take off their collar if you push on their neck and they don't go crazy. You watch and see if they move their head left and right, and that's sort of a way of clearing them. Is that, is that accurate? Yeah, that's pretty much what we do, yep, OK, great. That's pretty much how we do it as well. All right, well, I think that was a great summary of C-SPine. Well, let's totally shift gears here and go to a different part of the body now. So now you have a 12-year-old who was riding his bike. We actually had this patient come in last night. And had a handlebar injury and the patient comes in and he's hemodynamically stable. He's complaining of some abdominal tenderness. I'm sorry, he's complaining of some abdominal pain and he has abdominal tenderness. You see a mark in his epigastrum. You get a CAT scan and it shows evidence of a possible neck of the pancreas injury. There's some fluid around the pancreas and no free air uh and uh no thickened loops of bowel. How would you manage that patient? So I think the challenge in pancreas trauma is really trying to figure out is there a duct, a duct injury or not. I think that's, that's your number one, your number one question and your number one concern, and I think there's still debate out there in the literature, and, um, and in fact, there's the group from Texas Children's is actually now trying to get together. A study, a prospective randomized study to start looking at who we should operate on or who we should not and how we determine that with pancreatic trauma because the literature is, is mixed and it depends honestly which paper you read and and and where you've trained as far as how aggressively folks feel about operating on these or not. There is though more and more evidence that if you have a true duct, true duct disruption, that a distal, ideally a splenic preserving distal pancreatectomy. Um, early is, is better treatment and that would be for the, you know, with the grade 3 spleen injuries. Now the challenge is that's easy to say, but Clinically, it becomes hard to always know based on your CAT scan. The kids can have pretty significant injuries, um, and we've had several here that look pretty bad, and then we get an ERCP or even an MRCP now, um, and despite the, the big crack through the neck of that pancreas, the duct is vis visualized and intact. And those kids will heal. It's the ones that have a duct disruption. So I think it's a matter of can your can your CT definitively show that, or do you need to move to an MRCP or an ERCP. And the ERCP has advantages and disadvantages. The advantages you could potentially even put a stent in, so it's potentially therapeutic as well. The disadvantages, as we all know, is you're injecting dye into that duct and you, you run the risk of getting their pancreas angry and, and inflamed, um, as a result of the test which you don't have that risk with your MRCP. So I think it depends on. Who you have access to at your center, um, which, which one of those routes you need to go down, but the challenge is figuring that out. There's data that's a conservative management can work even if there is a duct disruption. They may get a pseudocyst, but those are manageable and drainable. But there's also data that says that takes longer, more TPN time, more hospital length of stay. As opposed to that I can say that's generally been our practice up until until recently, um, where we're considering more, um, pancreatectomies, but, um, but we do see we do have kids that stay for a while and then but they get out of an operation. The other side of that is we've also had kids transferred to us who've had a distal pancreatectomy and we managed their, their, their duct leak in their pancreatic fistula for a while. So there's both sides of that. So I think that's the reason to continue to study this question as to what's safest and best, and I think some of it's going to come down to, um, as we all know, you know, who, how often do we do pancreatectomies and who's doing that pancreatectomy and if. You're someone who feels comfortable and does a fair number of operations on the pancreas, then you're probably going to have a good outcome from operating on more of these kids. If you're someone who I haven't operated on the pancreas in in years, and now this kid with pancreatic trauma, I'm going to go in and try to do a distal pancreatectomy, and you may be at more risk and put them at more complication risk, and that's part of the problem with the studies that have happened so far. The ones that say distal pancreatectomy are a good thing are done at centers that. and especially laparoroscopic distal pancreatectomies or centers that have folks that are very comfortable operating back there laparoscopically or very comfortable operating on the pancreas, do it all the time. The center that doesn't do it that often is not likely to have those same outcomes and maybe in the patient's best interest to manage it non-operatively. So, you