Nonoperative management of blunt liver and spleen injury in children: Evaluation of the ATOMAC guideline using GRADE

The Diagnosis and Management of Pediatric Blunt Abdominal Trauma-A Comprehensive Review

Blunt abdominal trauma in childhood has always been full of diagnostic and therapeutic challenges that have tested the clinical and radiological skills of pediatric surgeons and radiologists. Despite the guidelines and the studies carried out so far, to this day, there is no absolute consensus on certain points of view. Around the world, a paradigm shift towards non-operative treatment of hemodynamically stable children, with low complication rates, is noticeable. Children with blunt abdominal trauma require a standardized methodology to provide the best possible care with the best possible outcomes. This comprehensive review systematizes knowledge about all aspects of caring for children with blunt abdominal trauma, from pre-hospital to post-hospital care.

Contemporary National Trend in Surgical Management of Hemodynamically Unstable Pediatric Blunt Splenic Injury

BACKGROUND

Evaluation of response to blood transfusion after blunt splenic injury (BSI) may prevent the need for splenectomy. The aim of this study was to evaluate factors associated with splenectomy in pediatric patients with isolated BSI who presented with hemodynamic instability with a focus on timing of transfusion.

METHODS

The 2021 Trauma Quality Improvement Project database was queried for children ≤18 years with BSI who arrived with a shock index>1.1. Interfacility transfer patients and those with additional intra-abdominal injuries were excluded. Demographic, injury characteristic and timing, transfusion, operative, and outcome data were collected. A sub-analysis of patients without brain injury was also performed.

RESULTS

516 patients met inclusion criteria; 60.1% were male, with mean age 12.3 ± 5.5 years. Initial mean shock index was 1.4 ± 0.4, ISS was 31.7 ± 15.1, and GCS was 10.7 ± 5. Splenectomy occurred in 27% of patients. Among splenectomy patients, 26.2% did not receive blood prior to splenectomy. While treatment at a pediatric trauma center showed an increased OR of splenectomy in univariable analysis, when controlling for lack of transfusion, no differences in splenectomy persisted. Patient Age (aOR-1.26, p < 0.001), BSI grade (aOR-2.30, P < 0.001), male gender, (aOR-2.2, p = 0.003), being non-white (aOR-2.0) ISS (aOR-1.03, p = 0.003), and GCS (aOR-0.95, p = 0.034) were associated with splenectomy.

CONCLUSION

More than 26% of patients undergoing splenectomy did not receive blood prior to surgery. Differences in risk of splenectomy by center type seen on univariable analysis were not seen when controlling for transfusion. Evaluating response to blood transfusion may be an opportunity to reduce the frequency of splenectomy.

LEVEL OF EVIDENCE

Treatment Study Level III.

Outcomes after Embolization in Pediatric Abdominal Solid Organ Injury: A Trauma Center Experience

Background  Trauma is a significant cause of morbidity and mortality worldwide among children. Nonoperative management is the standard of care in hemodynamically stable children with blunt abdominal solid organ injury. Embolization is a potential pathway, which has shown increasing evidence for benefit in adult trauma patients. However, the data in children is limited. Materials and Methods  A retrospective analysis of hospital data of all children (<18 years of age), presenting to a tertiary-care trauma center in India, with history of blunt trauma from January 2021 to June 2023, was performed. Preprocedural imaging, angiographic and embolization details, number of blood transfusions, and length of hospital stay were assessed. Results  Two hundred and sixteen children (average age: 11.65 years) presented with a history of abdominal trauma during the study period. Eighty four children were FAST positive, out of whom, 67 patients had abdominal solid organ injury on computed tomography. Liver was the most commonly injured solid organ ( n  = 45), followed by the spleen and kidney. Ten children had solid abdominal organ arterial injuries for which eight children underwent embolization. The average length of hospital stay in embolization group ( n  = 8) was 4 days, as compared to 11 days in children undergoing operative management ( n  = 2). At 6 months follow-up, all children were asymptomatic. Conclusion  Superselective embolization is a safe and feasible procedure in appropriately selected children with abdominal injury.

Assessing associated factors for failure of nonoperative management in pediatric blunt liver and spleen injuries: a secondary analysis of the SHIPPs study

PURPOSE

The purpose of this study was to describe the characteristics of pediatric patients who underwent nonoperative management (NOM) for blunt splenic and hepatic injuries and to explore factors associated with NOM failure.

METHODS

This was a secondary analysis of a multicenter cohort study of pediatric patients with blunt liver and spleen injuries in Japan. Participants included pediatric trauma patients aged 16 years or younger between 2008 and 2019 with NOM, which was defined as no surgery provided within 6 h of hospital arrival. NOM failure, defined as abdominal surgery performed after 6 h of hospital arrival, was the primary outcome. Descriptive statistics were provided and exploratory analysis to assess the associations with outcome using logistic regression.

RESULTS

During the study period, 1339 met our eligibility criteria. The median age was 9 years, with a majority being male. The median Injury Severity Score (ISS) was 10. About 14.0% required transfusion within 24 h, and 22.3% underwent interventional radiology procedures. NOM failure occurred in 1.0% of patients and the in-hospital mortality was 0.7%. Factors associated with NOM failure included age, positive focused assessment with sonography for trauma (FAST), contrast extravasation on computed tomography (CT), severe liver injury, concomitant pancreas injury, concomitant gastrointestinal injury, concomitant mesenteric injury, and ISS.

CONCLUSIONS

In our study, NOM failure were rare. Older age, positive FAST, contrast extravasation on CT, severe liver injury, concomitant pancreas injury, concomitant gastrointestinal injury, concomitant mesenteric injury, and higher ISS were suggested as possible risk factors for NOM failure.

Multidisciplinary management of high-grade pediatric liver injuries

OBJECTIVE

To present our experience of multidisciplinary management of high-grade pediatric liver injuries.

INTRODUCTION

Pediatric high-grade liver injuries pose significant challenge to management due to associated morbidity and mortality. Emergency surgical intervention to control hemorrhage and biliary leak in these patients is usually suboptimal. Conservative management in selected high-grade liver injuries is now becoming standard of care. Management of hemobilia due to pseudoaneurysm formation and traumatic bile leaks requires multidisciplinary management.

METHODS

A retrospective review was undertaken for patients presenting with blunt liver injuries at two tertiary care centers in Karachi, Pakistan, from March 2021 to December 2022. Twenty-eight patients were identified, and four patients fulfilled the criteria for grade 4 and above blunt liver injury during this period.

RESULTS

One case with grade 4 liver injury developed hemobilia on 7th day of injury. He required two settings of angioembolization but had recurrent leak from pseudoaneurysm. He ultimately needed right hepatic artery ligation. Second patient presented with massive biliary peritonitis 2 days following injury. He was managed initially with tube laparostomy followed by ERCP and stent placement. The third patient developed large hemoperitoneum managed conservatively. One case with grade 5 injury expired during emergency surgery.

CONCLUSION

Conservative management of advanced liver injuries can result in significant morbidity and mortality due to high risk of complications. Trauma surgeons need to have multidisciplinary team for management of these patients to gain optimal outcome.

The use and timing of angioembolization in pediatric blunt liver and spleen injury

BACKGROUND

Nonoperative management (NOM) is the standard of care for the management of blunt liver and spleen injuries (BLSI) in the stable pediatric patient. Angiography with embolization (AE) is used as an adjunctive therapy in the management of adult BLSI patients, but it is rarely used in the pediatric population. In this planned secondary analysis, we describe the current utilization patterns of AE in the management of pediatric BLSI.

METHODS

After obtaining IRB approval at each center, cohort data was collected prospectively for children admitted with BLSI confirmed on CT at 10 Level I pediatric trauma centers (PTCs) throughout the United States from April 2013 to January 2016. All patients who underwent angiography with or without embolization for a BLSI were included in this analysis. Data collected included patient demographics, injury details, organ injured and grade of injury, CT finding specifics such as contrast blush, complications, failure of NOM, time to angiography and techniques for embolization.

RESULTS

Data were collected for 1004 pediatric patients treated for BLSI over the study period, 30 (3.0%) of which underwent angiography with or without embolization for BLSI. Ten of the patients who underwent angiography for BLSI failed NOM. For patients with embolized splenic injuries, splenic salvage was 100%. Four of the nine patients undergoing embolization of the liver ultimately required an operative intervention, but only one patient required hepatorrhaphy and no patient required hepatectomy after AE. Few angiography studies were obtained early during hospitalization for BLSI, with only one patient undergoing angiography within 1 hour of arrival at the PTC, and 7 within 3 hours.

