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A Lower Extremity Musculoskeletal and Vascular Trauma Protocol in a Children's Hospital May Improve Treatment
Itai Gans1, Keith D Baldwin, L Scott Levin
1*Children's Hospital of Philadelphia; and †Hospital of the University of Pennsylvania, Philadelphia, PA.
Insights
Implementing a lower extremity vascular trauma protocol (LEVP) significantly reduced revascularization times in pediatric patients. The protocol ensured no delays beyond 8 hours, improving care for limb-threatening injuries.
Area of Science:
- Pediatric vascular surgery
- Trauma care protocols
- Limb revascularization
Background:
- Pediatric lower extremity vascular injuries pose challenges due to limited access to microvascular surgeons.
- Delayed revascularization (>8 hours) increases morbidity, including limb loss.
Purpose of the Study:
- To assess the impact of a lower extremity vascular trauma protocol (LEVP) on revascularization time in pediatric patients.
- To evaluate changes in surgical team expertise and diagnostic study utilization after LEVP implementation.
Main Methods:
- Retrospective analysis of pediatric patients with ischemic lower extremities (2000-2013) at a Level I pediatric trauma center.
- Comparison of outcomes before and after the initiation of a specialized LEVP, including a 24/7 microvascular surgical team.
Main Results:
- Mean revascularization time decreased from 6.4 hours pre-protocol to 4.6 hours post-protocol.
- The incidence of delays exceeding 8 hours dropped from 20% to 0% after LEVP implementation.
- Utilization of preoperative radiographic vascular studies decreased from 37.5% to 0% post-protocol.
Conclusions:
- The LEVP effectively eliminated delays in revascularization for pediatric lower extremity vascular injuries.
- The protocol improved the timeliness and efficiency of care, reducing the need for preoperative imaging.
- Pediatric centers should consider implementing LEVPs to optimize vascular care for children.
Objectives:
Pediatric lower extremity (LE) vascular injuries present many issues: microvascular surgeons are usually unavailable to stand-alone pediatric institutions, and the rate of morbidity including limb loss can be high if revascularization is delayed beyond the critical period of 8 hours. We assessed if time to revascularization was impacted by institution of a lower extremity vascular trauma protocol (LEVP).
Design:
Level II retrospective prognostic.
Setting:
Level I pediatric trauma center.
Patients/Participants:
Pediatric patients presenting with ischemic lower extremities requiring urgent management (2000-2013).
Intervention:
LEVP-a team of specialized microvascular surgeons, who have developed and manage a call schedule for our pediatric trauma center to offer care 24 h-1·d-1, 7 d-1·wk-1, and 365 d-1·y-1 to our children's hospital.
Main Outcome Measurements:
Treatment team expertise, time to revascularization, and use of time-delaying preoperative radiographic vascular studies performed before and after initiation of LEVP.
Results:
We identified 22 patients with ischemic LEs (16 patients treated before/6 patients treated after LEVP initiation). Mean time from admission to definitive vascular care was 6.4 hours preprotocol (20% > 8 hours)/4.6 hours postprotocol (0% > 8 hours). Before protocol initiation, 38% of LE vascular injuries were treated by LE microvascular repair-capable surgeons, and 37.5% had a preoperative radiographic vascular study compared with 100% and 0%, respectively, postprotocol initiation. Before protocol initiation, 37.5% had a preoperative radiographic vascular study compared with 0% after protocol initiation.
Conclusions:
Since LEVP initiation, we have required no preoperative radiographic vascular studies, there has not been a revascularization delay of >8 hours, and with appropriate staff surgeon coverage, the flow of care has improved with the new ability to address and care for these challenging injuries. To potentially improve the timeliness of vascular care and better match the skills of the practitioner to the injury, pediatric centers should consider implementation of an LEVP within their institutions.
Level Of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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