Trauma
With Dr. Rich Falcone · hosted by Dr. Todd Ponsky · StayCurrentMD
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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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 trauma patients annually.
At Cincinnati Children's, the emergency department physician serves as team leader for all traumas, chosen because they are present when every patient arrives.
The ultimate risk of C-spine injury in pediatric trauma is actually pretty low.
At Cincinnati, 90% of children left in C-collars overnight can be clinically cleared the next morning when less distracted and not in the trauma bay.
Getting CT early in kids with normal neurologic exam and C-spine tenderness is not useful because clinicians won't feel comfortable removing the collar based on imaging alone without resolution of clinical tenderness.
There is enough evidence now that truly awake children without distracting injuries and no midline tenderness do not need X-rays for C-spine clearance.
For obtunded patients with severe TBI, Cincinnati's protocol is CT to rule out bony abnormalities followed by MRI if CT is clear, before removing the C-collar.
The primary challenge in pancreatic trauma is determining whether there is a pancreatic duct injury, which is the number one concern.
CT scans can show significant pancreatic injuries with large cracks through the neck, but ERCP or MRCP may still show the duct is intact, and those children will heal without surgery.
ERCP has the advantage of being potentially therapeutic with stent placement but the disadvantage of injecting dye that can cause pancreatic inflammation, a risk not present with MRCP.
Centers that perform frequent pancreatic operations and are comfortable with laparoscopic distal pancreatectomy have better outcomes operating on pancreatic trauma; centers that rarely operate on the pancreas may put patients at more complication risk and should consider non-operative management.
Cincinnati implemented standardized screening where all children under 2 admitted with head injuries from non-publicly-witnessed mechanisms receive skeletal surveys and social work evaluation, eliminating clinician bias in screening decisions.
Before implementing standardized screening, Cincinnati was more likely to perform skeletal surveys on low SES or minority children with head injuries than on middle/upper class non-minority families with identical injuries.
After implementing unbiased standardized screening criteria, Cincinnati's positive abuse rate remained at 50% despite evaluating more children, indicating they were finding abused children who would not have been screened under the previous biased system.
A screening test with nearly 50% positive rate for abuse in admitted children under 2 with head injuries is more productive than most screening tests used for other conditions.
Families find standardized screening more reassuring because clinicians can explain it is done for every family with this injury type without making judgments about truthfulness.
Cincinnati does not routinely perform ophthalmologic exams for non-accidental trauma screening, only obtaining them if skeletal survey is positive or there are other concerning findings like bruising or abnormal head findings inconsistent with the given story.
Cincinnati has gone away from getting LFTs, amylase, and lipase as routine in trauma patients, only obtaining them if there are other indications for CT scan such as abdominal bruising or tenderness.
Cincinnati has not used angioembolization for solid organ injury in the last 4-5 years despite their high trauma volume.
Cincinnati's current protocol for solid organ injuries: grade 1 gets one 12-hour lab check, grade 2 gets two checks, grade 3 may get two or three checks based on clinical exam.
The Trauma Association of Canada Pediatric Subcommittee published evidence-based C-spine clearance recommendations emphasizing clinical examination as the first test, with imaging only if clinical clearance is not possible.
For children over 8 with normal X-rays and normal neurologic exam, the Canadian guidelines recommend re-examination rather than immediate CT, with CT or MRI reserved only for those with abnormal neurologic exams.
A multi-site study published in Journal of Trauma 2009 developed a scoring system for children under 3: 3 points for GCS <14, 2 points for GCS injury score of 1, 2 points for motor vehicle collision, 1 point for age 2-3. Scores of 0-1 had 0.0% chance of C-spine injury; scores of 7-8 had 21% chance.
In the multi-site study of children under 3, pediatric Level 1 centers obtained C-spine CTs only 17% of the time compared to adult centers which obtained them 24-45% of the time, indicating pediatric centers do too many CTs overall.
There is increasing evidence that true pancreatic duct disruption is better treated with early distal pancreatectomy, ideally splenic-preserving, for grade 3 injuries.
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.
