Reducing Admissions for
Pediatric Blunt Trauma
Jim Holliman, M.D., F.A.C.E.P.
Program Manager
Afghanistan Health Care Sector Reconstruction Project
Center for Disaster & Humanitarian Assistance Medicine
Uniformed Services University of the Health Sciences
Bethesda, Maryland, U.S.A.
Thanks to Dr. Robert E. Cilley
(Pediatric Trauma Surgeon at the
Penn State Children’s Hospital in
Hershey, Pennsylvania) who
generously provided a number of
the slides in this presentation
Reducing Admissions for
Pediatric Blunt Trauma : Lecture
Outline and Goals
 Epidemiology
of pediatric blunt trauma
 Injury Prevention : the best way to reduce
admissions
 Develop hospital based Emergency Medicine
specialists : the next best way to reduce
admissions
 Current admission criteria
 Modifications of diagnostic workups
 Trends in surgical management affecting admission
decisions
Pediatric Trauma Epidemiology
• “After the first year of life, trauma is the
most serious pediatric health problem in the
U.S.”
• ½ of pediatric deaths after the first year of
life are due to trauma
• 22 million children (one in every 3) in the
U.S. are injured each year
• Child abuse (‘non-accidental trauma”) is
also a problem in all societies
Pediatric Trauma
Most Common Etiologies
•
•
•
•
•
Motor vehicle crashes*
Falls*
Child abuse
Fires
Penetrating trauma
– Increasingly common in teenagers,
particularly urban
*Together account for 80 % of
injuries in most centers
Eighteen Year Pediatric Trauma Statistics
Hershey Medical Center, Hershey, Pennsylvania
HMC population :
10 county total = 2.1 million
10 county < 18 years = 500,000
32 county total = 4.44 million
32 county < 18 years = 1,000,000
HMC Pediatric Trauma Registry Cases for Each Year :
1989
101
1990
168
1991
155
1992
179
1993
222
1994
227
2000
414
2001
434
2002
503
2003
530
2004
597
2005
601
1995
282
1996
263
1997
281
1998
316
600
All Pts
500
2006
686
PTOS
Pts
400
300
200
100
20
05
20
03
20
01
19
99
19
97
19
95
19
93
19
91
0
19
89
(Note increasing # of cases)
1999
353
Trend Summary in Pediatric Trauma
Cases at Hershey Medical Center
• Blunt trauma : 90 % of cases
– Motor vehicle crashes : 53 %
– Falls : 25 %
• Injury Severity Score > 15 : 40 to 60
cases per year
• Deaths : 4 to 12 per year (< 1 to 2 %)
Injury Prevention : By Far the Best
Way to Reduce Trauma Admissions
• Need to convince the public that
“accidents” are not random events
beyond the control of society
• Prevention education should begin in the
home
• Focused school-based programs are
additionally helpful
Injury Prevention Education for
Parents
• Counseling on providing appropriate
supervision for playtime activities
• Counseling on stress management to
help avoid abuse
• Poisoning prevention
• Fall precautions
• Instruction on cardiopulmonary
resuscitation
Injury Prevention
Environmental Factors
• “Retentive” fencing around play areas
• “Preventive” fencing around pools and
other potentially dangerous structures
• “Internal” fencing to limit access to
heaters and stoves
• Clearly marked crosswalks
• Carpets and railings for steps and stairs
• Rubber backings for carpets
Proven Injury Prevention Measures
Not Yet Well Legislated
Throughout the Middle East
• Bicycle and motorcycle helmets
– No excess riders
• Car seats and seatbelts
– No children in vehicle front seat
• Functioning headlights and turn signals
on vehicles
• Covering roadside drains
Developing Hospital-Based
Emergency Medicine
• The second best way to reduce admissions
• Countries without a well developed Emergency
Medicine specialty (such as Japan) have much
higher admission rates and more extended infacility observation periods
• Typically in the U.S. admission rates from the
Emergency Department are about 15 to 20 % overall,
with 10 % or less admission rate for trauma cases
Generally Accepted Admission
Criteria for Pediatric Blunt Trauma
• Shock
• Respiratory symptoms or signs
• Injury requiring surgical repair beyond
simple wound repair
• Glasgow Coma Score < 15
• Unsafe home environment
• Risk of deterioration of clinical status
(see next slide)
Admission Criteria Based on
Risk of Clinical Deterioration
• Nonsurgical injuries identified
– Small intracranial bleed
– Intraabdominal solid organ injury
– Possible development of compartment
syndrome
• Observation for manifestations of hollow
viscus injury
• Need for intravenous antibiotics
Splenic
Laceration.
No free blood.
No surgery
needed..
Normal CT 2
months
after injury
High grade blunt
splenic injury
Contusion left lobe
of liver. No surgery.
No transfusion.
Fracture through right
lobe of liver. Transfusion.
No operation needed.
Blunt renal
injury: fall
from horse.
Non
operative
treatment.
Pediatric Solid Organ Injuries :
Trends
• None or shorter stays in the intensive
care unit if hemodynamically stable
• Shorter hospitalizations (discharge when
pain free and eating)
• Fewer followup studies (no followup CT
scan if free of symptoms)
• Lesser restrictions :
– Bed rest for 2 weeks
– No contact sports for 2 months
Current Trends in Treatment of
Pediatric Pancreatic Injury
• Pancreas contusion : observe, feed when pain free and
biochemically normal. Percutaneously drain any pseudocyst
that develops.
