The use and timing of angioembolization in pediatric blunt liver and spleen injury.

BACKGROUND: Nonoperative management (NOM) is the standard of care for the management of blunt liver and spleen injuries (BLSI) in the stable pediatric patient. Angiography with embolization (AE) is used as an adjunctive therapy in the management of adult BLSI patients, but it is rarely used in the pediatric population. In this planned secondary analysis, we describe the current utilization patterns of AE in the management of pediatric BLSI. METHODS: After obtaining IRB approval at each center, cohort data was collected prospectively for children admitted with BLSI confirmed on CT at 10 Level I pediatric trauma centers (PTCs) throughout the United States from April 2013 to January 2016. All patients who underwent angiography with or without embolization for a BLSI were included in this analysis. Data collected included patient demographics, injury details, organ injured and grade of injury, CT finding specifics such as contrast blush, complications, failure of NOM, time to angiography and techniques for embolization. RESULTS: Data were collected for 1004 pediatric patients treated for BLSI over the study period, 30 (3.0%) of which underwent angiography with or without embolization for BLSI. Ten of the patients who underwent angiography for BLSI failed NOM. For patients with embolized splenic injuries, splenic salvage was 100%. Four of the nine patients undergoing embolization of the liver ultimately required an operative intervention, but only one patient required hepatorrhaphy and no patient required hepatectomy after AE. Few angiography studies were obtained early during hospitalization for BLSI, with only one patient undergoing angiography within 1 hour of arrival at the PTC, and 7 within 3 hours. CONCLUSION: Angioembolization is rarely used in the management of BLSI in pediatric trauma patients with blunt abdominal trauma and is generally used in a delayed fashion. However, when implemented, angioembolization is associated with 100% splenic salvage for splenic injuries. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Can you see with CT? Is cervical spine computed tomographic imaging sufficient in pediatric trauma?

BACKGROUND: Traumatic cervical spine injury (CSI) is fundamentally different in children, and imaging recommendations vary; however, prompt diagnosis is necessary. METHODS: We conducted a retrospective cohort study, evaluating children who presented after traumatic injury from 7/1/2012 to 12/31/2019 receiving a cervical spine CT. Evaluation of the incidence and clinical significance of CSI undetected on CT subsequently diagnosed on MRI was conducted. Additionally, all with CSI underwent image review to evaluate for potential overlooked, but visible pathology. RESULTS: 1487 children underwent a cervical spine CT, revealing 52 with CSI. 237 underwent MRI due to an abnormal CT or continued clinical concern. Ultimately, three were discovered to have clinically significant CSI missed on CT. In all cases, retrospective review demonstrated a retroclival hematoma when soft tissue windows were formatted in sagittal and coronal views. CONCLUSIONS: A normal CT may be sufficient to rule-out clinically significant CSI. However, the presence of a retroclival hematoma must be evaluated.

Hemodilution in pediatric trauma: Defining the expected hemoglobin changes in patients with liver and/or spleen injury: An ATOMAC+ secondary analysis.

BACKGROUND: Many children with blunt liver and/or spleen injury (BLSI) never bleed intraperitoneally. Despite this, decreases in hemoglobin are common. This study examines initial and follow up measured hemoglobin values for children with BLSI with and without evidence of intra-abdominal bleeding. METHODS: Children ≤18 years of age with BLSI between April 2013 and January 2016 were identified from the prospective ATOMAC+ cohort. Initial and follow up hemoglobin levels were analyzed for 4 groups with BLSI: (1) Non bleeding; (2) Bleeding, non transfused (3) Bleeding, transfused, and (4) Bleeding resulting in non operative management (NOM) failure. RESULTS: Of 1007 patients enrolled, 767 were included in one or more of four study cohorts. Of 131 non bleeding patients, the mean decrease in hemoglobin was 0.83 g/dL (+/-1.35) after a median of 6.3 [5.1,7.0] hours, (p = 0.001). Follow-up hemoglobin levels in patients with and without successful NOM were not different. For patients with an initial hemoglobin >9.25 g/dL, the odds ratio (OR) for NOM failure was 14.2 times less, while the OR for transfusion was 11.4 times less (p = 0.001). CONCLUSION: Decreases in hemoglobin are expected after trauma, even if not bleeding. A hemoglobin decrease of 2.15 g/dL [0.8 + 1.35] would still be within one standard deviation of a non bleeding patient. An initial low hemoglobin correlates with failure of NOM as well as transfusion, thereby providing useful information. By contrast, subsequent hemoglobin levels do not appear to guide the need for transfusion, nor correlate with failure of NOM. These results support initial hemoglobin measurement but suggest a lack of utility for routine rechecking of hemoglobin. LEVEL OF EVIDENCE: Level II Prognostic Study.

