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Elevated shock index pediatric age-adjusted (SIPA) has been shown to be associated with the need for both blood transfusion and intervention in pediatric patients with blunt liver and spleen injuries (BLSI). SIPA has traditionally been used as a binary value, which can be classified as elevated or normal, and this study aimed to assess if discreet values above SIPA cutoffs are associated with an increased probability of blood transfusion and failure of nonoperative management (NOM) in bluntly injured children.Children aged 1-18 y with any BLSI admitted to a Level-1 pediatric trauma center between 2009 and 2020 were analyzed. Blood transfusion was defined as any transfusion within 24 h of arrival, and failure of NOM was defined as any abdominal operation or angioembolization procedure for hemorrhage control. The probabilities of receiving a blood transfusion or failure of NOM were calculated at different increments of 0.1.There were 493 patients included in the analysis. The odds of requiring blood transfusion increased by 1.67 (95% CI 1.49, 1.90) for each 0.1 unit increase of SIPA (P 0.001). A similar trend was seen initially for the probability of failure of nonoperative management, but beyond a threshold, increasing values were not associated with failure of NOM. On subanalysis excluding patients with a head injury, increased 0.1 increments were associated with increased odds for both interventions.Discreet values above age-related SIPA cutoffs are correlated with higher probabilities of blood transfusion in pediatric patients with BLSI and failure of NOM in those without head injury. The use of discreet values may provide clinicians with more granular information about which patients require increased resources upon presentation.

Background Non-operative management (NOM) is the standard of care for the majority of children with blunt liver and spleen injuries (BLSI). The shock index pediatric age-adjusted (SIPA) was previously shown to predict the need for blood transfusions in pediatric trauma patients with BLSI. We combined SIPA with base deficit (BD) and International Normalized Ratio (INR) to create the BIS score. We hypothesized that the BIS score would predict the need for blood transfusions and/or failure of NOM in pediatric trauma patients with BLSI. Methods Patients (≤ 18 years) who presented to our Level I pediatric trauma center with BLSI from 2009 to 2019 were identified. BIS scores were calculated by giving 1 point for each of the following: base deficit ≤ -8.8, INR ≥ 1.5, or elevated SIPA. Receiver operating characteristic curves (ROC) were generated for BIS scores ≥ 1, ≥ 2, and ≥ 3. Area under the curve (AUC), sensitivity, and specificity of each score were calculated for ability to predict need for blood transfusions and/or failure of NOM. Results Of 477 children included, 19.9% required a blood transfusion and 6.7% failed NOM. A BIS score ≥ 1 was the best predictor of the need for blood transfusions with an AUC of 0.81 and a sensitivity of 96.0%. A BIS score ≥ 1 was also the best predictor of failure of NOM with an AUC of 0.72 and a sensitivity of 97.0%. Conclusion The BIS score is a highly sensitive tool that identifies pediatric patients with BLSI at risk for blood transfusions and/or failure of NOM. Level of evidence Level III. Type of study Retrospective comparative study.

BACKGROUND/PURPOSE The utility of thrombelastography (TEG) in pediatric trauma remains unknown, and differences in coagulopathy between blunt and penetrating mechanisms are not established. We aimed to compare TEG patterns in pediatric trauma patients with blunt solid organ injuries (BSOI) and penetrating injuries to determine the role of mechanism in coagulopathy. METHODS Highest-level pediatric trauma activations with BSOI or penetrating injuries and admission TEG at two pediatric trauma centers were included. TEG abnormalities were defined by each institution's normative values and compared separately by injury mechanism and evidence of shock (elevated SIPA) using Kruskal-Wallis or Fisher's exact tests. RESULTS Of 118 patients included, 64 had BSOI and 54 had penetrating injuries. There were no significant differences in TEG abnormalities between the BSOI and penetrating injury groups. Patients with shock were more likely to have decreased alpha-angles (30.9% vs. 8.0%, p = 0.01) and decreased maximum amplitude (MA) (44.1% vs. 8.0%, p

