Emergency department visits for mild traumatic brain injury in early childhood.

BACKGROUND: Brain injury during early childhood may disrupt key periods of neurodevelopment. Most research regarding mild traumatic brain injury (mTBI) has focused on school-age children. We sought to characterize the incidence and healthcare utilization for mTBI in young children presenting to U.S. emergency departments (ED). METHODS: The Nationwide Emergency Department Sample was queried for children age 0-6 years with mTBI from 2016 to 2019. Patients were excluded for focal or diffuse TBI, drowning or abuse mechanism, death in the ED or hospital, Injury Severity Score > 15, neurosurgical intervention, intubation, or blood product transfusion. RESULTS: National estimates included 1,372,291 patient visits: 63.5% were two years or younger, 57.5% were male, and 69.4% were injured in falls. The most common head injury diagnosis was "unspecified injury of head" (83%); this diagnosis decreased in frequency as age increased, in favor of a concussion diagnosis. Most patients were seen at low pediatric volume EDs (64.5%) and non-children's hospital EDs (86.2%), and 64.9% were seen at a non-teaching hospital. Over 98% were treated in the ED and discharged home. Computed tomography of the head and cervical spine were performed in 18.7% and 1.6% of patients, respectively, less often at children's hospitals (OR = 0.55, 95%CI = 0.41-0.76 for head and OR = 0.19, 95%CI = 0.11-0.34 for cervical spine). ED charges resulted in $540-681 million annually, and more than half of patients utilized Medicaid. CONCLUSIONS: Early childhood mTBI is prevalent and results in high financial burden in the U.S. There is wide variation in diagnostic coding and computed tomography scanning amongst EDs. More focused research is needed to identify optimal diagnostic tools and management strategies.

Efficacy of Smartphone Active and Passive Virtual Reality Distraction vs Standard Care on Burn Pain Among Pediatric Patients: A Randomized Clinical Trial.

Importance: It is unknown whether smartphone-based virtual reality (VR) games are effective in reducing pain among pediatric patients in real-world burn clinics. Objective: To evaluate the efficacy of a smartphone VR game on dressing pain among pediatric patients with burns. Design, Setting, and Participants: This randomized clinical trial included children aged 6 to 17 years who seen in the outpatient clinic of a large American Burn Association-verified pediatric burn center and level I pediatric trauma center between December 30, 2016, and January 23, 2019. Speaking English as their primary language was an inclusion criterion. Intention-to-treat data analyses were conducted from December 2019 to March 2020. Interventions: Active VR participants played a VR game; passive VR participants were immersed in the same VR environment without interactions. Both groups were compared with a standard care group. One researcher administered VR and observed pain while another researcher administered a posttrial survey that measured the child's perceived pain and VR experience. Nurses were asked to report the clinical utility. Main Outcomes and Measures: Patients self-reported pain using a visual analog scale (VAS; range, 0-100). A researcher observed patient pain based on the Face, Legs, Activity, Cry, and Consolability-Revised (FLACC-R) scale. Nurses were asked to report VR helpfulness (range, 0-100; higher scores indicate more helpful) and ease of use (range, 0-100; higher scores indicate easier to use). Results: A total of 90 children (45 [50%] girls, mean age, 11.3 years [95% CI, 10.6-12.0 years]; 51 [57%] White children) participated. Most children had second-degree burns (81 [90%]). Participants in the active VR group had significantly lower reported overall pain (VAS score, 24.9 [95% CI, 12.2-37.6]) compared with participants in the standard care control group (VAS score, 47.1 [95% CI, 32.1-62.2]; P = .02). The active VR group also had a lower worst pain score (VAS score, 27.4 [95% CI, 14.7-40.1]) than both the passive VR group (VAS score, 47.9 [95% CI, 31.8-63.9]; P = .04) and the standard care group (VAS score, 48.8 [95% CI, 31.1-64.4]; P = .03). Simulator sickness scores (range, 0-60; lower scores indicate less sickness) were similar for active VR (19.3 [95% CI, 17.5-21.1]) and passive VR groups (19.5 [95% CI, 17.6-21.5]). Nurses also reported that the VR games could be easily implemented in clinics (helpfulness, active VR: 84.2; 95% CI, 74.5-93.8; passive VR: 76.9; 95% CI, 65.2-88.7; ease of use, active VR: 94.8, 95% CI, 91.8-97.8; passive VR: 96.0, 95% CI, 92.9-99.1). Conclusions and Relevance: In this study, a smartphone VR game was effective in reducing patient self-reported pain during burn dressing changes, suggesting that VR may be an effective method for managing pediatric burn pain. Trial Registration: ClinicalTrials.gov Identifier: NCT04544631.

