pediatric trauma.

Pediatric Surgery
Discussion with Dr. Richard Falcone that touches on multiple topics in pediatric trauma.

Sections

  • PLAY FROM THE BEGINNING (00:00)
  • Cervical spine clearance (04:06)
  • Clearing the C-spine in severe TBI (13:08)
  • Assessing the C-spine in infants and toddlers (16:10)
  • Pancreatic trauma - nonoperative vs operative management (20:48)
  • Screening for non-accidental trauma in children with head injury (27:45)
  • Ophthalmologic exam for non-accidental trauma (33:20)
  • Role of labs and FAST exam for blunt abdominal trauma (34:32)
  • Management of solid organ injury (41:28)
  • Trauma activation system (48:30)

Additional Content

Dr. Ponsky: Let’s jump right into it. Actually I want to ask you, Rich, can you tell us, before we jump into things, can you tell us a little bit about your center—what kind of volumes you’re seeing there and what kind of trauma center you have there in Cincinnati?

Dr. Falcone: Yeah, absolutely. So, we are a level-one pediatric trauma center, free-standing. Well, we’ve actually been verified since 1993, consistently. We see about, or we’re approaching, 2,000 patients a year here.

Dr. Ponsky: That’s great. Let me ask you, who runs your traumas down there, is it the emergency room or the surgical team?

Dr. Falcone: Yeah so we’ve gone back and forth, as a lot of centers I’m sure have done over the years. Right now, with our focus on teamwork, we’ve decided and come to an agreement that actually the ED Physician is our team leader role for all of our traumas. We came to that after several back and forths, but really in the end it was: who’s there when the patient gets there, all the time?

 

Cervical Spine Clearance

 

Dr. Ponsky: That’s great, and actually, here at Akron Children’s Hospital we do the same thing. We’ve now moved it so the emergency department does take the lead. Well, let’s jump right into things here, Rich, and this is something that I think is probably the one topic that I really wanted to get a better understanding of and it seems like it’s changing frequently, and that is c-spine clearance. Can you take us through your thoughts on the new standards of care or how you summarize c-spine clearance and what is the role of CAT scan and how you would go about clearing a child’s c-spine?

Dr. Falcone: I think there’s a couple things that we’ve learned. One is that the ultimate risk of injury is actually pretty low. And a c-collar is often a useful adjunct that gives you time, so if you have a kid in a c-collar, there’s generally no rush to figure out, "Do they have an injury?” So one of the things, I’ll go into some others later, but one of the things that we frequently do is leave a kid in their c-collar, and we admit them to the hospital in their c-collar. I would say 90% of those kids the next morning when they’re less distracted and they’re not in the trauma bay, we can clinically clear their c-spine on rounds the next morning. That’s true for young kids, older kids, and later we’ll talk about normal under the new pediatrics GCS or the kids who are at least cooperative enough to do that from a head injury standpoint, but most of those kids we can do. We also have done with our emergency room of sending some kids home with their collar, follow up in our trauma clinic with our nurse practitioners in a week, and they clear them clinically there. So, we’ve really, through that practice, really minimized our use of CT.

Dr. Ponsky: Okay, Rich, so what I’m hearing you basically say is that, when in doubt, it’s great to leave the c-collar on these children.

Dr. Falcone: Correct.

Dr. Ponsky: Okay, so can you go a little more into when you would be using CT to evaluate the c-spine in children?

Dr. Falcone: The kids that cooperate, I mean we very rarely now will do a c-spine CT, but that’s really supported more and more by the literature. As you know, we want to minimize radiation in these kids, and there were 2 recent papers I think have talked to us and become a little more of our go-to standards. One was done by the Trauma Association of Canada Pediatric Subcommittee, and they published this in the Journal of Trauma 2 or 3 years ago from now, but they did an evidence-based review of spine clearance in children and really came out with some recommendations. Essentially they do what I’m kind of describing to you already, is rely heavily on your clinical exam, number one, and they kind of go through an algorithm, which is, "Are you able to clinically clear the c-spine?”, that’s your first test. If you’re able to do that, you don’t need any other imaging. You can clear them right there. If you’re not, then they go on, recommending your normal lateral, more standard AP and lateral x-rays. If you have those, they’re normal, and you have a normal neurologic exam, and the kid’s greater than 8, the recommendation fits pretty much what I’ve been describing which what we do is re-examine them. If you have a normal x-ray and you’re able to re-examine them and their exam is now normal, you can clear them. If they have an abnormal neurologic exam, that’s really the only branch-point there that goes to consider CT or MRI. So they have an abnormal neuro exam, they’re going to get a CT or MRI and get your spine surgeons, whether they’re neurosurgeons or orthopedic surgeons involved in their care.

Dr. Ponsky: Okay so I would like to repeat this, because I think this is an important point, if they have any tenderness at all, or you don’t think you can trust your exam, then you get an AP and lateral film to make sure there’s no bone injuries, and going along with that theme you said before, keep them in the collar and re-examine them the next day. And that the only time you should be getting a CAT scan if there are hard signs of a spinal cord injury or any neurologic spinal deficits, is that right?

Dr. Falcone: Correct.

