When all computers shut down: the clinical impact of a major cyber-attack on a general hospital.

Importance: Healthcare organizations operate in a data-rich environment and depend on digital computerized systems; thus, they may be exposed to cyber threats. Indeed, one of the most vulnerable sectors to hacks and malware is healthcare. However, the impact of cyberattacks on healthcare organizations remains under-investigated. Objective: This study aims to describe a major attack on an entire medical center that resulted in a complete shutdown of all computer systems and to identify the critical actions required to resume regular operations. Setting: This study was conducted on a public, general, and acute care referral university teaching hospital. Methods: We report the different recovery measures on various hospital clinical activities and their impact on clinical work. Results: The system malfunction of hospital computers did not reduce the number of heart catheterizations, births, or outpatient clinic visits. However, a sharp drop in surgical activities, emergency room visits, and total hospital occupancy was observed immediately and during the first postattack week. A gradual increase in all clinical activities was detected starting in the second week after the attack, with a significant increase of 30% associated with the restoration of the electronic medical records (EMR) and laboratory module and a 50% increase associated with the return of the imaging module archiving. One limitation of the present study is that, due to its retrospective design, there were no data regarding the number of elective internal care hospitalizations that were considered crucial. Conclusions and relevance: The risk of ransomware cyberattacks is growing. Healthcare systems at all levels of the hospital should be aware of this threat and implement protocols should this catastrophic event occur. Careful evaluation of steady computer system recovery weekly enables vital hospital function, even under a major cyberattack. The restoration of EMR, laboratory systems, and imaging archiving modules was found to be the most significant factor that allowed the return to normal clinical hospital work.

Consensus on resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian (pre-hospital) trauma care: a Delphi study.

BACKGROUND: REBOA could prevent lethal exsanguination and support cardiopulmonary resuscitation. In pre-hospital trauma and medical emergency settings, a small population with high mortality rates could potentially benefit from early REBOA deployment. However, its use in these situations remains highly disputed. Since publication of the first Delphi study on REBOA, in which consensus was not reached on all addressed topics, new literature has emerged. Aim of this study was to establish consensus on the use and implementation of REBOA in civilian pre-hospital settings for non-compressible truncal hemorrhage and out-of-hospital cardiac arrest as well as for various in-hospital settings. METHODS: A Delphi study consisting of three rounds of questionnaires was conducted based on a review of recent literature. REBOA-experts with different medical specialties, backgrounds and work environments were invited for the international panel. Consensus was reached when a minimum of 75% of panelists responded to a question and at least 75% (positive) or less than 25% (negative) of these respondents agreed on the questioned subject. RESULTS: Panel members reached consensus on potential (contra-)indications, physiological thresholds for patient selection, the use of ultrasound and practical, and technical aspects for early femoral artery access and pre-hospital REBOA. CONCLUSION: The international expert panel agreed that REBOA can be used in civilian pre-hospital settings for temporary control of non-compressible truncal hemorrhage, provided that personnel are properly trained and protocols are established. For pre-hospital REBOA and early femoral artery access, consensus was reached on (contra-) indications, physiological thresholds and practical aspects. The panel recommends the initiation of a randomized clinical trial investigating the use of pre-hospital REBOA for non-compressible truncal hemorrhage. LEVEL OF EVIDENCE: Delphi study (original research, care management), level 5.

Critical systolic blood pressure threshold for endovascular aortic occlusion-A multinational analysis to determine when to place a REBOA.

BACKGROUND: Systolic blood pressure (SBP) is a potential indicator that could guide when to use a resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma patients with life-threatening injuries. This study aims to determine the optimal SBP threshold for REBOA placement by analyzing the association between SBP pre-REBOA and 24-hour mortality in severely injured hemodynamically unstable trauma patients. METHODS: We performed a pooled analysis of the aortic balloon occlusion (ABO) trauma and AORTA registries. These databases record the details related to the use of REBOA and include data from 14 countries worldwide. We included patients who had suffered penetrating and/or blunt trauma. Patients who arrived at the hospital with a SBP pre-REBOA of 0 mm Hg and remained at 0 mm Hg after balloon inflation were excluded. We evaluated the impact that SBP pre-REBOA had on the probability of death in the first 24 hours. RESULTS: A total of 1,107 patients underwent endovascular aortic occlusion, of these, 848 met inclusion criteria. The median age was 44 years (interquartile range [IQR], 27-59 years) and 643 (76%) were male. The median injury severity score was 34 (IQR, 25-45). The median SBP pre-REBOA was 65 mm Hg (IQR, 49-88 mm Hg). Mortality at 24 hours was reported in 279 (32%) patients. Math modeling shows that predicted probabilities of the primary outcome increased steadily in SBP pre-REBOA below 100 mm Hg. Multivariable mixed-effects analysis shows that when SBP pre-REBOA was lower than 60 mm Hg, the risk of death was more than 50% (relative risk, 1.5; 95% confidence interval, 1.17-1.92; p = 0.001). DISCUSSION: In patients who do not respond to initial resuscitation, the use of REBOA in SBPs between 60 mm Hg and 80 mm Hg may be a useful tool in resuscitation efforts before further decompensation or complete cardiovascular collapse. The findings from our study are clinically important as a first step in identifying candidates for REBOA. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

