The diagnostic value of laboratory tests in detecting solid organ injuries in pediatric patients with blunt abdominal trauma.

BACKGROUND: Computed tomography of the abdomen (CT) is used as the gold standard for detecting solid organ injuries (SOI) after blunt abdominal trauma (BAT). However, patient selection for CT is still controversial due to its potential risks. In this study, we aimed to investigate the usefulness of laboratory tests in the detection or exclusion of SOI in pediatric patients evaluated in the emergency department due to BAT. METHODS: The study was planned as a prospective, observational study and was conducted in the emergency department of a university hospital between February 2018 and February 2019. Patients under the age of 18 who were evaluated for BAT in the emergency department were included in the study. In the study, the diagnostic value of abnormal laboratory tests in detecting SOI was calculated by accepting CT results as the gold standard. RESULTS: Of the 323 patients included in the study, 118 (36%) were male. There were 283 patients who underwent CT. SOI was detected in 18 (6%) patients. Abnormal alanine aminotransferase, aspartate aminotransferase, amylase and lipase tests were found to be statistically significant in predicting SOI (p < 0.05). However, none of the tests were found to have sufficient sensitivity and specificity. Hemoglobin, hematocrit, lactate and base excess values were not found to be statistically significant in predicting SOI (p > 0.005). CONCLUSIONS: The hematologic laboratory tests are insufficient to rule out solid organ injury in pediatric patient with BAT.

Correlation of rib fracture patterns with abdominal solid organ injury: A retrospective observational cohort study.

PURPOSE: Rib fractures are one of the most common causes of morbidity and mortality and are associated with abdominal solid organ injury (ASOI). The purpose of this study was to investigate the correlation of ASOI with the number, location, and involved segments of rib fracture(s) in blunt chest trauma. METHODS: This retrospective cohort study was conducted on patients with blunt chest trauma over the age of 15 years, who were hospitalized with the diagnosis of rib fractures from July 2015 to September 2020. After ethic committee approval, a retrospective chart review was designed and patients with a diagnosis of rib fractures were selected. Patients who had chest and abdominopelvic CT scan were included in the study and additional data including age, gender, injury severity score, trauma mechanism, number and sides of the fractured ribs (left/right/bilateral), rib fracture segments (upper, middle, lower zone) and results of chest and abdominal spiral CT scan were recorded. The correlation between ASOI and the sides, segments and number of rib fracture(s) was assessed by Pearson's correlation coefficient. RESULTS: Altogether 1056 patients with rib fracture(s) were included. The mean age was (42.76 ± 13.35) years and 85.4% were male. The most common mechanism of trauma was car accident (34.6%). Most fractures occurred in the middle rib zone (60.44%) and the most commonly involved ribs were the 6th and 7th ones (15.7% and 16.4%, respectively). Concurrent abdominal injuries were observed in 103 patients (34.91%) and were significantly associated with middle zone rib fractures. CONCLUSION: There is a significant relationship between middle zone rib fractures and ASOI. Intra-abdominal injuries are not restricted to fractures of the lower ribs and thus should always be kept in mind during management of blunt trauma patients with rib fractures.

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

BACKGROUND: Recent work has demonstrated that an accelerated pathway for pediatric patients with blunt solid organ injuries is safe; however, this is not well-studied in a dual trauma center. We hypothesized that implementation of an accelerated pathway would decrease length of stay (LOS) and hospitalization cost without increased mortality. METHODS: Retrospective review of patients < 15 years presenting to a dual level 1 trauma center between 2015 and 2020 with traumatic blunt liver and splenic injuries. Patients presenting pre- and post-protocol implementation were compared. The primary outcome was total hospital LOS. Secondary outcomes were number of lab draws, intensive care unit (ICU) LOS, cost of hospitalization, readmissions within 30 days, and mortality. RESULTS: 103 patients were evaluated, 67 pre-protocol and 63 post-protocol. LOS was significantly shorter post-protocol (2 days vs. 4 days, p < 0.001). The ICU LOS was unchanged. There was a decrease in direct hospitalization cost per patient from $6,246 pre-protocol to $4,294 post-protocol (p = 0.001). There was one readmission post-protocol and none pre-protocol. There were no deaths. CONCLUSION: Implementation of an accelerated pathway for management of blunt solid organ injury at a dual trauma center was associated with decreased LOS and decreased costs with no increased morbidity or mortality.

Changes in Approach to Solid Organ Injury: What the Radiologist Needs to Know.