Dr. Ponsky: What if they have tenderness on exam?

Dr. Falcone: If they have an abnormal exam, where they just have tenderness but no neurologic findings, those are kids where you can go on and consider a flexion-extension, or in our environment, sometimes those are the kids we’ll leave in the collar and re-evaluate them a day or up to a week later. Because sometimes you try to do those flexion- extension films early and the kid is too tender, too scared, and you get inadequate films anyway, and the same with CT. If you get a CT early and the kid’s still having tenderness, you’re not going to feel comfortable taking him out of that collar with just that image. You want to have both the imaging and some clinical findings that say they’re not having tenderness anymore, so we found that getting that CT early in kids with the normal neurologic exam really wasn’t useful and that’s what the evidence-based data would say.

Dr. Ponsky: So let me make sure I understand. And so let me just take some examples and you’ll guide me through analysis. A 10-year-old motor vehicle crash comes in. He had a c-collar placed just because of the mechanism. He’s got no real obvious distracting injuries. He’s looking at you, he’s talking normally, he’s got nothing obvious. Can you just clear him clinically without getting any films right there in the trauma bay?

Dr. Falcone: Yes. I think you have to trust your clinical exam and you have to trust your comfort level that it’s not midline tenderness and sorting some midline versus some lateral tenderness or stuff that’s more musculoskeletal. But I think if you have a truly awake kid with no distracting injuries, there’s enough evidence now that you don’t need to get an x-ray.

Dr. Ponsky: On that patient we can consider if he’s that kind of patient doing a clinical exam and clearing him and maybe even sending him home if he has nothing else going on.

Dr. Falcone: Correct.

Dr. Ponsky: What about the patient who is either frantic or has a distracting injury. That’s the one that you might wait, or I think I understood you might get maybe your lateral film and then wait until the next day to do anything further?

Dr. Falcone: Correct. So our general practice on those would be we’d probably end up getting an AP and lateral and let the kid go to the floor. Because generally those are kids that are going to get admitted anyway. Leave them in their collar, and most of those kids they’re now calmed down the next morning. Get a good exam, get them out of the collar, and follow up in the morning.

Dr. Ponsky: Okay so then tell me again of all the criteria you explained, which is a group of patients that would get a CAT scan?

Dr. Falcone: So the kids that have abnormal neurologic findings.

Dr. Ponsky: When you say neurologic findings you mean spinal neurologic problems.

Dr. Falcone: Correct. And those become pretty clear. The children who truly have point tenderness along their midline of their c-spine would have a higher chance of going down.

Dr. Ponsky: High suspicion. High suspicion patients are going to get a CAT scan.

Dr. Falcone: Correct. I think the bottom line is trust your clinical exam. I think we, across all pediatric surgery, and probably all adult surgery, have gone away from trusting your clinical exam and falling to imaging. So I think it’s the same rules for pediatric traumas. I mean, these kids can give you a reliable exam no matter how anxious. You distract them, and as pediatric surgeons we do that all the time.

Dr. Ponsky: And just to clarify, the CAT scan is really only looking at bony abnormalities.

Dr. Falcone: Correct.

Dr. Ponsky: And for the patient that you’re either going to get your plain films and observe, and you examine them the next day and they are tender, that’s the patient that, with no neurologic findings, that’s the patient that you would maybe get a flexion-extension film or send home with the c-collar?

Dr. Falcone: Correct. Yeah, so we’ll send them home with the c-collar. Almost more commonly as an inpatient, send them home with that c-collar before doing the flexion-extension film. Because if they still have muscle tenderness and they’re tender, we know it’s going to be an inadequate flexion-extension film and our radiologists are not going to be comfortable giving us a definitive answer. So we actually will send them home with some pain control and then see them back and if at that point we can’t clinically clear them, then we’ll usually get the flexion-extension.

Dr. Ponsky: Okay and you see them back in about a week?

Dr. Falcone: About a week, yeah, that’s in our nurse practitioner clinic.

Dr. Ponsky: Perfect. And I’ve spoken to some people that are much more liberal with getting MRIs. Do you incorporate that into your practice?

 

Clearing the C-spine in severe TBI

 

Dr. Falcone: We have only used MRIs for our obtunded patients. For our severe TBI patients, we’ll get an MRI before we clear those kids. And those are the kids that you’re not going to have a normal exam to be able to clinically clear them within a few days or a week even. And those kids will end up getting CT of their c-spine to make sure there’s no bony abnormalities. If that’s clear, we actually move onto an MRI and that’s what most of the pediatric literature would say. It’s not 100% clear, but I think most centers are doing it that way. In the adult literature, they’re getting a little more away. EAST [Eastern Association for the Surgery of Trauma] recently published a guideline that said you can clear even those obtunded patients with the CT. But I think most pediatric folks, and I don’t even think that most adult folks are really following that protocol yet, so an MRI would be there.

