UMEM Educational Pearls - By Jenny Guyther

Burns are common pediatric injuries and usually represent preventable unintentional trauma.
Approximately 10% of children hospitalized with burns are victims of abuse. Thermal burns are the most common type of burn and can result from scalding injuries or contact with objects (irons, radiators, or cigarettes). Features of scald burns that are concerning for inflicted trauma include clear lines of demarcation, uniformity of burn depth and characteristic pattern. Abusive contact burns tend to have distinct margins (branding of the hot object), while accidental contact burns tend to have less distinctive edges
How Kids are Different than Adults: 
- Kids have thinner skin, so time to burn/energy required to cause a burn is less. 
- Kids have increased blood volume relative to their mass, so may need more volume resuscitation compared to adults. 
- Kids are more likely to become hypoglycemic so give glucose in mIVF in kids <20 kgs.
- Risk of airway compromise in kids following inhalation injury is higher due to their smaller airway openings 
Treatment:
- Initial treatment should follow ABCs of resuscitation
- Airway: Airway management should include assessment for presence of airway or inhalation injury, with early intubation if such an injury is suspected. Smoke inhalation may be associated with carbon monoxide toxicity; 100% humidified oxygen should be given if hypoxia or inhalation is suspected.
- Circulation: Parkland's formula
     - Fluid requirements = TBSA burned (%) x weight (kg) x4mL
     - Give ½ of total requirements in 1st 8 hours, then give 2nd half over the next 16 hours. 
     - REMEMBER KIDS HAVE BIG HEADS
          - Rule of 9's for adults: 9% for each arm, 18% for each leg, 9% for head, 18% for front torso, 18% for back torso
          - Rule of 9's for children" 9% for each arm, 14% for each leg, 18% for head, 18% for front torso, 18% for back torso. 
Options for pain management
- fentanyl IN
- morphine IV
- ketamine IV
 Burns you should consider admission
- >6% TBSA
- full thickness burns
- specialty areas: face, eyes, airway, genitalia, palmar crease, sole of foot
- concern for non-accidental injury
- caused by treadmill

 

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Category: EMS

Title: What are risk factors in ambulance crashes?

Keywords: ambulance, crash, response, fatality, collision (PubMed Search)

Posted: 6/22/2023 by Jenny Guyther, MD
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Between 2010 and 2020, there were 279 fatalities related to ambulance accidents.  In up to 50% of accidents, EMS is not at fault.  The use of lights and sirens and intersections have been previously shown to be the most common risk factor for accidents.  There is a national push for a more judicious use of lights and sirens.  
Most ambulance crashes are minor, but up to 1/3 of crashes can result in significant injury or significant damage to the vehicle.  This study attempted to relate driver demographics and aggressive driving behavior to ambulance crashes using a vehicle telematics system.  The agency in this study responded to about 130,000 calls per year and the incident rate of any crash was 2.1/100,000 miles and the incident rate of a serious crash was 0.63/100,000 miles.  Injuries occured in 8% of the 214 crashes over the 3 year study period.  One third of the cases resulted in significant vehicle damage.  Female sex and age 18-24 were found to be independently associated with a collision.
Bottom line: Transporting patients via ambulance, especially when lights and sirens are used, is not a risk free event.  Even if injuries do not occur, the impact of damage to the vehicle can significantly impact the EMS system.

 

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Category: Pediatrics

Title: Omphalitis

Keywords: neonatal fever, cellulitis, bacteremia (PubMed Search)

Posted: 6/16/2023 by Jenny Guyther, MD (Updated: 4/24/2024)
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Omphalitis is a soft tissue infection involving the umbilicus and surrounding tissues with redness and induration around the umbilical stump.  Risk factors include: prematurity, prolonged rupture of membranes, maternal infection, low birth weight, history of umbilical catheter and home birth.  Pathogens include Staph, Strep and Gram Negative bacteria.  Studies have shown that bacteremia can be present in up to 13% of cases.
Omphalitis most often occurs in infants 8-22 days.  If fever is present, the AAP guidelines for neonatal fever should be followed.  In the well appearing, afebrile infant, blood cultures should be obtained, but CSF studies are not reflexively indicated.  Since urachal anomalies can be present in up to 1/4 of these patients, urine studies should be obtained and an ultrasound can be considered if drainage is present.  A surface culture should be obtained when possible as well.

