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Return On Investment:
30 Years Of Commitment To The Injured Child Has Become A Pathway To Success.
J.J. Tepas III MD, FACS, FAAP
Korean Conflict
•Air Ambulances
•Return to Larrey (MASH)
•Vascular Repair
•ARF (Acute Renal Failure)
Wilbur Mills’ “Three layered Cake”Medicare Part A – hospitalizationMedicare Part B – physicians feesMedicaid – state shared coverage of poor
7/30/65
Return of a “social agenda”
From this point on,
cost control!!!
CPI 79.7% riseHospital costs 237% rise!
Chrysler:•$600 Million for healthcare•More than for steel and rubber•Inpatient maternity twice as long as average•Podiatrists: one toe at a time!
“It’s hard to believe that once there was a time-even in this century – when retirement was nearly synonymous with poverty, and older Americans died in our streets.”WJC, 9/22/93
1,342 pages of undecipherable technical jargonHarry and Louise take to the airwaves
Republicans: against employer mandate, favor individual mandate!
1996 HIPAA – limit coverage denial1997 SCHIP – uninsured children
Cuts to Existing FFS System
•Market basket reductions
•DHS cuts
•Nonpayment for anything
preventable or
unnecessary.
Transform Existing System
•Bundled Payments
•Innovation Center
Demonstrations
Accountable Care
Organizations
REFORM’S “STRATEGIC” PLAN
Track 1 Track 2
Injury
Pre-hospital
Resuscitation
Evaluation
Critical Care
Convalescence
Recovery
Delay
Hypoxia
?? procedures
Wrong triage
Cold
Hypoxia
ContaminationImproper ventilation
Inappropriate studies
Cold
No leader
Fluid/Electrolyte anomaly
PNA
Slow D/C planning
Poor family support
Out of sight, out of mind.
Cracks In The System
Trauma Systems“If you build it, they will come” DOES NOT APPLY!
2005: Pediatric Criteria
58 L1; 44 PTRC
24 L2; 21 PTRC
65; 41 out
14 New PTC
Session: XI: Quickshots Paper QS16: 9:46-9:52
PEDIATRIC TRAUMA CENTERS AND AMERICAN COLLEGE OF
SURGEONS COMMITTEE ON TRAUMA VERIFICATION: IMPACT ON
MORTALITY
Emily E. Murphy MD, Mark D. Cipolle* MD,Ph.D., Glen Tinkoff* MD, Stephen
Murphy MD, Barry Hicks* MD, Gerard Fulda* MD, Christianacare Health Services
Invited Discussant: Jeremy Cannon, MD
Introduction: Pediatric mortality is lower in states with American College of Surgeons
Committee on Trauma (ACS COT) verified pediatric trauma centers (PTC) compared to states
without verified PTCs. We hypothesize that mortality rates will be lower for severely injured
children cared for at a PTC that is ACS verified.
Methods: Children ≤14 years old with an injury severity score (ISS) >15 were selected from
the 2010 National Trauma Databank research dataset (NTDB RDS). Entries with missing ISS
or age information were excluded. Patients who were dead on arrival were excluded. Univariate
analysis was performed for age, gender, mortality, ACS adult verification and ACS pediatric
verification. Significant variables were subsequently assessed by logistic regression. A subset
analysis was performed on freestanding pediatric hospitals. A p-value of <0.05 was considered
significant.
Results: The 2010 NTDB RDS included 11,859 pediatric patients with an ISS > 15.
Univariate analysis was statistically significant for the primary outcome of mortality among
the following variables: race, payment type, ISS, region, ACS adult verification and ACS
pediatric verification. Other variables (gender, age, ethnicity, location of injury, hospital type
and teaching status) were not statistically significant and were not included in logistic
regression. The results of the logistic regression are displayed in table 1. ISS, region, race,
payment and ACS pediatric level were significant among patients with an ISS >15. Subset
analysis of freestanding pediatric hospitals demonstrated that ACS pediatric level (p=.007), ISS
(p<0.001) and payment (p<0.001) had a significant impact on mortality, while region, race,
gender and teaching status were non-significant.
Conclusions: ACS pediatric verification is associated with decreased mortality of
severely injured children in ACS verified adult trauma centers as well as in
freestanding pediatric hospitals. ACS adult verification alone does not confer this
mortality benefit. Race, payment and region are additional factors that impact
pediatric trauma mortality.
Pediatric ATLS?
Poor Policy Invites Unintended Consequences
Stewardship
Care
Event
Phase
Acute
Professional
Rehabilitation
Reintegration
Chronic
Payer
INS, MCR, MCD, Subs
INS, MCR, MCD, ?Subs
INS, MCR
MCR-SSI,
INS, MCR, MCD
Fed
Taxpayer
FMAP
Fed &
State
Taxpayer
Cost shift =
Premium rise.
