Article 1
Timing and Volume of Crystalloid and Blood Products in Pediatric Trauma – An EAST Multicenter Prospective Observational Study. Polites SF, Moody S, Williams RF, et al. J Trauma Acute Care Surg. 2020 Mar 30. Online ahead of print.
Take Away:
Resuscitation with >1 crystalloid bolus was associated with worse outcomes including extended duration of mechanical ventilation and hospitalization in pediatric trauma patients with an elevated age-adjusted shock index on arrival. This study supports a crystalloid-sparing, early transfusion approach for resuscitation of severely injured children
Summary:
In this manuscript, the authors present a multi-institutional prospective observational study of pediatric trauma patients (<18 years) with an elevated age-adjusted shock index on arrival. Included patients were 712 children from 24 trauma centers with a mean age of 7.6 years. There were 149 (21%) patients who received blood and 65 (10%) with a massive transfusion activation. Patients who received blood first had less total fluid volume than those who received crystalloid first (50 vs 87 cc/kg) despite similar ISS. On multivariable analysis, there was no association with mortality however, in transfused patients, each crystalloid bolus after the first was incrementally associated with increased odds ratio of extended ventilator, ICU and hospital days. This data supports the most recent ATLS guidelines for strong consideration of blood product administration for ongoing resuscitation needs beyond the first crystalloid bolus.
Article 2
Identifying Predictors of Physical Abuse Evaluation of Injured Infants: Opportunities to Improve Recognition. Eismann E, Shapiro RA, Makoroff K, Theuerling J, Stephenson N, Duma E, Fain E, Frey T, Riney L, Thackeray J. Pediatr Emerg Care. 2020 May 19. Online ahead of print.
Take Away:
Child physical abuse in young children remains common, underrecognized, and a source of significant morbidity and mortality. Physical abuse should be considered when even minor injuries are identified in an infant younger than 6 months.
Summary:
In this study, the authors present a retrospective review of 387 infants presenting to a single institution’s emergency or urgent care centers from 2013-2017 with a visible injury. The average age was 9 months. Sixty-eight (18%) infants had visible injuries in multiple locations. Of the entire population, 53% underwent a skeletal survey. One-hundred fifty-seven infants presented with bruising, burns, and/or intraoral injury and 58% of these children received an indicated skeletal survey. Infants in this population were significantly less likely to undergo a skeletal survey if they were 3 months or older, African American or black, primarily presented to the institutions facilities, had an initial physical examination by a non-pediatric emergency medicine attending physician, had a burn, or had a chief complaint of “injury or fall”. In this cohort, 25% were found to have an occult fracture, 26% had a suspected fracture, 24% had intracranial hemorrhage and 12% had both occult fractures and intracranial hemorrhage. Overall, minor injuries in pre-ambulatory infants are highly concerning for physical abuse. The authors conclude that additional education for health care providers on the importance of universal physical abuse evaluation of pre-ambulatory infants with any injury is needed to improve recognition of abusive injuries and promote the secondary prevention of recurrent abuse.
Article 3
Simulation-based Training Is Associated With Lower Risk-Adjusted Mortality in ACS Pediatric TQIP Centers. Jensen AR, McLaughlin C, Subacius H, et al. Polites SF, Moody S, Williams RF, et al. J Trauma Acute Care Surg. 2019 October;87:841-848.
Take Away:
Timely resuscitation of pediatric trauma patients may be improved by simulation-based training due to the small numbers of children that present to pediatric centers in extremis. Simulation-based training has been shown in adults and single center studies to decrease time to complete critical procedures. This study reports improved risk-adjusted mortality in patients treated pediatric trauma centers with high volume simulation-based training though time to critical procedures was not decreased.
Summary:
This study examines the effect of simulation-based training on mortality in pediatric trauma patients that report to TQIP. Participating centers (n=125) were surveyed with a 75% response rate (n=94) and divided into no simulation, low volume (1-10 sessions over 2 years), high volume (11 or more session over 2 years) or unknown (1 center). TQIP data was used to assess over 57, 000 patients from 124 centers. Risk-adjusted mortality was lower in high volume centers when compared to no simulation-based training (odds ratio, 0.58; CI:0.37-0.92). The time required for resuscitation, evaluations and critical procedures (intubation, head computed tomography, craniotomy and surgery for hemorrhage control) was not different in centers based on level of simulation. Simulation in pediatric trauma centers should be examined to better understand the decrease in mortality and may be useful in adult or combined centers who infrequently manage children.
Article 4
The ABC-D Score Improves the Sensitivity in Predicting Need for Massive Transfusion in Pediatric Trauma Patients. Phillips R, Acker S, Shahi N, Meier M, Leopold D, Recicar J, Kulungowski A, Patrick D, Moulton S, Bensard D. J Pediatr Surg. 2020 Feb;55(2):331-334.
Take Away: Unlike in adult trauma, criteria for activation of massive transfusion protocols (MTP) in children are not well developed. The ABC-D score assigns one point for penetrating mechanism, positive FAST, elevated shock index- pediatric age-adjusted (SIPA) score, lactate, and base deficit. A score of 3 or more was 77% sensitive and 78% specific for need for massive transfusion in pediatric trauma.
Summary: The authors seek to create a straightforward scoring system that would allow for appropriate, early activation of MTP in pediatric patients. The ABC score (assessment of blood consumption) has been validated for this purpose in adult trauma care. This scoring system incorporates penetrating mechanism, positive FAST, SBP <90 and pulse >120. The authors previously evaluated an ABC-S score, which incorporated the pediatric age adjusted shock index score (SIPA) in substitution for the adult vital sign cutoffs. However, the ABC-S score did not accurately predict need for MTP in children. The authors build on this in the current study. It involves a 10 year review of the registry at a high volume level 1 pediatric trauma center. The authors evaluated the performance of the ABC-D score, which incorporates variables of penetrating mechanism, positive FAST, elevated SIPA, and abnormal lactate and base deficit. They assigned one point for each of these. They defined MTP as administration of > 40 ml/kg of blood products in the first 6h of care. As they applied the ABC-D score to the 211 transfused children, they found that a score of 1 was 98% sensitive, but only 40% specific. The greatest accuracy for the scoring system was at an ABC-D score of 3, which had a sensitivity of 77% and a specificity of 78%. The authors note that positive FAST and penetrating mechanism were uncommon events in their population of pediatric trauma patients.
