Value of computed tomographic angiography in neck and extremity pediatric vascular trauma

Purpose

We sought to define the sensitivity and specificity of computed tomographic angiography (CTA) in pediatric vascular injuries.

Methods

All neck and extremity CTAs performed in pediatric patients at a level 1 trauma center were reviewed from 2001 to 2007.

Results

Overall, 78 patients were identified with an average age of 15.0 ± 4.0 (0-18 years). Males outnumbered females 3.6:1. CTA was performed for 41 penetrating and 37 blunt traumas. Most penetrating injuries were due to missile wounds (71%) or stab wounds (17%). Eleven major vascular injuries resulted from penetrating trauma. For penetrating trauma, CTA was 100% sensitive and 93% specific. CTA for penetrating trauma had a positive predictive value (PPV) of 85% and negative predictive value (NPV) of 100%. Most blunt injuries were due to motor vehicle accidents (57%), followed by pedestrian hit by car (27%). Eight major vascular injuries resulted from blunt trauma. For blunt trauma, CTA was 88% sensitive and 100% specific. CTA for blunt trauma had a PPV of 100% and an NPV of 97%. The accuracy for penetrating and blunt trauma was 95% and 97%, respectively.

Conclusions

CTA is highly sensitive, specific, and accurate for pediatric neck and extremity vascular trauma.     

The spectrum and management of noniatrogenic vascular trauma in the pediatric population

Background

To describe the spectrum of noniatrogenic pediatric vascular injuries and their outcomes at a large tertiary pediatric hospital.

Complications of pediatric trauma: effects on pediatric trauma anesthesia

Pediatric trauma is a significant problem worldwide. The complications of pediatric trauma affect the emergency medical services provider, emergency physician, trauma surgeon, and anesthesiologist in different and challenging ways. Children have unique airway concerns, and require distinctive and safe approaches to protection of the airway. Moreover, the resuscitation of infants, children, and adolescents involved in trauma is complex and can be stressful for many caregivers. Therefore, the provision of anesthesia for acute pediatric trauma requires a synthesis of the usual issues of pediatric anesthesia with the overlying complications of trauma to effect an ideal anesthetic technique for each patient.     

Missile-induced vascular trauma

During seven and a half years of serious hostilities amidst the civilian population of Northern Ireland, a wide variety of vascular injuries inflicted by low and high velocity missiles and bomb explosions were observed. One hundred and thirteen patients, 96.5 per cent males of average age 26.8 years, sustained 191 vascular injuries and were treated at the Royal Victoria Hospital. Treatment commenced within one hour in 87 per cent of patients. Reduced limb ischaemia time, early bleeding control and vascular repair with restoration of flow within 6 hours of injury in 94.4 per cent of patients contributed to an excellent result in 85.5 per cent of survivors. Despite rapid admission, the mortality rate within 3 days of injury was 12.4 per cent, these patients sustaining trauma to major vessel trunks and vital organs. Associated nerve injuries (25 per cent) and skeletal injuries (30 per cent) were treated appropriately. A special group of 38 patients were ‘knee-capping’ victims and contributed to the majority of popliteal vessel trauma. A total of 14.9 per cent of primary arterial and 3 per cent of primary venous reconstructions failed due to thrombotic occlusion, but early postoperative revision was successful in every case. The overall amputation rate for lower limb injuries was 6.9 per cent; of these 5 cases, 4 had popliteal vessel injuries, in 2 of which infection (acute clostridial and chronic osteomyelitis) was partly responsible. Significant wound infection was otherwise absent. The pathophysiological aspects pertinent to the range of weaponry and methods of assault are presented. The operative and postoperative management and results are discussed in the light of documented military and civilian experience.     