Epidemiology and trend of US pediatric burn hospitalizations, 2003-2016.

BACKGROUND: Thermal injury is a leading cause of unintentional pediatric trauma morbidity and mortality. METHODS: This retrospective analysis of the 2003-2016 Kids' Inpatient Database (KID) included children <18 years old with a burn principal diagnosis. The objectives were to describe the trend of US pediatric burn hospital admissions and the patient and hospital characteristics of admitted children in 2016. The trends (2003-2012) and (2012-2016) were evaluated separately due to the 2015 implementation of International Classification of Diseases, Tenth Revision (ICD-10). RESULTS: The population rate of pediatric burn admissions decreased by 4.6% from 2003 to 2012, but the proportion of admissions to hospitals with burn pediatric patient volumes≥100 increased by 63.9%. The overall mortality rate of hospitalized burn patients decreased by 48.1%. Median length of stay increased slightly for patients with a burn ≥20% total body surface area (TBSA) but decreased for patients with TBSA burn <20%. From 2012 to 2016, the population rate decreased by 13.4%. In 2016, an estimated 8160 children were admitted with a burn principal diagnosis, and 41.4% transferred in from other facilities. Children age 1-4 years were the most commonly admitted age group (49.7%). Patients with ≥20% TBSA burns accounted for 7.8% of admissions (95% confidence interval [CI]: 5.1-10.4%). Burn-related complications were documented in 5.9% of admissions (95% CI: 4.6-7.1%). CONCLUSION: Pediatric burn hospitalizations and burn-related mortality have decreased over time. The increases in transfers and admissions to hospitals with high pediatric burn volumes suggest increasing regionalization of care.

Variation in acute fluid resuscitation among pediatric burn centers.

BACKGROUND: Accurate resuscitation of pediatric patients with large thermal injury is critical to achieving optimal outcomes. The goal of this project was to describe the degree of variability in resuscitation guidelines among pediatric burn centers and the impact on fluid estimates. METHODS: Five pediatric burn centers in the Pediatric Injury Quality Improvement Collaborative (PIQIC) contributed data from patients with ≥15% total body surface area (TBSA) burns treated from 2014 to 2018. Each center's resuscitation guidelines and guidelines from the American Burn Association were used to calculate estimated 24-h fluid requirements and compare these values to the actual fluid received. RESULTS: Differences in the TBSA burn at which fluid resuscitation was initiated, coefficients related to the Parkland formula, criteria to initiate dextrose containing fluids, and urine output goals were observed. Three of the five centers' resuscitation guidelines produced statistically significant lower mean fluid estimates when compared with the actual mean fluid received for all patients across centers (4.53 versus 6.35ml/kg/% TBSA, p<0.001), (4.90 versus 6.35ml/kg/TBSA, p=0.002) and (3.38 versus 6.35ml/kg/TBSA, p<0.0001). CONCLUSIONS: This variation in practice patterns led to statistically significant differences in fluid estimates. One center chose to modify its resuscitation guidelines at the conclusion of this study.

Assessing opioid administration in pediatric burn patients with nonsurgical management.

