PTS 2014 PRESIDENTIAL ADDRESS
Pediatric trauma and the Pediatric Trauma Society: Our time has come Barbara A. Gaines, MD, Pittsburgh, Pennsylvania
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hank you, Rich, for that introduction, it was really overwhelming. And thank you all for being here at the first Annual Meeting of the Pediatric Trauma Society. Before I start the ‘‘real’’ talk, I would like to spend a few moments reflecting back at the mentors that got me here. And these are two of the many (Fig. 1) V I call these my ‘‘trauma dads.’’ One is John Morris, the founder and former director of trauma at Vanderbilt. He was instrumental in supporting me through my general surgery residency and also provided tremendous mentorship during my critical care fellowship at Vanderbilt. He understood my interest in pediatric surgery and pediatric trauma, and saw early on that this was a viable career path. From a practical standpoint, he arranged for me to rotate through the pediatric intensive care unit, which was for surgical residents at that time. He is also a wonderful friend and an incredible mentor in terms of making sure that his trainees stayed ‘‘whole’’; that they received what they needed, both from a training perspective and from the emotional and family side. He had us to his home for Christmas lunch, and we were his guests at the 4th of July celebration at his country club (which was like stepping through the doors into the 1880s with a barbershop quartet and more fried chicken than I had ever seen). But really, it was just a wonderful way of welcoming residents and fellows into his family. The man on the left needs no introduction to this audience. Henri Ford was one of the principal reasons that I ended up in Pittsburgh for my pediatric surgery fellowship, and the reason that I stayed there after completing my training. He had the vision to see that a pediatric surgeon could have an academic career in trauma and has continued to be a tremendous influence in both my personal and professional development. I don’t think that there is a more accomplished pediatric surgeon than Henri Ford, and there are few more impressive human beings than him. All these people (Fig. 2) are my colleagues who have helped me get here, who have supported me, have given me ideas, have put up with me in a lot of respects. And I value their friendship. There are many more of you in the room but I was running out of space on the slide. It takes a village and I just want to thank you all you for the support that you’ve given me over the years. We all have a personal reason for trying to advance pediatric trauma and these are mine: Lili, Bobby, and Thomson. I certainly wouldn’t be here without the support of my husband, Richard. He has been there since I was in the lab in Pittsburgh, and has survived general surgery training, surgical critical care training, pediatric surgery training, and pediatric surgery life. Suffice it to say that I couldn’t have done any of this without his love and support; someone has to get the kids to school in the morning! Enough of the personal; now, I’m going to give a brief and biased history of pediatric trauma. I don’t think that it’s happenstance that we’re sitting in this room today. I think that this is something that was destined to happen, and that there are multiple forces that have coalesced to bring the field of pediatric trauma to where we are today. From antiquity, kids got injured, but since no one lived very long anyway, it didn’t seem to bother anyone very much. In the middle ages, kids got injured, but again, people didn’t live very long and they were worried about eating and staying warm. In the Renaissance, the same issues remained. But by the mid-20th century, we began to look at things a little differently. We recognized that kids get injured, and that was a bad thing. But from a practical perspective, they were essentially treated as little adults. But times were beginning to change. I think the seminal moment for pediatric trauma occurred in the late 1970s, when pediatric surgeons proposed a radical concept for the
From the Department of Surgery, Children’s Hospital of Pittsburgh of UPMC, 4401 Penn Ave, Pittsburgh, PA 15224. This was presented at the 1st Annual Pediatric Trauma Society Meeting, November 14Y15, 2014, in Chicago, Illinois. The author has nothing to disclose. Address for reprints: Barbara A. Gaines, MD, Department of Surgery, Children’s Hospital of Pittsburgh of UPMC, 4401 Penn Ave, Pittsburgh, PA 15224; email: [email protected]. DOI: 10.1097/TA.0000000000000709
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Figure 1. Dr Henri Ford (left) and Dr. John Morris (right).
treatment of splenic injury in children. In 1977, there was a publication in Pediatrics on the non-operative management of six children with splenic injuries.1 Then Dave Wesson, in 1981 in the Journal of Pediatric Surgery, published a case series from The Hospital for Sick Children in Toronto, of their five-year experience of 63 children with splenic injuries initially treated non-operatively.2 Of the 63 patients, 19 of them required a blood transfusion, 18 had some type of operative procedure, 15 of which were splenectomies, and there were 7 deaths, 6 of which were from head injury. The authors concluded ‘‘that we believe that where adequate facilities exist, non-operative treatment of splenic injuries is both safe and effective.’’ This was heresy.
Surgeons could not believe that someone would advocate for not operating on an injured spleen. We were going to let people V children V bleed to death. This was absolutely going against all conventional wisdom, and it took a long time for this concept to become accepted. By 2000 though, the non-operative management of splenic injuries in children was the standard of care. Steve Stylianos, then the Chair of the American Pediatric Surgical Association (APSA) Committee on Trauma, advanced the field of by organizing a study of the outcome of non-operative management of solid organ injuries in children. The initial publication was a study of 856 kids who were treated at 32 centers.3 Guidelines were proposed for the safe and optimal utilization of resources in routine cases. In 2002, the companion paper looked at a prospective application of those guidelines.4 That study reported on 312 children treated at 16 centers, and demonstrated a significant reduction in ICU length of stay, hospital stay, follow-up imaging and length of activity restriction with the application of the ‘‘APSA guidelines’’ without adverse sequelae. This has become the paradigm that we have been working under since the publication of the 2000/2002 papers. And, of course, the advantage of paradigms is that they can shift, and Shawn St. Peter, who has been a leader in evidence based medicine in pediatric surgery, in 2008 challenged V not the concept V but the details. He put forth an abbreviated protocol for the management of blunt spleen and liver injuries.5 So the paradigm has
Figure 2. Top row: Jeffery Upperman, MD; Michael Nance, MD; Richard Falcone, MD, MPH; Randall Burd, MD, PhD; Lynn Haas, MSN. Middle row: George Gittes, MD; Christine McKenna, MSN, CRNP; Michael Hirsch, MD; Mary Fallat, MD; Wayne Meredith, MD. Bottom Row: Andrew Peitzman, MD; Jonathan Groner, MD; Stephen Stylianos, MD; Michael Morant, MD. 1112
