Search

The objective of this study was to characterize how pediatric primary care and emergency medicine health care providers and trainees engage in injury prevention counseling and assess perceptions toward injury prevention resources. We surveyed physicians, advanced practice providers, and trainees in the Emergency Department, Primary Care Network, and Pediatric Residency Program at Children's Hospital of Philadelphia from September to November 2019. Of the 578 eligible participants, 208 (36.0%) completed the survey. When asked to rank the suitability of alternative personnel for providing counseling, 63.0% of the participants selected an injury prevention specialist as best suited. Seventy-six percent of the providers considered a tablet or mobile device used before a patient encounter to be a helpful resource. Variability existed in provider comfort, knowledge, and frequency of counseling by injury topic. Free-text responses cited time as a barrier to counseling. Opportunities exist to improve the provision of injury education through the utilization of novel resources and personnel.

Objectives: (1) Assess pediatric primary care providers' understanding of cognitive rest for concussion and (2) describe their concussion management practices., Methods: This study included (1) a survey of general pediatric providers and (2) an electronic medical record (EMR) review of children 5 to 18 years old treated for concussion from September 1, 2010, to May 31, 2011. The survey asked about treatment recommendations for concussion, and results were coded to identify cognitive rest recommendations. The EMR review included the following: injury details, medical evaluation, and recommendations for resuming school and sports/recreation., Results: In all, 89 of 201 providers responded to the survey, and 52 of the 84 clinicians who included comments about concussion management mentioned cognitive rest (62%, 95% confidence interval [CI] = 51%-72%). Of the 91 EMRs reviewed for patients' first visits following the concussion, only 10 (11%, 95% CI = 6%-19%) included written cognitive rest recommendations., Conclusions: Although the majority of pediatric providers identified cognitive rest as important in pediatric concussion management, few provided written recommendations in the EMR.

Objective: To determine the self-reported practices and attitudes surrounding concussion diagnosis and management in a single, large pediatric care network., Methods: A cross-sectional survey was distributed to pediatric primary care and emergency medicine providers in a single, large pediatric care network. For all survey participants, practices and attitudes about concussion diagnosis and treatment were queried., Results: There were 145 responses from 276 eligible providers, resulting in a 53% response rate, of which 91% (95% confidence interval [CI]: 86%-95%) had cared for at least 1 concussion patient in the previous 3 months. A Likert scale from 1 "not a barrier" to 5 "significant barrier" was used to assess providers' barriers to educating families about the diagnosis of concussion. Providers selected 4 or 5 on the scale for the following barriers and frequencies: inadequate training to educate 16% (95% CI: 11%-23%), inadequate time to educate 15% (95% CI: 12%-24%), and not my role to educate 1% (95% CI: 0.4%-5%). Ninety-six percent (95% CI: 91%-98%) of providers without a provider decision support tool (such as a clinical pathway or protocol) specific to concussion, and 100% (95% CI: 94%-100%) of providers without discharge instructions specific to concussion believed these resources would be helpful., Conclusions: Although pediatric primary care and emergency medicine providers regularly care for concussion patients, they may not have adequate training or infrastructure to systematically diagnose and manage these patients. Specific provider education, decision support tools, and patient information could help enhance and standardize concussion management.

Finite element (FE) modeling provides a means to examine how global kinematics of repetitive head loading in sports influences tissue level injury metrics. FE simulations of controlled soccer headers in two directions were completed using a human head FE model to estimate biomechanical loading on the brain by direction. Overall, headers were associated with 95th percentile peak maximum principal strains up to 0.07 and von Mises stresses up to 1450 Pa, and oblique headers trended toward higher values than frontal headers but below typical injury levels. These quantitative data provide insight into repetitive loading effects on the brain. [ABSTRACT FROM AUTHOR]

Sports-related concussion (SRC) is a common sports injury in children and adolescents. With the vast amount of youth sports participation, an increase in awareness of concussion and evidence that the injury can lead to consequences for school, sports and overall quality of life, it has become increasingly important to properly diagnose and manage concussion. SRC in the student athlete is a unique and complex injury, and it is important to highlight the differences in the management of child and adolescent concussion compared with adults. This review focuses on the importance of developing a multimodal systematic approach to diagnosing and managing pediatric sports-related concussion, from the sidelines through recovery. [ABSTRACT FROM AUTHOR]

