Air Guns: A Contemporary Review of Injuries at Six Pediatric Level I Trauma Centers.

BACKGROUND: Studies spanning the last three decades demonstrated the injury causing capability of air gun (AG) projectiles. Recent studies have suggested the impact and incidence of these injuries may be declining because of edcational efforts. We hypothesize that injuries in the pediatric population resulting from AGs remain a significant health concern. METHODS: A retrospective review (1/1/2007 to 12/31/2016), of AG-injured children < 19 years old, was performed across six level I Pediatric Trauma Centers, part of the ATOMAC research consortium. AG injuries were defined as injuries sustained by ball-bearing or pellet air-powered guns. Paint ball and soft foam AGs were excluded. Following institutional review board approval, patients were identified by ICD code from the trauma registry. Included were demographic data, injury severity scores, length of stay (LOS), outcome at discharge, and overall cost of admission. Descriptive statistics and parametric tests were employed. RESULTS: A total of 499 patients sustained injuries. Mean age 9.5 (±4.0) y; 81% of victims were male; all survived to hospital discharge. 30% (n = 151) required operative intervention. Hospital LOS was 2.3 (±2.2) d; with mean cost of $23,756 (±$34,441). Injury severity score mean of 3.7 (±4.6) on admission. Over 40% of the injuries to the head/thorax that were severe (AIS ≥ 3) required operative intervention (P < 0.001). CONCLUSIONS: AG injuries to the head or thorax seen at trauma centers were likely to require operative management. While no fatalities occurred, the cost was substantial. This study demonstrates pediatric injuries resulting from AG projectiles remain a significant health concern.

Reverse shock index multiplied by the motor component of the Glasgow Coma Scale predicts mortality and need for intervention in pediatric trauma patients.

BACKGROUND: Timely identification of high-risk pediatric trauma patients and appropriate resource mobilization may lead to improved outcomes. We hypothesized that reverse shock index times the motor component of the Glasgow Coma Scale (rSIM) would perform equivalently to reverse shock index times the total Glasgow Coma Scale (rSIG) in the prediction of mortality and the need for intervention following pediatric trauma. METHODS: The 2017-2020 National Trauma Data Bank datasets were used. We included all patients <16 years of age that had a documented prehospital and trauma bay systolic blood pressure, heart rate, and total GCS. We excluded all patients who arrived at the trauma center without vital signs and interfacility transport patients. Receiver operating characteristic (ROC) curves were used to model the performance of each metric as a classifier with respect to our primary and secondary outcomes, and the area under the ROC curve (AUC) was used for comparison. Our primary outcome was mortality prior to hospital discharge. Secondary outcomes included blood product administration or hemorrhage control intervention (surgery or angiography) < 4 hours following hospital arrival and ICU admission. RESULTS: After application of exclusion criteria, 77,996 patients were included in our analysis. rSIM and rSIG performed equivalently as predictors of mortality in the 1-2 (p = 0.05) and 3-5 (p = 0.28) year categories, but rSIM was statistically outperformed by rSIG in the 6-12 (AUC: 0.96 vs. 0.95, p = 0.04) and 13-16 (AUC: 0.96 vs. 0.95, p < 0.01) year-old age categories. rSIM and rSIG also performed similarly with respect to prediction of secondary outcomes. CONCLUSION: rSIG and rSIM are both outstanding predictors of mortality following pediatric trauma. Statistically significant differences in favor of rSIG were noted in some age groups. Because of the simplicity of calculation, rSIM may be a useful tool for pediatric trauma triage. LEVEL OF EVIDENCE: III, Diagnostic Tests or Criteria.

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.

Rethinking pediatric trauma triage.