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shifted slightly, but nonoperative management of the hemodynamically stable child with a liver or spleen injury is absolutely the norm. We can debate about the details of management. How many days should they stay in the hospital? Should we get hematocrits every six hours or every eight hours? When can they return to play? But we’re not debating whether we should or shouldn’t take that kid to the operating room immediately. We’ve accepted that. We’ve also defined that pediatric trauma is different than adult trauma, because adults don’t behave the same way. About 70% of adults are successfully managed nonoperatively, compared to greater than 90% of liver injuries in children and 95% of splenic injuries. Andrew Peitzman, another one of my mentors, raises a cautionary voice regarding the application of nonoperative management of blunt abdominal trauma in adults, asking ‘‘have we gone too far?’’6 Because, again, adults are injured differently, their response to injury is different, and they have different comorbidities. They are not just big kids. What we really have defined is that children behave differently when they are injured than adults. But Dr. Peitzman’s comment holds true of both populations, ‘‘Isafe nonoperative management requires adherence to the cardinal surgical principles, examination and re-examination of the patient and fastidious clinical judgement.’’ What else was happening in the ’70s and ’80s that set the stage for our meeting today? I think another major force was the development of trauma centers. The American College of Surgeons formed the Committee of Fractures in 1922, and the first edition of the Optimal Resource Guideline was published in 1976. Trauma centers were developed and verified. And then in 2006 V it’s kind of interesting that it took all the way to 2006 V Ellen McKenzie published, in the New England Journal of Medicine, that trauma centers save lives.7 It was hard to get that data. It seemed right, but it was hard to actually get the data and to get it in such a way that we could actually prove the benefit of trauma centers. But that was finally published in 2006. Pediatric trauma centers developed in parallel. But even today, large portions of the population still don’t have access to a pediatric trauma center. If it was hard to prove that trauma centers in general save lives, it’s been even harder to prove the benefits of pediatric trauma centers. But there have been some interesting studies. For example, Notrica et al published in 2012 that there are lower pediatric injury mortality rates in states with higher level pediatric trauma centers.8 So, in parallel with the adult experience, it does seem that where children receive specialized care for their injuries, they do better. What is also interesting is that the trauma center concept has now become a model for pediatric surgery in general. Recently the ‘‘Optimal Resources for Children’s Surgical Care’’ were published.9 These guidelines apply not only to trauma care, but to all surgical care in children. In partnership with the American College of Surgeons, facilities that provide surgical care to children will be verified, in a fashion very similar to the trauma center model. Again, the care of the injured patient has now become a model of care for other types of pediatric surgical issues. So that’s our current state, right? We’ve proven through our experience with the nonoperative management of solid organs that injured children are fundamentally different from
injured adults, and that we need to think about them differently. We just can’t take what we have learned from adults and apply it to children. Children are different. We have had a maturation of pediatric trauma systems, and we have also seen differences in outcome between children treated in pediatric versus adult centers, highlighting, again, that children are different.10,11 I think that these factors set the stage for what I’m going to call a tipping point.12 Because there were a lot of things happening that, taken together, ‘‘tipped’’ pediatric trauma to the point that today we have a society dedicated to pediatric trauma and the care of the injured child. Back in 2006 the Institute of Medicine (IOM) published Emergency Care for Children: Growing Pains.13 This was a companion to two other volumes that in sum formed an in-depth evaluation of emergency care in this country. In regard to pediatric care, the IOM identified a crisis in the emergency care of children, secondary to a general lack of equipment, facilities, and personnel. Widespread publicity of the IOM findings reinforced the concept that children require specialized resources and, that in many areas, that these were lacking. From a patient-care standpoint, we know that traumatic brain injury is the leading cause of death in kids, resulting in more than 3000 deaths in children less than 14 years and millions of concussions.14 But do we really know what are the best therapies? The Pediatric Neurotrauma Guidelines were published initially in 2003 and revised in 2012 (just by comparison, we weren’t too far behind the adults, who published guidelines in 2000).15,16 What I found fascinating about these guidelines is that what they really identified: the overwhelming lack of evidence supporting many of the recommendations. There are no class-one recommendations, but there are lots of consensus opinions. One of the by-products of the guideline process was the development of a research agenda and a call to action to formally study the issues. There will likely never be a randomized trial comparing mannitol vs. placebo. We can’t do that anymore. But there are number of other questions that can and should be studied. When you look at these types of evidence-based reviews, sometimes it’s surprising what we don’t have the evidence to support, but what we do simply because we think it’s right. What else was happening that was pushing pediatric trauma into the forefront? Well, what about mild TBI or concussions? We live in a world where the media is everywhere. These are just some headlines from not so long ago: ‘‘Former Chicago Bears Star Jim McMahon Opens Up About Dementia, Suicidal Thoughts,’’ ‘‘The Latest NFL Concussion Lawsuit Details Are Released,’’ ‘‘Junior Seau diagnosed with disease caused by hits to the head.’’17Y19 In Pittsburgh, our star hockey player, Sydney Crosby, was out for over a year secondary to a concussion, and probably a second concussion as well. Fortunately (for him), he recovered completely, and returned to the ice to win another gold medal for the Canadians in the 2014 Olympics. But concussions don’t only involve star athletes. There was also this case: Zack Lystedt was a talented youth athlete in Washington State. He was tackled twice in an 8th-grade football game and, after the second hit, collapsed on the field. He suffered from Second Impact Syndrome, a severe traumatic brain injury, and was treated at Harborview in Seattle. His recovery was lengthy and incomplete, and his family spearheaded the formation of a coalition to increase awareness regarding the
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potential devastating consequences of concussions. The coalition included the Seattle Sea Hawks, among many others, and the first concussion law was enacted in Washington State, effective in July 2009. With the strong support of the National Football League, all 50 states now have youth concussion legislation. While most of these are unfunded mandates, and there is very little data regarding whether the legislation actually reduces traumatic brain injuries in young athletes, these legislative initiatives have suddenly made this particular pediatric injury front-page news, and a significant concern of parents of school aged children. There are other headlines that impact us as pediatric traumatologists. NPR: ‘‘How CT Scans Have Raised Kids’ Risk for Future Cancer.’’20 USA Today: ‘‘Kids’ CT Scans Raise Fear of Cancer Risk As Use Soars.’’21 Maybe a little bit less popular press, but the popular scientific press, Scientific American: ‘‘How Much do CT Scans Increase the Risk of Cancer?’’22 The concern about cancer risk from diagnostic radiation and the pediatric population is all over the public domain. CT scans are responsible for a disproportionate amount of medical radiation exposure in children, accounting for 15% of procedures and 75% of the radiation dose.23 In addition, the number of scans performed on children has increased dramatically. It is estimated that 11% of all CT scans are performed on kids V that’s about 7 million scans a year. CTs can be performed over a wide range of techniques and with variable radiation exposure, increasing the complexity of the issue. Back in 2007 or 2008, the Pennsylvania Trauma Systems Foundation Pediatric Committee V of which I was Chair at the time V came up with an statement about imaging. We recommended: avoid protocolized scanning, utilize dose minimization strategies, defer imaging a child if they’re going to be transferred, and also reminding pediatric trauma centers not to re-scan unless absolutely necessary. The reason we came up with this, again, was that it was an issue. It was an issue that at the time was unique to kids, and one that affected kids in the trauma community. But there was