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   SickKids Specific Trauma Clinical Protocols

   University of Toronto Trauma Clinical Protocols

Trauma Care White Board Video

Dear Trauma Colleague,

We are excited to share with you our brand-new Trauma Care White Board Video. Based upon an identified need for trauma education resources, we sought to create a unique video that delivers high yield information on community trauma management and transport. This project was a collaborative effort with input from a diverse group of community and academic pediatric and adult trauma care providers and covers important commonalities and differences when caring for diverse patient populations. Of note, the video briefly references Ontario specific trauma services, however, the core content of the video is applicable to trauma care across Canada.

Our hope is to reach as large an audience as possible, and with your help we look to have a coordinated release of the video on March 8th 2018. This would include posting an active link on your website as well as sharing broadly over social media platforms and mailing lists.

Once the video has been released, we hope to evaluate its utility as an educational tool using a future survey. We would sincerely appreciate participation from those interested in providing feedback/constructive criticism that will inform future projects and serve to elevate innovation in medical education going forward.

We sincerely appreciate your time and effort in sharing this project, please find the active link below and the transport checklists that are on the website as well.

Alun Ackery, Suzanne Beno and Kealin Wong

Funding for the video was provided by University of Toronto Trauma & ACS, Sunnybrook Hospital, SickKids and St. Michael’s Hospital. The primary authors and developers of the video: Dr. Alun Ackery (SMH), Dr. Suzanne Beno (SickKids), and Dr. Kealin Wong (UofT, PGY2) have no conflicts of interest to declare.

Education

Fellowship

The SickKids Trauma Fellowship is designed to build competency in pediatric trauma management and leadership.  There are up to two trauma fellowships allowed per academic year, one through the division of General Surgery and one through the division of Paediatric Emergency Medicine.  Although slightly different (see below), the Trauma Fellowship is one year in length. The Trauma Fellow is the Trauma Team Leader (TTL), providing comprehensive TTL care to injured children and youth from the initial point of contact through to admission and/or discharge.

The fellowship is primarily based at SickKids, with at least 1 month spent at an accredited adult trauma facility (typically at Sunnybrook Hospital or St. Michael’s Hospital) to gain further exposure and expertise.   The fellowship can additionally be tailored to optimize a fellow’s exposure and experience in certain areas of interest, such as simulation, injury prevention etc.

Academic requirements for trauma fellows include leading quarterly interdisciplinary trauma rounds, attending the Trauma Program Management Committee meetings, preparing and discussing trauma morbidity and mortality rounds, helping facilitate simulation scenarios for team trauma training and engaging in a trauma-related quality improvement or research project.

The two trauma fellowship program directors are Dr. Paul Wales (General Surgery) and Dr. Suzanne Beno (Paediatric Emergency Medicine).

Surgical Fellows:

During the Fellowship, the Trauma Fellow will provide Senior Paediatric Surgical Resident coverage an average of five nights per month.  They will be responsible for the management of the Paediatric Surgical in-service and consultations to inpatient units and emergency along with supervision of junior Paediatric Surgical Residents while on-call.  Operative experience is primarily based on “on-call” exposure.  Applicants should contact Dr. Paul Wales for further information.

Emergency Fellows:

During the fellowship, the fellow will work as a staff physician in the Emergency Department with a set requirement for clinical work based upon the current PEM advanced training requirements.  A flexible schedule can be created, allowing for time away from SickKids, as well as maximal immersion in inpatient trauma management.  This will be discussed with program directors prior to commencing the fellowship.  Applicants must apply through the advanced fellowship in PEM stream and should contact Dr. Suzanne Beno for further information.

Our Fellows

Continuing Professional Development

Pediatric Polytrauma
From Emergency Medicine Cases Podcast, with Dr. Suzanne Beno.

