Tranexamic Acid Administration to Pediatric Trauma Patients in a Combat Setting: The Pediatric Trauma and Tranexamic Acid Study (PED-TRAX). Eckert MJ, Wertin TM, Tyner SD, Nelson DW, Izenberg S and Martin MJ. J Trauma Acute Care Surg. 2014 Dec;77(6):852-8.
This retrospective review explores mortality in pediatric trauma patients who received tranexamic acid (TXA) as an adjunct to hemorrhage control in a military combat hospital. In 2010, investigators in the CRASH-2 trial reported decreased mortality secondary to bleeding in injured adult patients treated with the fibrinolysis inhibitor, TXA. Several studies have since documented decreased intraoperative blood loss and transfusion requirement in pediatric patients undergoing elective spine, craniofacial and cardiac surgeries. No previous study has evaluated the use of TXA in pediatric trauma patients.
This study included a retrospective review of 766 patients younger than 18 years of age over a 4.5-year period. Standard adult dosing of TXA (1 g) intravenously within 3 hours of injury and re-dosing based on need was used. Stepwise logistic regression was performed to identify factors independently associated with mortality. To better understand the effect of TXA administration, a propensity analysis of closely matched patients was performed to account for differences in patient populations that did and did not receive TXA.
The majority of children sustained penetrating trauma, 35% required blood transfusion and 76% required surgery. 9% of patients received TXA; these patients had greater injury severity, hypotension, acidosis and coagulopathy than the no-TXA group. The presence of severe abdominal injuries (OR 3.45), extremity injuries (OR 2.98) and base deficit >5 (OR 3.45) were significant independent predictors associated with TXA use. After controlling for confounding factors (mechanism, ISS, hypotension, acidosis and GCS), TXA administration was independently associated with reduced mortality (OR 0.27). Additional outcomes beyond mortality were evaluated in the propensity matched groups; those patients in the large volume transfusion group that received TXA demonstrated improved neurologic status and a lower percentage of mechanical ventilation at the time of discharge or transfer.
TXA administration was associated with decreased mortality in pediatric combat trauma patients, typically with severe abdominal or extremity injuries and associated metabolic acidosis. Limitations of the study include the retrospective nature and inadequate information to assess the effect of TXA on blood loss, coagulation labs or TEG data. Further study is needed on the optimal dose and timing of TXA administration in the pediatric trauma population.
TXA should be considered in pediatric patients who present with significant hemorrhage secondary to injury.
Isolated Loss of Consciousness in Children with Minor Blunt Head Trauma. Lee LK, Monroe D, Bachman MC, Glass TF, Mahajan PV, Cooper A, Stanley RM, Miskin M, Dayan PS, Holmes JF, Kuppermann N; Traumatic Brain Injury (TBI) Working Group of Pediatric Emergency Care Applied Research Network (PECARN). JAMA Pediatr. 2014 Sep;168(9):837-43.
Blunt head trauma is a common reason for children to present to the emergency department (ED), and loss of consciousness (LOC) is a frequent clinical factor that influences the use of CT to evaluate such patients. Increasing attention is being given to childhood diagnostic radiation exposure as a risk factor for malignancy later in life. This study is a planned subanalysis of a large multicenter prospective observational cohort study of the Pediatric Emergency Care Applied Research Network (PECARN), involving 42,412 children aged 0-18 years with a GCS of 14-15 in the ED following blunt head trauma. LOC occurred in 6,286 of these children. Isolated LOC was defined as LOC in the absence of other predictors including altered mental status, important traumatic scalp/ skull findings, severe headache, severe mechanism of injury, seizure, neurologic deficit, amnesia, abnormal behavior, and history of vomiting. Outcomes of interest were traumatic brain injury (TBI) on CT and clinically important TBI (defined as death from intracranial injury, need for neurosurgical intervention, intubation >24h for TBI, and hospitalization at least 2 nights for TBI).
Among children with any LOC, the rate of clinically important TBI was 2.5%. 80% of children with LOC received a CT. Rates of TBI on CT were low among children with isolated LOC, 0.9-1.9%, depending on other predictors. Rates of clinically important TBI in children with isolated LOC were even lower, 0.2-0.5%. This rate was similar to the rate of clinically important TBI in children with no LOC, 0.5%. This study suggests that the use of CT to evaluate children with isolated LOC and no other clinical findings is very unlikely to identify patients with clinically important TBI. Likewise, routine observation before CT decision rather than routine early CT would decrease radiation exposure in children in this very low risk group.
Head CT is unlikely to identify important TBI in children with isolated LOC.
Contrast Blush in Pediatric Blunt Splenic Trauma Does Not Warrant the Routine Use of Angiography and Embolization. Bansal S, Karrer FM, Hansen K, Partrick DA. Am J Surg. 2015 Aug;210(2):345-50.
This single institution retrospective study evaluates the predictive value of contrast blush (CB) on CT scan in patients with splenic injury. Nonoperative management is standard practice in pediatric blunt splenic trauma. The presence of CB has been cited as a risk factor for failure of nonoperative management in the adults. Institutions have adopted adult protocols utilizing angiography and embolization in the presence of CB on initial CT scan in children.
Over a 10-year period (2002-11) patients <18 yrs. were divided into 2 groups: absence or presence of CB. Patients with high-grade (3-5) splenic injury were analyzed since CB was only seen in this group. A total of 270 pediatric blunt abdominal trauma patients had splenic injury (143 isolated and 127 multisystem). Of these, 47 patients (17.4%) had CB. Of 160 patients with high-grade splenic injuries, six resulted in splenectomy with CB present in 1/6. The decision for surgery was based on hemodynamic instability. There was no significant difference between splenic injuries with or without CB, including the need for blood transfusion. CB did not result in increased splenectomy, failure of non-operative management, or spleen related death.
Nonoperative management for pediatric splenic injuries has been the standard since 2000 with success rates approaching 90%. Splenic artery embolization has been advocated in adult trauma since 1995, with splenic salvage rates as high as 98%. Many institutions have advocated for the use of adult angiography protocols in pediatric patients. Other small series suggest that CB in children does not affect patient outcomes and that arterial embolization is not necessary. This retrospective study demonstrates no predictive value of CB for failure of nonoperative management, and arterial embolization would not have benefited patients with CB.
This study supports management of pediatric blunt splenic injuries based on patient hemodynamic status and physiologic response to resuscitation and not on the radiographic appearance of the injury.