know, I know this is not, uh, it's not great to be anecdotal, but, you know, I, I have vacillated. I used to do, believe in non-operative management. I've tried ERCP stenting, and those patients in my experience have seemed to be more of a challenge than early surgery. I think where I've really gone wrong is being indecisive and sort of going at like day 3. I think you either operate or you don't, but going in that middle ground was when I found myself in trouble. Yeah, and I think that's absolutely right. I think that's what more and more of the literature's, you know, agreeing exactly what you're saying on both accounts. More there, there is more of a sway towards um considering operating and operating more, more frequently, um, and but there's also the, if you're going to do it, you want to do it within that 1st 24 hours. I mean, it's not, it's not your true surgical emergency. You've got to go right from the trauma bay and make that decision, but. Um, you want to get your data whether it's via ERCP or via MRCP. Is your duct really disrupted, or do you have enough information on your CT and make your decision in that 24 hour window, OK, and, uh, you know, briefly, um, you know, I, I know that when, when I've done. My splenic splenic preservation, I've taken like a little ligature and just sort of divided the little vessels off the splenic. Is that how you do it? Do you pull it off of the splenic vessels? Yeah, that would be, yeah, and we honestly, to be frank, we don't do very many, which is Um, I, I think we're probably gonna start trending more, more data, but, um, I, I think it's a, it's a trend. I mean, we've, um, you know, as a group, we've written on non-operative management of these, um, more than we have operatives, so, uh, but it is a, it is a trend, and I think there's more and more data that says, yeah, if you know you have that duct disruption, go in, go in early and get it done. Got it. Now it's, it's, it's interesting if you go in and you look like, uh, you know, you go in to operate and you see that. There's parenchymal injury, but it's not a ductal disruption. Would you then just drain and get out, or would you go ahead and do your distal pancreatectomy? No, we would just drain and get out. OK. All right. The next question is more of a a social issue, but also something that we're faced with a lot, and that's screening for non-accidenal trauma in children that have a head injury. I know that being at different institutions we've managed it differently. Can you tell me the process you go through in screening these children? Yeah, absolutely. So we, we've looked at the data both our own and um and what's published by by others about screening and One of the things that that we struggled with is who's making that decision to that which kid needs to be screened and it and how much bias, how much bias there exists around that decision. So there, there is literature that says, well, if I, if I see someone who looks like me and, um, is from the same neighborhood as me, um, I'm less likely to, to be suspicious of them as, as abusing their child, even with the same injury pattern. As someone who may be from more typically is from a lower SES group looks different than me from different racial or ethnic background, folks are, whether we admit it or not, are more likely to screen those kids, and we were doing the same thing when we pulled our data. If you were low, low SES or you were a minority. Um, child with a, with a, a head injury, even of a mild, um, head injury, so a skull fracture that gets admitted, we were much more likely to, to do a skeletal survey, get our social services involved, and evaluate those kids, um, than we were the middle upper class, um, non-minority family. The, the literature supports that there may be some higher risk in the socially, um, stressed groups. Economic, uh, stress does add some risk, but abuse happens in, in all, in all races and all socioeconomic bands. So, we've gone to a pretty consistent, if you are admitted. Um, to us, and now we're working with our emergency room to, to expand how, how everybody gets it consistently, but where we had most control was the kids that got admitted. So if you're admitted to us with a child under 2 with a head injury, and that could be postconcussive, that could be a severe TBI, um, that could be a linear skull fracture, and your mechanism was something that was not. Witnessed publicly and we specifically characterized that because we didn't want it to be what was witnessed by mom and her boyfriend or dad and the babysitter or we wanted it to be, you know, the kid was at the supermarket and someone saw them fall out of the grocery cart. That's, that's a witness or they were in a motor vehicle collision. That's a witness in a public location. Everything other than that. We got, we get skeletal survey and get our social worker to evaluate the family. Um, across the board and by setting up that guideline one, we eliminated