The use and timing of angio-embolization 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 utilized as an adjunctive therapy in the management of adult BLSI patients, but it is rarely utilized 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 1 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 9 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 1 patient undergoing angiography within 1 hour of arrival at the PTC, and 7 within 3 hours. CONCLUSIONS: Angioembolization is rarely utilized in the management of BLSI in pediatric trauma patients with blunt abdominal trauma and is generally utilized in a delayed fashion. However, when implemented, angioembolization is associated with 100% splenic salvage for splenic injuries. LEVEL OF EVIDENCE: Level IV, therapeutic/care management.

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

BACKGROUND: Many children with blunt liver and/or spleen injury (BLSI) never bleed intraperitoneally. Despite this, decreases in hemoglobin are common. This study examines initial and follow up measured hemoglobin values for children with BLSI with and without evidence of intra-abdominal bleeding. METHODS: Children ≤18 years of age with BLSI between April 2013 and January 2016 were identified from the prospective ATOMAC+ cohort. Initial and follow up hemoglobin levels were analyzed for 4 groups with BLSI: (1) Non bleeding; (2) Bleeding, non transfused (3) Bleeding, transfused, and (4) Bleeding resulting in non operative management (NOM) failure. RESULTS: Of 1007 patients enrolled, 767 were included in one or more of four study cohorts. Of 131 non bleeding patients, the mean decrease in hemoglobin was 0.83 g/dL (+/-1.35) after a median of 6.3 [5.1,7.0] hours, (p = 0.001). Follow-up hemoglobin levels in patients with and without successful NOM were not different. For patients with an initial hemoglobin >9.25 g/dL, the odds ratio (OR) for NOM failure was 14.2 times less, while the OR for transfusion was 11.4 times less (p = 0.001). CONCLUSION: Decreases in hemoglobin are expected after trauma, even if not bleeding. A hemoglobin decrease of 2.15 g/dL [0.8 + 1.35] would still be within one standard deviation of a non bleeding patient. An initial low hemoglobin correlates with failure of NOM as well as transfusion, thereby providing useful information. By contrast, subsequent hemoglobin levels do not appear to guide the need for transfusion, nor correlate with failure of NOM. These results support initial hemoglobin measurement but suggest a lack of utility for routine rechecking of hemoglobin. LEVEL OF EVIDENCE: Level II Prognostic Study.

Infectious complications of intercostal nerve cryoablation mediated by perioperative hypothermia during pediatric Nuss procedure.

BACKGROUND: Intercostal nerve cryoablation (cryoanalgesia) is increasingly used for pain control in minimally invasive repair of pectus excavatum (MIRPE) by Nuss procedure. Cryoanalgesia may lower core body temperature and increase the risk of postoperative infectious complications. We investigated cryoanalgesia effects on infectious complications following MIRPE. METHOD: We performed a retrospective review of patients undergoing MIRPE at our institution. Patients treated via multimodal analgesia with cryoanalgesia (Cryo) were compared to patients treated via multimodal analgesia +/- elastomeric pain pumps (Non-cryo). Core body and intraoperative minimum/maximum temperatures were recorded. Primary outcomes were wound infection and pneumonia; secondary outcome was length of stay (LOS). Fisher's Exact and Mann-Whitney U tests compared proportions and medians respectively, p-value ≤ 0.05 being significant. RESULTS: 80 patients were included, 35(43.7%) Cryo and 45(56.3%) Non-cryo. There were no significant differences in median [IQR] for age(15[13.3,16.0];p =0.86), number of bars inserted (2[1,2];p = 0.57), or operative time(123.5[98.3, 148.8]; p = 0.11) between the two groups. We found no significant differences in median [IQR] minimum temperature (35.4°C [35.0,35.8];p = 0.76), median change in intraoperative temperature (-0.13°C [-0.44,0.00];p = 0.94) or median recovery temperature (-1.10°C [-1.56,-0.65]; p = 0.59) between Cryo and Non-cryo. PACU temperature was significantly lower in the Cryo group, 36.4°C [36.2,36.6] p = 0.04. There were no postoperative wound infections in either group and no significant difference in incidence of postoperative pneumonia (8.57% versus 2.22%,p =  0.31) or median[IQR] for LOS (4[3,4];p = 0.57), between Cryo and Non-cryo patients. CONCLUSION: Although cryoanalgesia for MIRPE resulted in lower core body temperature, there appears to be no significant difference between Cryo and Non-Cryo patients for LOS or infectious complications.

Intimate Partner Violence, Clinical Indications, and Other Family Risk Factors Associated With Pediatric Abusive Head Trauma.

