Background Trauma centers (TC) have been shown to decrease mortality in adults, but this has not been demonstrated at a population-level in all children. We hypothesized that seriously injured children would have increased survival in a TC vs. non-trauma center (nTC), but there would be no increased benefit from pediatric-designated vs. adult TC care. Methods This was a retrospective study of the unmasked California Office of Statewide Health and Planning Department patient discharge database (1999–2011). International Classification of Disease, Ninth Revision (ICD-9) diagnostic codes indicating trauma were identified for children (0–18) and injury severity was calculated from ICD-9 codes using validated algorithms. To adjust for hospital case mix, we selected patients with ICD-9 codes that were capable of causing death, and which appeared at both TCs and nTCs. Instrumental variable analysis using differential distance between the child’s residence to a trauma center and to the nearest hospital was applied to further adjust for unobservable differences in TC and nTC populations. IV regression models analyzed the association between mortality and TC vs. nTC care, as well as for pediatric vs. adult TC designations, adjusting for demographic and clinical variables. Results Unadjusted mortality for the entire population of children with nontrivial trauma (n=445,236) was 1.2%. In the final study population (n=77,874), mortality was 5.3%; 3.8% in nTCs and 6.1% in TCs. IV regression analysis demonstrated a 0.79 percentage point (95% CI −0.80 to −0.30; p=.044) decrease in mortality for children cared for in TC vs. nTC. No decrease in mortality was demonstrated for children cared for in pediatric vs. adult TCs. Conclusion Our IV TC outcome models use improved injury severity and case mix adjustment to demonstrate decreased mortality for seriously injured California children treated in TCs. These results can be used to take evidence-based steps to decrease disparities in pediatric access to, and subsequent outcomes for, trauma care. Level of Evidence Level III Therapeutic/Care Management.

Objective: The objective was to identify, screen, highlight, review, and summarize some of the most rigorously conducted and impactful original research (OR) and review articles (RE) in global emergency medicine (EM) published in 2020 in the peerreviewed and gray literature. Methods: A broad systematic search of peer-reviewed publications related to global EM indexed on PubMed and in the gray literature was conducted. The titles and abstracts of the articles on this list were screened by members of the Global Emergency Medicine Literature Review (GEMLR) Group to identify those that met our criteria of OR or RE in the domains of disaster and humanitarian response (DHR), emergency care in resource-limited settings (ECRLS), and EM development. Those articles that | 1329 TREHAN ET Al.

ObjectivesThe Global Emergency Medicine Literature Review (GEMLR) conducts a systematic annual search of peer‐reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most rigorously conducted and widely relevant research in global EM.MethodsAn electronic search of PubMed, a comprehensive retrieval of articles from specific journals, and search of the gray literature were conducted. Title and abstracts retrieved by these searches were screened by a total of 22 reviewers based on their relevance to the field of global EM, across the domains of disaster and humanitarian response (DHR), emergency care in resource‐limited settings (ECRLS), and emergency medicine development (EMD). All articles that were deemed relevant by at least one reviewer, their editor, and the managing editor underwent formal scoring of overall methodologic quality and importance to global EM. Two independent reviewers scored all articles; editors provided a third score in cases of widely discrepant scores.ResultsA total of 19,102 articles were identified by the searches and, after screening and removal of duplicates, a total of 517 articles underwent full review. Twenty‐five percent were categorized as DHR, 61% as ECRLS, and 15% as EMD. Inter‐rater reliability testing between the reviewers revealed a Cohen's kappa score of 0.213 when considering the complete score or 0.426 when excluding the more subjective half of the score. A total of 25 articles scored higher than 17.5 of 20; these were selected for a full summary and critique.ConclusionsIn 2018, the total number of articles relevant to global EM that were identified by our search continued to increase. Studies and reviews focusing on pediatric infections, several new and traditionally underrepresented topics, and landscape reviews that may help guide clinical care in new settings represented the majority of top‐scoring articles. A shortage of articles related to the development of EM as a specialty was identified.

