PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study.

BACKGROUND: Cervical spine injuries in children are uncommon but potentially devastating; however, indiscriminate neck imaging after trauma unnecessarily exposes children to ionising radiation. The aim of this study was to derive and validate a paediatric clinical prediction rule that can be incorporated into an algorithm to guide radiographic screening for cervical spine injury among children in the emergency department. METHODS: In this prospective observational cohort study, we screened children aged 0-17 years presenting with known or suspected blunt trauma at 18 specialised children's emergency departments in hospitals in the USA affiliated with the Pediatric Emergency Care Applied Research Network (PECARN). Injured children were eligible for enrolment into derivation or validation cohorts by fulfilling one of the following criteria: transported from the scene of injury to the emergency department by emergency medical services; evaluated by a trauma team; and undergone neck imaging for concern for cervical spine injury either at or before arriving at the PECARN-affiliated emergency department. Children presenting with solely penetrating trauma were excluded. Before viewing an enrolled child's neck imaging results, the attending emergency department clinician completed a clinical examination and prospectively documented cervical spine injury risk factors in an electronic questionnaire. Cervical spine injuries were determined by imaging reports and telephone follow-up with guardians within 21-28 days of the emergency room encounter, and cervical spine injury was confirmed by a paediatric neurosurgeon. Factors associated with a high risk of cervical spine injury (>10%) were identified by bivariable Poisson regression with robust error estimates, and factors associated with non-negligible risk were identified by classification and regression tree (CART) analysis. Variables were combined in the cervical spine injury prediction rule. The primary outcome of interest was cervical spine injury within 28 days of initial trauma warranting inpatient observation or surgical intervention. Rule performance measures were calculated for both derivation and validation cohorts. A clinical care algorithm for determining which risk factors warrant radiographic screening for cervical spine injury after blunt trauma was applied to the study population to estimate the potential effect on reducing CT and x-ray use in the paediatric emergency department. This study is registered with ClinicalTrials.gov, NCT05049330. FINDINGS: Nine emergency departments participated in the derivation cohort, and nine participated in the validation cohort. In total, 22 430 children presenting with known or suspected blunt trauma were enrolled (11 857 children in the derivation cohort; 10 573 in the validation cohort). 433 (1·9%) of the total population had confirmed cervical spine injuries. The following factors were associated with a high risk of cervical spine injury: altered mental status (Glasgow Coma Scale [GCS] score of 3-8 or unresponsive on the Alert, Verbal, Pain, Unresponsive scale [AVPU] of consciousness); abnormal airway, breathing, or circulation findings; and focal neurological deficits including paresthesia, numbness, or weakness. Of 928 in the derivation cohort presenting with at least one of these risk factors, 118 (12·7%) had cervical spine injury (risk ratio 8·9 [95% CI 7·1-11·2]). The following factors were associated with non-negligible risk of cervical spine injury by CART analysis: neck pain; altered mental status (GCS score of 9-14; verbal or pain on the AVPU; or other signs of altered mental status); substantial head injury; substantial torso injury; and midline neck tenderness. The high-risk and CART-derived factors combined and applied to the validation cohort performed with 94·3% (95% CI 90·7-97·9) sensitivity, 60·4% (59·4-61·3) specificity, and 99·9% (99·8-100·0) negative predictive value. Had the algorithm been applied to all participants to guide the use of imaging, we estimated the number of children having CT might have decreased from 3856 (17·2%) to 1549 (6·9%) of 22 430 children without increasing the number of children getting plain x-rays. INTERPRETATION: Incorporated into a clinical algorithm, the cervical spine injury prediction rule showed strong potential for aiding clinicians in determining which children arriving in the emergency department after blunt trauma should undergo radiographic neck imaging for potential cervical spine injury. Implementation of the clinical algorithm could decrease use of unnecessary radiographic testing in the emergency department and eliminate high-risk radiation exposure. Future work should validate the prediction rule and care algorithm in more general settings such as community emergency departments. FUNDING: The Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Health Resources and Services Administration of the US Department of Health and Human Services in the Maternal and Child Health Bureau under the Emergency Medical Services for Children programme.

Multidisciplinary Simulation for Blunt and Penetrating Pediatric Trauma Utilizing Standard and Rapid Cycle Deliberate Practice Models.