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This study looked at "low risk" patients who were being transferred from a community hospital to the system quaternary referral center.  Patients were selected by the referral center as low risk (closed fracture requiring reduction, eye problems, minor burns, laceration, ect) for transport by personnel vehicle (POV) regardless of IV status.  The families were then approached for consent.
Patients had to be between 4-17 years, without social concerns, unreliable transportation or communication differences.  
78 patients were eligible with 67 patients electing transport by POV.  All patients arrived safely.  29 patients had IVs in place.  Procedures were in place by the sending facility to secure the IV, educate the parents about IV care and supplies in case of dislodgement were given.  The drive was about 40 minutes.  All IVs were functional on arrival at the referral center and there were no noted complications.
Surveys were given to the patients' families and the results were overall positive.  The one negative point of feedback involved traffic and navigational difficulties.
 
Bottom line: In the appropriately selected patient, safe interfacility transport via POV is possible, even when an IV is in place.

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Category: Misc

Title: What do caregivers think of alternate EMS dispositions for pediatric patients?

Keywords: EMS, Alternate destinations, pediatric, EMS, reduce transport times (PubMed Search)

Posted: 5/17/2023 by Jenny Guyther, MD (Updated: 4/24/2024)
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Pediatric patients represent up to 10% of EMS transports, but studies suggest that between 10-60% of these patients can be safely transported by alternate means.  Many EMS agencies have begun to implement alternate destination programs for adult patients - including transport to an urgent care center, using a taxi service instead of an ambulance, or utilizing telehealth services.  One of the first steps in being able to expand these program into the pediatric population involves determining the caregivers perspectives on the concept of not being taken directly to an emergency department when 911 is called.
 
This study conducted focus groups in English and Spanish which included a total of 38 participants in the Washington DC area.  Key take away points include:
1) The reasons for calling 911 for a non emergent reason were multifactorial and included lack of transportation, lack of health insurance, uncertainty about the severity of the patient's complaint and difficulty with after hours primary care access.
2) Most participants were not familiar with alternate EMS disposition programs.
3) Most caregivers preferred telemedicine over telecommunication.
4) Caregivers worried that there would be a delay in care if their child had a genuine medical emergency or decompensation.  They were also concerned that there would not be pediatric resources and expertise at the alternate destination requiring a second transport.  Also, there were concerns about the coordination between 911, clinics and EMS.  Concerns about transportation included vehicle cleanliness and hygiene and provision of appropriate car seats.
 
Bottom line: Alternate destination for EMS is possible with pediatric patients, but the programs need to take into consideration the above parental concerns in order to be successful. 

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Category: Pediatrics

Title: Ketamine vs opiates for pediatric pain management

Keywords: Ketamine, morphine, fentanyl, pediatrics, EMS, pain control (PubMed Search)

Posted: 4/21/2023 by Jenny Guyther, MD (Updated: 4/24/2024)
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Multiple modalities are available for pain control in the pediatric setting.  Ketamine has recently been introduced into the prehospital environment as an alternative to opiates (fentanyl and morphine).  This study examines how ketamine and opiates compare in relation to pain reduction and adverse events.
9223 patients (< 18 years) were included with data from the ESO Collaborative. 190 patients received ketamine (2.1%) and 9033 received opiates (97.9%).  Ketamine was associated with a greater reduction in pain score (-4.4 vs -3.1) compared to opiates and a greater reduction in EMS clinician reported improvement.  Patients in the ketamine group did have a reduction in the GCS by -0.3 points.  There were no patients who required ventilatory support in the ketamine group and one patient who required support in the opiate group. No patients in either group required intubation or died.  This study did not examine medication doses or route.
Bottom line: Both ketamine and opiates are viable pain control options for pediatric patients in the prehospital environment.

