Adolescent trauma – destination unknown

Cite this article as:
Rie Yoshida. Adolescent trauma – destination unknown, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33178

Amit is a 16-year-old male who lives in a city in England. He is the front seat passenger in a serious road traffic accident and has sustained multiple severe injuries. The ambulance arrives. There is a child, mixed and adult major trauma centre within a similar distance. Which one should Amit be taken to? Will it affect the outcome?  

A recent EMJ publication by Evans et al. aimed to answer this question by comparing adolescent mortality rates in England between children’s, mixed and adult major trauma centres (MTCs). The results suggest mortality rates are lower in children’s major trauma centres and is worth exploring further. 

Evans J, Murch H, Begley R, et al.  Mortality in adolescent trauma: a comparison of children’s, mixed and adult major trauma centres. Emergency Medicine Journal Published Online First: 30 March 2021. http://dx.doi.org/10.1136/emermed-2020-210384

Firstly, how common is adolescent trauma and how do trauma networks work in England? 

Among children and young people, adolescence is the stage of life that carries the second-highest risk of death after infancy. There were approx. 1,330 deaths for young people aged 10 to 19 years across the UK in 2018 and this has increased since 2014 (ONS, 2018).  The leading cause of adolescent mortality is trauma.  

In a previous EMJ publication, Roberts et al. provided an overview of adolescent trauma epidemiology in England from 2008-2017 using the TARN (Trauma Audit Research Network) database. This paper, along with the Evans et al. study, extends the age definition of adolescents to 10-24 years as endorsed by the RCPCH. Over a 10 year period, they found that there were 40680 trauma cases. 80.5% of these cases were aged 16–24 years and 77.3% were male. The main mechanism of injury was road traffic collisions accounting for 50.3% of cases.

NB: The TARN database includes patients of any age who sustain injury resulting in hospital admission for three days or greater, critical care admission, transfer to a tertiary/specialist centre or in-hospital death within 30 days. 

Mechanism of injury in adolescent trauma in England 2008 – 2017

Trauma networks were established in England in 2012 with the designation of major trauma centres (MTCs) and linked trauma units (TUs). The 27 MTCs are divided into 11 adult, 5 paediatric and 11 mixed major trauma centres (MTCs).  Where you are treated depends on age and location. As a general rule,  trauma patients under 16 years will be triaged to children’s MTCs whilst those 16 years and above are triaged to adult MTCs. Mixed MTCs are able to treat both adult and paediatric trauma patients. Major trauma is defined as having an Injury Severity Score (ISS) of over 15.

Why was this study needed and what did it find?

Since the establishment of trauma networks, there have been no studies comparing the outcomes for adolescent trauma between MTC types. Adolescents are a unique and often neglected cohort, especially those at the age when services transition between children and adult services.  

In their cross-sectional study, Evans et al present data from TARN comparing the outcomes of adolescent trauma patients who had a primary transfer to an MTC from 2012 to 2018. Using this data, they compare mortality rates for severely injured adolescents in the different MTC types. Note the study does not include trauma units (TUs) or transfers from a TU to an MTC. 

The study population included 30321 patients aged 10–24.99 years in the 6 year period.  The majority were treated in mixed MTCs (54%) with the fewest being treated in children’s MTC (8%). Even accounting for the variation in numbers seen, the study found that children’s MTCs had a lower 30-day mortality rate for adolescent trauma than adult or mixed MTC.  

Percentage patients seen and mortality by MTC

So does this mean Amit should be taken to a children’s MTC after his road traffic collision? 

We need to take a look at this further under two themes: patients and setting.   

Patients

As you might imagine, the study found that mixed and adult MTCs were more likely to see patients with more severe injuries. Stabbings and shootings were more frequent in adult and mixed MTCs. Patients in children’s MTCs had a lower median Injury Severity Score and fewer comorbidities. All of these trends could reasonably contribute to the higher mortality rate in mixed and adult MTCs. However, the study accounted for all of these potential confounding factors and found that the lower mortality associated with children’s MTC remained statistically significant (Table 1).  

You could argue that comparing the treatment of 10-year-olds to 24-year-olds is unrealistic and that the extremes of age are not where the interest lies. Recognising this, the study analysed those aged 14-17.99 years given the potential of this age group to be treated in any MTC. In this subgroup, the adjusted odds ratio for mortality was significantly higher in adult MTCs in comparison to children’s MTCs. There was no significant difference between mixed and children’s MTCs.  