BACKGROUND: Despite the vast literature studying the opioid crisis, sparse data describe this in the pediatric burn population. This study sought to assess patient-level characteristics and their potential effects on opioid administration in nonsurgical pediatric burn inpatients. METHODS: Admitted burn patients from 2013 to 2018 with nonsurgical management at an American Burn Association (ABA) verified pediatric burn center were retrospectively identified. Morphine milligram equivalents by weight (MME/kg) per admission were evaluated through a multiple loglinear regression with race, sex, age, total body surface area burned (TBSA), and burn depth as predictors. Simple linear regression was used to evaluate the temporal trend of median opioid utilization. RESULTS: A total of 806 patients (55% White, 35% Black, 5% Hispanic, 5% Other) were included. In an adjusted analysis, no differences in opioid administration were seen by sex, burn degree, or for Blacks and Hispanics when compared with Whites. Increased MME/kg was associated with older age (10-18 years; p<0.0001) and larger burns (>5% TBSA burned; p<0.0001). From 2013 to 2018, median MME/kg per admission declined significantly (2013:0.21, 2018:0.09; p=0.0103). CONCLUSIONS: Nonsurgical burn patients who were older and presented with larger TBSA experienced marked increases in opioid utilization. Overall, opioid administration decreased over time.

The association between traumatic dental and brain injuries in American children.

BACKGROUND/AIM: It is crucial that dentists who treat traumatic dental injuries rule out concomitant brain injuries. Despite anatomic proximity, controversy exists regarding association between facial trauma and head injury. The aim of this study was to examine the association between dento-alveolar trauma (DAT) and traumatic brain injuries (TBI) using a national dataset of emergency department (ED) visits. MATERIAL AND METHODS: Nationwide Emergency Department Sample (NEDS) data, one of the Healthcare Cost and Utilization Project (HCUP) datasets, were analyzed. Encounters of patients age 0-18 years with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes associated with DAT and TBI in the 2010-2014 NEDS were identified. Data were analyzed using descriptive statistics, chi-square test, and logistic regression models to investigate the association between DAT and TBI and factors associated with TBI in DAT-positive patients. RESULTS: During the study period, 6 281 658 ED visits were associated with traumatic injuries. DAT was recorded in 93 408 (1.5%) and TBI was recorded in 996 334 (15.9%) of these traumatic injury visits. Within the group of DAT-positive encounters, 7035 (7.5%) had codes associated with TBI. Of trauma encounters where a DAT was not involved (6 188 250 encounters), 989 299 (16%) had an associated TBI code. Patients with DAT had 0.20 odds of having TBI (95% CI, 0.19-0.20, P < .0001) compared with patients who did not have DAT when all other confounding variables were kept constant. Having multiple injuries, being involved in motor vehicle crashes, and injuries due to assault were associated with higher odds of concomitant TBI in patients who sustained DAT. CONCLUSIONS: There was an inverse association between DAT and TBI in this study population.

Impact of a Dedicated Advanced Practice Provider Model for Pediatric Trauma and Burn Patients.

BACKGROUND: A free-standing, academic Level 1 pediatric trauma and verified pediatric burn center created a dedicated trauma and burn service advanced practice provider role, and restructured rounds. The changes were implemented to improve patient care. METHODS: A pre and postintervention study using historical controls was performed to compare 18 months prior (preintervention) and 18 months following (postintervention) practice changes. Data collection included demographics, injury characteristics, length of stay (LOS), complications, and patient satisfaction results. RESULTS: When compared with the preintervention period, the postintervention period had a higher patient volume and an increased number of severely injured patients. Mean LOS was stable for all patients and trauma patients, as were the complication rates related to trauma and burns. However, the mean LOS/total body surface area (TBSA) burned decreased from 1.36 to 1.04 days/TBSA (p = .160) in burn patients and from 0.84 to 0.62 days/TBSA (p = .060) in those with more than 5% TBSA. Patient satisfaction scores were stable in the categories of nursing care and the child's physician. Despite an increase in the volume and severity of patients, there was a clinically meaningful decrease in burn patient LOS/TBSA. CONCLUSION: The addition of a dedicated advanced practice provider and restructured trauma service appears to provide a benefit to pediatric burn patients.

