February 2024 - Pediatric Trauma
February 2024
EAST Monthly Literature Review
"Keeping You Up-to-Date with Current Literature"
Brought to you by the EAST Manuscript and Literature Review Committee
This issue was prepared by EAST Research Committee Member James Byrne, MD, PhD, EAST Manuscript and Literature Committee Members Brian Yorkgitis, DO, Caleb Butts, MD and EAST Member Ramitha Eshan.
Thank you to Haemonetics for supporting the EAST Monthly Literature Review.
In This Issue: Pediatric Trauma
Scroll down to see summaries of these articles
Article 1 reviewed by James Byrne, MD, PhD
A Pediatric Teletrauma Program Pilot Project: Improves Access to Pediatric Trauma Care and Timely Assessment of Pediatric Traumas. Eldredge RS, Moore Z, Smit J, Barnes K, Norton SP, Larsen K, Padilla BE, Swendiman RA, Fenton SJ, Russell KW. J Trauma Acute Care Surg. 2023 Jan 10.
Article 2 reviewed by Brian Yorkgitis, DO
Whole Blood hemostatic resuscitation in pediatric trauma: A nationwide propensity-match analysis. Anand T, et al. J Trauma Acute Care Surg. 2021 Oct 1;91(4):573-578.
Article 3 reviewed by Caleb Butts, MD
Pediatric Cervical Spine Injury Following Blunt Trauma in Children Younger Than 3 Years: The PEDSPINE II Study. Luckhurst CM, et al. JAMA Surg. 2023;158(11):1126-1132.
Article 1
A Pediatric Teletrauma Program Pilot Project: Improves Access to Pediatric Trauma Care and Timely Assessment of Pediatric Traumas. Eldredge RS, Moore Z, Smit J, Barnes K, Norton SP, Larsen K, Padilla BE, Swendiman RA, Fenton SJ, Russell KW. J Trauma Acute Care Surg. 2023 Jan 10.
Trauma is the leading cause of death among children in the United States. While mortality is greatly reduced for children treated at specialized pediatric trauma centers (PTCs), most children do not have access to PTCs owing to geographic constraints. For this reason, the ACS Committee on Trauma encourages PTCs to assume leadership within their regions and to partner with non-PTCs to provide optimal care. Telemedicine is one effective tool through which pediatric specialist evaluation can be performed, possibly avoiding unnecessary transfer, and allowing children to stay closer to home. In their paper, Eldredge et al. report a 4-year experience (2019-2023) with a teletrauma program implemented at their level 1 PTC. In collaboration with the State Pediatric Network, teletrauma consultations were offered to hemodynamically stable pediatric patients (<18 years) at partnering hospitals (PHs) in their region. Recommendations regarding need for transfer, treatment, and follow-up were made. Quality of care was ensured through daily virtual rounding by the PTC trauma team. In their analysis, all patients that received teletrauma consultation were reviewed. Avoidable transfers were also evaluated, defined as patients transferred to the PTC without teletrauma consultation who were discharged within 36 hours without intervention. Cost analysis was performed to estimate the potential savings due to the program.
Over the 4-year period, 151 teletrauma consultations were performed for trauma. The number of consultations increased from 1-2 to 4-7 consultations per month over the study period. The median distance to PHs was 34 miles (11 PHs were >100 miles from the PTC). The median age of patients evaluated by teletrauma consultation was 8 years (IQR 3 – 12 years). Head injuries were most common (70%). Teletrauma consultation resulted in avoidance of transfer in 97 (64%) cases. Of patients not transferred after consultation, 54 (56%) were safely discharged from the ED, while 43 (44%) were admitted at the PH. Three patients required delayed transfer to the PTC due to worsening neurologic exam in TBI, worsening abdominal pain, and parent concern regarding care of globe rupture. No major complications or deaths occurred among teletrauma consultation patients. Of 4,000 transfers to the PTC that occurred without teletrauma consultation, 923 (23%) were deemed avoidable. PHs were more likely to transfer patients without teletrauma consultation if they were closer to the PTC (63% from PHs <100 miles from the PTC vs. 23% from PHs ≥100 miles from the PTC). Teletrauma consultations were estimated to save $4.3 million due to avoided unnecessary transfers ($3.1 million due to saved transportation costs). While this study represents the experience of a single institution that might not be generalizable to all systems, the authors provide a thoughtful description and analysis of a successfully implemented telemedicine program spanning 32 partner hospitals in 5 states over a large geographic area. They highlight both needs for improvement and potential cost savings of such a program. The study is evidence that carefully implemented telemedicine programs are viable means to improve resource use and overcome geographic disparities in access to specialized trauma care for injured patients.
Article 2
Whole Blood hemostatic resuscitation in pediatric trauma: A nationwide propensity-match analysis. Anand T, et al. J Trauma Acute Care Surg. 2021 Oct 1;91(4):573-578.