Higher Co-
pay and
Deductible =
Medical
Debt
Three Opportunities
• Data: the glue that binds and the fuel that drives
• Tele-medical Resuscitation
Support
• Care of the Injured Brain
Impact of Poor EMR Design
60% of clinical questions go unanswered
50% of those answers would have had direct impact
33% of clinical time spent searching/organizing data
80% of encounters lack important information
40% of clinical data resides in “white space”
Current DysfunctionalClinical Data Ecosystem
Limited data
liquidity due to:
Lack of
interoperable
data
standards/API
data
infrastructure
Limited
business case
for improved
data flow and
better quality
for care
7
Data FROM StageSurgeon Record
Data TO
Referring EMR SSRNSQIP
CMS Other
1 Initial Assessment
2 Therapeutic Plan Devised
3 Risk Calculation
4 Risk Review/Documentation
5 Counseling/Consent
6 Pre-Surgery Care
7 Pre-op evaluation/review
8 Intra-operative Care
9 PACU Care
10 Post-operative Care
11 Follow-up Care
12 Long-term Management ACS
ACS
ACS
ACS
ACS
ACS
FIRST: Surgical Continuum of Care APP
Disease, Procedure, Specialty focused
APPs
ACS “APP suite”
THEN:
Build APPS designed to use ecosystem to optimize surgical care!
Surgical Procedures – NPTR II&IIIAbdominal Surgery
Organ Did Looked
ExLap 1013 17
SB 349
Colon 199
Liver 154
Stomach 103
Appendix 97
Duodenum 68
Pancreas 35
Mes. Repair 35
Rect 22
Enteric Access
Feed Jej 66
PEG 58
Gastrostomy 152 86
DPL 384
ABDOMINAL INJURIES
Splenic TraumaUpadhyaya & Simpson 1968
Howman-Giles, et al 1978
Wesson, et al 1981
MASSIVE BLEEDING
OR
ASSOCIATED INJURY
SPLENIC INJURY
NO BLEEDING
MODERATE
BLEEDING
TRANSFUSION
(UP TO 40ML/KG)
OBSERVATIONO.R.
FURTHER BLEEDING
(>40 ML/KG)
Angiography with two
foci
of active extravasation
Angiography status post proximal
splenic artery embolization
Pediatric
(age<18)11 0 (0%) 4 0 (0%) 1
Adult
(age≥18)34
11
(32.4%)61 3(4.9%) 0.003*
AE: Angioembolization; NOM: Non-operative management * p<0.05
• No role for AE in pediatric
patients regardless of grade of
injury
• Reemphasizes that successful NOM
in pediatric patients is based on
hemodynamic stability alone
Blunt Abdominal Trauma:
Liver
VS
Spleen
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
Splenic Hepatic L/S
Results – Mortality Rates
n=2553 n=2543 n=347
p < 0.05
0.7%
2.5%
8.7%
Hepato-splenic injury combination is a marker of even
greater mortality potential.
Hypotensive?
Yes
Belly Pain?
CT
No
OR
No
PositiveNegative
Observe
FAST
Negative Positive
YesOut
Transient
Sustained
BAT
UnstableStable OR
FAST
NegPOS
Non Specific Fluid
Non Renal Injury?
? Renal Injury
CDS
Multiple or severe?”
CT
Tender
Distracted
Non Tender
A
L
A
R
A
As Low As Reasonably Achievable
Acutely
Later
As
Reason
Asserts
BAT
UnstableStable OR
FAST
NegPOS
Non Specific Fluid
Non Renal Injury?
? Renal Injury
CDS
Multiple or severe?”
CT
Tender
Distracted
Non Tender
A
L
A
R
A
As Low As Reasonably Achievable
Acutely
Later
As
Reason
Dictates
Proposed Algorithm
Observe
No
CT Scan
- Abdominal wall or lower chest
bruising.
- Abdominal pain or tenderness.
- Low blood pressue – not shock.
1. Positive Ultrasound
2. Increased AST/ALT >
200/125.
3. Hematuria > 5 RBC/hpf.
Yes No
Yes
Pediatrictraumasociety.org
The Triumph of Reason Over Ritual
Is the patient stable?
Free Air on Cxr?
Peritonitis?
Is the belly tender?
Bleeding in the belly?
Patient distracted?
Y
N
Y
Y
Y
Y
Y
N
N
N
N
FAST
POS
NEG
END
O
R
CT
Clinical
Evaluation
e
d
e=expeditious
d=delayed
Start
N
What happens to the
brain cells after TBI?