Efforts to catalogue non-governmental organizations with a role in global burn relief.

INTRODUCTION: Non-governmental organizations (NGOs) have been instrumental in the treatment of traumatic injuries, including burns, particularly in low- and middle-income counties. The purpose of this project was to catalogue burn injury related NGO activities, describe coordinated efforts, and provide insight to burn health care professionals seeking volunteer opportunities. METHODS: Eligible burn NGOs were identified through internet searches, literature reviews, and social media. The organizations' websites were reviewed for eligibility and contact was attempted to confirm details. Global health organizations, including the World Health Organization, were consulted for their viewpoints. RESULTS: We identified 27 unique NGOs working in the area of burn care in African countries, all with differing missions, capacities, recruitment methods, and ability to respond to disaster. We also describe 14 global NGOs, some of which accept volunteers. Some NGOs were local, while others were headquartered in western countries. CONCLUSIONS: To our knowledge, this is the first effort towards the establishment of a Burn-NGO catalogue. Challenges included: frequent shifts in geographical regions supported, lack of collaboration among organizations, availability of public information, and austere environments. We invite collaborators to assist in the creation of a comprehensive, interactive and complete catalogue.

Pediatric blunt cerebrovascular injuries: A national trauma database study.

BACKGROUND: The incidence of blunt cerebrovascular injuries (BCVIs) in children is unknown. We aimed to determine the rate and consequences of BCVIs in pediatric blunt trauma patients. METHODS: We queried the National Trauma Data Bank (NTDB) for all blunt trauma patients between 2007 and 2014. BCVI patients were identified by ICD-9 codes. Demographic, emergency room, and concomitant injury data were analyzed. RESULTS: There were 732,702 blunt trauma patients, and 1682 BCVIs were identified (0.23%). 791 (47%) sustained carotid artery injuries (CAIs), 957 (57%) had vertebral artery injuries (VAIs), and 4% of patients sustained both. A majority of the injuries occurred in white patients (61%) and in motor vehicle accidents (53%). The average age was 12.1 ±â€¯5.4 years. CAIs had more skull base fractures (55% vs 35%, p < 0.0001), and cervical spine fractures were more common in VAIs (26 vs 11%, p < 0.0001). Intensive care length of stay was longer in the CAI patients (9.2 vs 7.9 days, p = 0.03), as was length of stay (12.5 vs 9.7 days, p = 0.0002). 5% of CAI patients were coded for stroke, versus 2% of VAIs (p = 0.002). CONCLUSIONS: BCVIs are rare in children. Vertebral injuries are more common. Carotid injuries are associated with a longer length of stay and higher stroke rates. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: III.

Comparison of manual and computer assigned injury severity scores.

BACKGROUND: The study objective was to compare the ISS manually assigned by hospital personnel and those generated by the ICDPIC software for value agreement and predictive power of length of stay (LOS) and mortality. METHODS: We used data from the 2010-2016 trauma registry of a paediatric trauma centre (PTC) and 2014 National Trauma Data Bank (NTDB) hospitals that reported manually coded ISS. Agreement analysis was performed between manually and computer assigned ISS with severity groupings of 1-8, 9-15, 16-25 and 25-75. The prediction of LOS was compared using coefficients of determination (R2) from linear regression models. Mortality predictive power was compared using receiver operating characteristic (ROC) curves from logistic regression models. RESULTS: The proportion of agreement between manually and computer assigned ISS in PTC data was 0.84 and for NTDB was 0.75. Analysing predictive power for LOS in the PTC sample, the R2=0.19 for manually assigned scores, and the R2=0.15 for computer assigned scores (p=0.0009). The areas under the ROC curve indicated a mortality predictive power of 0.95 for manually assigned scores and 0.86 for computer assigned scores in the PTC data (p=0.0011). CONCLUSIONS: Manually and computer assigned ISS had strong comparative agreement for minor injuries but did not correlate well for critical injuries (ISS=25-75). The LOS and mortality predictive power were significantly higher for manually assigned ISS when compared with computer assigned ISS in both PTC and NTDB data sets. Thus, hospitals should be cautious about transitioning to computer assigned ISS, specifically for patients who are critically injured.

