Physical Examination is the Best Predictor of the Need for Abdominal Surgery in Children Following Motor Vehicle Collision

Defining pediatric trauma center resource utilization: Multidisciplinary consensus-based criteria from the Pediatric Trauma Society

BACKGROUND

Pediatric trauma triage and transfer decisions should incorporate the likelihood that an injured child will require pediatric trauma center (PTC) resources. Resource utilization may be a better basis than mortality risk when evaluating pediatric injury severity. However, there is currently no consensus definition of PTC resource utilization that encompasses the full scope of PTC services.

METHODS

Consensus criteria were developed in collaboration with the Pediatric Trauma Society (PTS) Research Committee using a modified Delphi approach. An expert panel was recruited representing the following pediatric disciplines: prehospital care, emergency medicine, nursing, general surgery, neurosurgery, orthopedics, anesthesia, radiology, critical care, child abuse, and rehabilitation medicine. Resource utilization criteria were drafted from a comprehensive literature review, seeking to complete the following sentence: "Pediatric patients with traumatic injuries have used PTC resources if they..." Criteria were then refined and underwent three rounds of voting to achieve consensus. Consensus was defined as agreement of 75% or more panelists. Between the second and third voting rounds, broad feedback from attendees of the PTS annual meeting was obtained.

RESULTS

The Delphi panel consisted of 18 members from 15 institutions. Twenty initial draft criteria were developed based on literature review. These criteria dealt with airway interventions, vascular access, initial stabilization procedures, fluid resuscitation, blood product transfusion, abdominal trauma/solid organ injury management, intensive care monitoring, anesthesia/sedation, advanced imaging, radiologic interpretation, child abuse evaluation, and rehabilitative services. After refinement and panel voting, 14 criteria achieved the >75% consensus threshold. The final consensus criteria were reviewed and endorsed by the PTS Guidelines Committee.

CONCLUSION

This study defines multidisciplinary consensus-based criteria for PTC resource utilization. These criteria are an important step toward developing a criterion standard, resource-based, pediatric injury severity metric. Such metrics can help optimize system-level pediatric trauma triage based on likelihood of requiring PTC resources.

LEVEL OF EVIDENCE

Diagnostic Test/Criteria; Level II.

Pediatric chance fracture with seatbelt syndrome: A case report

Key Clinical Message

Prompt recognition and accurate diagnosis of seatbelt-related injuries such as Chance fractures are crucial for pediatric patients. Clinicians should be aware of the unique characteristics of children, including the presence of growth plates, and use advanced imaging techniques such as magnetic resonance imaging to guide appropriate treatment and minimize complications.

Abstract

Seatbelt-related injuries, known as the "seatbelt syndrome," encompass various injuries resulting from automobile accidents, including vertebral fractures, abdominal injuries, and great vessel traumas. Seatbelt signs include bruising or peeling of the anterior chest or abdominal wall, indicating abdominal pressure against the seatbelt. Chance fractures are a type of vertebral fracture characterized by fracture lines through multiple vertebral structures and are often associated with seatbelt injuries in adults. However, the unique features of Chance fractures in pediatric patients, such as the presence of growth plates, require a comprehensive diagnostic approach using advanced imaging techniques, including magnetic resonance imaging (MRI). This case report highlights the complexity of seatbelt-related injuries in children and emphasizes the importance of accurate diagnosis and multidisciplinary management. Understanding these factors can improve clinical knowledge and outcomes in children with seatbelt-related injuries.

CT scan in the evaluation of pediatric abdominal trauma

OBJECTIVE

to assess the need of computed tomography (CT) for the definition of management in pediatric abdominal trauma.

METHODS

observational retrospective study with patients under 18 years old victims of blunt or penetrating abdominal trauma that underwent CT of the abdomen and pelvis at admission. We evaluated CT scan findings, indications and management. We calculated the sensitivity, specificity, positive predictive value and negative predictive value of clinical variables and energy of trauma for findings on CT.

RESULTS

among the 236 patients included in our study, 72% (n=170) did not present abnormal findings on CT. It was performed surgical treatment in 15% (n=10), conservative treatment in 54,5% (n=36) and 27% (n=18) did not receive treatment for abdominal injuries. In the assessment of CT indications, 28,8% (n=68) presented no justifications. In this group, 91% (n=62) did not show any abnormal findings. Among the six patients with positive findings, half were selected for conservative treatment, while the rest did not need any treatment for abdominal injuries. The presence of abdominal pain, hemodynamic alterations and high energy blunt trauma had low positive predictive values when isolated, whereas the negative predictive values were higher.

