Jim Holliman, M.D., F.A.C.E.P. Program Manager

1. Reducing Admissions for Pediatric Blunt Trauma Jim Holliman, M.D., F.A.C.E.P. Program Manager Afghanistan Health Care Sector Reconstruction Project Center for Disaster & Humanitarian Assistance Medicine Uniformed Services University of the Health Sciences Bethesda, Maryland, U.S.A.

2. 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

3. Reducing Admissions for Pediatric Blunt Trauma : Lecture Outline and Goals • Epidemiology of pediatric blunt trauma • Injury Prevention : the best way to reduce admissions • Develop hospital based Emergency Medicine specialists : the next best way to reduce admissions • Current admission criteria • Modifications of diagnostic workups • Trends in surgical management affecting admission decisions

4. 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

5. 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

6. 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 101 168 155 179 222 227 282 263 281 316 353 2000 2001 2002 2003 2004 2005 414 434 503 530 597 601 2006 686 (Note increasing # of cases)

7. 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 %)

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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)

14. 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

15. Splenic Laceration. No free blood. No surgery needed..

16. Normal CT 2 months after injury High grade blunt splenic injury

17. Contusion left lobe of liver. No surgery. No transfusion. Fracture through right lobe of liver. Transfusion. No operation needed.

18. Blunt renal injury: fall from horse. Non operative treatment.

19. 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

20. 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.

21. Bicycle handlebar injury to the pancreas (also minor liver laceration)

22. 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

23. Lap belt injury. Small Bowel perforation. Free air. Laparotomy/primary repair. Lap belt injury. Duodenal rupture. Air extravasation in retroperitoneum. These may be missed if CT withheld.

24. 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)

25. Example case Intraperitoneal fluid without solid organ injury.

26. 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)

27. Laparoscopic view of mesenteric tear repair (hemoperitoneum present)

28. 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.

29. 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.

30. 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

31. 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

32. 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

33. 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.

34. 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

35. Thumbs up from Afghanistan

36. QUESTIONS ? Thanks for Your Attention