2016 1st Quarter Admissions

MONROE CARELL

JR. CHILDREN’S

HOSPITAL AT

VANDERBILT

June 24, 2016 Volume 4, Issue 5

Pediatric Trauma

Service IEP Upcoming ACS Vis-

it:

The ACS verification visit

has been scheduled for

September 19th and 20th.

On day 2 of the visit, the site

surveyors will be taking a

tour of the facility and often

ask the physicians they

encounter questions about

their role in the care of the

injured patient.

An important part of the

required survey paperwork

is the collection of CME

paperwork from various

services. Amber Greeno or

Tammy Tankersley may be

contacting you to obtain this

information.

Inside this issue:

Non-powder

firearm injuries

2

Family presence

during a

resuscitation

2

Blunt renal

trauma

management in

pediatrics

3

Highlights from

MCJCHV blunt

renal injury

guidelines

3

Triage rates 4

Level I and level II

activation criteria

4

Level Number of Activations Percentage of Total Activations

Level I 22 10%

Level II 86 39%

Consult 112 51%

Non-powder firearms have

proven to be a major source of

injury and disability in the

pediatric age group. (7)

Approximately 3.2 million air

guns are sold annually and are

used for various reasons such

as sport, hunting, firearm

training, or merely for fun. (6)

The CDC reported 200,645

nonfatal BB/pellet gun injuries

between 2003 and 2013, of

which 63.6% occurred in

children.

The velocity of non-powder

firearms have been reported to

be 80m/s to 300m/s, which is

similar to many powder

handguns, and can cause injury

up to 60 feet away.

The rates of non-powder

firearm injuries increase in the

summer months and are seen

most often in the teenage

population. The eye is the

most reported body area

injured (63%) followed by the

head, neck , and extremities.

Unfortunately to many adults

and physicians, air guns are not

regarded as weapons and are

viewed as harmless. However

new, sophisticated pellets and

changing power technology

that propels ammunition make

these toys as dangerous as the

projectiles of conventional

hand guns that have the power

to penetrate skin, soft tissue

and bones.

It has been stressed by both

product safety advocates and

medical providers that

consumers should be educated

on safety and proper handling

of these weapons prior to use.

“You’ll shoot your eye out!”

Family presence during a resuscitation

relationship with the health

care team as beneficial in their

coping process. In addition,

the study found that the

practice did not increase the

level of stress of the health

care providers involved in the

resuscitation. In another study,

very few family members were

thought to be aggressive or in

conflict with the medical team.

(2)

In a smaller, nonrandomized

study, the researchers found

that family presence in a failed

resuscitation was associated

with increased PTSD

symptoms. (1) Another small,

nonrandomized study found no

difference in symptoms

between families that did and

did not participate in the

resuscitation process.

A multicenter group took their

study a step further and

examined the legal aspects of

family presence during CPR.

With a mean follow-up of

approximately 2 years, they

found that no claims for

damages from any participating

families had been filed nor

were there any medicolegal

conflicts.

In a recent Trauma PM&I, an

interesting point brought up

was that there has been little

to no research on the effects of

witnessed resuscitation efforts

on families 5 to 6 years down

the road. It was hypothesized

that there might be an increase

in PTSD symptoms in families

that witnessed resuscitation

efforts and regret that they

now remember their child in

that state.

Family presence during

cardiopulmonary resuscitation

(CPR) is something that

remains controversial at

hospitals across the nation.

Several studies have been done

examining the pros and cons of

such a practice on both the

families and medical teams

involved.

Many advocates of family

presence believe that it

ultimately reduces the

likelihood of post-traumatic

stress disorder (PTSD) related

symptoms. One randomized

study showed a significant

reduction in the rate of PTSD,

a reduction in anxiety and

depression scores 90 days

after, and a favorable effect on

the work of grieving at one

year. (4) Families reported the

ability to be near the child and

the ability to have a good

Page 2 Pediatric Trauma Service IEP

Due to the anatomic features

of pediatric patients, renal

injuries are more likely to

occur in their population then

their adult counterparts.

According to the national

trauma data bank (NTDB),

more than 18,000 pediatric

renal injuries occurred over a 5

year period. (5) In a review of

the literature, all pediatric

studies support some

combination of frequent VS,

HCT checks, serial abdominal

exams, and IV fluid

resuscitation. Beyond those

items, most protocols have

some variation.

Bed rest

Most literature regarding

conservative management

report the need for bedrest in

patients with renal injuries.

Although most studies did not

report the duration of bed rest,

typically, bed rest was

maintained until resolution of

gross hematuria. One study

challenged the need for bedrest

and instead advocated for early

mobilization. (3) Although this

protocol led to a reduction in

LOS from a mean of 6.6 days

to 2.9 days after it was applied,

it is notable that this study

addressed a population with

greater than 50%low-grade

injuries with fewer than four

patients (5%) with Grade V

injury. In addition, five patients

(7%) required readmission,

although follow-up US results

were normal.

ICU admission

Admission to and duration of

stay in the PICU varied

considerably among the

protocols reviewed. Duration

of PICU stay was

recommended as 24 hours to 1

week. In protocols with longer

ICU LOS, an overall increase in

total HD were noted. Most of

the studies with minimal ICU

LOS consisted of mainly lower

grade injuries.