certainly external pressure from the general public as well. The controversy regarding pediatric imaging is another area in which there is a clear distinction between the pediatric and adult trauma communities. The NIH has also become interested in pediatric trauma as an independent field. There now is a Pediatric Trauma and Critical Injury branch of The Eunice Kennedy Shriver Institute, which was formed in 2013. The branch mission is to ‘‘support research and research training in pediatric trauma, injury, and critical illness throughout the continuum of care.’’24 Some of the activities of the branch include a request for funding for the development of a Consortium for Research on Pediatric Trauma and Injury via an R-24 mechanism, as well as support of the Collaborative Pediatric Critical Care Research Network (CPCCRN) and a KY12 clinical-scientist training program. At the American College of Surgeons, the Trauma Quality Improvement Program (TQIP), a risk-adjusted benchmarking program, was developed. The need for a pediatric product was quickly apparent, and under the leadership of Mike Nance, Pediatric TQIP went live in January of 2014. In the report that was released in early November 2014, 25 Level I, six Level II, and six unknown level centers contributed data. For the next round, it is estimated 40 more sites will participate. So 1114
again, there is tremendous interest in looking at improving the outcomes of pediatric trauma, in this case through benchmarking. Then there has been the pediatric involvement in traditionally adult trauma organizations. I’ll talk little bit more about this later in the talk, but the Eastern Association for the Surgery of Trauma (EAST) formed an Ad-hoc Pediatric Committee around 2010. There have been multiple sunrise sessions on pediatric topics and a collaborative agreement with the Pediatric Trauma Society. The American Association for the Surgery of Trauma (AAST) also formed a Pediatric Committee, which has sponsored lunch sessions, pre-conference sessions, and web-based grand rounds. The Society of Trauma Nurses (STN) has a pediatric special interest group, and has developed a pediatric version of their popular trauma process improvement course (TOPIC). Again, all of these organizations, where the major focus and most of the membership are those who primarily identify themselves as adult practitioners, have begun to have an increasing interest in the injured pediatric patient. Within the pediatric surgical community, both the president-elect of American Pediatric Surgical Association (Mary Fallat) and the president of the American Pediatric Surgical Nurses Association (Chris McKenna) are well known pediatric trauma leaders. Finally, injury prevention has always been an area of strength within in the pediatric trauma community. I do want to highlight the work of the Injury-Free Coalition for Kids, which was founded by Barbara Barlow, a pediatric surgeon in Harlem. Dr. Barlow developed a model in which trauma center data is used to identify the injuries of particular importance to the local community. This information is then taken back to the community and a coalition of community partners, including the trauma center, develop an intervention and, importantly, evaluate the effectiveness of that intervention. Injury Free, initially supported by the Robert Wood Johnson Foundation, now has 42 sites in trauma centers throughout the US and Canada, and the model underscores the important relationship between the local trauma center and the community that it serves. So that brings me to us, the Pediatric Trauma Society. I thought it would be worth reminding everyone of our mission: improving pediatric trauma outcomes, and our vision: to become a global leader in the field of pediatric trauma through optimal care guidelines, education, research, and advocacy. I think if you look at the program for this conference, we have stayed pretty true to that vision. We also strive to be an inclusive, multi-disciplinary organization, open to all those dedicated to the care of injured children. The history of PTS is brief. We had the inaugural meeting in Naples, Florida in 2011, under the auspices of EAST. The leadership of EAST has been very supportive of us, ‘‘incubating’’ the Society until we felt that we were ready to become independent. Fortunately EAST and STN also have close relationship, and that allowed for strong input from both trauma surgery and trauma nursing from the earliest in conception of PTS. The organization was officially incorporated in 2012. Our current membership is 663, with 306 physicians, 305 RNs and program managers, and 51 EMS professionals. We have members from 47 states, DC, and eight countries. Dave Mooney was the first president of the organization and Lynn Haas succeeded him. * 2015 Wolters Kluwer Health, Inc. All rights reserved.
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What have we done? Well, I think one of our really spectacular accomplishments was partnering with the Childress Institute to sponsor the Childress Summit of the Pediatric Trauma Society. This event was held April 22Y24, 2013 at the Graylyn International Conference Center in Winston-Salem, North Carolina, and hosted by Wayne Meredith. The summit goals were to define the current state of pediatric trauma and develop an ideal future state. The summit format was one of facilitated discussion, with invited participants assigned to one of four teams: trauma systems, traumatic brain injury, prehospital/emergency care, and critical care. Stakeholders from across the spectrum of pediatric injury participated. There were experts in trauma systems, emergency medicine, critical care, neurosurgery, rehabilitation, EMS, prevention, as well as government agencies including the NIH, NHTSA (National Highway Transportation Safety Administration), and EMSC (Emergency Medical Services for Children). Participants also spanned the professional spectrum, including nurses, physicians, PhDs, and social workers. It was a comprehensive group of experts who came together to talk about pediatric trauma, and to ultimately define pediatric trauma as an independent field of study and medical practice. The major, tangible deliverable was the publication of the proceedings in the Journal of Trauma and Acute Care Surgery.25 In addition, the Childress Institute announced funding for a pediatric trauma-related research grant. The recipient of that award was Fred Rivara and his team for the development of the pediatric trauma assessment and management database, and they will be reporting on their progress later in the meeting. The Childress Institute continues to be a major supporter of PTS and this meeting. Other activities of the Society include our continued partnership with EAST and their Pediatric Trauma Committee. We also have a number of important committees, including Research, Guidelines, Education, Membership, and new this year, IT. I hope that those who are interested in becoming more involved will let us know. Our electronic newsletter is published quarterly to keep the membership informed of our activities. We are very proud of the fact that the Journal of Trauma, the official publication vehicle of the major trauma organizations including AAST, EAST, Western Trauma, Trauma Association of Canada, Australian and New Zealand Association for the Surgery of Trauma, has now included the Pediatric Trauma Society in the group. As of the November 2014 issue, PTS is listed on the cover, along with the rest of the ‘‘official’’societies! The proceedings from this meeting will be published in the early summer, after formal peer review. I want to thank Jennifer Crebs, the managing editor, and Gene Moore, the editor-inchief, for making this relationship a reality. It is a major step in legitimizing the Pediatric Trauma Society within the overall trauma community. In addition, we now have received official recognition by the American College of Surgeons Committee of Trauma. Those of you who are in trauma centers know that the Trauma Medical Director at Level I and Level II centers must be a member of regional and national trauma organizations. The Pediatric Trauma Society is now officially recognized as an organization that fulfills this requirement. Again, this is an important step in validating our importance within the trauma community.