Dr. Ponsky: Okay, so in that patient that has a bad head injury, they come in with their c-collar, you probably get the CT/MRI combo. CT for bone, MRI for soft tissue, cord, and ligaments. If you see nothing on either of those, you’ll go ahead and take that collar off that patient 

Dr. Falcone: Correct. We’ll take the collar off. And the other thing that we do, and I think this works, is getting the severe TBI patients to the ICU. Even though we know there might be a high likelihood that we’re going to be scanning their c-spine at some point, we don’t do that during the initial resuscitation. We’ll scan their head and probably C1 and C2 as part of their head scan, and then get them to the ICU and manage their head injury. Because we know that almost all of those kids are going to go back down for follow-up head CT in the next 24 hours when they’re usually a little more stable, you know what’s going on, and then we spend that little bit of extra time to scan the neck.

Dr. Ponsky: Okay so for the purpose of bullet points at the end of this discussion, I just want to make sure we got this. We’re talking about, I just said it before but I’m going to say it again, so a patient over 3 years old who comes in who has no concerns of distracting injury, they’re awake and alert, you examine them and you potentially can do that clinically without radiography 

Dr. Falcone: Correct.

Dr. Ponsky: A patient that has any concern, or that you could not or may not get a reliable exam, you’re going to get an AP and lateral film, and likely observe them over night, and more than likely, if they’re still tender the next day, you send them home in a c-collar for a week, follow-up evaluation. At that point, if they’re tender, you might get a flexion-extension.

Dr. Falcone: Exactly.

Dr. Ponsky: Okay. And in the obtunded patient you’re going to get likely a CAT scan to evaluate the bones, and likely an MRI to evaluate the soft tissues.

 

Assessing the C-spine in infants and toddlers

 

Dr. Falcone: Correct. The other group people get challenged on is the young kids, the under 3 years of age group. And we were part of a multi-site review, a retrospective review that was done. I think that was published around 2009 in the Journal of Trauma where we looked for clinical clearance in blunt trauma patients under 3 years old and really came up with some criteria that can help you at least to put kids into a higher or lower risk groups, or where you need to be wary. Essentially for those under 3, the system that we came up with in that paper was giving them points. You get 3 points if you had a GCS less than 14, 2 points if you had a GCS eye score of 1, 2 points if you were in a motor vehicle collision, and 1 point if you were between 2 and 3 years old. And essentially what they found was that if you only had 0 or 1 points, using that scale, you had a 0% chance of having a c-spine injury, and really didn’t need much in the way of imaging. On the other hand, if you had a score of 7 or 8 on that, you had about a 21% chance of having an injury. And where you each fall as a center in your experience and comfort level in those scores between 1 and 7, I think 7 and 8, it’s pretty clear they need imaging, they have a high risk of injury. Scores of 0 or 1, pretty clear they don’t need much more, but a lot of kids are going to fall in that gray zone. I think that then is where your clinical judgement, and following what the Canadian group has described, following an algorithm to minimize that. Interesting in that study I was talking about, they actually also looked at how often CTs of the c-spine were being done, and because it was multi-site it was also multiple level 1 pediatric trauma centers, there were level 1 pediatric centers in adult hospitals, free-standing adult trauma centers, and then level 2 adult centers all contributing data for this. And, interestingly, just from a benchmarking standpoint, the pediatric level one centers were only giving CTs about 17% of that time, compared to the adult centers which were anywhere from 24-45% of the time depending on their level and their partnership with the pediatric center or not. So, clearly if you go benchmarking, we’re doing too many CTs overall for these kids. And I think you just have to take it in a stepwise fashion 

Dr. Ponsky: Repeat that again for me for case number 3, the bullet point.

Dr. Falcone: So we are pretty comfortable here, for the most part, if they don’t have a head injury, even clearing some of those clinically right off the bat if they’re age-appropriate and doing normally, even if it’s an infant, getting them cleared without imaging. But the paper that we were a part of really said if your GCS was less than 14, you’ve been in a motor vehicle collision, your GCS eye score is 1, you’re now considered to be in a higher risk group, and we weren’t able to say in the paper that that means you need a CT, but that means you need to be screened more carefully, whether that starts with films or proceeds to CT.

Dr. Ponsky: And the study, again, this is the Canadian study that did that stratification 

Dr. Falcone: So the stratification for the kids under 3 was led by the group from Massachusetts General. Adult and pediatric centers all combined data and they ended up with 12,000 patients younger than 3 to create that. It’s clinical clearance of the cervical spine in blunt trauma patients younger than 3 years, multi-center study of the American Association for the Surgery of Trauma, and that was in Journal of Trauma September 2009 

Dr. Ponsky: Perfect. And that paper, for the child that’s under three, helps to stratify them into high or low risk and helps make a clinical decision. You know, when I go by in the morning and I see these children who are little babies and I go to try to clear their c-spine, I was once told that you can go ahead and take off their collar if you push on their neck and they don’t go crazy. You watch and see if they move their head left and right and that’s sort of a way of clearing them. Is that accurate?

Dr. Falcone: Yeah that’s pretty much what we do. Yep.

 

Pancreatic trauma - nonoperative vs operative management

 

Dr. Ponsky: Okay, great. Alright well I think that was a great summary of c-spine. Let’s totally shift gears here and go to a totally different part of the body now. So now you have a 12-year-old who was riding his bike, we actually had this patient come in last night, and had a handle bar injury. The patient comes in and he’s hemodynamically stable, he’s complaining of some abdominal pain and he has abdominal tenderness, and you see a mark in his epigastrium. You get a CAT scan and it shows evidence of a possible neck of the pancreas injury. There’s some fluid around the pancreas, and no free air, and no thickened loops of bowel. How would you manage that patient?