CONCLUSION

Angioembolization is rarely used in the management of BLSI in pediatric trauma patients with blunt abdominal trauma and is generally used in a delayed fashion. However, when implemented, angioembolization is associated with 100% splenic salvage for splenic injuries.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Management of Pediatric Solid Organ Injuries

Solid organ injury (SOI) is common in children who experience abdominal trauma, and the management of such injuries has evolved significantly over the past several decades. In 2000, the American Pediatric Surgical Association (APSA) published the first societal guidelines for the management of blunt spleen and/or liver injury (BLSI), advocating for optimized resource utilization while maintaining patient safety. Nonoperative management (NOM) has become the mainstay of treatment for SOI, and since the publication of the APSA guidelines, numerous groups have evaluated how invasive procedures, hospitalization, and activity restrictions may be safely minimized in children with SOI. Here, we review the current evidence-based management guidelines in place for the treatment of injuries to the spleen, liver, kidney, and pancreas in children, including initial evaluation, inpatient management, and long-term care, as well as gaps that exist in the current literature that may be targeted for further optimization of protocols for pediatric SOI.

Follow-up computed tomography and unexpected hemostasis in non-operative management of pediatric blunt liver and spleen injury

PURPOSE

While follow-up CT and prophylactic embolization with angiography are often conducted during non-operative management (NOM) for BLSI, particularly in a high-grade injury, the utility of early repeated CT for preventing unexpected hemorrhage remains unclear. This study aimed to elucidate whether early follow-up computerized tomography (CT) within 7 days after admission would decrease unexpected hemostatic procedures on pediatric blunt liver and spleen injury (BLSI).

METHODS

A post-hoc analysis of a multicenter observational cohort study on pediatric patients with BLSI (2008-2019) was conducted on those who underwent NOM, in whom the timing of follow-up CT were decided by treating physicians. The incidence of unexpected hemostatic procedure (laparotomy and/or emergency angiography for ruptured pseudoaneurysm) and complications related to BLSI were compared between patients with and without early follow-up CT within 7 days. Inverse probability weighting with propensity scores adjusted patient demographics, comorbidities, mechanism and severity of injury, initial resuscitation, and institutional characteristics.

RESULTS

Among 1320 included patients, 552 underwent early follow-up CT. Approximately 25% of patients underwent angiography on the day of admission. The incidence of unexpected hemostasis was similar between patients with and without early repeat CT (8 [1.4%] vs. 6 [0.8%]; adjusted OR, 1.44 [0.62-3.34]; p = 0.40). Patients with repeat CT scans more frequently underwent multiple angiographies (OR, 2.79 [1.32-5.88]) and had more complications related to BLSI, particularly bile leak (OR, 1.73 [1.04-2.87]).

CONCLUSION

Follow-up CT scans within 7 days was not associated with reduced unexpected hemostasis in NOM for pediatric BLSI.

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.

Management of complex pediatric and adolescent liver trauma: adult vs pediatric level 1 trauma centers

PURPOSE

Management of high-grade pediatric and adolescent liver trauma can be complex. Studies suggest that variation exists at adult (ATC) vs pediatric trauma centers (PTC); however, there is limited granular comparative data. We sought to describe and compare the management and outcomes of complex pediatric and adolescent liver trauma between a level 1 ATC and two PTCs in a large metropolitan city.

METHODS

A retrospective review of pediatric and adolescent (age < 21 years) patients with American Association for the Surgery of Trauma (AAST) Grade 4 and 5 liver injuries managed at an ATC and PTCs between 2016 and 2022 was performed. Demographic, clinical, and outcome data were obtained at the ATC and PTCs. Primary outcomes included rates of operative management and use of interventional radiology (IR). Secondary outcomes included packed red blood cell (pRBC) utilization, intensive care unit (ICU) length of stay (LOS), and hospital LOS.

RESULTS

One hundred forty-four patients were identified, seventy-five at the ATC and sixty-nine at the PTC. The cohort was predominantly black (65.5%) males (63.5%). Six injuries (8.7%) at the PTC and forty-five (60%) injuries at the ATC were penetrating trauma. Comparing only blunt trauma, ATC patients had higher Injury Severity Score (median 37 vs 26) and ages (20 years vs 9 years). ATC patients were more likely to undergo operative management (26.7% vs 11.0%, p = 0.016) and utilized IR more (51.9% vs 4.8%, p < 0.001) compared to the PTC. The patients managed at the ATC required higher rates of pRBC transfusions though not statistically significant (p = 0.06). There were no differences in mortality, ICU, or hospital LOS.

CONCLUSION

Our retrospective review of high-grade pediatric and adolescent liver trauma demonstrated higher rates of IR and operating room use at the ATC compared to the PTC in the setting of higher Injury Severity Score and age. While the PTC successfully managed > 95% of Grade 4/5 liver injuries non-operatively, prospective data are needed to determine the optimal algorithm for management in the older adolescent population.

LEVEL OF EVIDENCE

Level IV.

A rare presentation of spontaneous splenic rupture from plasma cell leukaemia-a case report

Spontaneous/atraumatic splenic rupture is rare, and often associated with underlying infectious disease, or haematological malignancy. Plasma cell leukaemia (PCL) is a rare and aggressive subtype of multiple myeloma, with a higher prevalence of hepatosplenomegaly with a bleeding diathesis from secondary to thrombocytopaenia. We report the case of an 82-year-old male presenting to the emergency department with altered mentation and complaints of left abdominal pain. He presented with haemorrhagic shock. Imaging revealed a spontaneous splenic rupture. He underwent emergency laparotomy and splenectomy for which the histopathology yielded a diagnosis of PCL as the cause for rupture. He received four courses of bortezomib and hyperCVAD 1A therapy. After a long 64-day admission, he recovered well and was discharged home with outpatient haematology/oncology follow-up.

Association of Contrast Extravasation Grade With Massive Transfusion in Pediatric Blunt Liver and Spleen Injuries: A Multicenter Retrospective Cohort Study

BACKGROUND

This study aimed to assess whether the grade of contrast extravasation (CE) on CT scans was associated with massive transfusion (MT) requirements in pediatric blunt liver and/or spleen injuries (BLSI).

METHODS

This multicenter retrospective cohort study included pediatric patients (≤16 years old) who sustained BLSI between 2008 and 2019. MT was defined as transfusion of all blood products ≥40 mL/kg within the first 24 h of admission. Associations between CE and MT requirements were assessed using multivariate logistic regression analysis with cluster-adjusted robust standard errors to calculate the adjusted odds ratio (AOR).

RESULTS

A total of 1407 children (median age: 9 years) from 83 institutions were included in the analysis. Overall, 199 patients (14 %) received MT. CT on admission revealed that 54 patients (3.8 %) had CE within the subcapsular hematoma, 100 patients (7.1 %) had intraparenchymal CE, and 86 patients (6.1 %) had CE into the peritoneal cavity among the overall cohort. Multivariate analysis, adjusted for age, sex, age-adjusted shock index, injury severity, and laboratory and imaging factors, showed that intraparenchymal CE and CE into the peritoneal cavity were significantly associated with the need for MT (AOR: 2.50; 95 % CI, 1.50-4.16 and AOR: 4.98; 95 % CI, 2.75-9.02, respectively both p < 0.001). The latter significant association persisted in the subgroup of patients with spleen and liver injuries.

CONCLUSION

Active CE into the free peritoneal cavity on admission CT was independently associated with a greater probability of receiving MT in pediatric BLSI. The CE grade may help clinicians plan blood transfusion strategies.

LEVEL OF EVIDENCE

Level 4; Therapeutic/Care management.

Pediatric Blunt Splenic Trauma: Disparities in Management and Outcomes

INTRODUCTION

While nonoperative management has become widely accepted, whether nonoperative management of blunt splenic trauma is standardized across pediatric trauma centers and different racial groups warrants further investigation. Using the National Trauma Database, the purpose of this study was to quantify the differences in the management of pediatric splenic trauma across different pediatric trauma centers, with respect to injury severity, race, ethnicity, and insurance.

METHODS

Patients under 20 y of age with blunt splenic trauma reported to the 2018 and 2019 National Trauma Data Bank were identified. Primary outcomes were splenectomy, embolization, transfusion, mortality, injury severity score (ISS), and length of hospital stay (LOS) and length of intensive care unit stay. Continuous data and categorical data were analyzed using ANOVA and Chi-squared test, respectively. Nearest 1:1 neighbor matching was performed between minority patients and White patients. P < 0.05 for all comparative analyses was considered statistically significant.

RESULTS

Of the total cohort (n = 1919), 70.3% identified as White, while 21.6% identified as Black or Hispanic. The mortality rate was 0.3%. Among different race categories, the frequency of spleen embolization (P = 0.99), splenectomy (P = 0.99), blood transfusion (P = 1), and mortality (P = 1), were not significantly different. After controlling for ISS and age with propensity score matching, the mean hospital LOS remained significantly higher in minority patients, with a mean of 5.44 d compared to 4.72 d (P = 0.05). Mean length of intensive care unit stay was not significantly different after propensity matching, with a mean of 1.79 d and 1.56 spent in the ICU for minority and White patients respectively (P = 0.17). While propensity score matching preserved statistical significance, the ISS for the minority group remained 1.12 times higher than the ISS of the Caucasian group. There was no statistically significant difference among races with respect to different payment methods and insurance status, although Black and Hispanic patients were proportionally underinsured.