Elder child or young adult? Adolescent trauma mortality amongst pediatric and adult facilities.

BACKGROUND: While it is assumed adolescents receive comparable trauma care at pediatric trauma centers (PTC), adult trauma centers (ATC), and combined facilities (MTC), this remains understudied. METHODS: We conducted a retrospective cohort study through the NTDB evaluating patients 14-18 years of age who presented to an ACS-verified level 1 or 2 trauma facility between 1/1/2016 and 12/31/2019. Multiple logistic regression analyses were performed to compare mortality risk among trauma facility verification types. RESULTS: 91,881 adolescents presented after trauma over the four-years. Hypotension, severe TBI, firearm mechanism, and ISS >15 were associated with increased mortality. Compared to PTCs, the odds of trauma-related mortality were statistically higher at MTCs (OR 1.82, p = 0.004) and ATCs (OR 1.89-2.05, p = 0.001-0.002). CONCLUSIONS: Injured adolescents receiving care at ATCs and MTCs have higher mortality risk than those cared for at PTCs. Further evaluation of factors associated with this observed difference is warranted and may help identify opportunities to improve outcomes in injured adolescents.

Variability in opioid pain medication prescribing for adolescent trauma patients in a sample of US pediatric trauma centers.

Objectives: The primary objective of this study was to examine opioid prescription frequency and identify differences across a national cohort of pediatric trauma centers in rates of prescribing opioids to injured adolescents at discharge. Methods: This was a retrospective observational study using electronic health records of injured adolescents (12-17 years) admitted to one of 10 pediatric trauma centers. Results: Of the 1345 electronic health records abstracted, 720 (53.5%, 95% CI 50.8 to 56.2) patients received opioid prescriptions at discharge with variability across sites (28.6%-72%). There was no association between patient factors and frequency of prescribing opioids. Center's trauma volume was significantly positively correlated with a higher rate of opioid prescribing at discharge (r=0.92, p=0.001). There was no significant difference between the frequency of opioid prescriptions at discharge among alcohol and other drugs (AOD)-positive patients (53.8%) compared with AOD-negative patients (53.5%). Conclusions: Across a sample of 10 pediatric trauma centers, just over half of adolescent trauma patients received an opioid prescription at discharge. Prescribing rates were similar for adolescent patients screening positive for AOD use and those screening negative. The only factor associated with a higher frequency of prescribing was trauma center volume. Consensus and dissemination of outpatient pain management best practices for adolescent trauma patients is warranted. Level of evidence: III-prognostic. Trial registration number: NCT03297060.

Early vasopressor administration in pediatric blunt liver and spleen injury: An ATOMAC+ study.

BACKGROUND: No prior studies have examined the outcomes of early vasopressor use in children sustaining blunt liver or spleen injury (BLSI). METHODS: A planned secondary analysis of vasopressor use from a 10-center, prospective study of 1004 children with BLSI. Inverse probability of treatment weighting (IPTW) was used to compare patients given vasopressors <48 h after injury to controls based on pretreatment factors. A logistic regression was utilized to assess survival associated with vasopressor initiation factors on mortality and nonoperative management (NOM) failure. RESULTS: Of 1004 patients with BLSI, 128 patients were hypotensive in the Pediatric Trauma Center Emergency Department (ED); 65 total patients received vasopressors. Hypotension treated with vasopressors was associated with a sevenfold increase in mortality (AOR = 7.6 [p < 0.01]). When excluding patients first given vasopressors for cardiac arrest, the risk of mortality increased to 11-fold (AOR = 11.4 [p = 0.01]). All deaths in patients receiving vasopressors occurred when started within the first 12 h after injury. Vasopressor administration at any time was not associated with NOM failure. CONCLUSION: After propensity matching, early vasopressor use for hypotension in the ED was associated with an increased risk of death, but did not increase the risk of failure of NOM. LEVEL OF EVIDENCE: Level III prognostic and epidemiological, prospective.

