Article 1
Efficacy and Safety of Intranasal Fentanyl in Pediatric Emergencies: A Systematic Review and Meta-analysis. Alsabri M, Hafez AH, Singer E, Elhady MM, Waqar M, Gill P. Pediatr Emerg Care. 2024 Oct 1;40(10):748-752.
It has been established that pediatric patients do not have the same physiology as adults, and thus require special consideration for their trauma management. Notably, determining the best analgesia for pediatric patients with goals to minimize invasive procedures as well as medication adverse effects is key to optimizing pediatric trauma care. Numerous recent studies have demonstrated comparable efficacy and safety of intranasal fentanyl (INF) when compared to a long-time standard, intravenous (IV) morphine. Benefits of INF include avoiding IV access if not otherwise needed, as well as faster onset and shorter duration of analgesia. However, there has yet to be a consensus on preferred analgesia for pediatric emergency patients. Thus, the authors performed a systematic review and meta-analysis of the current studies of INF for analgesia in pediatric emergency patients. Importantly, they adhered to the Cochrane Handbook and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. They included studies with patients <18 years old, that compared INF with placebo or other analgesics, and pain scale assessments in the emergency department. They screened 3994 studies, excluded 3944 and fully assessed 50 studies. Of those 50, 42 did not meet their study question, and thus a total of 8 studies were included for review and meta-analysis.
The 8 studies were all randomized controlled trials and included a total of 806 pediatric patients (65% male). Of note, not all patients were trauma patients – with noted non-trauma mechanisms including vaso-occlusive sickle cell crisis, acute moderate to severe pain, and painful infectious mouth lesions. Though, other cited indications were acute extremity injury, isolated limb injury, closed long-bone fractures. The authors do not describe each of the 8 studies in detail for us to understand which studies contained trauma patients, which is a limitation as we seek to apply their findings to trauma patients. Nonetheless, the authors found that INF was superior to other analgesia comparators for decreasing pain at 15-20 minutes from administration, though there was no difference in pain scales at 30-60 minutes. In terms of adverse events, INF had a reduced pooled relative risk compared with alternative analgesia, though the authors noted the pooled studies were heterogenous for this outcome, which may limit the validity of this result. Additionally, INF had lower relative risk for nausea and vomiting, but there was no significant difference for dizziness or hallucinations. The limitations of this study pertain to the included indications for INF, as well as a lack of detail of the comparator medications used in each study. That said, the methodology and statistics utilized were sound. Overall, this meta-analysis provides a high level of evidence that INF is a safe and non-inferior analgesic in the pediatric emergency setting, including for traumatically injured patients.
Article 2
Comparison of helicopter and ground transportation in pediatric trauma patients. Ciaraglia A, Lumbard D, Murala A, et al. Pediatr Res. 2024 Jan;95(1):188-192.
The discussion of transportation to definitive care among trauma patients is an ongoing one, and oftentimes studies are limited when it comes to pediatric-specific needs. Ciaraglia et al notes that the use of helicopter emergency medical services (HEMS) is supported in the literature as compared to ground emergency medical services (GEMS) or private vehicles in pediatric populations for its significant decrease in time to arrival in definitive care — citing Odetola et al from 2015 that showed that children who arrived to their level 1 pediatric trauma center within 60 minutes as opposed to beyond 60 minutes were 13-fold more likely to be transported by air than by ground — but the mortality benefit remains in question. That being said, there are many factors that play a role in selecting transportation method seeing as not every patient can feasibly have or warrant transport via HEMS. The authors note that over-triage raises questions regarding cost-effectiveness and resource utilization when making such decisions.
Thus, the authors used the National Trauma Data Bank (NTDB) to determine if mode of transportation had an impact on in-hospital mortality and discharge disposition in pediatric trauma patients hypothesizing that HEMS transport is associated with reduced mortality and increased rates of discharge home compared to GEMS. They looked at all pediatric trauma patients (age <18) who presented to any designated trauma center by HEMS or GEMS between 2007 and 2016 without exclusion based on injury pattern, mechanism, or severity.
