Establishing a core outcome set for blunt cerebrovascular injury: an EAST modified Delphi method consensus study.

Objectives: Our understanding of blunt cerebrovascular injury (BCVI) has changed significantly in recent decades, resulting in a heterogeneous description of diagnosis, treatment, and outcomes in the literature which is not suitable for data pooling. Therefore, we endeavored to develop a core outcome set (COS) to help guide future BCVI research and overcome the challenge of heterogeneous outcomes reporting.

Methods: After a review of landmark BCVI publications, content experts were invited to participate in a modified Delphi study.

Comparison of Pediatric Trauma Scoring Tools That Incorporate Neurological Status for Trauma Team Activation.

Background: Two novel pediatric trauma scoring tools, SIPAB+ (defined as elevated SIPA with Glasgow Coma Scale ≤8) and rSIG (reverse Shock Index multiplied by Glasgow Coma Scale and defined as abnormal using cutoffs for early outcomes), which combine neurological status with Pediatric Age-Adjusted Shock Index (SIPA), have been shown to predict early trauma outcomes better than SIPA alone. We sought to determine if one more accurately identifies children in need of trauma team activation.

Methods: Patients 1 to 18 years old from the 2014-2018 Pediatric Trauma Quality Improvement Program database were included.

Use of prehospital reverse shock index times Glasgow Coma Scale to identify children who require the most immediate trauma care.

Background: Appropriate prehospital trauma triage ensures transport of children to facilities that provide specialized trauma care. There are currently no objective and generalizable scoring tool for emergency medical services to facilitate such decisions. An abnormal reverse shock index times Glasgow Coma Scale (rSIG), which is calculated using readily available parameters, has been shown to be associated with severely injured children.

Use of reverse shock index times Glasgow coma scale (rSIG) to determine need for transfer of pediatric trauma patients to higher levels of care.

Introduction: Most children in the US live more than one hour from a Level 1 PTC. The Need For Trauma Intervention (NFTI) score was developed to assess trauma triage criteria and is dependent on whether someone requires one of six urgent interventions (NFTI+). We sought to determine if a novel scoring tool, rSIG, could predict NFTI and facilitate the transfer decision making process.

Blood Transfusion is Associated With Adverse Outcomes in Pediatric Solid Tumor Oncology Patients Following Tumor Resection.

Background: Packed red blood cell (PRBC) transfusion is a lifesaving intervention that also has proinflammatory and immunosuppressive effects. Adults with a malignancy who receive PRBC transfusion have increased rates of infection, tumor recurrence, and decreased survival. The effect of PRBC transfusion among children with solid tumors is unknown.

Discreet Values of Shock Index Pediatric Age-Adjusted (SIPA) to Predict Intervention in Children With Blunt Organ Injuries.

Introduction: Elevated shock index pediatric age-adjusted (SIPA) has been shown to be associated with the need for both blood transfusion and intervention in pediatric patients with blunt liver and spleen injuries (BLSI). SIPA has traditionally been used as a binary value, which can be classified as elevated or normal, and this study aimed to assess if discreet values above SIPA cutoffs are associated with an increased probability of blood transfusion and failure of nonoperative management (NOM) in bluntly injured children.

Materials And Methods: Children aged 1-18 y with any BLSI admitted to a Level-1 pediatric trauma center between 2009 and 2020 were analyzed.

Adolescent blunt solid organ injury: Differences in management strategies and outcomes between pediatric and adult trauma centers.

Background: Adolescents with blunt solid organ injuries (BSOI) are cared for at both pediatric trauma centers (PTC) and adult trauma centers (ATC). Over the past decade, treatment strategies have shifted towards non-operative management with reported favorable outcomes. The aim of this study was to compare management strategies and outcomes between PTC and ATC.

Pediatric cardiac and great vessel injuries: Recent experience at two pediatric trauma centers.

Background: Cardiac injuries are rare in pediatric trauma patients and data regarding this type of injury is limited. There is even less data on traumatic great vessel injuries. This study sought to examine and summarize our recent experience at two pediatric trauma centers, which serve a major metropolitan area and large geographic region.