Screening Adolescent Trauma Patients for Substance Use at 10 Pediatric Trauma Centers.

BACKGROUND: The American College of Surgeons Committee on Trauma recommends universal alcohol screening be part of the evaluation of admitted trauma patients. Yet, suboptimal screening rates have been reported for admitted adult and adolescent trauma patients. This lack of screening, in turn, has limited the ability of trauma services to provide patients with brief interventions during their hospital admission and subsequent referrals to treatment after discharge. The primary aim of this study was to examine current rates of alcohol and other drug screening with admitted injured adolescents across a national cohort of 10 pediatric trauma centers. METHODS: This retrospective observational study was nested within a larger adolescent screening, brief intervention, and referral to treatment implementation study (Clinicaltrials.gov NCT03297060). Ten pediatric trauma centers participated in a retrospective chart review of a random sample of adolescent trauma patients presenting for care between March 1, 2018, and November 30, 2018. RESULTS: Three hundred charts were abstracted across the 10 participating trauma centers (n = 30 per site). Screening rates varied substantially across centers from five (16.7%) to 28 (93.3%) of the 30 extracted charts. The most frequent screening type documented was blood alcohol concentration (BAC) (N = 80, 35.2% of all screens), followed by the CRAFFT (N = 79, 26.3%), and then the urine drug screen (UDS) (N = 77, 25.6%). The BAC test identified 11 patients as positive for recent alcohol use. The CRAFFT identified 11 positive patients. CONCLUSIONS: Alcohol and drug screening is underutilized for adolescents admitted to pediatric trauma centers. More research is warranted on how best to utilize the teachable moment of the pediatric trauma visit to ensure comprehensive screening of adolescent alcohol or other drug (AOD) use.

Integrated multi-wavelength control of an ion qubit.

Monolithic integration of control technologies for atomic systems is a promising route to the development of quantum computers and portable quantum sensors1-4. Trapped atomic ions form the basis of high-fidelity quantum information processors5,6 and high-accuracy optical clocks7. However, current implementations rely on free-space optics for ion control, which limits their portability and scalability. Here we demonstrate a surface-electrode ion-trap chip8,9 using integrated waveguides and grating couplers, which delivers all the wavelengths of light required for ionization, cooling, coherent operations and quantum state preparation and detection of Sr+ qubits. Laser light from violet to infrared is coupled onto the chip via an optical-fibre array, creating an inherently stable optical path, which we use to demonstrate qubit coherence that is resilient to platform vibrations. This demonstration of CMOS-compatible integrated photonic surface-trap fabrication, robust packaging and enhanced qubit coherence is a key advance in the development of portable trapped-ion quantum sensors and clocks, providing a way towards the complete, individual control of larger numbers of ions in quantum information processing systems.

Association of Insurance Status With Treatment and Outcomes in Pediatric Patients With Severe Traumatic Brain Injury.