This review aims to examine the challenges facing radiologists interpreting trauma computed tomography (CT) images in this era of a changing approach to management of solid organ trauma. After reviewing the pearls and pitfalls of CT imaging protocols for detection of traumatic solid organ injuries, we describe the key changes in the 2018 American Association for the Surgery of Trauma Organ Injury Scales for liver, spleen, and kidney and their implications for management strategies. We then focus on the important imaging findings in observed in patients who undergo nonoperative management and patients who are imaged post damage control surgery.

Nonoperative management of penetrating abdominal solid organ injuries in children.

BACKGROUND: Nonoperative management (NOM) of penetrating solid organ injuries (SOI) has not been well described in the pediatric population. The objective of this study was to characterize the epidemiology, injury patterns, and factors associated with trial and failure of NOM. METHODS: This is a retrospective cohort analysis of the National Trauma Data Bank for the period of 2007-2014. The study population included patients ≤18 y with penetrating injury to the liver, spleen, or kidney. NOM was defined as no operative intervention (exploratory laparotomy or operation involving the liver, spleen, or kidney) < 4 h of emergency department arrival. Failed NOM was defined as operative intervention ≥4 h after emergency department arrival. Multivariate logistic regression explored clinical factors potentially associated with trial and failure of NOM. RESULTS: Of 943,000 pediatric trauma patients included in the National Trauma Data Bank, 3005 (0.32%) met our inclusion criteria. Median age was 17.0 y; 88.8% were male. Gunshot wounds (GSW) accounted for 71.7% of injury mechanisms and stab wounds accounted for the remaining 28.3%. Median injury severity score was 9 (interquartile range: 5-13). Two thousand one hundred and twenty-one (70.6%) patients sustained kidney injury, 1210 (40.3%) liver injury, and 159 (5.3%) splenic injury. NOM was pursued in 615 (20.5%) patients. Factors significantly associated with immediate operative intervention included GSW, hypotension, and associated hollow viscus injury. Failed NOM was identified in 175 patients (28.5%). Factors significantly associated with failed NOM included GSW, high-grade SOI, and associated hollow viscus injury. Overall mortality was 26 (0.9%). CONCLUSIONS: NOM can be safe in a carefully selected group of pediatric patients with penetrating SOI. Future prospective studies are warranted to validate its feasibility.

Diagnostic imaging of blunt abdominal trauma in pediatric patients.

Trauma is a leading cause of morbidity and mortality in childhood, and blunt trauma accounts for 80-90 % of abdominal injuries. The mechanism of trauma is quite similar to that of the adults, but there are important physiologic differences between children and adults in this field, such as the smaller blood vessels and the high vasoconstrictive response, leading to the spreading of a non-operative management. The early imaging of children undergoing a low-energy trauma can be performed by CEUS, a valuable diagnostic tool to demonstrate solid organ injuries with almost the same sensitivity of CT scans; nevertheless, as for as urinary tract injuries, MDCT remains still the technique of choice, because of its high sensitivity and accuracy, helping to discriminate between an intra-peritoneal form a retroperitoneal urinary leakage, requiring two different managements. The liver is the most common organ injured in blunt abdominal trauma followed by the spleen. Renal, pancreatic, and bowel injuries are quite rare. In this review we present various imaging findings of blunt abdominal trauma in children.

Comparison between MRI and CEUS in the follow-up of patients with blunt abdominal trauma managed conservatively.