CONCLUSIONS

While minority patients had a relatively higher number of operative interventions and longer hospital and ICU stays, after propensity score matching, mean ISS remained higher in the minority group. Our findings suggest that injury severity is likely to influence the difference in LOS between the two groups. Furthermore, our data highlight how nonoperative management is not standardized across pediatric trauma centers.

National Management Trends in Pediatric Splenic Trauma - Are We There yet?

INTRODUCTION

Guidelines recommend nonoperative management of blunt splenic injury (BSI) for hemodynamically stable children. The aim of this study was to determine the contemporary national trends of nonoperative management in pediatric BSI.

METHODS

A retrospective review was preformed utilizing KIDS database between 2012 and 2019. Pediatric BSI cases age ≤16 years were selected for analysis. Patient demographics, severity, and interventions were compared between hospital types.

RESULTS

8,296 BSIs were identified, with 74.3% treated at non-pediatric hospitals. Overall, 96.3% of BSI were nonoperative; 2.5% undergoing angioembolization. Rates of splenectomy from 2012 to 2019 remained stable (6.8% versus 7.1% (p = 0.856)). Splenic injuries treated at adult hospitals were more likely to undergo operative management (11.9% versus 4.4%, OR 2.94, p < 0.001) and more likely to undergo angiography (4.8% vs 1.3%, OR 3.133, p < 0.001). On multivariate regression pediatric BSI treated at adult centers were associated with triple the risk of splenectomy (OR 3.50, p < 0.001). Over seven years, high grade BSI treated at children's hospitals increased from 14.6% to 51.7% (p < 0.001) and, splenectomy rates at children's hospitals increased from 1% to 4% (p < 0.001).

CONCLUSION

More than 70% of pediatric splenic injuries are treated at adult hospitals, however, children's hospitals predominately caring for high-grade BSI. After controlling for confounding factors, children treated at adult centers continue to have 3-fold likelihood of splenectomy. Over the last 7 years, pediatric hospitals have seen a significant rise in their overall splenectomy rate, which may suggest a shift in case severity to children's hospitals.

LEVEL OF EVIDENCE

Level III.

TYPE OF STUDY

Treatment study.

Mobility and Sporting Activity After Renal Trauma: A Survey Regarding Best Clinical Practice During the Recovery Stage

OBJECTIVE

To evaluate strategies that are followed after pediatric renal trauma during the recovery stage, with an emphasis on mobility and involvement in subsequent sporting activities. Renal trauma is the most common urogenital trauma in children. The American Association for the Surgery of Trauma (AAST) scale is most commonly used to stratify the severity of injury. There is no consensus in the existing literature with respect to the recovery stage following renal trauma.

METHODS

A survey was constructed by the European Association of Urology (EAU) - Young Academic Urologists (YAU) Pediatric Urology Working Group and then made digitally available on SurveyMonkey. The survey consists of 15 questions exploring relevant factors and timing to start again with mobility and activity.

RESULTS

In total 153 people responded, of whom 107 completed the entire survey. The presence of pain and severity of trauma were acknowledged as most important factors to commence mobilization, whereas presence of hematuria was identified as an additional factor for sporting activity. Regardless of severity of trauma a minimum of 90% of respondents recommend return to noncontact sports within 12weeks. For contact sports, a minimum of 33% of respondents advised >12weeks minimum before starting again. A small number of respondents would never allow sporting activities again.

CONCLUSION

The time to allow sporting activity shows high variation among the respondents, some even restricting sporting activities completely. This survey highlights the need for a standardized protocol based on multicenter follow-up data.

Embolization for pediatric trauma

BACKGROUND

The management of pediatric trauma with trans-arterial embolization is uncommon, even in level 1 trauma centers; hence, there is a dearth of literature on this subject compared to the adult experience.

OBJECTIVE

To describe a single-center, level 1 trauma center experience with arterial embolization for pediatric trauma.

MATERIALS AND METHODS

A retrospective review was performed to identify demographics, transfusion requirements, pre-procedure imaging, procedural details, adverse events, and arterial embolization outcomes over a 19-year period. Twenty children (age 4.5 months to 17 years, median 13.5 years; weight 3.6 to 108 kg, median 53 kg) were included. Technical success was defined as angiographic resolution of the bleeding-related abnormality on post-embolization angiography or successful empiric embolization in the absence of an angiographic finding. Clinical success was defined as not requiring additional intervention after embolization.

RESULTS

Seventy-five percent (n=15/20) of patients required red blood cell transfusions prior to embolization with a mean volume replacement 64 ml/kg (range 12-166 ml/kg) and the median time from injury to intervention was 3 days (range 0-16 days). Technical success was achieved in 100% (20/20) of children while clinical success was achieved in 80% (n=16/20). For the 4 children (20%) with continued bleeding following initial embolization, 2 underwent repeat embolization, 1 underwent surgery, and 1 underwent repeat embolization and surgery. Mortality prior to discharge was 15% (n=3). A post-embolization mild adverse event included one groin hematoma, while a severe adverse event included one common iliac artery pseudoaneurysm requiring open surgical ligation.

CONCLUSIONS

In this single-center experience, arterial embolization for hemorrhage control in children after trauma is feasible but can be challenging and the clinical failure rate of 20% in this series reflects this complexity. Standardization of pre-embolization trauma assessment parameters and embolic techniques may improve outcomes.

Validation for Abbreviated Hospital Stay in Pediatric Patients with Solid Organ Injury

BACKGROUND

In 2000, the American Pediatric Surgical Association (APSA) published guidelines for the management of pediatric solid organ injury, recommending a hospital length of stay (LOS) of grade of injury plus 1 day. Since the publication of these guidelines, several studies have suggested that it is safe to discharge patients sooner based upon hemodynamic and clinical factors. The results of several of these studies have been confounded by the existence of other injuries. The aim of this study was to examine LOS and outcomes in children with strictly isolated solid organ injuries.

MATERIALS AND METHODS

This is a 12-year retrospective review of pediatric patients with isolated trauma to the kidney, liver, or spleen to determine LOS. Patients were excluded for associated intracranial, neurologic, orthopedic, or pulmonary injuries which would impact length of stay. Documented hemodynamic parameters were reviewed as determinants of patient stability.

RESULTS

A total of 156 patients were included in the study. The projected average LOS for all patients based on the 2000 APSA guidelines would have been 3.71 ± 0.98 days. The actual average LOS for all patients 2.85 ± 3.32 days. Need for operation, ICU stay, and transfusion all contributed to increased LOS. The number of episodes of abnormal vitals positively correlated with increased LOS.

DISCUSSION

This study validates that management of isolated solid organ injuries based upon hemodynamic parameters and clinical status is safe and decreases hospital length of stay. Consistently normal vital signs indicate these children can be safely discharged sooner.

The Blunt Liver and Spleen Trauma (BLAST) audit: national survey and prospective audit of children with blunt liver and spleen trauma in major trauma centres

PURPOSE

To compare the reported and observed management of UK children with blunt liver or spleen injury (BLSI) to the American Pediatric Surgical Association (APSA) 2019 BLSI guidance.

METHODS

UK Paediatric Major Trauma Centres (pMTCs) undertook 1 year of prospective data collection on children admitted to or discussed with those centres with BLSI and an online questionnaire was distributed to all consultants who care for children with BLSI in those centres.

RESULTS

All 21/21 (100%) pMTCs participated; 131 patients were included and 100/152 (65%) consultants responded to the survey. ICU care was reported and observed to be primarily determined using haemodynamic status or concomitant injuries rather than injury grade, in accordance with APSA guidance. Bed rest was reported to be determined by grade of injury by 63% of survey respondents and observed in a similar proportion of patients. Contrary to APSA guidance, follow-up radiological assessment of the injured spleen or liver was undertaken in 44% of patients before discharge and 32% after discharge, the majority of whom were asymptomatic.

CONCLUSIONS

UK management of BLSI differs from many aspects of APSA guidance. A shift towards using clinical features to determine ICU admission and readiness for discharge is demonstrated, in line with a strong evidence base. However, routine bed rest and re-imaging after BLSI is common, contrary to APSA guidance. This disparity may exist due to concern that evidence around the incidence, presentation and natural history of complications after conservatively managed BLSI, particularly bleeding from pseudoaneurysms, is weak.

Utility of continuous pulse CO-oximetry for hemoglobin monitoring in pediatric patients with solid organ injuries at level 1 trauma centers: A pilot study

INTRODUCTION

Hemorrhage is a major cause of preventable death in injured children. Monitoring after admission often requires multiple blood draws, which have been shown to be stressful in pediatric patients. The Rainbow-7 device is a continuous pulse CO-oximeter that measures multiple wavelengths of light, permitting continuous estimation of the total hemoglobin (Hb) level. The purpose of this study was to evaluate the utility of the noninvasive Hb measurement for monitoring pediatric trauma patients admitted with solid organ injury.