Despite advances in the delivery of trauma care, trauma remains the leading cause of death amongst the pediatric population within the United States and is one of the leading causes of death in children worldwide.  Accurately triaging pediatric trauma patients is essential to minimize preventable mortality without burdening the system by utilizing unnecessary resources.  This article will review the accuracy of current pediatric trauma triage practices and how it will evolve in the future including moving away from mechanism of injury towards physiologic scoring tools such as the pediatric age-adjust shock index, and intervention-based systems including. Need for Surgeon Presence and Need For Trauma Intervention. This paper will also present evidence regarding over-utilization of air transport for pediatric trauma patients and the associated unnecessary costs placed on the trauma system.

Is it time for firearm injury to be a separate activation criteria in children? An assessment of penetrating pediatric trauma using need for surgeon presence.

BACKGROUND: Penetrating injury independently predicts the need for surgeon presence (NSP) upon arrival. Penetrating injury is often used as a trauma triage indicator, however, it includes a wide range of specific mechanisms of injury. We sought to compare firearm-related and non-firearm related pediatric penetrating injuries with respect to NSP, ISS and mortality. METHODS: Patients <18 from the 2016 National Trauma Quality Improvement Program Database were included. Penetrating injury was identified and grouped using ICD-10 mechanism codes into firearm and non-firearm related injury. NSP, ISS, and mortality were compared between the two groups. RESULTS: A total of 1715 (4.2%) patients with penetrating injury were; 832 firearm-related and 883 non-firearm. No deaths occurred among the non-firearm group compared to 94 (11.3%) among firearm-related patients. Among non-firearm patients, 22.7% had a NSP indicator compared to 51.2% of patients injured by a firearm. CONCLUSION: There is a significantly higher proportion of severe injury and mortality with firearm penetrating injury when compared to non-firearm pediatric penetrating injury. Consideration should be given to dividing it into firearm and non-firearm penetrating injury.

Delay in diagnosis and treatment of blunt intestinal perforation does not adversely affect prognosis in the pediatric trauma patient.

BACKGROUND: Blunt intestinal injury (BII) requiring surgical intervention in the pediatric trauma population remains difficult to diagnose. We sought to analyze whether delay in treatment in the event of perforation had an adverse affect on patient outcome. METHODS: A multi-institutional retrospective chart review by the members of the American Pediatric Surgical Association Committee on Trauma was initiated after the approval of Institutional Review Board at each of the 18 institutions. All children 12 hours) based on time from injury to intervention and whether they had perforation or not. Early and late complications as well as hospital days, injury severity score, and time to full feeds were compared in each group. There were two deaths from an abdominal source in the <6-hour nonperforation group, one in the 6-hour perforation group, and one in the 6-hour to 12-hour nonperforation group. Injury severity score was significantly greater in the <6-hour intervention group regardless of perforation status. There was no correlation between time to surgery and complication rate nor was there a significant increase in hospital days. CONCLUSIONS: These data suggest that delay in operative intervention does not have a significant effect on prognosis after pediatric blunt intestinal perforation. Appropriate observation and serial examination rather than repeat computed tomography and/or urgent exploration would appear adequate when the diagnosis is in question.

Helicopter transport in pediatric trauma: A new methodology using Need for Surgeon Presence to evaluate the necessity of air transport.

BACKGROUND: When to transport pediatric trauma patients directly from scene to a trauma center via helicopter (HT) has been a long debated topic. This study proposes Need for Surgeon Presence (NSP) matrix as an alternative method to assess appropriate utilization of HT of pediatric trauma patients directly from the scene of injury. METHOD: We utilized the 2016 TQIP database. NSP was defined as having one or more of the following: intubation, transfusion, operation for hemorrhage control/craniotomy, vasopressors, interventional radiology, spinal cord injury, tube thoracostomy, emergency thoracotomy, intracranial pressure monitor, or pericardiocentesis. The outcome of interest was the presence or absence of a NSP indicator. RESULTS: The NSP + patients had a: longer LOS, GCS<14, positive SIPA index value, went to OR/ICU from the ED, and had penetrating injury. Among patient with an ISS≥16, mortality for those also NSP+ was 18.8% versus 1.4% among the NSP-. CONCLUSION: The disparity between NSP and traditional ISS thresholds supports NSP as an additional metric to validate pre-hospital triage criteria and may be a better indicator of overall hospital resource utilization.