Background: Due to the scarcity of specialized resources for pediatric trauma, "regionalization," or a system designed to get "the right child, to the right place, at the right time," is vital to quality pediatric trauma care. In Northern California, four pediatric trauma centers serve 3.9 million children within a geographically diverse area of 113,630 square miles. A significant proportion of children with trauma is initially triaged to nontrauma hospitals and may require subsequent transfer to a specialty center. Trauma transfer patterns to a pediatric trauma center may provide insight into regional primary triage practices. Transfers from hospitals in close proximity to pediatric trauma centers might suggest that some children could have avoided transfer with minimal additional transport time. While pediatric trauma centers are scarce and serve as regional resources, transfers from beyond the regular catchment area of a trauma center could be an indication of clinical need.Objectives: The objective of this study was to gain an understanding of patterns of pediatric trauma transfer to all pediatric trauma centers within the region as a first step in assessing the efficacy and efficiency of trauma triage. The authors examined three groups of transfer patients: transfers from within the same county as the pediatric trauma center (near transfers), transfers from counties adjacent to the pediatric trauma center (catchment transfers), and transfers from more distant counties (far transfers). The hypothesis was that catchment transfers would form the bulk of transfers, near transfers would compose < 10% of total transfers, and far transfers would be younger and more severely injured than catchment transfers.Methods: This was a retrospective analysis of institutional trauma registry data of children < 18 years from all pediatric trauma centers in Northern California from 2001 through 2009. Transfers were characterized by the location of the transfer hospital relative to the location of the pediatric trauma center. Characteristics associated with near transfer compared to primary triage to a pediatric trauma center were identified, as well as characteristics associated with far transfer compared to catchment transfer.Results: A total of 2,852 of 11,952 (23.9%) pediatric trauma patients were transfers. Near transfers comprised 24.5% of cases, catchment transfers were 37.4%, and far transfers were 38.2%. After controlling for demographic, clinical, and geographic factors, younger age, higher Injury Severity Score (ISS), public versus private insurance, and an injury mechanism of "fall" were associated with near transfer rather than direct triage. Older age, higher ISS, and mechanism of "motor vehicle crash" were associated with far rather than catchment transfer.

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Conclusions: We found that the overall risk of CE with USGIVs placed by RNs to be low (4.1%), but significantly greater compared to IVs placed using standard technique (0.21%). These results are similar to a previously published study, in which USGIVs were placed by physicians. While further study is needed to delineate what, if any, operator characteristics are associated with CEs, our results suggest that USGIVs placed by RNs trained in the procedure perform as well those placed by physicians. Extravasation events are relatively rare, and the small number of CEs in the USGIV group (n¼12) did not allow for meaningful comparisons of IV characteristics between the two groups. Larger data sets, likely drawn from multiple institutions (given the relative paucity of extravasations via USGIVs) are needed to ascertain whether IV gauge, location, or catheter length have an affect on contrast extravasation.

populations. The identification and type of BCVI was correlated with several clinical variables, mortality, morbidity and hospital length-of-stay. Results: Monthly CTAn utilization increased 5.6 fold under new protocol. BCVI incidence went from 13.8/1000 blunt traumas (BT) to 34.8/1000 BT. Groups did not differ significantly with regards to age, injury severity score, or sex (p>0.05). The percentage of patients meeting Denver criteria dropped from 85.1% to 58.3% (p¼0.0001). There was a significant increase in grade 1 (518%), grade 2 (274%), and grade 3 (432%) injuries (p¼0.0001). Decreases in ischemic stroke (7.5%-2.6%, p¼0.09) and in hospital mortality (10.4%-5.1%, p¼0.15) were not significantly different. Hospital length-of-stay (p¼0.008) and intensive care unit length-of-stay (p¼0.0093) were significantly reduced between the restrictive and expanded groups. Increased contrast administration did not alter the rates of acute kidney injury (AKI) (p¼0.51) or acute respiratory distress syndrome (ARDS) (p¼0.59). Conclusions: Adherence to Denver criteria for BCVI screening in blunt trauma patients misses a significant group of injured patients at risk for stroke. These injuries are not limited to low-grade injuries. These changes also are correlated with decreased hospital length-of-stay, mortality, and rate of stroke with no change in morbidity. Expansion of Denver criteria should be considered to improve early diagnosis of BCVI in blunt injury trauma patients.

Breastfeeding has demonstrable benefits for children and their mothers; however, breastfeeding can be particularly difficult for women who return to the workplace in the months after a child's birth. The challenge of continuing to provide breast milk to an infant after a mother returns to work is evident in the day-to-day lives of health professionals who choose to do so and is reflected in the literature, which shows a marked reduction in breastfeeding rates corresponding to a woman's return to work. These barriers are even more apparent when travel is required for professional obligations or advancement, such as to attend or present at national conferences or to take standardized examinations at test centers. This article provides guidelines and practical advice for event organizers and testing centers to support a lactating mother's ability to provide for her child without compromising her professional career. In particular, we describe the physical requirements of lactation spaces, considerations for milk storage, ways to create a lactation-friendly environment, and unique considerations and accommodations for test takers and test centers. Supporting lactating health professionals should be seen as part of a larger endeavor to support gender equity, advance women in medicine, and integrate wellness and family into our professional lives.