Over half of fatal pediatric traumatic brain injuries are estimated to be the result of physical abuse, i.e., abusive head trauma (AHT). Although intimate partner violence (IPV) is a well-established risk for child maltreatment, little is known about IPV as an associated risk factor specifically for AHT. We performed a single-institution, retrospective review of all patients (0-17 years) diagnosed at a Level 1 pediatric trauma center with head trauma who had been referred to an in-hospital child protection team for suspicion of AHT between 2010 and 2016. Data on patient demographics, hospitalization, injury, family characteristics, sociobehavioral characteristics, physical examination, laboratory findings, imaging, discharge, and forensic determination of AHT were extracted from the institution's forensic registry. Descriptive statistics (mean, median), chi-square and Mann-Whitney U tests were used to compare patients with fatal head injuries to patients with nonfatal head injuries by clinical characteristics, family characteristics, and forensic determination. Multiple logistic regression was used to estimate adjusted odds ratios for the presence of IPV as an associated risk of AHT while controlling for other clinical and family factors. Of 804 patients with suspicion for AHT in the forensic registry, there were 240 patients with a forensic determination of AHT; 42 injuries were fatal. There were 101 families with a reported history of IPV; 64.4% of patients in families with reported IPV were <12 months of age. IPV was associated with a twofold increase in the risk of AHT (Exp(ß) = 2.3 [p = .02]). This study confirmed IPV was an associated risk factor for AHT in a single institution cohort of pediatric patients with both fatal and nonfatal injuries. Identifying IPV along with other family factors may improve detection and surveillance of AHT in medical settings and help reduce injury, disability, and death.

Evaluating abusive head trauma in children <5 years old: Risk factors and the importance of the social history.

BACKGROUND: Abusive head trauma (AHT) is the leading cause traumatic death in children ≤5 years of age. AHT remains seriously under-surveilled, increasing the risk of subsequent injury and death. This study assesses the clinical and social risks associated with fatal and non-fatal AHT. METHODS: A single-institution, retrospective review of suspected AHT patients ≤5 years of age between 2010 and 2016 using a prospective hospital forensic registry data yielded demographic, clinical, family, psycho-social and other follow-up information. Descriptive statistics were used to look for differences between patients with AHT and accidental head trauma. Logistic regression estimated the adjusted odds ratios (AOR) for AHT. A receiver operating characteristic (ROC) curve was created to calculate model sensitivity and specificity. RESULTS: Forensic evaluations of 783 children age ≤5 years with head trauma met the inclusion criteria; 25 were fatal with median[IQR] age 23[4.5-39.0] months. Of 758 non-fatal patients, age was 7[3.0-11.0] months; 59.5% male; 435 patients (57.4%) presented with a skull fracture, 403 (53.2%) with intracranial hemorrhage. Ultimately 242 (31.9%) were adjudicated AHT, 335(44.2%) were accidental, 181 (23.9%) were undetermined. Clinical factors increasing the risk of AHT included multiple fractures (Exp(ß) = 9.9[p = 0.001]), bruising (Expß = 5.7[p < 0.001]), subdural blood (Exp(ß) = 5.3[p = 0.001]), seizures (Exp(ß) = 4.9[p = 0.02]), lethargy/unresponsiveness (Exp(ß) = 2.24[p = 0.02]), loss of consciousness (Exp(ß) = 4.69[p = 0.001]), and unknown mechanism of injury (Exp(ß) = 3.9[p = 0.001]); skull fracture reduced the risk of AHT by half (Exp(ß) = 0.5[p = 0.011]). Social risks factors included prior police involvement (Exp(ß) = 5.9[p = 0.001]), substance abuse (Exp(ß) = 5.7[p = .001]), unknown number of adults in the home (Exp(ß) = 4.1[p = 0.001]) and intimate partner violence (Exp(ß) = 2.3[p = 0.02]). ROC area under the curve (AUC) = 0.90([95% CI = 0.86-0.93] p = .001) provides 73% sensitivity; 91% specificity. CONCLUSIONS: To improve surveillance of AHT, interviews should include and consider social factors including caregiver/household substance abuse, intimate partner violence, prior police involvement and household size. An unknown number of adults in home is associated with an increased risk of AHT. STUDY TYPE/LEVEL OF EVIDENCE: Prognostic, Level III.

Early vasopressor administration in pediatric blunt liver and spleen injury: An ATOMAC+ study.