So you need a surgeon? Need for surgeon presence as an alternative metric to predict outcomes and assess triage in the pediatric trauma population.

BACKGROUND: Injury Severity Score (ISS) is the primary metric by which triage has been evaluated in trauma activations. We compared ISS to a previously described set of criteria defined as Need for Surgical Presence (NSP). We hypothesize that NSP may serve as a way to augment ISS in predicting mortality and assessing triage in pediatric trauma patients. METHODS: A total of 19,139 pediatric trauma patients in the 2016 National Trauma Quality Improvement Program Database (excluding transfers) had complete data for mortality, mode of transport, age, injury type, ISS, and NSP factors. NSP was defined as having one or more of the following: intubation, transfusion, operation for hemorrhage control/craniotomy, vasopressors, interventional radiology, spinal cord Injury, tube thoracostomy, emergency thoracotomy, intracranial pressure monitor, or pericardiocentesis. RESULTS: Overall mortality was 1.3% and 96% of all patients suffered blunt injury. A total of 2787 (14.6%) patients had an NSP indicator compared to 2036 (10.8%) with an ISS ≥16. NSP was noninferior to ISS in predicting mortality with the AUC of 0.91 (95% CI 0.89-0.92) and 0.90 (95% CI 0.88-0.92) respectively. CONCLUSION: NSP predicts mortality in pediatric trauma patients as well as ISS, and may compliment ISS. NSP status can be assigned shortly after patient arrival. Proper assessment of over and undertriage allows for optimal resource utilization by the medical facility and ultimately benefits the hospital, physician and patient. STUDY TYPE: Retrospective national dataset study. LEVEL OF EVIDENCE: Level II.

Factors that predict the need for early surgeon presence in the setting of pediatric trauma.

INTRODUCTION: Evidence based variables predicting the need for surgeon presence (NSP) on arrival of an injured child are limited. We sought to identify prehospital factors that best correlate with NSP and highest level of activation in pediatric trauma. A secondary analysis was also performed to determine whether injury severity score (ISS) was predictive of NSP in pediatric trauma. METHODS: This was a retrospective, single institution study of injured patients age ≤ 16 years delivered from scene to our Pediatric Level I trauma center between January 2016 and June 2017. 526 patients had complete data available for analysis. NSP was previously described as the presence of any of these factors: intubation, transfusion, emergent operation with the trauma team/craniotomy with the neurosurgery team, vasopressors, interventional radiology, spinal cord Injury, chest tube, emergency department thoracotomy, intracranial pressure monitor, pericardiocentesis, or death in the trauma bay. Multivariable analysis was performed with covariates of interest including scene and ED arrival vitals and interventions. RESULTS: Independent predictors of NSP and highest level of activation were GCS of ≤12 (OR 22.3), penetrating trauma (OR 5.4), and hypotension (age adjusted) (OR 10.2). We also found that ISS ≥ 16 was a poor indicator of NSP with a sensitivity of only 61%. CONCLUSION: A validated model based on these variables may be useful in predicting NSP and highest level of activation prior to arrival of pediatric trauma patients. NSP may augment assessment of over and undertriage in pediatric trauma patients as compared to the ISS/Cribari system alone. Level of evidence Level III, retrospective cohort study.

A Multicenter Evaluation of a Firearm Safety Intervention in the Pediatric Outpatient Setting.