Excerpt:

Management of the pediatric trauma patient is challenging regardless of where you work. In this EM Cases episode, with the help of two leading pediatric trauma experts, Dr. Sue Beno from Hospital for Sick Children in Toronto and Dr. Fuad Alnaji from Children’s Hospital of Eastern Ontario in Ottawa we answer such questions as: what are the most important physiologic and anatomic differences between children and adults that are key to managing the trauma patient? How much fluid should be given prior to blood products? What is the role of POCUS in abdominal trauma? Which patients require abdominal CT? How do you clear the pediatric c-spine? Are atropine and fentanyl recommended as pre-induction agents in the pediatric trauma patient? How can the BIG score help us prognosticate? Is tranexamic acid recommended in early pediatric trauma like it is in adults? Is the Pediatric Trauma Score helpful in deciding which patients should be transferred to a trauma center? and many more…

View blog post and full podcast →

Pediatric Trauma: Pearls and Pitfalls
Authors: Kirsten Morrissey, MD & Hilary E. Fairbrother, MD, MPH, FACEP // Edited by: Jennifer Robertson, MD and Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

Excerpt:

In the United States, injury remains the leading cause of death and disability in children. Based on data from the National Trauma Database, the leading mechanisms of injury were falls in children 0-9 years of age, and motor vehicle collisions (MVCs) in children ages 10-18.  Overall, MVCs accounted for more than 60% of trauma-related deaths in children under age 18. Although blunt trauma accounts for the majority of pediatric injury, in children without insurance or with public insurance penetrating trauma accounted for 21% of injuries among adolescents.

View blog post →

Pediatric Blunt Trauma And Microhaematuria
Author: Taylan Gurgenci

Excerpt:

Bottom line pearls:

  • Gross haematuria must be taken seriously as it raises the likelihood of finding significant renal pathology
  • Microhaematuria of any degree is most useful when serial urinalyses are performed.  Seeing a downward trend in the degree of microhaematuria is much more useful than the actual number.
  • The received wisdom suggesting a microhaematuria of 50RBC/HPF is the dividing line between trivial and significant haematuria is not supported by much evidence.
  • Microhaematuria in a child with a possible renal injury is best managed by serial examination, serial FBC, and serial urinalysis.  Discharge is safe if the examination remains stable, the FBC is stable, and the microhaematuria resolves.
  • There is no role for the urine dipstick in suspected renal injury.
  • Adult imaging protocols may be applied to paediatric blunt trauma though with some important provisos.

View blog post →

Traumatic Brain Injury
Author: Adam Bartlett

Excerpt:

An 8 year old boy is rushed into ED following a fall from a fourth story window.  He landed on concrete and has obvious signs of external damage to his skull and a GCS of 5. He’s clearly sustained a serious traumatic brain injury – how is this best managed?

View blog post →

Head Injury - Who To Scan?
Author: Anna Ings

Excerpt:

Kids come into emergency EVERY day with head injury. In many cases imaging decisions are simple. Especially when the child rolled off the bed, cried straight away & is now tearing up the ED – BUT plenty of cases present a diagnostic dilemma for physicians. This summary of recent guidelines aims to help with imaging decisions.

View blog post →

Multisystem Trauma in Children Part One: Airway, Chest Tubes, and Resuscitative Thoracotomy
Author: Tim Horeczko

Excerpt and Full podcast:

Traumatized children need your full attention. Protocols work well for adults, but trauma in children requires that we exercise our clinical muscles just a bit more.

View blog post →

Multisystem Trauma in Children Part Two: Massive Transfusion, Trauma Imaging, and Resuscitative Pearls
Author: Tim Horeczko

Excerpt and Full podcast:

A 5-year-old boy was playing with his older brother in front of their home when he was struck by a car. He sustained a femur fracture, splenic laceration, and blunt head trauma – the so-called Waddell’s triad.

View blog post →

Local U of T and SickKids initiatives

Research

These articles are just some pertinent learning material.  This section is updated on a yearly basis.

Local

Which pediatric blunt trauma patients do not require pelvic imaging?
Haasz M, Simone LA, Wales PW, Stimec J, Stephens D, Beno S, Schuh S. Which pediatric blunt trauma patients do not require pelvic imaging? J Trauma Acute Care Surg. 2015 Nov;79(5):828-32. doi: 10.1097/TA.0000000000000848. PubMed PMID: 26496109.

Abstract:

BACKGROUND: This study aimed to develop a tool in identifying traumatized children at low risk of pelvic fracture and to determine the sensitivity of this low-risk model for pelvic fractures. We hypothesized that the proportion of children without predictors with pelvic fracture is less than 1%.

METHODS: This is a retrospective trauma registry analysis of previously healthy children 1 year to 17 years old presenting to the pediatric emergency department with blunt trauma. Postulated predictors of pelvic fracture on radiograph or computed tomography included pain/abnormal examination result of the pelvis/hip, femur deformity, hematuria, abdominal pain/tenderness, Glasgow Coma Scale (GCS) score of 13 or lower, and hemodynamic instability. We used multivariable logistic regression to identify independent predictors of fracture.