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Category: Pediatrics

Title: Is croup caused by COVID more severe compared to other etiologies?

Keywords: Croup, respiratory distress, stridor, URI (PubMed Search)

Posted: 3/17/2023 by Jenny Guyther, MD (Updated: 4/24/2024)
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Patients with croup often present with a "barky" cough, stridor, and trouble breathing, traditionally worse at night.  The mainstay of treatment is a dose of dexamethasone and if there is moderate to severe distress, racemic epinephrine is added.  Croup has typically been caused by viruses, mainly parainfluenza, but influenza, non-COVID coronavirus, adenovirus and RSV have also been shown to cause croup.  
When COVID variant Omicron BA.1 became the dominant strain, the rate of pediatric emergency department visits and hospitalizations due to croup were noted to increase.  This retrospective study of 499 pediatric patients showed that those who tested positive for COVID within one week of presentation had a significantly higher degree of stridor at rest, hypoxia, the need for additional doses of racemic epinephrine, admission to the floor, admission to the intensive care unit and increasing respiratory support.  
Bottom line: Consider testing for COVID in your croup patient who is not responding to traditional therapies.

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Category: Pediatrics

Title: Does purulent eye discharge need to be treated topically in pediatrics?

Keywords: conjunctivitis, pink eye, eye drops (PubMed Search)

Posted: 2/17/2023 by Jenny Guyther, MD (Updated: 4/24/2024)
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It is often difficult to clinically differentiate between viral and bacterial conjunctivitis, but previous studies have shown that the vast majority of the discharge is bacterial. Topical antibiotics are often prescribed, but the efficacy of these antibiotics compared to no treatment has not been well studied.
This study included 88 children aged 6 months to 7 years with acute infective conjunctivitis who were randomized to receive moxifloxacin eye drops, placebo eye drops or no intervention.  Acute infective conjunctivitis was defined as conjunctival inflammation, discharge, soreness or swelling of the eyelids.  The clinical cure was significantly shorter in the moxifloxacin group compared to the no intervention group (3.8 vs 5.7 days).  Both moxifloxacin and placebo eye drops had a shorter time to clinical cure compared to placebo suggesting that placebo eye drops may be beneficial due to their washout effect.
Bottom line: Topical antibiotics for acute infective conjunctivitis were associated with significantly shorter recovery times from acute infective conjunctivitis.

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Should EMS place an advanced airway in out of hospital cardiac arrests?  Current studies suggest that advanced airway management is not superior to BVM in pediatric out of hospital cardiac arrest (OHCA).  

Pediatric OHCA carries a high mortality rate and those that do survive often have a poor neurologic outcome.  This study evaluated BVM vs supraglottic airway (SGA) placement vs endotracheal intubation (ETI) in relation to one month survival and favorable neurological outcomes.  SGA and ETI were also grouped together and categorized as advanced airway management (AAM).

This study was conducted using the Pan Asian Resuscitation Outcomes Study Clinical Research Network.  3131 pediatric patients were included.  85% received BVM, 11.8% SGA and 2.6 % ETI.  In a matched cohort, one month survival and survival with favorable neurological outcome was higher in the BVM group compared to the AAM group and in the BVM group compared to the SGA group.  There was no significant difference noted between the ETI group and BVM group.

Bottom line: In this study, AAM was associated with decreased one month survival and less favorable neurological status in pediatric OHCA.

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Pseudohyperkalemia can result from the use of small bore IVs, excessive tourniquet time, fist clenching and mechanical stress during collection.  These factors may affect pediatric blood draws. 
 