Background Neutropenic enterocolitis is uncommon but potentially life-threatening, with the cornerstone of treatment being medical management (MM), and surgical intervention reserved for clinical deterioration or bowel perforation. We hypothesized that the Shock Index Pediatric Age-Adjusted (SIPA) is elevated in patients who are at greatest risk for surgical intervention and mortality. We also sought to identify computed tomography (CT) findings associated with surgical intervention and mortality. Methods A single-center cancer registry was reviewed for neutropenic enterocolitis patients from 2006 -2018. Survival models compared patients with normal versus elevated SIPA throughout their hospitalizations for the time to surgical management (SM), as well as in-hospital mortality. Results Seventy-four patients with neutropenic enterocolitis were identified; 7 underwent surgery. In-hospital mortality was 12% in MM and 29% in SM; mortality among patients with elevated SIPA was 4.7 times higher compared to those with normal SIPA (95% CI: 1.1, 19.83, p = 0.04). CT findings of bowel obstruction, pneumatosis, and a greater percentage of large bowel involvement were associated with surgical intervention (all ps Conclusion Select pre-operative CT findings were associated with need for operative management. Elevated SIPA was associated with increased mortality. Elevated SIPA in pediatric cancer patients with neutropenic enterocolitis may help to identify those with more severe disease and expedite beneficial interventions.

Background Shock index pediatric age-adjusted (SIPA) is a validated measure to identify severely injured children. Previous literature categorized SIPA as normal or elevated, but the relationship between specific SIPA values and outcomes has not been determined. We sought to determine specific SIPA cut points in the pre-hospital and Emergency Department (ED) settings to identify patients at risk for massive transfusion (MT) and/or mortality. Methods Patients ≤ 18 years old admitted to our Level I pediatric trauma center following trauma activation were included. Youdin J index was used to define pre-hospital and ED SIPA cut points to identify those at risk of MT and/or mortality for the following age groups: 12 years old. Sensitivity, specificity, accuracy, and area under the curve (AUC) were calculated to determine SIPA threshold values associated with MT and/or mortality. Results Of 1,072 patients, 6.3% (n = 68) required MT and 8.4% (n = 90) died. For predicting MT, pre-hospital SIPA cut points performed best in the > 12 year-old age group (AUC = 0.86) and ED SIPA cut points performed best in the 6–12 year-old age group (AUC = 0.87). For predicting mortality, pre-hospital (AUC = 0.78) and ED SIPA cut points (AUC = 0.84) performed best in the > 12 year-old age group. Conclusion Pre-hospital and ED SIPA cut points performed better at predicting MT and/or mortality in older pediatric patients compared to very young children. Age remains an important factor when determining the validity of SIPA to predict outcomes in pediatric trauma patients. Study type/level of evidence Level III, Retrospective Cohort Study.

Background The pediatric age-adjusted shock index (SIPA) accurately identifies severely injured children following trauma without accounting for neurological status. Understanding how the presence of traumatic brain injury (TBI) affects the generalizability of SIPA as a bedside triage tool is important given high rates of TBI in the pediatric trauma population. We hypothesized that SIPA combined with TBI (SIPAB+) would more accurately identify severely injured children. Methods Patients (1-18 years old) in the American College of Surgeons Pediatric Trauma Quality Improvement Program database (2014-2017) with an elevated SIPA upon arrival to a pediatric trauma center were included. Pediatric age-adjusted shock index combined with TBI was defined as elevated SIPA with Glasgow Coma Scale score of ≤8. Pediatric age-adjusted shock index without TBI (SIPAB-) was defined as elevated SIPA with Glasgow Coma Scale score of >9. Patients were stratified into SIPAB+ and SIPAB-. A subanalysis of patients with isolated brain injury and those with brain injury and multisystem injuries was also performed. Data were compared through univariate models and three separate logistic regression models. Results Overall, 25,068 had an elevated SIPA, with 12.3% classified as SIPAB+ and the remainder SIPAB-. Patients classified as SIPAB+ received more blood transfusions within 4 hours of injury and had higher mortality rates. On logistic regression, SIPAB+ patients had significantly higher odds of early blood transfusion and a combination of both. Mortality and early blood transfusion were also higher in SIPAB+ patients on subanalysis for patients with isolated TBI and those with multisystem injuries. Conclusion The use of SIPAB+ as a bedside triage tool accurately identifies traumatically injured children at high risk for early blood transfusion and/or death while incorporating the presence of neurological injury. This is true for patients with isolated TBI and those with multisystem injury, indicating its utility in predicting outcomes for TBI patients with elevated SIPA regardless of presence of concomitant injuries. Incorporation of this as a triage tool should be considered to better predict resources in this population. Level of evidence Prognostic, level III.

