All right. Speaking of which, uh, Katie always teases me about my lack of knowledge of updates in trauma. We are gonna talk about trauma now, um, with, uh, Katie Russell, who is at Primary Children's in Utah, and Regan Williams, who is at Labanner Children's Hospital and is like a million incredible titles, by the way, and that's pretty impressive, uh, that's seeing be running the hospital soon. All right, so you're gonna be talking about updates and trauma. Looking forward to hearing this. Diamond, particularly at the end. All right, thanks for having us. We're gonna give you a couple of updates in pediatric trauma. The first is on vascular trauma, then we're gonna switch to DVT prophylaxis with Katie, and then we're gonna end with Reboa. And if you don't know what those letters stand for, we'll talk about it. So, our first case is a 16-year-old female who was in a motor vehicle accident and presented in shock to your emergency department. This is her imaging. She's a grade 5 splenic injury and a blunt grade 2 thoracic aortic injury. Think about what you would do. So in this room for her thoracic aortic injury, what would y'all do at your centers? Luke We're, we're gonna deal with the life-threatening issue first, right? I mean, obviously that that wasn't highlighted, but um. Oh yeah, I need the mic here. Deal with a life-threatening injury first, right? So take out the spleen if, if that has to happen. I know that that's like anathema. If there's head injuries and things like that, you could think about doing that, but deal with the life-threatening thing first, uh, depending on how they respond. And then I think you have to, it's a, it's a little bit of push pull. You'd like to use beta-blockers, you'd like to use, you know, uh, control, pressure control, um, of the, Aortic wall to help, um, but that may not be feasible if you're in an active resuscitation for this patient that's otherwise very sick and maybe concomitant injury. So, um, I mean, I think A would be my initial choice if the context allows itself. Who in the room would take out the spleen? Anybody, it's grade 5, right? Grade 5 spleen presents in shock. Hasn't gotten blood yet. OK, well, come on. That's actually a legitimate question because when we look at it, um, nationwide, the majority of splenectomies happen before they actually give blood. I mean, I know you wouldn't do that, but, well, I mean, I have, so in full disclosure, I've taken the spleen out in the last 5 years, but it was in a 17-year-old, or sorry, 15-year-old with a bad head injury and was getting resuscitated and not responding. So, good point. This patient became stable after blood transfusion, so we did not have to take out the spleen. However, we did take the patient to IR because of the splenic injury, and we didn't know about the thoracic aortic injury until they were in IR. Which was sort of interesting. So let's go to the poll and see what everybody feel like, oh yeah, sorry, thank you. OK, this is super awesome. So, 48% of people would do endovascular repair with stent placement, uh, 37% would do beta blockade. Um, C 13 are gonna repeat imaging and nobody would do an open repair on cardiac bypass. So, next slide, um, the super interesting, thoracic aortic injury is very, very rare in children, so you're almost never gonna see it. But in a national survey of what we do, actually about 67% were managed non-operatively, which kind of goes in line with what we saw in our poll. 27% were managed endovascularly and 6% were managed open. The important thing to note is that that non-operative management may not be the right treatment for children with these injuries because they may progress, um, and you actually have better outcomes with endovascular repair than non-operative management. So I think that that depends a lot on the age. My guess is that the people who are doing non-operative management, they're very small children, and they don't want to put a stent in them. What do y'all do? Well, you know, I was just thinking about it, um. It's a case by case basis. You know, it's so infrequent. And then there's also the questions about who do you call, you know, is this the cardiac surgeon that helps you? Is it the vascular surgeons from across the street? Is it IR? um, I think at our institution, it is not totally consistent. Yes, Reagan, can I ask you a question about, uh, you said that you didn't know this was there until the patient went for the embolization, presumably when they injected dye or something, you saw it there. So, is there an incidence of undiagnosed aortic injury in children that you're just missing when you say, you know, when we look at the data and that those kids are effectively managed non-operatively and do well? I do think that we do miss some of them. We actually had looked at the scans and it was, it was the radiologist review, like the attending radiologist 3 hours later that found the injury. Um, we just missed it when we looked at it. Um, but I do think that there are injuries we missed because children are really small and if they have like a little intimate repair, you may totally miss that. And then also, we've been pretty aggressive about trying to convince people not