This was a 5 year retrospective analysis of patients 0-17 years.  187 patients had a hemolyzed sample that showed hyperkalemia.  145 children had repeat testing and only 3 children had true hyperkalemia (2%).  All three of these patients had underlying conditions that would have raised suspicion for hyperkalemia (chronic renal failure and diabetic ketoacidosis).  There were no abnormalities to the BUN or creatinine in the patients without hyperkalemia.
 
Bottom line: This small study suggests that it may not be necessary to obtain repeat blood samples for hyperkalemia in patients with normal BUN and creatinine.  Larger studies are needed before bringing this into mainstream practice.

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Category: Pediatrics

Title: What is the proper ratio of blood products in the bleeding pediatric trauma patient?

Keywords: Pediatric trauma, blood transfusion, ratios (PubMed Search)

Posted: 11/18/2022 by Jenny Guyther, MD (Updated: 4/24/2024)
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Research in the pediatric trauma patient has finally shown that crystalloid volume should be limited and blood products should be used early in resuscitation.  Whole blood transfusion is currently being studied.  Studies are also being conducted looking at the proper ratio of blood products for these pediatric trauma patients.
This was a retrospective review of the Trauma Quality Improvement Program.  Patients younger than 18 years old who received at least 1 unit of FFP and PRBCsduring the initial 4 hours of admission were included.  The study looked at 1,233 patients who received FFP:PRBC ratios of 1:1, 1:2, 1:3 and 1:3+ and 24 hour mortality, hospital mortality, complications and 24 hour PRBC requirements.
The 1:1 transfusion group had the lowest 24 mortality and in-hospital mortality.  There was no difference between the groups for complications.  The 1:1 ratio group also had the lowest 24 hour PRBC requirements.  This study did not include those patients who required massive transfusion on arrival. 
Bottom line: FFP:PRBC ratio of 1:1 was associated with increased survival in children.  More studies are needed regarding whole blood and massive transfusion in pediatrics.

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Category: Pediatrics

Title: Once intuccesption has been diagnosed, when should reduction occur?

Keywords: intuccesption, air enema, reduction timing (PubMed Search)

Posted: 10/21/2022 by Jenny Guyther, MD (Updated: 4/24/2024)
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Once the diagnosis of intussusception is made, there are often delays in 1) getting the patient to a center where reduction can be performed and 2) getting the staff available to perform an air enema, especially during evenings and nights. Previous studies have shown worse outcomes when there is longer than a 24 hour delay in reduction. This was a retrospective single center study looking at 175 cases of intussusception and evaluating the time between the radiology final read of intussusception and the timing of reduction and if enema based reduction was successful. In this group of patients, there was no statistically significant difference in reduction efficacy, requirement for surgical reduction or complication rate (bowel resection or perforation) in the patients studied which included delay intervals up to 8 hours. Successful first attempt reductions ranged from 72-81% in each study group (1hr, 1-3hr, 3-6hr and 6+ hr). The caveat to this study is that there were only 11 patients included in the 6-8 hour group. This study also did not take into account the timing from symptom onset to reduction time. Bottom line: More evidence is needed, but this small study provides evidence that up to 8 hours from radiology diagnosis of intussusception to the 1st reduction attempt was not less efficient compared to those with an attempt in under 1 hour.