The shock index pediatric age-adjusted (SIPA) predicts the need for increased resources and mortality among pediatric trauma patients without incorporating neurological status. A new scoring tool, rSIG, which is the reverse shock index (rSI) multiplied by the Glasgow Coma Scale (GCS), has been proven superior at predicting outcomes in adult trauma patients and mortality in pediatric patients compared with traditional scoring systems. We sought to compare the accuracy of rSIG to Shock Index (SI) and SIPA in predicting the need for early interventions in civilian pediatric trauma patients.Patients (aged 1-18 years) in the 2014 to 2018 Pediatric Trauma Quality Improvement Program database with complete heart rate, systolic blood pressure, and total GCS were included. Optimal cut points of rSIG were calculated for predicting blood transfusion within 4 hours, intubation, intracranial pressure monitoring, and intensive care unit admission. From the optimal thresholds, sensitivity, specificity, and area under the curve were calculated from receiver operating characteristics analyses to predict each outcome and compared with SI and SIPA.A total of 604,931 patients with a mean age of 11.1 years old were included. A minority of patients had a penetrating injury mechanism (5.6%) and the mean Injury Severity Score was 7.6. The mean SI and rSIG scores were 0.85 and 18.6, respectively. Reverse shock index multiplied by Glasgow Coma Scale performed better than SI and SIPA at predicting early trauma outcomes for the overall population, regardless of age.Reverse shock index multiplied by Glasgow Coma Scale outperformed SI and SIPA in the early identification of traumatically injured children at risk for early interventions, such as blood transfusion within 4 hours, intubation, intracranial pressure monitoring, and intensive care unit admission. Reverse shock index multiplied by Glasgow Coma Scale adds neurological status in initial patient assessment and may be used as a bedside triage tool to rapidly identify pediatric patients who will likely require early intervention and higher levels of care.Prognostic, level III.

Most children in the US live more than one hour from a Level 1 PTC. The Need For Trauma Intervention (NFTI) score was developed to assess trauma triage criteria and is dependent on whether someone requires one of six urgent interventions (NFTI+). We sought to determine if a novel scoring tool, rSIG, could predict NFTI and facilitate the transfer decision making process.Children 1-18 years old transferred to our level 1 PTC from 2010 - 2020 with complete vital signs and Glasgow Coma Scale (GCS) score at the transferring facility were included. rSIG was calculated as previously described [(SBP/HR) x GCS], and the following cutoffs were used for each age group: ≤13.1, ≤16.5, and ≤20.1 for 1-6, 7-12, and 13-18 years, respectively. Clinical outcomes upon arrival to the PTC were collected to determine if patients met any NTFI criteria.A total of 456 patients met inclusion criteria. The proportion of patients with an abnormal rSIG was 60.1% (274) and 37.0% (169) were NFTI+. Patients with an abnormal rSIG had an odds ratio of 6.18 (95% CI: 3.90, 10.07), p 0.001 of being NFTI+ compared to those with a normal rSIG.Children with an abnormal rSIG are more likely to be NFTI+ and require higher levels of care, indicating this scoring tool can identify pediatric trauma patients who may benefit from expedited transfer. Incorporating rSIG into initial evaluation and triage of traumatically injured children may expedite the transfer decision making process and limit delays in transport to a PTC.Retrospective Comparative Study LEVEL OF EVIDENCE: III.