The impact of driving time on pediatric TBI follow-up visit attendance.

Objective: Examine the effect of driving time on follow-up visit attendance for children hospitalized with a traumatic brain injury (TBI). We hypothesized that families who lived further from the hospital would show poorer follow-up attendance.Participants: 368 children admitted to the hospital with TBI.Design & Outcome Measures: Using a retrospective chart review, we calculated driving time from patients' homes. The primary outcome was attendance at the first appointment post-discharge. We used logistic regression to examine the effect of driving time on attendance, including an analysis of the effects of injury and sociodemographic covariates on the model.Results: Majority of children attended their first appointment. Patients living 30-60 min from the hospital were most likely to attend, and those living 15 min away were least likely to attend. After adjusting for patient characteristics, families with driving time of 30-60 min had significantly higher odds of returning for follow-up than those with driving time <15 min, though the significance of this relationship disappeared after specific socioeconomic (SES) factors were included.Conclusions: Distance plays a significant role on follow-up attendance for pediatric patients with TBI. However, neighborhood SES may be an additional factor that influences the significance of the distance effect.Abbreviations: TBI: Traumatic brain injury; SES: socioeconomic status; ISS: Injury severity scale; AIS: Abbreviated injury scale.

Horseback riding-related injuries treated in emergency departments: Risk factors and prevention strategies.

INTRODUCTION: Despite inherit dangers of horseback riding (HBR), research on HBR-related injuries is sparse. This study used both quantitative and qualitative methods to (1) examine HBR-related injuries treated in emergency departments (EDs) and associated risk factors and (2) explore HBR-related injury experiences and recommendations for prevention strategies from the perspective of riders. METHOD: We retrospectively analyzed data from the Nationwide Emergency Department Sample (NEDS), identifying HBR-related ED visits between 2010 and 2014. Additionally, we conducted 10 phone interviews with active horseback riders to understand their experiences and perspectives regarding HBR-related injuries and recommendations for prevention measures. RESULTS: A total of 21,899 ED visits for HBR-related injuries were identified. When weighted, these represented 100,964 ED visits in the United States. Females had a consistently higher proportion of ED visits compared to males across the study period, with the proportion of ED visits being highest in females aged 15-19. Most injuries (85.9%) were treated and released from the ED. Three primary themes were identified as key to the prevention of HBR-related injuries: (1) rider safety (e.g., use of protective equipment), (2) external factors (e.g., awareness of environment), and (3) rider and horse interactions (e.g., matching skill level of the rider to the horse). CONCLUSIONS: Results indicate that HBR-related injuries treated in EDs are prevalent, with female riders aged 15-19 years having the highest proportion of injuries treated in EDs. Practical Applications: There is a critical need for injury prevention programs that not only promote the use of protective equipment, but that also educate horseback riders on horse behavior, the proper handling of horses, and safe riding practices.

Trends in US physician diagnosis of child physical abuse and neglect injuries, 2006-2014.