Early, balanced blood product resuscitation is recommended in the management of severely injured children that are hemorrhaging. With the advancement and further understanding of the benefits of whole blood (WB) transfusion in the adult populations, bringing this life saving therapy to the pediatric population is the next step. The advantages of single donor product rather than multiple donor component therapy are very beneficial in the pediatric population.1
Anand et al explore the use of WB in pediatric trauma resuscitation using the Trauma Quality Improvement Program 2017 database.2 They propensity match 135 patients receiving WB-CT (whole blood with component therapy) to 270 receiving only component therapy (CT) among pediatric trauma patient receiving transfusion in the first 4 hours after presentation.
There was no difference in patient- and center related variables. In the CT therapy population, all patients received at least a unit each of PRBCs, plasma and platelets. Patients in the CT group required higher volumes of PRBCs, plasma and platelets at the 4 and 24 hour point than did the WB-CT group. When examining massive transfusion protocol (MTP) thresholds of 40cc/kg in first 24 hours, there was a difference with 183 (67.8%) of CT patients verses 66 (48.9%) in the WB-CT) (p<0.001) receiving greater than this threshold. Thus, WB-CT transfusion requirement was less when looking at a variety of timepoints and MTP threshold. There were no differences in mortality, hospital length of stay and other major complications. The WB-CT group required less ventilator days (1[2-6] vs. 2[2-8] days; p=0.021).2
This study added to the literature for the use of WB among pediatric trauma patients. Pediatric patient receiving WB-CT received less total transfusion, thus decreasing their exposure to multiple blood products with its associated risks of antibody exposure, dilutional coagulopathy, increase time to transfuse multiple CT units separately, donors antibodies, citrate that can cause hypocalcemia and total volume received.1 It is not unexpected that this would lead to less ventilator days. Trauma centers should evaluate the feasibility of WB protocols for pediatric trauma patients in their centers.
- Russell RT, et al. Pediatric traumatic hemorrhagic shock consensus conference recommendations. J Trauma Acute Care Surg. 2023;94(1S Suppl 1):S2-S10.
- Anand T, Obaid O, Nelson A, Chehab M, Ditillo M, Hammad A, Douglas M, Bible L, Joseph B. Whole blood hemostatic resuscitation in pediatric trauma: A nationwide propensity-matched analysis. J Trauma Acute Care Surg. 2021;91(4):573-578.
Article 3
Pediatric Cervical Spine Injury Following Blunt Trauma in Children Younger Than 3 Years: The PEDSPINE II Study. Luckhurst CM, et al. JAMA Surg. 2023;158(11):1126-1132.
Cervical spine injury (CSI) is a rare traumatic injury in children with prevalence of 0.6 to 2%. Missed injuries carry an increased rate of mortality and potentially lifelong morbidity. While diagnosis relies on imaging, this is not without costs, in terms of radiation (for XR/CT), need for sedation (for MRI), or potentially prolonged unnecessary periods of immobilization. For older children and adults, there are cervical spine clearance tools (i.e. NEXUS and Canadian C-spine rule) that allows for clearance without imaging, but these rely on patients being able to communicate and participate in the exam. PEDSPINE was originally published in 2009. It used a logistic regression model to identify patients at risk for CSI based on four clinical factors that created a score of 0-8: GCS<14 = 3 points, GCS eye of 1 = 2 points, MVC mechanism = 2 points, and age>2 = 1 point. For patients with a score of less than 2, the negative predictive value of CSI was 99.3%, making additional imaging likely unnecessary. Despite its publication nearly 15 years ago, there continues to be widespread variability and, in some cases, overreliance on imaging. PEDSSPINE II looked to re-evaluate PEDSPINE with a more contemporary cohort, as well as develop new prediction models to guide imaging decisions.
Fifteen centers participated in this study, retrospectively enrolling more than 10,000 patients from a 10.5 year period. PEDSPINE scoring was performed for each patient. For the new prediction model, each injury was classified into one of three categories: 1) no CSI, 2) osseous (fractures/dislocations) injuries, or 3) ligamentous injuries/hematomas/spinal cord injury without radiographic abnormality (SCIWORA). Overall, 1.4% of patients had any CSI. Patients with CSI tended to have lower overall GCS, as well as lower scores for each component of the GCS. They also were more likely to present with a mechanism of MVC, pedestrian struck, or suspected abuse, and much less likely to present after a fall. When testing PEDSPINE, the overall AUC was 0.81, down from an AUC of 0.92 in the original study. This was attributed to a higher rate of CSI and increased use of MRI in this cohort. In comparison, the newly developed PEDSPINE II model had an AUC of 0.90 in all-comers, and 0.89 in patients that would not have automatically received imaging based on history or physical exam alone. In addition, the PEDSPINE II model provides risk assessment for the presence of each type of injury outcome (i.e. no injury, osseous injury, or ligamentous/hematoma/SCIWORA). The availability of this data could potentially allow for more tailored use of imaging to identify the most likely type of injury (i.e. ligamentous injury in non-accidental trauma). The authors write that they hope to make PEDSPINE available as a handheld application that would aid with clinical decision-making at the bedside, though it does not seem to be currently available. CSI in the youngest trauma patients remains a rare and challenging pathology.
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