Background Hemorrhage is the leading cause of preventable death in pediatric trauma patients. In adults, goal-directed thrombelastography (TEG) has been shown to reduce mortality when used to guide massive transfusion (MT) resuscitation. There remains a paucity of data on the utility of TEG in directing resuscitation of pediatric trauma patients. We hypothesize that abnormalities on admission TEG will differ in pediatric trauma patients who undergo MT, compared to those who do not. Methods Pediatric patients (≤ 18 years) who were highest level trauma activations at two trauma centers from 2015 to 2018 were analyzed. We included patients who had admission TEGs and excluded those who did not. Patients were stratified into two groups: those who received MT (> 40 cc/kg total blood product within 6 h of admission) and those who did not. We defined TEG abnormalities based on each institution’s normative values and compared TEG abnormalities between the groups. Results Of 117 children included, 39 had MT. MT patients had higher injury severity scores (30 vs. 23, p = 0.0004), lactates levels (7.0 vs. 3.5, p

Early and accurate identification of pediatric trauma patients who will receive massive transfusion (MT) is not well established. We developed the ABCD (defined as penetrating mechanism, positive focused assessment with sonography for trauma, shock index, pediatric age-adjusted [SIPA], lactate, and base deficit [BD]) and BIS scores (defined as a combination of BD, international normalized ratio [INR], and SIPA) and hypothesized that the BIS score would perform best in the ability to predict the need for MT in children.Pediatric trauma patients (≤18 years old) admitted to our trauma center between 2008 and 2019 were identified. Using a receiver operator curve, we defined cutoff points for lactate (≥3.2), BD (≤-6.9), and INR (≥1.4). ABCD scores were calculated by combining penetrating mechanism; positive focused assessment with sonography for trauma examination; SIPA; lactate; and BD. BIS scores were calculated by combining BD, INR, and SIPA. The sensitivity, specificity, and accuracy of each score were calculated based on receiving MT.Seven hundred seventy-two patients were included, of which 59 (7.6%) underwent MT. The best predictor of receiving MT was achieved by a BIS score of ≥2 that was 98% sensitive and 23% specific with an area under the curve of 0.81. The ABCD score of ≥2 was 97% sensitive and 20% specific with an area under the curve of 0.77.The BIS score, which takes into account derangements in acidosis, coagulopathy, and SIPA, is accurate and easy to perform and can be incorporated into a simple bedside screening tool for triggering MT in pediatric trauma patients.Diagnostic Tests or Criteria, Level IV.

Thrombelastography (TEG) has emerged as a useful tool to diagnose coagulopathy and guide blood product usage during trauma resuscitations. This study sought to evaluate the correlation between TEG-directed blood product administration in severely injured pediatric trauma patients with blunt solid organ injuries (BSOIs).Patients (≤18 years) with severe BSOIs who presented as highest-level trauma activations at two pediatric trauma centers were included. Thrombelastography results were evaluated to determine indications for blood product administration and rates of TEG-directed resuscitation. Tetrachoric correlations and regression modeling were used to correlate TEG-directed resuscitation with clinical outcomes.Of 64 patients who met the inclusion criteria, 32.8% (21) had elevated R times and 23.4% (15) had shortened α angles. Maximum amplitude was shortened in 29.7% (19), and percent clot lysis 30 minutes after maximum amplitude that is3% was seen in 17.0% (9). Thrombelastography-directed resuscitation of fresh frozen plasma was followed 54.7% of the time compared with 67.2% and 81.2% for platelets and cryoprecipitate, respectively. Thrombelastography-directed resuscitation with platelets (odds ratio, 0.56; 95% confidence interval, 0.33-0.93; p = 0.03) and/or cryoprecipitate (odds ratio, 0.09; 95% confidence interval, 0.01-0.42, p = 0.003) were associated with decreased hospital length of stay and mortality, respectively.Severely injured pediatric trauma patients with BSOIs were often coagulopathic upon presentation to the emergency department. Thrombelastography-directed resuscitation with platelets and/or cryoprecipitate was followed for the majority of patients and was associated with improved outcomes.Therapeutic/Care Management, level III.