OBJECTIVE: To determine if US child physical abuse and neglect injury rates changed from 2006 to 2014, whether definitive diagnoses of physical abuse and neglect were used more often over time, and what patient factors influenced definitive physical maltreatment diagnoses. METHODS: Nationally estimated rates of definitive and suggestive physical abuse and neglect injuries for children <10 years were generated using the Nationwide Emergency Department Sample, the National Inpatient Sample, and census estimates. Trends over time were evaluated, including the trend in the proportion of definitive diagnoses to all diagnoses (definitive plus suggestive). Logistic regression was used to evaluate whether patient characteristics and hospital patient volumes were associated with definitive versus suggestive diagnoses. RESULTS: The population rates of child physical maltreatment medically treated injuries were unchanged from 2006 to 2014; the trends were not statistically significant for ED or hospitalized patients. Over time, physician definitive diagnoses as a proportion of all physical maltreatment diagnoses (definitive plus suggestive) increased in admitted children from 17.6% in 2006 to 22.0% in 2014 (p = 0.02). Older age, white race, lower income by zip code, and public insurance as well as larger patient volumes increased the odds of definitive rather than suggestive diagnoses of physical abuse and neglect injuries. CONCLUSIONS: Definitive diagnoses of physical abuse and neglect increased over the study period and were associated with hospital volume and patient characteristics which may reflect provider experience and possible bias. The use of electronic medical records may have influenced the coding of definitive diagnoses.

A new weighted injury severity scoring system: better predictive power for adult trauma mortality.

BACKGROUND: An accurate injury severity measurement is essential in the evaluation of trauma care and in outcome research. The traditional Injury Severity Score (ISS) does not consider the differential risks of the Abbreviated Injury Scale (AIS) from different body regions, and the three AIS involved in the calculation of ISS are given equal weights. The objective of this study was to develop a weighted injury severity scoring (wISS) system for adult trauma patients with better predictive power than the traditional Injury Severity Score (ISS). METHODS: The 2007-2014 National Trauma Data Bank (NTDB) Research Datasets were used. We identified adult trauma patients from the NTDB and then randomly split it into a study sample and a test sample. Based on the association between mortality and the Abbreviated Injury Scale (AIS) from each of the six ISS body regions in the study sample, we evaluated 12 different sets of weights for the component AIS scores used in the calculation of ISS and selected one best set of weights. Discrimination (areas under the receiver operating characteristic curve, sensitivity, specificity, positive predictive value, negative predictive value, concordance) and calibration were compared between the wISS and ISS. RESULTS: The areas under the receiver operating characteristic curves from the wISS and ISS are all 0.83, and 0.76 vs. 0.73 for patients with ISS = 16-74 and 0.68 vs. 0.53 for patients with ISS = 25-74. The wISS showed higher specificity, positive predictive value, negative predictive value, and concordance when they were compared at similar levels of sensitivity. The wISS had better calibration than the ISS. CONCLUSIONS: By weighting the AIS from different body regions, the wISS had significantly better predictive power for mortality than the ISS, especially in critically injured adults.

The Surgical Intervention for Traumatic Injury Scale: A Clinical Tool for Traumatic Brain Injury.

INTRODUCTION: There is no widely used method for communicating the possible need for surgical intervention in patients with traumatic brain injury (TBI). This study describes a scoring system designed to communicate the potential need for surgical decompression in TBI patients. The scoring system, named the Surgical Intervention for Traumatic Injury (SITI), was designed to be objective and easy to use. METHODS: The SITI scale uses radiographic and clinical findings, including the Glasgow Coma Scale Score, pupil examination, and findings noted on computed tomography. To examine the scale, we used the patient database for the Progesterone for the Treatment of Traumatic Brain Injury III (ProTECT III) trial, and retrospectively applied the SITI scale to these patients. RESULTS: Of the 871 patients reviewed, 164 (18.8%) underwent craniotomy or craniectomy, and 707 (81.2%) were treated nonoperatively. The mean SITI score was 5.1 for patients who underwent surgery and 2.5 for patients treated nonoperatively (P<0.001). The area under the receiver operating characteristic curve was 0.887. CONCLUSION: The SITI scale was designed to be a simple, objective, clinical decision tool regarding the potential need for surgical decompression after TBI. Application of the SITI scale to the ProTECT III database demonstrated that a score of 3 or more was well associated with a perceived need for surgical decompression. These results further demonstrate the potential utility of the SITI scale in clinical practice.