Dr. Falcone: So I think the challenge in pancreas trauma is really trying to figure out is there a duct injury or not. I think that that’s your number one question and your number one concern, and I think there’s still debate out there in the literature. In fact, a group from Texas Children’s is now trying to get together a prospective randomized study to start looking at who we should operate on and who we should not and how we determine that with pancreatic trauma. Because the literature is mixed and it depends, honestly, on which paper you read and where you trained as far as how aggressively folks feel about operating on these or not. There is more and more evidence that if you have a true duct disruption, ideally a splenic-preserving distal pancreatectomy early is a better treatment, and that would be for the grade 3 spleen injuries. Now the challenge is that’s easy to say but clinically it becomes hard to always know based on your CAT scan. Kids can have pretty significant injuries and we’ve had several here that look pretty bad and we get an ERCP or even an MRCP now and despite the big crack through the neck of that pancreas, the duct is visualized and intact, and those kids will heal. It’s the ones that have a duct disruption. So I think it’s a matter of can your CT definitively show that or do you need to move to an ERCP or an MRCP. And an ERCP has advantages and disadvantages. The advantages you could potentially even put a stent in so it’s potentially therapeutic as well. The disadvantage, as we all know, is you’re injecting dye into that duct and you run the risk of getting their pancreas angry and inflamed as a result of the that test which you don’t have that risk with your MRCP. So I think it depends on who you have access to at your center, which one of those routes you need to go down. But the challenge is figuring that out. There’s data that conservative management can work. Even if there is a duct disruption they may get a pseudocyst but those are manageable and drainable but there’s also data that says that takes longer, more TPN time, more hospital length of stay. As opposed to that, I can say that’s generally been our practice up until recently, where we’re considering more pancreatectomies, but we do have kids that stay for a while but they get out of an operation. The other side of that is we’ve also had kids transferred to us who’ve had a distal pancreatectomy and we’ve managed their duct leak and their pancreatic fistula for a while, so there’s both sides to. So I think that’s the reason to continue to study this question as to what’s safest and best and I think some of it’s going to come down to, as we all know, how often do we do pancreatectomies and who is doing that pancreatectomy and if you’re someone who feels comfortable and does a fair number of operations on the pancreas, then you’re probably going to have a good outcome from operating on more of these kids. If you’re someone who hasn’t operated on a pancreas in years and now this kid with pancreatic trauma I’m going to go in and do a distal pancreatectomy, you may be at more risk and put them at more complication risk and that’s part of the problem with the studies that have happened so far. The ones that say distal pancreatectomy are a good thing are done at centers that, and especially laparoscopic distal pancreatectomies are at centers that have folks that are very comfortable operating back there laparoscopically, they do it all the time. Centers that don’t do it as often are not likely to have those same outcomes and it may be in the patient’s best interest to manage it non-operatively.

Dr. Ponsky: I know that it’s not great to be anecdotal but I have vacillated. I used to believe in non-operative management, I’ve tried ERCP stenting and those patients, in my experience, have seemed to be more of a challenge than early surgery. I think where I’ve really gone wrong is being indecisive and sort of going at like day 3. I think either operate or you don’t, but going in at that middle ground was when I’ve found myself in trouble.

Dr. Falcone: Yeah, and I think that’s absolutely right. I think that more and more of the literature is agreeing with exactly what you’re saying on both accounts. There is more of a sway towards considering operating and operating more frequently, but there’s also the, if you’re going to do it, you want to do it within the first 24 hours. I mean it’s not your true surgical emergency, you’ve got to go right from the trauma bay and make that decision, but you want to get your data whether it’s via ERCP or via MRCP, is your duct really obstructed or do you have enough information on your CT, and make your decision in that 24-hour window 

Dr. Ponsky: Okay. And you know briefly I know when I’ve done my splenic preservation I’ve taken like a little ligature and sort of divided the vessels off the splenic. Is that how you do it? Do you pull it off of the splenic vessels?

Dr. Falcone:  Yeah, and we honestly don’t do very many which is why we’re going to start trending more data, but I think it’s a trend. I mean, we’ve as a group we’ve written about non-operative management of these more than we have on operative, but it is a trend and I think there’s more and more data that says if you know you have that duct disruption, go in early and get it done.

Dr. Ponsky: Got it. Now it’s interesting. If you go in to operate and you see that there’s parenchymal injury but it’s not a ductal disruption, would you then just drain and get out or would you go ahead and do your distal pancreatectomy 

Dr. Falcone: No, we would just drain and get out.

 

Screening for non-accidental trauma in children with head injury

 

Dr. Ponsky: Okay. All right the next question is more of a social issue but also something that we’re faced with a lot, and that is screening for non-accidental trauma in children that have a head injury. I know that being at different institutions, we’ve managed it differently. Can you tell me the process you go through in screening these children?

