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Pediatric Trauma: Brain Injury, Simulations, Penetrating Trauma and Transfusions

OCTOBER 29, 2019
Clinical Congress Daily Highlights, Tuesday Second Edition

Pediatric trauma is a diverse, continuously evolving field. A Tuesday panel covered updates in traumatic brain injury, trauma care simulation, penetrating trauma, and coagulation and transfusions, with the goal of informing best practices for those who provide care for critically injured children.

Charles S. Cox, MD, FACS, University of Texas, Houston, began by outlining his ideal protocol for traumatic brain injury management. This strategy advocates adopting a variation of the Lund Concept in place of the Brain Trauma Foundation approach. In addition, Dr. Cox’s protocol includes early aggressive plasma, monitoring, and hypertonic saline over Mannitol as the osmotherapeutic of choice. There should be early and repetitive dosing of cell-based therapeutics and the use of advanced imaging strategies to document outcomes. Finally, it is important to recognize multi-compartment syndrome. Dr. Cox wrapped up his protocol by noting the need to establish outcomes with this paradigm as a new baseline for subsequent therapies.

Aaron R. Jensen, MD, MEd, FACS, FAAP, University of California San Francisco Benioff Children’s Hospital, Oakland, CA, discussed innovations in trauma care simulations. The use of simulations is increasing, both as a training tool and as a diagnostic to identify areas needing improvement. Centers that use simulations have lower mortality rates. At the same time, there is still room for improvements. Training factors (such as who to train, frequency, and simulation lab vs. in situ) need to be optimized. We need better assessment techniques as well as a clearer understanding of the relationship between simulations and real world clinical outcomes. While there are barriers to overcome, Dr. Jensen believes they are surmountable through partnerships, sharing resources, and use of artificial intelligence.

Bindi Naik-Mathuria, MD, MPH, FACS, Texas Children’s Hospital, Baylor College of Medicine, Houston, provided updates in pediatric penetrating trauma. Dr. Naik-Mathuria began with statistics on firearm injuries in children, mentioning that penetrating trauma in children is on the rise and medical centers need to be prepared for these patients. Dr. Naik-Mathuria presented lessons learned from adult trauma surgery, and how the literature is relevant to pediatric patients. Her presentation covered emergency department thoracotomy, the REBOA catheter, other endovascular options, penetrating cardiac injuries, and nonoperative management for abdominal injuries.

Barbara A. Gaines, MD, FACS, University of Pittsburgh School of Medicine, PA, presented on coagulation disorders and transfusion in pediatric trauma. Dr. Gaines highlighted that international normalized ratio does not represent a treatment target, but rather, a marker of systemic dysregulation and overall injury severity. Dr. Gaines’ discussion also covered fibrinolysis, transfusion timing, and transfusion protocols.

Additional Information:

The Panel Session, Pediatric Trauma: What’s New and Improved?, was held Tuesday, October 29 at the American College of Surgeons Clinical Congress 2019 in San Francisco (program, webcast and audio information).