FAST IN PEDIATRIC TRAUMA

Ahmad Althekair, MDFellow, Pediatric Emergency MedicineHospital for Sick Children

OBJECTIVES1. Pediatric trauma triage and mortality prediction2. Balanced hemostatic resuscitation in pediatrics

(emerging role of TXA & massive hemorrhage protocols)

3. Clinical decision rules in pediatric trauma (ciTBI, IAI, cervical spine clearance)

4. Imaging risks – why kids don’t get pan-scanned5. The role of FAST in pediatric trauma6. Submersion and management of severe hypothermia

EPIDEMIOLOGY Leading cause of death above the age of infancy

25% of traumatic injuries occur in children & youth

Bimodal distribution in injury death rates: Young children and teens

Teens are at increased risk due to: Increased exposure to hazards

Infants: Higher risk of inflicted trauma

EPIDEMIOLOGYMost common causes of injury-related deaths: Motor vehicle crashes Submersion injury Homicide Suicide Fires

Leading anatomic & physiologic etiologies: Traumatic brain injury Hemorrhagic shock (thoracoabdominal injury)

BLEEDING AND TRANSFUSION

Still bleeding and

Hemodynamically unstable?

Activate Massive

Hemorrhage protocol

Give TXA?

ANY TESTS?rTEG provided valuable goal-directed hemostatic resuscitation data for critically injured children.

ViscoElastic tests are not yet routine in most pediatric trauma centers.

Vogel AM, Radwin ZA, Cox CS Jr, Cotton BA: Admission rapid thrombelastography delivers real-time ‘actionable’ data in pediatric trauma. J Ped Surg 2013, 48:1371–1376

2ND THING TO KNOW Viscoelastic tests hold promise, but are not yet routine in pediatric practice and need further evidence and validation.

TRANEXAMIC ACID – PEDS?Beyond 3 hours of

injury timeEarly

(Upfront)

<12 year or < 50kg: 15mg/kg over 10 min then 2mg/kg/hr for 8 hours

>12 year or > 50Kg : 1 gm over 10 min then 1 gm infusion over 8 hours

No role for use in adults or pediatrics

Evidence Statement. Major trauma and the use of tranexamic acid in children. November 2012 Royal College of Paediatrics and Child HealthRoberts I, Shakur H, Ker K et al. Antifibrinolytic drugs for acute traumatic injury (Review) Cochrane Database Syst Rev. 2012;12:CD004896

WHY IT MAKES SENSE…Hemorrhage, like in adults, is the second leading and main preventable cause of traumatic death

Trauma-associated coagulopathy exists in kids

Hyperfibrinolysis - very likelyTrack record of safety and efficacy when used in HIGH doses in pediatric surgery

Children have healthier vascular systems Beno S, Ackery A, Calum J, Rizoli S. Tranexamic Acid in Pediatric Trauma – Why Not? Critical Care 2014

FIRST PEDIATRIC EVIDENCETXA used in approximately 10% of pediatric combat trauma patients.

Severe abdominal or extremity trauma and metabolic acidosis predicted use of TXA

TXA administration independently associated with decreased mortality (OR 0.3, p = 0.03)

Matthew J. Eckert, MD, et al, Tranexamic acid administration to pediatric trauma patients in a combat setting: The pediatric trauma and tranexamic acid study (PED-TRAX) J Trauma Acute Care Surg. 2014;77: 852Y858.

3RD THING TO KNOW Some retrospective evidence for TXA in pediatric trauma now, and strong evidence for its use in adult trauma.

PERN (PECARN leading) planning global multicenter prospective RCT evaluating TXA in both head injury and thoracoabdominal injury in children

PEDIATRIC MASSIVE TRANSFUSIONA threshold of 40 mL/kg of all blood products given at any time in the first 24 hours reliably identifies critically injured children at high risk for early and in-hospital death.

Lucas P. Neff, et al, Clearly defining pediatric massive transfusion: Cutting through the fog and friction with combat data, J Trauma Acute Care Surg. 2015;78: 22-29.

MASSIVE HEMORRHAGE PROTOCOL - SICKKIDS

Foundation ratio of PRBC(2) : FFP(1)

>50kg6U PRBC : 3U

FFP

<50kg4U PRBC : 2U

FFP

<6 months2U PRBC : 1U

FFP

Dzik Whet al. B: Clinical review: Canadian National Advisory Committee on Blood and Blood Products - massive Transfusion Consensus Conference 2011: report of the panel. Crit Care 2011, 15:242.