348,107 patients met criteria for inclusion of which 18.6% were transported by HEMS. However, the authors used propensity score matching (PSM) to optimize matching for injury characteristics, demographics, and type of injury where 29,751 patients were compared in the GEMS and HEMS groups, respectively.
While the authors dive deeply into comparisons of age, race, sex, injury type, injury severity, mechanism of injury and vital sign differences between HEMS and GEMS, the authors overall found fewer deaths were associated with HEMS than GEMS (p=0.01). In addition, as a secondary outcome, Ciaraglia et al note that patients transported by HEMS were more likely to be discharged with home care services than those who were transported by GEMS (p=0.16). Given this study is the largest so far to show a difference in outcomes based on transport modality, this is a well-powered study to bring these results to life.
With all of this said, there are certainly limitations to this study, many of which the authors present. Given the nature of the NTBD, while it provides a very large sample size over several years, there limitations based on incomplete or missing data (including to the level of detail one may want for deeper analysis), variability of accuracy of reporting, lack of long-term outcomes, and limits to the pre-hospital data in the level of detail one may want for this type of study. The authors point out a need for more detailed investigation as to why there is an association between transportation modality and discharge disposition. While geographic information, population diversity, home-service availability, HEMS availability in some regions, and other socioeconomic factors can impact those results, based on this study, those conclusions cannot be drawn.
Overall, the article points to HEMS being associated with decreased odds of mortality and discharge from the hospital with home service, though more non-database data is needed to better understand and characterize these study outcomes. However, this sparks an important conversation regarding how multifactorial the decision to use HEMS versus GEMS is in pediatric trauma populations as we seek to use accurately triage patients to the correct transport modality so that they receive the care that they need without overutilizing certain resources where not indicated.
Article 3
Similar Associated Risks of Complications and Mortality for Adolescent Gunshot Wounds Treated at Pediatric-Only Hospitals Compared to Combined Pediatric and Adult Centers. Nguyen L, Grigorian A, Lee C, Goodman LF, Guner Y, Kuza C, Swentek L, Nahmias J. J Am Coll Surg. 2024 Dec 2.
Firearm injuries remain the leading cause of death among children, with adolescent (12–17 years) populations being particularly affected. Given the high prevalence of gunshot wounds (GSWs) in this age group, the management of these patients continues to be critically evaluated. Previous studies have explored the care of pediatric trauma patients treated at pediatric-only trauma hospitals (POHs) versus combined pediatric and adult centers (CPACs). Historically, pediatric centers were thought to offer more specialized, tailored care for adolescents due to their focus on interdisciplinary pediatric expertise. However, others argue that the increased severity of penetrating trauma, particularly GSWs, seen at adult trauma centers suggests that adolescent patients requiring urgent surgical intervention and additional resources may fare better at CPACs. The aim of this study was to compare injury patterns, complications, and mortality rates in adolescents sustaining GSWs who presented to CPACs versus POHs.
This study utilized the 2017-2021 Trauma Quality Improvement Program (TQUIP) database to examine adolescents (ages 12–17) who sustained isolated GSWs. Patients who were transferred from outside hospitals or had traumatic brain injuries were excluded. The primary outcome was mortality, and the secondary outcomes included complications such as ventilator-associated pneumonia, unplanned returns to the operating room (OR), unplanned intubation, surgical site infections, and catheter-associated infections. Demographic variables and injury profiles were compared, and total hospital length of stay (LOS) as well as intensive care unit (ICU) LOS were analyzed.
Among 3,064 adolescents presenting with GSWs, 1,512 (49.3%) were treated at CPACs. Those who presented to CPACs were older (16 vs. 15 years, p<0.001), had a higher Injury Severity Score (ISS) (9 vs. 4, p<0.001), and sustained more injuries to the spine, heart, lungs, liver, and spleen. Patients treated at CPACs had a higher rate of emergent operations within 24 hours of arrival (31.9% vs. 23.5%, p<0.001). After controlling for all variables through multivariable analysis, adolescents who presented to CPACs had similar risks of in-hospital complications and mortality compared to those treated at POHs. The strongest independent risk factors for complications included undergoing surgery (p<0.001), receiving a blood transfusion (p<0.001), tachycardia on arrival (p=0.04), and a higher ISS (p<0.001).