Adjusted odds ratio for mortality by MTC type – variables include mechanism, the severity of trauma, comorbidities, baseline physiological parameters and GCS

Setting

Could the difference in mortality rate be explained by differences in staff experience and specialism at each MTC type? Do the MTCs use different management strategies or guidelines that could account for the difference in outcomes? These questions were not within the scope of this study although it did look at the most senior clinician present at the initial resuscitation and time to CT as secondary outcomes. It found that consultants were the most senior clinician likely to be present at all MTC types. With regards to imaging, trauma cases were less likely to have a CT if they presented to a children’s MTC reflecting one of the differences in managing adult and childhood trauma cases. It also took longer to perform a CT at children’s MCTs when compared with other MTC types but this does not seem to have affected the outcome.  

Number of patients receiving CT scan by MTC and average time taken to perform

In their editorial, Leech et al (2021)  suggest further reasons for the outcomes found in this study. They highlight that the majority of trauma patients present to non-children’s MTCs with the inherent danger of ‘trauma alert fatigue’. The rarer incidence of these alerts in paediatric centres may, however, give a more focused response. Other influences may be different approaches to education and training and also the nature of parents often being present for children and young people. What impact this has will probably need to be the subject of further research and evaluation.

Back to Amit, our 16-year-old patient post-RTC.  He is being transferred to the nearest adult MTC as per current protocol. 

Has this study changed your opinion on where he should be seen? Should the cut-off age for triage for adolescents be changed based on this study? More research is required but this study does show us that children’s MTCs can manage adolescent trauma with good outcomes despite seeing a lower volume of cases.  

Some thoughts from Jordan Evans

Adolescent healthcare crosses paediatric and adult services with transition predominantly based on age (16 in the UK). The same applies for trauma provision, with an adolescent trauma patient potentially treated in a children’s, adult or mixed MTC. What I wanted to know was does the centre type (children’s, adult or mixed) that an adolescent trauma patient attends affect the outcome?

We used one of the largest trauma databases in Europe (TARN) to help answer this question, defining adolescence as 10-24, in keeping with our previous research and international consensus. Appreciating that some would find this definition too broad, we performed sub-group analysis narrowing the age to 14-17.99 and for those defined as severe trauma (ISS>15). The primary outcome was mortality at 30 days and secondary outcomes included grade running resus, CT and length of stay. Both crude and adjust statistical analysis were performed (adjusting for mechanism, ISS, physiology amongst others).

Our total population for the study was 30 321 patients of which 54% presented to a mixed MTC, 38% to an adult MTC and 8% to a children’s MTC. Mortality within 30 days of injury was higher in mixed (4.4%) and adult MTCs (4.9%) compared with children’s MTCs (2.5%, p<0.0001). The same trend was noted in the adjusted analysis. For those aged 14–17.99 the crude OR of mortality was 1.73 (p=0.032) and adjusted 2.77 (p=0.030) in adolescents treated at the adult MTC. The trend for improved outcomes in children’s MTC was also noted in those with severe trauma.  For secondary outcomes, there was no difference in median total or ICU length of stay although less CT’s were performed in the children’s MTCs compared to the others. A slightly higher proportion of cases were managed by juniors in adult MTCs.

I think this is a timely paper and I feel greater attention is being paid to the adolescent cohort who are often appropriately labelled as the ‘forgotten tribe. The divided approach to adolescent healthcare is certainly a hindrance, with neither adult or paediatric services fully embracing the challenge to help drive down the high mortality and morbidity rates. A sister paper to this, reported an increase in adolescent trauma cases within the UK and a marked rise in stabbings, placing the onus on us to formulate a cross speciality approach to address the needs of this cohort.

I would thoroughly recommend reading the commentary in EMJ by Caroline Leech and Rachel Jenner who give a balanced discussion on the results with the authors hailing from adult and paediatric EM backgrounds. Personally, I would not suggest changing current trauma provision based solely on this data but that it acts as a conduit for further research and discussion. 