CONCLUSION

although CT is necessary in some instances, there is a possible high number of exams that did not make any difference in the management of the pediatric population.

Determinants of mortality and intensive care requirement in pediatric thoracoabdominal injuries

BACKGROUND

Thoracoabdominal injuries (TAI) are an important cause of trauma-related morbidity in children. Early and correct intervention is essential to reduce mortality. We aimed to determine factors associated with mortality and the need for intensive care in TAI.

METHODS

The children admitted to the pediatric emergency department of a tertiary care hospital with TAI in a 6-year-period were enrolled. Demographic data; mechanism of injuries; clinical, laboratory and imaging findings; length of hospital and intensive care unit (ICU) stay; invasive procedures and medical treatments; surgical interventions; and survival outcomes were recorded.

RESULTS

The median age of the 136 children was 9 (IQR: 5-14) years and 72.8% were male. The vast majority of injuries were caused by blunt trauma (92.7%). Pulmonary contusion, pneumothorax, splenic, and liver injuries were the most common diagnoses. Motor vehicle accidents were seen in more than half of the cases (52.2%). The median length of hospital stay was 5 (IQR: 2-8) days; 21 patients were hospitalized in the ICU (15.4%). The need for intensive care was higher in patients with lower Glasgow Coma Scale (GCS) scores and lower Pediatric Trauma Scores (PTSs), in the presence of multiple injuries, pulmonary contusion, and pneumothorax (p<0.001). Mortality was seen in nine patients, eight of whom had multiple injuries. The mortality rate was higher in patients with pulmonary contusion and pneumothorax (p=0.002 and p=0.003, respectively). The PTS and GCS were found to be lower in patients who died in hospital (p<0.001). Prolongation of coagulation parameters and hyperglycemia was more common in the non-survivor group (p=0.005 and p=0.004, respectively).

CONCLUSION

Although thoracoabdominal trauma is not common in childhood, it is an important part of trauma-associated mortality. Multiple injuries, pulmonary contusion, pneumothorax, lower GCS, and PTSs can be a sign of serious injuries to which physicians must be alert.

External validation of a pediatric decision rule for blunt abdominal trauma

INTRODUCTION

Blunt traumatic injuries are a leading cause of morbidity and mortality in the pediatric population. Contrast-enhanced multidetector computed tomography is the best imaging tool for screening patients at risk of blunt abdominal injury. The Pediatric Emergency Care Applied Research Network (PECARN) abdominal rule was derived to identify patients at low risk for significant abdominal injury who do not require imaging.

METHODS

We conducted a retrospective review of pediatric patients with blunt trauma to validate the PECARN rule in a non-pediatric specialized hospital from February 3, 2013, through December 31, 2019. We excluded those with penetrating or mild isolated head injury. The PECARN decision rule was retrospectively applied for the presence of a therapeutic intervention, defined as a laparotomy, angiographic embolization, blood transfusion, or administration of intravenous fluids for pancreatic or gastrointestinal injury. Sensitivity and specificity analysis were conducted along with the negative and positive predictive values.

RESULTS

A total of 794 patients were included in the final analysis; 23 patients met the primary outcome for an acute intervention. The PECARN clinical decision rule (CDR) had a sensitivity of 91.3%, a negative predictive value of 99.5, and a negative likelihood ration of 0.16.

CONCLUSION

In a non-pediatric specialty hospital, the PECARN blunt abdominal CDR performed with comparable sensitivity and negative predictive value to the derivation and external validation study performed at specialized children's hospitals.

Tomografia computadorizada na avaliação do trauma abdominal pediátrico

RESUMO Introdução: avaliar a necessidade da tomografia computadorizada (TC) para definição de condutas em trauma abdominal pediátrico. Métodos: estudo observacional retrospectivo com pacientes menores de 18 anos vítimas de trauma abdominal contuso ou penetrante e que realizaram TC de abdome e pelve na admissão. Avaliou-se achados das tomografias, condutas e justificativas para indicação da TC. Foram calculados sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo de fatores clínicos e energia do trauma para alterações na TC. Resultados: dentre os 236 pacientes incluídos, 72% (n=170) não apresentaram alterações na TC. Foi realizado tratamento cirúrgico em 15% (n=10), tratamento conservador em 54,5% (n=36) e 27% (n=18) não receberam tratamento por lesões abdominais. Na avaliação das indicações de TC, 28,8% (n=68) não apresentavam nenhuma justificativa, sendo que nesse grupo 91% (n=62) resultaram em ausência de achados. Dentre os seis pacientes com achados positivos, metade recebeu tratamento conservador, enquanto o restante não necessitou de tratamento por lesões abdominais. A presença de dor abdominal, alteração hemodinâmica e trauma contuso de alta energia apresentaram baixos valores preditivos positivos de forma isolada, enquanto os valores preditivos negativos foram mais altos. Conclusão: apesar de a TC ser necessária e justificável em alguns casos, há um possível excesso de tomografias dispensáveis para definição de condutas em população pediátrica.