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Laryngospasm is defined as the cessation of ventilation despite persistent respiratory effort related to glottic closure.  Complications include hypoxia, bradycardia, and cardiac arrest.  In OR cases, one recent study found the laryngospasm to occur in 0.45/1000 cases.  In these children undergoing general anesthesia, risk factors included current upper respiratory infection, active asthma, airway anomalies, airway procedures, age < 3 months and the use of an LMA.  
Studies of the rates of laryngospasm in pediatric sedation have shown varied incidence, with prevalence between 0.43/1000 to 2.1/1000.  A metaanalysis showed that laryngospasm was more common with a combination of propofol and ketamine.
This study looked at moderate sedation cases where laryngospasm was not relieved with chin repositioning or the use of an airway adjunct.  Over a 7 year study period, 276,832 sedations were examined with 913 patients experiencing laryngospasm (3.3/1000 cases).  About 5% of these patients required intubation.  There were 2 cases of cardiac arrest, one with an underlying cardiac condition and one with a URI who was undergoing an echo.  Both of these patients had multiple agents used for sedation.
The isolated use of IV ketamine had a laryngospasm rate of 1.4/1000 cases.  The highest prevalence occured with propofol + ketamine (6.6/1000), propofol + midazolam + opiate (6.1/1000) and propofol + dexmedetomidine (5.8/1000).
The risk of laryngospasm was associated with a higher ASA status, younger age, presence of a URI, airway procedures, and certain propofol combination regimens.
Bottom line: While the prevalence of laryngospasm remains low during pediatric sedation, risk factors should be taken into consideration and the risk/benefits should be discussed in detail with the families.  Always be prepared for an airway emergency during sedation.

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Category: Pediatrics

Title: Secondary Transmission of SARS-CoV2 with regards to Masking in Schools

Keywords: COVID, kids, masking, school (PubMed Search)

Posted: 8/19/2022 by Jenny Guyther, MD (Updated: 4/24/2024)
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This was a multistate, prospective, observational cohort of children and teachers attending in person schools in kindergarden through 12th grade where the school districs had the ability to perform contact tracing and determine primary vs secondary infections.  During the study period (6/21-12/21) 46 districts had universal masking policies and 6 districts had optional masking policies.  

Districts that optionally masked had 3.6x the rate of secondary transmission compared to universally masked school districts.  Optionally masked districts had 26.4 cases of secondary transmission per 100 community acquired cases compared to only 7.3 cases in universally masked districts.

Bottom line: Universial masking was associated with reduced secondary transmission of SARS-CoV2 compared with optional masking policies. 

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Category: Pediatrics

Title: The Pediatric Pause - Introducing a Trauma Informed Care Protocol

Keywords: trauma informed care, pediatric resuscitation (PubMed Search)

Posted: 7/15/2022 by Jenny Guyther, MD (Updated: 4/24/2024)
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Traumatic injuries are a leading cause of morbidity and mortality in pediatric patients.  Even in the setting of a full recovery, there can be negative psychological sequelae associated with the traumatic events.  The child's perceived risk of death and parental trauma related distress have both been associated with the development of post traumatic stress.
 
Previous studies have suggested the key components of trauma informed pediatric care include: minimizing potentially traumatic aspects of medical care and procedures, providing children and family with basic support and information, addressing child distress such as pain, fear, and loss,  promoting emotional support, screening children and families who might need support and providing anticipatory guidance about adaptive ways of coping.
 
The Pediatric PAUSE was introduced at a pediatric trauma center to help to reduce post traumatic stress.  
 
PAUSE stands for Pain/Privacy, Anxiety/IV access, Urinary Catheter/Rectal Exam/Genital Exam, Support for family or staff and Explain to patient/Engage the PICU team.  The article contains a table with a more detailed outline of the PAUSE.
 
This study evaluated the pediatric PAUSE to see if its implementation would interfere with the timeliness of the ACS/ATLS evaluation.  The PAUSE was inserted after the primary and ABCDE assessment (except in the unstable patient).  The use of this protocol did not prolong time between trauma bay arrival and critical imaging studies.

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Category: Pediatrics

Title: What is the ideal length of treatment for pediatric community acquired pneumonia?

Keywords: PNA, pediatrics, duration of treatment (PubMed Search)

Posted: 6/17/2022 by Jenny Guyther, MD (Updated: 4/24/2024)
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This was a randomized placebo controlled trial looking at 380 pediatric patients aged 6 months to 5 years who were diagnosed with nonsevere CAP and who showed early clinical improvement.  On day 6, one patient group was switched to a placebo while the other group continued with the antibiotics.
 
