Pediatric Trauma With Dr. Richard Falcone
With Dr. Richard Falcone · hosted by Dr. Todd Ponsky · StayCurrentMD
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What the experts said
Cincinnati Children's Hospital is a Level 1 pediatric trauma center verified since 1993, seeing approximately 2000 patients per year.
At Cincinnati Children's, the ED physician serves as team leader for all traumas, chosen because they are present when the patient arrives.
The ultimate risk of C-spine injury in pediatric trauma is actually pretty low.
Approximately 90% of children admitted in C-collars can be clinically cleared the next morning when they are less distracted and not in the trauma bay.
Getting CT early in kids with normal neurologic exam and persistent tenderness is not useful because you won't feel comfortable removing the collar based on imaging alone without clinical improvement.
There is enough evidence now that you don't need to get an X-ray on every awake child without distracting injuries and no midline tenderness.
The challenge in pancreatic trauma is determining whether there is a duct injury or not, which is the number one question and concern.
There is more and more evidence that if you have a true duct disruption, a distal, ideally splenic-preserving distal pancreatectomy early is better treatment for grade 3 pancreatic injuries.
ERCP has advantages (potentially therapeutic with stent placement) and disadvantages (risk of inducing pancreatitis by injecting dye), while MRCP doesn't have the pancreatitis risk.
Conservative management of pancreatic duct disruption can work and pseudocysts are manageable and drainable, but this approach takes longer with more TPN time and longer hospital length of stay compared to early pancreatectomy.
Centers that perform frequent pancreatic operations and are comfortable with laparoscopic distal pancreatectomy are more likely to have good outcomes with surgical management of pancreatic trauma.
There is more of a trend toward considering operating on pancreatic duct injuries more frequently, and if you're going to do it, you want to do it within the first 24 hours.
If you go in to operate on pancreatic trauma and find parenchymal injury but not ductal disruption, you should just drain and get out rather than proceeding with distal pancreatectomy.
Cincinnati Children's was more likely to do skeletal surveys and involve social services for low socioeconomic status or minority children with head injuries compared to middle/upper class non-minority families.
Abuse happens in all races and all socioeconomic bands, though economic stress does add some risk.
Cincinnati Children's implemented universal screening: any child under 2 admitted with a head injury from an unwitnessed mechanism (not witnessed publicly, not motor vehicle collision) gets skeletal survey and social work evaluation.
After implementing universal screening criteria for non-accidental trauma, the percentage of positive abuse cases remained at nearly 50%, despite evaluating more children, indicating the protocol was finding previously missed abuse cases.
A screening test that gives nearly a 50% positive rate of abuse is more productive than most screening tests we do for other things.
Families find universal non-accidental trauma screening more reassuring because it's easier to say 'we do this for every family with this type of injury' rather than making it seem like a judgment about the specific family.
Ophthalmologic exams are not routine but are obtained if the skeletal survey is positive or if there are other concerning findings like bruising or abnormal head findings that don't fit the given story.
Abnormal LFTs greater than 150-200 indicate a good chance of some sort of abdominal injury, but normal LFTs provide very little evidence that you're safe, so they may be useful as screening but not for ruling out injury.
Cincinnati Children's has gone away from getting LFTs, amylase, and lipase as routine; they only get them if there are other indications to scan (abdominal bruising, tenderness).
Normal labs don't prove you don't have an abdominal injury, they just make us feel better and give a false sense of security.
FAST is great for hypotensive patients to determine if they have blood in their abdomen, which is the classic reason FAST was developed.
A negative FAST in a stable, healthy child may still miss injuries if you trust it too much.
At Cincinnati Children's, it has been 4-5 years since they used angiography/embolization for a solid organ injury, though they use it for pelvic trauma and other reasons.
Angiography for solid organ injuries is used more often at adult centers, and there has been a trend of embolizing when seeing a blush or bad injury rather than waiting to see how the patient does.
There is no good evidence that seeing a blush on imaging mandates intervention; a blush puts you at higher risk for needing intervention or transfusion but doesn't mean you will need it.
You can mobilize children with solid organ injuries much more quickly from bed rest than originally outlined in Stylianos's paper, without the slow progression that was initially recommended.
There is growing support for less lab draws, shorter length of stay, and less bed rest for solid organ injuries in children.