Objective: Emergency maneuvers such as evasive swerving often precede a crash. These events are typically low-acceleration, time-extended events where the inertial forces have the potential to cause changes to the occupant's initial state (initial posture, position, muscle tension). The objective of this study was to systematically quantify the kinematics of pediatric and adult human volunteers during simulated pre-crash evasive swerving maneuvers and evaluate the effect of age and two vehicle-based countermeasures.Methods: A novel laboratory device was designed to expose subjects to non-injurious loading conditions that mimic real-world evasive swerving events. A four-cycle oscillatory lateral pulse with a maximum acceleration of 0.72 g (0.53 g for the first lateral movement in the first cycle) was applied. Forty seat belt restrained subjects across four age groups - 9-11 years (n = 10), 12-14 years (n = 10), 15-17 years (n = 10) and 18-40 years (n = 10) - were exposed to a series of test conditions (baseline, pre-pretensioned seat belt, sculpted vehicle seat with and without inflated torso bolsters) while their kinematics were captured using 3 D motion capture and muscle activity was recorded. Reaction loads were collected from the shoulder belt and footrest. Data are presented for the first cycle only.Results: Pre-pretensioning the shoulder belt before the onset of acceleration had the greatest restraining effect on the head and trunk for all age groups. In the pre-pretensioning trials, compared to baseline, subjects exhibited 34% and 33% less head excursion, into and out of the shoulder belt respectively. Similar reductions were observed with pre-pretensioning for trunk excursion (45% and 53% reductions, in and out of the belt respectively). Inflating seat torso bolsters reduced lateral kinematics relative to baseline but to a lesser extent than the pre-pretensioner (Head Out of belt: 11%; Head Into Belt: 32% and Trunk Out of Belt: 15%; Trunk Into Belt: 27%). Although there was no overall effect of age on the magnitude of lateral displacement, different age groups employed various neuromuscular strategies to control their kinematics.Conclusion: A pre-pretensioner was an effective vehicle countermeasure during evasive swerving maneuvers as it substantially reduced lateral head and trunk displacement for all age groups. Providing lateral restraint via a sculpted vehicle seat was less effective as the geometry of the torso bolsters when inflated did not provide substantial lateral support. [ABSTRACT FROM AUTHOR]

Designing motor vehicle safety systems requires knowledge of whole body kinematics during dynamic loading for occupants of varying size and age, often obtained from sled tests with postmortem human subjects and human volunteers. Recently, we reported pediatric and adult responses in low-speed (<4 g) automotive-like impacts, noting reductions in maximum excursion with increasing age. Since the time-based trajectory shape is also relevant for restraint design, this study quantified the time-series trajectories using basis splines and developed a statistical model for predicting trajectories as a function of body dimension or age. Previously collected trajectories of the head, spine, and pelvis were modeled using cubic basis splines with eight control points. A principal component analysis was conducted on the control points and related to erect seated height using a linear regression model. The resulting statistical model quantified how trajectories became shorter and flatter with increasing body size, corresponding to the validation data-set. Trajectories were then predicted for erect seated heights corresponding to pediatric and adult anthropomorphic test devices (ATDs), thus generating performance criteria for the ATDs based on human response. This statistical model can be used to predict trajectories for a subject of specified anthropometry and utilized in subject-specific computational models of occupant response. [ABSTRACT FROM PUBLISHER]