Introduction Many children with gastric feeding intolerance require postpyloric tube feeding via a gastrojejunal (GJ) tube. Placement or positioning of these tubes is typically a procedure with a low dose of radiation. Although the risk of developing cancer from radiation exposure owing to computed tomography scans is well-documented in children, the risk of cumulative radiation exposure owing to frequent GJ tube replacement often goes unnoticed in the clinical decision-making process. We sought to define the frequency and cost of GJ tube replacement, quantify the radiation doses associated with the initial placement and replacements, and assess the number of conversions to surgical jejunostomies. Methods All pediatric patients who underwent GJ tube placement or replacement by Interventional Radiology (IR), surgery, and gastroenterology between 2010 and 2018 at a single center were reviewed. We evaluated the total cost of the initial placement and replacement of each GJ tube, the total number of replacements, and the cumulative radiation dose (mGy). Results We identified 203 patients who underwent GJ tube placement and/or replacement, of which 150 had radiation data available. Patients underwent a median of five GJ tube replacement procedures, and there was a wide range in the number of replacements per patient, from zero to 88. Patients were exposed to a median cumulative dose of 6.0 mGy (IQR: 2.2, 22.6). Nine percent of patients with available radiation data were exposed to more than 50 mGy, solely from GJ tube replacements. The median cost per replacement was $1170. The sum of the cost of the replacements for dislodged GJs translated to more than $1.4 million during the study period. Conclusions Overall, the average dose per GJ replacement was 3.50 mGy among all patients with available data. Nine percent of patients (14/150) were exposed to greater than 50 mGy cumulative radiation solely from GJ replacements. Patients who receive more than 50 mGy of cumulative radiation dose, who undergo seven GJ tube replacements in one year, or two consecutive GJ tube replacement procedures with radiation doses exceeding 10 mGy (per replacement) should be considered for a surgical jejunostomy. Level of evidence IV Type of study Treatment study.

The role of non-invasive measures of physiologic reserve, specifically the Compensatory reserve index (CRI) and the Shock index pediatric age-adjusted (SIPA), is unknown in the management of children with acute appendicitis. CRI is a first-in-class algorithm that uses pulse oximetry waveforms to continuously monitor central volume status loss. SIPA is a well-validated, but a discontinuous measure of shock that has been calibrated for children. Children with suspected acute appendicitis (2–17 years old) were prospectively enrolled at a single center from 2014 to 2015 and monitored with a CipherOx CRI™ M1 pulse oximeter. CRI values range from 1 (normovolemia) to 0 (life-threatening hypovolemia). SIPA is calculated by dividing heart rate by systolic blood pressure and categorized as normal or abnormal, based on age-specific cutoffs. Univariate and multivariable regression models were developed with simple versus perforated appendicitis as the outcome. Almost half the patients (45/94, 48%) had perforated appendicitis. On univariate analysis, the median admission CRI value was significantly higher (0.60 versus 0.33, p

