Pediatric trauma challenges for a rural state

1. L R Tres Scherer, III, MD, FACS
St Luke’s Children’s Hospital
Indiana University School of Medicine

3.  Rural: everything that is not urban (HRSA)
 What is Urban?
 Populations > 50,000 and/or surrounding
clusters >10,000
 Census blocks
 >1000/400 km2, and clusters >500/400 km2

9. State Area (km2) width (km) Length (km)
Highest elev
(m)
Lowest elev
(m)
Mean elev
(m) % water
Idaho 216,632 491 771 3860 217 1520 1
Indiana 94,321 225 435 383 97 210 1.5
Kentucky 104,660 225 610 1260 78 230 1.7
Oregon 255,000 580 640 3429 0 580 2.4
Utah 219,900 435 565 4120 1000 1860 3.3
Washington 184,800 400 580 4392 0 520 6.6

15. State Population Density/km2
Interstate
Hwy Total Km Km/Density Counties
Idaho 1,600,000 7.4 3 980 132.4 44
Indiana 6,500,000 70.2 8 2076 29.5 92
Kentucky 4,380,400 42.5 5 1147 27 120
Oregon 3,899,300 15 2 1174 78.3 36
Utah 2,855,300 13.2 4 1528 115.7 29
Washington 6,897,000 39.6 3 1230 31.1 39

26.  EMS
 Fire
 Search and Rescue
 Forest Service
 Bureau of Land Management
 Aeromedical

28. State Year Regions
Trauma
Ctrs Level I Level II Level III Level IV Level V Peds I Peds II
Oregon 1987 7 46 2 4 13 25 2
Washington 1990 8 89 1 4 26 33 16 1 2
Utah 2000 0 19 2 3 3 9 1 1
Indiana 200810? 8 2 4 0 0 0 1 3
Kentucky 2009 0 10 2 0 2 4 2
Idaho 2014? ? 3 3

29. State Year Registry Hospitals Deaths/Reg Deaths/VS
Oregon 1987 yes 46 558 2700
Washington 1990 yes 89 700 2663
Utah 2000 yes 19 209 1050
Indiana 2008 yes 43 820 2690
Kentucky 2009 yes 16 365 2264
Idaho 2014? yes(12) 33 (peds) 55 (peds) 224

49. Esposito, TJ, et al. J Trauma 39:955-62, 1995
 Retrospective panel review of 324 deaths
attributable to mechanical trauma in the
state of Montana
 Preventable deaths - 13%
 Preventable hospital deaths - 27%
 Pre-hospital deaths - extended response
time 40%; scene time greater than 20
minutes 23%
 Inappropriate care in ER - 68%
 (Inappropriate airway management,
failure to diagnose and treat chest
injuries, inadequate volume
resuscitation, delays to OR)
 In appropriate care post-ER 49%
Esposito TJ, et al. Am Assoc Surg Trauma, Sept 2002
 Retrospective panel review of 347 blunt
trauma deaths in Montana; comparison to pre-
system study
 Preventable deaths - 13% to 8% (p < 0.02)
 Preventable hospital deaths - 27% to 16%
 Inappropriate pre-hospital care - 37% to 22%
 Inappropriate care in ER - 68% to 40%
 (Inappropriate airway management, failure to
diagnose and treat chest injuries, inadequate
volume resuscitation, delays to OR)
 Inappropriate care post-ER 49% to 29%

51. UTAH TRAUMA FACILITY STANDARDS
LEVEL I
• Acts as a regional tertiary care facility
in the trauma system.
• Provides definitive, and
comprehensive care for the injured
adult and/or pediatric patient with
complex, multi-system trauma.
• Provides leadership in professional
and community education, trauma
prevention, research, rehabilitation and
system planning.
• Board certified surgeons,
neurosurgeons and anesthesiologists
are on-call and promptly available.
• A broad range of sub-specialists
(cardiac surgery, hand surgery,
microvascular (replantation), infectious
disease) are on-call and promptly
available to provide consultation or care
to the patient.
• ICU physician coverage 24 hours/day,
full time Trauma Coordinator, OR suites
staffed in-house 24 hours/day,
cardiopulmonary bypass.
• Level I Regional Pediatric Trauma Centers
have separate standards specific to the care of
pediatric Trauma patients.
LEVEL II
• Provides definitive care for complex
and severely injured pediatric and
adult trauma patients.
• Physicians are ATLS trained and
experienced in caring for trauma
patients. Nurses and ancillary staff
are in-house and immediately
available to initiate resuscitative
measures and stabilization for the
trauma patient.
• Board certified surgeons,
neurosurgeons and anesthesiologists
are on-call and promptly available.
• A broad range of sub-specialists
(critical care, cardiology, orthopedic
surgery) are on-call and promptly
available to provide consultation or
care to the patient.
• Serves as a regional resource center
for definitive care, quality assurance,
community education, outreach and
injury prevention.
•Level II Pediatric Trauma Centers have
separate standards specific to the care of
pediatric Trauma patients.