Background: A home exercise program (HEP) can provide an equitable and cost-effective method for therapy targeted towards visio-vestibular deficits that are common following concussion. It is unclear if pediatric patients prescribed a HEP demonstrate improved visio-vestibular function. Purpose: To explore if a HEP affects visio-vestibular function in concussed pediatric patients. Methods: This observational study included 1,041 patients (614 female(59.0%); age=14.0±2.5 years) reporting to a specialty care concussion center for an initial visit within 28 days of injury and a first follow-up visit within 60 days of injury. All patients completed a Visio-Vestibular Examination (VVE) at both time points, which consisted of 9 maneuvers: smooth pursuit, horizontal/vertical saccades and gaze stability, binocular convergence, left/right monocular accommodation, and complex tandem gait. Patients were given a HEP at initial visit which consisted of exercises, including saccades, gaze stability, convergence, and balance, and instructed to complete these exercises 1-2 times daily. At follow-up, patients were asked to report their progress with the HEP, which was categorized as 1) has not done the HEP, 2) is currently doing the HEP, or 3) has completed the HEP. Primary outcomes included HEP status at first follow-up, VVE subtests (normal/abnormal), and total VVE (abnormal=2+ abnormal subtests). Separate chi-square tests with Bonferroni corrections were used to determine if the proportion of abnormal VVE outcomes was associated with HEP status (α=0.017 a priori). Results: At initial visit, 812 (77.6%) patients presented with abnormal total VVE. The proportion of abnormal subtests at initial visit ranged from 16.0% (right monocular accommodation) to 77.4% (horizontal gaze stability). At first follow-up, the proportion of abnormal total VVE did not differ among patients reporting not doing the HEP (101(62.0%)), patients currently doing the HEP (516(69.0%)), and patients who had completed the HEP (51(69.0%)). However among VVE subtests, a lower proportion of patients who completed the HEP presented with abnormal smooth pursuit (7.5%), horizontal (3.8%) and vertical (3.8%) saccades, and complex tandem gait (0%) relative to patients who were currently doing the HEP (P≤0.003) and to patients not doing the HEP (P≤0.01). Conclusions: Our findings indicate that patients who completed the HEP presented with better aspects of visio-vestibular function (smooth pursuit, saccades, and complex tandem gait) relative to those who did not start or were currently doing the HEP. This suggests that a HEP may be effective in reducing visio-vestibular dysfunction following concussion. Additional research investigating cost-effective concussion management tools is needed to improve patient outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Previous research has quantified differences in head and spinal kinematics between children and adults restrained in an automotive-like configuration subjected to low speed dynamic loading. The forces and moments that the cervical spine imposes on the head contribute directly to these age-based kinematic variations. To provide further explanation of the kinematic results, this study compared the upper neck kinetics – including the relative contribution of shear and tension as well as flexion moment – between children (n=20, 6–14yr) and adults (n=10, 18–30yr) during low-speed (<4g, 2.5m/s) frontal sled tests. The subjects were restrained by a lap and shoulder belt and photo-reflective targets were attached to skeletal landmarks on the head, spine, shoulders, sternum, and legs. A 3D infrared tracking system quantified the position of the targets. Shear force (F x ), axial force (F z ), bending moment (M y ), and head angular acceleration () were computed using inverse dynamics. The method was validated against ATD measured loads. Peak F z and significantly decreased with increasing age while M y significantly increased with increasing age. F x significantly increased with age when age was considered as a univariate variable; however when variations in head-to-neck girth ratio and change in velocity were accounted for, this difference as a function of age was not significant. These results provide insight into the relationship between age-based differences in head kinematics and the kinetics of the cervical spine. Such information is valuable for pediatric cervical spine models and when scaling adult-based upper cervical spine tolerance and injury metrics to children. [Copyright &y& Elsevier]

Objective To estimate the risk of serious nonfatal injuries in frontal crashes among belted children seated in the right front seat of vehicles in which second-generation passenger air bags deployed compared with that of belted children seated in the right front seat of vehicles in which first-generation passenger air bags deployed. Design and Setting We enrolled a probability sample of 1781 seat belt–restrained occupants aged 3 through 15 years seated in the right front seat, exposed to deployed passenger air bags in frontal crashes involving insured vehicles in 3 large US regions, between December 1, 1998, and November 30, 2002. A telephone interview was conducted with the driver of the vehicle using a previously validated instrument. The study sample was weighted according to each subject’s probability of selection, with analyses conducted on the weighted sample. Main Outcome Measure Risk of serious injury (Abbreviated Injury Scale score of ≥2 injuries and facial lacerations). Results The risk of serious injury for restrained children in the right front seat exposed to deployed second-generation passenger air bags was 9.9%, compared with 14.9% for similar children exposed to deployed first-generation passenger air bags (adjusted odds ratio, 0.59; 95% confidence interval, 0.36-0.97). Conclusion This study provides evidence based on field data that the risk of injury to children exposed to deploying second-generation passenger air bags is reduced compared with earlier designs. [ABSTRACT FROM AUTHOR]