INTRODUCTION: Over the past two decades, there has been a shift toward non-operative treatment of patients undergoing a solid organ injury, thus requiring an increasing number of imaging studies to monitor the healing of lesions, which were performed by computed tomography (CT). In consideration of the use of ionizing radiation and contrast media, nowadays there is a trend toward the use contrast-enhanced ultrasound (CEUS) in the follow-up of blunt abdominal trauma. However CEUS has some limits, especially in the assessments of small lesions and in the evaluation of urinary tract lesions and vascular complications. Magnetic resonance imaging (MRI) is a useful alternative, since its lack of use of ionizing radiation, its panoramicity, the possibility to avoid contrast media and the ability to properly evaluate even small lesions. The aim of this study is to evaluate the usefulness and the feasibility of MRI in the follow-up of patients with low-grade blunt abdominal trauma. MATERIALS AND METHODS: We performed a retrospective review of a cohort including 270 consecutive patients with a history of blunt abdominal trauma; among them, 118 underwent a high-energy trauma, and 152 a low-energy trauma. 124 patients had findings of abdominal injuries at the contrast-enhanced multidetector CT (CE-MDCT), including 68 from the group of major trauma and 56 from the group of minor trauma. 39 patients were operated for incoming lesions. The remaining 85 patients were treated conservatively. Eight patients underwent surgery later for delayed bleeding. The remaining 77 underwent the full follow-up protocol. Follow-up protocol included CEUS at 24 and 72 h and CEUS and MRI at 1 month after trauma; only MRI was performed until the complete resolution. RESULTS: CEUS at 24-h and at 72-h from trauma showed a very good correlation with onset CE-MDCT in lesions staging. With respect to onset CE-MDCT, CEUS did not identified 2 adrenal injuries and 2 lesions of urinary tract, an intrinsic limit of this technique. CEUS performed at 1 month did not show traumatic lesions in 49/77 of patients. In the remaining 28/77 cases, CEUS demonstrated reduction of the size of the lesions ranging from 25 to 50%. MRI performed at 1 month from trauma did not show traumatic injuries in 37/77 patients; it demonstrated persistence of organ lesion in 40/77 patients. Therefore, in 12/77 patients MRI performed at 1-month demonstrated the persistence of minimal or moderate organ injury, while CEUS was completely negative. In addition, MRI allowed to enhance the persistence of adrenal lesions in 2 cases and the integrity of urinary tract in 2. In the remaining 28 patients, in which both CEUS and MRI showed disease persistence, MRI, however, allowed a better definition of injury extension with respect to CEUS, in terms of dimensions, edges, and morphological evolution. DISCUSSION AND CONCLUSIONS: MRI allowed to make a better assessment of injuries than CEUS, allowing also a temporal stage of lesions. Infact, there are different evolution stages corresponding to accurate imaging findings. To our knowledge, this is the first study that describes the evolution of blood collection in parenchymal abdominal organs. Therefore, in patients who underwent abdominal traumatic injuries conservatively treated, the follow-up at 1 month can be made by MRI, due to its panoramicity and its high contrast resolution, which allow a better morphological and temporal trauma staging respect to the CEUS.

Accuracy of contrast-enhanced ultrasound (CEUS) in the identification and characterization of traumatic solid organ lesions in children: a retrospective comparison with baseline US and CE-MDCT.

INTRODUCTION: Localized low-energy abdominal trauma is very frequent in the pediatric population. The findings of several studies have shown that ultrasonography (US) can represent a useful and cost-effective tool in the evaluation of blunt abdominal trauma both in adults and children. However, many parenchymal injuries are not correctly visualized at baseline US examination. The introduction of specific US contrast agents contrast-enhanced ultrasound (CEUS) has enabled a better identification of traumatic organ injuries. The correct use of CEUS could therefore identify and select the children who need further diagnostic investigation computed tomography (CT), avoiding unnecessary radiation and iodinated contrast medium exposure. The purpose of our study was to assess the sensibility and feasibility of CEUS in the assessment of low-energy abdominal trauma compared to baseline US in pediatric patients, using contrast-enhanced MDCT as the reference standard. MATERIALS AND METHODS: We retrospectively reviewed 73 children (51 M and 22 F; mean age 8.7 ± 2.8 years) who presented in our Emergency Department between October 2012 and October 2013, with history of minor abdominal trauma according to the Abbreviated Injury Scale and who underwent US, CEUS, and CE-MDCT. Inclusion criteria were: male or female, aged 0-16, hemodynamically stable patients with a history of minor blunt abdominal trauma. Exclusion criteria were adulthood, hemodynamical instability, history of major trauma. Sensitivity, specificity, PPV, NPV, and accuracy were determined for US and CEUS compared to MDCT. RESULTS: 6/73 patients were negative at US, CEUS, and MDCT for the presence of organ injuries. In the remaining 67 patients, US depicted 26/67 parenchymal lesions. CEUS identified 67/67 patients (67/67) with parenchymal lesions: 21 lesions of the liver (28.8 %), 26 lesions of the spleen (35.6 %), 7 lesions of right kidney (9.6 %), 13 lesions of left kidney. MDCT confirmed all parenchymal lesions (67/67). Thus, the diagnostic performance of CEUS was better than that of US, as sensitivity, specificity, PPV, NPV, and accuracy were 100, 100, 100, 100, and 100 % for CEUS and 38.8, 100, 100, 12.8, and 44 % for US. In some patients CEUS identified also prognostic factors as parenchymal active bleeding in 8 cases, partial devascularization in 1 case; no cases of vascular bleeding, no cases of urinoma. MDCT confirmed all parenchymal lesions. Parenchymal active bleeding was identified in 16 cases, vascular bleeding in 2 cases, urinoma in 2 cases, partial devascularization in 1 case. CONCLUSIONS: CEUS is more sensitive and accurate than baseline US and almost as sensitive as CT in the identification and characterization of solid organs lesions in blunt abdominal trauma. CT is more sensitive and accurate than CEUS in identifying prognostic indicators, as active bleeding and urinoma. CEUS should be considered as a useful tool in the assessment and monitoring of blunt abdominal trauma in children.

