Children represent a significant portion of the patient population treated at combat support hospitals. There is significant data regarding post injury seizures in adults but with children it is ...lacking. We seek to describe the incidence of post-traumatic seizures within this population.
This is a secondary analysis of previously described data from the Department of Defense Trauma Registry (DODTR). Within our dataset, we searched for documentation of seizures after admission.
Of the 3439 encounters in our dataset, we identified 37 casualties that had a documented seizure after admission. Most were in the 1-4 year age group (37.8%), male (59.4%), injured by explosive (40.5%), with serious injuries to the head/neck (75.6%). The median ISS was higher in the seizure group (22 versus 10, p<0.001). Most survived to hospital discharge with no statistically significant increased mortality noted in the seizure group (seizure 90.2% versus 91.8%, p = 1.000). In the prehospital setting, the seizure group was more frequently intubated (16.2% versus 6.0%, p = 0.023), received ketamine (20.0% versus 3.2%, p<0.001), and administered an anti-seizure medication (5.4% versus 0.1%, p = 0.001). In the hospital setting, the seizure group was more frequently intubated (56.7% versus 17.7%, p<0.001), had intracranial pressure monitoring (24.3% versus 2.6%, p<0.001), craniectomy (10.8% versus 2.5%, p = 0.014), and craniotomy (21.6% versus 4.7%, p<0.001).
Within our dataset, we found an incidence of 1% of pediatric casualties experiencing a post-traumatic seizure. While this number appears infrequent, there is likely significant under detection of subclinical seizures.
Background
Whole blood therapy—which contains the ideal balance of components, and particularly fresh whole blood—has been shown to be beneficial in adult trauma. It remains unclear whether there is ...potential benefit in the pediatric population.
Study Design and Methods
This is a secondary analysis of previously published data analyzing pediatric casualties undergoing massive transfusion in the Department of Defense Trauma Registry. Pediatric patients with traumatic injury who were transfused at least one blood product were included in the analysis. We compared children who received component therapy exclusively to those who received any amount of warm fresh whole blood.
Results
Of the 3439 pediatric casualties within our dataset, 1244 were transfused at least one blood product within the first 24 h. There were 848 patients without severe head injury. Within this cohort, 23 children received warm fresh whole blood overall, 20 of whom did not have severe head injury. In an adjusted analysis, the odds ratio (95% confidence interval CI) for survival for warm fresh whole blood recipients was 2.86 (0.40–20.45). After removing children with severe brain injury, there was an independent association with improved survival for warm fresh whole blood recipients with an odds ratio (95% CI) of 58.63 (2.70–1272.67).
Discussion
Our data suggest that warm fresh whole blood may be associated with improved survival in children without severe head injury. Larger prospective studies are needed to assess the efficacy and safety of whole blood in children with severe traumatic bleeding.
Children make up a significant cohort of patients treated at combat support hospitals. Where traumatic head injury, including intracranial hemorrhage (ICH), is well studied in military adults, such ...research is lacking regarding pediatric patients. We seek to describe the incidence and outcomes of ICH within this population.
This is a secondary analysis of a previously published dataset from the Department of Defense Trauma Registry for all pediatric casualties in Iraq and Afghanistan from January 2007 to January 2016. Within our dataset, we searched for casualties with an ICH.
Of the 3439 pediatric encounters in our dataset, we identified 495 (14%) casualties that had at least 1 type of ICH. Most were between 5 and 12 years of age, male (74%), and injured by an explosive (42%). Of the casualties with ICHs, 82 had epidural (16.6%), 237 had subdural (47.9%), 153 had subarachnoid (30.9%), 157 had parenchymal bleeds (31.7%), and 239 had ICHs not otherwise specified (48.3%). In the hospital setting, the epidural group was more frequently treated with skull decompression (41%) and craniotomy with skull elevation (28%). The subdural group was more frequently treated with a craniectomy (17%) and the parenchymal group had more frequent intracranial pressure monitoring (18%). In our dataset, 22 received ketamine prehospital (4.4%) and most were discharged alive from the hospital (79%).
Within our dataset, we identified 495 cases of ICH in pediatric patients. Most survived to hospital discharge despite less than half undergoing a decompression procedure.
Recommended devices include the Combat Application Tourniquet (CAT, C-A-T Resources, LLC, Rock Hill, South Carolina), which can serve as reference for newer device evaluation (Fig. 1) 5. The Smart ...Tactical Application Tourniquet (STAT, S.T.A.T. Medical Devices, LLC, Freehold, New Jersey) boasts its 76.2 cm non-elastic plastic and zip tie-like strap “can stop bleeding within 5-10 seconds” despite no published peer-reviewed studies 6. BMC wrote the first draft, and all authors read, provided critical revisions, and approved the final manuscript.Financial disclosure We have no relevant disclosures to report.Funding We received no funding for this study.Disclaimer The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, or the Department of Defense or the U.S. Government.Acknowledgements None.