METHODS

This is a prospective, dual-center, observational trial for patients younger than age 18 years admitted to a Level I pediatric trauma center. Following admission, blood was routinely measured as per current solid organ injury protocols. Noninvasive Hb monitoring was initiated after admission. Time-synced data for Hb levels were compared with that taken using blood draws. Data were evaluated using bivariate correlation, linear regression, and Bland-Altman analysis.

RESULTS

Over a 1-year period, 39 patients were enrolled. The mean ± SD age was 11 ± 3.8 years. Forty-six percent (n = 18) of patients were male. The mean ± SD Injury Severity Score was 19 ± 13. The average change in Hb levels between laboratory measurements was -0.34 ± 0.95 g/dL, and the average change in noninvasive Hb was -0.12 ± 1.0 g/dL per measurement. Noninvasive Hb values were significantly correlated with laboratory measurements ( p < 0.001). Trends in laboratory Hb measurements were highly correlated with changes in noninvasive levels ( p < 0.001). Bland-Altman analysis demonstrated similar deviation from the mean throughout the range of Hb values, but the differences between measurements were increased by anemia, African American race, and elevated shock index, pediatric age-adjusted score and Injury Severity Score.

CONCLUSION

Noninvasive Hb values demonstrated correlation with measured Hb concentration as isolated measurements and trends, although results were affected by skin pigmentation, shock, and injury severity. Given the rapid availability of results and the lack of requirement of venipuncture, noninvasive Hb monitoring may be a valuable adjunct for pediatric solid organ injury protocols. Further study is required to determine its role in management.

LEVEL OF EVIDENCE

Dianostic Test or Criteria; Level III.

In Solid Organ Injury Patients Requiring Blood Transfusion, Hemostatic Procedures are Associated with Improved Survival Over Observation

Introduction

Selective nonoperative management (NOM) is the standard of care for blunt solid organ injury (SOI). Hemodynamic instability is a contraindication for NOM, but it is unclear whether the need for blood transfusion should be a criterion for instability. This study looks at the outcome of blood-transfused SOI patients to determine whether NOM is safe for this group.

Methods

This is a retrospective cohort study using the National Trauma Data Bank years 2017 through 2019. We selected patients with blunt liver, spleen, and kidney injuries. Within this group, we compared the mortality for those managed with NOM versus the hemostatic procedures of laparotomy and angioembolization. Significance for univariate analysis is tested with Chi-square for categorical variables. Multivariate analysis is performed with Cox proportional hazards regression with time-dependent covariate.

Results

108,718 (3.5%) patients for the years 2017 through 2019 had a SOI. 20,569 (18.9%) of these received at least one unit of packed red blood cells (PRBCs) within the first 4 h. Of the SOI patients who received blood, 8264 (40.2%) underwent laparotomy only, 2924 (14.2%) underwent embolization only, and 1119 (5.4%) underwent both procedures. The adjusted odds ratios (ORs) of death for transfused SOI patients who underwent laparotomy only, embolization only, and both procedures are 0.93 (P = not significant), 0.27 (P < 0.001), and 0.48 (P < 0.001), respectively. The ORs of death with laparotomy for patients receiving >1 through 4 units are 0.87, 0.78, 0.75, and 0.72, respectively (P ≤ 0.01 for all). For embolization, the ORs are 0.27, 0.30, 0.30, and 0.30, respectively (P < 0.001 for all).

Conclusion

Laparotomy is independently associated with survival for patients who receive >1 unit of PRBCs. Angioembolization is independently associated with survival for the entire cohort, including transfused patients. Given the protective association of laparotomy in the blood-transfused SOI group, need for blood transfusion should be considered a meaningful index of instability and a relative indication for laparotomy. The protective association with angioembolization supports current practices for angioembolization of high-risk patients in the transfused and nontransfused groups.

Analysis of the efficacy and safety of conservative treatment of blunt abdominal trauma in children: retrospective study. Conservative treatment of blunt abdominal trauma in children

INTRODUCTION

in Brazil, trauma is responsible for 40% of deaths in the age group between 5 and 9 years old, and 18% between 1 and 4 years, and bleeding is the leading cause of preventable death in the traumatized child. Conservative management of blunt abdominal trauma with solid organs injury - started in the 60s - is the current world trend, with studies showing survival rates above 90%. The objective was to assess the efficacy and safety of conservative treatment in children with blunt abdominal trauma treated at the Clinical Hospital of the University of Campinas, in the last five years.

METHODS

retrospective analysis of medical records of patients classified by levels of injury severity, in 27 children.

RESULTS

only one child underwent surgery for initial failure of conservative treatment (persistent hemodynamic instability), resulting in a 96% overall success rate of the conservative treatment. Five other children (22%) developed late complications that required elective surgery: a bladder injury, two cases of infected perirenal collections (secondary to injury of renal collecting system), a pancreatic pseudocyst and a splenic cyst. Resolution of the complications was attained in all children, with anatomical and functional preservation of the affected organ. There were no deaths in this series.

CONCLUSION

the conservative initial approach in the treatment of blunt abdominal trauma was effective and safe with high resolution and low rate of complications leading to a high preservation rate of the affected organs. Level of evidence III - prognostic and therapeutic study.

Updated APSA Guidelines for the Management of Blunt Liver and Spleen Injuries

BACKGROUND

Non-operative management of blunt liver and spleen injuries was championed initially in children with the first management guideline published in 2000 by the American Pediatric Surgical Association (APSA). Multiple articles have expanded on the original guidelines and additional therapy has been investigated to improve care for these patients. Based on a literature review and current consensus, the management guidelines for the treatment of blunt liver and spleen injuries are presented.

METHODS

A recent literature review by the APSA Outcomes committee [2] was utilized as the basis for the guideline recommendations. A task force was assembled from the APSA Committee on Trauma to review the original guidelines, the literature reported by the Outcomes Committee and then to develop an easy to implement guideline.

RESULTS

The updated guidelines for the management of blunt liver and spleen injuries are divided into 4 sections: Admission, Procedures, Set Free and Aftercare. Admission to the intensive care unit is based on abnormal vital signs after resuscitation with stable patients admitted to the ward with minimal restrictions. Procedure recommendations include transfusions for low hemoglobin (<7 mg/dL) or signs of ongoing bleeding. Angioembolization and operative exploration is limited to those patients with clinical signs of continued bleeding after resuscitation. Discharge is based on clinical condition and not grade of injury. Activity restrictions remain the same while follow-up imaging is only indicated for symptomatic patients.

CONCLUSION

The updated APSA guidelines for the management of blunt liver and spleen injuries present an easy-to-follow management strategy for children.

LEVEL OF EVIDENCE

Level 5.

Failure-to-rescue and mortality after emergent pediatric trauma laparotomy: How are the children doing?

INTRODUCTION

Emergent trauma laparotomy is associated with mortality rates of up to 40%. There is a paucity of data on the outcomes of emergent trauma laparotomies performed in the pediatric population. The aim of our study was to describe the outcomes, including mortality and FTR, among pediatric trauma patients undergoing emergent laparotomy and identify factors associated with failure-to-rescue (FTR).

METHODS

We performed a one-year (2017) retrospective cohort analysis of the American College of Surgeons Trauma Quality Improvement Program dataset. All pediatric trauma patients (age <18 years) who underwent emergent laparotomy (laparotomy performed within 2 h of admission) were included. Outcome measures were major in-hospital complications, overall mortality, and failure-to-rescue (death after in-hospital major complication). Multivariate regression analysis was performed to identify factors independently associated with failure-to-rescue.

RESULTS

Among 120,553 pediatric trauma patients, 462 underwent emergent laparotomy. Mean age was 14±4 years, 76% of patients were male, 49% were White, and 50% had a penetrating mechanism of injury. Median ISS was 25 [13-36], Abdomen AIS was 3 [2-4], Chest AIS was 2 [1-3], and Head AIS was 2 [0-5]. The median time in ED was 33 [18-69] minutes, and median time to surgery was 49 [33-77] minutes. The most common operative procedures performed were splenectomy (26%), hepatorrhaphy (17%), enterectomy (14%), gastrorrhaphy (14%), and diaphragmatic repair (14%). Only 22% of patients were treated at an ACS Pediatric Level I trauma center. The most common major in-hospital complications were cardiac (9%), followed by infectious (7%) and respiratory (5%). Overall mortality was 21%, and mortality among those presenting with hypotension was 31%. Among those who developed in-hospital major complications, the failure-to-rescue rate was 31%. On multivariate analysis, age younger than 8 years, concomitant severe head injury, and receiving packed red blood cell transfusion within the first 24 h were independently associated with failure-to-rescue.