that disparity of who was getting screened, but interestingly our percentage of positive abuse remained consistent. So despite evaluating more kids, we would, you would have expected if you increased your denominator, um, you know, your percent positives, you know, positive abuse rates are going to drop. We actually didn't see that. We saw it stayed exactly the same, which to us, and I think implies that. There were, we were finding kids that we probably wouldn't have screened before that were being abused and in fact in that population we're finding almost 50% positive abuse. Now it's a biased population because they've had enough injury to get admitted to the hospital. Um, they're not your your outpatient type thing, so they're probably a little more. At risk in general. But to me, for a screening test that gives you a nearly a 50%, you know, positive rate of, of abuse, um, that's more, that's a more productive screening test than most screening tests we do for other things. So wait, Rich, I want to repeat this because I think this is fascinating. What I think I hear you saying is that originally, you only screened those who you found suspicious, and the incidence of child abuse was 50%. And then you said, you know what, let's. Have standard screening criteria and take any bias opinion out of it so that any child under 2 years of age that had a head injury of any sort. That was unwitnessed got screened for child abuse just like those that you found suspicious, and when you did that. They also had a 50% incidence of child abuse. In other words, that group that you originally felt were not suspicious for child abuse had the same incidence of child abuse as those that you did feel were suspicious, so that we should be screening any child under the age of 2 that has an unwitnessed head injury, is that? Exactly. So these kids are unfortunately at high risk, and, and we need to be ever, ever aware, not let our, our kind of personal biases get in the way of, of who we do or don't, um, don't evaluate for non-accidental. And families find it. More reassuring now with our new system, and it's easier, quite honestly, for us to be able to say we do this for every family with this type of injury. We're not making any judgment about you. We're not making any judgment about whether you're telling us the truth or not. This is our standard to make sure we don't miss injuries and keep kids safe. The families are reassured by that. I really like that. In fact, I can see that that's something that I'm going to recommend we start here. It's easy to tell the family. Anyone under 2 with a head injury is going to get this workup. Um, what about, do you get ophthalmologic exams? So we don't do that as a routine right now. We get that if the skeletal survey is positive, if the social worker or we have other reasons that we're particularly worried there's other bruising, there's other abnormal head findings that make that don't fit with. Given story then we will get that but that's not part right now that is not part of our routine screening. It'd be interesting to see if one or the other or even adjunctively, um, collectively they worked together so you a higher rate and it's interesting. I don't have all the the data or all the expertise on this, but our, our child abuse experts are actually working on a. Um, a study where they're looking at kind of organized social questioning and and some key answers within that that are are may may actually in fact be better screening than the skeletal survey because they're finding there are key terms or key situations that um that can light up as a as a risk factor, um, so there'll be more to come on that one, but it's an interesting whole field of of screening and sadly we need to worry about it all the time. Um, let's move on to a different question. So can you talk to me about, uh, when a patient comes in with blunt abdominal trauma, I've, I've always wondered the accuracy of this. Can you talk about what labs you get and how they help you and, and when do you use FAST in these patients? It's a great question, and it's, it's a challenging question, and um there's several groups, the PCA and the Pediatric Emergency Care Research Network, they've done a lot of work on, on this topic of kind of who to screen and what tests to use, um, and, and that actually their most recent publication came out in the Annals of Emergency Medicine in 2013. Um, identifying children at very low risk of clinically important blunt abdominal injuries, and that was an interesting and good study. They did a couple of things that a lot of the other studies did not do, and that was really define clinically important blunt abdominal injuries because, you know, to say, well, we used a screening test and we missed a, you know, minor grade one spleen injury, is that, you know, is that enough to justify that all those kids needed scanned, but. Um, but they looked at this and really came up with a stratification