Blunt Abdominal Trauma in Pregnancy: Higher Rates of Severe Abdominal Injuries.

BACKGROUND: Previous studies suggest increased abdominal girth in obese individuals provides a "cushion effect," against severe abdominal trauma. In comparison, the unique anatomic/physiological condition of pregnancy, such as the upward displacement of organs by an expanding uterus, may decrease risk of abdominal injury. However, increased overall blood volume and vascularity of organs during pregnancy raise concerns for increased bleeding and potentially more severe injuries. Therefore, this study aimed to elucidate whether the "cushion effect" observed in obese patients extends to pregnant trauma patients (PTPs). We hypothesized a lower risk of blunt solid organ injury (BSOI) (liver, spleen, and kidney) in pregnant vs non-pregnant blunt trauma patients. METHODS: The 2020-2021 Trauma Quality Improvement Program was queried for all female blunt trauma patients (age<50 years) involved in motor vehicle collisions (MVCs). We compared pregnant vs non-pregnant patients. The primary outcomes were incidence of BSOI, and severity of abdominal trauma defined by abbreviated injury scale (AIS). RESULTS: From 94,831 female patients, 2598 (2.7%) were pregnant. When compared to non-pregnant patients, PTPs had lower rates of liver (5.5% vs 7.6%, P < .001) and kidney (1.8% vs 2.6%, P = .013) injury. However, PTPs had higher rates of serious (13.4% vs 9.0%, P < .001) and severe abdominal injury (7.5% vs 4.3%, P < .001). DISCUSSION: BSOI occurred at a lower rate in PTPs compared to non-PTPs; however, contrary to the "cushion effect" observed in obese populations, pregnant women had a higher rate of severe abdominal injuries. These data support comprehensive evaluations for PTPs presenting after a MVC. LEVEL OF EVIDENCE: IV (therapeutic).

Evaluation of management of CT scan proved solid organ injury in blunt injury abdomen-a prospective study.