BACKGROUND: No prior studies have examined the outcomes of early vasopressor use in children sustaining blunt liver or spleen injury (BLSI). METHODS: A planned secondary analysis of vasopressor use from a 10-center, prospective study of 1004 children with BLSI. Inverse probability of treatment weighting (IPTW) was used to compare patients given vasopressors <48 h after injury to controls based on pretreatment factors. A logistic regression was utilized to assess survival associated with vasopressor initiation factors on mortality and nonoperative management (NOM) failure. RESULTS: Of 1004 patients with BLSI, 128 patients were hypotensive in the Pediatric Trauma Center Emergency Department (ED); 65 total patients received vasopressors. Hypotension treated with vasopressors was associated with a sevenfold increase in mortality (AOR = 7.6 [p < 0.01]). When excluding patients first given vasopressors for cardiac arrest, the risk of mortality increased to 11-fold (AOR = 11.4 [p = 0.01]). All deaths in patients receiving vasopressors occurred when started within the first 12 h after injury. Vasopressor administration at any time was not associated with NOM failure. CONCLUSION: After propensity matching, early vasopressor use for hypotension in the ED was associated with an increased risk of death, but did not increase the risk of failure of NOM. LEVEL OF EVIDENCE: Level III prognostic and epidemiological, prospective.

Impact of helmet laws on motorcycle crash mortality rates.

BACKGROUND: Helmets are effective in reducing traumatic brain injury. However, population effects of helmet laws have not been well described. This study assesses the impact of helmet laws on the motorcycle (MC) fatality rate in the United States from 1999 to 2015. METHODS: Fatality Analysis Reporting System MC fatalities (aged ≥16 years), crash characteristics, and MC-related laws were collected by year for all 50 states from 1999 to 2015 to create a pooled time series. Generalized linear autoregressive modeling was applied to assess the relative contribution of helmet laws to the MC fatality rate while controlling for other major driver laws and crash characteristics. RESULTS: Universal helmet laws were associated with a 36% to 45% decline in the motorcycle crash mortality rate during the study period across all age cohorts (unstandardized regression coefficients are reported): 16 to 20 years, B = -0.45 (p < 0.05); 21 to 55 years, B = -0.42 (p < 0.001); 56 to 65 years, B = -0.38 (p < 0.04); and older than 65 years, B = -0.36 (p < 0.02). Partial helmet laws were associated with a 1% to 81% increase in the fatality rate compared with states with no helmet laws and a 22% to 45% increase compared with universal laws. Helmet usage did not attenuate the countervailing effect of weaker partial laws for 16 to 20 years (B = 0.01 [p < 0.001]). Other laws associated with a declining motorcycle crash mortality rate included the following: social host/overservice laws, 21 to 55 years (B = -0.38 [p < 0.001]); 56 to 65 years (B = -0.16 [p < 0.002]), and older than 65 years (B = -0.12 [p < 0.003]); laws reducing allowable blood alcohol content, 21 to 55 years (B = -4.9 [p < 0.02]); and laws limiting passengers for new drivers 16 to 20 years (B = -0.06 [p < 0.01]). CONCLUSION: During the period of the study, universal helmet laws were associated with a declining mortality rate, while partial helmet laws were associated with an increasing mortality rate. Other state driver laws were also associated with a declining rate. In addition to universal helmet laws, advocating for strict alcohol control legislation and reevaluation of licenses in older riders could also result in significant reduction in MC-related mortality. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

The impact of state laws on motor vehicle fatality rates, 1999-2015.

BACKGROUND: Motor vehicle crash (MVC) fatalities have been declining while states passed various legislation targeting driver behaviors. This study assesses the impact of state laws on MVC fatality rates to determine which laws were effective. METHODS: Publically available data were collected on driver-related motor vehicle laws, law strengths, enactment years, and numbers of verified-trauma centers. Prospective data on crash characteristics and MVC fatalities 16 years or older from Fatality Analysis Reporting System 1999 to 2015 (n = 850) were obtained. Generalize Linear Autoregressive Modeling was used to assess the relative contribution of state laws to the crude MVC fatality rate while controlling for other factors. RESULTS: Lowering the minimum blood alcohol content (BAC) was associated with largest declines for all ages, especially the older cohorts: 16 years to 20 years (B = 0.23; p < 0.001), 21 years to 55 years (B = 1.7; p < 0.001); 56 years to 65 years (B = 3.2; p < 0.001); older than 65 years (B = 4.1; p < 0.001). Other driving under the influence laws were also significant. Per se BAC laws accompanying a reduced BAC further contributed to declines in crude fatality rates: 21 years to 55 years (B = -0.13; p < 0.001); older than 65 years (B = -0.17; p < 0.05). Driving under the influence laws enhancing the penalties, making revocation automatic, or targeting social hosts had mixed effects by age. Increased enforcement, mandatory education, vehicle impoundment, interlock devices, and underage alcohol laws showed no association with declining mortality rates. Red light camera and seatbelt laws were associated with declines in mortality rates for all ages except for older than 65 years cohort, but speed camera laws had no effect. Graduated Driver License laws were associated with declines for 16 years to 21 years (B = -0.06; p < 0.001) only. Laws targeting specific risks (elderly, motorcycles, marijuana) showed no effect on declining MVC mortality rates during the study period. CONCLUSION: States have passed a wide variety of laws with varying effectiveness. A few key laws, specifically laws lowering allowable BAC, implementing red light cameras, and mandating seatbelt use significantly reduced MVC mortality rates from 1999 to 2015. Simply adding more laws/penalties may not equate directly to lives saved. Continued research on state laws will better inform policy makers to meet evolving public health needs in the management of MVC fatalities. LEVEL OF EVIDENCE: Epidemiological, Level III.