again for who's at really low risk and what tests, and interestingly they didn't use labs or fast in order to do this. They said if you have no abdominal wall, evidence of abdominal wall bruising, seatbelt sign, that handlebar sign that you had, you had a normal GCS score, 14 or 15, really. You had no abdominal tenderness. You had no thoracic wall trauma. You had no abdominal pain. You had no alteration in your breath sounds and you had no vomiting. You had a 0.1% chance of having an intraabdominal injury. So they classified those as very low risk of clinically important abdominal injury and said those kids, you meet all those criteria, you don't need to be scanned. What no one's really looked at well is, OK, if you have one of those factors, do all of those kids still need to be CT scanned? And I would say and even that that paper found that in fact if they followed the rules that they came up with and scanned everyone who wasn't in the very low risk group, they actually would be recommending more CTs than what what we're all doing, you know, those of us at pediatric trauma centers are doing already. So if you're at the very low risk, you probably absolutely don't need a scan. If you're above, if you have one of those findings, there may be some kids that don't need a scan, and we, we at Level 1 centers and Level 2 centers and places that have access to a pediatric surgeon probably aren't scanning them. Um, all of those kids. Now, labs have been, have been shown to be kind of very variable, um, positive abnormal LFTs greater than, you know, 150 to 200, and it's pretty good that you have a good chance of an injury of some sort. But if they're normal, there's very little evidence that that means you're safe, so they may be useful as a screening. So if you say, well, I think they're at pretty low risk. I want to do one more test to help me feel a little more comfortable, I think that's where people are using it. But we have gone away from getting LFTs, amylase lipase as a routine. We only, if we have other indications to do a scan, so we have abdominal bruising. We have tenderness and we're going to scan that kit anyway because of the concern with those. We, we've found that there's not any value in the literature of getting those labs. The only ones we get labs on are, I don't think they need a scan, no one thinks they need a scan. We do them, and I have to say we're starting to get a little bit away from that because of the high, you know, it gives you a false sense of security. I think normal labs don't prove that you don't have an. Injury, they just make us feel better. Eric Scaife out in Utah recently published on the FAST the same thing that they were using FAST to screen the kids they thought were low risk, and when they looked at it, they were really just giving themselves a false sense of security because of the low sensitivity of FAST, and it's very FAST is very user dependent, just like any other ultrasound test. Now FAST is great if you have a hypotensive patient. Um, that you're really looking for the, the, as I'd say, the classic reason that FAS was developed, the hypotensive patient you're trying to prove, do they have a bunch of blood in their, in their abdomen or not. Those are, those are still the kids that fast is going to be, going to be helpful. Um, a negative fast in, in a kid that's otherwise stable and healthy literature would still caution you that there's a you may miss stuff if you trust that too much. So I just want to summarize here. So in a patient that has one of those criteria that you mentioned, then you would get a CAT scan. Well, what they, what they were careful to say is if you had none of those criteria, you don't need a CAT scan, but they were very careful in saying just because you have one does not mean you have to get a CAT scan. I see. So they were identifying the group that didn't need a CAT scan by having like these 0, right? If you had 0 of those predictors, you did not need a CAT scan is what they were saying. So then who does need a CAT scan? If you had, you know, so if you were. If they looked at it, they, if you had abdominal wall trauma, meaning a seatbelt sign, a handlebar sign, um, you know, or your GCS was less than 14, um, you had about a 5% chance of abdominal injury. So it allows it allows you to have a little bit more. Judgment. OK, I know there's a 5% chance, and are we going to observe this kid? Do I feel comfortable with that risk, if you will, um, if you didn't have that, but you just had some abdominal tenderness, your actual, what they found was your risk was down to about 1.4% of having an intraabdominal injury, um, that needed some sort of intervention. Again, their interventions were as little as IV fluids for 24 hours, um. And if you just had, you didn't have any of those and you just had thoracic wall trauma, a little vague complaint of abdominal pain, or some vomiting, your risk actually was only 0.7%. So again, it allows you to