Dr. Falcone: Yeah, absolutely, so we’ve looked at the data, both our own and what’s published by others about screening, and one of the things that we struggled with was who’s making that decision of which kid needs to be screened and how much bias there exists around that decision. So there is literature that says, well, if I see someone who looks like me and is from the same neighborhood as me, I’m less likely to be suspicious of them abusing their child even with the same injury pattern as someone who more typically is from a lower SES group, looks different than me, from different racial or ethnic background, folks, whether we like to admit it or not, we are more likely to screen those kids. And we were doing the same thing. When we pulled our data, if you were low SES or you were a minority child with a head injury, even with a mild head injury, so a skull-fracture that gets admitted, we were much more likely to do a skeletal survey, get our social services involved, and evaluate those kids, than we were with the middle/upper-class, non-minority family. The literature supports that there may be some higher risk in the socially stressed groups, economic stress does add some risk, but abuse happens in all races, in all socioeconomic bands and so we’ve gone to a pretty consistent. If you are admitted to us, and now we’re working with our emergency room to expand how everybody gets consistently but where we had most control was the kids who got admitted. So, if you’re admitted with us, a child under 2, with a head injury, and that could be post-concussive, it could be a severe TBI, that could be a linear skull fracture, and your mechanism was something that was not witnessed publically, and we specifically characterize that because we didn’t want it to be what was witnessed by mom and her boyfriend, or dad and the babysitter, or you know we want it to be the kid was at the supermarket and someone saw them fall out of the grocery cart, that’s a witness. Or, they were in a motor vehicle collision, that’s a witness in a public location. Everything other than that, we get a skeletal survey and we get the social worker to evaluate the family across the board. And, by setting up that guideline, one, we eliminate that disparity of who was getting screened, but interestingly our percentage of positive abuse remained consistent so despite evaluating more kids, you would have expected if you increased your denominator, positive abuse rates are going to drop, but we actually didn’t see that. We saw it stayed exactly the same which to us I think implies that we were finding kids that we probably wouldn’t have screened before that were being abused, and in fact in the population we’re finding almost 50% positive abuse. Now, it is a biased population because they’ve had enough injury to get admitted to the hospital they are not your outpatient type thing so they’re probably a little more at risk in general. But, to me, for a screening test that gives you a nearly 50% positive rate of abuse, that’s a more productive screening test than most screening tests we do for other things.

Dr. Ponsky: So, wait, Rich, I want to repeat this because I think this is fascinating. What I think I hear you saying is that originally you only screened those who you found suspicious and the incidence of child abuse was 50%. And then you said, let’s have standard screening criteria and take any bias opinion out of it so that any child under 2 years of age that had a head injury of any sort that was unwitnessed got screened for child abuse, just like those you found suspicious, and when you did that, they also had a 50% incidence of child abuse. In other words, that group, who you originally felt were not suspicious for child abuse had the same incidence of child abuse as those that you did feel were suspicious, so that we should be screening any child under the age of 2 that has an unwitnessed head injury. Is that right?

Dr. Falcone: Exactly. So these kids are unfortunately at high risk and we need to be ever aware and not let our personal biases get in the way of who we do or don’t evaluate for non-accidental. And families find it more reassuring now in our new system and it’s easier quite honestly for us to be able to say "We do this for every family with this type of injury. We’re not making any type of judgement about you, we’re not making any type of judgement about whether you’re telling us the truth or not, this is our standard to make sure we don’t miss injuries and keep kids safe.” Families are reassured by that.

 

Ophthalmologic exam for non-accidental trauma

 

Dr. Ponsky: Rich, I really like that. In fact, I can see that’s something that I’m going to recommend we start here. It’s easy to tell the family anyone under 2 with a head injury, you’re going to get this work-up. What about, do you give ophthalmologic exams?

Dr. Falcone: So we don’t do that as routine right now. We get that if the skeletal survey is positive, if the social worker or we have other reasons that we’re particularly worried that there’s other bruising, there’s other abnormal head findings that don’t fit with the given story, then we will get that. But right now that is not part of our routine screening.

Dr. Ponsky: Okay, it would be interesting to see, one or the other or even adjunctively, collectively they work together to give you a higher rate.

Dr. Falcone: And it’s interesting, I don’t have all the data or all the expertise on this but our child abuse experts are actually working on a study where they’re looking at organized social questioning and some key answers within that that may actually in fact be better screening than the available survey because they’re finding there are key terms or key situations that can light up as a risk factor. So there will be more to come on that one, but it’s interesting, the whole field of screening, and sadly we need to worry about it all the time.

 

Role of labs and FAST exam for blunt abdominal trauma

 

Dr. Ponsky: Let’s move onto a different question. So, can you talk to me about, when a patient comes in with blunt abdominal trauma, I’ve always wondered about the accuracy of this. Can you talk to me about what labs you get and how they help you and when do you use FAST in these patients?

