Sweating the Little Things: Tourniquet Application Efficacy in Two Models of Pediatric Limb Circumference

Abstract Background Current military recommendations include the use of tourniquets (TQ) in appropriate pediatric trauma patients. Although the utility of TQs has been well documented in adult patients, the efficacy of TQ application in pediatric patients is less clear. The current study attempted to identify physical constraints for TQ use in two simulated pediatric limb models. Methods Five different TQ (Combat Application Tourniquet (CAT) Generation 6 and Generation 7, SOFTT (SOF Tactical Tourniquet), SOFTT-W (SOF Tactical Tourniquet – Wide), SWAT-T (Stretch Wrap and Tuck – Tourniquet) and a trauma dressing were evaluated in two simulated pediatric limb models. Model one employed four cardiopulmonary resuscitation (CPR) manikins simulating infant (Simulaids SaniBaby), 1 year (Gaumard HAL S3004), and 5 years (Laerdal Resusci Junior, Gaumard HAL S3005). Model two utilized polyvinyl chloride (PVC) piping with circumferences ranging from 4.25” to 16.5”. Specific end-points included tightness of the TQ and ability to secure the windlass (where applicable). Results In both models, the ability to successfully apply and secure the TQ depended upon the simulated limb circumference. In the 1-year-old CPR manikin, all windlass TQs failed to tighten on the upper extremity, while all TQs successfully tightened at the high leg and mid-thigh. With the exception of the CAT7 and the SOFTT-W at the mid-thigh, no windlass TQ was successfully tightened at any extremity location on the infant. The SWAT-T was successfully tightened over all sites of all CPR manikins except the infant. No windlass TQ was able to tighten on PVC pipe 5.75” circumference or smaller (age < 24 months upper extremity). All windlass TQs were tightened and secured on the 13.25” and 15.5” circumference PVC pipes (age 7–12 years lower extremity, age >13 years upper extremity). The SWAT-T was tightened on all PVC pipes. Discussion The current study suggests that commercial windlass TQs can be applied to upper and lower extremities of children aged 5 years and older at the 50%th percentile for limb circumference. In younger children, windlass TQ efficacy is variable. Further study is required to better understand the limitations of TQs in the youngest children, and to determine actual hemorrhage control efficacy.

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Coagulopathy Predicts Mortality in Pediatric Patients with Traumatic Brain Injury

Blood ◽

10.1182/blood.v124.21.2891.2891 ◽

2014 ◽

Vol 124 (21) ◽

pp. 2891-2891 ◽

Cited By ~ 1

Author(s):

Bhavya S. Doshi ◽

Shannon L. Meeks ◽

Jeanne E Hendrickson ◽

Andrew Reisner ◽

Traci Leong ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Pediatric Patients ◽