PURPOSE: Firearm injuries continue to be a common cause of injury for American children. This pilot study was developed to evaluate the feasibility of providing guidance about firearm safety to the parents of pediatric patients using a tablet-based module in the outpatient setting. METHODS: A tablet-based questionnaire that included a firearm safety message based on current best practice was administered to parents of pediatric patients at nine centers in 2018. Parents were shown a firearm safety video and then asked a series of questions related to firearm safety. RESULTS: The study was completed by 543 parents from 15 states. More than one-third (37%) of families kept guns in their home. The majority of parents (81%, n = 438) thought it was appropriate for physicians to provide firearm safety counseling. Two-thirds (63%) of gun owning parents who do not keep their guns locked said that the information provided in the module would change the way they stored firearms at home. CONCLUSION: Use of a tablet based firearm safety module in the outpatient setting is feasible, and the majority of parents are receptive to receiving anticipatory guidance on firearm safety. Further data is needed to evaluate whether the intervention will improve firearm safety practices in the home. LEVEL OF EVIDENCE: Level III.

Delaying Decannulation After Extracorporeal Membrane Oxygenation Is Safe and Advantageous.

Removal of extracorporeal membrane oxygenation (ECMO) cannulae and discontinuing systemic anticoagulation typically occurs soon after separation from ECMO. We have found, however, that delaying decannulation after terminating ECMO therapy does not predispose to adverse outcomes and may be advantageous. Between January 2014 and June 2016, 36 postcardiotomy patients at the Children's Hospital of Oklahoma required ECMO. In this cohort of 36 patients, there was a need for 42 ECMO runs. Of the 42 ECMO runs, 29 (69%) survived to decannulation. Of those ECMO runs that survived to decannulation, 18 (62%) were cannulated centrally and 11 (38%) were cannulated via the neck. For the runs where the patient survived to decannulation, the mean number of days on ECMO support was 4 ± 2 days. There was an average time interval of 21 ± 14 hours from ECMO termination to decannulation. A single patient failed being separated from ECMO support and required reinstitution of ECMO 18 hours after separation (but did not require recannulation).

Computed Tomography with Intravenous Contrast Is Not Associated with Development of Acute Kidney Injury in Severely Injured Pediatric Patients.

Data for the incidence of acute kidney injury (AKI) related to intravenous contrast administration in the pediatric trauma population are limited. Obtaining a creatinine value before elective CT scans is a relatively accepted standard of care. We sought to determine whether there was any significant difference in the incidence of AKI between severely injured patients who received IV contrast and those who did not. We reviewed data from the trauma registry at our Level I pediatric trauma center. We limited the patients to severely injured pediatric traumas (<15 years old) directly transported from the scene of injury with a creatinine level measured on arrival. Two hundred and eleven patients were included in the study. AKI was defined by the criteria of the AKI Network. We then compared incidence of AKI in those who received a CT scan with IV contrast with those who did not receive IV contrast. The two groups were comparable in age, gender, Glasgow Coma Scale, Injury Severity Score, mean creatinine on arrival, and mean creatinine post-CT scan/arrival. There was no significant difference in AKI between the two. In a subgroup analysis of patients presenting in shock, there was no significant difference in AKI. Our study suggests that IV contrast is not associated with the development of AKI in severely injured pediatric trauma patients. Although obtaining a creatinine value before exposure is ideal, a CT scan with IV contrast in severely injured children should not be delayed to obtain a creatinine value.

Use of Laparoscopy in Pediatric Blunt and Spleen Injury: An Unexpectedly Common Procedure After Cessation of Bleeding.

Background: Recently, several series have reported the use of laparoscopy in pediatric trauma, most commonly for bowel and pancreatic injury within the first 12 or 24 hours. During a multicenter trial at 10 Level 1 pediatric trauma centers, selective use of laparoscopy in children with blunt liver or spleen injury (BLSI) was noted. A secondary analysis was performed to describe the frequency and application of these procedures to pediatric BLSI. Patients and Methods: Prospective data were collected on all children age ≤18 years with BLSI presenting to 1 of 10 pediatric trauma centers. An unplanned secondary analysis of children who underwent laparoscopy was done. Results: Of 1008 children with BLSI, 59 initially underwent a laparotomy, but 11 underwent a laparoscopic procedure during their index admission; 1 of these was 22 hours postlaparotomy and 2 others were laparoscopy-assisted and converted to laparotomy. Median age of patients undergoing a laparoscopic procedure was 11.5 years (interquartile range [IQR]: 5.8-16.4). Laparoscopy was performed at 7 of the 10 centers. Median time to surgery was 42 hours (IQR: 8-96). Most patients had a liver (n = 6) injury; 4 had spleen and 1 had both. One of the laparoscopies was for pancreatic surgery, and 2 were for bowel injury (but converted to open). Conclusions: Laparoscopy was utilized in 16% of children requiring abdominal surgery after BLSI, with a median time of 42 hours postinjury. Uses included diagnostic laparoscopy, drain placement, laparoscopic pancreatectomy, and washout of hematoma.