RESULTS: Of 1,121 eligible patients (mean [SD] age, 8.5 [4.6] years), 87 (7.8%) had pelvic fracture. Independent predictors included pain/abnormal examination result of the pelvis/hip (odds ratio [OR], 16.7; 95% confidence interval [CI], 9.6-29.1), hematuria (OR, 6.6; 95% CI, 3.0-14.6), femoral deformity (OR, 5.9; 95% CI, 3.1-11.3), GCS score of 13 or lower (OR, 2.4; 95% CI, 1.3-4.3), and hemodynamic instability (OR, 3.4; 95% CI, 1.7-6.9). One of 590 children (0.2%; 95% CI, 0-0.5%) without predictors had pelvic fractures versus 86 (16.2%) of 531 in those with one or more predictors (OR, 119; 95% CI, 16.6-833). One of 87 children with pelvic fractures had no predictors (1.1%; 95% CI, 0-3%). When assuming a 100% radiography rate, this tool saves 53% pelvic radiographs.

CONCLUSION: Children with multiple blunt trauma without pain/abnormal examination result of the pelvis/hip, femur deformity, hematuria, abdominal pain/tenderness, GCS score of 13 or lower, or hemodynamic instability constitute a low-risk population for pelvic fracture, with less than 0.5% risk rate. This population does not require routine pelvic imaging.

LEVEL OF EVIDENCE: Therapeutic study, level IV.

Get article →

The BIG Score and Prediction of Mortality in Pediatric Blunt Trauma.
Davis AL, Wales PW, Malik T, Stephens D, Razik F, Schuh S. The BIG Score and Prediction of Mortality in Pediatric Blunt Trauma. J Pediatr. 2015 Sep;167(3):593-8.e1. doi: 10.1016/j.jpeds.2015.05.041. Epub 2015 Jun 26. PubMed PMID: 26118931.

Abstract:

OBJECTIVES: To examine the association between in-hospital mortality and the BIG (composed of the base deficit [B], International normalized ratio [I], Glasgow Coma Scale [G]) score measured on arrival to the emergency department in pediatric blunt trauma patients, adjusted for pre-hospital intubation, volume administration, and presence of hypotension and head injury. We also examined the association between the BIG score and mortality in patients requiring admission to the intensive care unit (ICU).

STUDY DESIGN: A retrospective 2001-2012 trauma database review of patients with blunt trauma ≤ 17 years old with an Injury Severity score ≥ 12. Charts were reviewed for in-hospital mortality, components of the BIG score upon arrival to the emergency department, prehospital intubation, crystalloids ≥ 20 mL/kg, presence of hypotension, head injury, and disposition.

RESULTS: 50/621 (8%) of the study patients died. Independent mortality predictors were the BIG score (OR 11, 95% CI 6-25), prior fluid bolus (OR 3, 95% CI 1.3-9), and prior intubation (OR 8, 95% CI 2-40). The area under the receiver operating characteristic curve was 0.95 (CI 0.93-0.98), with the optimal BIG cutoff of 16. With BIG <16, death rate was 3/496 (0.006, 95% CI 0.001-0.007) vs 47/125 (0.38, 95% CI 0.15-0.7) with BIG ≥ 16, (P < .0001). In patients requiring admission to the ICU, the BIG score remained predictive of mortality (OR 14.3, 95% CI 7.3-32, P < .0001).

CONCLUSIONS: The BIG score accurately predicts mortality in a population of North American pediatric patients with blunt trauma independent of pre-hospital interventions, presence of head injury, and hypotension, and identifies children with a high probability of survival (BIG <16). The BIG score is also associated with mortality in pediatric patients with trauma requiring admission to the ICU.

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Tranexamic acid in pediatric trauma: why not?
Beno S, Ackery AD, Callum J, Rizoli S. Tranexamic acid in pediatric trauma: why not? Crit Care. 2014 Jul 2;18(4):313. doi: 10.1186/cc13965. Review. PubMed PMID: 25043066; PubMed Central PMCID: PMC4095612.