Injury Severity ◽

Pediatric Trauma ◽

Morbidity And Mortality ◽

P Value ◽

Trauma Patients ◽

Severity Scores ◽

Pediatric Tbi

Abstract Trauma is the leading cause of death in children ages 1 to 21 years of age. Traumatic brain injury (TBI) poses a high risk of both morbidity and mortality within the subset of pediatric trauma patients. Numerous adult studies have shown that coagulopathy is commonly observed in patients who have sustained trauma and that the incidence is higher when there is TBI. Previously, it was thought that coagulopathy related to trauma was dilutional (i.e. due to replacement of red cells and platelets without plasma) but more recent studies show that the coagulopathy in trauma is early and likely independent of transfusion therapy. Additionally, abnormal coagulation studies (PT, PTT, INR, platelet count, fibrinogen, and D-dimer) following TBI are associated with increased morbidity and mortality in adults. Although coagulopathy after traumatic brain injury in adults is well documented, the pediatric literature is fairly sparse. A recent study by Hendrickson et al in 2008 demonstrated that coagulopathy is both underestimated and under-treated in pediatric trauma patients who required blood product replacements. Here we present the results of a retrospective pilot study designed to assess coagulopathy in the pediatric TBI population. We analyzed all children admitted to our facility with TBI from January 2012 to December 2013. Patients were excluded if they had underlying diseases of the hemostatic system. All patients had baseline characteristics measured including: age, sex, mechanism of injury, Glasgow Coma Scale (GCS), injury severity score (ISS), initial complete blood count, DIC profile, hematological treatments including transfusions, ICU and hospital length of stay, ventilator days and survival status. Coagulation studies were defined as "abnormal" when they fell outside the accepted reference range of the pediatric hospital laboratory (PT 12.6-15.9, PTT 23.6-42.1 seconds, fibrinogen < 180 mg/dL units, platelets < 185 103/mL and hemoglobin < 11.5 g/dL). Survival was measured as survival at 30 days from admission or last known status at hospital discharge. One hundred and twenty patients met the inclusion criteria of the study and all were included in outcome analysis. Twenty-three of the 120 patients died (19.2%). Logistic regression analysis was used to compare survivors and non-survivors and baseline demographic data showed no difference in age or weight between the two groups with p-values of 0.1635 and 0.1624, respectively. Non-survivors had a higher ISS (30.26 vs 20.92, p-value 0.0004) and lower GCS (3 vs 5.8, p-value 0.0002) compared to survivors. Univariate analysis of coagulation studies to mortality showed statistically significant odds-ratios for ISS (OR 1.09, 95% CI 1.04-1.15), PT (OR 5.91, 95% CI 1.86-18.73), PTT (OR 6.48, 95% CI 2.04-20.52) and platelets (OR 5.63, 95% CI 1.74 – 18.21). Abnormal fibrinogen levels were not predictive of mortality (OR 2.56, 95% CI 0.96-6.79). These results are summarized in Table 1. Our results demonstrate that, consistent with adult studies, abnormal coagulation studies are also associated with increased mortality in pediatric patients. Higher injury severity scores and lower GCS scores are also predictive of mortality. Taken together, these results suggest that possible early correction of coagulopathy in severe pediatric TBI patients could improve outcomes for these patients. Table 1. OR 95% CI p-value ISS 1.09 1.04—1.15 .0009 PT > 15.9 sec 5.91 1.86—18.73 0.0026 PTT > 42.1 sec 6.48 2.04—20.52 0.0015 Fibrinogen < 180 mg/dL 2.56 0.96—6.79 0.0597 Platelets < 185 x 103/mL 5.63 1.74—18.21 0.0040 Disclosures No relevant conflicts of interest to declare.

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Validation of Age-specific Survival Prediction in Pediatric Patients With Blunt Trauma Using Trauma and Injury Severity Score Methodology: A Ten-year Nationwide Observational Study

10.21203/rs.3.rs-92194/v1 ◽

2020 ◽

Author(s):

Chiaki Toida ◽

Takashi Muguruma ◽

Masayasu Gakumazawa ◽

Mafumi Shinohara ◽

Takeru Abe ◽

...

Keyword(s):

Injury Severity Score ◽

Blunt Trauma ◽

Severity Score ◽

Pediatric Patients ◽

Injury Severity ◽

Pediatric Trauma ◽

Survival Prediction ◽

Trauma Patients ◽

Interval Group ◽

Trauma And Injury

Abstract Background: In-hospital mortality in trauma patients decreased recently owing to improved trauma injury prevention systems. However, no study which evaluated the validity of Trauma and Injury Severity Score (TRISS) in pediatrics by detailed classification of patients’ age and injury severity in Japan. This retrospective nationwide study evaluated the validity of TRISS in predicting survival in Japanese pediatric patients with blunt trauma by age and injury severity.Methods: Data were obtained from the Japan Trauma Data Bank during 2009−2018.Results: In all age categories, the area under the curve (AUC) for TRISS demonstrated high performance (0.935, 0.981, 0.979, and 0.977). The Accuracy of TRISS was 99.9%, 98.2%, 92.1%, 76.7%, 55.3%, and 72.1% in survival probability (Ps) interval groups (0.96−1.00), (0.91−0.95), (0.76.−0.90), (0.51−0.75), (0.26−0.50), and (0.00−0.25), respectively. The AUC for TRISS demonstrated moderate performance in the Ps interval group (0.96−1.00) and low performance in other Ps interval groups.Conclusions: The TRISS methodology appears to predict survival accurately in Japanese pediatric patients with blunt trauma; however, there were several problems in adopting the TRISS methodology for younger blunt trauma patients with higher injury severity. In the future, we should consider to conducting a simple, high-quality prediction model that is more suitable for pediatric trauma patients than the current TRISS model.

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Effects of the COVID-19 pandemic on pediatric trauma in Southern California

Pediatric Surgery International ◽

10.1007/s00383-021-05050-6 ◽

2021 ◽

Author(s):

Eric O. Yeates ◽

Areg Grigorian ◽

Morgan Schellenberg ◽

Natthida Owattanapanich ◽

Galinos Barmparas ◽

...