Inflicted versus unintentional injury: towards improved detection and surveillance of supervisory neglect.

BACKGROUND: Many children evaluated for child abuse have non-inflicted injuries due to supervisory neglect. Despite its prevalence, supervisory neglect has received minimal attention. METHODS: We performed a retrospective review of patients maintained in a hospital forensic registry. Text analytics software was used to classify types of supervisory neglect from reported mechanism of injury (MOI). Logistic regression was used to assess risks associated with supervisory neglect. RESULTS: For 1185 eligible patients, 553 were classified as having unintentional injuries. Text analysis identified four types of supervisory neglect for falls (N = 376): interrupted supervision (53.4%); failure to adapt the home (26.7%); safety equipment non-compliance (12.8%); inadequate substitute care (7.0%); a fifth category was identified for non-falls (N = 54): rough handling (32.0%). Supervisory neglect was associated with MOI consistent with the injury (AOR = 15.5[p < 0.001]), no loss of consciousness (AOR = 6.8(p < 0.001]), no bruising away from the injury site (AOR = 3.7[p < 0.001]), and direct hospital presentation (AOR = 1.8[p < 0.05]). Of the 553 with unintentional injury, 62% had isolated head injuries; 20%, however, had evidence of prior head trauma. CONCLUSIONS: Interrupted supervision was the most common form of supervisory neglect. Twenty percent of forensics patients with head injury found to have non-inflicted injuries had evidence of prior head injury. Supervisory neglect suggests a high-risk population. LEVEL OF EVIDENCE: Level II, Prognosis.

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.

The effect of verified pediatric trauma centers, state laws, and crash characteristics on time trends in adolescent motor vehicle fatalities, 1999-2015.

BACKGROUND: Motor vehicle crashes are a leading cause of adolescent death from trauma. A recent study found American College of Surgeons-verified pediatric trauma centers (vPTC) were inversely correlated with pediatric mortality, but the analysis was limited to a single year. This study assesses the contribution of vPTCs, crash characteristics, and state driver laws on 15- to 17-year-old motor vehicle crash mortality for all 50 states from 1999 to 2015. METHODS: Prospective data on motor vehicle fatalities, crash characteristics, state driving laws, and American College of Surgeons-verified trauma centers were collected from publicly available sources for 50 US states from 1999 to 2015. A mixed fixed/random effects multivariate regression model was fitted to assess the relative contribution of crash characteristics, state laws, and vPTCs while controlling for state variation and time trends. RESULTS: The final regression model included driver and crash characteristics, verified trauma centers, and state laws. Camera laws ([B = -0.57 [p < 0.001]) were associated with a 57% decrease in the rate of change in adolescent crude fatalities. The lagged Level 1 vPTC crude rate (B = -0.12 [p < .001]) was protective and contributed independently to a 12% decline in the rate of change in teen fatalities over the time period. Seat belt laws (B = -0.15 [p < 0.001]), graduated driver's license passenger restrictions (B = -0.07[p < 0.001]), graduated driver's license learner permit period (B = -0.04 [p < 0.002]), nondeployed airbag (B = -0.003 [p < 0.001]), and Hispanic heritage (B = -0.003 [p < 0.05]) were protective. Increased risk of fatality was associated with minivan (B = 0.01 [p < 0.001]), speed > 90 mph (B = 0.004 [p < 0.001]), rural roads (B = 0.002 [p < 0.002], unknown seat belt compliance (B = 0.004 [p < 0.001]), and dry road surface (B = 0.005 [p < 0.001]). CONCLUSIONS: State camera laws during the study time frame are associated with a 57% decrease in the rate of change in adolescent crude fatalities; vPTCs during the study time period reduced overall rate of change in the crude fatality rate by 12%. State laws, restrictions on teenage passengers and longer learner's permit periods, and seat belt laws are associated with significant decreases in the crude teen mortality rate. LEVEL OF EVIDENCE: Prospective study and prevention, level III.

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.