BACKGROUND: Trauma especially road traffic injury is one of the major health-related issues throughout the world, especially in developing countries like India (Mattox 2022). Solid organ injury is the most common cause of morbidity and mortality in patients with blunt abdominal trauma. The non-operative management (NOM) is being consistently followed for hemodynamically stable patients with respect to solid organ injuries. This study aims to provide an evidence base for management modalities of solid organ injuries in blunt abdominal trauma. AIM: The aim of this study is to evaluate the effectiveness of various treatment modalities for solid organ injury in blunt abdominal trauma. OBJECTIVES: Evaluating the characteristics of blunt abdominal injury with respect to age and gender; distribution, mode of injury, most common organ injured, and severity of injury; effect of delay in getting treatment on the management outcome for patients with solid organ injury; evaluating the various modalities of treatment of CT-proven solid organ injury; incidence of complications in different modes of treatment. METHODS: All patients aged more than 18 years and suffering from CT-proven solid organ injury secondary to blunt abdominal trauma between February 2021 and September 2022 were included in this prospective observational study. Sixty-five patients were enrolled in the study after meeting the inclusion criteria. Details such as age, gender, mechanism of injury, the time between injury to first hospital contact, presenting complaints, organ and grade of injury, Revised Trauma Score (RTS), Trauma Score and Injury Severity Score (TRISS), management, and outcomes were collected using self-designed pro forma and analyzed. Different modalities of treatment were evaluated and patients undergoing operative and non-operative management were compared. Patients in whom non-operative management failed were compared with patients with successful non-operative management. RESULTS: The mean age of patients involved were 36.8 years with a male:female ratio of 7.125:1 and the most common age group affected being between 21 and 30 years. The most common mode of injury was noted to be road traffic accidents (72.3%). The most common presenting complaints were abdominal pain (64.6%) followed by chest pain (29.2%) and vomiting (13.8%). There was no significant relationship between latent period and type of intervention or failure of non-operative management. FAST positivity rate was noted to be 92.3%. Chronic alcoholism and bronchial asthma were significant predictors for patients undergoing upfront surgery (p = 0.003 and 0.006 respectively). The presence of pelvic and spine injury was statistically significant for predicting mortality in polytrauma patients (p = 0.003). Concurrent adrenal injury was found in 24.6% of patients but was not related to failure of non-operative management or mortality. RTS significantly predicts the multitude of organ involvement (p = 0.015). The liver was the most common organ injured (60%) followed by the spleen (52.3%) and the kidney (20%). The liver and the spleen (9.2%) were noted to be the most common organ combination involved. No specific organ or organ injury combination was noted to predict failure of non-operative management or mortality. But the multitude of organ involvement was statistically significant for predicting patients undergoing upfront surgery (p = 0.011). Out of 65 patients enrolled in the study, 7 patients (10.8%) underwent immediate surgery, and 58 patients (89.2%) underwent non-operative management. Among the 68 chosen for non-operative management, 6 patients (9.2%) failed non-operative management and 52 patients (80%) had success of non-operative management. A significant drop in hemoglobin (83.3%) on day 1 (66.6%) was seen to be the commonest reason for failure of non-operative management. The spleen was noted to be the most commonly involved organ intra-operatively (61.5%) followed by the liver (30.8%). Concordance between pre-operative and intra-operative grading of organ injuries was highest for liver and kidney injuries (100%) and lowest for pancreatic injuries (0%). Requirement of blood transfusion and liver injuries were significant factors for failure of non-operative management (p = 0.012 and 0.045 respectively). The presence of pancreatic leak was significant between the non-operated patients and patients operated upfront (p = 0.003). Mortality was noted to be 10.8% (7 patients) in our study. CONCLUSION: Solid organ injury in blunt abdominal trauma is an important cause of morbidity and mortality. RTS was noted to be a good predictor for solid organ injury in blunt abdominal trauma. Pancreatic injuries are notorious for being under-staged on CT findings; hence, the need arises for multimodality imaging for suspected pancreatic injuries. Non-operative management is a successful modality of treatment for majority of patients suffering from multiple solid organ injuries in blunt abdominal trauma provided serial close monitoring of patient's clinical signs and hemoglobin is instituted along with the presence of an emergency surgery team.

Management of Pediatric Solid Organ Injuries.

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

Similar rate of venous thromboembolism (VTE) and failure of non-operative management for early versus delayed VTE chemoprophylaxis in adolescent blunt solid organ injuries: a propensity-matched analysis.

BACKGROUND: Early initiation of venous thromboembolism (VTE) chemoprophylaxis in adults with blunt solid organ injury (BSOI) has been demonstrated to be safe but this is controversial in adolescents. We hypothesized that adolescent patients with BSOI undergoing non-operative management (NOM) and receiving early VTE chemoprophylaxis (eVTEP) (≤ 48 h) have a decreased rate of VTE and similar rate of failure of NOM, compared to similarly matched adolescents receiving delayed VTE chemoprophylaxis (dVTEP) (> 48 h). METHODS: The 2017-2019 Trauma Quality Improvement Program database was queried for adolescents (12-17 years of age) with BSOI (liver, kidney, and/or spleen) undergoing NOM. We compared eVTEP versus dVTEP using a 1:1 propensity score model, matching for age, comorbidities, BSOI grade, injury severity score, hypotension on arrival, and need for transfusions. We performed subset analyses in patients with isolated spleen, kidney, and liver injury. RESULTS: From 1022 cases, 417 (40.8%) adolescents received eVTEP. After matching, there was no difference in matched variables (all p > 0.05). Both groups had a similar rate of VTE (dVTEP 0.6% vs. eVTEP 1.7%, p = 0.16), mortality (dVTEP 0.3% vs. eVTEP 0%, p = 0.32), and failure of NOM (eVTEP 6.7% vs. dVTEP 7.3%, p = 0.77). These findings remained true in all subset analyses of isolated solid organ injury (all p > 0.05). CONCLUSIONS: The rate of VTE with adolescent BSOI is exceedingly rare. Early VTE chemoprophylaxis in adolescent BSOI does not increase the rate of failing NOM. However, unlike adult trauma patients, adolescent patients with BSOI receiving eVTEP had a similar rate of VTE and death, compared to adolescents receiving dVTEP.