Introduction: Pediatric trauma resuscitations are low-frequency, high-stakes events that require skilled multidisciplinary teams with strong medical knowledge and communication skills. Methods: This pediatric trauma simulation training session included two cases and formats. The first case was designed in a traditional format and featured a 12-month-old child with inflicted blunt head and abdominal trauma. The second case was organized in successive rounds utilizing the rapid cycle deliberate practice (RCDP) model and featured an 18-month-old with gunshot wounds to the abdomen and chest. Educational objectives included effective communication in a multidisciplinary team, timely completion of primary and secondary surveys, awareness of systems and processes related to trauma care, and increasing competency with low-frequency pediatric trauma skills. Necessary equipment included high-fidelity toddler-sized mannequins, chest tube task trainer or applicable mannequin and equipment, intubation equipment and supplies, intraosseous access, and blood products with rapid delivery infusers. This training session was designed for learners in a multidisciplinary team including physician trainees, nurses, and advanced practice providers; adjustments could be made to the team members as desired. Results: Quantitative and qualitative evaluations demonstrated high learner satisfaction and engagement, particularly in the RCDP style of learning. Discussion: Multidisciplinary team practice of pediatric trauma scenarios, particularly utilizing the RCDP simulation model, provides the opportunity to improve teamwork and communication, practice procedural skills, and deepen team members' understanding of and comfort with trauma resuscitations.

Development of the Red Flag Scorecard Screening Tool for Identification of Child Physical Abuse in the Emergency Department.

BACKGROUND: Child physical abuse (CPA) may have subtle presenting signs and can be challenging to identify, especially at emergency centers that do not treat many children. The purpose of this study is to determine the performance of a simple CPA screening tool to identify children most at risk. METHODS: A screening tool ("Red Flag Scorecard") was developed utilizing available evidence-based presenting findings and expert consensus. Retrospective chart review of children treated for injuries between 2014 and 2018 with suspected or confirmed CPA at a level I pediatric trauma center was then performed to validate the screening tool. Descriptive statistics and chi square tests were used to analyze the data. RESULTS: Of 408 cases, median age was 7 months and 60% were male. The majority (69%) were under 1 year of age. The most common history finding was delay in seeking care (58%, 236/408; p = <0.0001), the most common physical exam finding was bruising located away from bony prominences (45%, 182/408), and the most common imaging finding was unexplained brain injury (49%, 201/408). The majority, 84% (343/408), had at least 2 history findings. The combination score of at least 2 history findings and 1 physical/imaging finding was most sensitive (79%). The scorecard would have identified 94% of children who presented with no trauma history (198/211). CONCLUSION: The Red Flag Scorecard may serve as a quick and effective screening tool to raise suspicion for child physical abuse in emergency centers. Prospective study is planned to validate these results. LEVEL OF EVIDENCE: IV.

Barely benign: The dangers of BB and other nonpowder guns.

OBJECTIVE: To characterize the risks of nonpowder guns commonly used by children for recreation. METHODS: We conducted a retrospective review of children ≤18 years of age treated for nonpowder gun injuries at a pediatric level I trauma center during 2013-2017. Demographics, injury characteristics, treatments, and outcomes were reviewed and analyzed using descriptive statistics. RESULTS: Forty-six cases were identified; of these, 78% were male and the median age was 10 years (IQR 7-13). All guns were either ball-bearing or pellet guns. Eighty-five percent (38/46) of injuries were penetrating. The most common location was the head and neck (28%), followed by the anterior torso (26%) and eye (24%). Significant injuries that penetrated organs or body cavities occurred in 39% (18/46) and included subarachnoid hemorrhage; lung, liver, and kidney lacerations; pulmonary artery injury; and tracheal injury. Nine percent (4/26) were admitted to the intensive care unit, 37% (17/46) underwent surgery, and there were no deaths. DISCUSSION: Injuries from recreational nonpowder guns such as ball-bearing or pellet guns can cause severe injuries in children. A thorough penetrating trauma workup should always be undertaken. Safety precautions should be taken when using these guns and access to young children should be restricted. LEVEL OF EVIDENCE: Prognosis level IV.

The Pediatric Submersion Score Predicts Children at Low Risk for Injury Following Submersions.

