RESUMEN
PURPOSE: Focused abdominal sonography for trauma (FAST) has been popularized for the initial evaluation of trauma patients. We sought to understand the scope of practice on a national level with specific attention to its use in the pediatric age group. METHODS: An electronic survey was sent to all American College of Surgeons level I trauma centers and the National Association of Children's Hospitals and Related Institutions that were freestanding children's hospitals. RESULTS: The survey was emailed to 124 centers, and 98 (79%) completed the survey. Of the surveyed centers, 23% cared for adults only, 28% were freestanding children's hospitals, and 49% managed both. At adults-only institutions, 96% use FAST and at children's hospitals, only 15%; it is used at 85% of centers that care for both. For the centers that use FAST on children, 88% have no age limit. Of all the institutions that typically use FAST, the individual performing the examination could be a surgeon (73%), an emergency department doctor (48%), or a radiologist (3%). Of the centers that perform FAST, 51% bill for the FAST examination. CONCLUSIONS: Adult hospitals are much more likely to perform FAST examinations in the trauma patient, and many adult centers routinely use FAST to examine pediatric patients.
Asunto(s)
Traumatismos Abdominales/diagnóstico por imagen , Pautas de la Práctica en Medicina/estadística & datos numéricos , Ultrasonografía/métodos , Distribución de Chi-Cuadrado , Humanos , Pediatría/métodos , Encuestas y Cuestionarios , Centros Traumatológicos , Estados UnidosRESUMEN
BACKGROUND: Optimizing patient outcomes has promoted a protocol-driven environment within the trauma bay. No standardized laboratory panel exists during the initial evaluation of injured children. METHODS: In 2004, we implemented a standard trauma panel consisting of an i-STAT analysis (electrolytes, hematocrit, and blood gas), and type and cross. We reviewed the experience of this protocol 1 year prior (T1) and after (T2) its implementation. RESULTS: During T1, 23% of patients underwent a traditional trauma panel compared with T2 where 43.5% received the new standard trauma panel. Neither the mean number of laboratory draws per patient (T1 = 4.6 vs. T2 = 4.3, p = 0.77) nor the mean number of laboratory tests obtained (T1 = 15.0 vs. T2 = 12.7, p = 0.99) were significantly different between the two groups. The mean amount of blood drawn within the trauma bay was significantly more in T1 compared with T2 (10 mL vs. 3.8 mL, respectively, p < 0.0001). The initial laboratory costs were $307.97 during T1 and $177.51 during T2, although the mean total laboratory charges were not significantly different between the two groups (T1 = $2,119.97 vs. T2 = $2,143.77, p = 0.62). CONCLUSIONS: The implementation of a standard laboratory panel increased the uniformity of care without compromising quality. We limited the volume and initial cost of blood drawn which is advantageous in small children.
Asunto(s)
Pruebas Diagnósticas de Rutina/normas , Servicio de Urgencia en Hospital , Heridas y Lesiones/diagnóstico , Adolescente , Niño , Preescolar , Ahorro de Costo , Pruebas Diagnósticas de Rutina/economía , Servicio de Urgencia en Hospital/economía , Femenino , Precios de Hospital , Hospitales Universitarios/economía , Humanos , Masculino , Garantía de la Calidad de Atención de Salud/economía , Garantía de la Calidad de Atención de Salud/normas , Resucitación/economía , Resucitación/normas , Estados Unidos , Utah , Heridas y Lesiones/economía , Heridas y Lesiones/cirugíaRESUMEN
OBJECT: Currently, no diagnostic or procedural standards exist for clearing the cervical spine in children after trauma. The purpose of this study was to determine if reeducation of nonneurosurgical personnel and initiation of a new protocol based on the National Emergency X-Radiography Utilization Study criteria could safely increase the number of pediatric cervical spines cleared of suspected injury without a neurosurgical consultation. METHODS: Data regarding cervical spine clearance in children (ages 0-18 years) after trauma protocol activation at Primary Children's Medical Center between 2001 and 2005 were collected and reviewed. Radiographic and clinical methods of clearing the cervical spine as well as the type and management of injuries were determined for two time frames: Period I (January 2001-December 2003) and Period II (January 2004-July 2005). Between 2001 and 2003, 95% of 936 cervical spines were cleared of suspected injury by the neurosurgical service. Twenty-one ligamentous injuries (2.2%) and 12 fracture-dislocations (1.3%) were detected, with five patients requiring surgical stabilization (0.5%). Between January 2004 and July 2005, 507 (68%) of 746 cervical spines were cleared by nonneurosurgical personnel. Six ligamentous injuries (0.8%) and 10 fracture-dislocations (1.3%) were identified, with three patients (0.4%) requiring surgical stabilization. No late injuries were detected in either period. CONCLUSIONS: The protocol used has been effective in enabling detection of cervical spine injuries in children after trauma, with the new protocol increasing by more than 60% the number of cervical spines cleared by nonneurosurgical personnel. Reeducation with establishment of the new protocols can safely facilitate clearance of the cervical spine by nonneurosurgical personnel after trauma.