Selected references

  1. Office for National Statistics. Deaths registered in England and Wales – 21st-century mortality: November 2018.
  2. Roberts Z, Collins J, James D. On behalf of PERUKI, et al. Epidemiology of adolescent trauma in England: a review of TARN data 2008–2017Emergency Medicine Journal 2020;37:25-30.
  3. Evans J, Murch H, Begley R, et al.  Mortality in adolescent trauma: a comparison of children’s, mixed and adult major trauma centres. Emergency Medicine Journal Published Online First: 30 March 2021. doi: 10.1136/emermed-2020-210384
  4. Leech C, Jenner R Injured adolescents—should they be treated as big kids or little adults?Emergency Medicine Journal Published Online First: 30 March 2021. doi: 10.1136/emermed-2020-211105

Notes

Given the age cut-off of 16 years of age, there is limited overlap in the patients treated at children’s and adult MTCs making the comparison difficult.  However, there are times when triaging by age is not possible.  Indeed, the study found that there were 430 patients in the study under 16 years old who were treated in adult MTCs (9.9% of all aged <16 years) and 17 patients over 16 years attended a children’s MTC (0.1% of all aged 16–24.99 years). 

Blast Injuries: Paul Reavley at DFTB19

Cite this article as:
Team DFTB. Blast Injuries: Paul Reavley at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21941

Paul Reavley works as a consultant at the Bristol Royal Infirmary.  In this talk he uses his experience in the armed forces to talk about blast injuries. According to Save the Children, one in five children worldwide is living in a conflict zone.  We heard from Nat Thurtle about the crisis in Syria and the bombing of those places which should be safe havens for all. It is a public health problem. And unfortunately, as we have seen recently in Manchester, no one is immune.

 

 

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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Taking your trauma team to the next level: Anna Dobbie at DFTB19

Cite this article as:
Team DFTB. Taking your trauma team to the next level: Anna Dobbie at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22066

Anna Dobbie works in HEMS, PEM, and Adult ED and is a badass at all of them. She is the person you’d want leading your trauma team. Want to be just a little more like Anna? Then watch her talk and find out how to step up.

As we are so fond of saying, “You set the tone.” That first two minutes of any resus is critical – and not just because of the decisions you make. If you can appear calm and in control, your teams’ actions will reflect that. Running every trauma call the same allows for cognitive off-loading as some behaviours become automatic. Whether they are ‘real’ calls or not so serious ones the team is expected to act the same either way.

 

 
 
DoodleMedicine sketch by @char_durand 
 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

iTunes Button
 

 

Paediatric Chest Drains

Cite this article as:
Andrew Tagg. Paediatric Chest Drains, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18913

We know that critical procedures are rare in clinical practice but that when they do need to be done they need to be done right. Whether for relieving a haemo-pneumothorax or a large empyema it is incumbent upon us to know what to do when the need arises. With the exception of our South African colleagues most of us may only ever insert a chest drain every other year. So let’s take a look at what you need to know with the help of this paper from the trauma team at the Royal Children’s Hospital in Melbourne.

A future towards zero: Warwick Teague at DFTB18

Cite this article as:
Team DFTB. A future towards zero: Warwick Teague at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18203

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFTB19, which will be held in London, UK, are now on sale from www.dftb19.com.

Thinking FAST, and slow

Cite this article as:
Andrew Tagg. Thinking FAST, and slow, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17324

10-year-old Elliott is brought into your emergency department after falling off his bike. Whilst trying to escape from a gang of bullies he went off-road, left the ground and landed awkwardly. The front wheel twisted and the handlebars hit his belly. He is complaining of pain in the left upper quadrant. He has been treated with intranasal fentanyl and is haemodynamically stable. Your registrar asks if he can do a FAST exam on him.

 

Basics principles of the FAST exam

The Focused Abdominal Sonography for Trauma exam superseded diagnostic peritoneal lavage in the late 1980s as a means of determining significant intra-abdominal free fluid. The actual monicker, FAST, was first used by Royzycki et al back in the mid-90s.

The FAST exam is a rapidly performed test that looks at four specific areas – RIGHT upper quadrant, LEFT upper quadrant, subxiphoid region, and pelvis. The wielder of the probe is looking for free fluid rather than directly looking for solid organ injury.

The 4 traditional FAST views – RUQ, LUQ, subxiphoid and pelvic.

It’s important to remember that the FAST exam came about as a tool to examine haemodynamically UNSTABLE patients in order to determine who needed to go to the operating theatre or needed a critical intervention (such as pericardiocentesis).

According to Rippey and Royce, the sensitivity of FAST in adults ranges from 64-98%. But…

 

What about in kids?

CT is considered the gold standard for the examination of intra-abdominal injury in children but it is not without risk. As clinicians we are reluctant to expose kids to needless radiation and try and act within the ALARA (As Low As Reasonably Possible) principle. With an increased focus on the use of point of care ultrasound throughout paediatrics it can be tempting to translate the adult approach of using the FAST scan, in kids.