Adherence to APSA activity restriction guidelines and 60-day clinical outcomes for pediatric blunt liver and splenic injuries (BLSI).

BACKGROUND: After NOM for BLSI, APSA guidelines recommend activity restriction for grade of injury +2 in weeks. This study evaluates activity restriction adherence and 60 day outcomes. METHODS: Non-parametric tests and logistic regression were utilized to assess difference between adherent and non-adherent patients from a 3-year prospective study of NOM for BLSI (≤18 years). RESULTS: Of 1007 children with BLSI, 366 patients (44.1%) met the inclusion criteria of a completed 60 day follow-up; 170 (46.4%) had liver injury, 159 (43.4%) had spleen injury and 37 (10.1%) had both. Adherence to recommended activity restriction was claimed by 279 (76.3%) patients; 49 (13.4%) reported non-adherence and 38 (10.4%) patients had unknown adherence. For 279 patients who adhered to activity restrictions, unplanned return to the emergency department (ED) was noted for 35 (12.5%) with 16 (5.7%) readmitted; 202 (72.4%) returned to normal activity by 60 days. No patient bled after discharge. There was no statistical difference between adherent patients (n = 279) and non-adherent (n = 49) for return to ED (χ2 = 0.8 [p < 0.4]) or readmission (χ2 = 3.0 [p < 0.09]); for 216 high injury grade patients, there was no difference between adherent (n = 164) and non-adherent (n = 30) patients for return to ED (χ2 = 0.6 [p < 0.4]) or readmission (χ2 = 1.7 [p < 0.2]). CONCLUSION: For children with BLSI, there was no difference in frequencies of bleeding or ED re-evaluation between patients adherent or non-adherent to the APSA activity restriction guideline. LEVEL OF EVIDENCE: Level II, Prognosis.

Reimaging in pediatric blunt spleen and liver injury.

BACKGROUND: APSA guidelines do not recommend routine reimaging for pediatric blunt liver or spleen injury (BLSI). This study characterizes the symptoms, reimaging, and outcomes associated with a selective reimaging strategy for pediatric BLSI patients. METHODS: A planned secondary analysis of reimaging in a 3-year multi-site prospective study of BLSI patients was completed. Inclusion required successful nonoperative management of CT confirmed BLSI without pancreas or kidney injury and follow up at 14 or 60 days. Patients with re-injury after discharge were excluded. RESULTS: Of 1007 patients with BLSI, 534 (55%) met inclusion criteria (median age: 10.18 [IQR: 6, 14]; 62% male). Abdominal reimaging was performed on 27/534 (6%) patients; 3 of 27 studies prompting hospitalization and/or intervention. Abdominal pain was associated with reimaging, but decreased appetite predicted imaging findings associated with readmission and intervention. CONCLUSION: Selective abdominal reimaging for BLSI was done in 6% of patients, and 11% of studies identified radiologic findings associated with intervention or re-hospitalization. A selective reimaging strategy appears safe, and even reimaging symptomatic patients rarely results in intervention. Reimaging after 14 days did not prompt intervention in any of the 534 patients managed nonoperatively. LEVEL OF EVIDENCE: Level II, Prognosis.

Negative Focused Abdominal Sonography for Trauma examination predicts successful nonoperative management in pediatric solid organ injury: A prospective Arizona-Texas-Oklahoma-Memphis-Arkansas + Consortium study.