Dr. Falcone: That’s a great question and it’s a challenging question there are several groups, the PECARN (Pediatric Emergency Care Applied Research Network) have done a lot of work on this topic of who to screen and what tests to use, and actually their most recent publication came out in the Annals of Emergency Medicine in 2013, identifying children at very low risk of critically important blunt abdominal injuries, and that was an interesting and good study. They did a couple things that a lot of the studies did not do, and that was really define clinically important blunt abdominal injuries because you know to say well we used a screening test and we missed a minor grade-one spleen injury, is that enough to justify that all those kids needed scans? But they looked at this and really came up with a stratification again for who’s at really low risk and what tests and, interestingly, they didn’t use labs or FAST exams in order to do this. They said, if you have no evidence of abdominal wall bruising, they’ll find that handlebar sign that you had. You had a normal GCS score, 14 or 15 really, you had no abdominal tenderness, you had no thoracic wall trauma, you had no abdominal pain, you had no alteration in your breath sounds, and you had no vomiting, you had a 0.1% chance of having an intra-abdominal injury, so they classified those as very low-risk of clinically important abdominal injury and said those kids, you meet all those criteria, you don’t need to be scanned. What no one’s really looked at well is, okay, if you have one of those factors, do all those kids still need to be CT scanned? And I would say, and even that paper found, in fact, if they followed the rules they came up with and scanned everyone who wasn’t in the very low risk group, they actually would be recommending more CTs than those of us at pediatric trauma centers are doing already. So, if you’re at very low risk, you absolutely don’t need a scan. If you have one of those findings, there may be some kids that don’t need a scan, and we at level-one centers and level-two centers and places that have access to pediatric surgeons probably aren’t scanning them, all of those kids. Now, labs have been shown to be kind of very variable. With positive, abnormal LFTs greater than 150-200, you have a good chance of an injury of some sort. But, if they’re normal, there’s very little evidence, and that means you’re safe. So, they may be useful as a screening tool. So if you say I think they’re at pretty low risk, I want to do one more test to help me feel a little more comfortable, I think that’s where people are using it, but we have gone away from getting LFTs, amylase, and lipase as a routine. We only, if we have other indications to do a scan, so we have abdominal bruising, we have tenderness, and we’re going to scan that kid anyway because of the concern with those, we’ve found that there’s not any value in the literature of getting those labs. The only ones we get labs on are, I don’t think they need a scan, no one thinks they need a scan, we do them. And I have to say, we’re starting to get a little bit away from that because of the high, you know it gives you a false sense of security. Normal labs don’t prove that you don’t have an injury, they just make us feel better. Eric Scaife out in Utah recently published on FAST exams, the same thing. They were using FAST exams to screen the kids they thought were low-risk and when they looked at it they really just were giving themselves a false sense of security because of the low sensitivity of FAST exams. And FAST exams are very user-dependent, just like any other ultrasound test. Now, FAST exams are great if you have a hypotensive patient that you’re really looking for I’d say the classic reason that FAST exams was developed , a hypotensive patient and you’re trying to prove do they have a bunch of blood in their abdomen or not—those are still the kids that FAST exams are going to be helpful. A negative FAST exam in a child that’s still healthy, the literature would caution you that you may miss stuff if you trust that too much.

Dr. Ponsky: So I just want to summarize here. So, in a patient that has one of those criteria that you mentioned, you would get a CAT scan.

Dr. Falcone: When what they were careful to say is if you have none of those criteria, you don’t need a CAT scan; but, they were very careful of saying just because you have one does not mean you have to get a CAT scan.

Dr. Ponsky: I see, so they were identifying the group that didn’t need a CAT scan by having these zero.

Dr. Falcone: Right if you have zero of these predictors you did not need a CAT scan is what they were saying.

Dr. Ponsky: Got it. So then who does need a CAT scan?

Dr. Falcone: If you had abdominal wall trauma, meaning a seatbelt sign, a handlebar sign, or you know your GCS was less than 14, you had about a 5% chance of abdominal injury. So it allows you to have a little more judgement. Knowing there’s a 5% chance we can observe this kid and "do I feel comfortable with that risk?”, if you will. If you didn’t have that but you just had abdominal tenderness, what they found was your risk was down to about 1.4% of having an intra-abdominal injury that needed some sort of intervention. Again, their interventions were as little as IV fluids for 24 hours. And if you didn’t have any of those and you just had thoracic wall trauma, a little complaint of abdominal pain, or some vomiting, your risk was actually only 0.7% so again it allows you to use that. If you had none of those, your risk was only 0.1%. So it doesn’t tell you who, but it allows you to have a little more judgement and balance those factors.

Dr. Ponsky: And summarize for me again who you believe the labs would maybe affect your management.

Dr. Falcone: I think to me it would be a kid who has really pretty vague symptoms, vague mechanism. So I fell off my bike, I have a little bit of belly pain but I don’t have any bruising, hemodynamically stable I’m not tachycardic, parents and I want to send the kid home, I’m going to maybe send those labs just to be that one more test.

Dr. Ponsky: And if those labs come back negative?

Dr. Falcone: I’d probably feel comfortable sending him home. If it comes back positive, then that brings me back down the CT path.

 

Management of solid organ injury

 

Dr. Ponsky: Right. Okay, that’s interesting. Let’s move onto a different topic, and still along the idea of solid organ injury, so you know in the adult population they’re using a lot of angiography, for solid organ injury. Tell me, we don’t seem to do so much with children. What is your use of that in children?