OBJECTIVES: Pediatric submersion victims often require admission. We wanted to identify a cohort of children at low risk for submersion-related injury who can be safely discharged from the emergency department (ED) after a period of observation. METHODS: This was a single-center retrospective derivation/validation cross-sectional study of children (0-18 years) who presented postsubmersion to a tertiary care, children's hospital ED from 2008 to 2015. We reviewed demographics, comorbidities, and prehospital and ED course. Primary outcome was safe discharge at 8 hours postsubmersion: normal mentation and vital signs. To identify potential scoring factors, any p-value of ≤0.25 was included in binary logistic regression; p-values < 0.05 were included in the final score. In the validation data set, we generated a one-point scoring system for each normal ED item. Receiver operating characteristic curves with area under the curve (AUC) were generated to test sensitivity and specificity. RESULTS: The derivation data set consisted of 356 patients and validation data set of 89 patients. Five factors generated a safe discharge score at 8 hours: normal ED mentation, normal ED respiratory rate, absence of ED dyspnea, absence of need for airway support (bag-valve mask ventilation, intubation, and CPAP), absence of ED systolic hypotension (maximum score = 5; range = 0-5). Only the 80 patients with values for all five factors were included in the sensitivity/specificity analysis. This resulted in an AUC of 0.81 (95% confidence interval [CI] = 0.71-0.91; p < 0.001). Based on the sensitivity/specificity analysis, the discriminative ability peaks at 75% with a score of ≥3.5. A score of 4 or higher in the ED would suggest a safe discharge at 8 hours (sensitivity = 88.2% [95% CI = 72.5%-96.7%]; specificity = 62.9% [95% CI = 44.9%-78.5%]; positive predictive value = 69.8% [95% CI = 53.9%-82.8%]; negative predictive value = 84.6% [95% CI = 65.1%-95.6%]). CONCLUSIONS: A risk score can identify children at low risk for submersion-related injury who can be safely discharged from the ED after observation.

Characteristics and outcomes of acute pediatric blunt torso trauma based on injury intent.

INTRODUCTION: Blunt trauma is a leading cause of pediatric morbidity. We compared injuries, interventions and outcomes of acute pediatric blunt torso trauma based on intent. METHODS: We analyzed de-identified data from a prospective, multi-center emergency department (ED)-based observational cohort of children under age eighteen. Injuries were classified based on intent (unintentional/inflicted). We compared demographic, physical and laboratory findings, ED disposition, hospitalization, need for surgery, 30-day mortality, and cause of death between groups using Chi-squared or Fisher's test for categorical variables, and Mann-Whitney test for non-normal continuous factors comparing median values and interquartile ranges (IQR). RESULTS: There were 12,044 children who sustained blunt torso trauma: Inflicted=720 (6%); Unintentional=9563 (79.4%); Indeterminate=148 (1.2%); Missing=1613 (13.4%). Patients with unintentional torso injuries significantly differed from those with inflicted injuries in median age in years (IQR) [10 (5, 15) vs. 14 (8, 16); p-value<0.001], race, presence of pelvic fractures, hospitalization and need for non-abdominal surgery. Mortality rates did not differ based on intent. Further adjustment using binary, logistic regression revealed that the risk of pelvic fractures in the inflicted group was 96% less than the unintentional group (OR: 0.04; 95%CI: 0.01-0.26; p-value=0.001). CONCLUSIONS: Children who sustain acute blunt torso trauma due to unintentional causes have a significantly higher risk of pelvic fractures and are more likely to be hospitalized compared to those with inflicted injuries.

Management of pediatric snake bites: are we doing too much?

BACKGROUND: The optimal management of children with snake bite injuries is not well defined. The purpose of this study was to review the use of antivenom, diagnostic tests, and antibiotics in children bitten by venomous snakes in a specific geographic region (Southeast Texas). METHODS: This is a retrospective single-center review of all patients with snake bite injury from 1/2006 to 6/2012. An envenomated bite was defined as causing edema, discoloration of the skin, necrosis, or systemic effects. The severity of injury was scored using a novel 4-point scale based on initial physical examination alone. RESULTS: One hundred fifty-one children (mean age 8.4±4.3years) were treated for a snake bite. There were no mortalities. Lower extremity injuries were most common (60%). Most bites were from copperheads (43%). Envenomation was evident in 82% (average wound score: 2.61±0.81). The median hospital stay for admitted patients (79%) was 2days (range 1-7). Four patients required surgery for complications of the snake bite. Fifty-two children (34%) received CroFab, with one allergic reaction. 22/135 (16%) had evidence of coagulopathy. Seventy-two children (48%) received IV antibiotics. CONCLUSION: Despite a high rate of envenomated bites in Southeast Texas, significant morbidity is rare. Children with an envenomation score of 1 or 2 are unlikely to be coagulopathic, suggesting that laboratory investigation should be reserved for patients with higher scores. The indications for the administration of CroFab deserve further prospective study.