BACKGROUND: Focused Abdominal Sonography for Trauma (FAST) examination has long been proven useful in the management of adult trauma patients, however, its utility in pediatric trauma patients is not as proven. Our goal was to evaluate the utility of a FAST examination in predicting the success or failure of nonoperative management (NOM) of blunt liver and/or spleen (BLSI) in the pediatric trauma population. METHODS: A retrospective analysis of a prospective observational study of patients younger than 18 years presenting with BLSI to one of ten Level I pediatric trauma centers between April 2013 and January 2016. 1,008 patients were enrolled and 292 had a FAST examination recorded. We analyzed failure of NOM of BLSI in the pediatric trauma population. We then compared FAST examination alone or in combination with the pediatric age adjusted shock index (SIPA) as it relates to success of NOM of BLSI. RESULTS: Focused Abdominal Sonography for Trauma examination had a negative predictive value (NPV) of 97% and positive predictive value (PPV) of 13%. The odds ratio of failing with a positive FAST examination was 4.9 and with a negative FAST was 0.20. When combined with SIPA, a positive FAST examination and SIPA had a PPV of 17%, and an odds ratio for failure of 4.9. The combination of negative FAST and SIPA had an NPV of 96%, and the odds ratio for failure was 0.20. CONCLUSION: Negative FAST is predictive of successful NOM of BLSI. The addition of a positive or negative SIPA score did not affect the PPV or NPV significantly. Focused Abdominal Sonography for Trauma examination may be useful clinically in determining which patients are not at risk for failure of NOM of BLSI and do not require monitoring in an intensive care setting. LEVEL OF EVIDENCE: Prognostic study, level IV; therapeutic/care management, level IV.

Blunt traumatic scapular fractures are associated with great vessel injuries in children.

BACKGROUND: Patients with stable blunt great vessel injury (GVI) can have poor outcomes if the injury is not identified early. With current pediatric trauma radiation reduction efforts, these injuries may be missed. As a known association between scapular fracture and GVI exists in adult blunt trauma patients, we examined whether that same association existed in pediatric blunt trauma patients. METHODS: Bluntly injured patients younger than 18 years old were identified from 2012 to 2014 in the National Trauma Data Bank. Great vessel injury included all major thoracic vessels and carotid/jugular. Demographics of patients with and without scapular fracture were compared with descriptive statistics. The χ test was used to examine this association using SAS Version 9.4 (SAS Institute, Inc, Cary, NC). RESULTS: We found a significant association between pediatric scapular fracture and GVI. Of 291,632 children identified, 1,960 had scapular fractures. Children with scapular fracture were 10 times more likely to have GVI (1.2%) compared to those without (0.12%, p < 0.0001). Most common GVI seen were carotid artery, thoracic aorta, and brachiocephalic or subclavian artery or vein. Children with both scapular fracture and GVI were most commonly injured by motor vehicles (57% collision, 26% struck). CONCLUSIONS: Injured children with blunt scapular fracture have a 10-fold greater risk of having a GVI when compared to children without scapular fracture. Presence of blunt traumatic scapular fracture should have appropriate index of suspicion for a significant GVI in pediatric trauma patients. LEVEL OF EVIDENCE: Epidemiologic and prognostic study, level III; Therapeutic, level IV.

The incidence of delayed splenic bleeding in pediatric blunt trauma.

BACKGROUND: One of the concerns associated with nonoperative management of splenic injury in children has been delayed splenic bleed (DSB) after a period of hemostasis. This study evaluates the incidence of DSB from a multicenter 3-year prospective study of blunt splenic injuries (BSI). METHODS: A 3-year prospective study was done to evaluate nonoperative management of pediatric (≤18years) BSI presenting to one of 10 pediatric trauma centers. Patients were tracked at 14 and 60days. Descriptive statistics were used to summarize patient and injury characteristics. RESULTS: During the study period, 508 children presented with BSI. Median age was 11.6 [IQR: 7.0, 14.8]; median splenic injury grade was 3 [IQR: 2, 4]. Nonoperative management was successful in 466 (92%) with 18 (3.5%) patients undergoing splenectomy at the index admission, all within 3h of injury. No patient developed a delayed splenic bleed. At least one follow-up visit was available for 372 (73%) patients. CONCLUSION: A prior single institution study suggested that the incidence of DSB was 0.33%. Based on our results, we believe that the rate may be less than 0.2%. LEVEL OF EVIDENCE: Level II, Prognosis.