And that brings us to today. This is our first annual meeting. There are 256 registrants, representing 35 states, and eight countries. It is a truly international meeting. We have 50 podium presentations, 14 poster presentations, several panel discussions, invited speakers, networking, and even wine. It has been an incredibly informative and fun meeting. I will say that with success come increased expectations. Planning for the second annual meeting starts today V well maybe tomorrow V but in any event, we need to start thinking about how to make it even better. I know that this room has been a little cozy; that’s because more of you are here than we initially anticipated. Next year’s venue will be bigger, but then you had better come back! We know that yesterday was a very busy day and we have some ideas of how to make it a little bit less intense. We know that there wasn’t a huge amount of time for networking among colleagues, and so we’re going to try to build that into the next meeting. We all need to continue to spread the word about PTS and our mission, and to reach out to our colleagues in emergency medicine, critical care, orthopedics, neurosurgery, anesthesia, et cetera, to fulfill the goal of a truly multidisciplinary organization focused on the continuum of care of the injured child. Finally, we need to harness the energy of this meeting to continue our efforts to improve the outcome of injured children. And with that, I want to thank all of you for making PTS a reality. I think five years ago we would be hard pressed to imagine that this meeting was really going to happen. But it was an idea that was the right one at the right time, and now, with your help we have become a reality. Please give yourselves a round of applause! REFERENCES 1. Aronson DZ, Scherz AW, Einhorn AH, Becker JM, Schneider DM. Nonoperative management of splenic trauma in children: a report of six consecutive cases. Pediatrics. 1977;60(4):482Y485. 2. Wesson DE, Filler Rm, Ein Sh, Shandling B, Simpson JS, Stephens CA. Ruptured spleenVwhen to operate? J Pediatr Surg. 1981;16(3):324Y326. 3. Stylianos S. Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. The APSA Trauma Committee. J Pediatr Surg. 2000;35(2):164Y167. 4. Stylianos S. Compliance with evidence-based guidelines in children with isolated spleen or liver injury: a prospective study. J Pediatr Surg. 2002; 37(3):453Y456. 5. St Peter SD, Keckler SJ, Spilde TL, Holcomb GW 3rd, Ostlie DJ. Justification for an abbreviated protocol in the management of blunt spleen and liver injury in children. J Pediatr Surg. 2008;43(1):191Y193. 6. Peitzman AB, Ferrada P, Puyana JC. Nonoperative management of blunt abdominal trauma: have we gone too far? Surg Infect (Larchmt). 2009; 10(5):427Y433. 7. MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, Salkever DS, Scharfstein DO. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354(4):366Y378. 8. Notrica DM, Weiss J, Garcia-Filion P, Kuroiwa E, Clarke D, Harte M, Hill J, Moffat S. Pediatric trauma centers: correlation of ACS-verified trauma centers with CDC statewide pediatric mortality rates. J Trauma Acute Care Surg. 2012;73(3):566Y570. 9. Oldham KT. Optimal resources for children’s surgical care. J Pediatr Surg. 2014;49(5):667Y677. 10. Potoka DA, Schall LC, Gardner MJ, Stafford PW, Peitzman AB, Ford HR. Impact of pediatric trauma centers on mortality in a statewide system. J Trauma. 2000;49(2):237Y245. 11. Farrell LS, Hannan EL, Cooper A. Severity of injury and mortality associated with pediatric blunt injuries: hospitals with pediatric intensive care units versus other hospitals. Pediatr Crit Care Med. 2004;5(1):5Y9.
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12. Gladwell M. The Tipping Point, Little, Brown, and Company; 2000. 13. Institute of Medicine. Emergency care for children: growing pains. Washington DC: The National Academies Press; 2007. 14. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. ‘‘Fatal Injury Data.’’ http://www.CDC.gov/ injury/wisqars/fatal.html. Page updated: February 17, 2015. Accessed April 14, 2015. 15. Adelson PD, Bratton SL, Carney NA, Chesnut RM, du Coudray HE, Goldstein B, Kochanek PM, Miller HC, Partington MD, Selden NR, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children and adolescents. Pediatr Crit Care Med. 2003; 4(3):S1YS75. 16. Kochanek PM, Carney N, Adelson PD, Ashwal S, Bell MJ, Bratton S, Carson S, Chesnut RM, Ghajar J, Goldstein B, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescentsVsecond edition. Pediatr Crit Care Med. 2012; 13(Suppl 1):S1YS82. 17. Seligman A. Former Chicago Bears star Jim McMahon opens up about dementia, suicidal thoughts. http://www.huffingtonpost.com/2014/06/17/ jim-mcmahon-dementia-suicidal-thoughts_n_5505041.html. Associated Press. Published: June 17, 2014. Accessed: April 21, 2015. 18. Hagan BA. Latest NFL concussion lawsuit details are released. http:// www.24-7pressrelease.com/press-release/latest-nfl-concussion-lawsuitdetails-are-released-389103.php. Published: July 2, 2013. Accessed: April 21, 2015. 19. Avila J, Pearle L, Goldman R. Junior Seau diagnosed with disease caused by hits to head: ABC News Exclusive. http://abcnews.go.com/US/junior-
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seau-diagnosed-brain-disease-caused-hits-head/story?id=18171785. ABC News. Published: January 10, 2013. Accessed: April 21, 2015. Shute N. How CT scans have raised kids’ risk for future cancer. http:// www.npr.org/blogs/health/2013/06/10/190449001/how-ct-scans-have-raisedkids-risk-for-future-cancer. NPR. Published: June 11, 2013. Accessed: April 21, 2015. Wilemon T. Kids’ CT scans raise fears of cancer risk as use soars. http:// usatoday30.usatoday.com/news/health/medical. USA Today. Published: December 12, 2011. Accessed: April 21, 2015. Storrs C. How much do CT scans increase the risk of cancer? http:// www.scientificamerican.com/article/how-much-ct-scans-increase-riskcancer. Scientific American. Published: June 18, 2013. Accessed: April 21, 2015. Brody AS, Frush DP, Huda W, Brent RL. American Academy of Pediatrics Section on Radiology. Radiation risk to children from computed tomography. Pediatrics. 2007;120(3):677Y682. National Institute of Child Health and Human Development. Pediatric Trauma and Critical Illness Branch (PTCIB). http://www.nichd.nih.gov/ about/org/der/branches/ptcib. Page updated: March 30, 2015. Accessed: April 21, 2015. Gaines BA, Hansen K, Mckenna C, McMahon M, Meredith JW, Mooney DP, Snow SK, Upperman JS. Childress Summit of the Pediatric Trauma Society Work Groups. Report from the Childress Summit of the Pediatric Trauma Society, April 22Y24, 2013. J Trauma Acute Care Surg. 2014; 77(3):504Y509.