Asunto(s)
Vértebras Cervicales/diagnóstico por imagen , Vértebras Cervicales/fisiopatología , Protocolos Clínicos , Heridas y Lesiones/diagnóstico , Heridas y Lesiones/fisiopatología , Vértebras Cervicales/patología , Niño , Preescolar , Humanos , Ligamentos Longitudinales/lesiones , Imagen por Resonancia Magnética , Estudios Prospectivos , Tomografía Computarizada por Rayos XRESUMEN
OBJECT: Currently, no diagnostic or procedural standards exist for clearing the cervical spine in children after trauma. The establishment of protocols has been shown to reduce the time required to accomplish clearance and reduce the number of missed injuries. The purpose of this study was to determine if reeducation and initiation of a new protocol based on the National Emergency X-Radiography Utilization Study criteria could safely increase the number of pediatric cervical spines cleared by nonneurosurgical personnel. METHODS: The authors collected and reviewed data regarding cervical spine clearance in children (age range 0-18 years) who presented to the emergency department at Primary Children's Medical Center in Salt Lake City, Utah, between 2001 and 2006 after sustaining significant trauma. Radiographic and clinical methods of clearing the cervical spine, as well as the type and management of injuries, were determined for two periods: Period I (January 2001-December 2003) and Period II (January 2004-February 2006). Between 2001 and 2003, 95% of 936 cervical spines were cleared by the neurosurgical service. Twenty-one ligamentous injuries (2.2%) and 12 fracture/dislocations (1.3%) were detected, and five patients (0.5%) required operative stabilization. Since January 2004, 585 (62.4%) of 937 cervical spines have been cleared by nonneurosurgical personnel. Twelve ligamentous injuries (1.3%) and 14 fracture/dislocations (1.5%) were identified, and four patients (0.4%) required operative stabilization. No late injuries were detected in either time period. CONCLUSIONS: The protocol outlined in the paper has been effective in detecting cervical spine injuries in children after trauma and has increased the number of cervical spines cleared by nonneurosurgical personnel by nearly 60%. Reeducation with the establishment of protocols can safely facilitate clearance of the cervical spine after trauma by nonneurosurgical personnel.
Asunto(s)
Vértebras Cervicales/lesiones , Adolescente , Tirantes , Vértebras Cervicales/diagnóstico por imagen , Vértebras Cervicales/patología , Niño , Preescolar , Protocolos Clínicos , Bases de Datos Factuales , Humanos , Lactante , Recién Nacido , Luxaciones Articulares/diagnóstico , Luxaciones Articulares/terapia , Ligamentos Articulares/lesiones , Imagen por Resonancia Magnética , Procedimientos Neuroquirúrgicos , Fracturas de la Columna Vertebral/diagnóstico , Fracturas de la Columna Vertebral/terapia , Tomografía Computarizada por Rayos X , Heridas y Lesiones/diagnóstico , Heridas y Lesiones/terapiaRESUMEN
BACKGROUND: Small children are vulnerable to serious accidents when a motor vehicle is placed in motion in a driveway. We describe a series of such accidents, consider the predisposing factors, and analyze the outcomes. METHODS: We conducted a retrospective review of the trauma database of a large, level I, freestanding children's hospital with specific attention to driveway auto-pedestrian accidents. RESULTS: During an 8-year period, 495 children were treated for injuries sustained in auto-pedestrian accidents, with 128 occurring in the driveway. The children's median age was 2.9 years, with 54% of the injuries sustained by boys. These often serious accidents carried an overall mortality rate of 6%. The most common injuries were abrasions, blunt head injury, and fractures. Chest trauma was associated with the highest mortality (11%), and both chest and abdominal trauma had the highest median Injury Severity Score of 13. Orthopedic injuries were the most common reason for operative intervention. Thirty-one percent of the children required intensive care unit monitoring, with their average unit stay being 3.9 days. Cars, trucks, and sports utility vehicles comprised 55%, 25%, and 12% of the accidents, respectively. Truck accidents carried the highest mortality rate (19%). Accidents were more likely to occur between 3:00 and 8:00 pm, between Thursday and Saturday, and between May and October. An increasing number of accidents occurred during the last 4 years of the study. CONCLUSIONS: Driveway injuries are an underrecognized often severe form of auto-pedestrian accidents. To prevent these family tragedies, drivers of large vehicles with children younger than 12 years old should be extremely attentive and account for children outside the vehicle before moving.
Asunto(s)
Traumatismos Abdominales/epidemiología , Accidentes de Tránsito/estadística & datos numéricos , Vehículos a Motor , Traumatismos Torácicos/epidemiología , Traumatismos Abdominales/etiología , Traumatismos Abdominales/mortalidad , Conducción de Automóvil , Niño , Preescolar , Diseño de Equipo , Salud de la Familia , Femenino , Humanos , Masculino , Prevalencia , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Traumatismos Torácicos/etiología , Traumatismos Torácicos/mortalidadRESUMEN
BACKGROUND: Recent literature expresses concern for an increased risk of cancer in children exposed to low-dose radiation during computed tomography (CT). In response, children's hospitals have implemented the ALARA (as low as reasonably achievable) concept, but this is not true at most adult referring institutions. The purpose of this study was to assess the diagnostic necessity of CT in the evaluation of pediatric trauma patients. METHODS: A retrospective review was conducted of the trauma database at a large, level I, freestanding children's hospital with specific attention to the pattern of CT evaluations. RESULTS: From January 1999 to October 2003, 1,653 children with traumatic injuries were evaluated by the trauma team, with 1,422 patients undergoing 2,361 CT scans. Overall, 54% of obtained scans were interpreted as normal. Fifty percent of treated patients were transferred from referring hospitals. Approximately half arrived with previous CT scans with 9% of these requiring further imaging. Of the 897 patients that underwent abdominal CT imaging, only 2% were taken to the operating room for an exploratory laparotomy. In addition, of those patients who had abnormal findings on an abdominal CT scan, only 5% underwent surgical exploration. CONCLUSIONS: CT scans are used with regularity in the initial evaluation of the pediatric trauma patient, and perhaps abdominal CT imaging is being used too frequently. A substantial number of these scans come from referral institutions that may not comply with ALARA. The purported risk of CT radiation questions whether a more selective approach to CT evaluation of the trauma patient should be considered.