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Jim Holliman, M.D., F.A.C.E.P.Jim Holliman, M.D., F.A.C.E.P.Program ManagerProgram ManagerAfghanistan Health Care Sector Reconstruction ProjectAfghanistan Health Care Sector Reconstruction ProjectCenter for Disaster & Humanitarian Assistance MedicineCenter for Disaster & Humanitarian Assistance MedicineUniformed Services University of the Health SciencesUniformed Services University of the Health SciencesBethesda, Maryland, U.S.A.Bethesda, Maryland, U.S.A.
Reducing Admissions Reducing Admissions for Pediatric Blunt for Pediatric Blunt
Trauma Trauma
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 Reducing Admissions for Pediatric Blunt Trauma : Pediatric Blunt Trauma : Lecture Outline and GoalsLecture Outline and Goals
Epidemiology of pediatric blunt traumaEpidemiology of pediatric blunt traumaInjury Prevention : the best way to reduce Injury Prevention : the best way to reduce admissionsadmissions
Develop hospital based Emergency Develop hospital based Emergency Medicine specialists : the next best way to Medicine specialists : the next best way to reduce admissionsreduce admissions
Current admission criteriaCurrent admission criteriaModifications of diagnostic workupsModifications of diagnostic workupsTrends in surgical management affecting Trends in surgical management affecting admission decisionsadmission 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 TraumaMost 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
Eighteen Year Pediatric Trauma Statistics Hershey Medical Center, Hershey, Pennsylvania
HMC population :10 county total = 2.1 million 32 county total = 4.44 million
10 county < 18 years = 500,000 32 county < 18 years = 1,000,000
HMC Pediatric Trauma Registry Cases for Each Year :1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
1999
101 168 155 179 222 227 282 263 281 316353
2000 2001 2002 2003 2004 2005
414 434 503 530 597 601
2006
686
0
100
200
300
400
500
600All Pts
PTOSPts
(Note increasing # of cases)
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 in-facility 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
SplenicLaceration.
No free blood.No surgery needed..
High grade blunt splenic injury
Normal CT 2 monthsafter injury
Fracture through rightlobe of liver. Transfusion.No operation needed.
Contusion left lobeof liver. No surgery.No transfusion.
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 injuryto 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 Bowelperforation. Free air. Laparotomy/primary repair.
Lap belt injury. Duodenalrupture. Air extravasationin retroperitoneum.
These may be missed if CT withheld.
The Dilemma of What to do About Free Fluid Seen on CT or Ultrasound
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)
Intraperitoneal fluid without solid organ injury.
Example case
Considerations About Laparoscopy for Cases of Free Fluid Seen on CT or
Ultrasound
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
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