Therapeutic laparoscopy for pediatric abdominal trauma. Evans PT, Phelps HM, Zhao S, Van Arendonk KJ, Greeno AL, Collins KF, Lovvorn HN. J Pediatr Surg. 2020 Jul;55(7):1211-1218.
The study was a simultaneous review of single institutional data (2005-2017) and the National Trauma Data Bank (2010-2015). Patients who underwent therapeutic laparoscopy were compared to those who underwent therapeutic laparotomy. Single institutional and NTDB data were similar however; institutional data had more patients who had suffered blunt mechanism (63% vs. 50%) and more patients who underwent therapeutic laparoscopy (16% vs 12%). Laparoscopy was more commonly attempted than laparotomy (19% vs. 13%) for therapy at pediatric facilities. In both datasets, laparoscopy was more commonly used following blunt abdominal trauma in patients who were younger, female and had a lower ISS. When adjusting for ISS, laparoscopy was associated with fewer complications (4% vs. 17%) and utilization increased over time.
Appropriately selected pediatric trauma patients who undergo therapeutic laparoscopy have similar or better outcomes to patients treated with laparotomy, with no increase in adverse events or missed injuries. Laparoscopy was more commonly employed following a blunt mechanism of trauma, in younger patients, and in patients with a lower injury severity score.
Predictors for Pediatric Blunt Cerebrovascular Injury (BCVI): An International Multicenter Analysis. Weber CD, Lefering R, Weber MS, Bier G, Knobe M, Pishnamaz M, Kobbe P, Hildebrand F; TraumaRegister DGU. World J Surg. 2019 Sep;43(9):2337-2347.
The study was a review of a prospectively maintained international trauma registry. The authors evaluated pediatric patients (age 0-17 years) over a twelve-year period (1/2002 – 12/2015) with major injuries (defined as ISS ³ 9). Patients with BCVI were compared to those without BCVI. Overall, 48 BCVI were identified in 42 patients for an incidence of 0.5%. The vast majority of patients with BCVI were older (age > 15 years) but there was no significant difference in age between those with BCVI and those without BCVI. Patients with BCVI Patients with BCVI had higher injury severity, lower GCS, and a higher incidence of motor vehicle collision, shock, and coagulopathy. Additionally, patients with BCVI has a higher incidence of head, facial, cervical spine, spine, chest, and basilar skull fracture. Logistic regression identified cervical spine injury (OR 8.2, 95% CI 3.3020.3), facial injury (OR 4.4, 95% CI 2.2-9.2), basilar skull fracture (OR 2.4, 95% CI 1-5.5), and higher ISS (OR 1.05 [per point], 95% CI 1.03-1.07) as predictors of BCVI. Not surprisingly, the risk of BCVI increases the more risk factos are present. Of note, there was an increased incidence of thromboembolic complications, multiorgan failure, and in-hospital mortality in children with BCVI.
This article adds to the grown body of literature regarding pediatric blunt cerebrovascular injury. The authors found that BCVI is more common in children with high-energy trauma and that cervical spine and facial injuries along with basilar skull fractures are predictive.
Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary Kochanek PM, Tasker RC, Carney N, Totten AM, Adelson PD, Selden NR, Davis-O'Reilly C, Hart EL, Bell MJ, Bratton SL, Grant GA, Kissoon N, Reuter-Rice KE, Vavilala MS, Wainwright MS. Pediatr Crit Care Med. 2019 Mar;20(3):280-289.
Summary: This is the third and most up-to-date edition of the authoritative guidelines for management of pediatric severe traumatic brain injury, defined as children ≤ 18 yr with GCS 3-8. These recommendations are based on a comprehensive review of the literature, assessment of evidence quality, and graded levels of recommendation by experts of multiple disciplines from multiple institutions. A total of 22 recommendations are endorsed. Nine of these recommendations are new since the previous edition of these guidelines in 2012. Current evidence supports no level I recommendations, 3 level II recommendations (above), and 19 level III recommendations. New recommendations include: 1. NOT using a normal initial CT to exclude elevated intracranial pressure (ICP). 2. Bolus hypertonic saline (3%) for acute management of elevated ICP. 3. Bolus 23.4% hypertonic saline for refractory ICP. 4. Appropriate analgesia and sedation, while avoiding bolus midazolam and/ or fentanyl during ICP crises. 5. Prophylaxis against early post-traumatic seizures. 6. NOT using prophylactic hypothermia as a way to improve overall outcomes. 7. Moderate hypothermia may be used to treat elevated ICP. 8. Initiation of early enteral nutrition (< 72hr) to decrease mortality. 9. NOT using corticosteroids to improve outcome or reduce ICP. Finally, this article references a companion article which proposes a treatment algorithm for management of severe TBI in children. The authors acknowledge that a treatment algorithm incorporates a significant level of expert opinion, and thus, they wanted to keep the evidence-based recommendations clear and distinct from the algorithm.
Take Away: Current evidence for management of pediatric severe traumatic brain injury (TBI) supports the use of bolus hypertonic saline (3%) at 2-5 ml/kg over 10-20 minutes for acute management of intracranial hypertension. It does NOT support either prophylactic moderate hypothermia or the use of immune-modulating diets. Everyone who cares for children with severe TBI should integrate this brief, high-impact article into practice.
Rethinking the definition for major trauma: The need for trauma intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers. Roden-Foreman JW, Rapier NR, Foreman ML, Zagel AL, Sexton KW, Beck WC, McGraw C, Coniglio RA, Blackmore AR, Holzmacher J, Sarani B, Hess JC, Greenwell C, Adams CA Jr, Lueckel SN, Weaver M, Agrawal V, Amos JD, Workman CF, Milia DJ, Bertelson A, Dorlac W, Warne MJ, Cull J, Lyell CA, Regner JL, McGonigal MD, Flohr SD, Steen S, Nance ML, Campbell M, Putty B, Sherar D, Schroeppel TJ. J Trauma Acute Care Surg. 2019 Sep;87(3):658-665.
Summary: This is a multi-institutional study including 38 adult and pediatric centers with over 80,000 encounters evaluated. Using a mixed linear model, the association of ISS > 15, RTS < 7.84 and NFTI (+) with outcomes was tested and compared. Outcomes included 1) discharge to continuing care facility, 2) complications and 3) length of stay. All definitions of major trauma increased the odds of complications, but the NFTI (+) model provided the best fit with the highest adjusted odds ratio, 9.44. NFTI (+) was also associated with a longer length of stay, 215% longer than patients without a NFTI (NFTI -). Though ISS, RTS and NFTI were associated with discharge to a continuing care facility, the NFTI (+) again had a better model fit. The NFTI may be superior to ISS and RTS as an indicator of major trauma and could be used as part of the performance improvement process to improve triage criteria and decrease under-triage rates.
Take away: The need for trauma intervention (NFTI) may be a better indicator of major trauma than injury severity score (ISS) or Revised Trauma Score (RTS). NFTI criteria are 1) receiving blood products within 4 hours of arrival 2) transfer to operating room or interventional radiology from ED 3) ICU admission for 3 or more days, 4) nonprocedural intubation within 72 hours, and 5) death within 60 hours of arrival. NFTI had a stronger association with complications, discharge to continuing care facility and hospital length of stay than ISS and RTS.