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Pediatric trauma and the Pediatric Trauma Society: Our time has come Barbara A. Gaines, MD, Pittsburgh, Pennsylvania
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hank you, Rich, for that introduction, it was really overwhelming. And thank you all for being here at the first Annual Meeting of the Pediatric Trauma Society. Before I start the ‘‘real’’ talk, I would like to spend a few moments reflecting back at the mentors that got me here. And these are two of the many (Fig. 1) V I call these my ‘‘trauma dads.’’ One is John Morris, the founder and former director of trauma at Vanderbilt. He was instrumental in supporting me through my general surgery residency and also provided tremendous mentorship during my critical care fellowship at Vanderbilt. He understood my interest in pediatric surgery and pediatric trauma, and saw early on that this was a viable career path. From a practical standpoint, he arranged for me to rotate through the pediatric intensive care unit, which was for surgical residents at that time. He is also a wonderful friend and an incredible mentor in terms of making sure that his trainees stayed ‘‘whole’’; that they received what they needed, both from a training perspective and from the emotional and family side. He had us to his home for Christmas lunch, and we were his guests at the 4th of July celebration at his country club (which was like stepping through the doors into the 1880s with a barbershop quartet and more fried chicken than I had ever seen). But really, it was just a wonderful way of welcoming residents and fellows into his family. The man on the left needs no introduction to this audience. Henri Ford was one of the principal reasons that I ended up in Pittsburgh for my pediatric surgery fellowship, and the reason that I stayed there after completing my training. He had the vision to see that a pediatric surgeon could have an academic career in trauma and has continued to be a tremendous influence in both my personal and professional development. I don’t think that there is a more accomplished pediatric surgeon than Henri Ford, and there are few more impressive human beings than him. All these people (Fig. 2) are my colleagues who have helped me get here, who have supported me, have given me ideas, have put up with me in a lot of respects. And I value their friendship. There are many more of you in the room but I was running out of space on the slide. It takes a village and I just want to thank you all you for the support that you’ve given me over the years. We all have a personal reason for trying to advance pediatric trauma and these are mine: Lili, Bobby, and Thomson. I certainly wouldn’t be here without the support of my husband, Richard. He has been there since I was in the lab in Pittsburgh, and has survived general surgery training, surgical critical care training, pediatric surgery training, and pediatric surgery life. Suffice it to say that I couldn’t have done any of this without his love and support; someone has to get the kids to school in the morning! Enough of the personal; now, I’m going to give a brief and biased history of pediatric trauma. I don’t think that it’s happenstance that we’re sitting in this room today. I think that this is something that was destined to happen, and that there are multiple forces that have coalesced to bring the field of pediatric trauma to where we are today. From antiquity, kids got injured, but since no one lived very long anyway, it didn’t seem to bother anyone very much. In the middle ages, kids got injured, but again, people didn’t live very long and they were worried about eating and staying warm. In the Renaissance, the same issues remained. But by the mid-20th century, we began to look at things a little differently. We recognized that kids get injured, and that was a bad thing. But from a practical perspective, they were essentially treated as little adults. But times were beginning to change. I think the seminal moment for pediatric trauma occurred in the late 1970s, when pediatric surgeons proposed a radical concept for the
From the Department of Surgery, Children’s Hospital of Pittsburgh of UPMC, 4401 Penn Ave, Pittsburgh, PA 15224. This was presented at the 1st Annual Pediatric Trauma Society Meeting, November 14Y15, 2014, in Chicago, Illinois. The author has nothing to disclose. Address for reprints: Barbara A. Gaines, MD, Department of Surgery, Children’s Hospital of Pittsburgh of UPMC, 4401 Penn Ave, Pittsburgh, PA 15224; email: [email protected]. DOI: 10.1097/TA.0000000000000709
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Figure 1. Dr Henri Ford (left) and Dr. John Morris (right).
treatment of splenic injury in children. In 1977, there was a publication in Pediatrics on the non-operative management of six children with splenic injuries.1 Then Dave Wesson, in 1981 in the Journal of Pediatric Surgery, published a case series from The Hospital for Sick Children in Toronto, of their five-year experience of 63 children with splenic injuries initially treated non-operatively.2 Of the 63 patients, 19 of them required a blood transfusion, 18 had some type of operative procedure, 15 of which were splenectomies, and there were 7 deaths, 6 of which were from head injury. The authors concluded ‘‘that we believe that where adequate facilities exist, non-operative treatment of splenic injuries is both safe and effective.’’ This was heresy.
Surgeons could not believe that someone would advocate for not operating on an injured spleen. We were going to let people V children V bleed to death. This was absolutely going against all conventional wisdom, and it took a long time for this concept to become accepted. By 2000 though, the non-operative management of splenic injuries in children was the standard of care. Steve Stylianos, then the Chair of the American Pediatric Surgical Association (APSA) Committee on Trauma, advanced the field of by organizing a study of the outcome of non-operative management of solid organ injuries in children. The initial publication was a study of 856 kids who were treated at 32 centers.3 Guidelines were proposed for the safe and optimal utilization of resources in routine cases. In 2002, the companion paper looked at a prospective application of those guidelines.4 That study reported on 312 children treated at 16 centers, and demonstrated a significant reduction in ICU length of stay, hospital stay, follow-up imaging and length of activity restriction with the application of the ‘‘APSA guidelines’’ without adverse sequelae. This has become the paradigm that we have been working under since the publication of the 2000/2002 papers. And, of course, the advantage of paradigms is that they can shift, and Shawn St. Peter, who has been a leader in evidence based medicine in pediatric surgery, in 2008 challenged V not the concept V but the details. He put forth an abbreviated protocol for the management of blunt spleen and liver injuries.5 So the paradigm has
Figure 2. Top row: Jeffery Upperman, MD; Michael Nance, MD; Richard Falcone, MD, MPH; Randall Burd, MD, PhD; Lynn Haas, MSN. Middle row: George Gittes, MD; Christine McKenna, MSN, CRNP; Michael Hirsch, MD; Mary Fallat, MD; Wayne Meredith, MD. Bottom Row: Andrew Peitzman, MD; Jonathan Groner, MD; Stephen Stylianos, MD; Michael Morant, MD. 1112
