September 2023 - Pediatric Trauma
September 2023
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 Manuscript and Literature Committee Members Brian Yorkgitis, DO, FACS, Caleb Butts, MD, EAST Research - Scholarship Committee Member James Byrne, MD, PhD and EAST Member Ramitha Eshan Ruwanpathirana, MBBS.
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 Brian Yorkgitis, DO, FACS
Association of Emergency Department Pediatric Readiness with Mortality to 1 Year Among Injured Children Treated at Trauma Centers. Newgard CD, Lin A, Goldhaber-Fiebert J, et al. JAMA Surg. 2022 Apr 1;157(4):e217419.
Article 2 reviewed by Caleb Butts, MD
External validation of a pediatric decision rule for blunt abdominal trauma. Siagal AP, Deaner T, Woods S, et al. J Am Coll Emerg Physicians Open. 2022 Jan 15;3(1):e12623.
Article 3 reviewed by James Byrne, MD, PhD
Association of Prehospital Transfusion With Mortality in Pediatric Trauma. Morgan KM, Abou-Khalil E, Strotmeyer S, Richardson WM, Gaines BA, Leeper CM. JAMA Pediatr. 2023 Jul 1;177(7):693-699.
Artcile 4 reviewed by Ramitha Eshan Ruwanpathirana, MBBS
Pediatric traumatic hemorrhagic shock consensus conference recommendations. Russell RT, Bembea MM, Borgman MA, Burd RS, Gaines BA, Jafri M, Josephson CD, Leeper CM, Leonard JC, Muszynski JA, Nicol KK, Nishijima DK, Stricker PA, Vogel AM, Wong TE, Spinella PC. J Trauma Acute Care Surg. 2023 Jan 1;94(1S Suppl 1):S2-S10.
Article 1
Association of Emergency Department Pediatric Readiness with Mortality to 1 Year Among Injured Children Treated at Trauma Centers. Newgard CD, Lin A, Goldhaber-Fiebert J, et al. JAMA Surg. 2022 Apr 1;157(4):e217419.
Pediatric trauma patients are often initially evaluated and resuscitated at non-pediatric trauma centers. Recognizing the need for improved pediatric care, the National Pediatric Readiness Program (NPRP) was developed to assist hospitals, particularly non-pediatric centers improve their capabilities to care for sick or injured children. NPRP includes an assessment of pediatric readiness based off self-report metrics categorized into six domains (administration/care coordination; personnel; quality improvement plan; pediatric patient safety; policies and procedures; equipment and supplies). Pediatric readiness can be quantified with a weighted Pediatric Readiness Score (wPRS), higher signifying improved readiness.
To evaluate the impact of wPRS, a retrospective cohort study of trauma patients <18 years among 983 EDs that have an available wPRS from the 2013 assessment. They divided the hospitals into quartiles based on their wPRS (0-58, 59-72, 73-87, 88-100). Of the over 90,000 injured children treated at one of 592 EDs in the study, 1820 (2%) died during the index hospitalization including 1032 in the ED.
The adjusted odds of dying in a hospital were 60% lower for children treated at a high-readiness ED (wPRS quartile 4 vs 1, aOR, 0.4; 95% CI, 0.25-0.60). The authors estimated that 288 lives could have been if injured children were treated in highest quartile of readiness EDs versus lower. Looking at injured children with 1-year outcomes, the risks of death to 1 year was lowest in those treated in high-readiness EDs (aOR, 0.34; 95% CI 0.25-0.45).
This study further adds to the body of literature that pediatric trauma patients fair better if their initial trauma care is delivered at a high-readiness ED. Since the majority of children are initially seen at non-pediatric trauma centers, it is imperative that all trauma centers be Peds Ready. This has been recognized by the American College of Surgeons Committee on Trauma and included in the 2022 Resources for Optimal Care of the Injured Patient. Each trauma center should participate in the NPRP assessment and use the findings of their results to improve their readiness for pediatric patients.
Article 2
External validation of a pediatric decision rule for blunt abdominal trauma. Siagal AP, Deaner T, Woods S, et al. J Am Coll Emerg Physicians Open. 2022 Jan 15;3(1):e12623.