use that. If you had none of those, your risk was only 0.1%. So it doesn't tell you who, but it gives you, it allows you to have a little bit more judgment and. Balance those factors and summarize for me again who you believe that labs would maybe affect your management. I think to me it would be a kid who has really pretty vague, vague symptoms, vague mechanisms. So I fell off my bike. I have a little bit of, I have a little bit of belly pain, but I don't have any bruising. I'm hemodynamically stable. I'm not tachycardic. Um, I want to go, you know, parents, and I want to send the kid home. I'm going to maybe send those labs just to be that one more test and adjunct, and if those labs come back negative, I'd probably feel comfortable sending them home. If they came back positive, then that brings me back down the CT path, right? OK, that's interesting. Um, let's move on to a different topic and still along the. Idea of solid organ injury. So you know, in the adult population they're using a lot of angio angiography for solid organ injury. Tell me, you know, I don't know, we don't seem to do so much with children. When, what is your use of that in children? Yeah, ours, ours as well is, is extremely limited. Um, in fact, even given our volume, I can't think in the last 4 or 5 years when we've, when we've embolized for a solid organ injury. Now we use it, we've used it for pelvic, um, trauma and other reasons, but for a solid organ injury, it's probably been 4 or 5 years since we've used it. And I think where it gets used more often than pediatric trauma centers where you and I, you know, spent more of our time at is at adult centers who do angiography for adult patients more often. I think there's been more, there had been, and I think it's hopefully reversing some, but this trend of if I see a blush or I see a bad injury, I'm going to embolize rather than wait to see how the patient does. Um, and I, I think there's no good evidence. And in those small kids, you actually may be putting them at more risk of an injury from, from angioing them, um, or from making, knocking out most of their spleen anyway and losing any benefit of not doing the splenectomy in the first place, um, by doing that. Um, well, we found this a blush puts you at higher risk for needing an intervention or needing a transfusion, but it doesn't mandate that you're going to need it. I saw plenty of kids that have a blush, and there's, I don't think I have that paper here, um, handy, but there's plenty of, there's paper support that a blush does. Not mean you need to intervene. Um, so I think we have to be careful, and I think it's probably even more so for our adult counterparts who are used to thinking about Angio more frequently than we are in the Ped world that are willing to pull that trigger. And I think it's also, if I don't have the, if I'm at an institution that doesn't have the resources to keep an eye on that kid as well as I'd like overnight. I might sleep a little better if I embolize them, knowing I wouldn't be able to react as quickly if that blush turned into something, and that's been the argument from some smaller centers around the country who don't have the same resources as a level one, you know, I know that a lot of us use Dr. Stiganos's paper as a guide to understanding how to manage solid organ injury. Has that changed? Should we still be following those rules? Yeah, I mean, I think that was, that was clearly, you know, a landmark paper really back in, I think it was 1999 that they originally published that with the absolute trauma Committee, and it really, you know, changed how we all managed spleen trauma and in fact and solid organ liver trauma, and in fact, it's one of the things that as surgeons we can be proud the adult trauma surgeons have followed, followed our, our suit as opposed to the other way around. Um, so it was great. I think more and more though we're all realizing and and Sean St. Peter and the group in Kansas City have published a couple of papers on this now that we can probably start, we can start shortening those those windows. The length of time at bed rest for the grade 1 and 2 probably at most need to be overnight, one night, that 12 hours or so. Um, and maybe two nights for those kids with grade 3 or 4s. Now grade 5s gets a little more complicated and then and and more challenging. You have to do it individually by patient, but they found by doing that you can cut down significantly your length. Stay for these kids and not have readmissions, not have complications from that. We kind of anecdotally have gone back and looked at our series as well, and even without changing our guideline, we realized we were starting to do that because we were seeing these kids that looked, you know, so good and you were keeping them in bed doing nothing that we started liberalizing. We also, I think the original guidelines talked about, you know, a slow progression up the bathroom first and then, and