Pediatric Handlebar Injuries: More Than Meets the Abdomen

OBJECTIVES

Injuries associated with bicycles can generally be categorized into 2 types: injuries from falling from/off bicycles and injuries from striking the bicycle. In the second mechanism category, most occur as a result of children striking their body against the bicycle handlebar. The purpose of this study was to evaluate the presentation, body location, injury severity, and need for intervention for pediatric handlebar injuries at a single level one pediatric trauma center and contrast these against other bicycle-related injuries in children.

METHODS

This work is a retrospective review of the trauma registry over an 8-year period. Individual charts were then reviewed for patients' demographic factors, injury details, and other clinical/radiographic findings. Each patient was then categorized as either having a handlebar versus nonhandlebar injury. Additionally, each patient's injuries were classified according to affected body "zone(s)" and the need for intervention in relation to these injuries. During the course of chart review, several unique radiographic and history/physical findings were noted and are also reported.

RESULTS

During the study period, 385 patients were identified that met study criteria. Bicycle handlebars were involved in 27.8% (107/385) of injuries and 72.2% (278/385) were nonhandlebar injuries. There were differences in injury severity score, Head Abbreviated Injury Scale, length of stay between patients with handlebar versus nonhandlebar injuries, respectively. There were also differences in incidence of injuries across most body zones between patients with handlebar versus nonhandlebar injuries. There was statistically significant difference in need for intervention for abdominal solid organ injuries among handlebar versus nonhandlebar injuries mechanisms (21.6% vs 0%; P = 0.026), respectively. Sixteen patients with a handlebar injury underwent abdominal computed tomography (CT), which found only pericolic/pelvic free fluid or were negative for any disease and had normal/mildly elevated liver function test results at the time of arrival with otherwise normal laboratory workup results. Two patients required laparotomy for bowel injury and presented with peritonitis less than 12 hours after injury. The remaining patients did not have peritonitis on examination and were discharged without operative intervention 12 to 24 hours after injury without further event.

CONCLUSIONS

The bicycle handlebar is a unique mechanism of injury. The location, need for intervention, and the nature of the injury can vary significantly compared to other bicycle injuries. Handlebar injuries are more likely to cause abdominal and soft tissue injuries, whereas nonhandlebar injuries are more likely to cause extremity and skull/neck/central nervous system injuries. Because more than 20% of the reported handlebar injuries did not involve the abdomen or thoracoabdominal/extremity soft tissue as well as the variable presentation of handlebar injuries, it is imperative for the physician to consider this mechanism in all bicycle injuries. In addition, even within the same area of the body, handlebar injuries can be very different compared to nonhandlebar (i.e., orthopedic vs vascular injuries in the extremities). Physical examination and observation remain paramount when laboratory and radiographic workups are equivocal.

Traumatic abdominal wall hernias in children: A case for early exploration

PURPOSE

Traumatic abdominal wall hernia (TAWH) is a rare consequence of blunt abdominal trauma (BAT). We examined a series of patients suffering TAWH to evaluate its frequency, rate of associated concurrent intraabdominal injuries (CAI) and correlation with CT, management and outcomes.

METHODS

A Level 1 pediatric trauma center trauma registry was queried for children less than 18 years old suffering TAWH from BAT between 2009 and 2019.

RESULTS

9370 patients were admitted after BAT. TAWH was observed in 11 children, at incidence 0.1%. Eight children (73%) were male, at mean age 10 years, and mean ISS of 16. Six cases (55%) were because of MVC, three (27%) impaled by a handlebar or pole, and two (18%) dragged under large machinery. Seven (64%) had a CAI requiring operative or interventional management. Patients with CAI were similar to those without other injury, with 20% and 50% CT scan sensitivity and specificity for detection of associated injury, respectively. Five patients had immediate hernia repair with laparotomy for repair of intraabdominal injury, three had delayed repair, two have asymptomatic unrepaired TAWH, and one resolved spontaneously.