Age-adjusted shock index: From injury to arrival.

BACKGROUND: Studies have demonstrated the superiority of the shock index, pediatric age-adjusted (SIPA) in predicting outcomes in pediatric blunt trauma patients. However, all have utilized SIPA calculated on emergency department (ED) arrival. We sought to evaluate the utility of SIPA at the trauma scene and describe changes in SIPA from the trauma scene to the ED. METHODS: We used 2014-2016 Trauma Quality Improvement Program Data to identify blunt trauma patients 1-15 years old with an injury severity score (ISS) > 15. We calculated SIPA using vitals obtained at the trauma scene and on ED arrival. Outcome measures included ISS, transfusion within 24 h, intensive care unit (ICU), hospital length of stay (LOS), ventilator days, and mortality. RESULTS: We identified 2917 patients, and 34.2% had a persistently elevated SI from the injury scene to ED arrival, whereas 17.9% had a persistently elevated SIPA. An elevated SIPA at the trauma scene was more predictive of greater ISS, LOS, and ventilator requirements. Furthermore, a SIPA that remained abnormal was associated with greater ISS, LOS, ICU admission, mechanical ventilation, and mortality. CONCLUSIONS: Prehospital SIPA values predict worse outcomes in pediatric trauma patients, and their change over time may have greater predictive utility than a single value alone. LEVEL OF EVIDENCE: II TYPE OF STUDY: Prognosis Study.

Prehospital Versus Trauma Center Glasgow Coma Scale in Pediatric Traumatic Brain Injury Patients.

BACKGROUND: Traumatic brain injury (TBI) is a major source of morbidity and mortality in children. The Glasgow Coma Scale (GCS) can be challenging to calculate in pediatric patients. Our objective was to determine its reproducibility between prehospital providers and pediatric trauma hospital personnel. MATERIALS AND METHODS: The institutional trauma database for a level 1 pediatric trauma center was queried for patients aged ≤18 y who presented with a TBI. Demographics, mechanism, prehospital GCS, and trauma center GCS were collected. Agreement was evaluated with weighted kappa (κ) coefficients (0 = agreement no better than that expected by chance alone, 1 = perfect agreement). RESULTS: The inclusion criteria were met by 1711 patients, 263 of whom were aged <3 y. Prehospital GCS and trauma center GCS differed in 766 patients (44.8%). Agreement between prehospital GCS and trauma center GCS was moderate for all patients (κ = 0.61, 95% confidence interval [CI] 0.57-0.64). Agreement was slightly better than chance alone in patients with trauma center GCS between 9 and 12 y (κ = 0.09, 95% CI 0.03-0.15) and was lower for children aged 0-2 y (κ = 0.51, 95% CI 0.42-0.61) than for those aged between 3 and 18 y (κ = 0.63, 95% CI 0.59-0.66). Younger children were more likely to have score differences of at least 3 points (21.3% versus 13.6% of 3- to 18-y-olds, P < 0.001). CONCLUSIONS: Prehospital and trauma center GCS scores frequently disagree in children, particularly in TBI patients aged <3 y and those with moderate TBI. Centers should consider the inconsistency of the pediatric GCS when triaging TBI patients.

Attending Follow-up Appointments After Pediatric Traumatic Brain Injury: Caregiver-Perceived Barriers and Facilitators.