Objectives: To assess the distribution of injury mechanisms and activities among children with concussions in a large pediatric healthcare system.Study Design: All patients, age 0-17 years, who had at least 1 clinical encounter with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of concussion in the Children's Hospital of Philadelphia's electronic health record system from July 1, 2012 to June 30, 2014, were selected (N = 8233) and their initial concussion-related visit identified. Approximately, 20% of the patients (n = 1625) were randomly selected for manual record review to examine injury mechanisms and activities.Results: Overall, 70% of concussions were sports related; however, this proportion varied by age. Only 18% of concussions sustained by children aged 0-4 were sports related, compared with greater proportions for older children (67% for age 5-11, 77% for age 12-14, and 73% for age 15-17). When the concussion was not sports related, the primary mechanisms of injury were struck by an object (30%) and falls (30%).Conclusions: Sports-related injuries in children older than 6 years of age contributed to the majority of concussions in this cohort; however, it is important to note that approximately one-third of concussions were from non-sports-related activities. Although there is increased participation in community and organized sports activities among children, a focus on prevention efforts in other activities where concussions occur is needed. [ABSTRACT FROM AUTHOR]

Objective:Rollover crashes account for more than 33% of all motor vehicle–related fatalities and have the highest fatality risk of all crash types, at 1.37% in the United States. There is increased awareness of the high fatality rate associated with this crash type, but there is very limited pediatric-specific data related to rollover crashes in the United States. Recent focus on rollover mitigation has resulted in implementation of countermeasures, making it important to evaluate injury causation for child occupants in rollover crashes with a more current data set. Methods:We queried the Crash Injury Research and Engineering Network (CIREN) from case years 1998 through 2013. Rollover crashes for passenger vehicles of model year 1998 or newer with at least one restrained occupant (excluding drivers) between 0 and 19 years of age were included. Vehicle-involved physical component and occupant–vehicle contact maps were developed with the CIREN data set. Results and Conclusions:Of the 20 CIREN cases that met the inclusion criteria, 15 had one or more injuries attributed to contact with some part of the vehicle structure. The CIREN analyses revealed that the head was the most common seriously injured body region, primarily due to contact with the roof side rail and/or vehicle interior. This finding was true for both adolescents and younger pediatric passengers in outboard seating positions. Fifty percent of head injury causation scenarios involving the vehicle interior had component intrusion of 20+ cm at the point of contact. Further exploration of pediatric rollover injury mechanisms using computational modeling and real-world testing is recommended in order to improve upon current mitigation strategies. [ABSTRACT FROM PUBLISHER]

Objective:Motor vehicle crashes are a leading cause of injury and mortality for children. Mitigation of these injuries requires biofidelic anthropomorphic test devices (ATDs) to design and evaluate automotive safety systems. Effective countermeasures exist for frontal and near-side impacts but are limited for far-side impacts. Consequently, far-side impacts represent increased injury and mortality rates compared to frontal impacts. Thus, the objective of this study was to evaluate the biofidelity of the Hybrid III and Q-series pediatric ATDs in low-speed far-side impacts, with and without shoulder belt pretightening. Methods:Low-speed (2g) far-side oblique (60°) and lateral (90°) sled tests were conducted using the Hybrid III and Q-series 6- and 10-year-old ATDs. ATDs were restrained by a lap and shoulder belt equipped with a precrash belt pretightener. Photoreflective targets were attached to the head, spine, shoulders, and sternum. ATDs were exposed to 8 low-speed sled tests: 2 oblique nontightened, 2 oblique pretightened, 2 lateral nontightened, 2 lateral pretightened. ATDs were compared with previously collected 9- to 11-year-old (n= 10) volunteer data and newly collected 6- to 8-year-old volunteer data (n= 7) tested with similar methods. Kinematic data were collected from a 3D target tracking system. Metrics of comparison included excursion, seat belt and seat pan reaction loads, belt-to-torso angle, and shoulder belt slip-out. Results:The ATDs exhibited increased lateral excursion of the head top, C4, and T1 as well as increased downward excursion of the head top compared to the volunteers. Volunteers exhibited greater forward excursion than the ATDs in oblique nontightened impacts. These kinematics correspond to increased shoulder belt slip-out for the ATDs in oblique tests (ATDs = 90%; volunteers = 36%). Contrarily, similar shoulder belt slip-out was observed between ATDs and volunteers in lateral impacts (ATDs = 80%; volunteers = 78%). In pretightened impacts, the ATDs exhibited reduced lateral excursion and torso roll-out angle compared to the volunteers. Conclusions:In general, the ATDs overestimated lateral excursion in both impact directions, while underestimating forward excursion of the head and neck in oblique impacts compared to the pediatric volunteers. This was primarily due to pendulum-like lateral bending of the entire ATD torso compared to translation of the thorax relative to the abdomen prior to the lateral bending of the upper torso in the volunteers, likely due to the multisegmented spinal column in the volunteers. Additionally, the effect of belt pretightening on occupant kinematics was greater for the ATDs than the volunteers. [ABSTRACT FROM PUBLISHER]