International registry on aortic balloon occlusion in major trauma: Partial inflation does not improve outcomes in abdominal trauma.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method for temporary hemorrhage control used in haemodynamically unwell patients with severe bleeding. In haemodynamically unwell abdominal trauma patients, laparotomy remains the initial procedure of choice. Using REBOA in patients as a bridge to laparotomy is a novel option whose feasibility and efficacy remain unclear. We aimed to assess the clinical outcome in patients with abdominal injury who underwent both REBOA placement and laparotomy. METHODS: This is a retrospective study, including trauma patients with an isolated abdominal injury who underwent both REBOA placement and laparotomy, during the period 2011-2019. All data were collected via the Aortic Balloon Occlusion Trauma Registry database. RESULTS: One hundred and three patients were included in this study. The main mechanism of trauma was blunt injury (62.1%) and the median injury severity score (ISS) was 33 (14-74). Renal failure and multi-organ dysfunction syndrome (MODS) occurred in 15.5% and 35% of patients, respectively. Overall, 30-day mortality was 50.5%. Post balloon inflation systolic blood pressure (SBP) >80 mmHg was associated with lower 24-h mortality (p = 0.007). No differences in mortality were found among patients who underwent partial occlusion vs. total occlusion of the aorta. CONCLUSIONS: Our results support the feasibility of REBOA use in patients with isolated abdominal injury, with survival rates similar to previous reports for haemodynamically unstable abdominal trauma patients. Post-balloon inflation SBP >80 mmHg was associated with a significant reduction in 24-h mortality rates, but not 30-day mortality. Total aortic occlusion was not associated with increased mortality, MODS, and complication rates compared with partial occlusion.

When the lights go down in the delivery room: Lessons from a ransomware attack.

OBJECTIVE: To describe the challenges facing the obstetric division following a cyberattack and discuss ways of preparing for and overcoming another one. METHODS: A retrospective descriptive study conducted in a mid-sized medical center. Division activities, including the number of deliveries, cesarean sections, emergency room visits, admissions, maternal-fetal medicine department occupancy, and ambulatory encounters, from 2 weeks before the attack to 8 weeks following it (a total of 11 weeks), were compared with the retrospective period in 2019 (pre-COVID-19). In addition, we present the challenges and adaptation measures taken at the division and hospital levels leading up to the resumption of full division activity. RESULTS: On the day of the cyberattack, critical decisions were made. The media announced the event, calling on patients not to come to our hospital. Also, all elective activities other than cesarean deliveries were stopped. The number of deliveries, admissions, and both emergency room and ambulatory clinic visits decreased by 5%-10% overall for 11 weeks, reflecting the decrease in division activity. Nevertheless, in all stations, there were sufficient activities and adaptation measures to ensure patient safety, decision-making, and workflow of patients were accounted for. CONCLUSIONS: The risk of ransomware cyberattacks is growing. Healthcare systems at all levels should recognize this threat and have protocols for dealing with them once they occur.

Comparison of Sense of Humor and Burnout in Surgeons and Internal Medicine Physicians.

OBJECTIVES: We aimed to evaluate humor styles in surgeons and internists and investigate the association between humor and burnout. METHODS: A cross-sectional survey of physicians in surgical and medicine departments was conducted, assessing sense of humor and burnout using the Humor Styles Questionnaire and the Emotional Exhaustion subscale of the Maslach Burnout Inventory-Human Services Survey for Medical Personnel. RESULTS: For 131 surgeons and 72 internists, no differences in humor styles were found. A sense of personal accomplishment was more common among surgeons (P = 0.03) and rates of burnout were lower for surgeons (P = 0.02). Physicians with a higher-than-average score in affiliative and self-enhancing humor were less likely to suffer from burnout (P < 0.0001 and P = 0.03, respectively). CONCLUSIONS: Surgeons and internists have similar styles of humor. Surgeons suffer less from burnout. Affiliative and self-enhancing humor styles are associated with reduced burnout.

