Level I Compliance 2015

Isolated head injuries linked to shock and hypotension

According to current ATLS guide-

lines, “For all practical purposes,

shock does not result from isolat-

ed brain injuries.”(1) Following

these guidelines, when shock is

identified, immediate resuscita-

tion with fluid boluses followed

by blood products as needed.

Shock associated with trauma is

often thought to be hemorrhagic

but emerging evidence is suggest-

ing that it could also be associated

with isolated head injuries (IHI).

One study set out to identify if

presenting hypotension could

indeed be associated with ISI.

The study was able to utilize 2009

data from the National Trauma

Data Bank (NTDB) and extract

78,673 patients with relevant data

recorded. (2)

Their results concluded that

among patients with IHI, the

rates of hypotension were greatest

in the 0-4 years of age grouping.

In fact, researchers found that

within this age group, one third

of hypotension was associated

with IHI as opposed to one fifth

with hemorrhagic injury and only

one hundredth with spinal cord

injury.

Several causes of this finding were

hypothesized including a possible

neurogenic response similar to

spinal shock or an autonomic

process with increased vagal tone

or poor sympathetic tone.

Because of the association of

increased cerebral edema with

large volumes of isotonic fluids,

providers may have to adjust their

treatment plans to include less

volume resuscitation and early

administration of vasopressors to

increase sympathetic tone or atro-

pine to block increased vagal

tone.

M O N R O E C A R E L L J R . C H I L D R E N ’ S H O S P I T A L A T V A N D E R B I L T

January 20, 2016

Volume 4, Issue 1

Pediatric Trauma Service IEP Special points of

interest:

Remember after re-

viewing the IEP con-

tent, you must suc-

cessfully pass the

post-test in order to

receive assigned CME

credit of 1.5 hr.

Inside this issue:

WBCT scanning in adult and pediatric centers

2

Benefits of protocol utilization in association with abdominal trauma

2

MCJCHV Abdominal Trauma Work-Up Algorithm

3

MCJCHV Chest Trauma Work-Up Algorithm

3

MCJCHV CHI ≥2 yo Work-Up Algorithm

4

MCJCHV CHI <2 yo Work-Up Algorithm

5

Vascular injuries in pediatric

6

References 6

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Total

Total 9 8 8 10 16 13 17 10 15 4 7 16 133

Present 8 6 7 10 12 12 15 8 15 3 5 12 113

No show 1 2 2 1 1 2 1 1 4 15

Time not 1 1

Past time 1 2 1 4

Percentage 86% 75% 88% 100% 82% 92% 88% 80% 100% 75% 71% 75% 85%

For Level I activations, attendings &/or fellows have 15 minutes to respond to the bedside from time of arrival.

Per ACS, Level I facilities must maintain 80% or greater

Over the last 20 years, there has been a

fivefold increase in the utilization of CT

scans in pediatric patients who present

to the emergency department, with head

injury being the most frequent

indication that prompts CT scan use.

(3) With the rising awareness of

radiation-induced malignancy, a

nationwide push towards limiting the

use of CT scans has been observed since

2008. In the pediatric population,

physicians often rely on these radiology

studies since physical exam may be an

unreliable means of identifying injuries.

One study examined the frequency of

CT utilization, specifically whole body

computed tomography (WBCT), in

adult versus pediatric trauma centers.

Utilizing the National Trauma Data

Bank (NTDB), they were able to identify

30,667 patients to include in the study,

of which 38.3% were managed at a

designated pediatric trauma center. (3)

The following factors were linked to

the use of WBCT scanning: age ≥ 6

years, male gender, intoxication, GCS

score ≤ 8, hypotension and tachycardia

on presentation, blunt injury, motor

cycle collision, head, thoracic or

abdominal AIS ≥ 3, injury severity

score ≥ 25 and management in an

ATC. After adjusting for age, GCS

score, admission vital parameters,

mechanism, type and severity of injury,

patients who presented in an ATC

were 1.8 times more likely to undergo

a WBCT scan ultimately increasing

their risk of radiation without a

difference in outcomes. There was no

noted difference in hospital and ICU

length of stay as well as hospital

disposition between adult and

pediatric center patients that received

WBCTs.

Of note, head CT rates did not differ

between adult and pediatric trauma

centers, however the use of thoracic and

abdominal CTs were significantly higher

in the adult programs. (3) This may be

attributed to the utilization of

guidelines and prediction models put in

place at pediatric trauma centers. These

guidelines recommend selective imaging

based on mechanism of injury, physical

examination, and laboratory studies.

At MCJCHV, liaisons from PEM,

PICU, Trauma, NSGY, Ortho, ANES,

and Radiology have collaborated to

establish recommended radiology work-

ups for trauma patients presenting with

blunt chest, blunt abdominal, and

closed head injuries. These are

included in this issue for your review.

should take into account the patient’s GCS, reliability of an abdominal exam, and the presence of abdominal wall bruising.