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shifted slightly, but nonoperative management of the hemodynamically stable child with a liver or spleen injury is absolutely the norm. We can debate about the details of management. How many days should they stay in the hospital? Should we get hematocrits every six hours or every eight hours? When can they return to play? But we’re not debating whether we should or shouldn’t take that kid to the operating room immediately. We’ve accepted that. We’ve also defined that pediatric trauma is different than adult trauma, because adults don’t behave the same way. About 70% of adults are successfully managed nonoperatively, compared to greater than 90% of liver injuries in children and 95% of splenic injuries. Andrew Peitzman, another one of my mentors, raises a cautionary voice regarding the application of nonoperative management of blunt abdominal trauma in adults, asking ‘‘have we gone too far?’’6 Because, again, adults are injured differently, their response to injury is different, and they have different comorbidities. They are not just big kids. What we really have defined is that children behave differently when they are injured than adults. But Dr. Peitzman’s comment holds true of both populations, ‘‘Isafe nonoperative management requires adherence to the cardinal surgical principles, examination and re-examination of the patient and fastidious clinical judgement.’’ What else was happening in the ’70s and ’80s that set the stage for our meeting today? I think another major force was the development of trauma centers. The American College of Surgeons formed the Committee of Fractures in 1922, and the first edition of the Optimal Resource Guideline was published in 1976. Trauma centers were developed and verified. And then in 2006 V it’s kind of interesting that it took all the way to 2006 V Ellen McKenzie published, in the New England Journal of Medicine, that trauma centers save lives.7 It was hard to get that data. It seemed right, but it was hard to actually get the data and to get it in such a way that we could actually prove the benefit of trauma centers. But that was finally published in 2006. Pediatric trauma centers developed in parallel. But even today, large portions of the population still don’t have access to a pediatric trauma center. If it was hard to prove that trauma centers in general save lives, it’s been even harder to prove the benefits of pediatric trauma centers. But there have been some interesting studies. For example, Notrica et al published in 2012 that there are lower pediatric injury mortality rates in states with higher level pediatric trauma centers.8 So, in parallel with the adult experience, it does seem that where children receive specialized care for their injuries, they do better. What is also interesting is that the trauma center concept has now become a model for pediatric surgery in general. Recently the ‘‘Optimal Resources for Children’s Surgical Care’’ were published.9 These guidelines apply not only to trauma care, but to all surgical care in children. In partnership with the American College of Surgeons, facilities that provide surgical care to children will be verified, in a fashion very similar to the trauma center model. Again, the care of the injured patient has now become a model of care for other types of pediatric surgical issues. So that’s our current state, right? We’ve proven through our experience with the nonoperative management of solid organs that injured children are fundamentally different from
injured adults, and that we need to think about them differently. We just can’t take what we have learned from adults and apply it to children. Children are different. We have had a maturation of pediatric trauma systems, and we have also seen differences in outcome between children treated in pediatric versus adult centers, highlighting, again, that children are different.10,11 I think that these factors set the stage for what I’m going to call a tipping point.12 Because there were a lot of things happening that, taken together, ‘‘tipped’’ pediatric trauma to the point that today we have a society dedicated to pediatric trauma and the care of the injured child. Back in 2006 the Institute of Medicine (IOM) published Emergency Care for Children: Growing Pains.13 This was a companion to two other volumes that in sum formed an in-depth evaluation of emergency care in this country. In regard to pediatric care, the IOM identified a crisis in the emergency care of children, secondary to a general lack of equipment, facilities, and personnel. Widespread publicity of the IOM findings reinforced the concept that children require specialized resources and, that in many areas, that these were lacking. From a patient-care standpoint, we know that traumatic brain injury is the leading cause of death in kids, resulting in more than 3000 deaths in children less than 14 years and millions of concussions.14 But do we really know what are the best therapies? The Pediatric Neurotrauma Guidelines were published initially in 2003 and revised in 2012 (just by comparison, we weren’t too far behind the adults, who published guidelines in 2000).15,16 What I found fascinating about these guidelines is that what they really identified: the overwhelming lack of evidence supporting many of the recommendations. There are no class-one recommendations, but there are lots of consensus opinions. One of the by-products of the guideline process was the development of a research agenda and a call to action to formally study the issues. There will likely never be a randomized trial comparing mannitol vs. placebo. We can’t do that anymore. But there are number of other questions that can and should be studied. When you look at these types of evidence-based reviews, sometimes it’s surprising what we don’t have the evidence to support, but what we do simply because we think it’s right. What else was happening that was pushing pediatric trauma into the forefront? Well, what about mild TBI or concussions? We live in a world where the media is everywhere. These are just some headlines from not so long ago: ‘‘Former Chicago Bears Star Jim McMahon Opens Up About Dementia, Suicidal Thoughts,’’ ‘‘The Latest NFL Concussion Lawsuit Details Are Released,’’ ‘‘Junior Seau diagnosed with disease caused by hits to the head.’’17Y19 In Pittsburgh, our star hockey player, Sydney Crosby, was out for over a year secondary to a concussion, and probably a second concussion as well. Fortunately (for him), he recovered completely, and returned to the ice to win another gold medal for the Canadians in the 2014 Olympics. But concussions don’t only involve star athletes. There was also this case: Zack Lystedt was a talented youth athlete in Washington State. He was tackled twice in an 8th-grade football game and, after the second hit, collapsed on the field. He suffered from Second Impact Syndrome, a severe traumatic brain injury, and was treated at Harborview in Seattle. His recovery was lengthy and incomplete, and his family spearheaded the formation of a coalition to increase awareness regarding the
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potential devastating consequences of concussions. The coalition included the Seattle Sea Hawks, among many others, and the first concussion law was enacted in Washington State, effective in July 2009. With the strong support of the National Football League, all 50 states now have youth concussion legislation. While most of these are unfunded mandates, and there is very little data regarding whether the legislation actually reduces traumatic brain injuries in young athletes, these legislative initiatives have suddenly made this particular pediatric injury front-page news, and a significant concern of parents of school aged children. There are other headlines that impact us as pediatric traumatologists. NPR: ‘‘How CT Scans Have Raised Kids’ Risk for Future Cancer.’’20 USA Today: ‘‘Kids’ CT Scans Raise Fear of Cancer Risk As Use Soars.’’21 Maybe a little bit less popular press, but the popular scientific press, Scientific American: ‘‘How Much do CT Scans Increase the Risk of Cancer?’’22 The concern about cancer risk from diagnostic radiation and the pediatric population is all over the public domain. CT scans are responsible for a disproportionate amount of medical radiation exposure in children, accounting for 15% of procedures and 75% of the radiation dose.23 In addition, the number of scans performed on children has increased dramatically. It is estimated that 11% of all CT scans are performed on kids V that’s about 7 million scans a year. CTs can be performed over a wide range of techniques and with variable radiation exposure, increasing the complexity of the issue. Back in 2007 or 2008, the Pennsylvania Trauma Systems Foundation Pediatric Committee V of which I was Chair at the time V came up with an statement about imaging. We recommended: avoid protocolized scanning, utilize dose minimization strategies, defer imaging a child if they’re going to be transferred, and also reminding pediatric trauma centers not to re-scan unless absolutely necessary. The reason we came up with this, again, was that it was an issue. It was an issue that at the time was unique to kids, and one that affected kids in the trauma community. But