Shock index-pediatric age-adjusted (SIPA) is a proven tool to predict outcomes in blunt pediatric trauma. We hypothesized that an elevated SIPA in either the pre-hospital or in the emergency department (ED) would identify children with blunt liver or spleen injury (BLSI) needing a blood transfusion and those at risk for failure of non-operative management (NOM).Pediatric patients (1-18 years) in the ACS pediatric-TQIP database (2014-2016) with a BLSI were included. Patients were stratified by the need for a blood transfusion and/or abdominal operation.A total of 3561 patients had BLSI, of which 4% received a blood transfusion, and 4% underwent an abdominal operation. Patients who received blood had higher ISS scores (27.0 vs. 5.0, p 0.001) and mortality (22% vs. 0.4%, p 0.001). Those who failed NOM had higher ISS scores (17.0 vs. 5.0, p 0.001) and mortality (7.9% vs. 0.9%, p 0.001). On multivariable regression, an elevated SIPA score in either pre-hospital or ED was significantly associated with blood transfusion (odds ratio (OR) 8.2, 95% confidence intervals (CI) 5.8-11.5, p 0.001) and failure of NOM (OR 2.3, CI 1.5-3.4, p 0.001).Hemodynamic instability, represented by an elevated pre-hospital or ED SIPA, accurately identifies children with BLSI who may need blood products or an operative intervention.Retrospective Comparative Study.Level III.

Background The principal triggers for intervention in the setting of pediatric blunt solid organ injury (BSOI) are declining hemoglobin values and hemodynamic instability. The clinical management of BSOI is, however, complex. We therefore hypothesized that state-of-art machine learning (computer-based) algorithms could be leveraged to discover new combinations of clinical variables that might herald the need for an escalation in care. We developed algorithms to predict the need for massive transfusion (MT), failure of non-operative management (NOM), mortality, and successful non-operative management without intervention, all within 4 hours of emergency department (ED) presentation. Methods Children (≤ 18 years) who sustained a BSOI (liver, spleen, and/or kidney) between 2009 and 2018 were identified in the trauma registry at a pediatric level 1 trauma center. Deep learning models were developed using clinical values [vital signs, shock index-pediatric adjusted (SIPA), organ injured, and blood products received], laboratory results [hemoglobin, base deficit, INR, lactate, thromboelastography (TEG)], and imaging findings [focused assessment with sonography in trauma (FAST) and grade of injury on computed tomography scan] from pre-hospital to ED settings for prediction of MT, failure of NOM, mortality, and successful NOM without intervention. Sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve (AUC) were used to evaluate each model's performance. Results A total of 477 patients were included, of which 5.7% required MT (27/477), 7.2% failed NOM (34/477), 4.4% died (21/477), and 89.1% had successful NOM (425/477). The accuracy of the models in the validation set was as follows: MT (90.5%), failure of NOM (83.8%), mortality (91.9%), and successful NOM without intervention (90.3%). Serial vital signs, the grade of organ injury, hemoglobin, and positive FAST had low correlations with outcomes. Conclusion Deep learning-based models using a combination of clinical, laboratory and radiographic features can predict the need for emergent intervention (MT, angioembolization, or operative management) and mortality with high accuracy and sensitivity using data available in the first 4 hours of admission. Further research is needed to externally validate and determine the feasibility of prospectively applying this framework to improve care and outcomes. Level of Evidence III Study Type Retrospective comparative study (Prognosis/Care Management).