Judicious use of CT imaging in the evaluation of the traumatically injured child remains an elusive goal. There are many different clinical decision rules (CDRs) that can avoid unnecessary ionizing radiation exposure. The Pediatric Emergency Care Applie Research Network (PECARN) CDR for abdominal trauma relies on 7 clinical criteria to rule out the need for CT imaging: evidence of abdominal wall trauma/seat belt sign, abdominal tenderness, complaints of abdominal pain, vomiting, Glasgow Coma Scale (GCS) of 13 or less, evidence of thoracic wall trauma, and decreased breath sounds. The presence of any one of these criteria is considered “PECARN positive”, while the absence of all 7 is considered “PECARN negative”, which should effectively rules out the need for CT imaging. This CDR was first prospectively evaluated by the PECARN network of pediatric emergency departments (ED) with good results (sensitivity of 97.0%, negative predictive value (NPV) of 99.9%) (PMID: 23375510). It was subsequently retrospectively evaluated by a pediatric emergency department at a tertiary care center with ACS level 1 designation (PMID: 30502218) with similar findings. The study reviewed today sought to retrospectively apply the CDR in a community non-pediatric-specific emergency department with ACS level 1 verification who saw a fairly large volume of pediatric patients (~20% overall, 6.6% of all trauma activations).
Over the nearly seven-year study period, 1,953 traumatically injured pediatric patients were identified. After excluding penetrating injuries, isolated head injuries, and a variety of isolated extremity injuries with low likelihood of abdominal trauma, 1,006 were reviewed. Two hundred and twelve patients (21%) had incomplete data to assess whether they were PECARN positive or negative, leaving 794 for analysis. Of those, 373 were PECARN positive, while 491 were PECARN negative. PECARN negative patients’ charts were then reviewed for potential missed intraabdominal injuries requiring intervention (IAI-I), defined as undergoing therapeutic laparotomy, angiographic embolization due to intraabdominal injury, blood transfusion due to hemorrhage, IV fluids for 2 or more nights due to pancreatic or gastrointestinal injury, or death. This was identified by reviewing CT scans that were obtained at index assessment (since this was a retrospective review) or, if no CTs were obtained, by reviewing the chart for any subsequent ED visits. Of these 421 PECARN negative patients, 2 had injuries necessitating intervention—one that required transfusion with a pelvic fracture that required orthopedic surgery, and another that required transfusion with a grade 2 liver injury and concomitant penetrating extremity wound with active bleeding that necessitated operative control. The results in this study were roughly similar to prior studies, with a sensitivity of 91.3% and NPV of 99.5%.
This study is limited by its retrospective nature and large number of patients with missing variables. These excluded patients were primarily low energy mechanisms, with falls as the mechanism for over half of all patients with missing variables. A prospective analysis should reduce the number of patients excluded for missing variables. In addition, it is challenging to say that because a patient did not re-present to a particular ED within a week that they did not visit a different ED for a missed injury, but this is likely the best way to assess for this in a retrospective analysis. Finally, the authors make an insightful point that being PECARN positive may not necessarily mandate CT imaging, but can be used as a two-step process in conjunction with other CDRs, such as those that employ other factors (presence of abnormal chest x-ray, hypotension, abnormal exam, elevated liver or pancreatic enzymes, decreased hematocrit, or microhematuria) that are more sensitive for injuries. Overall, this study validates PECARN CDR for assessment in community EDs that do not specialize in pediatric care.
Article 3
Association of Prehospital Transfusion With Mortality in Pediatric Trauma. Morgan KM, Abou-Khalil E, Strotmeyer S, Richardson WM, Gaines BA, Leeper CM. JAMA Pediatr. 2023 Jul 1;177(7):693-699.
Prehospital blood transfusion is lifesaving among adults with life-threatening hemorrhage in both civilian and military environments. However, the practice is rare among injured children and there is a paucity of research evaluating the potential benefit in pediatric trauma care. In this retrospective cohort study, the authors used data derived from the Pennsylvania Trauma Systems Foundation dataset (2009–2019) to determine if prehospital transfusion was associated with survival among bleeding children. The study population were children aged 0 to 17 years old. The exposure was blood product transfusion in the prehospital setting (PHT) compared to the emergency department. The primary outcome was 24-hour mortality. Confounding control was performed in two ways: 1) first, using propensity score matching to match on age, mechanism of injury, shock index, and prehospital GCS; 2) second, using multilevel logistic regression on the final matched cohort to adjust for sex, injury severity, and insurance status. The latter model accounted for clustering of children within hospitals. The authors calculated the number needed to treat (NNT) to reduce 24-hour mortality. An “E-value” was calculated to estimate the magnitude of potential unmeasured confounding.