One designated pediatric trauma center instituted their own protocol in hopes of decreasing the negative CT rate and the cost of laboratory studies utilized in the evaluation of abdominal trauma. (5) After institut-ing their evidenced based protocol, the rate of positive CT scan findings increased from 23% to 49%. For them, protocol deviation occurred most frequently in the conscious, reliable exam group (40%) with the scans being obtained in the absence of abdominal tenderness/pain or lack of surgery consult prior to the scan.

When evaluating pediatric patients, assessing for abdominal trauma can be challenging due to few external signs, unreliable communication, difficulty obtaining an accurate abdominal exam, a physiological reserve that maintains normotension despite ongoing volume loss, and injury patterns specific to cer-tain age groups. (5) CTs of the abdo-men and pelvis are routinely obtained for adult patients if the physical exam is unreliable. However with children, current data suggests judicious use of CT radiation due to the increased can-cer risk. Many institutions have report-ed overuse of CT scanning in pediatrics, especially when evaluating for ab-dominal trauma. Guidelines determin-ing the diagnostic work up in children

Only 8% of patients had clinically sig-nificant scans when the protocol was not followed as opposed to 31% when the protocol was followed.

This protocol also led to the reduction of total laboratory costs of 39%. The protocol specified ordering a HGB/HCT and AST/ALT instead of a CBC and CMP or liver panel.

The majority of studies covering the topic recommend a combination of specific laboratory studies and physical exam in determining the need for CT. Specifically hematuria and elevated ALT with an abnormal abdominal exam are the best predictors of intra-abdominal injury.

Utilization of whole body CT scans in adult and pediatric trauma centers

The benefits of protocol utilization in abdominal trauma

Page 2

Pediatric Trauma Service IEP

Key points : When performed,

CT should always be performed with IV contrast to avoid the need for repeat imaging.

A hemodynamically stable patient with normal cognition can generally be safely screened with careful physical exam (tenderness or abdominal bruising) and laboratory values (AST, ALT, Amylase, HCT).

For evaluation of the pelvis, a CT is only recommended if a fracture is identified on x-ray or if there is uncertainty regarding the presence of a fracture. (4)

Page 3

Volume 4, Issue 1

Key points : Chest CT should be

reserved for cases where the chest radiograph is abnormal or there is an abnormally high level of clinical concern despite a normal chest radiograph.

CT is highly recommended in penetrating chest trauma no matter the CXRY however.

Pediatric Trauma Service IEP

Volume 4, Issue 1

Epidemiology Account for only 0.6%-1.4% of all pediatric injuries. Upper extremity injuries most common in 2-6 years of age. Lower extremity injuries most common in >12 years of age. Brachial artery injuries occur in 53% of cases followed by

popliteal at 9.5%, and the common femoral arties at 5.9%.

Fallon, S., Delemos, D., Akikuotu, A., Christopher, D., & Naik-Mathuria, B. (2016). The use of an institutional pediatric abdominal trauma protocol improves resource use. Journal of Trauma and Acute Care Surgery, 80(1), 57-63.

Gardner, A., Diz, D., Tooze, J., Miller, C., & Petty, J. (2015). Injury patterns associated with hypotension in pediatric trauma patients: A national trauma database review. Journal of Trauma and Acute Care Surgery, 78(6), 1143-1148.

Pandit, V., Michailidou, M., Rhee, P., Zangbar, B., Kulvatunyou, N., Khalil, M., . . . Joseph, B. (2015). The use of whole body computed tomography scans in pediatric trauma patients: Are there differences among adults and pediatric centers? Journal of Pediatric Surgery.

Pierce, D., Mangona, K., Bisset, G., & Naik-Mathuria, B. (2015). Computed tomography in the evaluation of pediatric trauma. Clinical Pediatric Emergency Medicine, 16(4), 220-229.

Wahlgren, C., & Kragsterman, B. (2015). Management and outcome of pediatric vascular injuries. Journal of Trauma and Acute Care Surgery, 79(4), 563-567.

References

Pediatric Trauma Service IEP

Vascular injuries

Operative techniques Repair techniques include interposition graft (24%),

patch (19%), primary repair- lateral suture/direct anastomosis (12%), bypass (9.5%), endovascular techniques (3.7%), and miscellaneous- i.e., thrombectomy, thrombendarterectomy, ligation(8.1%)

Exploration or release of artery was performed 23% of the time.

Vein is the leading graft material followed by synthetics. In younger patients (≤10 years), patch repair techniques

were more common (28% vs. 9.6%). In the older pediatric population (11-15 years),

reconstruction with interposition and bypass grafts was more common (49% vs. 23%).

Complications and follow-up Arterial occlusion/thrombosis most common

postoperative complication. Amputations are associated with occluded vein grafts in

reconstructions at the level of the femoral artery.

CME instructions