to scan the chest in kids. True, true. When should you scan the chest and kids? We could go on and on with this. We could, um, you need, so this would be my statement's gonna be controversial, but you definitely need to scan the chest if you're worried about the chest X-ray. So if you think that there is mediastinal widening on the chest X-ray, that is a concern for some kind of great vessel injury that definitely needs a CTA of the chest. Um, I personally, in the really sick kids, uh, where I wanna scan the neck and I wanna scan the belly, I personally scan the chest, though I know not everybody does that. Yeah, so this patient definitely got scanned because they were in shock. They had a slightly wide mediastinum on the X-ray, um, the mechanism, even though we said sometimes that's not important, um, and that's how we found the injury. Um, and this patient, I was on call and I called, we consulted vascular surgery to review and they wanted to do a stent, and I thought that was a terrible idea, so I called the main vascular surgeon and she was in Egypt and she said, no, Regan, it's OK. You can put a stent in them. And then I looked at this paper which is right here. It's a 10 year review looking at um NTDB data that actually shows TAR is. Very safe in children, um, that, um, you can that it decreases mortality. It's gonna decrease risk of spinal cord injury from doing an open procedure, um, and it gets them out of the hospital faster. Um, also, I've been working a lot with the SVS and the Society for Vascular Surgeons, and there's really small stents that you can use in children so you can deploy and get these things repaired. Um, and then this was a 16 year old. So 16-year-olds are really close to adults. Um, and if you look at the adult SVS recommendations, it would 100% be for endovascular repair. So if you have a patient with a thoracic aortic injury, I do want you to consider getting it repaired, and that might be interventional radiology. It might be vascular surgery. It's going to be different depending on what your hospital has. Was there an age that that paper went down to, or was it all children? So the paper, um, it did all pediatric children, but it was really weird and how it separated them because it did like almost like down to 2, but it also went up to 21 and then it made them like child, adolescent, and pediatric. I don't consider a 19 year old to be a pediatric patient, but that is what the paper did. But it did include the smaller children and when you looked at treatment, the younger children were more likely to be managed in operatively, but you can use in a vascular repair if you need to in those children. You just have to use a really small stin. So they have expandable stents now. Um, and you can actually, I don't know all this stuff, but I just listened to a vascular surgeon talk about it at VAM this year. And they had these expandable stents that they go in as they grow and they make them bigger with a balloon. Any other questions, comments? All right, we're gonna go on to our next one. All right, guys, I want to tell you about a 15-year-old who is in a high-speed motor vehicle crash, is hemodynamically normal with a hematocrit of 28 in the trauma bay, but he's got several injuries. He's got a 3 millimeter subdural hemorrhage that is stable on a CT scan 6 hours after injury. He had an operative pelvis fracture, and he's gonna be non-weight bearing for 6 weeks. Now, this might be black diamond. It might also be Very boring for some people out there, but we think it's important to talk about. So, um, you know, in terms of many of us went through general surgical residencies, and we know that we talk about DVT prophylaxis, right? And basically, every surgical patient that's in the hospital, we talk less about it in kids, but again, this is a 16-year-old that's had serious trauma and is going to be in a wheelchair for 6 weeks. So when should we start chemical DVT prophylaxis in this kid? Um, you know, I think we pretty much all believe that people should all have squeezers. You know, all adolescents should probably have squeezers in the hospital, but when should we give Lovenox or something like that? I'm curious in the room here because this is where I was schooled up by our trauma NPs, um, because I'm so afraid of giving anything. Um, I'm just curious, how do people respond to this in the room here? Any comments? Within 24 hours, you know, and that this is the, the, the big challenge is that the neurosurgical community is in large denial of the data. You know, that, that says that it's safe to do and that if you don't do it, you have big complications. The trauma world gets it. The literature is clear. I, I just don't understand what's the barrier in that world. And this is a, so this is a non-operative head, right? So it's a non-operative head, a very small head bleed, a kid who has like a GCS that is normal and now has a repeat head CT that is stable, um, but this is true for any time there is a. Uh, potential bleeding organ. When can you start DVT prophylaxis? Um, so, yeah, so we're getting some right now's in the audience. I think this question, um, really came out of a paper from the Midwest Consortium. So