Management of pediatric renal trauma: Results from the American Association for Surgery and Trauma Multi-Institutional Pediatric Acute Renal Trauma Study

BACKGROUND

Pediatric renal trauma is rare and lacks sufficient population-specific data to generate evidence-based management guidelines. A nonoperative approach is preferred and has been shown to be safe. However, bleeding risk assessment and management of collecting system injury are not well understood. We introduce the Multi-institutional Pediatric Acute Renal Trauma Study (Mi-PARTS), a retrospective cohort study designed to address these questions. This article describes the demographics and contemporary management of pediatric renal trauma at Level I trauma centers in the United States.

METHODS

Retrospective data were collected at 13 participating Level I trauma centers on pediatric patients presenting with renal trauma between 2010 and 2019. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Descriptive statistics were used to report on demographics, acute management, and outcomes.

RESULTS

In total, 1,216 cases were included in this study. Of all patients, 67.2% were male, and 93.8% had a blunt injury mechanism. In addition, 29.3% had isolated renal injuries, and 65.6% were high-grade (American Association for the Surgery of Trauma Grades III-V) injuries. The mean Injury Severity Score was 20.5. Most patients were managed nonoperatively (86.4%), and 3.9% had an open surgical intervention, including 2.7% having nephrectomy. Angioembolization was performed in 0.9%. Collecting system intervention was performed in 7.9%. Overall mortality was 3.3% and was only observed in patients with multiple injuries. The rate of avoidable transfer was 28.2%.

CONCLUSION

The management and outcomes of pediatric renal trauma lack data to inform evidence-based guidelines. Nonoperative management of bleeding following renal injury is a well-established practice. Intervention for renal trauma is rare. Our findings reinforce differences from the adult population and highlights opportunities for further investigation. With data made available through Mi-PARTS, we aimed to answer pediatric specific questions, including a pediatric-specific bleeding risk nomogram, and better understanding indications for interventions for collecting system injuries.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Diagnosis and management of blunt cardiac injury: What you need to know

ABSTRACT

Blunt cardiac injury (BCI) encompasses a wide spectrum, from occult and inconsequential contusion to rapidly fatal cardiac rupture. A small percentage of patients present with abnormal electrocardiogram or shock, but most are initially asymptomatic. The potential for sudden dysrhythmia or cardiac pump failure mandates consideration of the presence of BCI, including appropriate monitoring and management. In this review, we will present what you need to know to diagnose and manage BCI.

Survival bias in pediatric hemorrhagic shock: Are we misrepresenting the data?

BACKGROUND

Studies of hemorrhage following pediatric injury often use the occurrence of transfusion as a surrogate definition for the clinical need for a transfusion. Using this approach, patients who are bleeding but die before receiving a transfusion are misclassified as not needing a transfusion. In this study, we aimed to evaluate the potential for this survival bias and to estimate its presence among a retrospective observational cohort of children and adolescents who died from injury.

METHODS

We obtained patient, injury, and resuscitation characteristics from the 2017 to 2020 Trauma Quality Improvement Program database of children and adolescents (younger than 18 years) who arrived with or without signs of life and died. We performed univariate analysis and a multivariable logistic regression to analyze the association between the time to death and the occurrence of transfusion within 4 hours after hospital arrival controlling for initial vital signs, injury type, body regions injured, and scene versus transfer status.

RESULTS

We included 6,063 children who died from either a blunt or penetrating injury. We observed that children who died within 15 minutes had lower odds of receiving a transfusion (odds ratio, 0.1; 95% confidence interval, 0.1-0.2) compared with those who survived longer. We estimated that survival bias that occurs when using transfusion administration alone to define hemorrhagic shock may occur in up to 11% of all children who died following a blunt or penetrating injury but less than 1% of all children managed as trauma activations.

CONCLUSION

Using the occurrence of transfusion alone may underestimate the number of children who die from uncontrolled hemorrhage early after injury. Additional variables than just transfusion administration are needed to more accurately identify the presence of hemorrhagic shock among injured children and adolescents.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Development and validation of a nomogram to predict postsurgical intra-abdominal infection in blunt abdominal trauma patients: A multicenter retrospective study

BACKGROUND

Intra-abdominal infection is a common complication of blunt abdominal trauma. Early detection and intervention can reduce the incidence of intra-abdominal infection and improve patients' prognoses. This study aims to construct a clinical model predicting postsurgical intra-abdominal infection after blunt abdominal trauma.

METHODS

This study is a retrospective analysis of 553 patients with blunt abdominal trauma from the Department of General Surgery of 7 medical centers (2011-2021). A 7:3 ratio was used to assign patients to the derivation and validation cohorts. Patients were divided into 2 groups based on whether intra-abdominal infection occurred after blunt abdominal trauma. Multivariate logistic regression and least absolute shrinkage and selection operator regression were used to select variables to establish a nomogram. The nomogram was evaluated, and the validity of the model was further evaluated by the validation cohort.

RESULTS

A total of 113 were diagnosed with intra-abdominal infection (20.4%). Age, prehospital time, C-reactive protein, injury severity score, operation duration, intestinal injury, neutrophils, and antibiotic use were independent risk factors for intra-abdominal infection in blunt abdominal trauma patients (P < .05). The area under the receiver operating curve (area under the curve) of derivation cohort and validation cohort was 0.852 (95% confidence interval, 0.784-0.912) and 0.814 (95% confidence interval, 0.751-0.902). The P value for the Hosmer-Lemeshow test was .135 and .891 in the 2 cohorts. The calibration curve demonstrated that the nomogram had a high consistency between prediction and practical observation. The decision curve analysis also showed that the nomogram had a better potential for clinical application. To facilitate clinical application, we have developed an online at https://nomogramcgz.shinyapps.io/IAIrisk/.

CONCLUSION

The nomogram is helpful in predicting the risk of postoperative intra-abdominal infection in patients with blunt abdominal trauma and provides guidance for clinical decision-making and treatment.

Performance of three predictive scores to avoid delayed diagnosis of significant blunt bowel and mesenteric injury: A 12-year retrospective cohort study

BACKGROUND

Avoiding missed diagnosis and therapeutic delay for significant blunt bowel and mesenteric injuries (sBBMIs) after trauma is still challenging despite the widespread use of computed tomography (CT). Several scoring tools aiming at reducing this risk have been published. The purpose of the present work was to assess the incidence of delayed (>24 hours) diagnosis for sBBMI patients and to compare the predictive performance of three previously published scores using clinical, radiological, and laboratory findings: the Bowel Injury Prediction Score (BIPS) and the scores developed by Raharimanantsoa Score (RS) and by Faget Score (FS).

METHODS

A population-based retrospective observational cohort study was conducted; it included adult trauma patients after road traffic crashes admitted to Lausanne University Hospital, Switzerland, between 2008 and 2019 (n = 1,258) with reliable information about sBBMI status (n = 1,164) and for whom all items for score calculation were available (n = 917). The three scores were retrospectively applied on all patients to assess their predictive performance.