Variation in the management of adolescent patients with blunt abdominal solid organ injury between adult versus pediatric trauma centers: an analysis of a statewide trauma database.

BACKGROUND: Optimal management of adolescent trauma patients with blunt abdominal solid organ injury (SOI) remains controversial. The purpose of this study was to identify management differences in adolescents with SOI treated at adult trauma centers (ATC) versus pediatric trauma centers (PTC). We hypothesized that adolescents with SOI would undergo different treatment at ATC and PTC. MATERIALS AND METHODS: Retrospective review of the Pennsylvania Trauma Systems Foundation database from 2005-2010 was performed. Adolescent patients (13-18 y old) with SOI (spleen, liver, and kidney injury) were included. Patient baseline characteristics and care processes for each injury were compared between ATC and PTC. RESULTS: A total of 1532 patients with at least one SOI were identified: 946 patients had a splenic injury, 505 had a liver injury, and 424 had a kidney injury. Spleen and liver procedures were performed more often at ATC than at PTC irrespective of injury grade (respectively, 16.1% versus 3.2%, 5.9% versus 0%; P < 0.01). Transarterial embolization for splenic injury was more frequently performed at ATC (2.8% versus 0.6%; P = 0.02). After adjusting for potential confounding factors, care at PTC was significantly associated with lower odds of splenic procedure for patients with splenic injury (OR: 0.16, 95% CI: 0.08-0.36, P < 0.001). In a subgroup analysis of nontransfer patients, care at PTC remained significantly associated with lower odds of splenic procedure (OR: 0.24, 95% CI: 0.10-0.59, P = 0.002) despite higher median injury severity score than ATC. CONCLUSIONS: Significant differences in the management of adolescents with SOI were identified in Pennsylvania. Operative intervention for SOI was more often performed at ATC than at PTC. Further study will be needed to address the impact of these disparities on patient outcomes.

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

BACKGROUND: In 2000, the American Pediatric Surgical Association (APSA) published guidelines for the management of pediatric solid organ injury, recommending a hospital length of stay (LOS) of grade of injury plus 1 day. Since the publication of these guidelines, several studies have suggested that it is safe to discharge patients sooner based upon hemodynamic and clinical factors. The results of several of these studies have been confounded by the existence of other injuries. The aim of this study was to examine LOS and outcomes in children with strictly isolated solid organ injuries. MATERIALS AND METHODS: This is a 12-year retrospective review of pediatric patients with isolated trauma to the kidney, liver, or spleen to determine LOS. Patients were excluded for associated intracranial, neurologic, orthopedic, or pulmonary injuries which would impact length of stay. Documented hemodynamic parameters were reviewed as determinants of patient stability. RESULTS: A total of 156 patients were included in the study. The projected average LOS for all patients based on the 2000 APSA guidelines would have been 3.71 ± 0.98 days. The actual average LOS for all patients 2.85 ± 3.32 days. Need for operation, ICU stay, and transfusion all contributed to increased LOS. The number of episodes of abnormal vitals positively correlated with increased LOS. DISCUSSION: This study validates that management of isolated solid organ injuries based upon hemodynamic parameters and clinical status is safe and decreases hospital length of stay. Consistently normal vital signs indicate these children can be safely discharged sooner.

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

Introduction: Selective nonoperative management (NOM) is the standard of care for blunt solid organ injury (SOI). Hemodynamic instability is a contraindication for NOM, but it is unclear whether the need for blood transfusion should be a criterion for instability. This study looks at the outcome of blood-transfused SOI patients to determine whether NOM is safe for this group. Methods: This is a retrospective cohort study using the National Trauma Data Bank years 2017 through 2019. We selected patients with blunt liver, spleen, and kidney injuries. Within this group, we compared the mortality for those managed with NOM versus the hemostatic procedures of laparotomy and angioembolization. Significance for univariate analysis is tested with Chi-square for categorical variables. Multivariate analysis is performed with Cox proportional hazards regression with time-dependent covariate. Results: 108,718 (3.5%) patients for the years 2017 through 2019 had a SOI. 20,569 (18.9%) of these received at least one unit of packed red blood cells (PRBCs) within the first 4 h. Of the SOI patients who received blood, 8264 (40.2%) underwent laparotomy only, 2924 (14.2%) underwent embolization only, and 1119 (5.4%) underwent both procedures. The adjusted odds ratios (ORs) of death for transfused SOI patients who underwent laparotomy only, embolization only, and both procedures are 0.93 (P = not significant), 0.27 (P < 0.001), and 0.48 (P < 0.001), respectively. The ORs of death with laparotomy for patients receiving >1 through 4 units are 0.87, 0.78, 0.75, and 0.72, respectively (P ≤ 0.01 for all). For embolization, the ORs are 0.27, 0.30, 0.30, and 0.30, respectively (P < 0.001 for all). Conclusion: Laparotomy is independently associated with survival for patients who receive >1 unit of PRBCs. Angioembolization is independently associated with survival for the entire cohort, including transfused patients. Given the protective association of laparotomy in the blood-transfused SOI group, need for blood transfusion should be considered a meaningful index of instability and a relative indication for laparotomy. The protective association with angioembolization supports current practices for angioembolization of high-risk patients in the transfused and nontransfused groups.