Improved identification of severely injured pediatric trauma patients using reverse shock index multiplied by Glasgow Coma Scale.

Background: The shock index pediatric age-adjusted (SIPA) predicts the need for increased resources and mortality among pediatric trauma patients without incorporating neurological status. A new scoring tool, rSIG, which is the reverse shock index (rSI) multiplied by the Glasgow Coma Scale (GCS), has been proven superior at predicting outcomes in adult trauma patients and mortality in pediatric patients compared with traditional scoring systems. We sought to compare the accuracy of rSIG to Shock Index (SI) and SIPA in predicting the need for early interventions in civilian pediatric trauma patients.

The benefits of limiting scheduled blood draws in children with a blunt liver or spleen injury.

Background: Nonoperative management protocols of blunt liver and spleen injury in children usually call for serial monitoring of the child's hemoglobin and hematocrit (H/H) at scheduled intervals. We previously demonstrated that the need for emergent intervention is triggered by changes in vital signs, not the findings of scheduled blood draws and changed our protocol accordingly. The current aim is to evaluate the safety of this change.

Central venous lines in critically ill children: Thrombosis but not infection is site dependent.

Background: Central venous catheters (CVC) are vital to the management of critically ill children. Despite efforts to minimize complications, central line associated bloodstream infection (CLABSI) and venous thromboembolisms (VTE) still occur.

Methods: We performed a retrospective review of a prospectively collected database for children admitted to the pediatric intensive care unit (PICU) between November 2013 and December 2016.

Survival after emergency department thoracotomy in the pediatric trauma population: a review of published data.

Background/purpose: The utility of EDT in the adult trauma population, using well-defined guidelines, is well established, especially for penetrating injuries. Since the introduction of these guidelines, reports on the use of EDT for pediatric trauma have been published, and these series reveal a dismal, almost universally fatal, outcome for EDT following blunt trauma in the child. This report reviews the clinical outcomes of EDT in the pediatric population.

Mapping pediatric injuries to target prevention, education, and outreach.

Background: Initiatives exist to prevent pediatric injuries, but targeting these interventions to specific populations is challenging. We hypothesized that mapping pediatric injuries by zip code could be used to identify regions requiring more interventions and resources.

Methods: We queried the trauma registries of two level I trauma centers for children 0-17years of age injured between 2009 and 2013 with home zip codes in our state.

Shock index, pediatric age-adjusted (SIPA) is more accurate than age-adjusted hypotension for trauma team activation.

Background: We demonstrated previously that shock index, pediatric age-adjusted identifies severely injured children accurately after blunt trauma. We hypothesized that an increased shock index, pediatric age-adjusted would identify more accurately injured children requiring the highest trauma team activation than age-adjusted hypotension.

Methods: We reviewed all children age 4-16 admitted after blunt trauma with an injury severity score ≥15 from January 2007-June 2013.

Rapid Response Team Activations in Pediatric Surgical Patients.

 The rapid response team (RRT) is a multidisciplinary team who evaluates hospitalized patients for concerns of nonemergent clinical deterioration. RRT evaluations are mandatory for children whose Pediatric Early Warning System (PEWS) score (assessment of child's behavior, cardiovascular and respiratory status) is ≥4. We aimed to determine if there were differences in characteristics of RRT calls between children who were admitted primarily to either medical or surgical services.

Adult-Based Massive Transfusion Protocol Activation Criteria Do Not Work in Children.

 In the adult population, assessment of blood consumption (ABC) score [penetrating mechanism, positive focused assessment sonography for trauma (FAST), systolic blood pressure < 90, and heart rate (HR) > 120] ≥2 identifies trauma patients who require massive transfusion (MT) with sensitivity and specificity of 75 and 86%. We hypothesized that the adult criteria cannot be applied to children, as the vital sign cut-offs are not age-adjusted. We aimed to determine if the use of a shock index, pediatric age-adjusted (SIPA) would improve the discriminate ability of the ABC score in children.

Establishing Benchmarks for Resuscitation of Traumatic Circulatory Arrest: Success-to-Rescue and Survival among 1,708 Patients.