RESULTS

The incidence of sBBMI after road traffic crash was 3.3% (38 of 1,164), and in 18% (7 of 38), there was a diagnostic and treatment delay of more than 24 hours. The diagnostic performances of the FS, the RS, and the BIPS to predict sBBMI, expressed as the area under the receiver operating characteristic curve, were 95.3% (95% confidence interval [CI], 92.7-97.9%), 89.2% (95% CI, 83.2-95.3%), and 87.6% (95% CI, 81.8-93.3%) respectively.

CONCLUSION

The present study confirms that diagnostic delays for sBBMI still occur despite the widespread use of abdominal CT. When CT findings during the initial assessment are negative or equivocal for sBBMI, using a score may be helpful to select patients for early diagnostic laparoscopy. The FS had the best individual diagnostic performance. However, the BIPS or the RS, relying on clinical and laboratory variables, may be helpful to select patients for early diagnostic laparoscopy when there are unspecific CT signs of bowel or mesenteric injury.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Pediatric Blunt Cerebrovascular Injuries: Approach and Management

ABSTRACT

The low incidence of blunt cerebrovascular injury (BCVI) reported in pediatric studies (<1%) might be related to an underreporting due to both the absence of current screening guidelines and the use of inadequate imaging techniques. This research is a review of the literature limited to the last 5 years (2017-2022) about the approach and management of BCVI in pediatrics. The strongest predictors for BCVI were the presence of basal skull fracture, cervical spine fracture, intracranial hemorrhage, Glasgow Coma Scale score less than 8, mandible fracture, and injury severity score more than 15. Vertebral artery injuries had the highest associated stroke rate of any injury type at 27.6% (vs 20.1% in carotid injury). The sensitivity of the well-established screening guidelines of BCVI varies when applied to the pediatric population (Utah score - 36%, 17%, Eastern Association for the Surgery of Trauma (EAST) guideline - 17%, and Denver criteria - 2%). A recent metaanalysis of 8 studies comparing early computed tomographic angiogram (CTA) to digital subtraction angiography for BCVI detection in adult trauma patients demonstrated high variability in the sensitivity and specificity of CTA across centers. Overall, CTA was found to have a high specificity but low sensitivity for BCVI. The role of antithrombotic as well as the type and duration of therapy remain controversial. Studies suggest that systemic heparinization and antiplatelet therapy are equally effective.

Management of Blunt Chest Trauma

Common mechanisms of blunt thoracic injury include motor vehicle collisions and falls. Chest wall injuries include rib fractures and sternal fractures; treatment involves supportive care, multimodal analgesia, and pulmonary toilet. Pneumothorax, hemothorax, and pulmonary contusions are also common and may be managed expectantly or with tube thoracostomy as indicated. Surgical treatment may be considered in select cases. Less common injury patterns include blunt trauma to the tracheobronchial tree, esophagus, diaphragm, heart, or aorta. Operative intervention is more often required to address these injuries.

Bladder trauma: a guideline of the guidelines

OBJECTIVES

To identify and review the most up-to-date guidelines pertaining to bladder trauma in a unifying document as an updated primer in the management of all aspects relating to bladder injury.

METHODS

In accordance with the PRISMA statement, the most recent guidelines pertaining to bladder injury were identified and subsequently critically appraised. An electronic search of PubMed and Scopus databases was carried out in September 2023.

RESULTS

A total of six guidelines were included: European Association of Urology (EAU) guidelines on urological trauma (2023), EAU guidelines on paediatric urology (2022), Urotrauma: American Urological Association (AUA) (2020), Kidney and Uro-trauma: World Society of Emergency Surgery and the American Association for the Surgery of Trauma (WSES-AAST) guidelines (2019), Management of blunt force bladder injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma (EAST) (2019), and EAU guidelines on iatrogenic trauma (2012). Recommendations were summarised with the associated supporting level of evidence and strength of recommendation where available.

CONCLUSION

Several widely recognised professional organisations have published guidelines relating to the diagnosis, investigation, classification, management, and follow-up related to bladder injury. There is consensus amongst all major guidelines in terms of diagnosis and management but there is some discrepancy and lack of recommendation with regards to the follow-up of bladder injuries, iatrogenic bladder injury, paediatric bladder trauma, and spontaneous bladder rupture. The role of increasing minimally invasive techniques seem to be gaining traction in the select haemodynamically stable patient. Further research is required to better delineate this treatment option.

Emergency hybrid surgery for transection of pancreas at the head and neck after blunt abdominal trauma: A case report and review of the literature

INTRODUCTION

A complete disruption of main pancreatic duct (MPD) presents a significant challenge to the surgeon. Historically, the standard surgical approach for addressing a complete disruption of the MPD involved distal pancreatic resection and pancreaticojejunostomy Roux-en-Y anastomosis. Nevertheless, there have been no reported cases of hybrid surgery being employed for the complete disruption of the MPD.

PATIENT CONCERNS

A 63-year-old male patient presented with blunt trauma in the upper abdomen and was transferred to our trauma center 10 hours after injury. Upon arrival at the emergency department, he was conscious, hemodynamically stable, and complained of upper abdominal pain and distention. Physical examination revealed right upper abdominal tenderness and slight abdominal tension. Abdominal contrast-enhanced CT scan revealed a complete transection of pancreatic parenchyma at the junction of the head and neck.

DIAGNOSES

Complete transection of pancreatic parenchyma at the junction of the head and neck combined with complete disruption of the MPD, AIS grade IV.

INTERVENTIONS

The hybrid surgery was initially utilized for complete MPD disruption, incorporating endoscope-assisted stent placement in the MPD along with primary repair of the pancreatic parenchyma and duct.

OUTCOMES

The postoperative period went smoothly, and the patient recovered and was discharged 4 weeks after operation. The MPD stent was removed under endoscope 4 months after operation, and Endoscopic Retrograde Pancreatography examination showed that the MPD was patency and slight MPD stenosis without pancreatic leakage. At the most recent follow-up, the patient had returned to normal life and work without any pancreatic endocrine or exocrine dysfunction.

LESSONS

The hybrid surgery, incorporating endoscope-assisted MPD stent placement and primary repair of the pancreatic parenchyma and duct, emerges as a promising alternative for complete MPD disruption in hemodynamically stable patients. The challenge in this hybrid surgery is the precise localization of the distal end of the MPD.

Pediatric Traumatic Lumbar Hernias and Associated Injuries: A Case Series

OBJECTIVE

Traumatic lumbar hernias are a rare entity mostly seen with high-impact, blunt abdominal trauma. This injury occurs when there is disruption of the posterior musculature along with bony structures, allowing for herniation of abdominal contents. There are minimal cases of this entity reported in adults, but even fewer in the pediatric population.