Pediatric casualties account for a notable proportion of encounters in the deployed setting based on the humanitarian medical care mission. Previously published data demonstrates that an age-adjust ...shock index may be a useful tool in predicting massive transfusion and death in children. We seek to determine if those previous findings are applicable to the deployed, combat trauma setting.
We queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to US and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. This is a secondary analysis of casualties seeking to validate previously published data using the shock index, pediatric age-adjusted. We then used previously published thresholds to determine patients outcome for validation by age grouping, 1-3 years (1.2), 4-6 years (1.2), 7-12 years (1.0), 13-17 years (0.9).
From January 2007 through January 2016 there were 3439 pediatric casualties of which 3145 had a documented heart rate and systolic pressure. Of those 502 (16.0%) underwent massive transfusion and 226 (7.2%) died prior to hospital discharge. Receiver operating characteristic (ROC) thresholds were inconsistent across age groups ranging from 1.0 to 1.9 with generally limited area under the curve (AUC) values for both massive transfusion and death prediction characteristics. Using the previously defined thresholds for validation, we report sensitivity and specificity for the massive transfusion by age-group: 1-3 (0.73, 0.35), 4-6 (0.63, 0.60), 7-12 (0.80, 0.57), 13-17 (0.77, 0.62). For death, 1-3 (0.75, 0.34), 4-6 (0.66-0.59), 7-12 (0.64, 0.52), 13-17 (0.70, 0.57). However, negative predictive values (NPV) were generally high with all greater than 0.87.
Within the combat setting, the age-adjusted pediatric shock index had moderate sensitivity and relatively poor specificity for predicting massive transfusion and death. Better scoring systems are needed to predict resource needs prior to arrival, that perhaps include other physiologic metrics. We were unable to validate the previously published findings within the combat trauma population.
Hemorrhage is common among the combat injured, and plasma plays a vital role in blood product resuscitation. Regarding freeze dried plasma (FDP), US forces have had limited access to this product ...compared with other countries. In 2018, the US Food and Drug Administration provided emergency authorization for Department of Defense (DoD) use through the newly congressionally directed military use pathway. We describe the documented uses of FDP by US forces by performing a secondary analysis of two previously described datasets from the DoD Trauma Registry. In 11 identified cases, the median age was 28; cases were most frequently male, part of Operation Enduring Freedom, with US military affiliation, and injured by explosive or gunshot wound. The median injury severity score was 21; most did not receive a massive transfusion. Most survived to hospital discharge. Ongoing surveillance is warranted to optimize the implementation of FDP into military prehospital guidelines, training, and doctrine.
INTRODUCTIONEmergency department (ED) utilization continues to climb nationwide resulting in overcrowding, increasing wait times, and a surge in patients with non-urgent conditions. Patients ...frequently choose the ED for apparent non-emergent medical issues or injuries that after-the-fact could be cared for in a primary care setting. We seek to better understand the reasons why patients choose the ED over their primary care managers. METHODSWe prospectively surveyed patients that signed into the ED at the Brooke Army Medical Center as an emergency severity index of 4 or 5 (non-emergent triage) regarding their visit. We then linked their survey data to their ED visit including interventions, diagnoses, diagnostics, and disposition by using their electronic medical record. We defined their visit to be non-urgent and more appropriate for primary care, or primary care eligible, if they were discharged home and received no computed tomography (CT) imaging, ultrasound, magnetic resonance imaging (MRI), intravenous (IV) medications, or intramuscular (IM) controlled substances. RESULTSDuring the 2-month period, we collected data on 208 participants out of a total of 252 people offered a survey (82.5%). There were 92% (n=191) that were primary care eligible within our respondent pool. Most reported very good (38%) or excellent (21%) health at baseline. On survey assessing why they came, inability to get a timely appointment (n=73), and a self-reported emergency (n=58) were the most common reported reasons. Most would have utilized primary care if they had a next-morning appointment available (n=86), but many reported they would have utilized the ED regardless of primary care availability (n=77). The most common suggestion for improving access to care was more primary care appointment availability (n=96). X-rays were the most frequent study (37%) followed by laboratory studies (20%). Before coming to the ED, 38% (n=78) reported trying to contact their primary care for an appointment. Before coming to the ED, 22% (n=46) reported contacting the nurse advice line. Based on our predefined model, 92% (n=191) of our respondents were primary care eligible within our respondent pool. CONCLUSIONSPatient perceptions of difficulty obtaining appointments appear to be a major component of the ED use for non-emergent visits. Within our dataset, most patients surveyed stated they had difficulty obtaining a timely appointment or self-reported as an emergency. Data suggests most patients surveyed could be managed in the primary care setting.
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