Dr. Falcone: Yeah ours as well is extremely limited and even given our volume I can’t think in the last 4 or 5 years when we’ve embolized for a solid organ injury. We’ve used it for pelvic trauma and other reasons, but for solid organ injury, it’s probably been 4 or 5 years since we’ve used it. And I think where it gets used more often than pediatric trauma centers where you and I have spent more of our time at, is at adult centers who do angiography for adult patients more often. I think that there had been, I think it’s hopefully reversing some, but this trend of if I see a blush or I see a bad injury I’m going to embolize rather than wait to see how the patient does. And I think there’s no good evidence and in the small kids you actually may be putting them at more risk of an injury from angio-ing them or from knocking out most of their spleen anyway and losing any benefit of not doing the splenectomy in the first place by doing that. We’ve found that a blush puts you at a higher risk for needing an intervention or a transfusion, but it doesn’t mandate that you’re going to need it. There are plenty of kids that have a blush and, I don’t think I have that paper here handy, but there’s papers to support that a blush does not mean that you need to intervene. So I think we have to be careful and I think it’s probably even more so for adult counterparts who are used to thinking about angio more frequently than we are in pediatric world that are willing to pull that trigger. And, I think it’s also that if I’m at an institution that doesn’t have the resources to keep an eye on that kid as well as I’d like overnight, I might sleep a little better if I embolized them, knowing I wouldn’t be able to react as quickly if that blush turned into something. And that’s been the argument from smaller centers around the country that don’t have the resources we do at level-one.

Dr. Ponsky: I know that a lot of us use Dr. Stylianos’ paper as a guide on how to manage solid organ injury. Has that changed? Should we still be following those rules?

Dr. Falcone: Yeah I think that that was clearly a landmark paper, really, back in I think it was 1999 that he originally published that with the APSA trauma committee and it really changed how we all managed spleen trauma and solid organ liver trauma, and in fact it’s one of the things as pediatric surgeons we can be proud the adult trauma surgeons have followed our suit as opposed to the other way around. I think more and more though we’re all realizing and it’s something Shawn St. Peter and the group in Kansas City have published a couple papers on this now, that we can probably start shortening those windows: the length of time of bedrest for the grade 1 and 2, probably at most need to be overnight, one night, about 12 hours or so, and maybe 2 nights for those kids with grade 3 or 4s. Now, grade 5s gets a little more complicated and more challenging, you have to do it individually by patient. But, they found by doing that you can cut down significantly your length of stay for these kids and not have readmissions, not have complications from that. We kind of anecdotally have gone back and looked at our series as well, and even without changing our guidelines we realized we were starting to do that because we were starting to see these kids that looked so good and you were keeping them in bed doing nothing. Then, we started liberalizing. I think the original guidelines talked about a slow progression: up to the bathroom first, and then ambulate, and then just a slow progression. And what I think Shawn St. Peter and their group found, and what we found here locally, is that you can move these kids a lot more quickly. There’s also growing evidence that very few of these grade one injuries, if any, are going to need a transfusion, so all the lab-draws that initially were outlined in Stylianos’ paper probably aren’t necessary. There was a presentation from the group in Colorado, Dennis Bensard and their group at the Western Trauma Association meeting that really was starting to propose don’t even do any lab-draws if they’re clinically okay. If they’re not tachycardic, they’re not having pain, they’re not having any vital sign changes, use your labs totally as directed by your physical findings and your tachycardia. Now, I’m not sure if everyone’s ready to go to that level yet, there’s probably a need for some more data on the no-lab-approach, but there’s definitely growing support for less lab-draws, shorter length of stay and bedrest for these kids.

Dr. Ponsky: So you know some of the things you mentioned sort of were suggestions such as grade 1 or 2 overnight, grade 3 or 4 two days. Do you have a protocol that you’re using now, an abbreviated protocol at Cincinnati, and/or is there an article that proposes a protocol?

Dr. Falcone: Yeah, so we do have a protocol that I can share with you and get for you. There’s also Shawn St. Peter, their group has published theirs. I’m trying to see if I can find that protocol because it was in the Journal of Pediatric Surgery in 2011 and Shawn St. Peter was the first author on that. They looked at and published their protocol which is pretty similar to ours here at Cincinnati. But yeah really trying to continuously shorten that but always balance that with what’s safe. There’s even people talking about do isolated grade one spleen injuries potentially even need to be admitted to the hospital. We’ve looked at our data and I know Shawn has looked at their data, they never get transfused, they never have a problem. If that’s their only injury, they may not need to even stay in the hospital.

Dr. Ponsky: Okay and are you checking the labs about every 12 hours?

Dr. Falcone: Grade ones we’ll do one 12 hour check and that’s it, grade two we’ll do two, and then that’s it. And grade threes we may only do two based on their clinical exam, or do a third one.