CONCLUSIONS

Our results show that emergent trauma laparotomies performed in the pediatric population are associated with high morbidity, mortality, and failure-to-rescue rates. Quality improvement programs may use our findings to improve patient outcomes, by increasing focus on avoiding hospital complications, and further refinement of resuscitation protocols.

LEVEL OF EVIDENCE

Level IV STUDY TYPE: Epidemiologic.

Therapeutic strategies for pseudoaneurysm following blunt liver and spleen injuries: A multicenter cohort study in the pediatric population

BACKGROUND

Little guidance exists for the treatment of pseudoaneurysm (PA) following pediatric blunt liver and/or spleen injuries (BLSIs). We aimed to describe the incidence of delayed PA development and the subsequent clinical course of PA in pediatric BLSIs.

METHODS

This multicenter retrospective cohort study from Japan included pediatric patients (16 years and younger) who sustained BLSIs from 2008 to 2019. The cohort was divided into four groups based on hemostatic intervention within 48 hours of admission, namely, nonoperative management (NOM), NOM with interventional radiology (IR), operative management (OM), and combined IR/OM. Descriptive statistics were used to describe the incidence of delayed PA among the groups and to characterize the clinical course of any PAs.

RESULTS

A total of 1,407 children (median age, 9 years) from 83 institutions were included. The overall number (incidence) of cases of delayed PA formation was 80 (5.7%), and the number with delayed PA rupture was 16 cases (1.1%) in the entire cohort. Patients treated with NOM (1,056), NOM with IR (276), OM (53), and combined IR/OM (22) developed 43 (4.1%), 32 (12%), 2 (3.8%), and 3 (14%) delayed PAs, respectively. Among patients who developed any PAs, 39% of patients underwent prophylactic IR for unruptured PA, while 13% required emergency angioembolization for delayed PA rupture, with one ruptured case requiring total splenectomy. At least 45% of patients experienced spontaneous resolution of PA without any interventions.

CONCLUSION

Our results suggest that the risk of delayed PA still exists even after acute phase IR as an adjunct to NOM for BLSIs in children, indicating the necessity of a period of further observation. While endovascular interventions are usually successful for PA management, including rupture cases, given the high incidence of spontaneous resolution, the ideal management of PA remains to be investigated in future studies.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Management of pediatric blunt abdominal trauma with split liver or spleen injuries: a retrospective study

BACKGROUND

Blunt abdominal trauma is a prevailing cause of pediatric morbidity and mortality. It constitutes the most frequent type of pediatric injuries. Contrast-enhanced sonography (CEUS) and contrast-enhanced computed tomography (CECT) are considered pivotal diagnostic modalities in hemodynamically stable patients.

AIM

To report the experience in management of pediatric split liver and spleen injuries using CEUS and CECT.

PATIENTS AND METHODS

This study included 246 children who sustained blunt abdominal trauma, and admitted and treated at three tertiary hospitals in the period of 5 years. Primary resuscitation was offered to all children based on the advanced trauma and life support (ATLS) protocol. A special algorithm for decision-making was followed. It incorporated the FAST, baseline ultrasound (US), CEUS, and CECT. Patients were treated according to the imaging findings and hemodynamic stability.

RESULTS

All 246 children who sustained a blunt abdominal were studied. Patients' age was 10.5 ± 2.1. Road traffic accidents were the most common cause of trauma; 155 patients (63%). CECT showed the extent of injury in 153 patients' spleen (62%) and 78 patients' liver (32%), while the remaining 15 (6%) patients had both injuries. CEUS detected 142 (57.7%) spleen injury, and 67 (27.2%) liver injury.

CONCLUSIONS

CEUS may be a useful diagnostic tool among hemodynamically stable children who sustained low-to-moderate energy isolated blunt abdominal trauma. It may be also helpful for further evaluation of uncertain CECT findings and follow-up of conservatively managed traumatic injuries.

Hemodilution in pediatric trauma: Defining the expected hemoglobin changes in patients with liver and/or spleen injury: An ATOMAC+ secondary analysis

BACKGROUND

Many children with blunt liver and/or spleen injury (BLSI) never bleed intraperitoneally. Despite this, decreases in hemoglobin are common. This study examines initial and follow up measured hemoglobin values for children with BLSI with and without evidence of intra-abdominal bleeding.

METHODS

Children ≤18 years of age with BLSI between April 2013 and January 2016 were identified from the prospective ATOMAC+ cohort. Initial and follow up hemoglobin levels were analyzed for 4 groups with BLSI: (1) Non bleeding; (2) Bleeding, non transfused (3) Bleeding, transfused, and (4) Bleeding resulting in non operative management (NOM) failure.

RESULTS

Of 1007 patients enrolled, 767 were included in one or more of four study cohorts. Of 131 non bleeding patients, the mean decrease in hemoglobin was 0.83 g/dL (+/-1.35) after a median of 6.3 [5.1,7.0] hours, (p = 0.001). Follow-up hemoglobin levels in patients with and without successful NOM were not different. For patients with an initial hemoglobin >9.25 g/dL, the odds ratio (OR) for NOM failure was 14.2 times less, while the OR for transfusion was 11.4 times less (p = 0.001).

CONCLUSION

Decreases in hemoglobin are expected after trauma, even if not bleeding. A hemoglobin decrease of 2.15 g/dL [0.8 + 1.35] would still be within one standard deviation of a non bleeding patient. An initial low hemoglobin correlates with failure of NOM as well as transfusion, thereby providing useful information. By contrast, subsequent hemoglobin levels do not appear to guide the need for transfusion, nor correlate with failure of NOM. These results support initial hemoglobin measurement but suggest a lack of utility for routine rechecking of hemoglobin.

LEVEL OF EVIDENCE

Level II Prognostic Study.

Pediatric trauma and emergency surgery: an international cross-sectional survey among WSES members

BACKGROUND

In contrast to adults, the situation for pediatric trauma care from an international point of view and the global management of severely injured children remain rather unclear. The current study investigates structural management of pediatric trauma in centers of different trauma levels as well as experiences with pediatric trauma management around the world.

METHODS

A web-survey had been distributed to the global mailing list of the World Society of Emergency Surgery from 10/2021-03/2022, investigating characteristics of respondents and affiliated hospitals, case-load of pediatric trauma patients, capacities and infrastructure for critical care in children, trauma team composition, clinical work-up and individual experiences with pediatric trauma management in response to patients´ age. The collaboration group was subdivided regarding sizes of affiliated hospitals to allow comparisons concerning hospital volumes. Comparable results were conducted to statistical analysis.

RESULTS

A total of 133 participants from 34 countries, i.e. 5 continents responded to the survey. They were most commonly affiliated with larger hospitals (> 500 beds in 72.9%) and with level I or II trauma centers (82.0%), respectively. 74.4% of hospitals offer unrestricted pediatric medical care, but only 63.2% and 42.9% of the participants had sufficient experiences with trauma care in children ≤ 10 and ≤ 5 years of age (p = 0.0014). This situation is aggravated in participants from smaller hospitals (p < 0.01). With regard to hospital size (≤ 500 versus > 500 in-hospital beds), larger hospitals were more likely affiliated with advanced trauma centers, more elaborated pediatric intensive care infrastructure (p < 0.0001), treated children at all ages more frequently (p = 0.0938) and have higher case-loads of severely injured children < 12 years of age (p = 0.0009). Therefore, the majority of larger hospitals reserve either pediatric surgery departments or board-certified pediatric surgeons (p < 0.0001) and in-hospital trauma management is conducted more multi-disciplinarily. However, the majority of respondents does not feel prepared for treatment of severe pediatric trauma and call for special educational and practical training courses (overall: 80.2% and 64.3%, respectively).

CONCLUSIONS

Multi-professional management of pediatric trauma and individual experiences with severely injured children depend on volumes, level of trauma centers and infrastructure of the hospital. However, respondents from hospitals at all levels of trauma care complain about an alarming lack of knowledge on pediatric trauma management.

Análise de eficácia e segurança do tratamento conservador do trauma abdominal contuso em crianças: estudo retrospectivo. Tratamento conservador de trauma abdominal contuso em crianças

RESUMO Introdução: no Brasil, o trauma é responsável por 40% dos óbitos na faixa etária entre 5 e 9 anos, e 18% entre 1 e 4 anos, e o sangramento é a principal causa de prevenção morte na criança traumatizada. O manejo conservador de trauma abdominal contuso com lesão de órgãos sólidos - iniciado na década de 60 - é a tendência mundial atual, com estudos mostrando taxas de sobrevivência acima de 90%. O objetivo do presente trabalho foi avaliar a eficácia e segurança do tratamento conservador em crianças com trauma abdominal contuso tratado no Hospital das Clínicas da Universidade de Campinas, nos últimos cinco anos. Métodos: análise retrospectiva de prontuários de pacientes classificados por níveis de gravidade da lesão, em 27 crianças. Resultados: apenas uma criança foi submetida a cirurgia por falha inicial do tratamento conservador (instabilidade hemodinâmica persistente), resultando em uma taxa de sucesso global de 96% do tratamento conservador inicial. Outras cinco crianças (22%) desenvolveram complicações tardias que exigiram cirurgias eletivas: lesão na bexiga, dois casos de coleção perirenal infectada (secundária à lesão de sistema de coleta renal), um pseudocisto pancreático e um cisto esplênico. Resolução da complicação foi atingida em todas as crianças, com preservação anatômica e funcional do órgão afetado. Não houve mortes nesta série. Conclusão: a abordagem inicial conservadora no tratamento de trauma abdominal contundente foi eficaz e segura com alta resolução e baixa taxa de complicações levando a uma alta taxa de preservação dos órgãos afetados. Nível de evidência III - estudo prognóstico e terapêutico.