Contrast-enhanced ultrasound (CEUS) in the follow-up of abdominal solid organ trauma: an international survey prior to the PseAn study.

BACKGROUND: The blunt and penetrating abdominal trauma follow-up relies on contrast CT scan to detect solid organ injuries. CEUS is not widely used worldwide, despite its accuracy and feasibility in identifying parenchymal and vascular lesions. This survey aims to define the current use of CEUS in Trauma Centers and the expectations of Emergency Surgeons regarding its role. METHODS: We sent an online questionnaire composed of 10 questions to trauma physicians worldwide during the period of September 2022 to March 2023. RESULTS: 59 participants from 53 different centers answered the questionnaire. 76.2% of the enrolled participants have CEUS available at their Institution, and 49.2% think that it can replace CT scan. Contrast-CT scan remains the preferred option in the follow-up of blunt liver (69.5%), spleen (72.9%) and kidney (76.3%) injuries, followed by CEUS which is used in 18.6% for liver, 20.3% for spleen and 15.3% for kidney injuries. The results are similar for penetrating abdominal trauma, with contrast CT scan being the first-line imaging technique (91.5% for liver, 91.5% for spleen and 88.1% for kidney injuries), followed by CEUS (5.1% for liver, 5.1% for spleen and 6.8% for kidney injuries). CONCLUSIONS: Our survey shows that CEUS is still underutilized in the follow-up of abdominal trauma, even though many emergency surgeons consider it as a valid alternative to contrast CT scan.

General Surgery Resident Operative Experiences in Solid Organ Injury: An Examination of Case Logs.

BACKGROUND: Non-operative management (NOM) of traumatic solid organ injury (SOI) has become commonplace. This paradigm shift, along with reduced resident work hours, has significantly impacted surgical residents' operative trauma experiences. We examined ongoing changes in residents' operative SOI experience since duty hour restriction implementation, and assessed whether missed operative experiences were gained elsewhere in the resident experience. METHODS: We examined data from American College of Graduate Medical Education case log reports from 2003 to 2018. We collected mean case volumes in the categories of non-operative trauma, trauma laparotomy, and splenic, hepatic, and pancreatic trauma operations; case volumes for comparable non-traumatic solid organ operations were also collected. Solid organ injury operative volumes were compared against non-traumatic cases, and change over time was analyzed. RESULTS: Over the study period, both trauma laparotomies and non-operative traumas increased significantly (P < .001). In contrast, operative volumes for splenic, hepatic, and pancreatic trauma all significantly decreased (P < .001; P = .014; P < .001, respectively). Non-traumatic spleen cases also significantly decreased (P < .001), but liver cases and distal pancreatectomies increased (P < .001; P = .017). Pancreaticoduodenectomies increased, albeit not to a significant degree (P = .052). CONCLUSIONS: Continuing increases in NOM of SOI correlate with declining resident experience with operative solid organ trauma. These decreases can adversely affect residents' technical skills and decision-making, although trends in specific non-traumatic areas may help to mitigate such losses. Further work should determine the impact of these trends on resident competence and autonomy.