• Pancreas transection : Some need distal pancreatectomy with
spleen preservation. Some may heal without surgery :
–
–
–
–
–
–
–
Keep NPO, start Total Parenteral Nutrition (TPN).
Discharge on home TPN if possible.
Serial CT scans to monitor healing.
Feed when CT shows healing and biochemically normal.
Percutaneously drain pseudocysts if they develop.
Benefits : Nonoperative management successful in 80 %.
Drawbacks : expensive, time consuming, possible delayed surgery.
Bicycle handlebar injury
to the pancreas (also minor
liver laceration)
Consideration of Paradoxical
Indication to Increase Admission
Rates
• Recent estimate that up to 2 % of cancers may be
induced by increased use of computed tomography
(CT), particularly in children
• So may be effective to withhold abdomen CT in
patients with minimal findings and admit for frequent
re-exams (don’t forget ultrasound)
– Withholding head CT not as reliable at avoiding
unexpected clinical deteriorations (particularly in
patients less than 2 years of age)
• Increased access to MRI may obviate this dilemma
Lap belt injury. Small Bowel
perforation. Free air.
Laparotomy/primary repair.
Lap belt injury. Duodenal
rupture. Air extravasation
in retroperitoneum.
These may be missed if CT
withheld.
The Dilemma of What to do About
Free Fluid Seen on CT or Ultrasound
The real question : is there a ruptured viscus ?
Options when fluid is present on CT scanning :
 attribute to solid organ injury if present (How
dangerous is this assumption? It works in
practice.)
 diagnostic peritoneal lavage (largely unhelpful)
 observation with serial examination
(compromised when patient is un-evaluable)
 Laparoscopy : diagnostic / therapeutic
 Laparotomy (open)
Example case
Intraperitoneal fluid
without solid organ injury.
Considerations About Laparoscopy for
Cases of Free Fluid Seen on CT or
Ultrasound
Trend toward laparoscopic evaluation :
 May be helpful in the evaluation of stable
patients with abnormal physical exam or CT
scan findings
 Not helpful when immediate control of
bleeding is needed in unstable patients
 Therapeutic for control of minor bleeding,
 Adjunct in the repair of intestinal injury
 (other applications include repair of diaphragm
injuries, drain placement)
Laparoscopic view of mesenteric tear
repair (hemoperitoneum present)
Reducing Non-Therapeutic
Laparotomies for Blunt Abdominal
Trauma
• In developing countries, obtaining
availability of diagnostic imaging
(ultrasound and / or CT), and utilizing
trauma team care protocols has been
shown to do this (thereby reducing
morbidity, hospital stays, and costs).
– Example references :
• Ped Surg Int 2000 ; 16(7): 505-509.
• Eur J Ped Surg 2007 ; 17(2): 90-95.
Reducing Admissions Based
on Practice Patterns
• Children with mild closed head injury, a
normal complete neurologic exam, and a
normal head CT scan do NOT need to be
admitted
– These patients have been shown to not have any
delayed deterioration that requires medical
intervention
– Sample references :
• J Pediatric Surg 2001 ; 36(1): 119-121.
• Amer J Emer Med 2003 ; 21(2): 111-114.
Reducing Admission Rates
After Procedures
• Main effective way to do this is to use
short acting agents such as propofol,
and careful lower dosing of other agents,
so there is not prolonged post-procedure
recovery requiring extended observation
or admission
To Have Success in a Pediatric Trauma Program :
Integrated, Multidisciplinary Care for the Injured Child Is Needed
Prehospital / Ambulance / Emergency Department Care
Pediatric Trauma Service (Pediatric Surgeons, Case Management Coordinators)
Pediatric Critical Care Medicine / Pediatric ICU
Neurosurgery / Orthopedics
Otolaryngology / Plastic Surgery / Ophthalmology / Urology
Anesthesia
Radiology
Nursing (Emergency Department, PICU, Operating Room, Inpatient Wards)
Pastoral Services /Social Work / Child Life Services / Philanthropies
Pediatric Rehabilitation (Occupational Therapy, Physical Therapy, Speech)
Support (Nutrition, Lab Services, Abstractors, Coders, etc.)
Injury Prevention
Performance Improvement Program
Effects of Regionalization of Care
for Pediatric Blunt Trauma
• Multiple studies show improved survival
(particularly for patients with severe head
injury) for pediatric trauma patients treated at
specialty centers
– Example references :
• J Trauma 2001 ; 50(5): 784-791.
• Ped Crit Care Med 2004 ; 5(1): 5-9.
– So ambulance systems and non-trauma hospitals
should have training to identify patients suitable
for direct transfers to trauma centers
Besides Reducing Admissions,
Can We Also Reduce Costs for
Pediatric Trauma Cases ?
• Yes, by reducing the use of standard
laboratory panels :
– For blunt abdominal trauma, “no routine lab test
had excellent sensitivity, specificity, PPV, or NPV”
(in cases where CT was done) ; reference Ped
Emer Care 2006 ; 22(7) : 480-484.
• Yes, by following clinical care team protocols
(to reduce hospital length of stay)
– J Trauma Nurs 2002 ; 9(1) : 6-14.
Reducing Pediatric Blunt Trauma
Admissions : Summary
• Prevention is still the best way to reduce
admissions
• Establishing good Emergency Department
evaluation and care is the next best method
• Carefully dose procedural sedation and use
short-acting agents
• Carefully assess the home status before
discharging any patient
Thumbs up from
Afghanistan
QUESTIONS ?
Thanks for Your Attention