OBJECTIVE: To determine whether a health insurance disparity exists among pediatric patients with severe traumatic brain injury using the National Trauma Data Bank. DESIGN: Retrospective cohort study. SETTING: National Trauma Data Bank, a dataset containing more than 800 trauma centers in the United States. PATIENTS: Pediatric patients (< 18 yr old) with a severe isolated traumatic brain injury were identified in the National Trauma Database (years 2007-2016). Isolated traumatic brain injury was defined as patients with a head Abbreviated Injury Scale score of 3+ and excluded those with another regional Abbreviated Injury Scale of 3+. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Procedure codes were used to identify four primary treatment approaches combined into two classifications: craniotomy/craniectomy and external ventricular draining/intracranial pressure monitoring. Diagnostic criteria and procedure codes were used to identify condition at admission, including hypotension, Glasgow Coma Scale, mechanism and intent of injury, and Injury Severity Score. Children were propensity score matched using condition at admission and other characteristics to estimate multivariable logistic regression models to assess the associations among insurance status, treatment, and outcomes. Among the 12,449 identified patients, 91.0% (n = 11,326) had insurance and 9.0% (n = 1,123) were uninsured. Uninsured patients had worse condition at admission with higher rates of hypotension and higher Injury Severity Score, when compared with publicly and privately insured patients. After propensity score matching, having insurance was associated with a 32% (p = 0.001) and 54% (p < 0.001) increase in the odds of cranial procedures and monitor placement, respectively. Insurance coverage was associated with 25% lower odds of inpatient mortality (p < 0.001). CONCLUSIONS: Compared with insured pediatric patients with a traumatic brain injury, uninsured patients were in worse condition at admission and received fewer interventional procedures with a greater odds of inpatient mortality. Equalizing outcomes for uninsured children following traumatic brain injury requires a greater understanding of the factors that lead to worse condition at admission and policies to address treatment disparities if causality can be identified.

Air Guns: A Contemporary Review of Injuries at Six Pediatric Level I Trauma Centers.

BACKGROUND: Studies spanning the last three decades demonstrated the injury causing capability of air gun (AG) projectiles. Recent studies have suggested the impact and incidence of these injuries may be declining because of edcational efforts. We hypothesize that injuries in the pediatric population resulting from AGs remain a significant health concern. METHODS: A retrospective review (1/1/2007 to 12/31/2016), of AG-injured children < 19 years old, was performed across six level I Pediatric Trauma Centers, part of the ATOMAC research consortium. AG injuries were defined as injuries sustained by ball-bearing or pellet air-powered guns. Paint ball and soft foam AGs were excluded. Following institutional review board approval, patients were identified by ICD code from the trauma registry. Included were demographic data, injury severity scores, length of stay (LOS), outcome at discharge, and overall cost of admission. Descriptive statistics and parametric tests were employed. RESULTS: A total of 499 patients sustained injuries. Mean age 9.5 (±4.0) y; 81% of victims were male; all survived to hospital discharge. 30% (n = 151) required operative intervention. Hospital LOS was 2.3 (±2.2) d; with mean cost of $23,756 (±$34,441). Injury severity score mean of 3.7 (±4.6) on admission. Over 40% of the injuries to the head/thorax that were severe (AIS ≥ 3) required operative intervention (P < 0.001). CONCLUSIONS: AG injuries to the head or thorax seen at trauma centers were likely to require operative management. While no fatalities occurred, the cost was substantial. This study demonstrates pediatric injuries resulting from AG projectiles remain a significant health concern.

Use of Laparoscopy in Pediatric Blunt and Spleen Injury: An Unexpectedly Common Procedure After Cessation of Bleeding.

Background: Recently, several series have reported the use of laparoscopy in pediatric trauma, most commonly for bowel and pancreatic injury within the first 12 or 24 hours. During a multicenter trial at 10 Level 1 pediatric trauma centers, selective use of laparoscopy in children with blunt liver or spleen injury (BLSI) was noted. A secondary analysis was performed to describe the frequency and application of these procedures to pediatric BLSI. Patients and Methods: Prospective data were collected on all children age ≤18 years with BLSI presenting to 1 of 10 pediatric trauma centers. An unplanned secondary analysis of children who underwent laparoscopy was done. Results: Of 1008 children with BLSI, 59 initially underwent a laparotomy, but 11 underwent a laparoscopic procedure during their index admission; 1 of these was 22 hours postlaparotomy and 2 others were laparoscopy-assisted and converted to laparotomy. Median age of patients undergoing a laparoscopic procedure was 11.5 years (interquartile range [IQR]: 5.8-16.4). Laparoscopy was performed at 7 of the 10 centers. Median time to surgery was 42 hours (IQR: 8-96). Most patients had a liver (n = 6) injury; 4 had spleen and 1 had both. One of the laparoscopies was for pancreatic surgery, and 2 were for bowel injury (but converted to open). Conclusions: Laparoscopy was utilized in 16% of children requiring abdominal surgery after BLSI, with a median time of 42 hours postinjury. Uses included diagnostic laparoscopy, drain placement, laparoscopic pancreatectomy, and washout of hematoma.