CONCLUSIONS

Children with TAWH have high rates of CAI requiring operative repair. CT scans have low sensitivity and specificity for detecting associated injuries. A high suspicion of injury and low threshold for exploration must be maintained in TAWH cases.

LEVEL OF EVIDENCE

IV.

Pediatric traumatic abdominal wall hernia as a component of the seatbelt syndrome: a case series and review of the literature

BACKGROUND

Blunt impact-induced traumatic abdominal wall hernia (TAWH) is an uncommon pediatric surgical problem classically associated with handlebar injury but increasingly seen with seatbelt use in motor vehicle collisions (MVC). Herein we describe the largest case series of pediatric TAWH to date and review the literature to establish the unique syndromic characteristics of MVC-associated TAWH.

METHODS

In this single-institution series, we discuss four pediatric patients, all with seatbelt-associated TAWH after high-speed MVC characterized by full-thickness disruption of the lateral abdominal wall. We then performed a review of the literature to identify additional pediatric MVC-associated TAWH and define the characteristics of patients who sustained this unique injury.

RESULTS

In addition to the four patients in our case series, five additional pediatric patients presenting with TAWH after restrained MVC were identified in the literature. Of these nine patients, eight (89%) presented with an obvious seatbelt sign (bruising/laceration to the abdominal wall). Six (67%) had associated injuries typical of the seatbelt syndrome, including four spinal flexion injuries (44%) and five bowel injuries requiring repair or resection (56%). Overall, 56% of seatbelt-associated TAWH occurred in children with a BMI percentile > 95%.

CONCLUSIONS

In this case series and literature review, we note a high rate of seatbelt syndrome injuries in pediatric patients presenting with TAWH after restrained MVC. Suspicion for TAWH should be high in children presenting with a seatbelt sign and should trigger a low threshold for pursuing additional axial imaging.

LEVEL OF EVIDENCE

Level IV; case series.

Utilization of CT imaging in minor pediatric head, thoracic, and abdominal trauma in the United States

BACKGROUND

Liberal use of CT scanning in children with blunt trauma risks unnecessary radiation exposure and cost. Recent literature questions the utility of whole-body CT in stable children without clinical evidence of significant injury, but this is often done based on injury mechanism. The purpose of this study is to quantify the utilization of CT scans of the head, chest, abdomen, and pelvis based on injury severity in these body regions and to assess the impact of American College of Surgeons (ACS) pediatric trauma center designation on CT utilization in children with minor or no injuries.

METHODS

We queried the National Trauma Databank for 2014, 2015, and 2016 to identify all patients 14 years and younger. Using Abbreviated Injury Scale (AIS) score as a proxy for injury severity, we analyzed the number of head, thoracic, and abdominal CT scans done for patients at low levels of injury severity (AIS 0-2) in each of these body regions and according to trauma center level designation (ACS I, II, III, standalone pediatric I or II, and non ACS accredited).

RESULTS

Of 257,661 children who were entered into the database for any reason, overall CT utilization was 20% for head, 5% for the chest and 9% for the abdomen and pelvis. Children with no injuries or minimal injury to the head were scanned 7% and 46% of the time, respectively, for the chest 3% and 13% and for the abdomen 6% and 30%. For all body regions and all levels of injury severity, level 1 stand-alone pediatric centers displayed significantly lower CT utilization rates than others.

CONCLUSION

CT scan rates for children with minimal or no injuries to the head, chest, abdomen and pelvis are significant. Level 1 stand-alone pediatric trauma centers are least likely to perform these studies. Widespread education and acceptance of clinical guidelines for imaging in stable patients throughout trauma systems could alleviate this disparity.

LEVEL OF EVIDENCE

Level III retrospective comparative study.

Strategies in liver Trauma

The management of pediatric liver trauma has evolved significantly over the last few decades. While surgical intervention was frequently and mostly unsuccessfully practiced during the first half of the last century, the 1960s were witness to the birth and gradual acceptance of non-operative management of these injuries. In 2000, the American Pediatric Surgical Association (APSA) Trauma Committee disseminated evidenced-based guidelines to help guide the non-operative management of pediatric blunt solid organ injury. The guidelines significantly contributed to conformity in the management of these patients. Since then, a number of well-designed studies have questioned the strict categorization of these injuries and have led to a renewed reliance on clinical signs of the patient's hemodynamic status. In 2019, APSA introduced an updated set of guidelines emphasizing the use of physiologic status rather than radiologic grade as a driver of clinical decision making for these injuries. This review will focus on liver injuries, in particular blunt injury, as this mechanism is by far the most commonly seen in children. Procedures required when non-operative management fails will be detailed, including surgery, angioembolization, and less commonly employed interventions. Finally, the updated inpatient and post-discharge aspects of care will be reviewed, including hemoglobin monitoring, bedrest, length of hospital stay, and activity restriction.

