Pediatric trauma and the Pediatric Trauma Society

Thank 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) — 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.Figure 1: Dr Henri Ford (left) and Dr. John Morris (right).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.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.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 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 — children — 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 — not the concept — but the details. He put forth an abbreviated protocol for the management of blunt spleen and liver injuries.5 So the paradigm has 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, “...safe 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 — it’s kind of interesting that it took all the way to 2006 — 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.”17–19 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 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 this pediatric injury and a significant of of school children. There are other headlines that us as pediatric for of a little less but the do the of The about from and the pediatric population is all over the are for a of in children, for of and of the In the number of on children has It is that of all are on kids — that’s about 7 a can be over a of and with the of the Back in or the Trauma Pediatric Committee — of which I was Chair at the time — up with an about We imaging a child going to be and also pediatric trauma centers not to absolutely The reason we up with again, was that it was an It was an that at the time was to kids, and one that kids in the trauma But there was certainly from the general as well. The regarding pediatric imaging is another in which there is a between the pediatric and adult trauma The has also become in pediatric trauma as an field. There now is a Pediatric Trauma and of The which was formed in The is to research and research training in pediatric trauma, injury, and critical the of of the of the a for for the development of a for on Pediatric Trauma and an as as support of the Pediatric Care and a training the American College of Surgeons, the Trauma a was The need for a pediatric was and under the of Nance, Pediatric live in of In the that was in early six and six level centers data. For the it is more will So again, there is tremendous interest in at the of pediatric trauma, in this case through Then there has been the pediatric in adult trauma little more about this in the talk, but the Association for the of Trauma formed an Pediatric Committee There have been multiple on pediatric and a with the Pediatric Trauma Society. The American Association for the of Trauma also formed a Pediatric which has and The of Trauma has a pediatric interest and has developed a pediatric of their trauma process Again, all of these where the major and most of the are those who as adult have to have an interest in the injured pediatric the pediatric surgical both the of American Pediatric Surgical Association and the of the American Pediatric Surgical Association are pediatric trauma injury has been an of in the pediatric trauma I do want to the of the for which was by a pediatric surgeon in Dr. developed a model in which trauma center data is to the injuries of to the This is then taken back to the and a coalition of the trauma an and, the of that initially supported by the now has in trauma centers the and and the model the between the trauma center and the that it So that me to the Pediatric Trauma Society. I it would be of our pediatric trauma and our to become a leader in the field of pediatric trauma through optimal care and I think you look at the for this we have stayed true to that We also to be an to all those dedicated to the care of injured children. The history of is We had the meeting in in under the of The of has been very of the we that we were to become Fortunately and also have and that for strong from both trauma surgery and trauma from the in of The was in current is with and and We have from and eight Dave was the first of the and Lynn him. What have we Well, I think one of our really was with the Institute to the of the Pediatric Trauma Society. This was at the in and by Wayne The were to the current of pediatric trauma and an The was one of with to one of trauma systems, traumatic brain injury, care, and critical care. from the of pediatric injury There were in trauma systems, emergency critical care, as as the and for also the professional and It was a of who to about pediatric trauma, and to pediatric trauma as an field of study and The was the publication of the in the Journal of Trauma and Care In the Institute for a pediatric research The of that was and his for the development of the pediatric trauma and management and they will be on their in the The Institute to be a major of and this of the our continued partnership with and their Pediatric Trauma We also have a number of and this I that those who are in more will let us is published to the of our We are very of the that the Journal of Trauma, the publication of the major trauma Trauma, Trauma Association of and New Association for the of Trauma, has now included the Pediatric Trauma in the of the 2014 is on the with the of the The from this meeting will be published in the early after I want to thank the and the for making this a It is a major in the Pediatric Trauma the trauma In we now have received by the American College of Surgeons Committee of of you who are in trauma centers know that the Trauma at I and centers be a of and trauma The Pediatric Trauma is now recognized as an that this Again, this is an in our the trauma And that us to today. This is our first There are and eight It is a We have 50 14 and even It has been an and I will say that with for the second meeting today — — but in any we need to start about to it even better. I know that this room has been a little that’s because more of you are here than we initially will be but then you had We know that was a very and we have some of to it a little less We know that there a of time for among and so we’re going to to that into the We all need to to the about and our and to out to our colleagues in emergency critical care, et to the of a on the of care of the injured child. we need to the of this meeting to our to the outcome of injured children. And with that, I want to thank all of you for making a I think years we would be hard to that this meeting was really going to But it was an that was the one at the and now, with we have become a give a of

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