then ambulate, and then, you know, the slow progression. Um, and I think what Sean Saint Peter and their group found and what we found, um, here locally is that you can move these kids a lot more, more quickly, um, from mobilizing them. There's also growing evidence that very few of these grade ones, if any, are going to need a transfusion. Um, so all the lab draws that were initially even outlined in, in Stiligiano's paper, um, probably aren't, aren't necessary, um. There was a a presentation from the group in Colorado, Dennis Bensard and their group at the Western Trauma Association meeting that that really was starting to propose don't even do any lab draws if they're clinically OK, if they're not tachycardic, they're not having pain, they're not having any vital sign changes, don't, you know. Use your labs totally as directed by your your physical findings. Now I'm not sure and your tachycardia, I'm not sure everyone's willing to to go to that level yet. There's probably a little need for some more data on the no lab approach, but um, there's definitely growing support for less lab draws, shorter length of stay, and, and bed. For these kids, so you know, some of the things you mentioned were, you know, sort of suggestions such as grade 1 or 2, overnight, grade 3 or 42 days. Do you have a protocol that you're using now, an abbreviated protocol at Cincinnati, and, and or is there an article that proposes a protocol? Yeah, so we, we do, we do have a protocol that I can share with you and and get for you. Um, there's also, um, Sean Saint Peter. The group has published theirs. I'm trying to see if I can find that, um, that because I think it was, it was in the Journal of Pediatric Surgery in 2011, um, and Sean Saint Peter was the, uh, the first author on that, um, that looked at and published their protocol which is is pretty similar, um, to ours here in Cincinnati, um, but yeah, really trying to continually shorten that but obviously balance that with what's safe and there's even. People talking about the grade one isolated grade one spleen injuries even potentially need to be admitted to the hospital because we've, you know, we've looked at our data and I know Sean has looked at their data. They never get transfused. They never have a problem. Um, if that's their only injury, they might not need to even stay in the hospital. OK, um, and so you are you checking the labs about every 12 hours? We, we, we've gone to the low grades. We do one grade ones we'll do 1 12 hour check and that's it. Um, grade 2 we'll do 2, and then, um, and then that's it, um, and grade 3s we generally, we may do 2 based on their cli only 2 based on their clinical exam, um, or do, do a third one, OK. Um, just before we finish here, can you give me a brief, your brief assessment of our trauma activation system, the high level traumas? Is there evidence behind that system, or is it arbitrary? So there's there's evidence that a tiered system is valuable. There's definitely support for a tiered system of activations within, and this is talking about not who goes to a trauma center. But if they're coming to your trauma center having a different level, so we all, we all are at least used to a two level, some places have a 3 level tiers, and then ours is a 3 level. We have lowest acuity is just the ED sees them and calls us if they need it. Mid level is ED and a and a surgery resident and a couple other folks, and then the highest level is an attending the OR staff, anesthesia and ICU all respond to it, and we started looking at this a few years ago saying. You know what is the evidence for which criteria we're using to tell us which kids to to activate um for that highest level and they're all different strategizing ways to say, well, are you over triage and under triage and people use things like injury severity score um. What injuries they ended up having, we decided to look at this and we did this with the, I think it was a total of 9 other Pete's trauma centers back and published this, when did we publish that 2012, that it was a multi-center prospective analysis of pediatric trauma activation criteria, and we really wanted to look at the ACS, the American College of. Surgeon says there's 6 criteria that you have to use, but they're generic. They're adult-based, and even those, if you really go looking for evidence, there's not wasn't a whole lot of evidence, and they also say that you need to use these 6, but each center could add on whatever other criteria they want based on their individual decisions. And what we were doing and what I think a lot of centers would do would be. Oh, we had a kid last week that came in with this random stray injury, and we should have activated that at our highest level. We didn't because it didn't meet any of our criteria. So let's add that to our criteria. And there are centers that were having 10 to 15 to 20 criteria and things would get confused. So we wanted to look at. What about if you matched