Predictive Model for Operative Intervention after Blunt Abdominal Trauma in Children with Equivocal CT Findings: A Pilot Study

BACKGROUND

To study the clinical and radiologic factors predicting the need for surgical intervention after blunt abdominal trauma (BAT) in children with equivocal computed tomography (CT) scan findings.

METHODS

We performed a retrospective review of the trauma database at our level I pediatric trauma center between 2011 and 2019. We selected patients with BAT and equivocal findings for surgical intervention on CT scan. We studied five factors: abdominal wall bruising (AWB), abdominal pain/tenderness (APT), thoracolumbar fracture, the presence of free fluid (FF), and the presence of solid organ injury, all previously reported in the literature to predict the need for operative intervention. We used t-test, the Kruskal-Wallis test and logistic regression to study the association of these factors with the need for operation in our pediatric cohort.

RESULTS

Of 3044 blunt trauma patients, 288 had abdominal CT scans with 61 patients demonstrating equivocal findings. Operation was performed for 12 patients (19.7%) confirming surgically correctable traumatic injuries. The need for surgical intervention was significantly associated with the age of the patients (P = 0.03), the presence of APT (P = 0.001), AWB (P = 0.01), and FF (P = 0.04). The presence of thoracolumbar fracture and solid organ injury were not significantly associated with the need for operation. For the subset of 37 patients who were injured in a motor vehicle crash, five (13.5%) required surgical intervention, which was significantly associated with the presence of AWB (P = 0.04), APT (P = 0.01), and FF (P = 0.03). A predictive model that used these factors produced a receiver operating characteristic curve of 0.86.

CONCLUSIONS

In cases of equivocal abdominal CT scan findings to evaluate BAT in children, the presence of abdominal wall tenderness, AWB, or FF may be significant factors predicting more accurately the need for operative intervention. A predictive model using the combination of clinical and image findings might determine with more certainty, the need for surgical intervention in children with BAT and equivocal CT findings. Validation on a larger multi-institutional data set should be done.

Three cases of paediatric pancreatic injury involving the main pancreatic duct

We report on 3 patients aged 9–12 years with pancreatic injury involving the main pancreatic duct. None of them presented with shock. They were initially transported to secondary emergency care facilities, leading to delays in diagnosis and treatment. Two patients underwent organ (spleen and pancreatic tail)-preserving surgery and one underwent non-operative management (NOM). They recovered and were discharged without major complications. Although the indications for NOM for paediatric pancreatic injury might increase in the future, we believe that it is preferable for patients to be transferred to the tertiary care hospital from the very beginning to recieve appropriate diagnosis and treatment.

Assessing outpatient follow-up care compliance, complications, and sequelae in children hospitalized for isolated traumatic abdominal injuries

BACKGROUND

Currently there is limited knowledge on compliance with follow-up care in pediatric patients after abdominal trauma. The Indiana Network for Patient Care (INPC) is a large regional health information exchange with both structured clinical data (e.g., diagnosis codes) and unstructured data (e.g., provider notes). The objective of this study is to determine if regional health information exchanges can be used to evaluate whether patients receive all follow-up care recommended by providers.

METHODS

We identified 61 patients treated at a Pediatric Level I Trauma Center who were admitted for isolated abdominal injuries. We analyzed medical records for two years following initial hospital discharge for injury using the INPC. The encounters were classified by the type of encounter: outpatient, emergency department, unplanned readmission, surgery, imaging studies, and inpatient admission; then further categorized into injury- and non-injury-related care, based on provider notes. We determined compliance with follow-up care instructions given at discharge and subsequent outpatient visits, as well as the prevalence of complications and sequelae.

RESULTS

After reviewing patient records, we found that 78.7% of patients received all recommended follow-up care, 6.6% received partial follow-up care, and 11.5% did not receive follow-up care. We found that 4.9% of patients developed complications after abdominal trauma and 9.8% developed sequelae in the two years following their initial hospitalization.

CONCLUSIONS

Our findings suggest that health information exchanges such as the INPC are useful in evaluation of follow-up care compliance and prevalence of complications/sequelae after abdominal trauma in pediatric patients.

LEVEL OF EVIDENCE

Level IV.