Blunt Traumatic Arrest In Kids: Are They Little Adults?
Over and over, we hear that children are not just little adults. They are a different size, a different shape. Their “normal” vital signs are weird. Drug doses are different; some drugs don’t work, some work all too well.
But in many ways, they recover more quickly and more completely after injury. What about after what is probably the biggest insult of all, cardiac arrest after blunt trauma? The NAEMSP and the ACS Committee on Trauma recently released a statement regarding blunt traumatic arrest (BTA):
“Resuscitation efforts may be withheld in any blunt trauma patient who, based on out-of-hospital personnel’s thorough primary patient assessment, is found apneic, pulseless, and without organized ECG activity upon arrival of EMS at the scene.”
The groups specifically point out that the guidelines do not apply to the pediatric population due to the scarcity of data for this age group.
The Children’s Hospital of Los Angeles and USC conducted a study of the National Trauma Data Bank, trying to see if children had a better outcome after this catastrophic event. Patients were considered as children if they were up to and including age 18.
Here are the factoids:
- Of 116,000 pediatric patients with blunt trauma, 7,766 had no signs of life (SOL) in the field (0.25%)
- The typical male:female distribution for trauma was found (70:30)
- 75% of those without SOL in the field never regained them. Only 1.5% of these survived to discharge from the hospital.
- 25% regained SOL with resuscitation, and 14% of them were discharged alive.
- 499 patients underwent ED thoracotomy, and only 1% survived to discharge. There was no correlation of thoracotomy with survival.
- It appeared that there was a tendency toward survival for the very young (age 0-4) without SOL, but statistical analysis did not bear this out
Bottom line: Children are just like little adults when it comes to blunt cardiac arrest after trauma. Although it is a retrospective, registry-based study, this is about as big as we are likely to see. And don’t get suckered into saying “but 1.5% with no vital signs ever were discharged!” This study was not able to look at the quality of life of survivors, but there is usually significant and severe disability present in the few adult survivors after this event.
Feel free to try to re-establish signs of life in kids with BTA. This usually means lots of fluid and/or blood. If they don’t respond, then it’s game over. And, like adults, don’t even think about an emergency thoracotomy; it’s dangerous to you and doesn’t work!
Reference: Survival of pediatric blunt trauma patients presenting with no signs of life in the field. J Trauma 77(3):422-426, 2014.
Phlebotomy And Pediatric Solid Organ Injury
I recently wrote about this journal article from a couple of pediatric trauma programs in New York. The article tried to focus on reducing the rate of phlebotomy in children who are being observed for solid organ injury. I was more excited about the overall protocol being used to manage liver and spleen injury, as it was a great advance over the original APSA guideline. But let’s look at the phlebotomy part as well.
This is an interestingly weird study, and you’ll see what I mean shortly. Two New York trauma hospitals that take care of pediatric patients pooled 4 years of registry records on children with isolated blunt liver and/or spleen injuries. Then they did a tabletop excercise, looking at “what if” they had applied the APSA guideline, and “what if” they had applied their new, proposed guideline.
Interestingly, this implies that they were using neither! I presume they are trying to justify (and push all their partners) to move to the new protocol from (probably) random, individual choice.
Here are the factoids:
- 120 records were identified across the 2 hospitals that met criteria
- Late presentation to the hospital, contrast extravasation, comorbidities, lack of imaging, operative intervention at an outside hospital excluded 59 patients, leaving 61 for analysis. Three of those patients became unstable and were also excluded.
- None of the remaining patients required operation or angioembolization
- Use of the “new” (proposed) protocol would reduce ICU admissions by 65%, reduce blood draws by 70%, and reduce hospital stay by 37%
- Conclusion: use of the protocol would eliminate the need for serial phlebotomy (huh?)
Bottom line: Huh? All this to justify decreasing blood draws? I know, kids hate needles, but the data on decreased length of stay in the hospital and ICU is much more important! We’ve been using a protocol similar to their “new” one at Regions Hospital, which I’ve shared below. We’ve been enjoying decreased resource utilization, blood draws, and very short lengths of stay for over a decade. And our analysis showed that we save $1000 for every patient entering the protocol, compared to the old-fashioned and inefficient way we used to manage them.
Reference: Reducing scheduled phlebotomy in stable pediatric patients with liver or spleen injury. J Ped Surg 49(5):759-762, 2014.
More On DVT In Children
Deep venous thrombosis has been a problem in adult trauma patients for some time. Turns out, it’s a problem in injured children as well although much less common (<1%). However, the subset of kids admitted to the ICU for trauma have a much higher rate if not given prophylaxis (approx. 6%). Most trauma centers have protocols for chemical prophylaxis of adult patients, but not many have similar protocols for children.
The Medical College of Wisconsin looked at trends prior to and after implementation of a DVT protocol for patients < 19 years old. They used the following protocol to assess risk in patients admitted to the PICU and to determine what type of prophylaxis was warranted:
The need for and type of prophylaxis was balanced against the risk for significant bleeding, and this was accounted for in the protocol. The following significant findings were noted:
- The overall incidence of DVT decreased significantly (65%) after the protocol was introduced, from 5.2% to 1.8%
- The 1.8% incidence after protocol use is still higher than most other non-trauma pediatric populations
- After the protocol was used, all DVT was detected via screening. Suspicion based on clinical findings (edema, pain) only occurred pre-implementation.
- Use of the protocol did not increase use of anticoagulation, it standardized management in pediatric patients
Bottom line: DVT does occur in injured children, particularly in severely injured ones who require admission to the ICU. Implementation of a regimented system of monitoring and prophylaxis decreases the overall DVT rate and standardizes care in this group of patients. This is another example of how the use of a well thought out protocol can benefit our patients and provide a more uniform way of managing them.
Reference: Effectiveness of clinical guidelines for deep vein thrombosis prophylaxis in reducing the incidence of venous thromboembolism in critically ill children after trauma. J Trauma 72(5):1292-1297, 2012.
Contrast Blush in Children
A contrast blush is occasionally seen on abdominal CT in patients with solid organ injury. This represents active arterial extravasation from the injured organ. In most institutions, this is grounds for call interventional radiology to evaluate and possibly embolize the problem. The image below shows a typical blush from extravasation.
This thinking is fairly routine and supported by the literature in adults. However, it cannot be generalized to children!
Children have more elastic tissue in their spleen and tend to do better with nonoperative management than adults. The same holds true for contrast blushes. The vast majority of children will stop bleeding on their own, despite the appearance of a large blush. In fact, if children are taken to angiography, it is commonplace for no extravasation to be seen!
Angiography introduces the risk of local complications in the femoral artery as well as more proximal ones. That, coupled with the fact that embolization is rarely needed, should keep any prudent trauma surgeon from ordering the test. It should be reserved for cases where nonoperative management is failing, but hypotension (hard fail) has not yet occurred.
The only difficult questions is “when is a child no longer a child?” Is there an age cutoff at which the spleen starts acting like an adult and keeps on bleeding? Unfortunately, we don’t know. I recommend that you use the "eyeball test", and reserve angiography for kids with contrast extravasation who look like adults (size and body habitus).
Reference: What is the significance of contrast “blush” in pediatric blunt splenic trauma? Davies et al. J Pediatric Surg 2010 May; 45(5):916-20.