Synchronous Malignancies Identified by PET-CT Scan in Breast Cancer Patients.

Breast cancer is a common malignancy and a common cause of cancer-related mortality in women. Pre-treatment workup of breast cancer does not routinely include positron emission tomography scans. We aimed to review cases of women with breast cancer and a synchronous second primary malignancy. We present three cases of women with non-metastatic cancer in whom a synchronous second primary malignancy was found. Synchronous, second primary malignancies which were identified included rectal cancer, gastrointestinal stromal tumor, and non-small cell lung cancer. All second primary malignancies were identified by a PET-CT scan. In conclusion, PET-CT may be used for detection of secondary primary malignancies in select breast cancer patients.

Is Diffuse Axonal Injury Different in Adults and Children? An Analysis of National Trauma Database.

BACKGROUND: Diffuse axonal injury (DAI) is typically associated with significant mechanisms of injury and the effects of acceleration-deceleration forces on brain tissues. The prognosis of DAI remains a matter of active investigation, but little is known about outcome differences between adult and pediatric populations with DAI. METHODS: We performed a retrospective cohort study involving blunt trauma patients with DAI between the years 1997 and 2018 from the Israeli National Trauma Registry. The patients were divided to pediatric (age <15 years) and adult (age >15 years) groups, with subsequent comparison of demographics and outcomes. RESULTS: Diffuse axonal injury was identified in 1983 patients, including 469 pediatric victims (23.6%) and 1514 adults (76.4%). Adults had higher Injury Severity Score (20.5% vs 13.2%, P = 0.0004), increased mortality (17.7% vs 13.4%, P < 0.0001), longer hospitalizations (58.4% vs 44.4%, P < 0.001), and higher rehabilitation need rates (56.4% vs 41.8%, P < 0.0001). Associated extracranial injuries were also more common in adults, particularly to the chest. CONCLUSIONS: Pediatric patients with DAI have improved outcomes and fewer associated injuries than adult counterparts.

Biliary Tract Instrumentations Prior to Elective Cholecystectomy: Effect on Biliary Microbiome.

Background: Calculus biliary disease is a common condition that requires invasive procedures in complicated cases. The effect of biliary instrumentation on the biliary microbiome and its impact on surgical complications after elective cholecystectomy remains unclear. This study aimed to assess the impact of prior biliary instrumentation on the biliary microbiome, as well as on the clinical outcomes of cholecystectomy. Patients and Methods: This retrospective study included all patients who underwent elective cholecystectomy for calculus biliary disease between 2015 and 2020 in a single medical center. Data regarding biliary instrumentation prior to cholecystectomy, biliary cultures obtained during cholecystectomy, and clinical outcomes were collected. A comparison between patients with and without prior instrumentation was performed with regard to biliary cultures and clinical outcomes. Results: Of the 508 patients studied, 109 patients underwent biliary instrumentation prior to cholecystectomy. Patients with prior instrumentation were older and more likely to be men (p < 0.0001). Prior instrumentation was also associated with higher rates of conversion to open surgery (p < 0.0001). Positive biliary cultures and polymicrobial growth were both more common among patients with prior instrumentation (p < 0.0001). Prior instrumentation was associated with longer length of hospital stay, as well as higher rates of perioperative complications and surgical site infection (p < 0.0001). Conclusions: Prior instrumentation was associated with poorer clinical outcomes and affected the biliary microbiome. The different results of biliary cultures in these patients may suggest that an alternative empiric antibiotic regimen should be considered when treating patients with biliary instrumentation.

Multiple rib fractures: does flail chest matter?