there was certainly external pressure from the general public as well. The controversy regarding pediatric imaging is another area in which there is a clear distinction between the pediatric and adult trauma communities. The NIH has also become interested in pediatric trauma as an independent field. There now is a Pediatric Trauma and Critical Injury branch of The Eunice Kennedy Shriver Institute, which was formed in 2013. The branch mission is to ‘‘support research and research training in pediatric trauma, injury, and critical illness throughout the continuum of care.’’24 Some of the activities of the branch include a request for funding for the development of a Consortium for Research on Pediatric Trauma and Injury via an R-24 mechanism, as well as support of the Collaborative Pediatric Critical Care Research Network (CPCCRN) and a KY12 clinical-scientist training program. At the American College of Surgeons, the Trauma Quality Improvement Program (TQIP), a risk-adjusted benchmarking program, was developed. The need for a pediatric product was quickly apparent, and under the leadership of Mike Nance, Pediatric TQIP went live in January of 2014. In the report that was released in early November 2014, 25 Level I, six Level II, and six unknown level centers contributed data. For the next round, it is estimated 40 more sites will participate. So 1114
again, there is tremendous interest in looking at improving the outcomes of pediatric trauma, in this case through benchmarking. Then there has been the pediatric involvement in traditionally adult trauma organizations. I’ll talk little bit more about this later in the talk, but the Eastern Association for the Surgery of Trauma (EAST) formed an Ad-hoc Pediatric Committee around 2010. There have been multiple sunrise sessions on pediatric topics and a collaborative agreement with the Pediatric Trauma Society. The American Association for the Surgery of Trauma (AAST) also formed a Pediatric Committee, which has sponsored lunch sessions, pre-conference sessions, and web-based grand rounds. The Society of Trauma Nurses (STN) has a pediatric special interest group, and has developed a pediatric version of their popular trauma process improvement course (TOPIC). Again, all of these organizations, where the major focus and most of the membership are those who primarily identify themselves as adult practitioners, have begun to have an increasing interest in the injured pediatric patient. Within the pediatric surgical community, both the president-elect of American Pediatric Surgical Association (Mary Fallat) and the president of the American Pediatric Surgical Nurses Association (Chris McKenna) are well known pediatric trauma leaders. Finally, injury prevention has always been an area of strength within in the pediatric trauma community. I do want to highlight the work of the Injury-Free Coalition for Kids, which was founded by Barbara Barlow, a pediatric surgeon in Harlem. Dr. Barlow developed a model in which trauma center data is used to identify the injuries of particular importance to the local community. This information is then taken back to the community and a coalition of community partners, including the trauma center, develop an intervention and, importantly, evaluate the effectiveness of that intervention. Injury Free, initially supported by the Robert Wood Johnson Foundation, now has 42 sites in trauma centers throughout the US and Canada, and the model underscores the important relationship between the local trauma center and the community that it serves. So that brings me to us, the Pediatric Trauma Society. I thought it would be worth reminding everyone of our mission: improving pediatric trauma outcomes, and our vision: to become a global leader in the field of pediatric trauma through optimal care guidelines, education, research, and advocacy. I think if you look at the program for this conference, we have stayed pretty true to that vision. We also strive to be an inclusive, multi-disciplinary organization, open to all those dedicated to the care of injured children. The history of PTS is brief. We had the inaugural meeting in Naples, Florida in 2011, under the auspices of EAST. The leadership of EAST has been very supportive of us, ‘‘incubating’’ the Society until we felt that we were ready to become independent. Fortunately EAST and STN also have close relationship, and that allowed for strong input from both trauma surgery and trauma nursing from the earliest in conception of PTS. The organization was officially incorporated in 2012. Our current membership is 663, with 306 physicians, 305 RNs and program managers, and 51 EMS professionals. We have members from 47 states, DC, and eight countries. Dave Mooney was the first president of the organization and Lynn Haas succeeded him. * 2015 Wolters Kluwer Health, Inc. All rights reserved.
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What have we done? Well, I think one of our really spectacular accomplishments was partnering with the Childress Institute to sponsor the Childress Summit of the Pediatric Trauma Society. This event was held April 22Y24, 2013 at the Graylyn International Conference Center in Winston-Salem, North Carolina, and hosted by Wayne Meredith. The summit goals were to define the current state of pediatric trauma and develop an ideal future state. The summit format was one of facilitated discussion, with invited participants assigned to one of four teams: trauma systems, traumatic brain injury, prehospital/emergency care, and critical care. Stakeholders from across the spectrum of pediatric injury participated. There were experts in trauma systems, emergency medicine, critical care, neurosurgery, rehabilitation, EMS, prevention, as well as government agencies including the NIH, NHTSA (National Highway Transportation Safety Administration), and EMSC (Emergency Medical Services for Children). Participants also spanned the professional spectrum, including nurses, physicians, PhDs, and social workers. It was a comprehensive group of experts who came together to talk about pediatric trauma, and to ultimately define pediatric trauma as an independent field of study and medical practice. The major, tangible deliverable was the publication of the proceedings in the Journal of Trauma and Acute Care Surgery.25 In addition, the Childress Institute announced funding for a pediatric trauma-related research grant. The recipient of that award was Fred Rivara and his team for the development of the pediatric trauma assessment and management database, and they will be reporting on their progress later in the meeting. The Childress Institute continues to be a major supporter of PTS and this meeting. Other activities of the Society include our continued partnership with EAST and their Pediatric Trauma Committee. We also have a number of important committees, including Research, Guidelines, Education, Membership, and new this year, IT. I hope that those who are interested in becoming more involved will let us know. Our electronic newsletter is published quarterly to keep the membership informed of our activities. We are very proud of the fact that the Journal of Trauma, the official publication vehicle of the major trauma organizations including AAST, EAST, Western Trauma, Trauma Association of Canada, Australian and New Zealand Association for the Surgery of Trauma, has now included the Pediatric Trauma Society in the group. As of the November 2014 issue, PTS is listed on the cover, along with the rest of the ‘‘official’’societies! The proceedings from this meeting will be published in the early summer, after formal peer review. I want to thank Jennifer Crebs, the managing editor, and Gene Moore, the editor-inchief, for making this relationship a reality. It is a major step in legitimizing the Pediatric Trauma Society within the overall trauma community. In addition, we now have received official recognition by the American College of Surgeons Committee of Trauma. Those of you who are in trauma centers know that the Trauma Medical Director at Level I and Level II centers must be a member of regional and national trauma organizations. The Pediatric Trauma Society is now officially recognized as an organization that fulfills this requirement. Again, this is an important step in validating our importance within the trauma community.