 

Trauma activation system

 

Dr. Ponsky: Okay. Just before we finish here, can you give me your brief assessment of our trauma activation system, high level traumas, is there evidence behind that system or is it arbitrary 

Dr. Falcone: So there’s evidence that a tiered system is valuable. There’s definitely support for a tiered system of activations within, and this is talking about not just who goes to a trauma center but if they’re coming to your trauma center having a different level, so we all at least are used to a 2 level, some places have 3 level tiers, and ours is a 3-level. We have lowest acuity is just the ED see and surgery on call if they need it. The midlevel (level 2) is ED and a surgery resident and a couple other folks, and then the highest level is an attending, the OR staff, and ICU all respond to it. And we started looking at this a few years ago saying, you know what is the evidence for which criteria we’re using to tell us which kids to activate for that highest level, and there are all different strategizing ways to say are you overtriage or undertriage and people use things like injury severity scores, what injuries they ended up having. We decided to look at this and we did this with I think it was a total of 9 other peds trauma centers back in 2012, that was a multicenter prospective analysis of pediatric trauma activation criteria and we really wanted to look at the ACS that said there’s 6 criteria that you have to use but they’re generic, they’re adult-based, and even those if you going looking for evidence there wasn’t a whole lot of evidence. And they’ll say that you need to use these 6 but each center could add on whatever other criteria they want based on their individual decisions, and what we were doing, and what I think a lot of centers would do would be, we had a kid last week that came in with this random stray injury and we should’ve activated that as our highest level; we didn’t because it didn’t meet any of our criteria, so let’s add that to our criteria. There were centers that were having 10 to 15 to 20 criteria and things would get confused, so we wanted to look at, what if you matched up criteria to resources used, because your high-level team uses a lot of resources that you know it takes your attending surgeon away, it takes, depending on your system, it takes an anesthesiologist away, it takes ICU, takes nursing, and really ties up a lot of resources. It potentially puts an OR on hold, whatever your system may call for. We want to say let’s look at it based on resources, so we said we’re going to say it was an appropriate triage if you needed things like an intubation, you needed blood transfusion within the first 30 minutes, you needed a test tube within the first 30 minutes, some obvious you know you were giving CPR within the first 30 minutes, you needed to go to the OR within 60 minutes of arrival, and matched up the criteria with that. And doing that, we were able to identify criteria that increase your chance and gave you better over and under triage-rate. And we really came down to penetrating wound to the head, neck, or torso, age, tachycardia, or evidence of poor perfusion, receiving blood prior to arrival at your institution, systolic blood pressure less than 90 or age appropriate, hypotension you’ve got 40 mL/kg of fluid prior to arrival, any respiratory distress or failure, GCS less than or equal to 8 as the criteria. And by doing that we were able to bring down some of our overtriage and it’s always okay to have some overtriage in order to not miss, but also to correct our undertriage problem and get things closer. We found that doing this we would’ve had an overtriage rate of 39% and an undertriage of only 10%. Now, we also looked at this. There’s no doubt the more criteria you add, the lower your undertriage rate is going to be, you’re not going to ever undertriage anybody, but you’re going to have a much growing overtriage and that break point was around 8 or 9 criteria. So I think there’s still work to be done there but I think matching it to resources as opposed to what injuries you ultimately have. And we just published another paper that I was a part of in the Journal of Trauma with the lead author is Brooke Learner that really used a Delphi method to look at more formally defining what should be considered high resources that justify that activation of that high level team. And it’s a lot of things we did in our initial paper but a couple others, needing ICU stay for greater than 48 hours was in there, and a few other pieces, but I think we need to continue to look at that, because I think right now there’s some evidence, and our work is some of that, but there’s a lot of room for more evidence and the next level of that is how do we get that information from EMS and our prehospital providers, because it’s great to come up with these criteria that we use at the pediatric trauma center or recommend people use, but if the prehospital providers can’t provide us that information or can’t get us that information accurately because they don’t see enough kids, it doesn’t help our system and it delays getting the kids the right care. So I think there’s lots of room for that to get better.

Dr. Ponsky: Yeah and that we be fantastic for us to have sort of a data-based system. Let me ask you real quick, who comes to your higher-level activation? Do the entire anesthesia and OR team come in?

Dr. Falcone: Yeah so we have in-house anyway, but for our highest level activations, anesthesia responds, it’s definitely a surgery fellow or attending responds, OR nursing person responds, and an ICU fellow or nurse responds to those who are all additional people and we also get blood products for those kids.

Dr. Ponsky: Okay. Well, Rich I appreciate you taking time out of your day to do this. This has certainly been some high-yield information and I think all of us really appreciate you sort of focusing in on some of the things that we’re all sort of unsure about as the data is ever-changing. So, thank you very much and I hope you have a good rest of your day today.

Dr. Falcone: Thanks again.

Dr. Ponsky: Take care. We hope you enjoyed today’s episode on pediatric trauma. I know that Dr. Falcone wanted to invite everyone listening to the second annual Pediatric Trauma Society meeting being held in Scottsdale, Arizona November 5th-November 7th.  There’s also a call for abstracts which are due on May 15th. You can sign up for the meeting or submit your abstracts at www.pediatrictraumasociety.org. We hope you enjoyed this episode of "Stay Current” in pediatric surgery. Download the Global Cast MD podcast app to receive notifications when new podcasts are released and to send comments or questions to other listeners or faculty. Also, subscribe to the Global Cast MD podcast. We’ll see you next time.

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