Empiric antibiotics

Empiric antibiotics were used

in 6 studies with grade 4/5

renal injuries. (5)

Foley catheters

Foley catheter insertion was

recommended by two studies

for bladder decompression,

close monitoring of hematuria

and to encourage bedrest.

One specifically did not use

foleys unless unable to void,

but this was also the protocol

that encouraged early

ambulance despite grade and

no minimal amount of HDs. (3)

Serial imaging

Guidelines for serial imaging is

somewhat inconsistent in the

literature. A few studies

recommended repeat imaging

within 24-72 hours while one

recommended daily bedside US

for grade 5 injuries. One study

was much more conservative

and strictly utilized US for

evaluation of clinical changes

and only used repeat CT if US

was ineffective.

Blunt renal trauma management in pediatrics

Highlights from MCJCHV blunt renal injury guidelines

Page 3 Volume 4, Issue 5

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5

ICU days None Attending discretion

Minimal HLOS 1 2 3 4 5

Repeat imaging None TBD by pt condition

IV antibx use None Zosyn x 3D (urine leak only)

Bed rest (BR) Overnight BR, OOB

as tolerated with

stable PCV

BR x 1 day, OOB as

tolerated with

stable PCV

BR x 2 day, OOB as

tolerated with

stable PCV

BR x 3 day, OOB as

tolerated with

stable PCV

BR x 4 day, OOB as

tolerated with

stable PCV

Foley Not indicated Indicated (urine leak only)

MONROE CARELL

JR. CHILDREN’S

HOSPITAL AT

VANDERBILT

Level I Activation Criteria

Any intubated patient

Unstable airway:

Significant facial or neck injury causing

airway compromise

Respiratory distress/ compromise:

increased work of breathing

Any episode of sustained tachycardia OR

hypotension

Cardiac arrest/CPR (in field or en route)

Blood transfusion en route

Significant blood loss or hemorrhage

Penetrating injury (head, neck, torso or

proximal extremity)

Excludes any penetrating

injury isolated to the eye

Amputation, near-amputation, de-

gloving, crush injury proximal to wrist/

ankle

Extremity with no pulse, duskiness,

cyanosis, or paralysis

GCS ≤ 8 or “P” or “U”

Worsening neurological exam: decline in

GCS by ≥2, decline in AVPU by letter

Paralysis, motor weakness, decreased

sensation, or signs of spinal cord injury

2nd and/or 3rd degree thermal burns

≥30% TBSA and/or chemical or

electrical burns

ED physician discretion

Level II Activation Criteria

Suspected smoke inhalation injury

Sub-Q emphysema of chest and above

Suspected/confirmed pulmonary contusions/ rib

fractures or pneumo/hemothorax

Suspected chest trauma with NRB necessary to

maintain saturations >93%

Controlled arterial bleeding, stable VS

Two or more proximal long bone fractures

Femur fracture with significant mechanism

Pelvic fractures

Amputation, crush injury, or degloving distal to

wrist/ankle to exclude digits

Penetrating injury distal extremities (not digits)

GCS 9-13 or “V”

Open or depressed skull fracture

Confirmed but “stable” EDH, SDH, SAH

Closed head injury with +SZ

LOC >5 minutes

Suspected/confirmed cervical spine or spinal cord

injury without or resolved motor/sensory deficit

Suspected/confirmed intra-abdominal injury

MVC with: rollover, ejection, death of passenger,

significant damage/intrusion, or spider windshield

MCC, ATV with rollover, ejection

Fall >20 feet (2nd story)

Struck, dragged, or run over by vehicle

Penetrating injury isolated to the eye

2nd and/or 3rd degree thermal burns 15-29% TBSA

ED physician discretion

MCJCHV Trauma Activation Criteria

Resources:

1. Compton S, Levy P, Griffin M,

Waselewsky D, Mango L, Zalenski R.

Family-witnessed resuscitation:

bereavement outcomes in an urban

environment. J Palliat Med

2011;14:715-21.

2. De Stefano, C., Normand, D., Jabre,

P., Aloulay, E., Kentish-Barnes, N.,

Lapostolle, F., . . . Javaud, N. (2016).

Family presence during resuscitation:

A qualitative analysis from a national

multicenter randomized clinical trial.

PLoS One, 11(6), e1-12.

2. Graziano KD, J. D., & St Peter, S.

(2014). Prospective observational

study with an abbreviated protocol in

the management of blunt renal injury

in children. J Pediatr Surg, 49(1), 198-

200.

3. Jabre, P., Belpomme, V., Azoulay, E.,

Jacob, L., Bertrand, L., Lapostolle, F., .

. . Brouche, C. (2013). Family pres-

ence during cardiopulmonary resusci-

tation. The New England Journal of

Medicine, 1008-1018.

4. LeeVan, E., Zmora, O., Cazzulino, F.,

Burke, R., Zagory, J., & Upperman, J.

(2016). Management of pediatric

blunt renal trauma: A systematic

review. J Trauma Acute Care Surg, 80

(3), 519-528.

5. Taskinlar, H., Erdogen, C., Yigit, D.,

Ozgur, A., Avlan, D., & Nayci, A.

(2016). Dangerous Toys for Teenag-

ers: AirWeapons. Trauma Mon. In

Press, e1-5.

6. Veenstra, M., Prasad, J., Schaewe, H.,

Donoghue, L., & Langenburg, S.

(2015). Nonpowder firearms cause

significant pediatric injuries. J Trauma

Acute Care Surg, 1138-1142.