TBI, Bleeding Control Are Among Hot Topics in Pediatric Trauma

In yesterday’s Panel Session, “Hot Topics in Pediatric Trauma: Best Practices and Review of the Literature,” four expert panelists shared their thoughts on trauma topics that have new and growing evidence to support future treatment decisions.

A common theme running through each talk was an abundance of care in gaining an accurate diagnosis with the appropriate level of imaging and, if necessary, intervention—an area of particular concern when faced with a potentially serious cervical spine injury.

In her talk, Katie W. Russell, MD, FACS, trauma medical director at Primary Children’s Hospital in Salt Lake City, Utah, discussed how effective screening and clearance can lead to more efficient, safer care.

Looking at screening, Dr. Russell emphasized that surgeons need to know who they need to screen and to what intensity. 

“Children are different from adults—we can’t just pan scan all kids, because we need to balance injury identification against the radiation of CT scans,” she said, noting that research shows children who receive CT scans are at increased risk of fatal cancers later in their lives.

There are predictive rules and calculators for cervical spine injuries that can be used to determine the likelihood of a severe injury and the subsequent need to perform a CT scan, she shared. At the other end of the cervical spine injury process is clearance, which current guidelines also often suggest additional imaging to grant. But Dr. Russell suggests that it may not be necessary.

“The question is, can we push for pediatric c-spine clearance with a high-quality negative CT scan alone? There will always a role for MRI, but there is much to glean from CT,” she said, adding that data at her hospital showed CT scans had a 100% accuracy in spotting injuries.

Shifting toward brain injuries, Vijay M. Ravindra, MD, MSPH, FACS, a pediatric neurosurgeon also at Primary Children’s Hospital, spoke on the role of intracranial pressure (ICP) monitoring versus external ventricular drainage (EVD) in pediatric patients with severe traumatic brain injury (TBI).

The decision to monitor or treat severe TBI is about weighing the risks and benefits. Increased ICP can impair cerebral infusion and lead to adverse outcomes, so the inclination may to be not just monitor, but also drain—and both can have benefits, with EVD providing both monitoring and treatment, and ICP monitoring gained through an easily placed probe.

However, Dr. Ravindra said, a review of evidence for placing a drain shows a lack of strong evidence as it relates to improved outcomes for severe TBI, and similarly, there is no overall reduction in mortality with ICP monitoring.

“We don’t have the evidence to support the use of an EVD over an ICP monitor—and truthfully, we don’t have great evidence for ICP monitoring itself,” he said, suggesting guidelines need additional evidence to build best practices.

Christine Leeper, MD, MS, FACS, an assistant professor of surgery and critical care medicine at the University of Pittsburgh in Pennsylvania, evaluated the role of viscoelastic monitoring (VEM) and tranexamic acid (TXA) for bleeding control.

VEM comes in two forms: thromboelastography and rotational thromboelastometry.

“These are functional tests that provide rapid and relatively comprehensive depiction of an individual’s coagulation profile” including clot initiation, amplification and propagation, and so on, Dr. Leeper said.

However, while VEM is included in some trauma organizations guidelines for treating a pediatric patient, evidence gaps and limitations make them weak recommendations, she noted.

TXA, on the other hand, has robust evidence in adult populations as an effective antifibrinolytic agent that prevents the breakdown of blood clots, but the literature has shown mixed results in children.

The challenge is variability in dosing that is inherent to children as variable sizes, and that TXA is most effective within 3 hours of injury, Dr. Leeper said, adding that “there is a need for clinical trials to better clarify the indications, safety, and outcomes after administration to injured children.”

The final talk of the session, delivered by Allison McNickle, MD, MS, FACS, an associate professor and vice chief of trauma at the University of Nevada, Las Vegas, returned to brain trauma, but with a focus on using brain injury guidelines (BIG) to guide response to the more subtle gradient of mild to moderate cases.

Dr. McNickle noted that there are nearly 500,000 pediatric TBIs each year in the US, and 70%–90% of these are classified as mild. These figures demand that surgeons and hospitals carefully consider how to approach these injuries because of their potential impact on costs, resources, and unnecessary imaging for children.

Dr. McNickle reviewed several guidelines based on recent literature and illustrated the significance of the need for careful consideration of treatment for mild or moderate injuries by examining the decision to take an initial CT scan.

One study looking at children older and younger than 2 years old found that the vast majority of children at low and intermediate risk for clinically significant TBI received an initial CT scan—which has implications for future treatment.

“Twenty to nearly 60% of children who had an initial scan had interval imaging, and while there were findings of radiological change in up to a quarter of patients, only 1 in 400 required intervention,” she said, suggesting that interval imaging is not required in a stable pediatric patient.

Pediatric BIG can be optimized to extending this knowledge to other resource-intensive care such as intrahospital transfers, reducing healthcare costs and unnecessary treatments for injured children, she said.