Adherence to APSA activity restriction guidelines and 60-day clinical outcomes for pediatric blunt liver and splenic injuries (BLSI).

BACKGROUND: After NOM for BLSI, APSA guidelines recommend activity restriction for grade of injury +2 in weeks. This study evaluates activity restriction adherence and 60 day outcomes. METHODS: Non-parametric tests and logistic regression were utilized to assess difference between adherent and non-adherent patients from a 3-year prospective study of NOM for BLSI (≤18 years). RESULTS: Of 1007 children with BLSI, 366 patients (44.1%) met the inclusion criteria of a completed 60 day follow-up; 170 (46.4%) had liver injury, 159 (43.4%) had spleen injury and 37 (10.1%) had both. Adherence to recommended activity restriction was claimed by 279 (76.3%) patients; 49 (13.4%) reported non-adherence and 38 (10.4%) patients had unknown adherence. For 279 patients who adhered to activity restrictions, unplanned return to the emergency department (ED) was noted for 35 (12.5%) with 16 (5.7%) readmitted; 202 (72.4%) returned to normal activity by 60 days. No patient bled after discharge. There was no statistical difference between adherent patients (n = 279) and non-adherent (n = 49) for return to ED (χ2 = 0.8 [p < 0.4]) or readmission (χ2 = 3.0 [p < 0.09]); for 216 high injury grade patients, there was no difference between adherent (n = 164) and non-adherent (n = 30) patients for return to ED (χ2 = 0.6 [p < 0.4]) or readmission (χ2 = 1.7 [p < 0.2]). CONCLUSION: For children with BLSI, there was no difference in frequencies of bleeding or ED re-evaluation between patients adherent or non-adherent to the APSA activity restriction guideline. LEVEL OF EVIDENCE: Level II, Prognosis.

Massive transfusion in pediatric trauma: An ATOMAC perspective.

BACKGROUND/PURPOSE: Massive transfusion protocols (MTPs) are considered valuable in pediatric trauma. Important questions regarding the survival benefit and optimal blood component ratio remain unknown. METHODS: The study time frame was January 2007 through December 2013 five Level I Pediatric Trauma Centers reviewed all trauma activations involving children ≤18 years of age. Included were patients who either had the institutional MTP or received >20 mL/kg or > 2 units packed red blood cells (PRBCs). RESULTS: 110/202 qualified for inclusion. Median age was 5.9 years (3.0-11.4). 73% survived to discharge; median hospitalization was 10 (3.1-22.8) days. Survival did not vary by arrival hemoglobin (Hgb), gender or age. Partial prothrombin time (PTT), INR, GCS and injury severity score (ISS) significantly differed for nonsurvivors (all p < 0.05). Logistic regression found increased mortality (OR 3.08 (1.10-8.57), 95% CI; p = 0.031) per unit increase over a 1:1 ratio of pRBC:FFP. CONCLUSION: In pediatric trauma pRBC:FFP ratio of 1:1 was associated with the highest survival of severely injured children receiving massive transfusion. Ratios 2:1 or ≥3:1 were associated with significantly increased risk of death. These data support a higher proportion of plasma products for pediatric trauma patients requiring massive transfusion. LEVEL OF EVIDENCE: Level IV.

Reimaging in pediatric blunt spleen and liver injury.

BACKGROUND: APSA guidelines do not recommend routine reimaging for pediatric blunt liver or spleen injury (BLSI). This study characterizes the symptoms, reimaging, and outcomes associated with a selective reimaging strategy for pediatric BLSI patients. METHODS: A planned secondary analysis of reimaging in a 3-year multi-site prospective study of BLSI patients was completed. Inclusion required successful nonoperative management of CT confirmed BLSI without pancreas or kidney injury and follow up at 14 or 60 days. Patients with re-injury after discharge were excluded. RESULTS: Of 1007 patients with BLSI, 534 (55%) met inclusion criteria (median age: 10.18 [IQR: 6, 14]; 62% male). Abdominal reimaging was performed on 27/534 (6%) patients; 3 of 27 studies prompting hospitalization and/or intervention. Abdominal pain was associated with reimaging, but decreased appetite predicted imaging findings associated with readmission and intervention. CONCLUSION: Selective abdominal reimaging for BLSI was done in 6% of patients, and 11% of studies identified radiologic findings associated with intervention or re-hospitalization. A selective reimaging strategy appears safe, and even reimaging symptomatic patients rarely results in intervention. Reimaging after 14 days did not prompt intervention in any of the 534 patients managed nonoperatively. LEVEL OF EVIDENCE: Level II, Prognosis.