52. UTAH TRAUMA FACILITY STANDARDS
LEVEL III
• Provides initial resuscitation and
immediate operative intervention to
control hemorrhage and to assure
maximal stabilization prior to referral to
a higher level of care.
• Comprehensive medical and surgical
inpatient services are available to those
patients who can be maintained in a
stable or improving condition without
specialized care.
• Works collaboratively with other
trauma centers to develop transfer
protocols and a well defined transfer
sequence.
• An in-house multi-disciplinary trauma
resuscitation team is available to assess,
resuscitate, stabilize and initiate
transfer if necessary upon arrival of the
patient to the emergency department.
• A board certified general surgeon
trained in ATLS is on-call and available
to the patient.
• Level III trauma centers work with
Level I and II facilities to develop and
implement outreach programs for Level
IV and V facilities in their region.
• Provides community education,
outreach and injury prevention
LEVEL IV
• Generally licensed, small rural facility with a commitment to the
resuscitation of the trauma patient.
•Provides initial resuscitation, evaluation, stabilization, diagnostic
capabilities and written transfer protocols in place for major
trauma patients to be transferred to a higher level of care.
•Staffed with a physician on call from outside the hospital and also
requires a general surgeon to be on call outside of the hospital.
•May provide immediate operative surgical intervention to control
hemorrhage to assure maximum stabilization prior to transfer.
•Trauma trained nursing personnel are immediately available to
initiate life-saving maneuvers and critical care services as defined
in the service’s scope of trauma care.
LEVEL V
•Provides initial evaluation, stabilization and transfer to a higher
level of care.
•Generally licensed, small rural facilities with a commitment to the
resuscitation of the trauma patient.
•May or may not be staffed with a trauma-trained physicians but
rather a physicians assistant, or nurse practitioner.
•Major trauma patients are resuscitated and transferred.

53. TRAUMA ONE ACTIVATION CRITERIA
Physiologic:
 Glasgow Coma score < 12,
 Systolic Blood Pressure < 90 mmHg at any time,
 Respiratory Rate < 8 or > 30,
 Revised Trauma Score < 11,
 Intubated or question of airway security,
 Transferred from outside facility receiving blood products.
Anatomic:
 All penetrating injuries to the head, chest, abdomen (including
back), or extremities
 proximal to the elbow or knee,
 Amputation or de-gloving injury proximal to the ankle or wrist,
 Flail chest,
 Suspected spinal cord injury with paralysis,
 Open or depressed skull fracture,
 Combination of trauma with burns,
 Significant burns (i.e. significant 3rd degree burns, >10% 2nd
degree burns TBSA for any age, inhalation burns, etc.)
Clinical:
 Discretion of ED physician and/or RN.
TRAUMA TWO ACTIVATION CRITERIA
Physiologic:
 Patient age < 5 or > 65 with significant physical impact,
 - Pregnancy of 3 months or greater.
Anatomic:
 Two or more long bone fractures,
 Significant maxillofacial trauma without evidence of airway
compromise,
 Crush injury proximal to ankle or wrist,
 Trauma with burns,
 Pelvic fracture (excluding isolated unilateral pubic rami
fracture),
 Cervical, thoracic or lumbo-sacral spine fracture without CNS
involvement,
 Major laceration of torso involving fascia,
 Subcutaneous emphysema,
 Significant burns not meeting Trauma 1 criteria
Mechanism of Injury:
 Fall > 20 feet
 Pedestrian struck by a vehicle moving > 20mph
 MVA with rollover/ejection
 Extrication time > 20 minutes
 Death in same passenger compartment

55. Pre-transp
location Transport # patients ISS GCS RTS # ICU pts ICU hrs
Transfer Amb 2140 7.26 14.9 7.72 163 26
Transfer Fixed 455 13.4 12.5 6.73 204 66.1
Transfer Heli 1019 14.9 11.9 6.5 580 59.2
Field Amb 774 7.44 14.5 7.6 118 52.8
Field Heli 564 12.42 12.8 6.82 183 101.2
Field POV 1334 7.29 14.9 7.68 97 31.7

56. Pre-transp
location Transport home (%) rehab (%) transfers (%) deaths (%)
Transfer Amb 1854 (99.9) 0 0 1 (.1)
Transfer Fixed 408 (89.7) 19 (4.2) 3 (.1) 15 (3.3)
Transfer Heli 896 (88) 39 (3.8) 4 (.4) 58 (5.7)
Field Amb 674 (87.1) 5 (.5) 4 (.5) 8 (1)
Field Heli 466 (82.6) 18 (3.2) 5 (.1) 27 (4.8)
Field POV 1334 (100) 0 0 0

57.  Unintentional injuries
 964 admissions
 17 hospital deaths
 96 deaths reported to the Health department

58.  Trauma systems improve access to care
 Pre-hospital
 Trauma center designation
 Improved medical care
 Decrease mortality rate
 Mortality rate higher for children in rural areas
 More children die outside the hospital

59.  Trauma systems must continue:
 Maturing
 Inclusive
 Evaluate access to care
 Evaluate out of hospital deaths