METHODS

We describe 3 cases of traumatic lumbar hernia at our institution as well as provide a review of the literature to elucidate the most common mechanisms, severity of injury, and associated injuries.

RESULTS

Traumatic lumbar hernia is most commonly seen in restrained passengers involved in motor vehicle collisions. A majority of cases are diagnosed using computed tomography imaging and less frequently during primary surgical exploration. The most common associated injuries were mesenteric and bowel injuries, followed by spinal and chest trauma. Traumatic lumbar hernia often leads to prolonged hospital stays and increased need for posthospital rehabilitation because of associated traumatic comorbidities.

CONCLUSIONS

Traumatic lumbar hernia is a rare entity in children, and early suspicion and identification of associated injuries is necessary in the management of these patients.

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.

Close-Range Fire Inflicting Behind Armor Blunt Trauma: Case-Series and Implications for Battlefield Care

Behind armor blunt trauma (BABT) is a non-penetrating injury caused by energy transfer and rapid deformation of protective body armor. Although modern military body armor is designed to prevent penetrating trunk injuries, high-energy projectiles can produce a significant energy transfer to tissues behind the armor and inflict injuries such as fractures or organ contusions. However, knowledge of BABT is limited to biomechanical and cadaver modeling studies and rare case reports. We report two cases of BABT resulting from close-range fire and discuss the potential implications for triaging patients with BABT in battlefield scenarios. In the first case, a 19-year-old male soldier sustained a single close-range 5.56-mm assault rifle gunshot to his chest body armor. The soldier initially reported mild pain in the parasternal region and assessment revealed a 4 cm × 3 cm skin abrasion. Following emergency department evaluation, the soldier was diagnosed with a non-displaced transverse fracture of the sternal body. In the second case, a 20-year-old male sustained five machine gun bullets (7.62 mm) to his body armor. Computed tomography of the chest revealed pulmonary contusions in the right lower and middle lobes. Both soldiers achieved full recovery and returned to combat duty within several weeks. These cases highlight the potential risks of energy transfer from high-velocity projectiles impacting body armor and the need for frontline providers to be aware of the risk of underlying blunt injuries. Further reporting of clinical cases and modeling studies using high-velocity projectiles could inform recommendations for triaging, evacuating, and assessing individuals with BABT.

SEVERE MACULAR EDEMA AFTER TRAUMATIC HEAD INJURY: A CASE OF WHIPLASH MACULOPATHY

PURPOSE

Whiplash or "traumatic" maculopathy is associated with retinal concussion, typically after the rapid acceleration/deceleration experienced in motor vehicle collisions. It has rarely been discussed in the literature, likely given the spontaneous and relatively rapid nature with which the acute macular edema resolves. A focused clinical history around the trauma and characteristic signs and structural features on retinal imaging help to distinguish this condition from other sequelae of concussive retinal injury. We report a case of whiplash maculopathy after a blunt injury to the head, which presented with unilateral and substantial macular edema in the left eye.

METHODS

Case report.

RESULTS

A 38-year-old man presented with complaint of a central scotoma in his left eye after a blunt trauma to his head. Comprehensive ophthalmological evaluation and retinal imaging with optical coherence tomography confirmed whiplash maculopathy, with acute macular edema in his left eye. Management with observation and close follow-up showed rapid improvement in his visual symptoms over the course of days and improvement in the severity of macular edema. One month after his injury, macular edema had resolved with only mild structural irregularities, the patient's vision had improved, and he was asymptomatic.

CONCLUSION

When observing patients with significant macular edema after concussive head injury, whiplash maculopathy should be considered, regardless of a history of motor vehicle collision. The condition can present with significant asymmetry of disease. The diagnosis generally carries a good prognosis for vision; however, there are cases of persistent central visual disturbances.

Blunt pancreatic injury in children: Lessons from 11-year experience in a pediatric center

OBJECTIVE

To study the diagnosis, management strategies, and outcomes of pediatric patients with blunt pancreatic injury.

METHODS

The clinical data of patients with blunt pancreatic injury at Children's Hospital, Zhejiang University School of Medicine from January 2011 to September 2022 were collected and analyzed retrospectively.

RESULTS

A total of 51 patients were enrolled. According to the American Association for the Surgery of Trauma (AAST) classification of pancreatic injury, 41 patients were categorized in the low-grade and nine in the high-grade groups. On admission, serum amylase and lipase levels in the high-grade group were significantly higher than in the low-grade group (P = 0.025 and P = 0.021, respectively). The peak levels of serum amylase and lipase in the high-grade group were considerably higher than in the low-grade group (P = 0.017 and P = 0.038, respectively). Two patients received surgical treatment, but none experienced pancreatectomy. The remaining 49 patients were successfully treated with conservative methods. The incidence of pancreatic pseudocysts in patients was 47.1% (24/51), and half required external drainage.

CONCLUSION

Conservative management is safe for most children with blunt pancreatic injury, surgical intervention should be adopted in patients with hemodynamic instability or multiple organ failure.

Characterization of Ocular Injuries Caused by Orbeez Hydrated Gel Pellet Projectiles: Clinical Insights and Implications

PURPOSE

To examine the clinical characteristics of patients who have experienced blunt ocular injuries from "Orbeez" hydrated gel pellets (Spin Master Corp.), and to describe ocular morbidity, visual acuity (VA), and intraocular pressure (IOP) after Orbeez-related ocular trauma.

DESIGN

Retrospective, institutional, observational case series.

METHODS

Patients sustaining Orbeez-related ocular trauma at a single institution over a 13-month period were identified. Clinical parameters including VA, IOP, and anterior and fundus examination findings were assessed upon initial and final presentation. Basic statistical testing was performed to compare differences within this cohort.

RESULTS

A total of 17 eyes from 17 patients with Orbeez-related trauma were identified. Orbeez-related blunt ocular injuries included corneal abrasion (n = 7), hyphema (n = 9), commotio retinae (n = 5), intraretinal hemorrhage (n = 3), preretinal hemorrhage (n = 1), vitreous hemorrhage (n = 2), and retinal tear (n = 1). Adolescents (14-18 years of age) showed higher rates of posterior segment complications compared to other ages (P = .0152). The presence of elevated IOP and hyphema upon initial examination correlated with increased likelihood of requiring invasive treatment following Orbeez impact (P = .0275).

CONCLUSION

Orbeez-related ocular trauma may be associated with severe visual morbidity and varied anterior and posterior segment intraocular sequelae. Adolescents could be at increased risk for posterior segment complications following these injuries. Initial findings of elevated IOP and hyphema may indicate a need for more aggressive interventions. Prevention remains paramount in managing Orbeez-related ocular trauma; it is critical to raise awareness regarding the importance of wearing eye protection meeting high-impact standards and minimizing exposure to such projectiles.

Open or Not Open the Retroperitoneum: A Pandora's Box for Blunt High-Grade Pancreatic Trauma?