OBJECTIVE: To examine barriers and facilitators for follow-up care of children with traumatic brain injury (TBI). SETTING: Urban children's hospital. PARTICIPANTS: Caregivers of children (aged 2-18 years) discharged from an inpatient unit with a TBI diagnosis in 2014-2015. DESIGN: Survey of caregivers. MAIN MEASURES: Caregiver-reported barriers and facilitators to follow-up appointment attendance. RESULTS: The sample included 159 caregivers who completed the survey. The top 3 barriers were "no need" (38.5%), "schedule conflicts" (14.1%), and "lack of resources" (10.3%). The top 5 identified facilitators were "good hospital experience" (68.6%), "need" (37.8%), "sufficient resources" (35.8%), "well-coordinated appointments" (31.1%), and "provision of counseling and support" (27.6%). Caregivers with higher income were more likely to report "no need" as a barrier; females were less likely to do so. Nonwhite caregivers and those without private insurance were more likely to report "lack of resources" as a barrier. Females were more likely to report "good hospital experience" and "provision of counseling and support" as a facilitator. Nonwhite caregivers were more likely to report "need" but less likely to report "sufficient resources" as facilitators. CONCLUSIONS: Care coordination, assistance with resources, and improvements in communication and the hospital experience are ways that adherence might be enhanced.

Alcohol and drug screening of adolescent trauma alert patients at a level 1 pediatric trauma center.

BACKGROUND: Adolescent trauma patients are reported to have increased incidence of alcohol and other drug (AOD) use, but previous studies have included inadequate screening of the intended populations. A Level 1 Pediatric Trauma Center achieved a 94% rate of AOD screening. We hypothesized that a positive AOD screening result is associated with males, increasing age, lower socioeconomic status, violent injury mechanism, higher Injury Severity Score (ISS), lower GCS, need for operation and increased hospital length of stay. METHODS: After achieving high rates of screening among admitted trauma alert patients 12-17 years old, we evaluated patients presenting during 2014-2015. Chi-square tests were used to compare the percentage of patients with positive test results across sociodemographic, injury severity measures and patient outcomes. RESULTS: Three hundred and one patients met criteria for AOD screening during the study period. Ninety-four percent of these patients received screening and 18% were positive. Males (21.4%) were more often positive than females (11.6%). Increasing age was directly correlated with AOD use. Race was associated with a positive screen. Black patients more often had positive screens (40.9%), as compared with White patients (13.8%) and other races (23.5%). Patients with commercial insurance (6.6%) were less likely to be positive than those with no insurance (19.0%) or Medicaid (30.9%). Lower median household income was associated with positive AOD screening. Patients with violent injury mechanisms were more likely to screen positive (36.2%) than those with non-violent mechanisms (18.0%). No statistical differences were found with injury severity scores, the need for operation, or hospital length of stay. CONCLUSIONS: With near universal screening of adolescent trauma alert admissions, positive AOD results were more often found with males, increasing age, lower socioeconomic status, and violent injury mechanism. LEVEL OF EVIDENCE: Level III, Retrospective comparative study without negative criteria. STUDY TYPE: Prognostic.

Abnormal lymphocyte response after pediatric thermal injury is associated with adverse outcomes.

BACKGROUND: Burns are a leading cause of morbidity in children, with infections representing the most common group of complications. Severe thermal injuries are associated with a profound inflammatory response, but the utility of laboratory values to predict infections in pediatric burn patients is poorly understood. MATERIALS AND METHODS: Our institutional burn database was queried for patients aged 18 y and younger with at least 10% total body surface area burns. Demographics, mechanism, laboratory results, and outcomes were extracted from the medical record. Patients were classified as having an abnormal or normal total white blood cell count, neutrophil percentage, and lymphocyte percentage using the first complete blood count drawn 72 or more hours postinjury. Outcomes were compared between groups. RESULTS: White blood cell data were available for 90 patients, 84 of whom had neutrophil and lymphocyte percentages. Abnormal lymphocyte percentage 72 h or more after burn injury was associated with a significant increase in infections (67.9% versus 32.3%, P = 0.003), length of stay (33.1 versus 18.8 d, P = 0.02), intensive care unit length of stay (13.1 versus 3.7 days, P = 0.01), and ventilator days (5.8 versus 2.3, P = 0.02). It was also an independent predictor of infection (odds ratio 7.2, 95% confidence interval 2.1-24.5). CONCLUSIONS: Abnormal lymphocyte percentage at or after 72 h after burn injury is associated with adverse outcomes, including increased infectious risk.