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

BACKGROUND: Non-operative management of blunt liver and spleen injuries was championed initially in children with the first management guideline published in 2000 by the American Pediatric Surgical Association (APSA). Multiple articles have expanded on the original guidelines and additional therapy has been investigated to improve care for these patients. Based on a literature review and current consensus, the management guidelines for the treatment of blunt liver and spleen injuries are presented. METHODS: A recent literature review by the APSA Outcomes committee [2] was utilized as the basis for the guideline recommendations. A task force was assembled from the APSA Committee on Trauma to review the original guidelines, the literature reported by the Outcomes Committee and then to develop an easy to implement guideline. RESULTS: The updated guidelines for the management of blunt liver and spleen injuries are divided into 4 sections: Admission, Procedures, Set Free and Aftercare. Admission to the intensive care unit is based on abnormal vital signs after resuscitation with stable patients admitted to the ward with minimal restrictions. Procedure recommendations include transfusions for low hemoglobin (<7 mg/dL) or signs of ongoing bleeding. Angioembolization and operative exploration is limited to those patients with clinical signs of continued bleeding after resuscitation. Discharge is based on clinical condition and not grade of injury. Activity restrictions remain the same while follow-up imaging is only indicated for symptomatic patients. CONCLUSION: The updated APSA guidelines for the management of blunt liver and spleen injuries present an easy-to-follow management strategy for children. LEVEL OF EVIDENCE: Level 5.

Routine Repeat Imaging of Pediatric Blunt Solid Organ Injuries Is Not Necessary.

INTRODUCTION: Nonoperative management of hemodynamically stable patients with blunt splenic and/or hepatic injury has been widely accepted in the pediatric population. However, variability exists in the utilization and timing of repeat imaging to assess for delayed complications during index hospitalization. Recent level-IV evidence suggests that repeat imaging in children should be performed based on a patient's clinical status rather than on a routine basis. The aim of this study is to examine the rate of delayed complications and interventions in pediatric trauma patients with blunt splenic and/or hepatic injuries who undergo repeat imaging prompted either by a clinical change (CC) or non-clinical change (NCC). METHODS: A 9-year (2011-2019), retrospective, dual-institution study was performed of children (0-17 years) with blunt splenic and/or hepatic injuries. Patients were grouped based on reason for repeat imaging: CC or NCC. The rate of organ-specific delayed complications and interventions was examined by reason for scan. RESULTS: A total of 307 injuries were included in the study period (174 splenic, 113 hepatic, and 20 both). Of 194 splenic injuries, 30(15.5%) underwent repeat imaging (CC = 19; NCC = 11). Of 133 hepatic injuries, 27(20.3%) underwent repeat imaging (CC = 21; NCC = 6). There was no difference in the incidence of organ-specific delayed complications between the CC and NCC groups. Of the 4 patients with complications necessitating intervention, only one was identified based on NCC. CONCLUSIONS: Our data suggest routine repeat imaging is unnecessary in children with blunt splenic and/or hepatic injuries; therefore, practitioners may rely on a patient's clinical change.

Pseudoaneurysm Screening after Pediatric High Grade Solid Organ Injury.

BACKGROUND: High grade solid organ injuries carry risk of complications, including pseudoaneurysms (PSA). The optimal approach to PSA screening among pediatric patients is unknown and may include delayed Computed Tomography Angiography (dCTA) and/or contrast-enhanced ultrasound (CEUS). This study endeavored to define dCTA/CEUS yield in PSA diagnosis after pediatric high grade solid organ injury. METHODS: Patients <18y presenting to our ACS-verified Level 1 trauma center with ≥1 AAST grade ≥3 abdominal solid organ injury (kidney, liver, and spleen) were included (01/2017-10/2021). Transfers in, death <48h, and immediate nephrectomy/splenectomy were exclusions. PSA screening was pursued selectively based on attending discretion. Demographics, clinical/injury data, and outcomes were collected. Primary outcome was performance of dCTA or CEUS. RESULTS: Forty-two patients satisfied criteria, with median age 12.5y and ISS 22. Liver injuries were most frequent (48%), followed by spleen (33%) and kidney (19%). Initial management strategy was most commonly nonoperative (liver 60%, spleen 64%, kidney 75%). Overall, 26% underwent PSA screening at a median of hospital day 4, with dCTA (21%) or CEUS (5%). CEUS was only used among liver injuries (10%), with no PSA identified. One PSA was diagnosed on dCTA after splenic injury and was managed with observation. CONCLUSION: PSA screening occurs infrequently after pediatric high grade solid organ injury, potentially due to concerns about radiation exposure from dCTA which would be mitigated with CEUS. Further delineation of PSA incidence and yield of screening investigations are needed to avoid missing this important diagnosis and to determine the diagnostic accuracy of dCTA and CEUS.