Keyword(s):

Intensive Care Unit ◽

Pediatric Patients ◽

Demographic Data ◽

Pediatric Trauma ◽

Penetrating Trauma ◽

Trauma Patients ◽

Single Center ◽

Trauma Population ◽

Time Periods ◽

And Control

Abstract Purpose The COVID-19 pandemic resulted in increased penetrating trauma and decreased length of stay (LOS) amongst the adult trauma population, findings important for resource allocation. Studies regarding the pediatric trauma population are sparse and mostly single-center. This multicenter study examined pediatric trauma patients, hypothesizing increased penetrating trauma and decreased LOS after the 3/19/2020 stay-at-home (SAH) orders. Methods A multicenter retrospective analysis of trauma patients ≤ 17 years old presenting to 11 centers in California was performed. Demographic data, injury characteristics, and outcomes were collected. Patients were divided into three groups based on injury date: 3/19/2019–6/30/2019 (CONTROL), 1/1/2020–3/18/2020 (PRE), 3/19/2020–6/30/2020 (POST). POST was compared to PRE and CONTROL in separate analyses. Results 1677 patients were identified across all time periods (CONTROL: 631, PRE: 479, POST: 567). POST penetrating trauma rates were not significantly different compared to both PRE (11.3 vs. 9.0%, p = 0.219) and CONTROL (11.3 vs. 8.2%, p = 0.075), respectively. POST had a shorter mean LOS compared to PRE (2.4 vs. 3.3 days, p = 0.002) and CONTROL (2.4 vs. 3.4 days, p = 0.002). POST was also not significantly different than either group regarding intensive care unit (ICU) LOS, ventilator days, and mortality (all p > 0.05). Conclusions This multicenter retrospective study demonstrated no difference in penetrating trauma rates among pediatric patients after SAH orders but did identify a shorter LOS.

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Tabletop Application of SALT Triage to 10, 100, and 1000 Pediatric Victims

Prehospital and Disaster Medicine ◽

10.1017/s1049023x20000163 ◽

2020 ◽

Vol 35 (2) ◽

pp. 165-169

Author(s):

Nicholas McGlynn ◽

Ilene Claudius ◽

Amy H. Kaji ◽

Emilia H. Fisher ◽

Alaa Shaban ◽

...

Keyword(s):

Pediatric Patients ◽

Pediatric Trauma ◽

Mass Casualty Incident ◽

Mass Casualty ◽

Trauma Patients ◽

Kappa Test ◽

Life Saving ◽

Number Of Patients ◽

Level 1 ◽

Level 1 Trauma Center

AbstractIntroduction:The Sort, Access, Life-saving interventions, Treatment and/or Triage (SALT) mass-casualty incident (MCI) algorithm is unique in that it includes two subjective questions during the triage process: “Is the victim likely to survive given the resources?” and “Is the injury minor?”Hypothesis/Problem:Given this subjectivity, it was hypothesized that as casualties increase, the inter-rater reliability (IRR) of the tool would decline, due to an increase in the number of patients triaged as Minor and Expectant.Methods:A pre-collected dataset of pediatric trauma patients age <14 years from a single Level 1 trauma center was used to generate “patients.” Three trained raters triaged each patient using SALT as if they were in each of the following scenarios: 10, 100, and 1,000 victim MCIs. Cohen’s kappa test was used to evaluate IRR between the raters in each of the scenarios.Results:A total of 247 patients were available for triage. The kappas were consistently “poor” to “fair:” 0.37 to 0.59 in the 10-victim scenario; 0.13 to 0.36 in the 100-victim scenario; and 0.05 to 0.36 in the 1,000-victim scenario. There was an increasing percentage of subjects triaged Minor as the number of estimated victims increased: 27.8% increase from 10- to 100-victim scenario and 7.0% increase from 100- to 1,000-victim scenario. Expectant triage categorization of patients remained stable as victim numbers increased.Conclusion:Overall, SALT demonstrated poor IRR in this study of increasing casualty counts while triaging pediatric patients. Increased casualty counts in the scenarios did lead to increased Minor but not Expectant categorizations.

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Cardiopulmonary Resuscitation in Pediatric Trauma Patients

The Journal of Trauma: Injury, Infection, and Critical Care ◽

10.1097/00005373-199907000-00001 ◽

1999 ◽

Vol 47 (1) ◽

pp. 1-7 ◽

Cited By ~ 36

Author(s):

Guohua Li ◽

Nelson Tang ◽

Carla DiScala ◽

Zachary Meisel ◽

Nadine Levick ◽

...