Subclavian-axillary vascular trauma

Traumatic vascular injuries to the subclavian and axillary vessels are often associated with permanent neurologic impairment either by direct injury to the brachial plexus or by compression from an expanding hematoma. Prompt decompression of the plexus by evacuation of the hematoma may avoid permanent neurologic damage and decrease the morbidity of these injuries. We reviewed our experience with these injuries with particular reference to the effect of early decompression of the brachial plexus. From 1963 to 1984 we treated 40 patients. The causes of the injuries were penetrating trauma in 85% and blunt trauma in 15%. The results of arterial repair were excellent with only two failed repairs; neither resulted in severe ischemia. Two patients were suspected of having thrombosed venous repairs. Among the 12 patients with direct injury to the brachial plexus (partial or complete transection), only six had subsequent improvement of their neurologic dysfunction. In contrast, six of seven patients in whom there was only compression of the plexus by hematoma but no direct injury, had neurologic improvement following evacuation of the hematoma. This finding suggests that prompt decompression of the brachial plexus following these injuries may reduce the amount of neurologic impairment and reduce the morbidity of these injuries.     

Progress in pediatric trauma

The handling of trauma victims in the pediatric age group has undergone change and improvement in a number of ways. First, receiving facilities, emergency rooms, medical centers, and tertiary pediatric care facilities have all been brought together by community, state, regional, and national planning which has taken into account population needs and the resources of each facility. Communication by telephone, radio, and computerized information transmitters has linked together a series of medical facilities which now assures that each child is treated appropraitely or passed along to a different unit in the chain. The education of all members of the emergency medical services to the special techniques, equipment, and needs of pediatric patients has been essential to proper handling of injured children. Improvement in body imaging, which allows details of injured sites intracranially and in other body cavities, has changed radically the diagnosis and early clinical management of all injured patients. This, in turn, has allowed more precise surgical decisions such as splenic salvage, and conservative handling of such organs as the liver and brain. All of these advances have taken place on a stage and in a time in which the handling of infection and the response to nutritional needs have improved so dramatically. Much has been done, but accidents still kill more children ages 1 to 14 years than all other causes combined. Thus, prevention holds the real solution for future progress.

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Resumen El manejo de víctimas de trauma en la edad pediátrica ha evolucionado y mejorado en numerosos aspectos. En primer lugar, las unidades asistenciales, salas de urgencias, centros médicos y facilidades terciarias de atención pediátrica han sido reunidas por los planes comunitarios, regionales y nacionales, los cuales han tenido en cuenta las necesidades de las poblaciones y los recursos de cada institución. La comunicación telefónica y los transmisores de radio y de informatión computadorizada han integrado a una serie de facilidades médicas que ahora pueden garantizar que un niño será tratado en forma adecuada o será transferido a otra unidad del sistema. La educatión de todos los miembros de los servicios médicos de emergencia en técnicas especiales, en el manejo de equipos y en la atención de las necesidades de los pacientes pediátricos ha sido esencial para el manejo adecuado de los niños lesionados.El adelanto en la imagenología corporal, que permite obtener detalles de lesiones intracraneanas y de otras cavidades, ha modificado en forma radical el diagnóstico y el manejo clínico inicial de los pacientes lesionados. Esto, a su vez, ha hecho posible la toma de decisiones más precisas, tales como la preservatión esplénica y el manejo orientado a la preservación de órganos tales como el hígado y el cerebro. Todos estos avances han ocurrido en un momento durante el cual el tratamiento de la infección y la respuesta a los requerimientos nutricionales han exhibido progresos dramáticos. Mucho ha sido logrado, pero los accidentes todavía matan a más niños en las edades de 1 a 4 años, que todo el resto de causas combinadas. Por lo tanto, la preventión significa la solución real para un continuado progreso en el futuro.

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Résumé Le traitement des traumatismes chez l'enfant s'est modifié et amélioré de multiples façons. En premier lieu, grâce à la planification par les collectivités communales, régionales et nationales de l'organisation de la chirurgie pédiatrique en ce qui concerne l'accueil, les soins d'urgence, les centres chirurgicaux et les centres de soins postopératoire où sont traités les enfants victimes de traumatismes. La communication par voie téléphonique par radio et/ou centre informatique reliant tous les maillons de la chaîne de soins permet de traiter les blessés de façon rationnelle, cette amélioration allant de pair avec la formation adéquate des membres du corps chirurgical appelés à leur donner des soins adaptés aux techniques et aux lésions particulières de la chirurgie infantile.Les nouvelles méthodes d'imagerie médicale qui permettent de déceler avec précision les lésions intra-craniennes ou des autres cavités du corps ont modifié radicalement les conditions du diagnostic et du traitement précoce des traumatismes de l'enfant. Elles ont permis par exemple le traitement conservateur des lésions de la rate, du foie et du cerveau. Ces progrès se sont développés parallèlement à ceux réalisés dans le traitement de l'infection et dans la nutrition du blessé. Beaucoup a été fait, cependant le traumatisme reste la cause de mort la plus fréquente de l'enfant âgé de 1 à 14 ans. C'est la prévention qui représente la réelle solution du problème.

