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”

Vietnam Conflict

Air Ambulances

unopposed

ARF solved

(Shires/Moyer)

New problem:

Danang lung

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!

Civilian Trauma Systems

The Surgeon and The Injured Child

APSA May 1984

NPTRApril 1 1985

Mt. Blanc / Imo

12/6/17

Halifax Harbor

Wesson et al

Hospital for Sick Children

Harbinger?

First Comparison of

Pediatric to Adult

Centers

Score Wars!!

1988Resources and Training

“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

Functional Clinical Data Ecosystem Use Cases

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)

Splenic Procedures

Splenic Surgery Partial

splenectomy

10%

Splenorraphy

36%

Splenectomy

54%

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.

Imaging: How To Decide?

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.

Level III Recommendations

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

0

50

100

150

200

250

300

0 20 40 60 80

Serum

Urine

DDAVP

Acute Sodium Flux

Survived

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

Pillars of Care

• Success is related to a seamless continuum of

care.

• The first 48 hours are still most critical.

• Effective treatment is based on preemptive

restoration of homeostasis, using evidence

based, standardized processes of care.