INTRODUCTION

The optimal management strategy for pancreatic trauma remains unclear. We aimed to determine whether the initial nonoperative management (NOM) strategy based on percutaneous drainage combined with endoscopic retrograde cholangiopancreatography guided stent placement would improve outcomes for blunt high-grade pancreatic trauma.

METHODS

Patients with blunt abdominal trauma who were hemodynamically stable without signs of diffuse peritonitis were consecutively enrolled at a high-volume center. The primary outcome was the occurrence of severe complications (Clavien‒Dindo classification ≥ Ⅲb) for patients who underwent initial laparotomy (LAP) versus NOM. Modified Poisson regression was used to model the primary outcome. Propensity score matching and weighting models were included into a regression-based sensitivity analysis.

RESULTS

Of 119 patients with grade III/IV pancreatic trauma, 29 patients underwent initial NOM, and 90 underwent initial LAP. The incidence of severe complications in the LAP group was higher than that in the NOM group (65/90 [72.2%] versus 9/29 [31.0%], P < 0.001). In the multivariable modified Poisson regression model, the relative risk for severe complications was decreased in the NOM group (relative risk, 0.52; 95% confidence interval, 0.30-0.90; P = 0.020). The results of the sensitivity analysis were consistent with those of the multivariable analysis. The mean number of reinterventions per patient was 1.8 in the NOM group and 2.6 in the LAP group (P = 0.067).

CONCLUSIONS

For blunt high-grade pancreatic trauma patients with stable hemodynamics and no diffuse peritonitis, the NOM strategy was associated with a lower risk of severe complications (Clavien‒Dindo classification ≥ Ⅲb) and did not require more invasive reintervention procedures. In high-volume centers with sufficient expertise, percutaneous drainage combined with endoscopic retrograde cholangiopancreatography guided stent placement may serve as an initial reasonable option for selected patients.

Decreased Glycocalyx Shedding on Presentation in Hemorrhaging Geriatric Trauma Patients

INTRODUCTION

Plasma levels of syndecan-1 (Sdc-1), a biomarker of endothelial glycocalyx (EG) damage, correlate with worse outcomes in trauma patients. However, EG injury is not well characterized in injured older adults (OA). The aims of this study were to characterize Sdc-1 shedding in OA trauma patients relative to younger adults (YA) and determine associations with putative regulators of EG sheddases.

METHODS

We performed a secondary analysis of data from the Pragmatic, Randomized Optimal Platelet, and Plasma Ratios (PROPPR) trial, stratifying bluntly injured subjects into OA and YA groups based on upper age quartile (57 y). Plasma Sdc-1 levels were compared in OA and YA at hospital arrival through postinjury day 3, and the independent association between age and Sdc-1 level at arrival was determined after adjusting for differences in gender, shock index (SI), and pre-existing comorbidities. In a follow-up analysis, case-control matching was used to create populations of OA and YA with equivalent SI and injury severity score. Levels of Sdc-1 were compared between these matched groups, and the relationships with candidate regulators of EG shedding were assessed.

RESULTS

Of 680 subjects in the Pragmatic, Randomized Optimal Platelet, and Plasma Ratios trial, 350 (51%) had blunt injuries, and 92 (26.3%) of these were OA. Plasma Sdc-1 levels at arrival, 2 h, and 6 h were significantly lower in OA compared to YA (all P < 0.05). After adjusting for sex, pre-existing morbidities and SI, age was associated with decreased Sdc-1 levels at arrival. In the matched analyses, Sdc-1, high-mobility group box 1 and tissue inhibitor of metalloproteinase-2 levels were lower in OA compared to YA. Both high-mobility group box-1 and tissue inhibitor of metalloproteinase-2 significantly correlated with arrival Sdc-1 and were inversely associated with age.

CONCLUSIONS

This study indicates that increased age is independently associated with decreased Sdc-1 levels among patients with blunt injuries. Suppressed plasma levels of sheddases in relation to diminished Sdc-1 shedding suggest that mechanisms regulating EG cleavage may be impaired in injured older adults. These findings provide novel insight into the age-dependent impact of injury on the vascular endothelium, which could have important implications for the clinical management of older adults following trauma.

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.

Development and Validation of a Novel Hollow Viscus Injury Prediction Score for Abdominal Seatbelt Sign: A Pacific Coast Surgical Association Multicenter Study

BACKGROUND

High-quality CT can exclude hollow viscus injury (HVI) in patients with abdominal seatbelt sign (SBS) but performs poorly at identifying HVI. Delay in diagnosis of HVI has significant consequences necessitating timely identification.

STUDY DESIGN

This multicenter, prospective observational study conducted at 9 trauma centers between August 2020 and October 2021 included adult trauma patients with abdominal SBS who underwent abdominal CT before surgery. HVI was determined intraoperatively and physiologic, examination, laboratory, and imaging findings were collected. Least absolute shrinkage and selection operator- and probit regression-selected predictor variables and coefficients were used to assign integer points for the HVI score. Validation was performed by comparing the area under receiver operating curves (AUROC).

RESULTS

Analysis included 473 in the development set and 203 in the validation set. The HVI score includes initial systolic blood pressure <110 mmHg, abdominal tenderness, guarding, and select abdominal CT findings. The derivation set has an AUROC of 0.96, and the validation set has an AUROC of 0.91. The HVI score ranges from 0 to 17 with score 0 to 5 having an HVI risk of 0.03% to 5.36%, 6 to 9 having a risk of 10.65% to 44.1%, and 10 to 17 having a risk of 58.59% to 99.72%.

CONCLUSIONS

This multicenter study developed and validated a novel HVI score incorporating readily available physiologic, examination, and CT findings to risk stratify patients with an abdominal SBS. The HVI score can be used to guide decisions regarding management of a patient with an abdominal SBS and suspected HVI.

Central retinal artery occlusion following pediatric blunt ocular trauma

BACKGROUND

To analyze the clinical profile, presentation, possible pathophysiology, and outcomes of central retinal artery occlusion (CRAO) following blunt trauma in pediatric subjects.

METHODOLOGY

The medical charts of subjects aged 18 years or less with a diagnosis of CRAO following blunt ocular trauma were analyzed retrospectively for demography, details of the trauma, ocular findings, additional imaging reports if any, and final outcome. A Medline search was done (key words like central retinal artery occlusion, blunt trauma, children, pediatric subjects, and adolescents) to gather information available in the literature on the subject.

RESULTS

A total of 11 patients (11 eyes), mean age of 14.3 ± 3.4 years, and 100% male preponderance, with an average time duration from trauma to presentation to the hospital of 8.1 days were included. Visual acuity ranged from no light perception (four eyes) to finger count at a 1 m distance. Intraocular pressure was raised in three patients, of which two were suffering from sickle cell disease. In two eyes, the CRAO coexisted with optic nerve avulsion and the cilioretinal artery was spared. Disk pallor was seen in six eyes as early as 12 days from the trauma. None of the cases revealed any bony fracture in the CT scan.