Abstract: No electromyography (EMG) responses data exist of children exposed to dynamic impacts similar to automotive crashes, thereby, limiting active musculature representation in computational occupant biomechanics models. This study measured the surface EMG responses of three neck, one torso and one lower extremity muscles during low-speed frontal impact sled tests (average maximum acceleration: 3.8g; rise time: 58.2ms) performed on seated, restrained pediatric (n =11, 8–14years) and young adult (n =9, 18–30years) male subjects. The timing and magnitude of the EMG responses were compared between the two age groups. Two normalization techniques were separately implemented and evaluated: maximum voluntary EMG (MVE) and neck cross-sectional area (CSA). The MVE-normalized EMG data indicated a positive correlation with age in the rectus femoris for EMG latency; there was no correlation with age for peak EMG amplitudes for the evaluated muscles. The cervical paraspinous exhibited shorter latencies compared with the other muscles (2–143ms). Overall, the erector spinae and rectus femoris peak amplitudes were relatively small. Neck CSA-normalized peak EMG amplitudes negatively correlated with age for the cervical paraspinous and sternocleidomastoid. These data can be useful to incorporate active musculature in computational models, though it may not need to be age-specific in low-speed loading environments. [Copyright &y& Elsevier]

Abstract: Aim: To quantitatively describe pauses in chest compression (CC) delivery during resuscitation from in-hospital pediatric and adolescent cardiac arrest. We hypothesized that CPR error will be more likely after a chest compression provider change compared to other causes for pauses. Methods: CPR recording/feedback defibrillators were used to evaluate CPR quality for victims ≥8 years who received CPR in the PICU/ED. Audiovisual feedback was supplied in accordance with AHA targets. Etiology of CC pauses identified by post-event debriefing/reviews of stored CPR quality data. Results: Analysis yielded 205 pauses during 304.8min of CPR from 20 consecutive cardiac arrests. Etiologies were: 57.1% for provider switch; 23.9% for pulse/rhythm analysis; 4.4% for defibrillation; and 14.6% “other.” Provider switch accounted for 41.2% of no-flow duration. Compared to other causes, CPR epochs following pauses due to provider switch were more likely to have measurable residual leaning (OR: 5.52; CI95: 2.94, 10.32; p <0.001) and were shallower (43±8 vs. 46±7mm; mean difference: −2.42mm; CI95: −4.71, −0.13; p =0.04). Individuals performing continuous CPR≥120s as compared to those switching earlier performed deeper chest compressions (42±6 vs. 38±7mm; mean difference: 4.44mm; CI95: 2.39, 6.49; p <0.001) and were more compliant with guideline depth recommendations (OR: 5.11; CI95: 1.67, 15.66; p =0.004). Conclusions: Provider switches account for a significant portion of no-flow time. Measurable residual leaning is more likely after provider switch. Feedback systems may allow some providers to continue high quality CPR past the recommended switch time of 2min during in-hospital resuscitation attempts. [Copyright &y& Elsevier]