|
Article 1
Meta-Analysis of Therapeutic Hypothermia for Traumatic Brain Injury in Adult and Pediatric Patients. Crompton EM, Lubomirova I, Cotlarciuc I, Han TS, Sharma SD and Sharma PJ. Crit Care Med. 2017 Apr;45(4):575-583.
Therapeutic hypothermia has been suggested to attenuate the effects of traumatic brain injuries (TBI). The optimal degree of hypothermia, length of treatment, rapidity of rewarming and impact of adjunct therapies are uncertain.
The purpose of this study was to perform a comprehensive meta-analysis to quantify the potential benefits of hypothermia therapy (TH) for TBI in adults and children by analyzing neurologic outcomes and mortality. Electronic databases were searched for relevant studies including patients with blunt TBI with induced hypothermia and appropriate neurologic and mortality data available. Data was extracted and outcomes for TH were divided into categories of safety and efficacy with pooled risk ratios calculated with 95% confidence intervals. TH was associated with an 18% reduction in mortality and a 35% improvement in neurologic outcomes in adults. The optimal management strategy for adults included cooling to a minimum of 33 degrees for 72 hours with spontaneous, natural rewarming. In contrast, a 66% increase in mortality and a marginal deterioration of neurologic outcomes was seen in children. Several previous studies and meta-analysis in children have made the same conclusion regarding TH. Children may have a different metabolic response to TBI than adults (decreased energy expenditure rather than hypermetabolic) and different adjunct therapies (high prevalence of barbiturates to control elevated intracranial pressure) which could limit the efficacy of TH treatment which acts to reduce metabolic response.
This study shows that in contrast to adults, therapeutic hypothermia following traumatic brain injury is associated with increased mortality and worse neurologic outcomes in children.
Article 2
Identifying Children at Very Low Risk for Blunt Intra-Abdominal Injury in Whom CT of the Abdomen Can Be Avoided Safely. Streck CJ, Vogel AM, Zhang J, Huang EY, Santore MT, Tsao K, Falcone RA, Dassinger MS, Russell RT, Blakely ML; Pediatric Surgery Research Collaborative. J Am Coll Surg. 2017 Apr;224(4):449-458.
Computed Tomography (CT) scan of the abdomen is a widely employed strategy to evaluate for intra-abdominal injury (IAI) in the setting of acute trauma. A current trend in adult trauma care favors “pan” CT to screen for injuries rather than selective CT. This trend runs counter to a trend in pediatric trauma care to “image gently” in order to minimize childhood radiation exposure and its long term cancer risks. The purpose of this study was to create a prediction rule that would identify children at low risk for IAI, for whom a CT could be safely avoided.
This collaborative study included prospective data from 14 level 1 pediatric trauma centers. Children <16 years old who sustained blunt abdominal trauma and who received trauma activation or trauma service consultation in the emergency department (ED) were included. Several variables based on readily available history, physical exam, imaging, and laboratory studies were evaluated as possible predictors of both IAI and also IAI requiring intervention (operation, transfusion, embolization). The use of CT was widely variable among participating centers. Patients were followed for 30 days after discharge. Five factors contributed to a significant prediction rule: AST>200, abnormal abdominal examination, abnormal chest x-ray (CXR), abdominal pain, and abnormal pancreatic enzymes. For patients with no positive findings in these factors, there was a 99.4% negative predictive value for IAI and a 100% negative predictive value for IAI requiring intervention. 34% of the study population met these very low risk criteria. This group might have avoided a CT safely.
CT of the abdomen may be safely avoidable in children with blunt abdominal trauma who have normal findings in five initial ED factors: AST <200, abdominal exam, CXR, abdominal pain, and pancreatic enzymes.
Article 3
Prospective validation of the shock index pediatric-adjusted (SIPA) in blunt liver and spleen trauma: An ATOMAC study. Linnaus ME, Notrica DM, Langlais CS, St Peter SD, Leys CM, Ostlie DJ, Maxson RT, Ponsky T, Tuggle DW, Eubanks JW, Bhatia A, Alder AC, Greenwell C, Garcia NM, Lawson KA, Motghare P, Letton RW. J Pediatr Surg. 2017 Feb;52(2):340-344.
Age-adjusted pediatric shock index (SIPA) correlates with mortality, serious injury, and need for transfusion in pediatric trauma.
This study was a secondary analysis of a prospective observational study from the ATOMAC group of 10 children’s hospitals. They looked at 386 patients (from 1088 enrolled) with a blunt liver or spleen injury, an ISS >15, and from ages 4 – 16 years. Patients with an ISS <15 were excluded. They compared the ability of standard shock index (SI) and age-adjusted shock index (SIPA) to detect severely injured patients.
321 (83%) had an elevated SI and 282 (73%) had an elevated SIPA. Elevated SI and SIPA were able to identify patients with higher ISS, longer ICU, need for blood transfusion, and longer LOS. SIPA was better at detecting patients requiring transfusion, ICU admission, and ISS >24. SIPA also demonstrated improved ability to distinguish patients with adverse outcomes.
SIPA is valid measure for predicting severely injured children with BLSI, especially in the population less than 12 years old.
Article 4
Prevalence and Impact of Admission Acute Traumatic Coagulopathy on Treatment Intensity, Resource Use, and Mortality: An Evaluation of 956 Severely Injured Children and Adolescents. Liras IN, Caplan HW, Stensballe J, Wade CE, Cox CS, Cotton BA. J Am Coll Surg. 2017 Apr;224(4):625-632.
The purpose of this study was to assess the prevalence and impact of admission coagulopathy using viscoelastic hemostatic assays (rapid thromboelastography; r-TEG) in injured children (age less than 17 years).
This was a retrospective review of the highest-level trauma activations from a prospectively maintained single institutional trauma registry. There were 956 patients included over a 6-year period (January 2010 through May 2016). Coagulaoathy, as defined by previously established r-TEG parameters was identified in 507 children (57%) with a breakdown of 35% by ACT, 6% by angle, 11% by MA, and 33% by Ly30. Coagulopahic children received more transfused blood products and hemostatic pharmacologic adjuncts (tranexamic acid). Coagulopathic patients had fewer ICU and ventilator-free days and regression analysis showed that coagulopathy was associated with an almost 4-fold increase in 30-day mortality. These relationships were more profound in the 197 patients with severe traumatic brain injury. Additionally, subset analysis of the 239 young children (age less than 5 years) in the cohort also showed an increase in mortality when admission coagulopathy is present.
Acute traumatic coagulopathy is common on admission in severely injured children and is associated with mortality, particularly in children with severe traumatic brain injury.
|