Evaluation of Vascular Injury in Penetrating Extremity Trauma in Children using a Practice Guideline
Eric H. Rosenfeld, M.D., M.P.H. 1; Christi Reeves, MSN, RN, TCRN, CEN, CPN2; Sohail R. Shah, M.D., M.S.H.A.1; Adam M. Vogel, M.D.1; Bindi Naik-Mathuria, M.D., M.P.H. 1
1Baylor College of Medicine/Texas Children's Hospital, Houston, TX; 2Texas Children's Hospital, Houston, TX
Purpose: The purpose of this study was to assess adherence and outcomes following creation of a practice guideline (PG) for penetrating extremity trauma.
Methods: Retrospective review of children presenting with penetrating extremity injuries at a freestanding children's hospital Level I trauma center from 2014-2018. The PG was implemented in 2016. Clinical and outcome data were analyzed using descriptive statistics.
Results: Of 22 patients, the median age was 11 [IQR 6-14], 73% (16/22) were male, and the majority (36%) were Caucasian. Mechanisms of injury were 17 gunshot wounds and 5 stab wounds. 50% (11/22) of injuries had concern for vascular injury and 23% (5/22) had vascular injury (20% (1) pre and 80% (4) post-protocol). Following initiation of the PG, the use of CT angiography (CTA) in the emergency room increased from 0% (0/4) to 50% (3/6), and presentation to CTA time decreased from median 13.9 hours to 1.3 hours. Although the difference was not significant, delayed CTA meant delayed time to repair. Measurement of ankle-brachial index (ABI) increased slightly from 29% (2/7) to 31% (4/13). Of all abnormal ABIs, vascular injury was identified in 33%. The PG identified criteria for "hard" signs of vascular injury: of the 2 patients who met criteria, 1 went directly to OR while the other received an expedited CTA. Vascular surgery performed all vascular repairs. There was one complication (graft aneurysm with delayed bleeding).
Conclusion: An institutional practice guideline for penetrating extremity injury in pediatric trauma may facilitate early identification and management of vascular injury.
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