European Pediatric Surgeons' Association Survey on the Use of Splenic Embolization in Blunt Splenic Trauma in Children

INTRODUCTION

 This article assesses (1) access to splenic embolization (SE), (2) indications for SE, and (3) post-embolization management in high-grade splenic trauma in children.

MATERIALS AND METHODS

 An online questionnaire was sent in 2021 to all members of European Pediatric Surgeons' Association.

RESULTS

 There were a total of 157 responses (50 countries, 83% academic hospitals). Among them, 68% have access to SE (SE) and 32% do not (nSE). For a hemodynamic stable patient with high-grade isolated splenic trauma without contrast extravasation (CE) on computed tomography (CT) scan, 99% SE and 95% nSE respondents use nonoperative management (NOM). In cases with CE, NOM decreases to 50% (p = 0.01) and 51% (p = 0.007) in SE and nSE centers, respectively. SE respondents report a significant reduction of NOM in stable patients with an associated spine injury requiring urgent surgery in prone position, both without and with CE (90 and 28%, respectively). For these respondents, in stable patients the association of a femur fracture only tends to decrease the NOM, both without and with CE (93 and 39%, respectively). There was no significant difference in NOM in group nSE with associated injuries with or without CE. After proximal SE with preserved spleen vascularization on ultrasound Doppler, 44% respondents prescribe antibiotics and/or immunizations.

CONCLUSION

 Two-thirds of respondents have access to SE. For SE respondents, SE is used even in stable patients when CE showed on initial CT scan and its use increased with the concomitant need for spinal surgery. There is currently a variation in the use of SE and antibiotics/immunizations following SE.

Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document

Background

In 2017, the World Society of Emergency Surgery published its guidelines for the management of adult and pediatric patients with splenic trauma. Several issues regarding the follow-up of patients with splenic injuries treated with NOM remained unsolved.

Methods

Using a modified Delphi method, we sought to explore ongoing areas of controversy in the NOM of splenic trauma and reach a consensus among a group of 48 international experts from five continents (Africa, Europe, Asia, Oceania, America) concerning optimal follow-up strategies in patients with splenic injuries treated with NOM.

Results

Consensus was reached on eleven clinical research questions and 28 recommendations with an agreement rate ≥ 80%. Mobilization after 24 h in low-grade splenic trauma patients (WSES Class I, AAST Grades I–II) was suggested, while in patients with high-grade splenic injuries (WSES Classes II–III, AAST Grades III–V), if no other contraindications to early mobilization exist, safe mobilization of the patient when three successive hemoglobins 8 h apart after the first are within 10% of each other was considered safe according to the panel. The panel suggests adult patients to be admitted to hospital for 1 day (for low-grade splenic injuries—WSES Class I, AAST Grades I–II) to 3 days (for high-grade splenic injuries—WSES Classes II–III, AAST Grades III–V), with those with high-grade injuries requiring admission to a monitored setting. In the absence of specific complications, the panel suggests DVT and VTE prophylaxis with LMWH to be started within 48–72 h from hospital admission. The panel suggests splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan, irrespective of injury grade. Regarding patients with WSES Class II blunt splenic injuries (AAST Grade III) without contrast extravasation, a low threshold for SAE has been suggested in the presence of risk factors for NOM failure. The panel also suggested angiography and eventual SAE in all hemodynamically stable adult patients with WSES Class III injuries (AAST Grades IV–V), even in the absence of CT blush, especially when concomitant surgery that requires change of position is needed. Follow-up imaging with contrast-enhanced ultrasound/CT scan in 48–72 h post-admission of trauma in splenic injuries WSES Class II (AAST Grade III) or higher treated with NOM was considered the best strategy for timely detection of vascular complications.

Conclusion

This consensus document could help guide future prospective studies aiming at validating the suggested strategies through the implementation of prospective trauma databases and the subsequent production of internationally endorsed guidelines on the issue.

Novel tool (BIS) heralds the need for blood transfusion and/or failure of non-operative management in pediatric blunt liver and spleen injuries

BACKGROUND

Non-operative management (NOM) is the standard of care for the majority of children with blunt liver and spleen injuries (BLSI). The shock index pediatric age-adjusted (SIPA) was previously shown to predict the need for blood transfusions in pediatric trauma patients with BLSI. We combined SIPA with base deficit (BD) and International Normalized Ratio (INR) to create the BIS score. We hypothesized that the BIS score would predict the need for blood transfusions and/or failure of NOM in pediatric trauma patients with BLSI.

METHODS

Patients (≤ 18 years) who presented to our Level I pediatric trauma center with BLSI from 2009 to 2019 were identified. BIS scores were calculated by giving 1 point for each of the following: base deficit ≤ -8.8, INR ≥ 1.5, or elevated SIPA. Receiver operating characteristic curves (ROC) were generated for BIS scores ≥ 1, ≥ 2, and ≥ 3. Area under the curve (AUC), sensitivity, and specificity of each score were calculated for ability to predict need for blood transfusions and/or failure of NOM.

RESULTS

Of 477 children included, 19.9% required a blood transfusion and 6.7% failed NOM. A BIS score ≥ 1 was the best predictor of the need for blood transfusions with an AUC of 0.81 and a sensitivity of 96.0%. A BIS score ≥ 1 was also the best predictor of failure of NOM with an AUC of 0.72 and a sensitivity of 97.0%.

CONCLUSION

The BIS score is a highly sensitive tool that identifies pediatric patients with BLSI at risk for blood transfusions and/or failure of NOM.

LEVEL OF EVIDENCE

Level III.

TYPE OF STUDY

Retrospective comparative study.

Severe Blunt Liver Injury Complicated by Delayed Massive Hemobilia in a Toddler: A Case Report and Literature Review

Introduction

Unintentional injuries remain a leading cause of disability among children. Although most of the pediatric patients suffering blunt liver injury can be successfully treated with non-operative therapy, the diagnosis and management of delayed life-threatening hemobilia following severe blunt liver injury, especially in the pediatric population, remain a challenge for clinicians.

Case Presentation

A previously healthy 2-year-old girl suffered a severe blunt liver injury related to an electric bike, which was inadvertently activated by herself. She initially received non-operative therapy and was in a stable condition in the first 2 weeks. On the 16th and 22nd postinjury days, the patient presented with life-threatening massive hemobilia, which was confirmed via repeat emergent gastroscopy and hepatic arterial angiography. An emergency selective transarterial embolization of the involved branch of the left hepatic artery was successfully performed. The patient recovered uneventfully, and long-term follow-up was needed owing to a mild dilatation of the left intrahepatic bile duct.

Discussion

Incidental injury in children should be considered as a major public health issue and preventive measures should be taken to reduce its occurrence. Delayed massive hemobilia after severe blunt liver trauma is rare, and its accurate and timely diagnosis via emergency hepatic arterial angiography and selective angioembolization may allow prompt and optimal management to achieve good outcomes in the pediatric population.

Pediatric trauma and the role of the interventional radiologist

PURPOSE

While interventional radiologists occupy a critical role in adult trauma management, the role of interventionalist in pediatric trauma continues to evolve. The indications for transarterial embolization (TAE) are significantly different in pediatric patients in whom non-operative management (NOM) has a much more prominent role than in adults. Contrast extravasation on imaging may not require acute surgical or interventional management as it would in an adult. There are also areas in which pediatric interventional radiology is increasingly useful such as pelvic TAE in failed management, or splenic embolization to treat bleeding without the loss of splenic function inherent to surgical splenectomy. The rapid evolution of techniques and devices in pediatric patients is also changing what interventions are possible in pediatric trauma management which necessitates frequent reassessment of the guidelines and interventional radiology's role in caring for these patients.

CONCLUSION

This review seeks to consolidate the recent literature to describe the evolving role of the interventional radiologist in pediatric trauma management.

Epidemiology and management of abdominal injuries in children

BACKGROUND

Although more guideline-adherent care has been described in pediatric compared to adult trauma centers, we aimed to provide a more detailed characterization of management and resource utilization of children with intra-abdominal injury (IAI) within pediatric centers. Our primary objective was to describe the epidemiology, diagnostic evaluation, and management of children with IAI across U.S. children's hospitals. Our secondary objective was to describe the interhospital variation in surgical management of children with IAI.