BACKGROUND: Recent studies have reported significant morbidity and mortality in patients with multiple rib fractures, even without flail chest. The aim of this study was to compare the clinical outcome and incidence of associated chest injuries between patients with and without flail chest, with three or more rib fractures. METHODS: This study included patients with blunt trauma with at least three rib fractures, hospitalised during 2010-2019 in the Hillel Yaffe Medical Center in central Israel (level II trauma centre). Patients with and without radiologically defined flail chest were compared with regard to demographics, Injury Severity Score (ISS), GCS, systolic blood pressure (SBP) on admission, radiological evidence of flail chest, associated chest injuries, length of stay in intensive care unit, length of hospitalisation and mortality. RESULTS: The study included 407 patients, of which 79 (19.4%) had flail chest. Overall, pneumothorax and haemothorax were more common among patients with flail chest (p<0.05). When comparing patients with three to five rib fractures, there was no difference in length of intensive care and length of hospitalisation or mortality; however, there was a higher incidence of pneumothorax (24.6% vs 50.0%, p<0.05). When comparing patients with six or more rib fractures, no difference was found between patients with and without flail chest. CONCLUSION: In patients with three to five rib fractures, pneumothorax is more common among patients with flail chest. Clinical significance of flail chest in patients with more than six rib fractures is questionable and flail chest may not be a reliable marker for severity of chest injury in patients with more than six fractures.

Spinal cord injury in the setting of traumatic thoracolumbar fracture is not reliably associated with increased risk of associated intra-abdominal injury following blunt trauma: An analysis of a National Trauma Registry database.

PURPOSE: There is a common opinion that spinal fractures usually reflect the substantial impact of injuries and therefore may be used as a marker of significant associated injuries, specifically for intra-abdominal injury (IAI). The impact of concomitant spinal cord injury (SCI) with the risk of associated IAI has not been well clarified. The aim of this study was to evaluate the incidence and severity of IAIs in patients suffering from spinal fractures with or without SCI. METHODS: A retrospective cohort study using the Israeli National Trauma Registry was conducted. Patients with thoracic, lumbar and thoracolumbar fractures resulting from blunt mechanisms of injury from January 1, 1997 to December 31, 2018 were examined, comparing the incidence, severity and mortality of IAIs in patients with or without SCI. The collected variables included age, gender, mechanism of injury, incidence and severity of the concomitant IAIs and pelvic fractures, abbreviated injury scale, injury severity score, and mortality. Statistical analysis was performed using GraphPad InStat ® Version 3.10, with Chi-square test for independence and two sided Fisher's exact probability test. RESULTS: Review of the Israeli National Trauma Database revealed a total of 16,878 patients with spinal fractures. Combined thoracic and lumbar fractures were observed in 1272 patients (7.5%), isolated thoracic fractures in 4967 patients (29.4%) and isolated lumbar fractures in 10,639 patients (63.0%). The incidence of concomitant SCI was found in 4.95% (63/1272), 7.65% (380/4967) and 2.50% (266/10639) of these patients, respectively. The overall mortality was 2.5%, proving higher among isolated thoracic fracture patient than among isolated lumbar fracture counterparts (11.3% vs. 4.6%, p < 0.001). Isolated thoracic fractures with SCI were significantly more likely to die than non-SCI counterparts (8.2% vs. 3.1%, p < 0.001). There were no differences in the incidence of IAIs between patients with or without SCI following thoracolumbar fractures overall or in isolated thoracic fractures; although isolated lumbar fractures patients with SCI were more likely to have renal (3.4% vs. 1.6%, p = 0.02) or bowel injuries (2.3% vs. 1.0%, p = 0.04) than the non-SCI counterparts. CONCLUSION: SCI in the setting of thoracolumbar fracture does not appear to be a marker for associated IAI. However, in a subset of isolated lumbar fractures, SCI patient is associated with increased risks for renal and bowel injury.

The Cyclicity of coronavirus cases: "Waves" and the "weekend effect".

INTRODUCTION: Medical statistics is one of the "milestones" of current medical systems. It is the foundation for many protocols, including medical care systems, government recommendations, epidemic planning, etc. At this time of global COVID-19, credible data on epidemic spread can help governments make better decisions. This study's aim is to evaluate the cyclicity in the number of daily diagnosed coronavirus patients, thus allowing governments to plan how to allocate their resources more effectively. METHODS: To assess this cycle, we consider the time series of the first and second differences in the number of registered patients in different countries. The spectral densities of the time series are calculated, and the frequencies and amplitudes of the maximum spectral peaks are estimated. RESULTS: It is shown that two types of cycles can be distinguished in the time series of the case numbers. Cyclical fluctuations of the first type are characterized by periods from 100 to 300 days. Cyclical fluctuations of the second type are characterized by a period of about seven days. For different countries, the phases of the seven-day fluctuations coincide. It is assumed that cyclical fluctuations of the second type are associated with the weekly cycle of population activity. CONCLUSIONS: These characteristics of cyclical fluctuations in cases can be used to predict the incidence rate.

A new modelling of the COVID 19 pandemic.