Cincinnati Children's protocol for solid organ injuries: grade 1 gets one 12-hour lab check, grade 2 gets two checks, grade 3 gets two checks or possibly a third based on clinical exam.
Grade 1 isolated spleen injuries may not even need hospital admission because they never get transfused and never have problems.
The Trauma Association of Canada Pediatric Subcommittee published evidence-based C-spine clearance recommendations in the Journal of Trauma 2-3 years ago, emphasizing clinical exam as the first test.
For children greater than 8 years with normal X-rays and normal neurologic exam, re-examination is recommended; if the repeat exam is normal, the C-spine can be cleared without further imaging.
CT or MRI of the C-spine should only be considered for patients with abnormal neurologic exam findings.
A multi-site study published in Journal of Trauma around 2009 developed a point system for C-spine injury risk in children under 3: 3 points for GCS <14, 2 points for GCSI score of 1, 2 points for motor vehicle collision, 1 point for age 2-3 years.
Children under 3 with a C-spine risk score of 0 or 1 had a 0.0% chance of C-spine injury and don't need imaging.
Children under 3 with a C-spine risk score of 7 or 8 had about a 21% chance of having a C-spine injury and need imaging.
Pediatric Level 1 centers were getting C-spine CTs only 17% of the time compared to adult centers which were getting them 24-45% of the time, indicating adult centers are doing too many CTs overall for pediatric patients.
There is literature showing that if you see someone who looks like you and is from the same neighborhood, you're less likely to be suspicious of child abuse even with the same injury pattern, compared to someone from a lower socioeconomic group or different racial/ethnic background.
The Pediatric Emergency Care Research Network published criteria in Annals of Emergency Medicine 2013 identifying children at very low risk (0.1% chance) of clinically important blunt abdominal injuries: no abdominal wall trauma, GCS 14-15, no abdominal tenderness, no thoracic wall trauma, no abdominal pain, no altered breath sounds, and no vomiting.
If the very low risk criteria were followed strictly and everyone else was scanned, it would actually recommend more CTs than pediatric trauma centers are currently doing.
Eric Scaife from Utah published that FAST was being used to screen low-risk kids but was giving false sense of security because of the low sensitivity of FAST, which is very user-dependent like any ultrasound test.
Dr. Stylianos's 1999 paper with the American Pediatric Surgical Association Trauma Committee was a landmark paper that changed how everyone managed spleen and liver trauma, and adult trauma surgeons followed pediatric surgeons' lead.
Sean St. Peter and the Kansas City group published papers showing we can shorten bed rest windows: grade 1 and 2 solid organ injuries need at most overnight (12 hours), and maybe two nights for grade 3 or 4 injuries.
By shortening bed rest for solid organ injuries, you can cut down significantly on length of stay without having readmissions or complications.
There is growing evidence that very few grade 1 solid organ injuries, if any, are going to need a transfusion, so all the lab draws initially outlined in Stylianos's paper probably aren't necessary.
Dennis Bensard's group from Colorado presented at Western Trauma Association proposing not doing any lab draws for solid organ injuries if the patient is clinically OK (not tachycardic, no pain, no vital sign changes), using labs totally as directed by physical findings.
A multi-center prospective analysis published in 2012 examined pediatric trauma activation criteria, finding that the American College of Surgeons' 6 required criteria are generic, adult-based, and lack strong evidence.
The multi-center study matched activation criteria to resources used (intubation, blood transfusion within 30 minutes, chest tube within 30 minutes, CPR within 30 minutes, OR within 60 minutes) rather than ultimate injuries sustained.
The evidence-based trauma activation criteria identified were: penetrating wound to head/neck/torso, age-appropriate tachycardia or poor perfusion, receiving blood prior to arrival, systolic BP <90 or age-appropriate hypotension, 40 mL/kg fluid prior to arrival, respiratory distress or failure, and GCS ≤8.
Using the evidence-based 8-9 criteria resulted in an over-triage rate of 39% and under-triage rate of only 10%, with the break point being around 8 or 9 criteria where adding more criteria lowers under-triage but increases over-triage.
Brooke Lerner led a recent Journal of Trauma paper using the Delphi method to formally define high resources justifying trauma team activation, including ICU stay greater than 48 hours and other criteria from the initial multi-center work.