While many adolescents still have limited access to POHs due to geographical constraints, CPACs remain critical in providing care for pediatric GSW patients. Access to CPACs is associated with reduced overall mortality on a national level. Other studies have similarly shown no significant difference in mortality and complications between adolescents treated at POHs versus CPACs. The authors attribute this finding to both types of institutions adhering to best care practices as established by the American College of Surgeons (ACS), ensuring that all patients with penetrating injuries receive optimal care, regardless of the hospital type. As reported in previous literature, increased mortality is most often related to hypotension at presentation, higher ISS, and the need for transfusion or urgent surgery.
Future studies should focus on patient-centered outcomes, such as rates of home discharge, neuropsychological support, and the utilization of imaging and radiation exposure in both POHs and CPACs. These variables were not captured in this study due to limitations in the TQIP database. In conclusion, this study highlights that adolescents presenting with GSWs have similar outcomes when treated at CPACs compared to POHs.
Article 4
The abdomen does not lie, but the labs might: Predictors of intra-abdominal injury on computed tomography imaging in pediatric blunt trauma patients. Otaibi B, Khurshid M, Hejazi K, et al. J Trauma Acute Care Surgery. 2025 Jan 6.
Blunt abdominal trauma (BAT) in children results, infrequently, in demonstrable intrabdominal injuries. Of those patients who sustain intrabdominal injuries (IAIs), only a small minority require intervention. Computed tomography is widely considered definitive imaging for most abdominal trauma, however, there are known risks of exposure to radiation (e.g., delayed malignancy), which drives a substantial effort to reduce unnecessary imaging. This holds especially true for children, whose growing and developing tissues are at increased risk of the effects of radiation exposure. Conversely, there is also a known, and potentially catastrophic, risk to missed IAIs. Finding a optimal, evidence-based balance between the risks and benefits of imaging remains an important and unresolved topic. Otaibi et al have attempted to add to the body of knowledge available to determine this balance.
This was a 5-year, retrospective analysis of the pediatric trauma database at an American College of Surgeons (ACS)-verified Level II pediatric trauma center. Of their 3,707 pediatric admissions during the study period, 23.6% presented with BAT; 16.7% received abdominal CT imaging. They excluded patients who had received imaging prior to transfer, as well as those with delayed presentation (>6 hours from injury). Study outcomes included the rate of IAI based on initial CT findings, as well as the rates of intervention in those with IAI.
Overall, only 17% of imaged patients were found to have IAI (defined as injury to the liver, spleen, kidney, pancreas, adrenal glands, or gastrointestinal tract), and only 17% of those with IAI required intervention. The high number of negative studies (and low frequency of need for intervention) support the idea that there may be further opportunity to reduce CT imaging, and reinforces the idea that a best set of predictors has yet to be identified.
Other variables included and analyzed by multivariate analysis included history/physical exam findings (e.g., presence of abdominal pain, abdominal tenderness, postinjury emesis), results of trauma bay imaging (e.g., positive FAST), and laboratory values (AST, ALT, lipase, hematocrit, UA). Factors identified to be predictive of with IAI were: positive FAST, abdominal tenderness, abnormal abdominal x-ray, abnormal AST, and blood product requirements.
It is important to highlight where this manuscript differs from findings in previous works. Previously, laboratory values were suggested as criteria to determine the need for abdominal imaging – and this has been adopted in many institutions’ protocols to guide the evaluation of pediatric BAT. In this manuscript, only 11.8% of patients had abnormal labs. The patients with abnormal labs and found to have IAI had at least one of the other predictive factors noted above. This suggests that more weight can be placed on physical exam and FAST, rather than traditional laboratory values when it comes to predicting IAI and/or the need for advanced imaging.
There were some limitations to the study, most of which are inherent in retrospective database analyses: the results outline associations, but cannot imply causation. The physical exam finding of abdominal tenderness is subjective and open to measurement bias. Additionally, the data reflects the experience at a single-institution; it is unclear if these results would be reproducible if multiple institutions (with their individual patient management pathways and patient population) were to be examined together. Further prospective studies would be necessary to establish the accuracy of any predictors/prediction models.