Failure of nonoperative management of pediatric blunt liver and spleen injuries: A prospective Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium study.

BACKGROUND: Nonoperative management (NOM) is standard of care for most pediatric blunt liver and spleen injuries (BLSI); only 5% of patients fail NOM in retrospective reports. No prospective studies examine failure of NOM of BLSI in children. The aim of this study was to determine the frequency and clinical characteristics of failure of NOM in pediatric BLSI patients. METHODS: A prospective observational study was conducted on patients 18 years or younger presenting to any of 10 Level I pediatric trauma centers April 2013 and January 2016 with BLSI on computed tomography. Management of BLSI was based on the Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium pediatric guideline. Failure of NOM was defined as needing laparoscopy or laparotomy. RESULTS: A total of 1008 patients met inclusion; 499 (50%) had liver injury, 410 (41%) spleen injury, and 99 (10%) had both. Most patients were male (n = 624; 62%) with a median age of 10.3 years (interquartile range, 5.9, 14.2). A total of 69 (7%) underwent laparotomy or laparoscopy, but only 34 (3%) underwent surgery for spleen or liver bleeding. Other (nonexclusive) operations were for 21 intestinal injuries; 15 hematoma evacuations, washouts, or drain placements; 9 pancreatic injuries; 5 mesenteric injuries; 3 diaphragm injuries; and 2 bladder injuries. Patients who failed were more likely to receive blood (52 of 69 vs. 162 of 939; p < 0.001) and median time from injury to first blood transfusion was 2.3 hours for those who failed versus 5.9 hours for those who did not (p = 0.002). Overall mortality rate was 24% (8 of 34) in those who failed NOM due to bleeding. CONCLUSION: NOM fails in 7% of children with BLSI, but only 3% of patients failed for bleeding due to liver or spleen injury. For children failing NOM due to bleeding, the mortality was 24%. LEVEL OF EVIDENCE: Therapeutic study, level II.

Prospective validation of the shock index pediatric-adjusted (SIPA) in blunt liver and spleen trauma: An ATOMAC+ study.

BACKGROUND: Age-adjusted pediatric shock index (SIPA) does not require knowledge of age-adjusted blood pressure norms, yet correlates with mortality, serious injury, and need for transfusion in trauma. No prospective studies support its validity. METHODS: A multicenter prospective observational study of patients 4-16years presenting April 2013-January 2016 with blunt liver and/or spleen injury (BLSI). SIPA (maximum heart rate/minimum systolic blood pressure) thresholds of >1.22, >1.0, and >0.9 in the emergency department were used for 4-6, 7-12 and 13-16year-olds, respectively. Patients with ISS ≤15 were excluded to conform to the original paper. Discrimination outcomes were compared between SIPA and shock index (SI). RESULTS: Of 1008 patients, 386 met inclusion. SI was elevated in 321, and SIPA elevated in 282. The percentage of patients with elevated index (SI or SIPA) and blood transfusion within 24 hours (30% vs 34%), BLSI grade ≥3 requiring transfusion (28% vs 32%), operative intervention (14% vs 16%) and ICU admission (64% vs 67%) was higher in the SIPA group. CONCLUSION: SIPA was validated in this multi-institutional prospective study and identified a higher percentage of children requiring additional resources than SI in BLSI patients. SIPA may be useful for determining necessary resources for injured patients with BLSI. LEVEL OF EVIDENCE: Level II prognosis.