     

Functional outcome in pediatric trauma

Two hundred fifty consecutive children hospitalized with severe injuries (at least one injury with an Abbreviated Injury Score [AIS] greater than or equal to 4 or two or more injuries with AIS scores greater than or equal to 2) were studied to determine their functional status at discharge and 6 months later using questions from the RAND Health Insurance Study (HIS) and the Glasgow Outcome Scale (GOS). Of the 217 surviving patients, 190 (88%) had one or more functional limitations by the HIS scale at discharge. Ten (5%) were in a vegetative state, 40 (18%) severely disabled, 97 (45%) moderately disabled, and 70 (32%) healthy by the GOS. Six-month followup was complete for 156 patients. Of these, 84 (54%) had one or more functional limitations by the HIS scale. Seven (4%) were in a vegetative state, 17 (11%) severely disabled, 50 (32%) moderately disabled, and 82 (53%) healthy by the GOS. A substantial proportion of the whole group of children hospitalized for the treatment of severe injuries had ongoing physical disabilities that limited their participation in normal activities 6 months after they were discharged. This suggests a need for greater emphasis on the rehabilitation of pediatric trauma patients.     

Mortality prediction in pediatric trauma

BackgroundIn trauma research, accurate estimates of mortality that can be rapidly calculated prior to enrollment are essential to ensure appropriate patient selection and adequate sample size. This study compares the accuracy of the BIG (Base Deficit, International normalized ratio and Glasgow Coma scale) score in predicting mortality in pediatric trauma patients to Pediatric Risk of Mortality III (PRISM III) score, Pediatric Index of Mortality 2 (PIM2) score and Pediatric Logistic Organ Dysfunction (PELOD) score.MethodsData were collected from Virtual Pediatric Systems (VPS, LLC) database for children between 2004 and 2015 from 149 PICUs. Logistic regression models were developed to evaluate mortality prediction. The Area under the Curve (AUC) of Receiver Operator Characteristic (ROC) curves were derived from these models and compared between scores.ResultsA total of 45,377 trauma patients were analyzed. The BIG score could only be calculated for 152 patients (0.33%). PRISM III, PIM2, and PELOD scores were calculated for 44,360, 45,377 and 14,768 patients respectively. The AUC of the BIG score was 0.94 compared to 0.96, 0.97 and 0.93 for the PRISM III, PIM2, and PELOD respectively.ConclusionsThe BIG score is accurate in predicting mortality in pediatric trauma patients.Level of evidenceLevel I prognosis.     

Multidisciplinary pediatric trauma team training using high-fidelity trauma simulation

Background

Trauma resuscitations require a high level of team performance. This study evaluated the impact of a comprehensive effort to improve trauma care through multidisciplinary education and the use of simulation training to reinforce training and evaluate performance.

Methods

For a 1-year period, expanded trauma education including monthly trauma simulation sessions using high-fidelity simulators was implemented. All members of the multidisciplinary trauma resuscitation team participated in education, including simulations. Each simulation session included 2 trauma scenarios that were videotaped for debriefing as well as subsequent analysis of team performance. Scored simulations were divided into early (initial 4 months) and late (final 4 months) for comparison.

Results

For the first year of the program, 160 members of our multidisciplinary team participated in the simulation. In the early group, the mean percentage of appropriately completed tasks was 65%, whereas in the late group, this increased to 75% (P < .05). Improvements were also observed in initial assessment, airway management, management of pelvic fractures, and cervical spine care.

Conclusions

Training of a multidisciplinary team in the care of pediatric trauma patients can be enhanced and evaluated through the use of high-fidelity simulation. Improvements in team performance using innovative technology can translate into more efficient care with fewer errors.