Keyword(s):

Cardiopulmonary Resuscitation ◽

Pediatric Trauma ◽

Trauma Patients

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Autologous Heterogeneous Skin Construct Closes Traumatic Lower Extremity Wounds in Pediatric Patients: A Retrospective Case Series

The International Journal of Lower Extremity Wounds ◽

10.1177/1534734621992284 ◽

2021 ◽

pp. 153473462199228

Author(s):

Gerhard S. Mundinger ◽

Mark W. Stalder ◽

James Lee ◽

Charles W. Patterson ◽

Silpa Sharma ◽

...

Keyword(s):

Lower Extremity ◽

Pediatric Patients ◽

Deep Structure ◽

Cohort Analysis ◽

Donor Site ◽

Pediatric Trauma ◽

Case Series ◽

Trauma Patients ◽

Retrospective Case ◽

Normal Tendon

Lower extremity traumatic wounds pose unique challenges in pediatric patients, including vessel caliber, compliance with postoperative instructions, parental concerns about multiple operations, and long-term function. An autologous heterogeneous skin construct (AHSC) has demonstrated the ability to cover avascular structures and regenerate full-thickness functional skin. The objective of this study is to report our experience using AHSC in a cohort of pediatric trauma patients. This study is a noncontrolled, retrospective cohort analysis of all pediatric patients (<19 years of age) treated with AHSC for lower extremity traumatic wounds with at least one exposed deep structure (tendon, bone, and/or joint) at a single institution between May 1, 2018, and April 1, 2019. Seven patients with 10 traumatic wounds met inclusion criteria. The median follow-up time was 11.8 months. Five patients were male (71%); the median age was 7 years (range = 2-15 years). Average wound size was 105 cm2. All wounds achieved coverage of exposed structures and epithelial closure in a median of 13 and 69 days, respectively. There were no donor site complications and no reoperations required. All patients returned to normal activity, ambulate without limp, can wear shoes normally, and have normal tendon gliding. AHSC covered exposed structures and achieved closure within a single application in complex traumatic lower extremity wounds in a pediatric cohort.

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Level of Comfort With Pediatric Trauma Transports: Survey of Prehospital Providers

The American Surgeon ◽

10.1177/0003134820973374 ◽

2020 ◽

pp. 000313482097337

Author(s):

Lilly Bayouth ◽

Lauren Edgar ◽

Brent Richardson ◽

David Ebler ◽

Joseph J. Tepas ◽

...

Keyword(s):

Pediatric Patients ◽

Pediatric Trauma ◽

Unintentional Injury ◽

Medication Administration ◽

Comfort Level ◽

Trauma Patients ◽

Web Based ◽

Knowledge Resources ◽

Comfort Levels ◽

Heavy Burden

Background Unintentional injury is the leading cause of death in pediatric patients. Despite a heavy burden of pediatric trauma, prehospital transport and triage of pediatric trauma patients are not standardized. Prehospital providers report anxiety and a lack of confidence in transport, triage, and care of pediatric trauma patients. Materials and Methods Prehospital transport providers with 3 organizations across southeast Georgia and northeast Florida were contacted via email (n = 146) and asked to complete 2 Web-based surveys to evaluate their comfort level with performing tasks in the transport of pediatric and adult trauma patients. Bivariate statistics and qualitative thematic analyses were performed to assess comfort with pediatric trauma transports. Results Survey 1 (N = 35) showed that mean comfort levels of prehospital providers were significantly lower for pediatric patients than adult trauma patients in 7 out of 9 tasks queried, including airway management and interpreting children’s physiology. The following themes emerged from survey 2 (N = 14) responses: additional clinical knowledge resources would be beneficial when caring for pediatric trauma patients, pediatric medication administration is a source of uncertainty, prehospital transport teams would benefit from additional pediatric trauma training, infrequent transport of pediatric trauma patients affects provider comfort level, and pediatric trauma generates higher levels of anxiety among providers. Discussion Prehospital transport of pediatric trauma patients is infrequent and a source of anxiety for prehospital providers. Rigs should be equipped with a reference tool addressing crucial tasks and deficiencies in training.

