Reducing Phlebotomy, Length of Stay, Cost: Development of a Blunt Abdominal Trauma Pathway in a Level I, Pediatric Trauma Center.

OBJECTIVES: Blunt abdominal trauma (BAT) is a leading cause of morbidity in children with higher hemodynamic stabilities when compared with adults. Pediatric patients with BAT can often be managed without surgical interventions; however, laboratory testing is often recommended. Yet, laboratory testing can be costly, and current literature has not identified appropriate pathways or specific tests necessary to detect intra-abdominal injury after BAT. Therefore, the present study evaluated a proposed laboratory testing pathway to determine if it safely reduced draws of complete blood counts, coagulation studies, urinalysis, comprehensive metabolic panels, amylase and lipase levels orders, emergency department (ED) length of stay, and cost in pediatric BAT patients. METHODS: A retrospective review of levels I, II, and III BAT pediatric patients (n = 329) was performed from 2015 to 2018 at our level I, pediatric trauma center. Patients were then grouped based on pre-post pathway, and differences were calculated using univariate analyses. RESULTS: After implementation of the pathway, there was a significant decrease in the number of complete blood counts, coagulation studies, urinalysis, comprehensive metabolic panels, amylase, and lipase levels orders ( P < 0.05). Postpathway patients had lower average ED lengths of stay and testing costs compared with the pre pathway patients ( P < 0.05). There was no increase in rates of return to the ED within 30 days, missed injuries, or readmissions of patients to the ED. CONCLUSIONS: Results displayed that the adoption of a laboratory testing pathway for BAT patients reduced the number of laboratory tests, ED length of stay, and associated costs pediatric patients without impacting quality care.

Pediatric Train Injuries: A 10-Year Review From the Pennsylvania Trauma Outcomes Study Database.

OBJECTIVES: Trains can cause severe injuries in pediatric patients requiring significant resource utilization. We sought to review train injuries in Pennsylvania to determine the burden of these injuries on the pediatric trauma system. METHODS: We queried the Pennsylvania Trauma Outcomes Study Database to identify patients younger than 18 years injured by trains between 2007 and 2016. Demographics, hospital course, outcomes, and resource utilization were reviewed. RESULTS: Thirty-five children from 17 Pennsylvania counties were included. Three counties accounted for 48.6% of injured children. The median age was 15.0 years, and most patients were White (60.0%) and male (77.1%). The median length of stay was 8.0 days and overall mortality 8.6%. Intensive care unit admission was required for 65.7%. The median Injury Severity and Functional Status at Discharge scores were 14.0 and 18.0, respectively. Major orthopedic injuries (fracture or amputation) were the most common (57.1%) followed by traumatic brain injury (45.7%), pneumothorax (14.3%), and solid organ injury (14.3%). Operative management was common with 65.7% undergoing surgery. CONCLUSIONS: Injuries caused by trains can be severe and are most commonly orthopedic or traumatic brain injuries. Targeted safety interventions may be possible given the common mechanisms and geographic clustering of these injuries.

Thoracoscopic intercostal to phrenic nerve transfer for diaphragmatic reanimation in a child with tetraplegia.

Context: To describe for the first time a novel technique of thoracoscopic intercostal nerve mobilization and intercostal to phrenic nerve transfer in the setting of tetraplegia with the goal of reanimating the diaphragm and decreasing ventilator dependence.Findings: A 5-year-old female on 24 h ventilator support secondary to traumatic tetraplegia was evaluated for possible phrenic nerve pacing. Left-sided phrenic nerve stimulation did not result in diaphragmatic contraction indicating a lower motor neuron injury. The patient underwent thoracoscopic mobilization of the left phrenic nerve and 10th intercostal nerve while positioned in the left lateral decubitus position using four 5 mm trocars. The mobilized intercostal nerve was transected close to its distal anterior termination and coapted without tension to the cut end of the terminal phrenic nerve using fibrin sealant. Lastly, phrenic nerve pacer leads and battery were implanted in the chest wall and connected to the electrode placed on the intercostal nerve. One year following the procedure, the patient was tolerating phrenic pacing during the day while requiring ventilation overnight. Currently, the patient is 2 years post-operative from this procedure and does not require ventilator support.Conclusion/clinical relevance: We have shown for the first time a novel approach of thoracoscopic nerve mobilization and phrenic to intercostal nerve transposition to be both safe and effective for restoring innervation of the diaphragm in a child. This minimally invasive procedure is recommended as the preferred approach to reanimate the diaphragm.