up criteria to resources used because your high level team uses a lot of resources, you know, it takes your attending surgeon away it takes it and it's depending on your system takes an anesthesiologist away, takes ICU, takes nursing, um, and really ties up a lot of resources, potentially puts an OR on hold, whatever your system may may call for, and we want to say let's look at it based on cri you know, resources, so we said. We're going to say it was an appropriate triage if you needed things like an intubation. You needed blood transfusion within the 1st 30 minutes. You needed a chest tube within the 1st 30 minutes. Some obvious, you know, you were getting CPR within that 1st 30 minutes. You needed to go to the OR within 60 minutes of arrival and matched up the criteria with that. And in doing that we were able to. Identify criteria that increased your trance and gave you a better over and under triage rate, and we really came down to penetrating wound to the head, neck, or torso age, age, tachycardia are evidence of poor perfusion, receiving blood prior to arrival at your institution. Um, systolic blood pressure less than 90 or age appropriate hypotension, got 40 mLs per kilo of fluid prior to arrival. Any respiratory distress or failure, GCS less than or equal to 8 as the criteria. And by doing that we were able to really kind of bring down, um, bring down some of our over triage, and it's always OK to have some over triage in order to not miss, but also. Correct our under triage problem and and get things closer. I mean, we, we found that doing this we would have had a under over triage rate of 39% and an under triage of of only 10 10%. Now we also looked at this. There, there's no doubt the more criteria you add, the lower your under triage rate's gonna be. You're not gonna ever under triage anybody, um, but you're gonna. Have a much growing higher triage and that break point was around 8 or 9 criteria. So I think there's still work to be done there, but I think matching it to resources as opposed to what injuries you ultimately have and I was fortunately we've just published another paper that I was a part of in the journal of trauma by the lead authors Brooke Lerner. That really used the Delphi method to look at more formally defining what should be considered high resources that justify that activation of that high level team um and it's a lot of things that we did in our initial paper, but a couple others meaning ICU stay for greater than 48 hours was in there um and and a few other pieces, but I think we need to continue to look at that because I think right now there's some evidence in our work is some of that. Um, but there's a lot of room for more evidence and, and the next level to that is how does, how do we get that information from EMS and our pre-hospital providers because it's great to come up with these criteria that we use, you know, pediatric trauma center or recommend people using, but if the pre-hospital providers can't provide us that information or can't get that information accurately because they don't see enough kids, well, it doesn't, it doesn't help our, our system and it delays getting the kids the right care. Um, so I think there's lots of room for that to get better, yeah, and that would be fantastic for, for us to have some sort of data-based system. Let me ask you, uh, real quick, who, who comes to your, your higher level activations? The entire, does the anesthesia and the OR team come in for that? Yeah, so we have in-house, um, anyway, but our for our highest level activations, um, anesthesia. Responds, it's definitely a surgery fellow or a pending response anesthesia, an OR OR nursing person responds down to that an ICU fellow or nurse respond and nurse respond to those that are all additional people, and we also get blood products for those kids, OK. Well, uh, Rich, I appreciate you taking, uh, time out of your day to do this. This has certainly been some high yield information and, uh, I think, uh, all of us really appreciate uh you sort of focusing in on some of the things that we're all sort of unsure about as the data is ever changing. So, uh, thank you very much and uh I hope you have a good rest of your day today. Thanks again. All right, Rich, take care. We hope you enjoyed today's episode on stay current in pediatric trauma. I know that Dr. Falcone wanted to invite everyone listening to the 2nd annual Pediatric Trauma Society meeting being held in Scottsdale, Arizona, November 5th through November 7th. There's also a call for abstracts which are due on May 15th. You can sign up for the meeting or submit your abstracts at www.pediatrictraumaSociety.org. We hope you enjoyed this episode of Stay Current in Pediatric Surgery. Download the Global Cat MD podcast app to receive notifications when new podcasts are released and to send comments or questions to other listeners or faculty. Also subscribe to the Global Cat MD podcast. We'll see you next time.