Background: Attempts are made with emergency department thoracotomy (EDT) to salvage trauma patients who present to the hospital in extremis. The EDT allows for relief of cardiac tamponade, internal cardiac massage, and proximal hemorrhage control. Minimally invasive techniques, such as endovascular hemorrhage control (EHC) are available, but their noninferiority to EDT remains unproven.

Pediatric appendicitis and need for antibiotics at time of discharge: Does route of administration matter?

Introduction: Following complicated appendicitis, there are limited data available to guide the surgeon regarding antibiotic selection, specifically in regards to route of administration. We hypothesized that among children with appendicitis who are discharged home with antibiotic therapy, the post-discharge readmission and complication rates do not differ between those children who receive IV antibiotics and those who receive PO antibiotics.

Methods: We performed a retrospective review of all children discharged home on antibiotics following appendectomy at a single institution between 11/10-10/14.

Goal-directed Hemostatic Resuscitation of Trauma-induced Coagulopathy: A Pragmatic Randomized Clinical Trial Comparing a Viscoelastic Assay to Conventional Coagulation Assays.

Background: Massive transfusion protocols (MTPs) have become standard of care in the management of bleeding injured patients, yet strategies to guide them vary widely. We conducted a pragmatic, randomized clinical trial (RCT) to test the hypothesis that an MTP goal directed by the viscoelastic assay thrombelastography (TEG) improves survival compared with an MTP guided by conventional coagulation assays (CCA).

Methods: This RCT enrolled injured patients from an academic level-1 trauma center meeting criteria for MTP activation.

A paradigm for achieving successful pediatric trauma verification in the absence of pediatric surgical specialists while ensuring quality of care.

Background: Pediatric trauma centers (PTCs) are concentrated in urban areas, leaving large areas where children do not have access. Although adult trauma centers (ATCs) often serve to fill the gap, disparities exist. Given the limited workforce in pediatric subspecialties, many adult centers that are called upon to care for children cannot sufficiently staff their program to meet the requirements of verification as a PTC.

Lack of utility of repeat monitoring of hemoglobin and hematocrit following blunt solid organ injury in children.

Background: Current management protocols for children with blunt solid organ injury to the liver and spleen call for serial monitoring of the child's hemoglobin and hematocrit every 6, 12, or 24 hours, depending on the injury grade. We hypothesized that children who require emergent intervention in the form of laparotomy, angioembolization, or packed red blood cell (PRBC) transfusion because of bleeding from a solid organ injury will have changes in their vital signs that alert the clinician to the need for intervention, making scheduled laboratory evaluation unnecessary.

Methods: We performed a retrospective review of all children admitted to either of two pediatric trauma centers following blunt trauma with any grade liver or spleen injury from January 2009 to December 2013.

Pediatric emergency department thoracotomy: A 40-year review.

Background/purpose: Emergency department thoracotomy (EDT) has been proposed to be futile in the pediatric patient population. This extreme procedure has survival rates of 0 to 26% in the nonadult population. When taking into consideration that the mechanism of injury is one of the strongest predictors of survival, we hypothesize that the low survival rate in pediatric patients is attributable to a higher rate of blunt trauma compared to their adolescent counterparts.

Is Routine Upper Gastrointestinal Contrast Study Necessary prior to Laparoscopic Gastrostomy Tube Placement in Children?

Introduction: Before gastrostomy tube (GT) placement, many pediatric surgeons request that children undergo a preoperative upper gastrointestinal contrast study (UGI) to evaluate for the presence of either gastroesophageal reflux (GER) or intestinal malrotation. We hypothesized that routine UGI is unnecessary before GT placement.

Materials And Methods: We performed a retrospective review of 500 consecutive children who had a GT placed in a single children's hospital from 2009 to 2012.

A pediatric specific shock index in combination with GMS identifies children with life threatening or severe traumatic brain injury.

Purpose: We have previously demonstrated that a shock index, pediatric age adjusted (SIPA) accurately identifies severely blunt injured children. We aimed to determine if SIPA could more accurately identify children with severe traumatic brain injury (TBI) than hypotension alone.

Methods: We performed subset analysis of those children with TBI among a cohort of children age 4-16 years with blunt trauma and injury severity score ≥15 from 1/07 to 6/13.