CONCLUSION

CRAO was observed to be an important primary or contributory cause of visual loss in children following blunt trauma, reflex vasospasm being the most common etiology. Early onset disk pallor could suggest an underlying vascular compromise of both retinal and optic disk circulation in addition to direct disk damage.

Thoracic Emergencies for the General Surgeon

In this review article, we aim to provide an overview of common and uncommon general surgery thoracic emergencies as well as basic thoracic anatomy, common diagnostic tests, and operative positioning and access considerations. We also describe specific thoracic procedures. We hope that this article simplifies some of the challenges associated with the management of thoracic emergencies.

Determinants of adverse management outcomes of blunt abdominal trauma patients operated at a referral hospital in southern Ethiopia: a retrospective record review

BACKGROUND

Abdominal trauma is one of the common reasons for emergency visits yet there is paucity of data about the subject in the horn of Africa. This study was aimed at determining the determinants of adverse management outcomes of blunt abdominal trauma among operated patients at Wolaita Sodo University Teaching and Referral Hospital, Ethiopia.

METHODS

This was a three-year retrospective review conducted among 128 patient records selected using purposive sampling in which all records for the patients operated for a diagnosis of blunt abdominal trauma during the study period were included. A pretested checklist was used to extract the data relating to adverse outcomes and characteristics of the patients. A descriptive analysis followed by logistic regression was done.

RESULTS

Of the 128 patients, adverse management outcomes related to blunt abdominal trauma occurred in 52%. Patients residing in rural areas (adjusted odds ratio 3.23, 95% confidence interval: 1.13-9.24) and those with tachycardia, (adjusted odds ratio = 3.25, 95% confidence interval: 1.19-8.83) or tachypnea (adjusted odds ratio 3.25, 95% confidence interval: 1.19-8.83) were more likely to have adverse management outcomes.

CONCLUSION

Adverse management outcomes are relatively high and associated with rural residence and deranged vital signs (tachycardia and tachypnea). Close monitoring targeting patients from rural residence and those presenting with tachycardia and tachypnea is recommended.

Emergency department management of pediatric blunt thoracic injuries

Pediatric chest trauma can present with a wide array of symptoms and with varying rates of morbidity and mortality. Children have unique thoracic anatomical and physiological characteristics, often necessitating diagnostic and management considerations that differ from management of blunt chest injury in adults. This review discusses diagnostic and treatment modalities for commonly encountered injuries in pediatric blunt thoracic trauma, such as pulmonary contusions, rib fractures, pneumothoraces, and hemothoraces. Rarely encountered but high-mortality injuries, including blunt cardiac injury, commotio cordis, tracheobronchial injury, and aortic injury, are also discussed.

A Novel Paradigm to Develop Regional Thoracoabdominal Criteria for Behind Armor Blunt Trauma Based on Original Data

INTRODUCTION

For behind armor blunt trauma (BABT), recent prominent BABT standards for chest plate define a maximum deformation distance of 44 mm in clay. It was developed for soft body armor applications with limited animal, gelatin, and clay tests. The legacy criterion does not account for differing regional thoracoabdominal tolerances to behind armor-induced injury. This study examines the rationale and approaches used in the legacy BABT clay criterion and presents a novel paradigm to develop thoracoabdominal regional injury risk curves.

MATERIALS AND METHODS

A review of the original military and law enforcement studies using animals, surrogates, and body armor materials was conducted, and a reanalysis of data was performed. A multiparameter model analysis describes survival-lethality responses using impactor/projectile (mass, diameter, and impact velocity) and specimen (weight and tissue thickness) variables. Binary regression risk curves with ±95% confidence intervals (CIs) and peak deformations from simulant tests are presented.

RESULTS

Injury risk curves from 74 goat thorax tests showed that peak deflections of 44.7 mm (±95% CI: 17.6 to 55.4 mm) and 49.9 mm (±95% CI: 24.7 to 60.4 mm) were associated with the 10% and 15% probability of lethal outcomes. 20% gelatin and Roma Plastilina #1 clay were stiffer than goat. The clay was stiffer than 20% gelatin. Penetration diameters showed greater variations (on a test-by-test basis, difference 36-53%) than penetration depths (0-12%) across a range of projectiles and velocities.

CONCLUSIONS

While the original authors stressed limitations and the importance of additional tests for refining the 44 mm recommendation, they were not pursued. As live swine tests are effective in developing injury criteria and the responses of different areas of the thoracoabdominal regions are different because of anatomy, structure, and function, a new set of swine and human cadaver tests are necessary to develop scaling relationships. Live swine tests are needed to develop incapacitation/lethal injury risk functions; using scaling relationships, human injury criteria can be developed.

[Persistent ST-elevation with elevated myocardial necrosis markers: a case of myocardial contusion]

Myocardial contusion is a rare and potentially fatal complication of chest trauma. There is no unique definition for this entity: some authors define myocardial contusion as a mild increase in cardiac biomarkers in the context of chest trauma, while for others the diagnosis requires evidence of pathologic findings at cardiac imaging. Consequently, the real incidence of myocardial contusion remains unknown, varying in reports between 8% and 71%. We describe a case of cardiac contusion secondary to a low-energy blunt chest trauma, manifesting as persistent ST-elevation associated with elevation of myocardial necrosis markers, with consequent myocardial stunning of the right ventricular free wall. As there is no consensus regarding the diagnostic pathway, it is essential to integrate first-level exams (ECG and laboratory findings) with cardiac magnetic resonance imaging, to define the presence of cardiac contusion and its extent, particularly if the echocardiographic data are unconclusive.

C-reactive protein in the early diagnosis of pneumonia complicating severe blunt chest trauma

INTRODUCTION

The early diagnosis of pneumonia following severe blunt chest trauma (SBCT) allows the early prescription of antibiotics and initiation of adequate supportive care.

AIM

To assess the usefulness of C-reactive protein (CRP) in the early diagnosis of pneumonia complicating SBCT.

METHODS

We conducted a prospective study of patients admitted to trauma intensive care unit for SBCT between January 2020 and February 2023. Patients were divided into two groups according to whether or not they developed pneumonia. The CRP levels were monitored daily.

RESULTS

One hundred sixty-seven patients were included. Pneumonia occurred in 40.1% of patients within a median of 5 days. We found statistically significant difference in mean CRP levels between groups from day 3 to day 9 following trauma. The increase in CRP level on the 4th day from a value greater than or equal to 192 mg/L was a marker of early diagnosis of pneumonia (sensitivity 80.6%; specificity 80.8%).

CONCLUSION

Daily CRP measurement from the 3rd day following SBCT may be useful for early diagnosis of pneumonia complicating SBCT.