The literature increasingly agrees that if operating for pancreatic duct disruption, it should be done within the first 24 hours, not as an immediate surgical emergency but within that window.
Literature shows clinicians are less likely to suspect abuse in families who look like them, are from the same neighborhood, and are from higher socioeconomic groups, even with identical injury patterns, compared to lower SES or minority families.
The PECARN study published in Annals of Emergency Medicine 2013 identified children at very low risk (0.1%) of clinically important blunt abdominal injuries: no abdominal wall trauma, GCS 14-15, no abdominal tenderness, no thoracic wall trauma, no abdominal pain, normal breath sounds, and no vomiting.
The PECARN study found that if their very low-risk criteria were followed and everyone else was scanned, it would actually recommend more CTs than pediatric trauma centers currently perform.
Abnormal liver function tests greater than 150-200 indicate a good chance of some abdominal injury, but normal LFTs provide very little evidence of safety and may create false security.
FAST ultrasound is very user-dependent and has low sensitivity. Normal FAST in stable healthy children may miss injuries if trusted too much. FAST remains useful for hypotensive patients to identify intra-abdominal blood.
Eric Scaife from Utah published that using FAST to screen low-risk children was giving false security due to the test's low sensitivity.
In the PECARN data, children with abdominal wall trauma (seatbelt sign, handlebar sign) or GCS <14 had about 5% chance of abdominal injury; those with only abdominal tenderness had 1.4% risk; those with only thoracic wall trauma, vague abdominal pain, or vomiting had 0.7% risk.
Adult trauma centers use angiography for solid organ injuries more frequently than pediatric centers, and there has been a trend of embolizing based on seeing a blush or bad injury rather than waiting to see how the patient does.
A blush on imaging puts children at higher risk for needing intervention or transfusion but does not mandate intervention. Literature supports that many children with blush do not require intervention.
Stylianos' 1999 paper with the American Pediatric Surgical Association Trauma Committee was a landmark that changed solid organ trauma management, with adult trauma surgeons following pediatric surgeons' lead rather than the reverse.
Sean St. Peter's group in Kansas City published papers showing grade 1 and 2 solid organ injuries need at most overnight observation (12 hours) and grade 3 or 4 injuries need maybe two nights, significantly shortening length of stay without readmissions or complications.
The original Stylianos guidelines recommended slow progression from bed rest to bathroom to ambulation, but current evidence supports mobilizing children much more quickly from solid organ injuries.
Very few grade 1 solid organ injuries require transfusion, so the lab draws initially outlined in Stylianos' paper are probably unnecessary.
Dennis Bensard's group in Colorado presented at Western Trauma Association proposing no lab draws for solid organ injuries if children are clinically stable without tachycardia, pain, or vital sign changes, using labs only as directed by physical findings.
Isolated grade 1 spleen injuries potentially do not need hospital admission because they never require transfusion and never have problems based on Cincinnati and Kansas City data.
A multi-center prospective analysis published in 2012 examined pediatric trauma activation criteria, finding that matching criteria to resources used (rather than injury severity scores) provides better over-triage and under-triage rates.
The American College of Surgeons requires 6 trauma activation criteria but they are generic, adult-based, and lack strong evidence. Centers often add 10-20 additional criteria based on individual cases, creating confusion.
The multi-center study defined appropriate high-level trauma activation as needing intubation, blood transfusion within 30 minutes, chest tube within 30 minutes, CPR within 30 minutes, or OR within 60 minutes of arrival.
Evidence-based trauma activation criteria identified by the multi-center study: penetrating wound to head/neck/torso, age-appropriate tachycardia or poor perfusion, receiving blood prior to arrival, systolic BP <90 or age-appropriate hypotension, 40ml/kg fluid prior to arrival, respiratory distress or failure, and GCS ≤8.
Using the evidence-based 8-9 criteria resulted in 39% over-triage rate and 10% under-triage rate. The break point where adding more criteria stops improving under-triage but increases over-triage is around 8 or 9 criteria.
A recent Journal of Trauma paper led by Brooke Lerner used the Delphi method to formally define high resources justifying trauma activation, including ICU stay greater than 48 hours among other criteria.