METHODS

We conducted a cross-sectional study of 33 hospitals in the Pediatric Health Information System. We included children aged <18 years evaluated in the emergency department from 2010 to 2019 with IAI, as defined by ICD coding, and who underwent an abdominal computed tomography (CT). Our primary outcome was abdominal surgery. We categorized IAI by organ system and described resource utilization data. We used generalized linear regression to calculate adjusted hospital-level proportions of abdominal surgery, with a random effect for hospital.

RESULTS

We studied 9265 children with IAI. Median (IQR) age was 9.0 (6.0-13.0) years. Abdominal surgery was performed in 16% (n = 1479) of children, with the lowest proportion of abdominal surgery observed in children aged <5 years. Liver (38.6%) and spleen (32.1%) were the most common organs injured. A total of 3.1% of children with liver injuries and 2.8% with splenic injuries underwent abdominal surgery. Although there was variation in rates of surgery across hospitals (p < 0.001), only three of 33 hospitals had rates that were statistically different from the aggregate mean of 16%.

CONCLUSIONS

Most children with IAI are managed nonoperatively, and most children's hospitals manage children with IAI similarly. These data can be used to inform future benchmarking efforts across hospitals to assess concordance with guidelines for the management of children with IAI.

Predicting morbidity and mortality in Australian paediatric trauma with the Paediatric Age-Adjusted Shock Index and Glasgow Coma Scale

BACKGROUND

Paediatric age-adjusted shock index (SIPA) has emerged as a predictor of morbidity and mortality in trauma. Poor sensitivity and low generalisability demonstrated in previous studies have limited its use. We evaluate the use of SIPA in the general Australian paediatric trauma population and the combination of SIPA with GCS.

METHODS

All patients from January 2015 to August 2020 at a major Australian paediatric trauma centre were reviewed. Pre-arrival SIPA (pSIPA) and arrival SIPA (aSIPA) were calculated. If SIPA was elevated or the Glasgow Coma Scale ≤ 13, SIPA with mental state (SIPAms) was marked positive for pre-arrival (pSIPAms) and arrival (aSIPAms) respectively.

RESULTS/DISCUSSION

Data from 480 patients were analysed. pSIPA and aSIPA poorly predicted outcomes of morbidity. Only aSIPA predicted mortality. However, both pre-arrival and arrival SIPAms variables predict mortality, major trauma (ISS≥12), hospital LOS, need for ICU admission, and major surgery. Furthermore, median ISS and lactate were significantly higher in positive pSIPA, aSIPA, pSIPAms, and aSIPAms groups than negative. aSIPAms has a sensitivity of 76% and specificity of 70% for major trauma.

CONCLUSION

Broad inclusion criteria reduce SIPA's ability to predict morbidity. Combining it with GCS improves this and is most valuable when calculated at arrival. In addition, the score is more reliable for major trauma (ISS≥12). Future studies should evaluate the use of SIPAms in activation criteria.

CT scans for pediatric injury in a middle-income country trauma center: Are we repeating past mistakes?

PURPOSE

Sustained efforts in high-income countries have decreased the rate of unnecessary computed tomography (CT) among children, aiming to minimize radiation exposure. There are little data regarding CT use for pediatric trauma in low- and middle-income countries. We aimed to assess the pattern and utility of CT performed during evaluation of trauma patients presenting to a middle-income country (MIC) trauma center.

METHODS

We reviewed pediatric (age<18) trauma admissions at a single tertiary referral center in South Africa. Patient demographics, injury details, surgical intervention(s), and mortality were abstracted from the medical record. CT indications, results, and necessity were determined by review.

RESULTS

Of 1,630 children admitted to the trauma center, 826 (51%) had CT imaging. Children undergoing imaging were younger (median age 11 [IQR: 6, 16] vs 13 [IQR: 7, 17]) and had higher median ISS [9 [IQR: 4, 13] vs 4 [2, 9]) compared to those without imaging (both p<0.001). Overall, 1,224 scans were performed with normal findings in 609 (50%). A median of 1 scan was performed per patient (range: 1-5). The most common location was CT head (n = 695, 57%). Among patients with positive findings on CT head (n = 443), 31 (7%) underwent either intracranial pressure monitoring or surgery. CT of the cervical spine had positive findings in 12 (7%) with no patients undergoing spine surgery. Of 173 patients with abdominal CT imaging, 83 (48%) had abnormal findings and 18 (10%) required operative exploration. Thirteen (16%) patients with abnormal findings on abdominal CT had exploratory laparotomy. Of 111 children undergoing whole body CT, 8 (7%) underwent thoracic and/or abdominal operations.

CONCLUSION

Use of CT during evaluation of pediatric trauma is common in an MIC center. A high rate of normal findings and low rates of intervention following head, cervical spine, and abdominal CT suggest potential overuse of this resource.

LEVEL OF EVIDENCE

Level III.

Clinicoradiological Predictors of Severity of Traumatic Intra-Abdominal Injury in Pediatric Patients: A Retrospective Study

Background

Adequate assessment of traumatic injury in patients of all age groups is essential for timely intervention and prevention of mortality and morbidity. This study aimed to assess the value of certain clinical as well as radiological factors as predictors of severity of the intra-abdominal injury as detected on computed tomography (CT) and to review the guidelines, protocols, and practices followed in imaging of abdominal trauma in patients of pediatric age group.

Methods

This retrospective observational study included 263 pediatric patients (18 years of age or younger) who presented to the emergency department (ED) with a history of trauma to the abdomen. The study was conducted over a period of 12 months. Correlation of five variables, i.e., age of the child, focused abdominal sonography in trauma (FAST) status, mechanism of injury, presenting complaints and clinical features (hypotension, tachycardia, etc), fractures identified on trauma X-ray series, was done with CT findings (severity of injury). All five variables were statistically analyzed and p-values were derived for age, mechanism of injury, presenting complaints, clinical features, and trauma x-ray series, while parameters like sensitivity and specificity were determined for FAST status

Results

All variables well correlated with the severity of injury with p-values <0.05. On multivariate analysis, FAST status had the highest (47.94) odds ratio among the five variables for predicting severe intra-abdominal injury while vital signs had the lowest (0.076). Further, age group of 0-4 years was found most prone to higher grades of injury with odds ratio of 7.83. Motor vehicle crash had odds ratio of 26.6 for severe injury, the highest among mechanisms of injury. While for FAST status, sensitivity was found to be 89.4%, specificity 85%, and negative predictive value 90%, trauma series radiographs had a sensitivity of 42.27%, specificity of 77.85% and negative predictive value of 60.55%.

Conclusion

Clinical parameters and traditional imaging techniques can predict the severity of injury on CT and guide further imaging and intervention.

Hospital-based intervention is rarely needed for children with low-grade blunt abdominal solid organ injury: An analysis of the Trauma Quality Improvement Program registry

BACKGROUND

Children with low-grade blunt solid organ injury (SOI) have historically been admitted to an inpatient setting for monitoring, but the evidence supporting the necessity of this practice is lacking. The purpose of this study was to quantify the frequency and timing of intervention for hemorrhage and to describe hospital-based resource utilization for low-grade SOI in the absence of other major injuries (OMIs).

METHODS

A cohort of children (aged <16 years) with blunt American Association for the Surgery of Trauma grade 1 or 2 SOI from the American College of Surgeons Trauma Quality Improvement Program registry (2007-2017) was analyzed. Children were excluded if they had confounding factors associated with intervention for hemorrhage (comorbidities, OMIs, or extra-abdominal surgical procedures). Outcomes included frequency and timing of intervention (laparotomy, angiography, or transfusion) for hemorrhage, as well as hospital-based resource utilization.

RESULTS

A total of 1,019 children were identified with low-grade blunt SOI and no OMIs. Nine hundred eighty-six (96.8%) of these children were admitted to an inpatient unit. Admitted children with low-grade SOI had a median length-of-stay of 2 days and a 23.9% intensive care unit admission rate. Only 1.7% (n = 17) of patients with low-grade SOI underwent an intervention, with the median time to intervention being the first hospital day. No child who underwent angiography was transfused or had an abnormal initial ED shock index.

CONCLUSION

Children with low-grade SOI are routinely admitted to the hospital and often to the intensive care unit but rarely undergo hospital-based intervention. The most common intervention was angiography, with questionable indications in this cohort. These data question the need for inpatient admission for low-grade SOI and suggest that discharge from the emergency room may be safe. Prospective investigation into granular risk factors to identify the rare patient needing hospital-based intervention is needed, as is validation of the safety of ambulatory management.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

Admission for Isolated Low-Grade Solid Organ Injury May Not Be Necessary in Pediatric Patients

BACKGROUND

Recent publications indicate that blunt solid organ injuries can be safely managed with reduced length of stay using pathways focused on hemodynamics. We hypothesized that pediatric patients with isolated blunt Grade I or II solid organ injuries may be safely discharged after brief observation with appropriate outpatient follow-up.