Negative Focused Abdominal Sonography for Trauma examination predicts successful nonoperative management in pediatric solid organ injury: A prospective Arizona-Texas-Oklahoma-Memphis-Arkansas + Consortium study.

BACKGROUND: Focused Abdominal Sonography for Trauma (FAST) examination has long been proven useful in the management of adult trauma patients, however, its utility in pediatric trauma patients is not as proven. Our goal was to evaluate the utility of a FAST examination in predicting the success or failure of nonoperative management (NOM) of blunt liver and/or spleen (BLSI) in the pediatric trauma population. METHODS: A retrospective analysis of a prospective observational study of patients younger than 18 years presenting with BLSI to one of ten Level I pediatric trauma centers between April 2013 and January 2016. 1,008 patients were enrolled and 292 had a FAST examination recorded. We analyzed failure of NOM of BLSI in the pediatric trauma population. We then compared FAST examination alone or in combination with the pediatric age adjusted shock index (SIPA) as it relates to success of NOM of BLSI. RESULTS: Focused Abdominal Sonography for Trauma examination had a negative predictive value (NPV) of 97% and positive predictive value (PPV) of 13%. The odds ratio of failing with a positive FAST examination was 4.9 and with a negative FAST was 0.20. When combined with SIPA, a positive FAST examination and SIPA had a PPV of 17%, and an odds ratio for failure of 4.9. The combination of negative FAST and SIPA had an NPV of 96%, and the odds ratio for failure was 0.20. CONCLUSION: Negative FAST is predictive of successful NOM of BLSI. The addition of a positive or negative SIPA score did not affect the PPV or NPV significantly. Focused Abdominal Sonography for Trauma examination may be useful clinically in determining which patients are not at risk for failure of NOM of BLSI and do not require monitoring in an intensive care setting. LEVEL OF EVIDENCE: Prognostic study, level IV; therapeutic/care management, level IV.

Resource utilization and indications for helicopter transport of head-injured children.

INTRODUCTION: Helicopter emergency medical services (HEMS) have provided benefit for severely injured patients. However, HEMS are likely overused for the transportation of both adult and pediatric trauma patients. In this study, we aim to evaluate the degree of overuse of helicopter as a mode of transport for head-injured children. In addition, we propose criteria that can be used to determine if a particular patient is suitable for air versus ground transport. MATERIALS AND METHODS: We identified patients who were transported to our facility for head injuries. We included only those patients who were transported from another facility and who were seen by the neurosurgical service. We recorded a number of data points including age, gender, race, Glasgow Coma Score (GCS), and intubation status. We also collected data on a number of imaging findings such as mass effect, edema, intracranial hemorrhage, and skull fractures. Patients undergoing emergent nonneurosurgical intervention were excluded. RESULTS: Of the 373 patients meeting inclusion criteria, 116 (31.1%) underwent a neurosurgical procedure or died and were deemed appropriate for helicopter transport. The remaining 68.9% of patients survived their injuries without neurosurgical intervention and were deemed nonappropriate for helicopter transport. Multivariable logistic regression identified GCS 3-8 and/or presence of mass effect, edema, epidural hematoma (EDH), and open-depressed skull fracture as appropriate indications for helicopter transport. CONCLUSIONS: The majority of patients transported to our facility by helicopter survived their head injury without need for neurosurgical intervention. Only those patients meeting clinical (GCS 3-8) or radiographic (mass effect, edema, EDH, open-depressed skull fracture) criteria should be transported by air. LEVEL OF EVIDENCE: Level III (Diagnostic Study).