Among 559 children included in the final analysis, 70 received PHT (13%) over the 11-year study period. Children that received PHT were more likely to manifest shock (55% vs. 44%) due to blunt trauma (81% vs. 57%) and had longer prehospital time intervals. After 3:1 matching, the propensity score matched cohort included 207 children. After further risk-adjustment using logistic regression, PHT was associated with significantly lower odds of 24-hour mortality (OR 0.46; 95%CI 0.23-0.91). The NNT to reduce 24-hour mortality was estimated to be 6 children. The E-value, the effect size that a potential unmeasured confounder would need to have to explain these findings, was estimated to be 3.80. Important limitations to these findings stem mainly from the small sample size of children receiving PHT. This limited the ability to perform matching or risk-adjustment to account for the full array of variables that might confound the association between PHT and survival. Other data pertaining to resuscitation such as crystalloid volumes, tranexamic acid use, or other hemostatic adjuncts could not be accounted for. It is also possible that injured children might have received treatment at facilities not contributing to the state-wide trauma registry. Accepting these limitations, the authors have performed a thoughtful, thorough, and transparent analysis that provides a best assessment of these imperfect data. There is good biologic rationale to believe that among children with bleeding due to trauma, early transfusion in the prehospital environment will be lifesaving. For this reason, there is need for a well-designed prospective multicenter study to evaluate prehospital transfusion as an intervention for injured kids.
Article 4
Pediatric traumatic hemorrhagic shock consensus conference recommendations. Russell RT, Bembea MM, Borgman MA, Burd RS, Gaines BA, Jafri M, Josephson CD, Leeper CM, Leonard JC, Muszynski JA, Nicol KK, Nishijima DK, Stricker PA, Vogel AM, Wong TE, Spinella PC. J Trauma Acute Care Surg. 2023 Jan 1;94(1S Suppl 1):S2-S10.
Hemorrhagic shock is a prevalent and preventable cause of rapid mortality in post-injury pediatric patients within the United States. The Pediatric Traumatic Hemorrhagic Shock Consensus Conference emerged to enhance clinical care outcomes for these patients by providing guidance and recommendations.
A panel of 16 interdisciplinary experts analyzed the literature in six domains, conducted a consensus meeting, and proposed 21 statements based on evidence, expert opinion, and good practice. Despite the dearth of pediatric-specific literature, the consensus panel's expertise and the synthesis of available data offer valuable insights.
The 6 domains covered: (1) blood products and fluid resuscitation for hemostatic resuscitation, (2) prehospital blood product use, (3) use of tranexamic acid and other hemostatic adjuncts, (4) use of tourniquets, (5) prehospital intubation and blood pressure management, and (6) resuscitation and use of hemostatic monitoring.
The main recommendations are:
- Prioritize the use of blood products over crystalloids.
- Use low-titer (<200 immunoglobulin G) group O whole blood over individual blood components (RBC, plasma, platelets).
- Target high plasma/red blood cell ratios (1:1) to minimize the plasma deficit.
- Target high platelet-to-RBC weight-based-ratios (1:1) to minimize platelet deficit.
- Consider prehospital transfusion by out-of-hospital emergency medical service (EMS) based on product availability and clinical judgment.
- Consider tranexamic acid (TXA) empirically within 3 hours of injury.
- Consider TXA over aminocaproic acid as an antifibrinolytic agent.
- Limited evidence supports the empirical use of prothrombin complex concentrate, fibrinogen supplementation, or viscoelastic monitoring (VEM) for antifibrinolytic therapy. Treat hypofibrogenemia with fibrinogen replacement.
- Trained Individuals should use commercially available tourniquets for exsanguinating extremity hemorrhage.
- Avoid permissive hypotension. The resuscitation goals should focus on optimal end-organ perfusion and oxygen delivery.
- Employ an initial empiric resuscitation with massive transfusion protocols and balanced blood product administration.
- Utilize a goal-directed resuscitation strategy to optimize hemostasis and correct coagulopathy post-initial resuscitation.
- When available, incorporate VEM as an adjunct tool.