Diagnostic Peritoneal Aspiration or Lavage in Stratified Groups of Hypotensive Blunt Trauma Patients

BACKGROUND

Some reports suggest Diagnostic peritoneal aspiration (DPA) or lavage (DPL) may better select which hypotensive blunt trauma patients (BTPs) require operation, compared to ultrasonography. However, whether both moderately hypotensive (systolic blood pressure [SBP] < 90 mmHg) and severely hypotensive (SBP < 70 mmHg) patients benefit from DPA/DPL is unclear. We hypothesized DPA/DPL used within the first hour increases risk of death for severely vs moderately hypotensive BTPs.

METHODS

The 2017-2019 Trauma Quality Improvement Program database was queried for BTPs ≥ 18 years old with hypotension upon arrival. We compared moderately and severely hypotensive groups. A multivariable logistic regression analysis was performed controlling for age, comorbidities, emergent operation, blood transfusions, and injury profile.

RESULTS

From 134 hypotensive patients undergoing DPA/DPL, 66 (49.3%) had severe hypotension. Patients in both groups underwent an emergent operation (43.9% vs 58.8%, P = .09) in a similar amount of time (median, 42-min vs 54-min, P = .11). Compared to the moderately hypotensive group, severely hypotensive patients had a higher rate and associated risk of death (84.8% vs 50.0%, P < .001) (OR 5.40, CI 2.07-14.11, P < .001). The strongest independent risk factor for death was age ≥ 65 (OR 24.81, CI 4.06-151.62, P < .001).

DISCUSSION

Among all BTPs undergoing DPA/DPL within the first hour of arrival, an over 5-fold increased risk of death for patients with severe hypotension was demonstrated. As such, DPA/DPL within this group should be used with caution, particularly for older patients, as they may be better served by immediate surgeries. Future prospective research is needed to confirm these findings and elucidate the ideal DPA/DPL population in the modern era of ultrasonography.

Risk Factors and Management of Blunt Inferior Vena Cava Injury: A Retrospective Study

BACKGROUND

Traumatic inferior vena cava (IVC) injuries are uncommon, but the mortality rate remains high at 38-70%. To date, most studies on traumatic IVC injuries have evaluated blunt rather than penetrating injuries. We aimed to identify the clinical features and risk factors that affect the prognosis of patients with blunt IVC injuries to improve treatment strategies for these patients.

METHODS

We retrospectively analyzed patients diagnosed with blunt IVC injury over 8 years at a single trauma center. Clinical and biochemical parameters; transfusion, surgical, and resuscitation methods; associated injuries; intensive care unit stay; and complications data were compared between survival and death groups to identify clinical features and risk factors of blunt IVC injury-related mortality.

RESULTS

Twenty-eight patients with blunt IVC injury were included during the study periods. Twenty-five (89%) patients underwent surgical treatment, and the mortality was 54%. The mortality rate according to the IVC injury location was the lowest for supra-hepatic IVC injury (25%, n = 2/8), whereas it was the highest for retrohepatic IVC injury (80%, n = 4/5). In the logistic regression analysis, Glasgow Coma Scale (GCS) (odds ratio [OR] = 0.566, 95% confidence interval [CI] [0.322-0.993], p = 0.047) and red blood cell (RBC) transfusion for 24 h (OR = 1.132, 95% CI [0.996-1.287], p = 0.058) were independent predictors for mortality.

CONCLUSIONS

Low GCS score and high-volume packed RBC transfusion requirements for 24 h were significant predictors of mortality in patients with blunt IVC injuries. Unlike IVC injuries caused by penetrating trauma, supra-hepatic IVC injuries caused by blunt trauma have a good prognosis.

TRAUMATIC PULMONARY HERNIATION: A RARE CHEST TRAUMA MANIFESTATION

Traumatic pulmonary hernia is an uncommon occurrence resulting from chest trauma, typically covered by the skin. Chest trauma may arise from penetrating or blunt mechanisms, with blunt trauma being more frequently observed. When lung herniation transpires, various symptoms such as chest pain, dyspnea, subcutaneous emphysema, bone crepitation, and hemoptysis (in cases of lung parenchymal damage) may manifest. We present the case of a 66-year-old woman suffering from chest pain and dyspnea after blunt chest trauma due to a fall induced by delirium following alcohol abuse.

Undertriage of Severely Injured Trauma Patients

INTRODUCTION

The American College of Surgeons (ACS) delineates trauma team activation (TTA) criteria to identify seriously injured trauma patients in the field. Patients are deemed to be severely undertriaged (SU), placing them at risk for adverse outcomes, when they do not meet TTA criteria but nonetheless sustain significant injuries (Injury Severity Score [ISS] ≥25).

OBJECTIVES

Delineate patient demographics, injuries, and outcomes after SU.

PARTICIPANTS

Trauma patients presenting to our ACS-verified Level 1 trauma center with ISS ≥25 were included (11/2015-03/2022). Transfers and private vehicle transports were excluded. Patients were dichotomized and compared by trauma arrival level: TTA (Appropriately Triaged, AT) vs routine consults (SU).

RESULTS

Study criteria were satisfied by 1653 patients: 1375 (83%) AT and 278 (17%) SU. Severely undertriaged patients were older than AT patients (47 vs 36 years, P < .001). Severely undertriaged occurred almost exclusively following blunt trauma (96% vs 71%, P < .001). Injury Severity Score was lower following SU than AT (29 vs 32, P < .001). The most common severe injuries (Abbreviated Injury Scale score [AIS] ≥3) among the SU group were in the Chest (n = 179, 64%). Severely undertriaged patients necessitated emergent intubation (n = 34, 12%), surgery (n = 59, 21%), and angioembolization (n = 22, 8%) at high rates. Severely undertriaged mortality was n = 40, 14%.

CONCLUSION

Severely undertriaged occurred among a substantial proportion of ISS ≥25 patients, predominately following blunt trauma. Severe chest injuries were most likely to evade capture. Rates of intubation, emergent intervention, and in-hospital mortality were high after SU. Efforts should be made to identify such patients in the field as they may benefit from TTA.

Focused Assessment with Sonography for Trauma (FAST) Exam: Image Acquisition

Over the past twenty years, the Focused Assessment with Sonography for Trauma (FAST) exam has transformed the care of patients presenting with a combination of trauma (blunt or penetrating) and hypotension. In these hemodynamically unstable trauma patients, the FAST exam permits rapid and noninvasive screening for free pericardial or peritoneal fluid, the latter of which implicates intra-abdominal injury as a likely contributor to the hypotension and justifies emergent abdominal surgical exploration. Further, the abdominal portion of the FAST exam can also be used outside of the trauma setting to screen for free peritoneal fluid in patients who become hemodynamically unstable in any context, including after procedures that may inadvertently injure abdominal organs. These "non-trauma" situations of hemodynamic instability are often triaged by providers from specialties other than emergency medicine or trauma surgery who are not familiar with the FAST exam. Therefore, there is a need to promulgate knowledge about the FAST exam to all clinicians caring for critically ill patients. Toward this end, this article describes FAST exam image acquisition: patient positioning, transducer selection, image optimization, and exam limitations. Since the free fluid is likely to be found in specific anatomic locations that are unique for each canonical FAST exam view, this work centers on the unique image acquisition considerations for each window: subcostal, right upper quadrant, left upper quadrant, and pelvis.