Abstract:

Trauma is a leading cause of death in pediatrics. Currently, no medical treatment exists to reduce mortality in the setting of pediatric trauma; however, this evidence does exist in adults. Bleeding and coagulopathy after trauma increases mortality in both adults and children. Clinical research has demonstrated a reduction in mortality with early use of tranexamic acid in adult trauma patients in both civilian and military settings. Tranexamic acid used in the perioperative setting safely reduces transfusion requirements in children. This article compares the hematologic response to trauma between children and adults, and explores the potential use of tranexamic acid in pediatric hemorrhagic trauma.

Get article →

Landmark

Team

Our Team is made up of specialists from across emergency and trauma care. Each member sits on several committees, all striving for the ultimate goal of Healthier Children, and a Better World.

Management Team

Dr. Suzanne Beno

Medical Co-Director

suzanne.beno@sickkids.ca

read more

Dorothy McDowall

Trauma Patient Care Coordinator

dorthy.mcdowall@sickkids.ca

Dr. Martin Gargan

Orthopedics Representative

martin.gargan@sickkids.ca

TBD

Unit 5C, Quality Leader

Dr. Paul Wales

Medical Co-Director

paul.wales@sickkids.ca

read more

Dr. Jamie Hutchinson

Critical Care Staff Representative

jamie.hutchison@sickkids.ca

Dr. Michael Aquino

Diagnostic Imaging Staff Representative

michael.aquino@sickkids.ca

Trauma Fellow

Linette Margallo

Trauma CHS Director

linette.margallo@sickkids.ca

Dr. Cengiz Karsli

Anesthesia Staff Representative

cengiz.karsli@sickkids.ca

Dr. Peter Dirks

Neurosurgery Staff Representative

peter.dirks@sickkids.ca

Andrea McCormick

PICU Senior Manager

craig.campbell@sickkids.ca

Interdisciplinary Team

Jennifer Bassin

Art Therapist

jennifer.bassin@sickkids.ca

Michael Marshall

Chaplain

michael.marshall@sickkids.ca

Erin Boyle

Childlife Specialist

erin.boyle@sickkids.ca

Gavin Ross

Childlife Specialist

gavin.ross@sickkids.ca

Stacey Segal

Dietitian

stacey.segal@sickkids.ca

Veronika Langos

Dietitian

veronika.langos@sickkids.ca

Antonietta Desideri

Music Therapist

antonietta.desideri@sickkids.ca

Dana Sequeira

Occupational Therapist

dana.sequeira@sickkids.ca

Nicky Brookes

Occupational Therapist

nicky.brookes@sickkids.ca

Margaret Duvnjak

Physiotherapist

margaret.duvnjak@sickkids.ca

Renee Haldenby

Physiotherapist

renee.haldenby@sickkids.ca

Emma Schoo

Physiotherapist

emma.schoo@sickkids.ca

Julie Keagan

Social Worker

julie.keagan@sickkids.ca

Michelle Nella

Speech Language Pathologist

michelle.nella@sickkids.ca

Harjinder Prasher

Transitional Care Coordinator

harjinder.prasher@sickkids.ca

Dorothy McDowall

Trauma Patient Care Coordinator

dorothy.mcdowall@sickkids.ca

Margaret Kreller

Trauma Data Analyst

margaret.kreller@sickkids.ca
Click on the specialities below to learn more about what we do and the services we provide.
Staff Physician (Doctor)
The Hospital for Sick Children is a teaching hospital and you may meet doctors at various stages of their training.

A staff physician works for The Hospital for Sick Children and is responsible for the medical care of your child while in the hospital. This doctor is a “specialist” who has had extra training and a lot of experience in the area of your child’s injury. Other specialists may be consulted if your child has more than one health need. You may meet many doctors while your child is in the hospital but the staff doctor that your child is admitted under is responsible for his or her medical care.

Fellow or Resident (Doctor)
The Hospital for Sick Children is a teaching hospital and you may meet doctors at various stages of their training.

These are experienced doctors who have come to The Hospital for Sick Children to specialize in a certain area of medicine and to advance their skills. They monitor your child on a daily basis and provide a plan of care under the supervision of the staff doctor.

Registered Nurse
A nurse will be responsible for caring for your child in the Emergency Department, Critical Care Unit, and the Trauma Unit. Nursing care:

  • Provides physical care at your child’s bedside
  • Works with the health-care team and you to make a plan of care for your child
  • Teaches you about the special care your child may need
  • Helps you access support and/or services you may need
  • Provides a link between you and the health care team.
Trauma Patient Care Coordinator
This coordinater is responsible for communication between the health-care team and patients/families involved in trauma.  They are often the contact person for trauma patients and families during hospitalization and after discharge, and are involved in the Trauma Programs’ development, including Quality Management activities.