А model of coronavirus incidence is proposed. Process of disease development is represented as analogue of first- and second order phase transition in physical systems. The model is very simple in terms of the data necessary for the calculations. To verify the proposed model, only data on the current incidence rate are required. However, the determination coefficient of model R2 is very high and exceeds 0.95 for most countries. The model permits the accurate prediction of the pandemics dynamics at intervals of up to 10 days. The ADL(autoregressive distributed lag)-model was introduced in addition to the phase transition model to describe the development of the disease at the exponential phase.The ADL-model allows describing nonmonotonic changes in relative infection over the time, and providing to governments and health care decision makers the possibility to predict the outcomes of their decisions on public health.

Hypotension on admission in patients with isolated traumatic brain injury: contemporary examination of the incidence and outcomes using a national registry.

PURPOSE: This study was primarily aimed at establishing the incidence and impact of hypotension in patients with blunt traumatic brain injury based on National Trauma Registry Database. METHODS: A retrospective cohort study using the National Trauma Registry was conducted. Patients with TBI following blunt mechanisms of injury were examined, comparing those with and without hypotension (SBP < 90 mm Hg) on arrival. RESULTS: During the period from 1998 to 2017, the registry included 437.354 blunt trauma patients. Of them, 7818 patients were hemodynamically unstable (SBP < 90 mm Hg) on admission. 513 met the inclusion criteria. Significant percentages of patients with high grade injures (ISS≥16) and low admission's GCS 3-12 (46% vs 16.4%), were found in the group of hypotensive TBI patients (p<0.0001). 323 (62.9%) patients had head AIS score 3-4 and only 190 (37.1%) patients AIS 5-6 (p<0.0001). Mortality in the hypotensive TBI group was 32.3%, whereas 6.1% patients died in the TBI hemodynamically stable group (p<0.0001). CONCLUSION: TBI patients presenting with hypotension represent an appreciable portion blunt trauma patients. Prompt brain CT, expedient efforts at optimal resuscitation and possibly early inotropic and vasopressors agents use may have an impact on final outcome in these patients.

Potential resuscitative endovascular balloon occlusion of aorta candidates: defining the potential need using the National Trauma Registry.

BACKGROUND: Most of the trauma patients who die in the first 24 h from arrival to the hospital do so as a result of haemorrhagic shock. Resuscitative endovascular balloon occlusion of the aorta (REBOA) facilitates expedient proximal aortic control, potentially bridging a needed gap for partial or non-responders to traditional resuscitation en route to emergent definitive haemostasis. This resuscitation tool continues to evolve and has recently achieved some consensus defined indications for its use. The aim of this study is designed to examine the potential utility of REBOA among trauma victims who die within 24 h of arrival. METHODS: Data of all trauma patients who died in the first 24 h, from 2012 to 2017 were extracted from the National Trauma Registry in the Gertner Institute for Epidemiology and Health Policy Research. Patients who died in the first half an hour, and those with neck and thorax injuries were excluded. Demographics, clinical and injury data were collected. RESULTS: Overall, 129 patients were included; 74% male and 26% female with the mean age of 46.4 years. A total of 76% suffered blunt trauma and 24% penetrating trauma. Mean survival time was 5.87 h. The cause of death was major abdominal organ injury in 47.2%, injury to major abdominal vessel in 23.3% and pelvic fractures in 21.7%. A total of 69 patients (53.5%) ultimately required delayed resuscitative thoracotomy in the operation room. CONCLUSION: Registry data suggest that there is a subset of patients presenting to modern trauma centres who might benefit from REBOA in order to avoid death.

Aortic balloon occlusion (REBOA) in pelvic ring injuries: preliminary results of the ABO Trauma Registry.