Early upfront TXA once decision to give child uncrossmatched blood

Goal directed therapy to guide platelet, cryoppt replacement

EVIDENCE FOR MTP IN PEDS MTPs widely adopted by hospitals to minimize the coagulopathy associated with hemorrhage.

Incorporating ‘real-time’ viscoelastic hemostatic monitoring into MTP in a hybrid resuscitation model may represent an optimal treatment paradigm for managing coagulopathic, critically ill trauma patients.

Chidester SJ, et al. A pediatric massive transfusion protocol. J Trauma Acute Care Surg. 2012 Nov;73(5):1273-7Hendrickson JE, et al. Implementation of a pediatric trauma massive transfusion protocol: one institution's experience. Transfusion 2012 Jun;52(6):1228-36.Pamela M. Choi and Adam M. Vogel, Acute coagulopathy in pediatric trauma. Curr Opin Pediatr 2014, 26:343–349.

4TH THING TO KNOW Massive hemorrhage in children: 40 ml/kg of all blood products given within the first 24 hr reliably identifies critically injured children at high risk for early or in-hospital death.

MTPs, unlike in adults, have not been shown to decrease mortality in children.

CASE 2 15 year old girl, cheerleader who was practicing and fell 18 ft hitting back of head, lost consciousness for 3 minutes.

In Trauma Bay, GCS 14 and normal exam.

What next?

CLINICAL DECISION RULES

CLINICAL DECISION RULES

GUIDELINES IN < 2 YEAR OLD

GCS = 14 or altered mental

status or palpable skull

fracture

• CT Recommended

Occipital or parietal or temporal

hematoma, LOC>5 sec,

Severe mechanism

• Observation vs. CT

Kuppermann N, Identification of children at very low risk of clinically‐important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160‐70.

GUIDELINES IN > 2 YEAR OLD

GCS=14 or altered mental

status or signs of basilar

skull fracture

• CT Recommended

History of LOC, or history of

vomiting,or severe

mechanism of injury,

or severe headache

• Observation vs. CT

Kuppermann N, Identification of children at very low risk of clinically‐important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160‐70.

COMPARING EVIDENCE

CATCH

CHALICEPECARN

Easter J. et al. Comparison of PECARN, CATCH, and CHALICE Rules for Children With Minor Head Injury: A Prospective Cohort Study. Ann Emerg Med. 2014 Mar 10. PMID: 24635987

5TH THING TO KNOW (PECARN) validated prediction rule identifies children at very low risk of ciTBI for whom routine CT head scans can be obviated.

HIGH SPEED CASE 8 year old boy belted in the back seat, involved in MVC. Presents with abdominal pain.

Hemodynamically stable.“My neck hurts”“My stomach hurts, I think I'm hungry”

FAST

FAST

CLINICAL PREDICTION RULE

RISK OF INTRA-ABDOMINAL INJURY

5.4%• Abd wall trauma/seatbelt sign• Or GCS<14 with blunt trauma

1.4% • Abdominal tenderness

0.7%

• Thoracic wall trauma/ Abdominal pain

• Decreased breath sounds/ Vomiting

Holmes JF, Lillis K, Monroe D, et al. Identifying children at very low risk of intra-abdominal injuries undergoing acute intervention. Ann Emerg Med 2013;62:107–16.

LIMITATIONS Laboratory testing was not routinely applied, and FAST was not included as few centers were using

HOW ABOUT FAST IN PEDS?Patients with a low - mod clinical suspicion of IAI are less likely to undergo a FAST exam.

True positive FAST exams rarely direct management in children.

Sensitivity too low to replace abdominal CT, as possibility of missing IAI is significant if clinical suspicion is high.

Jay Menaker, et al. Use of the focused assessment with sonography for trauma (FAST) examination and its impact on abdominal computed tomography use in hemodynamically stable children with blunt torso trauma. PECARN 2014 J Trauma Acute Care Surg. 2014 Sep;77(3):427-32.Eric R. Scaife, et al. The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation. J Pediatr Surg. 2013 Jun;48(6):1377-83.Clare Skerritt, Saira Haque, Erica Makin. Focused Assessment with Sonography in Trauma (FAST) Scans Are Not Sufficiently Sensitive to Rule out Significant Injury in Pediatric Trauma Patients. Open Journal of Pediatrics, 2014, 4, 236-242

POTENTIAL ROLE? Combined with normal physical exam, AST <250 and ALT <125 and urine neg for blood, a negative FAST is very likely sufficient to obviate the need for abdominal CT scans as these children at low risk for IAI.Work in progress – new data out soon from prospective RCT in California

E-FAST (pneumothorax and hemothorax) sensitive, specific and useful in pediatric trauma