Head Injury/Primary Injury
Biological Response/ Secondary
Injury
Cell Injury/Cell Death
Suppressed Cellular Function
Cognitive Impairment/ Motor
Disability
We are here!
Immediate Challenges of Traumatic Brain Injury
•Excitatory Imbalance
Immediate receptor blockade
•Perfusion Anomaly
ICP/CPP
BBB permeability - autoregulation
•Pro-inflammatory Cytokine Cascade
Pre-emptive management of S.I.R.S.
ICP
Brain Brain Brain
Art
BloodArt
Blood
Art
Blood
CS
F
Ven
ous
MASS/
EDEMA
MASS/
EDEMA
CS
F
Ven
Normal Compensated Uncompensated
10
30
50
Munro-Kellie Doctrine
TBI Current Therapeutic Goals
ICP < 20
CPP > 60
PbO2 > 25
PaCO2 ~ 32 - 34
Rectal Temp 36.5 – 37.5
Hb > 9, INR < 1.5
In Practical Terms:
Understanding the global stress response
Orchestrating multiple disciplines
Optimizing recovery:
Aggressive neurocare
Precise fluid management
Effective ventilator care
Adequate nutritional care
Injury Control: The Surgical Perspective
Paralytic Abx Steroid
Analgesic Pressor/Pent
Sedation Ulcer Prophylaxis
Seizure Prophylaxis Diuretics
PASS A SPUD!
Paralytics: Norcuron 0.1mg/kg
Analgesic: MSO4 0.1mg/kg
Sedation: Versed 0.1 mg/kg
Seizure Rx: Fosphentoin/Phenobarb- load and measure
Antibiotics: Carefully!
Steroids: SCI protocol ??? BPD
Pressors/Pent: Dopamine 3-20/Pentobarb. 0.5-5mg/hr
Ulcer prophylaxis: Carafate, not Zantac
Diuretics: HTS/Mannitol 0.25-1 gm/kg
Critical Management of TBI
Status T1 T2 T3
SaO2
IV
Analges/Sed
Foley
Tube feeds
Vent
ICP/EVDD
HTS/Man
Press/Pent
T1 T2 T3
Paralytics
Analgesic
Sedation
Seizure Rx
Antibiotics Careful!
Steroids: Rarely!
Pressors/Pent
Ulcer pro.
Diuretics
GCS: 15 13 - 8 <8
23.4 %HYPERTONIC SALINEBolus NOT Drip
Delta Na =5 → 5x.6BW = amount of Na meq
23.4% HS → 4 Meq /cc approximates .75BW!
•Hemodynamic
•Vasoregulatory
•Decreases Neutrophil Activation
•Stimulates Lymphocyte Proliferation
•Macrophages/ Monocytes:
Inhibits Pro-inflammatory Cytokines
Stimulates Anti-inflammatory Cytokines
Pharmacologic treatment of intracranial hypertension
Requires: Na<150 meq/l; Measured Osm <310
Dose = BW x .75 in cc over 30 min in CVL
Monocyte
CD14++/CD16- (90%)
CD14+/CD16++(10%)
HTS Data
240 doses in 22 patients
with severe TBI (within 96
hours of injury)
Response Comparison
0
5
10
15
20
25
30
35
1 - 5 6 - 10 11 - 15 16 - 20 21 - 25 26 - 30 31 - 35
ICP decrease
Cases Man
HTS
No Response41 (35%) 22 (18%)
Mean Decrease6.2 ± 8.2 8.3 ± 7.5
Response Comparison 27 Peds vs 211 Adult
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
1 - 5 6 - 10 11 - 15 16 - 20 21 - 25 26 - 30 >=31
Drop in ICP
Cases P
ed
s
0
5
10
15
20
25
30
35
Cases A
du
lt ManKids
NaClKids
ManAdlt
NaClAdlt
Mannitol
N = 118
23.4% HTS
N=120
Cell Type ~ Neuron or Glial
Process – Necrosis or Apoptosis
Cell locus-body, axon or synapse
Biomarker Mapping
N C
Repeat XIaII-spectrin PEST
- 280 kDa
CaM
150 kDa - - 150 kDa
145 kDa - - 120 kDa
Calpain-specific SBDPs Caspase-3-specific SBDPs
280 kD
150 kD
145 kD
TimeWestern Blot
120 kD
- calpain/caspase-3- calpain
- caspase-3
1 2 3 4
aII-Spectrin is a part of the TBI degradome
CSF Serum
Tau
MAP
MBP
UCH-L1
S100β
TNFα
IL1
IL6
IL8
IL10
sPLA2
Proposed Monitoring
ProcessPoint
post
Injury
sNa uNa Na-
in
sCl uCL Cl-in sOsm UOsm Fluid
IN
Urine
OUT
1
2
3
4
5
6
7
8
9
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