a bunch of you guys are in that. Does anybody want to give us, uh, the highlights of that paper? I'll highlight it for you though. I'm in the Western Consortium. Um, so Doctor Ehrlich, he was the senior author, and I, I think her last name was Witt, Amanda Witt or White. Um, so, you know, they looked at it and found that in trauma patients, if you gave DVT prophylaxis within 24 hours, um, so within 24 hours of injury, they are much, much less likely to get a DVT. Um, so I think our goal should be, and I don't know what you guys are doing, but our goal should be really to start within 24 hours. Yes, and what we do now is the trauma surgeon decides if the patient's gonna get DVT prophylaxis because we found that the neurosurgeons, they don't even necessarily say no, but they sort of like dance around it and then the PU decides that they're not gonna give it. And so we wrote the protocol that you just ask the trauma surgeon and what the trauma surgeon says is what we do. What about solid organ injury? You can absolutely give, uh, DVT prophylaxis and solid organ injuries, pelvic injury. Yes, I mean, I think once the patient's stable, and I think that's the thing that she said here, then say the tell me when I should not give it. I assess less than 25. You're smart, dude. Now, the, why would you say that, Luke? Yeah, why, why. We don't know the ISS, right? They're in the hospital for less than 25. Yeah, usually that's a retrospective thing. I mean you can calculate it, but nobody does that, uh, but, uh, the East guidelines, which are very, I think the best data we have, which is not great, and I'll be the first to admit pediatric guidelines in the, in the grade format tend to not be very robust because the data is just not there in aggregate, um, but they would suggest that for Adolescent patients with an ISS greater than 25, they need to get prophylaxis, and that's about all they can say. That is true. This is a 16 year old, so you can treat them like an adult if you want. Um. The pelvic fracture guys are not scared of DVT prophylaxis because they're all adult surgeons for the most part and like they've lived in this world of DVT prophylaxis for like way longer. So typically it's not the adult trauma, uh, the adult orthopedic trauma surgeons that are gonna give you a hard time about DVT prophylaxis. Some of the pediatrics. Orthopedic surgeons will, but it's just because they're like less familiar and they don't think it matters. I just would love you to send us like when I should not. I just am still wishy-washy on that. I, I get what you're saying, but when it comes on rounds the next day, I, I, you know, the question is, well, but maybe this case is different. Maybe so I think if the patient has A real risk of dying from bleeding for whatever reason, you should not give it. So if you have a head injury that's unstable that you're maybe gonna put an ICP monitor in, they have an ICP monitor, you're wondering if they need to get a cranny or not, should probably not give it to them. Grade 5 spleen. If you have a grade 5 spleen and you're actively transfusing them, you shouldn't give it. So it's really, but it's about the risk of bleeding, right, because that's what we're worried about. What we found in most children, they vasoconstrict very well. They're gonna stop bleeding. So if they don't have evidence of ongoing bleeding, then you're fine. We got 5 minutes left, so we'll rock on through. OK, here we go. Um, I did too just to bring up, Kenji made a great point at the Western Pediatric Trauma Conference about when a neurosurgeon has actually operated on someone. We probably really need to kind of respect that opinion because they were there and saw the bleeding, but in general, we're up here basically telling you guys that we as pediatric trauma surgeons should take more control over these things. These things can be like pretty well proto protocolized in pediatric trauma. So now we're going home, OK? So you were in the hospital, you started Lovenox, the kid's prophylaxis, but he's ready to go home. What are you going to send him on? Remember, he's in a wheelchair for 6 weeks. Aspirin, Lovenox, Coumadin, some kind of a new generation DA. Silence. Comments. Surgeries transplant. So we've translated anyone who needs, can you say that again? So, uh, do a lot of liver transplants and then rec shunts and other shunt vascular operations, and we've completely switched over to DOA, uh, easier to adapt, easier to kind of manage for family. They don't have to get the coaching for low molecular weight heparin injections and such. It just makes life easy for them. Is that prophylactic dosing or therapeutic dosing? Both, both. Would anybody use aspirin? So this is, um, very interesting. So, you know, about 25% of people are gonna go aspirin, um, and about 25% people DA, and then a lot of Lovenox, right? So I think everybody knows, but the downside to Lovenox is that it is an injection, um, and this would be totally black diamond and really kind of questioning the group of, is this something that we can get behind? Um, but if you go to the next slide, there was a well-done adult study that was published in the New England Journal of Medicine. And