And that brings us to today. This is our first annual meeting. There are 256 registrants, representing 35 states, and eight countries. It is a truly international meeting. We have 50 podium presentations, 14 poster presentations, several panel discussions, invited speakers, networking, and even wine. It has been an incredibly informative and fun meeting. I will say that with success come increased expectations. Planning for the second annual meeting starts today V well maybe tomorrow V but in any event, we need to start thinking about how to make it even better. I know that this room has been a little cozy; that’s because more of you are here than we initially anticipated. Next year’s venue will be bigger, but then you had better come back! We know that yesterday was a very busy day and we have some ideas of how to make it a little bit less intense. We know that there wasn’t a huge amount of time for networking among colleagues, and so we’re going to try to build that into the next meeting. We all need to continue to spread the word about PTS and our mission, and to reach out to our colleagues in emergency medicine, critical care, orthopedics, neurosurgery, anesthesia, et cetera, to fulfill the goal of a truly multidisciplinary organization focused on the continuum of care of the injured child. Finally, we need to harness the energy of this meeting to continue our efforts to improve the outcome of injured children. And with that, I want to thank all of you for making PTS a reality. I think five years ago we would be hard pressed to imagine that this meeting was really going to happen. But it was an idea that was the right one at the right time, and now, with your help we have become a reality. Please give yourselves a round of applause! REFERENCES 1. Aronson DZ, Scherz AW, Einhorn AH, Becker JM, Schneider DM. Nonoperative management of splenic trauma in children: a report of six consecutive cases. Pediatrics. 1977;60(4):482Y485. 2. Wesson DE, Filler Rm, Ein Sh, Shandling B, Simpson JS, Stephens CA. Ruptured spleenVwhen to operate? J Pediatr Surg. 1981;16(3):324Y326. 3. Stylianos S. Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. The APSA Trauma Committee. J Pediatr Surg. 2000;35(2):164Y167. 4. Stylianos S. Compliance with evidence-based guidelines in children with isolated spleen or liver injury: a prospective study. J Pediatr Surg. 2002; 37(3):453Y456. 5. St Peter SD, Keckler SJ, Spilde TL, Holcomb GW 3rd, Ostlie DJ. Justification for an abbreviated protocol in the management of blunt spleen and liver injury in children. J Pediatr Surg. 2008;43(1):191Y193. 6. Peitzman AB, Ferrada P, Puyana JC. Nonoperative management of blunt abdominal trauma: have we gone too far? Surg Infect (Larchmt). 2009; 10(5):427Y433. 7. MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, Salkever DS, Scharfstein DO. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354(4):366Y378. 8. Notrica DM, Weiss J, Garcia-Filion P, Kuroiwa E, Clarke D, Harte M, Hill J, Moffat S. Pediatric trauma centers: correlation of ACS-verified trauma centers with CDC statewide pediatric mortality rates. J Trauma Acute Care Surg. 2012;73(3):566Y570. 9. Oldham KT. Optimal resources for children’s surgical care. J Pediatr Surg. 2014;49(5):667Y677. 10. Potoka DA, Schall LC, Gardner MJ, Stafford PW, Peitzman AB, Ford HR. Impact of pediatric trauma centers on mortality in a statewide system. J Trauma. 2000;49(2):237Y245. 11. Farrell LS, Hannan EL, Cooper A. Severity of injury and mortality associated with pediatric blunt injuries: hospitals with pediatric intensive care units versus other hospitals. Pediatr Crit Care Med. 2004;5(1):5Y9.
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12. Gladwell M. The Tipping Point, Little, Brown, and Company; 2000. 13. Institute of Medicine. Emergency care for children: growing pains. Washington DC: The National Academies Press; 2007. 14. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. ‘‘Fatal Injury Data.’’ http://www.CDC.gov/ injury/wisqars/fatal.html. Page updated: February 17, 2015. Accessed April 14, 2015. 15. Adelson PD, Bratton SL, Carney NA, Chesnut RM, du Coudray HE, Goldstein B, Kochanek PM, Miller HC, Partington MD, Selden NR, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children and adolescents. Pediatr Crit Care Med. 2003; 4(3):S1YS75. 16. Kochanek PM, Carney N, Adelson PD, Ashwal S, Bell MJ, Bratton S, Carson S, Chesnut RM, Ghajar J, Goldstein B, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescentsVsecond edition. Pediatr Crit Care Med. 2012; 13(Suppl 1):S1YS82. 17. Seligman A. Former Chicago Bears star Jim McMahon opens up about dementia, suicidal thoughts. http://www.huffingtonpost.com/2014/06/17/ jim-mcmahon-dementia-suicidal-thoughts_n_5505041.html. Associated Press. Published: June 17, 2014. Accessed: April 21, 2015. 18. Hagan BA. Latest NFL concussion lawsuit details are released. http:// www.24-7pressrelease.com/press-release/latest-nfl-concussion-lawsuitdetails-are-released-389103.php. Published: July 2, 2013. Accessed: April 21, 2015. 19. Avila J, Pearle L, Goldman R. Junior Seau diagnosed with disease caused by hits to head: ABC News Exclusive. http://abcnews.go.com/US/junior-
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seau-diagnosed-brain-disease-caused-hits-head/story?id=18171785. ABC News. Published: January 10, 2013. Accessed: April 21, 2015. Shute N. How CT scans have raised kids’ risk for future cancer. http:// www.npr.org/blogs/health/2013/06/10/190449001/how-ct-scans-have-raisedkids-risk-for-future-cancer. NPR. Published: June 11, 2013. Accessed: April 21, 2015. Wilemon T. Kids’ CT scans raise fears of cancer risk as use soars. http:// usatoday30.usatoday.com/news/health/medical. USA Today. Published: December 12, 2011. Accessed: April 21, 2015. Storrs C. How much do CT scans increase the risk of cancer? http:// www.scientificamerican.com/article/how-much-ct-scans-increase-riskcancer. Scientific American. Published: June 18, 2013. Accessed: April 21, 2015. Brody AS, Frush DP, Huda W, Brent RL. American Academy of Pediatrics Section on Radiology. Radiation risk to children from computed tomography. Pediatrics. 2007;120(3):677Y682. National Institute of Child Health and Human Development. Pediatric Trauma and Critical Illness Branch (PTCIB). http://www.nichd.nih.gov/ about/org/der/branches/ptcib. Page updated: March 30, 2015. Accessed: April 21, 2015. Gaines BA, Hansen K, Mckenna C, McMahon M, Meredith JW, Mooney DP, Snow SK, Upperman JS. Childress Summit of the Pediatric Trauma Society Work Groups. Report from the Childress Summit of the Pediatric Trauma Society, April 22Y24, 2013. J Trauma Acute Care Surg. 2014; 77(3):504Y509.
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