EndoVascular and Hybrid Trauma Management (EVTM) has been recently introduced in the treatment of severe pelvic ring injuries. This multimodal method of hemorrhage management counts on several strategies such as the REBOA (resuscitative endovascular balloon occlusion of the aorta). Few data exist on the use of REBOA in patients with a severely injured pelvic ring. The ABO (aortic balloon occlusion) Trauma Registry is designed to capture data for all trauma patients in hemorrhagic shock where management includes REBOA placement. Among all patients included in the ABO registry, 72 patients presented with severe pelvic injuries and were the population under exam. 66.7% were male. Mean and median ISS were respectively 43 and 41 (SD ± 13). Isolated pelvic injuries were observed in 12 patients (16.7%). Blunt trauma occurred in 68 patients (94.4%), penetrating in 2 (2.8%) and combined in 2 (2.8%). Type of injury: fall from height in 15 patients (23.1%), traffic accident in 49 patients (75.4%), and unspecified impact in 1 patient (1.5%). Femoral access was gained pre-hospital in 1 patient, in emergency room in 43, in operating room in 12 and in angio-suite in 16. REBOA was positioned in zone 1 in 59 patients (81,9%), in zone 2 in 1 (1,4%) and in zone 3 in 12 (16,7%). Aortic occlusion was partial/periodical in 35 patients (48,6%) and total occlusion in 37 patients (51,4%). REBOA associated morbidity rate: 11.1%. Overall mortality rate was 54.2% and early mortality rate (≤ 24 h) was 44.4%. In the univariate analysis, factors related to early mortality (≤ 24 h) are lower pH values (p = 0.03), higher base deficit (p = 0.021), longer INR (p = 0.012), minor increase in systolic blood pressure after the REBOA inflation (p = 0.03) and total aortic occlusion (p = 0.008). None of these values resulted significant in the multivariate analysis. In severe hemodynamically unstable pelvic trauma management, REBOA is a viable option when utilized in experienced centers as a bridge to other treatments; its use might be, however, accompanied with severe-to-lethal complications.

Is computed tomography cystography indicated in children with pelvic fractures?

PURPOSE: Pelvic fracture evaluation with abdominopelvic computed tomography (CT) and formal CT cystography for rule out of urine bladder injury have been commonly employed in pediatric trauma patients. The additional delayed imaging required to obtain optimal CT cystography is, however, associated with increased doses of ionizing radiation to pelvic organs and represent a significant risk in the pediatric population for future carcinogenic risk. We hypothesized that avoidance of routine CT cystography among pediatric pelvic fracture victims would not result in an appreciable rate of missed bladder injuries and would aid in mitigating the radiation exposure risk associated with these additional images. METHODS: A retrospective cohort study involving blunt trauma pelvic fractures among pediatric trauma patients (age<14) between the years 1997 and 2016 was conducted utilizing the Israeli National Trauma Registry. Statistical analysis was performed using SAS statistical software version 9.4 via the tests of Chi-square test and two-sided Fisher's exact test. A p value of less than 0.05 was considered statistically significant. RESULTS: A total of 1072 children were identified from the registry for inclusion. Mean age of patients was 7.7 years (range 0-14) and 713 (66.5%) were male. Overall mortality in this population was 4.1% (44/1072). Only 2.1% (23) of pediatric patients with pelvic fractures had bladder injury identified, with just 9 children having intraperitoneal bladder rupture (0.8% of all the patients). CONCLUSION: The vast majority of blunt pediatric trauma victims with pelvic fractures do not have urine bladder injuries. Based on our study results we do not recommend the routine utilization of CT cystography in this unique population.

The Use of Chest Computed Tomographic Angiography in Blunt Trauma Pediatric Population.

INTRODUCTION: Blunt chest trauma in children is common. Although rare, associated major thoracic vascular injuries (TVIs) are lethal potential sequelae of these mechanisms. The preferred study for definitive diagnosis of TVI in stable patients is computed tomographic angiography imaging of the chest. This imaging modality is, however, associated with high doses of ionizing radiation that represent significant carcinogenic risk for pediatric patients. The aim of the present investigation was to define the incidence of TVI among blunt pediatric trauma patients in an effort to better elucidate the usefulness of computed tomographic angiography use in this population. METHODS: A retrospective cohort study was conducted including all blunt pediatric (age < 14 y) trauma victims registered in Israeli National Trauma Registry maintained by Gertner Institute for Epidemiology and Health Policy Research between the years 1997 and 2015. Data collected included age, sex, mechanism of injury, Glasgow Coma Scale, Injury Severity Score, and incidence of chest named vessel injuries. Statistical analysis was performed using SAS statistical software version 9.2 (SAS Institute Inc, Cary, NC). RESULTS: Among 433,325 blunt trauma victims, 119,821patients were younger than 14 years. Twelve (0.0001%, 12/119821) of these children were diagnosed with TVI. The most common mechanism in this group was pedestrian hit by a car. Mortality was 41.7% (5/12). CONCLUSIONS: Thoracic vascular injury is exceptionally rare among pediatric blunt trauma victims but does contribute to the high morbidity and mortality seen with blunt chest trauma. Computed tomographic angiography, with its associated radiation exposure risk, should not be used as a standard tool after trauma in injured children. Clinical protocols are needed in this population to minimize radiation risk while allowing prompt identification of life-threatening injuries.