A couple of concerns have been raised regarding the use of FAST in children:

 

Not all children with abdominal injuries have free fluid

A number of studies in haemodynamically stable children have found significant solid organ injuries (liver, spleen or kidney lacerations) on CT with normal bedside ultrasound. Whilst 22% of abdominal injuries in adults are not associated with free fluid this rises to a whopping 37% in children.

A 2007 meta-analysis by Holmes et al found an 80% sensitivity for detecting intra-peritoneal fluid via sonography. When the authors only looked at the more methodologically rigorous studies the sensitivity dropped to 66%.

 

The management of solid organ injuries in the paediatric population is different

Nearly all intra-abdominal injuries in children are managed conservatively and so accurate delineation is important. Finding free fluid on sonographic assessment does not mandate them going to theatre, even in the setting of haemodynamic instability. Operative management of hepatic injuries in children has been associated with higher mortality than a conservative approach.

 

So what does this all mean?

CT scanning does have its drawbacks – it involves ionising radiation, IV contrast and is time and money intensive in comparison with the FAST scan. But if ultrasound cannot tell us what we need to know then there is no comparison. A number of studies that have shown a better correlation between CT and US do not use the FAST scan but a modified form or even complete abdominal sonography by qualified sonographers. Given that US is very much an operator-dependent imaging modality it is vital that anyone using it has been trained (and accredited) in its use.

Emergency physicians may think they are amazing at performing a focused abdominal assessment and wield the probe at every given opportunity ‘for practice’. This will skew the accuracy of the test. If the pre-test probability of a positive result is low in the first place then the number of true negatives will, of course, be higher and the accuracy of the test will appear to be higher than it actually is.

In my attempt to trawl through some of the data I have consistently come across the idea that FAST is great because it is so accurate. The only way of knowing this is to look at the studies that compare it with a CT. Just because you do not pick up an injury immediately does not mean that one is not there. For example, in the Soudack et al. paper they described three negative FAST, positive CT cases – a haemo-peritoneum, one splenic laceration, and one hepatic laceration. Because the CT did not show free fluid these did not count as false-negatives!

A positive FAST is helpful but a negative one…not so much.

 

What do I do?

What I am really interested in is the Negative Predictive Value of the test i.e. the chance that if my scan is NEGATIVE there is NO free fluid. Unfortunately, a negative scan, in isolation does not tell me that there is not a significant intra-abdominal injury. In the setting of a worrying mechanism (e.g. handlebar versus spleen) with bruising and tenderness to the left upper quadrant and a NEGATIVE fast I cannot say that the child is okay and send them home. This is the concern that I have. That the test will stop the less astute clinician from thinking.

One has to be very wary when interpreting the literature surrounding FAST scans in paediatrics. All the scan tells you is that there is no free fluid. If the patient is haemodynamically stable and there is suspicion of an intra-abdominal injury then the patient should have a CT.

Haemodynamically stable patients

In the haemodynamically stable patient with an unconcerning physical exam, good quality images on a comprehensive abdominal ultrasound and the ability to serially examine the patient then a CT may not be warranted. A comprehensive abdominal ultrasound is NOT the same as FAST.

One might think that the use of ultrasound might have other benefits but a large study by Holmes et al. in 2017 showed no alteration in the number of CT scans requested, number of patients hospitalized or requiring surgery.

 

Haemodynamically unstable patients

These patients need resuscitation, often with blood products, until they are stable enough to enter the CT scanner/IR suite. A FAST scan is likely to be positive but given that over 90% of intra-abdominal injuries in children are managed without going to theatre it is unlikely to change my management.

Whilst this is clearly not a comprehensive review, any collection of data that has such a wide range of specificity needs to be considered. I could add another 10 studies and they might tighten up my spread but in the largest trials, involving ED physicians we are just not that great.

So the bottom line, when taken in isolation, as I see it is this best case/worst case…

Thanks to Arun Ilancheran and Ross Fisher for pushing me down this rabbit hole.

 

Selected references

Ashrafi A, Heydari F, Kolahdouzan M. The Utility of Ultrasound and Laboratory Data for Predicting Intra-abdominal Injury among Children with Blunt Abdominal Trauma. International Journal of Pediatrics. 2018 Aug 1;6(8):8047-59.

Calder BW, Vogel AM, Zhang J, Mauldin PD, Huang EY, Savoie KB, Santore MT, Tsao K, Ostovar-Kermani TG, Falcone RA, Dassinger MS. Focused assessment with sonography for trauma in children after blunt abdominal trauma: A multi-institutional analysis. Journal of Trauma and Acute Care Surgery. 2017 Aug 1;83(2):218-24.