Please contact our Trauma Patient Care Co-ordinator, Dorothy McDowall, at dorothy.mcdowall@sickkids.ca for any other questions regarding our Trauma Program

Trauma Data Analyst
A data analyst:

  • Extracts data from various internal and external sources for entry into the hospital Trauma Registry.
  • Calculates injury severity scores and codes charts for the Canadian Institute for Health Information and the Ontario Trauma Registry for reporting to the Ministry of Health.
  • Fulfills requests for statistics and research related to injury.
Physiotherapist
A physiotherapist helps children with movement problems after an injury. Physiotherapy services, including assessment, treatment and education, are available to children and families in the Trauma Program. The aim of physiotherapy is to help children to be strong, healthy and able to move well after an injury. The physiotherapist will see children who need help to:

  • Use a part of their body (for example: breathing exercises or to strengthen muscles)
  • Perform an activity (for example: to throw a ball or walk up the stairs)
  • Return to their community (for example: walk with crutches at school or move around at home).
Occupational Therapist
An occupational therapist assesses children to determine if they are having difficulty with doing everyday tasks after an injury. As a child recovers from injury, the occupational therapist will assess and provide therapeutic intervention to help with:

  • self-care skills (for example: eating and swallowing, dressing, washing)
  • play skills (for example: playing with toys or a game, moving to get a toy, playing with friends)
  • school skills (for example: attention and memory skills, problem solving, printing, writing).
Speech Therapist
A speech-language pathologist provides consultation, assessment, education and treatment to infants, children and their families regarding speech, language and overall communication skills. Injuries may have an impact on a wide range of functions necessary for effective communication. These functions may include:

  • Oral motor functioning (coordination of speech muscles for talking),
  • Language comprehension and production (ability to understand or express ideas)
  • Reading and writing
  • Thinking skills (memory, problem solving and reasoning)
  • Social interaction skills.
Neuropsychologist
A neuropsychologist is specially trained to look at the effects of a brain injury on your child’s memory, attention, problem solving, ability to make sense of information, and ability to behave the right way in different situations.  They can suggest how your child, you, and your child’s teachers can deal with the effects of your child’s brain injury.
Dietitian
Dietitians help decide what kind of food and liquids your child needs, and checks the amount your child is eating and his or her weight to make sure your child is getting the best food that will help him or her heal.
Child Life Therapist
A child life therapists supports the psychosocial well-being of children and adolescents during their time in the hospital.  They provide recreational activities to promote your child’s adjustment to the hospital, and promote optimum development, normal living patterns and minimizes the negative impact of illness and hospitalization for children and families.

We offer a range of therapeutic play based activities to build supportive relationships, helps patients gain mastery over their environments, cope with pain and painful procedures, and learn about hospital procedures.

Social Worker
Social work services are available to all patients and their families who are admitted to the SickKids Trauma Program. The social worker can assist you in any of the following areas:

  • Supporting you and your child during periods of crisis and throughout hospitalization.
  • Linking you to available hospital and community resources.
  • Advocating for you in hospital and in the community.
  • Offering individual counselling for your child.
  • Offering counselling for parents, couples and families.
Transitional Care Coordinator
A transitional care coordinator (TCC) promotes a seamless transition of patients and their family from SickKids to their community.  TCC’s facilitate the flow of medically complex children across the continuum from admission to discharge, and fosters effective communication with patients, families, caregivers, service providers and community agencies to ensure continuity, quality of care and optimal support and services.
Chaplain
Our chaplain is available to provide spiritual and emotional care to patients and families at any time of the day or night.  They can also counsel and support you and your family, offer prayers, and give sacraments.

Partners

TRanslating Emergency Knowledge for Kids (TREKK) is a network of health professionals and parents.  Most acutely ill and injured children in Canada are managed within emergency departments that are not part of a children’s hospital. Difficulties in getting the right resources and training have been cited as barriers to providing the best possible care in these settings. This has resulted in variable levels of emergency care for children within Canada. TREKK is a knowledge mobilization network established to address these critical knowledge gaps and improve emergency care for children across Canada.

The Trauma Association of Canada (TAC) is committed to reduce the incidence and relieve the burden of injury by bringing together multidisciplinary health care professionals involved in the care of the injured patient to improve the quality of injury care.

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