In this small study population, 5 days of a penicillin based antibiotic had a similar clinical response and antibiotic associated adverse effect profile compared to a 10 day course.  A 5 day course also reduced antibiotic exposure resistance compared to a 10 day course.  

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Category: Pediatrics

Title: Post fracture pain management in children.

Keywords: motrin, narcotics, oxycodone, fracture care (PubMed Search)

Posted: 5/20/2022 by Jenny Guyther, MD (Updated: 4/24/2024)
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This was a prospective study done in a pediatric emergency department where 329 children ages 4-16 years with isolated fractures were included.  After casting, children were prescribed either ibuprofen or oxycodone.  Pain score and activity level were followed by phone for 6 weeks.  The reduction in pain was comparable for motrin and oxycodone.  However, the children who received motrin experienced less side effects and quicker return to baseline activities compared to oxycodone.
Bottom line: Ibuprofen is a safe and effective option for fracture related pain and has fewer adverse effects compared to oxycodone.

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In 2013, the Pediatric Emergency Care Applied Research Network developed a prediction rule to identify patients who were at low risk of requiring acute intervention after blunt abdominal trauma.  Interventions included laparotomy, embolization, blood transfusion or IV fluids for more than 2 nights with pancreatic or bowel injuries.
If ALL of the following are true, the patient is considered very low risk (0.1%) of needing an acute abdominal intervention:  
- No evidence of abdominal wall trauma or seat belt sign
- GCS 14 or 15
- No abdominal tenderness
- No thoracic wall trauma
- No abdominal pain
- No decreased breath sounds
- No vomiting
 
This prediction rule was externally validated in 2018 showing a sensitivity of 99%.  This rule should be used to decrease the rate of CT scans of the abdomen following blunt trauma.

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In emergency departments in the US, the diagnosis of pneumonia is often made on chest xray.  In the outpatient setting, national guidelines focus on the clinical diagnosis of pneumonia and recommend against radiographs.  This study aimed to develop and validate a clinical tool that could be used to determine the risk of radiographic pneumonia.
The criteria in the Pneumonia Risk Score (PRS) evaluate for the presence of fever, rales, and wheeze and take into account age and triage oxygen saturation.  When developing this protocol, the investigators compared the patients who had pneumonia on chest xray with both clinical judgment and the PRS.  The PRS outperformed clinical judgment in predicting which patients would have pneumonia on chest xray.
Children who have a score of 2 or less were unlikely to have pneumonia on chest xray and would qualify for observation without an xray or empiric antibiotics use.  Children who had a score of 5 or greater were likely to have radiographic pneumonia and could be empirically treated with antibiotics. If the PRS score was 6, the specificity was 99.9%
This link https://links.lww.com/INF/E552. takes you to the excel spreadsheet where you can enter the patients clinical data and gives you a present probability of radiographic pneumonia.  (In case the link does not work, it is also found in the supplemental digital content.)
Bottom line: PRS outperforms clinical judgment when determining if pneumonia will be present on the pediatric chest xray.

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This study looked at just over 10,000 children using the National Trauma Data Bank between 2011 and 2012. Patients were divided into two age groups: 0 to 14 years and 15 to 18 years. Primary outcomes were emergency department and inpatient mortality depending on whether they were taken to a pediatric versus adult trauma center. Secondary outcomes included hospital length of stay, complication rate, ICU length of stay and ventilator days.

Children in the 0-14 year age group had lower ED and inpatient mortality when treated at pediatric trauma centers. This age group was also more likely to be discharged home and have fewer ICU and ventilator days when treated at the pediatric trauma centers.

There was no difference in ED mortality or inpatient mortality in the 15 to18 year-old age group to pediatric and adult trauma centers. There were no differences in complication rates in any age group between pediatric and adult trauma centers. 
 
Bottom line: Children aged 0-14 should ideally be evaluated primarily at pediatric trauma centers.

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