title: A Lower Extremity Musculoskeletal and Vascular Trauma Protocol in a Children's Hospital May Improve Treatment Response Times and Appropriate Microvascular Coverage.
abstract: OBJECTIVE
  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).
  
  
  METHODS
  Level II retrospective prognostic.
  
  
  METHODS
  Level I pediatric trauma center.
  
  
  METHODS
  Pediatric patients presenting with ischemic lower extremities requiring urgent management (2000-2013).
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: *Children's Hospital of Philadelphia; and †Hospital of the University of Pennsylvania, Philadelphia, PA.
authors.forename: Itai
authors.initials: I
authors.lastname: Gans
authors.forename: Keith D
authors.initials: KD
authors.lastname: Baldwin
authors.forename: L Scott
authors.initials: LS
authors.lastname: Levin
authors.forename: Michael L
authors.initials: ML
authors.lastname: Nance
authors.forename: Benjamin
authors.initials: B
authors.lastname: Chang
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Kovach
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Serletti
authors.forename: John M
authors.initials: JM
authors.lastname: Flynn
mesh_terms: D000293:Adolescent; D002648:Child; D002985:Clinical Protocols / Q000592:standards*; D005260:Female; D006776:Hospitals, Pediatric / Q000592:standards*; D006801:Humans; D007511:Ischemia / Q000601:surgery; D007869:Leg Injuries / Q000601:surgery*; D035002:Lower Extremity / Q000098:blood supply* / Q000293:injuries; D008297:Male; D055806:Microvessels / Q000293:injuries / Q000601:surgery; D009141:Musculoskeletal System / Q000293:injuries; D010561:Personnel Staffing and Scheduling; D011379:Prognosis; D012189:Retrospective Studies; D013997:Time Factors; D014193:Trauma Centers / Q000592:standards; D057772:Vascular System Injuries / Q000601:surgery*; D014947:Wounds and Injuries / Q000628:therapy