Blunt Traumatic Abdominal Wall Hernias: An Indicator for Emergent Laparotomy?

BACKGROUND

Traumatic abdominal wall hernias (TAWH) are relatively uncommon; however, the shearing force that results in fascial disruption could indicate an increased risk of visceral injury. The aim of our study was to evaluate whether the presence of a TAWH was associated with intra-abdominal injury requiring emergent laparotomy.

METHODS

The trauma registry was queried over an 8-year period (7/2012-7/2020) for adult patients with blunt thoracoabdominal trauma diagnosed with a TAWH. Those patients who were identified with a TAWH and greater than 15 years of age were included in the study. Demographics, mechanism of injury, ISS, BMI, length of stay, TAWH size, type of TAWH repair, and outcomes were analyzed.

RESULTS

Overall, 38,749 trauma patients were admitted over the study period, of which 64 (.17%) had a TAWH. Patients were commonly male (n = 42, 65.6%); the median age was 39 years (range 16-79 years) and a mean ISS of 21. Twenty-eight percent had a clinical seatbelt sign. Twenty-seven (42.2%) went emergently to the operating room, the majority for perforated viscus requiring bowel resection (n = 16, 25.0%), and 6 patients (9.4%) who were initially managed nonoperatively underwent delayed laparotomy. Average ventilator days was 14 days, with a mean ICU LOS of 14 days and mean hospital LOS of 18 days. About half of the hernias were repaired at the index operation, 6 of which were repaired primarily and 10 with mesh.

CONCLUSION

The presence of a TAWH alone was an indication for immediate laparotomy to evaluate for intra-abdominal injury. In the absence of other indications for exploration, nonoperative management may be safe.

[Bilateral thoracic trauma-"double the trouble"?]

BACKGROUND

Thoracic trauma is associated with a high morbidity and mortality. Assessing the risk for complications is essential for planning the further treatment strategies and managing resources in thoracic trauma.

OBJECTIVE

The aim of the study was to analyze concomitant injuries in unilateral and bilateral rib fractures and pulmonary contusions and evaluate differences in complication rates between the two.

MATERIAL AND METHODS

In a retrospective study, data from all patients diagnosed with thoracic trauma at a level I trauma center were analyzed. Bivariate and multivariate analysis were used to examine an association of unilateral or bilateral rib fractures, serial rib fractures, and pulmonary contusions with multiple injuries and outcomes. In addition, multivariate regression analysis was utilized to determine the impact of age, gender and additional injuries on outcome.

RESULTS

A total of 714 patients were included in the analysis. The mean Injury Severity Score (ISS) was 19. Patients with an additional thoracic spine injury had a significantly higher incidence of bilateral rib fractures. Pulmonary contusions were associated with younger age. Abdominal injuries were predictors for bilateral pulmonary contusions. Complications occurred in 36% of the patients. Bilateral injuries increased the complication rate up to 70%. Pelvic and abdominal injuries as well as the need for a chest drain were significant risk factors for complications. The mortality rate was 10%, with higher age, head and pelvic injuries as predictors.

CONCLUSION

Patients with bilateral chest trauma had an increased incidence of complications and a higher mortality rate. Bilateral injuries and significant risk factors must therefore be considered. Injury of the thoracic spine should be excluded in those patients.

Diagnostic accuracy of screening tools for pediatric blunt cerebrovascular injury: An ATOMAC multicenter study

BACKGROUND

Blunt cerebrovascular injury (BCVI) is rare but significant among children. There are three sets of BCVI screening criteria validated for adults (Denver, Memphis, and Eastern Association for the Surgery of Trauma criteria) and two that have been validated for use in pediatrics (Utah score and McGovern score), all of which were developed using retrospective, single-center data sets. The purpose of this study was to determine the diagnostic accuracy of each set of screening criteria in children using a prospective, multicenter pediatric data set.

METHODS

A prospective, multi-institutional observational study of children younger than 15 years who sustained blunt trauma to the head, face, or neck and presented at one of six level I pediatric trauma centers from 2017 to 2020 was conducted. All patients were screened for BCVI using the Memphis criteria, but criteria for all five were collected for analysis. Patients underwent computed tomography angiography of the head or neck if the Memphis criteria were met at presentation or neurological abnormalities were detected at 2-week follow-up.

RESULTS

A total of 2,284 patients at the 6 trauma centers met the inclusion criteria. After excluding cases with incomplete data, 1,461 cases had computed tomography angiography and/or 2-week clinical follow-up and were analyzed, including 24 cases (1.6%) with BCVI. Sensitivity, specificity, positive predictive value, and negative predictive value for each set of criteria were respectively 75.0, 87.5, 9.1, and 99.5 for Denver; 91.7, 71.1, 5.0, and 99.8 for Memphis; 79.2, 82.7, 7.1, and 99.6 for Eastern Association for the Surgery of Trauma; 45.8, 95.8, 15.5, and 99.1 for Utah; and 75.0, 89.5, 10.7, and 99.5 for McGovern.

CONCLUSION

In this large multicenter pediatric cohort, the Memphis criteria demonstrated the highest sensitivity at 91.7% and would have missed the fewest BCVI, while the Utah score had the highest specificity at 95.8% but would have missed more than half of the injuries. Development of a tool, which narrows the Memphis criteria while maintaining its sensitivity, is needed for application in pediatric patients.

LEVEL OF EVIDENCE

Diagnostic Test/Criteria; Level II.

Lower incidence of blunt cerebrovascular injury among young, properly restrained children: An ATOMAC multicenter study

BACKGROUND

Motor vehicle collision (MVC) remains a leading cause of injury and death among children, but the proper use of child safety seats and restraints has lowered the risks associated with motor vehicle travel. Blunt cerebrovascular injury (BCVI) is rare but significant among children involved in MVC. This study reviewed the incidence of BCVI after MVC causing blunt injury to the head, face, or neck, comparing those that were properly restrained with those that were not.

METHODS

A prospective, multi-institutional observational study of children younger than 15 years who sustained blunt trauma to the head, face, or neck (Abbreviated Injury Scale score >0) and presented at one of six level I pediatric trauma centers from 2017 to 2020 was conducted. Diagnosis of BCVI was made either by imaging or neurological symptoms at 2-week follow-up. Restraint status among those involved in MVC was compared for each age group.