Background Firearm injuries are the second leading cause of death among US children. While injury prevention has been shown to be effective for blunt mechanisms of injury, the rising incidence of accidental gunshot wounds, school shootings, and interpersonal gun violence suggests otherwise for firearm-related injuries. The purpose of the study is to describe the incidence, injury severity, and institutional costs of pediatric gun-related injuries in Colorado. Methods Pediatric patients (≤18 years), who sustained firearm injuries between 2008 and 2018, were identified from the trauma registries of three pediatric trauma centers in Colorado. Patients were stratified based on age: those younger than 14 years were defined as children and those 15 years to 18 years as adolescents. Results Our cohort (n = 308) was predominantly male (87%), with a median age of 14 years. The overall mortality rate was 11% (34/308), with significantly fewer children (5%) dying from their injuries when compared with adolescents (14%; p = 0.04). Sixty-five (21%) patients required blood product transfusions, with 23 (7.4%) patients receiving a massive transfusion. Overall, 52% (161/308) required a major operation, with 15% undergoing an exploratory laparotomy. One third (4/13) of the patients who had a thoracotomy in the emergency department survived to hospital discharge. Overall, 14.0% of patients had psychiatric follow-up at both 30 days and 1 year. The readmission rate for complications was 11.6% at 30 days and 14% at 1 year. The total cost of care for all pediatric firearm-related injuries was approximately US $26 million. Conclusion The survivors of pediatric firearm injuries experience high operative and readmission rates, sustain long-term morbidities, and suffer from mental health sequelae. Combining these factors with the economic impact of these injuries highlights the immense burden of disease. This burden may be palliated by a multipronged approach, which includes the development and dissemination of injury prevention strategies and better follow-up care for these patients. Level of evidence Epidemiological, Level III.

Pediatric traumatic vascular injuries are rare. Given the paucity of data to guide anti-coagulation (AC) management of these injuries in children, who have a lower overall risk for thrombosis compared to their adult counterparts, we sought to examine and summarize our recent experience.We conducted a retrospective review of all patients (18 years old) who sustained traumatic vascular injuries between 2010-2018 at a Level 1 and Level 2 Pediatric Trauma Center.Ninety-nine patients had traumatic vascular injuries. Eighty-four patients sustained a major arterial injury, 26 had a major venous injury, and 11 had both arterial and venous injuries. The arterial injury cohort had a median age of 13.3 years. Most of the arterial injury patients (65/84, 77%) required vascular repair. In-hospital AC management for the arterial injury patients consisted of a post-operative heparin drip (18%, 15/84), aspirin (39%, 26/84), enoxaparin (23%, 19/84), or none (42%, 43/84). Approximately one-half of the patients with arterial injuries (54%, 45/84) were discharged home on AC therapy, most commonly aspirin. Fifty-six patients (66%) followed up post-injury, of which 25% (14/56) had experienced complications.Pediatric traumatic arterial injuries that require surgical intervention other than ligation should be considered for discharge AC - most commonly aspirin - in the absence of contraindications. Pediatric patients with vascular injuries to the aorta, carotid artery, inferior vena cava, portal vein, or lower extremities that are managed non-operatively should also be considered for AC. The preferred AC for pediatric venous injuries is enoxaparin, in the absence of contraindications.Treatment Study LEVEL OF EVIDENCE: IV.

Packed red blood cell (PRBC) transfusion is a lifesaving intervention that also has proinflammatory and immunosuppressive effects. Adults with a malignancy who receive PRBC transfusion have increased rates of infection, tumor recurrence, and decreased survival. The effect of PRBC transfusion among children with solid tumors is unknown.We performed a retrospective review of all children who underwent operative resection of a solid tumor malignancy. Data collected included demographic information, location of operation, nadir hemoglobin, and any PRBC transfusion within 30 days of tumor resection.Three hundred sixty children underwent tumor resection at our institution between 2002 and 2013; 194 (54%) received a perioperative blood transfusion. After adjusting for stage at diagnosis, tumor location, preoperative chemotherapy and nadir hemoglobin, blood transfusion was associated with a higher rate of postoperative infectious complications, shorter disease-free interval, and a higher rate of tumor recurrence. Each additional transfused unit increased the risk of postoperative infection (odds ratio 3.83; 95% confidence interval 1.21, 14.22, P=0.031).Among children with solid tumor malignancies, PRBC transfusion within 30 days of operation is associated with higher rates of postoperative infection. If transfusion becomes necessary, single unit increments should be transfused.Level III.