again, this is 100% adult data with adult trauma patients that had orthopedic injuries. So, So it was a randomized controlled trial where they looked at 6000 adults and they gave them aspirin and 6000 adults and they gave them Lovenox. And what they found is that aspirin was non-inferior to Lovenox in terms of DVT prophylaxis in that patient population. So, I mean, if we think about pediatric trauma, we will never get the numbers needed to figure that out in a randomized fashion. Um, but, you know, I'm questioning, I think a lot of us are questioning, in these kids, can we put, they're 16, right? They're 16 years old and have a pelvic fracture. Can we send them home on aspirin 81 mg BID? That's most likely going to be, uh, followed way more than these Lovenox shots that we've been doing historically. So, comments? It's important to clarify if it's a baby, baby aspirin. Or uh what dose of aspirin they're using. And some kiddos don't respond to the aspirin the same way. So you have to do a platelet aggregation study to really see, um, you know, if your aspirin is being effective. So that is probably true when you have a shunt that you want to stay open. Probably not so true when we're looking at DVT prophylaxis for non-ambulatory teenagers. Great point. So I will, to be provocative, we have started discharging kids on aspirin, um, realizing that that is, you know, taking some adult data that is not perfect, um, but it's, it seems effective and it's a lot better than Lovenox and some of these kids and a lot better than nothing also, I think. Yes, we also discharge on aspirin and our orthopedic surgeon started doing that a year or so ago. Comments or questions. All right. All right, we have 2 minutes. 1 minute. This is gonna be really fast. 16-year-old shoots herself in the abdomen while cleaning her rifle. She is hypotensive and near arrest despite massive transfusion. What are you gonna do? Next step in management? Raise your hand if you're gonna do an ED thoracotomy. OK, nobody Who's gonna do a reboa? Also nobody, laparotomy. I got some a lot of laparotomies MTP. Most of the people in the room aren't going to do anything. Let's see what the poll says. Yeah, you can. Yes, yes, yes. Um, so 50% would do laparotomy. We have 23% for roboa and 18 for ED thoracotomy. That's a lot of roboa. That is a lot of roboa. So roboa, resuscitative endovascular balloon aortic occlusion. Um, here's the data. It can be used in. Children, it's not super, super effective. We don't do a lot of this in a pediatric hospital and so to do it very quickly in a patient population that you don't do it in very often is going to be very, very difficult, but you can do it if you have that at your center and you're very, very good and facile at it. Um, but the things that you really need to think about for this are two things. This is the Western guideline that's a Western PTS and East sponsored that looks at a pediatric emergency resuscitative thoracotomy and when to do it. So this would be the patient to do it if you could not get them to the operating room to actually control the source of bleeding. The second is the adult version of damage control, um, therapy for hypotension and shock, and you can see Reboa is actually under hemorrhage control. Um, and so it is an option, um, but it depends on what you have available at your center. The most important thing for this child is that you recognize shock and you treat it as quickly as you can in the most controlled environment, which at my hospital would be in the operating room doing a laparotomy. Have people in the room done roboa? Nope. It's, it's real hard to get access if you're not facile with cut down on a, a dead patient. Yeah. It's, it, it seems to me to take longer than opening the abdomen or the chest if you're just needing to cross clamp the aorta. It, yeah, it does show some, it looks some sort of survival advantage in adults, but also those patients were not as sick if you look at the main trial. So there isn't a clear survival advantage for using Roboa even on the adult side. So certainly not over to the kids' side. Thanks y'all. Thank you everyone awesome. Thank you. Um, I love this, and, in fact, um, just to show you, um, when was the, when was the Western in July, I, I was lucky to, to attend the trauma, Western Pediatric trauma meeting, and there was a conversation about BCBI. Remember, I didn't even know what that stood for, uh, 12 years ago, blunt cerebrovascular injury and this concept that, you know, there's a protocol for knowing when you should be imaging patients for risk of, of blunt cerebrovascular injury. I didn't know anything about it. Was it a week after 2 kids came in from, this was in Akron, 2 kids came in with a high-speed motor vehicle crash, and both had the shoulder strap, bad injuries on the skin on their neck. So I texted everyone, I don't know if I copied you and Mira and everyone. I said, so wait, I should be getting a, and I followed the protocol. I don't know if everyone has these algorithms, but it was amazing how a week after I put it right into practice, and those kids got better care because of your conference. So thank you.
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