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Prognostic predictors in polytraumatized children and their impact on outcome

International Surgery Journal ◽

10.18203/2349-2902.isj20170853 ◽

2017 ◽

Vol 4 (3) ◽

pp. 1014 ◽

Cited By ~ 1

Author(s):

Ahmed Abdelhady Essa ◽

Islam M. El-Shaboury ◽

Mohammed A. Ibrahim ◽

Emadeldien A. Abdelgwad ◽

Mohammed A. Gadelrab

Keyword(s):

Heart Rate ◽

Respiratory Rate ◽

Scoring System ◽

Pediatric Patients ◽

Pediatric Trauma ◽

Morbidity And Mortality ◽

Trauma Patients ◽

Prognostic Predictors ◽

Trauma Scoring ◽

The Mean

Background: Trauma is the leading cause of death and disability in children ≥ 1 year of age. More than 80% of injuries are caused by blunt trauma. Most seriously injured children have multiple injuries. Injury scoring systems are designed to accurately assess injury severity, appropriately triage the injured, and develop and refine trauma patient care. The pediatric trauma scoring (PTS) was devised specifically for the triage of pediatric trauma patients. The pediatric trauma scoring (PTS) was devised specifically for the triage of pediatric trauma patients. The PTS is calculated as the sum of individual scores from six clinical variables. The variables include weight, airway, systolic blood pressure (SBP), central nervous system (CNS) status (level of consciousness), presence of an open wound, and skeletal injuries. Other predicting factors for morbidity and mortality in polytraumatised children include age and gender of the patients, trauma type, arrival interval time, Glasgow Coma Scale (GCS), respiratory rate, heart rate, hematocrit value at admission. These factors can further help to prevent mortality. The objectives of this study were to assess the prognosis of polytraumatised pediatric patients by evaluation of pediatric trauma scoring system and clinical predictors of morbidity and mortality as prognostic predictors of trauma in pediatric patients.Methods: This was adescriptive study, included 60 polytraumatised pediatric patients who were attended emergency department in Suez Canal University Hospital, Ismailia, Egypt.Results: This study showed that the mean of the pediatric trauma scoring system was 10±2. According to the nature of the most severe injury, this study showed that 43 % of injuries among patients were of extremities and pelvis nature. According to length of resuscitation time among patients, this study showed that the mean time of resuscitation was 35.5±8.23 minutes. According to the type of treatment done for the patients, this study showed that 72% of the patients didn't need surgical intervention. This study showed that regarding the final outcome of the patients, 68% of the patients were admitted to inpatient.Conclusions: This study showed that both heart rate and respiratory rate had good sensitivity while both of them had lower specificity. This study showed that GCS good specificity and fair sensitivity. Regarding the PTS, this study showed that PTS had the highest specificity and the highest sensitivity among all the predictors.

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Helicopter Emergency Medical Service and Hospital Treatment Levels Affect Survival in Pediatric Trauma Patients

Journal of Clinical Medicine ◽

10.3390/jcm10040837 ◽

2021 ◽

Vol 10 (4) ◽

pp. 837

Author(s):

Felix Marius Bläsius ◽

Klemens Horst ◽

Jörg Christian Brokmann ◽

Rolf Lefering ◽

Hagen Andruszkow ◽

...

Keyword(s):

Emergency Medical Service ◽

Medical Service ◽

Pediatric Patients ◽

Pediatric Trauma ◽

Helicopter Emergency Medical Service ◽

Trauma Patients ◽

Trauma Centers ◽

Emergency Medical ◽

Level Ii ◽

Level I

(1) Background: Data on the effects of helicopter emergency medical service (HEMS) transport and treatment on the survival of severely injured pediatric patients in high-level trauma centers remain unclear. (2) Methods: A national dataset from the TraumaRegister DGU® was used to retrospectively compare the mortality rates among severely injured pediatric patients (1–15 years) who were transported by HEMS to those transported by ground emergency medical service (GEMS) and treated at trauma centers of different treatment levels (levels I–III). (3) Results: In total, 2755 pediatric trauma patients (age: 9.0 ± 4.8 years) were included in this study over five years. Transportation by HEMS resulted in a significant survival benefit compared to GEMS (odds ratio (OR) 0.489; 95% confidence interval (CI): 0.282–0.850). Pediatric trauma patients treated in level II or III trauma centers showed 34% and fourfold higher in-hospital mortality risk than those in level I trauma centers (level II: OR 1.34, 95% CI: 0.70–2.56; level III: OR 4.63, 95% CI: 1.33–16.09). (4) Conclusions: In our national pediatric trauma cohort, both HEMS transportation and treatment in level I trauma centers were independent factors of improved survival in pediatric trauma patients.

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