OBJECTIVE

The purpose of this study is to evaluate the need for admission of pediatric trauma patients with isolated low-grade solid organ injury resulting from blunt trauma.

METHODS

We performed a retrospective cohort study of trauma registry data from 2011 to 2018 to identify isolated blunt Grade I or II solid organ injuries among children younger than 19 years. "Complication or intervention" was defined as transfusions, transfer to the intensive care unit, repeat imaging, decrease in Hgb greater than 2 g/dl, fluid bolus after initial resuscitation, operation or interventional radiology procedure, or readmission within 1 week.

RESULTS

A total of 51 patients were admitted to the trauma service with isolated Grade I or II blunt solid organ injuries during the 8-year study period. The average age was 11 years. Among isolated Grade I or II injuries, seven (14%) had "complication or intervention" including greater than 2 g/dl drop in Hgb in four patients (8%), follow-up ultrasonography for pain in one patient (2%), readmission for pain in one patient (2%), or a fluid bolus in two patients (4%). None required transfusion or surgery. The most common mechanism of injury was sports related (45%), and the average length of stay was 1 day.

CONCLUSION

Among a cohort of 51 patients with isolated blunt Grade I or II solid organ injuries, none required a significant intervention justifying need for admission. All "complication or intervention" patients observed were of limited clinical significance. We recommend that hemodynamically stable patients with isolated low-grade solid organ injuries may be discharged from the emergency department after a brief observation along with appropriate instructions and pain management.

Volume Resuscitation in the Acutely Hemorrhaging Patient: Historic Use to Current Applications

Acute hemorrhage in small animals results from traumatic and non-traumatic causes. This review seeks to describe current understanding of the resuscitation of the acutely hemorrhaging small animal (dog and cat) veterinary patient through evaluation of pre-clinical canine models of hemorrhage and resuscitation, clinical research in dogs and cats, and selected extrapolation from human medicine. The physiologic dose and response to whole blood loss in the canine patient is repeatable both in anesthetized and awake animals and is primarily characterized clinically by increased heart rate, decreased systolic blood pressure, and increased shock index and biochemically by increased lactate and lower base excess. Previously, initial resuscitation in these patients included immediate volume support with crystalloid and/or colloid, regardless of total volume, with a target to replace lost vascular volume and bring blood pressure back to normal. Newer research now supports prioritizing hemorrhage control in conjunction with judicious crystalloid administration followed by early consideration for administration of platelets, plasma and red blood during the resuscitation phase. This approach minimizes blood loss, ameliorates coagulopathy, restores oxygen delivery and correct changes in the glycocalyx. There are many hurdles in the application of this approach in clinical veterinary medicine including the speed with which the bleeding source is controlled and the rapid availability of blood component therapy. Recommendations regarding the clinical approach to volume resuscitation in the acutely hemorrhaging veterinary patient are made based on the canine pre-clinical, veterinary clinical and human literature reviewed.

Implementation of an evidence-based accelerated pathway: can hospital length of stay for children with blunt solid organ injury be safely decreased?

BACKGROUND

Recent work has demonstrated that an accelerated pathway for pediatric patients with blunt solid organ injuries is safe; however, this is not well-studied in a dual trauma center. We hypothesized that implementation of an accelerated pathway would decrease length of stay (LOS) and hospitalization cost without increased mortality.

METHODS

Retrospective review of patients < 15 years presenting to a dual level 1 trauma center between 2015 and 2020 with traumatic blunt liver and splenic injuries. Patients presenting pre- and post-protocol implementation were compared. The primary outcome was total hospital LOS. Secondary outcomes were number of lab draws, intensive care unit (ICU) LOS, cost of hospitalization, readmissions within 30 days, and mortality.

RESULTS

103 patients were evaluated, 67 pre-protocol and 63 post-protocol. LOS was significantly shorter post-protocol (2 days vs. 4 days, p < 0.001). The ICU LOS was unchanged. There was a decrease in direct hospitalization cost per patient from $6,246 pre-protocol to $4,294 post-protocol (p = 0.001). There was one readmission post-protocol and none pre-protocol. There were no deaths.

CONCLUSION

Implementation of an accelerated pathway for management of blunt solid organ injury at a dual trauma center was associated with decreased LOS and decreased costs with no increased morbidity or mortality.

Implementation of a clinical guideline for nonoperative management of isolated blunt renal injury in children

Background

The aim was to evaluate the impact of a standardized nonoperative management protocol by comparing patients with isolated blunt renal injury before and after implementation.

Methods

We retrospectively reviewed the trauma registry at our Level 1 pediatric trauma center. We compared consecutive patients (≤ 18 years) managed nonoperatively for blunt renal injury Pre (1/2010–9/2014) and Post (10/2014–3/2020) implementation of a clinical guideline. Outcomes included length of stay, intensive care unit admission, urinary catheter use, and imaging studies.

Results

We included 48 patients with isolated blunt renal injuries (29 Pre, 19 Post). There were no differences in age, sex, injury grade, or mechanism (P > .05). Postprotocol had decreased length of stay (P = .040), intensive care unit admissions (P = .015), urinary catheter use (P = .031), and ionizing radiation imaging (P < .001).

Conclusion

These data suggest improved outcomes and resource utilization following implementation of a nonoperative management protocol of pediatric isolated blunt renal injuries.

•

Implementation of a standardized nonoperative management protocol for pediatric patients with isolated blunt renal injury improved outcomes and resource utilization.

•

Protocol implementation was associated with decreased length of stay, ICU admissions, urinary catheter use, and ionizing radiation imaging.

•

There were no differences in demographics, mechanism, or grade of injury between pre- and postprotocol groups.

Isolated high-grade splenic injury among pediatric patients in Japan: Nationwide descriptive study

BACKGROUND

Limited information exists regarding the clinical characteristics, management practice, and outcomes of pediatric patients with isolated splenic injury in Japan. This study aimed to evaluate the characteristics, management, and outcomes, such as survival and splenic salvage rate of pediatric patients with isolated splenic injury in Japan.

METHOD

This study was a multicenter retrospective cohort study using patient data from the Japan Trauma Data Bank (JTDB) collected between 2004 and 2018. Pediatric patients with isolated high-grade splenic injury whose abbreviated injury scale≥3 were classified according to management groups: nonoperative management (NOM); NOM with splenic artery embolization (SAE); and operative management (OM). The primary outcome was in-hospital survival and the secondary outcomes were splenic salvage rate, hospital length of stay (LOS), rate of discharging to home, and complications.

RESULTS

There were 230 pediatric patients with isolated high-grade splenic injury during the study period. Of these, 156 (68%) were managed by NOM, 62 (27%) were managed by NOM with SAE, and 12 (5.2%) were managed by OM. No pediatric patient with isolated high-grade splenic injury died between 2004 and 2018 in Japan, and the splenic salvage rate was 97%.

CONCLUSION

We identified a high survival rate and splenic salvage rate among pediatric patients with isolated high-grade splenic injury in Japan. SAE was often used, in contrast with previous reports.

LEVELS OF EVIDENCE

Level IV.

Abdominal angiography is associated with reduced in-hospital mortality among pediatric patients with blunt splenic and hepatic injury: A propensity-score-matching study from the national trauma registry in Japan

PURPOSE

The aim of this study was to assess the association between the implementation of abdominal angiography and outcome among pediatric patients with blunt splenic or hepatic injury.

METHODS

This was a retrospective observational study, with a study period of 14 years, from January 2004 to December 2017. Blunt-trauma patients with splenic or hepatic injury who were less than 19 years old were included in this study. We used propensity-score-(PS) matching analysis to assess the relationship between abdominal angiography and in-hospital mortality.

RESULTS

In total, 639 patients were eligible for analysis, with 257 patients included in the abdominal-angiography group and 382 patients in the no-abdominal-angiography group. After PS matching, 224 patients from each group were selected. In the PS matched patients, in-hospital mortality was lower in the abdominal-angiography group than in the no-abdominal-angiography group (4.9% vs. 11.2%, odds ratio 0.416, 95% confidence interval 0.177-0.903).

CONCLUSION

In this population, the implementation of abdominal angiography was significantly associated with lower in-hospital mortality among pediatric patients with blunt splenic or hepatic injury compared with nonimplementation of abdominal angiography.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

III.

Use of glue embolization in management of traumatic bile leak: A case report

Blunt abdominal trauma is a common cause of solid organ injury in children. Nonoperative management has been established as the standard of care for suspected liver and spleen injuries without peritonitis. Major ductal injury with resultant biloma is a rare complication of nonoperative management of blunt liver injury. Endoscopic retrograde cholangiopancreatography (ERCP) and/or percutaneous drain placement are considered to be safe adjuncts in the management of these bile leaks. However, in the rare cases of persistent bile leak, further nonoperative alternatives have not been reported. In this case report we present a novel multidisciplinary approach to managing persistent bile leaks in blunt liver injury.