Coley BD, Mutabagani KH, Martin LC, Zumberge N, Cooney DR, Caniano DA, Besner GE, Groner JI, Shiels WE. Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma. Journal of Trauma and Acute Care Surgery. 2000 May 1;48(5):902-6.

Emery KH, McAneney CM, Racadio JM, Johnson ND, Evora DK, Garcia VF. Absent peritoneal fluid on screening trauma ultrasonography in children: a prospective comparison with computed tomography. Journal of pediatric surgery. 2001 Apr 1;36(4):565-9.

Fox JC, Boysen M, Gharahbaghian L, et al. Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med 2011; 18:477– 482.

Holmes JF, Brant WE, Bond WF, Sokolove PE, Kuppermann N. Emergency department ultrasonography in the evaluation of hypotensive and normotensive children with blunt abdominal trauma. Journal of pediatric surgery. 2001 Jul 1;36(7):968-73.

Holmes JF, Kelley KM, Wootton-Gorges SL, Utter GH, Abramson LP, Rose JS, Tancredi DJ, Kuppermann N. Effect of abdominal ultrasound on clinical care, outcomes, and resource use among children with blunt torso trauma: a randomized clinical trial. Jama. 2017 Jun 13;317(22):2290-6.

Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. Journal of pediatric surgery. 2007 Sep 1;42(9):1588-94.

Kessler DO. Abdominal Ultrasound for Pediatric Blunt Trauma: FAST Is Not Always Better. Jama. 2017 Jun 13;317(22):2283-5.

Menaker J, Blumberg S, Wisner DH, Dayan PS, Tunik M, Garcia M, Mahajan P, Page K, Monroe D, Borgialli D, Kuppermann N. Use of the focused assessment with sonography for trauma (FAST) examination and its impact on abdominal computed tomography use in hemodynamically stable children with blunt torso trauma. Journal of Trauma and Acute Care Surgery. 2014 Sep 1;77(3):427-32.

Moore C, Liu R. Not so FAST—let’s not abandon the pediatric focused assessment with sonography in trauma yet. Journal of thoracic disease. 2018 Jan;10(1):1.

Murphy R, Ghosh A. The accuracy of abdominal ultrasound in paediatric trauma. Emergency medicine journal: EMJ. 2001 May;18(3):208.

Mutabagani KH, Coley BD, Zumberge N, McCarthy DW, Besner GE, Caniano DA, Cooney DR. Preliminary experience with focused abdominal sonography for trauma (FAST) in children: is it useful?. Journal of pediatric surgery. 1999 Jan 1;34(1):48-54.

Retzlaff T, Hirsch W, Till H, Rolle U. Is sonography reliable for the diagnosis of pediatric blunt abdominal trauma?. Journal of pediatric surgery. 2010 May 1;45(5):912-5.

Rippey JC, Royse AG. Ultrasound in trauma. Best Practice & Research Clinical Anaesthesiology. 2009 Sep 1;23(3):343-62.

Rozycki GS, Ochsner MG, Jaffin JH & Champion HR. Prospective evaluation of surgeons’ use of ultrasound in the evaluation of trauma patients. The Journal of Trauma 1993 Apr; 34(4): 516–526. discussion 26–7.

Scaife ER, Rollins MD, Barnhart DC, Downey EC, Black RE, Meyers RL, Stevens MH, Gordon S, Prince JS, Battaglia D, Fenton SJ. The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation. Journal of pediatric surgery. 2013 Jun 1;48(6):1377-83.

Schonfeld D, Lee LK. Blunt abdominal trauma in children. Current opinion in pediatrics. 2012 Jun 1;24(3):314-8.

Soudack M, Epelman M, Maor R, Hayari L, Shoshani G, Heyman‐Reiss A, Michaelson M, Gaitini D. Experience with focused abdominal sonography for trauma (FAST) in 313 pediatric patients. Journal of Clinical Ultrasound. 2004 Feb;32(2):53-61.

Soundappan SV, Holland AJ, Cass DT, Lam A. Diagnostic accuracy of surgeon-performed focused abdominal sonography (FAST) in blunt paediatric trauma. Injury. 2005 Aug 1;36(8):970-5.

Suthers SE, Albrecht R, Foley D, Mantor PC. Surgeon-Directed Ultrasound for Trauma is a Predictor of Intra-Abdominal Injury in Children/DISCUSSION. The American surgeon. 2004 Feb 1;70(2):164.