RESULTS

A total of 2,284 patients were enrolled at the 6 trauma centers. Of these, 521 (22.8%) were involved in an MVC. In this cohort, after excluding patients with missing data, 10 of 371 (2.7%) were diagnosed with a BCVI. For children younger than 12 years, none who were properly restrained suffered a BCVI (0 of 75 children), while 7 of 221 (3.2%) improperly restrained children suffered a BCVI. For children between 12 and 15 years of age, the incidence of BCVI was 2 of 36 (5.5%) for children in seat belts compared with 1 of 36 (2.8%) for unrestrained children.

CONCLUSION

In this large multicenter prospectively screened pediatric cohort, the incidence of BCVI among properly restrained children under 12 years after MVC was infrequent, while the incidence was 3.2% among those without proper restraint. This effect was not seen among children older than 12 years. Restraint status in young children may be an important factor in BCVI screening.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Management and Outcome of Blunt Pancreatic Trauma: A Retrospective Cohort Study

BACKGROUND

Pancreatic injury is rare, but it has a high mortality rate and its optimal treatment remains controversial. This study aimed to evaluate the clinical characteristics, management strategies, and outcomes of patients with blunt pancreatic injury.

METHODS

This retrospective cohort study was performed on patients with a confirmed blunt pancreatic injury who were admitted to our hospital from March 2008 to December 2020. The clinical characteristics and outcomes of patients receiving different management strategies were compared. The risk factors for in-hospital mortality were evaluated by performing a multivariate regression analysis.

RESULTS

A total of 98 patients diagnosed with blunt pancreatic injury were identified, with 40 patients having undergone nonoperative treatment (NOT) and 58 patients having undergone surgical treatment (ST). The overall in-hospital deaths were 6 (6.1%), including 2 (5.0%) and 4 (6.9%) in the NOT and ST groups, respectively. Pancreatic pseudocysts occurred in 15 (37.5%) and 3 (5.2%) of the NOT and ST groups, respectively, showing a significant difference between the two groups (P < 0.001). In the multivariate regression analysis, concomitant duodenal injury (OR = 14.42, 95% CI 1.27-163.52; P = 0.031) and sepsis (OR = 43.47, 95% CI, 4.15-455.75; P = 0.002) were independently associated with in-hospital mortality.

CONCLUSIONS

Except for the higher incidence of pancreatic pseudocysts in the NOT group than in the ST group, there were no significant differences in the other clinical outcomes between the two groups. Concomitant duodenal injury and sepsis were the risk factors for in-hospital mortality.

A rare case of isolated gallbladder rupture following blunt abdominal trauma

Isolated gallbladder rupture are rare injuries. We present a case of gallbladder traumatic rupture in a 47-year-old patient involved in a motor vehicle collision, that presented abdominal pain with maximal intensity in the right upper quadrant.CT is the imaging technique of choice to diagnosis this entity, however the final diagnosis of gallbladder rupture is confirmed with laparoscopy. Cholecystectomy is the definitive treatment.

Concomitant paracentral acute middle maculopathy and acute macular neuroretinopathy in eyes post-blunt trauma

Purpose

To analyze the imaging characteristics and the clinical course of patients showing concomitant paracentral acute middle maculopathy (PAMM) and acute macular neuroretinopathy (AMN) post-blunt trauma.

Methods

PAMM and AMN lesions post-blunt trauma diagnosed on enhanced depth imaging optical coherence tomography (EDI-OCT) were recruited for the study.

Results

: Thirteen eyes of 13 individuals with a history of blunt trauma were included in the study, of whom 11 (85%) were males. Mean age of the patients was 33.62 (range 16-67) years. Mean visual acuity at presentation and the last visit was 1.67 log of minimum angle of resolution (logMAR) and 0.82 logMAR, respectively. Mean interval between trauma and imaging was 5.08 (range 1-15) days. All patients had unilateral involvement, with the right eye being involved in 10 patients (77%). All patients had concomitant PAMM and AMN lesions.

Conclusion

: Presence of coincident PAMM and AMN suggests a common pathophysiologic etiology, but the description of concomitant PAMM and AMN in the setting of blunt trauma to eye is hitherto unreported. Identifying AMN in a setting of PAMM requires meticulous examination of the OCT and OCTA images. It can be a cause of suboptimal visual recovery in such eyes.

[Blunt abdominal trauma in children and adolescents: treatment concepts in the acute phase]

Fatal accidents due to blunt force trauma are the leading cause of death in children and adolescents [1]. Abdominal trauma is the third most common cause of death after traumatic brain injury and thoracic injuries [2]. Abdominal injury is seen in approximately 2-5% of children involved in accidents [3]. Blunt abdominal injuries are common sequelae of traffic accidents (for example as seat belt injury), falls, and sports accidents. Penetrating abdominal injuries are rare in central Europe. Spleen, liver, and kidney lacerations are the most common injuries after blunt abdominal trauma [4]. In most situations, nonoperative management (NOM) has become the gold standard with the surgeon leading the multidisciplinary treatment [5].

Low-Dose Heparin Infusion as Venous Thromboembolism Chemoprophylaxis in Patients With Blunt Cerebrovascular Injury

INTRODUCTION

Blunt cerebrovascular injury (BCVI) can result in devastating stroke. Because of operative inaccessibility, the most common treatment for BCVI is aspirin or a low-dose systemic heparin infusion. While it is assumed that low dose heparin infusion imparts venous thromboembolism (VTE) prophylaxis, this has not been evaluated in the BCVI population. The purpose of this study was to evaluate VTE rates in patients receiving low-dose heparin infusion as treatment for BCVI.

METHODS

Patients diagnosed with BCVI between 2014 and 2018 were reviewed for initiation of low-dose systemic heparin treatment. VTE was defined as a deep vein thrombosis or pulmonary embolism. BCVI patients without systemic heparin treatment were compared to BCVI patients with heparin treatment for overall VTE rates. Comparisons were also made to injured patients without a BCVI in our Trauma Activation Protocol (TAP) database.

RESULTS

During the 5-year study period, 265 patients were identified with a BCVI. The majority (61%) were men with a median injury severity score (ISS) 22 (interquartile range [IQR]:14-33). Of these patients, 146 (55.1%) received a heparin infusion to treat BCVI. VTE was identified in eight of these patients (5.5%). Compared to TAP patients (n = 1020) who received standard dosing of VTE chemoprophylaxis, there was no difference in VTE rates compared to BCVI patients who were started on a low dose heparin infusion (3% versus 5.5%, P = 0.16). Area under the receiver operating characteristics (AUROC) was used to evaluate the predictive power of time to initiation of heparin infusion (AUC = 0.64 95% CI 0.42-0.85, P = 0.2) and time to reaching PTT goal (AUC = 0.52 95% CI 0.27-0.77, P = 0.83) as a predictor VTE events.

CONCLUSIONS

Low dose heparin infusion is frequently used as an initial treatment of BCVI. In injured patients with BCVI, a low dose heparin infusion is associated with a low rate of VTE, comparable to injured patients without BCVI that received standard VTE chemoprophylaxis.