Cardiac injuries are rare in pediatric trauma patients and data regarding this type of injury is limited. There is even less data on traumatic great vessel injuries. This study sought to examine and summarize our recent experience at two pediatric trauma centers, which serve a major metropolitan area and large geographic region.This is a retrospective review of pediatric (18 years) patients who sustained cardiac or great vessel injuries and were managed at a Level 1 or Level 2 pediatric trauma center between January 1, 2010 and June 30, 2020. Demographic and clinical characteristics were compared using two-sample t-tests, Wilcoxon Rank-Sum tests, Fisher's exact tests and chi-squared tests for continuous, non-normally distributed continuous, and categorical variables, respectively.A total of 53 patients sustained cardiac and/or great vessel injuries. Of these, 37 (70%) sustained cardiac, 9 (17%) sustained great vessel, and 7 (13%) sustained both types of injuries. The median age was 14.9 years and 74% (n = 39) were male. The median injury severity score (ISS) was 36.0 and the injury mechanism was blunt in 31 (58%) patients. The most common cardiac and great vessel injury locations were left ventricle (n = 9) and thoracic aorta (n = 11), respectively. The overall mortality rate was 53% (n = 28). Mortality was highest among those who sustained great vessel injuries (89%).There is substantial heterogeneity in cardiac and great vessel injuries. Regardless, they are highly morbid and lethal, despite aggressive surgical and catheter-based interventions.

Adolescents with blunt solid organ injuries (BSOI) are cared for at both pediatric trauma centers (PTC) and adult trauma centers (ATC). Over the past decade, treatment strategies have shifted towards non-operative management with reported favorable outcomes. The aim of this study was to compare management strategies and outcomes between PTC and ATC.We queried the 2016-2018 Trauma Quality Improvement Program (TQIP) datasets to identify adolescents between the ages of 16 and 19 with BSOI. Characteristics were stratified by center type (pediatric or adult) for comparative analyses. Separate logistic regressions were used to assess the association of hospital type, location of injury, age, gender, weight, Glascow Coma Score (GCS), Injury Severity Score (ISS), and intensive care unit (ICU) admissions for outcomes of interest.Among the 3,011,310 patients enrolled in the 2016-2018 TQIP datasets, 106,892 (3.5%) had a BSOI ICD9/10 code. Of those, 9,193 (8.6%) were between 16 and 19 years of age and included in this analysis. Within this cohort, 6,073 (66.1%) were managed at an ATC and 3,120 (33.9%) were managed at a PTC. While statistically different, there were no clinically relevant differences for age, weight, and sex between groups. A significantly higher ISS and lower GCS score were observed among those admitted to ATC compared to PTC. ICU admissions were more frequent at ATC. Number of blood transfusions by 4 h after presentation were also higher among those admitted to an ATC. Despite a lower ISS and higher GCS at presentation, mortality was higher among those treated at a PTC with an odds ratio (95% confidence interval) of 2.42 (1.31-4.53). After excluding adolescents with a traumatic brain injury, a common cause of mortality among adolescent trauma patients, these differences in outcomes persisted.Our data suggest that adolescents with BSOI managed at a PTC are less likely to receive blood transfusions by 4 h of admission or be admitted to the ICU than those managed at an ATC. However, this more conservative approach may come at the expense of higher overall mortality. Further work is needed to understand these differences and determine if PTC need to be more aggressive in managing BSOI.

BACKGROUND Blunt cerebrovascular injuries (BCVI) are uncommon but potentially devastating. The epidemiology, outcomes, and screening criteria are well described in adults, but data in pediatric patients are extremely limited. The purpose of this study was to characterize pediatric BCVI in a large nationwide sample. We hypothesized that outcomes of BCVI in the pediatric blunt trauma population will vary by age. METHODS We conducted a retrospective cohort study of the Kids' Inpatient Database for pediatric BCVI from 2000 to 2012. Epidemiology, associated injuries, outcomes (including stroke and mortality), and the utility of standard screening criteria were analyzed. RESULTS There were 1,182 cases of BCVI identified, yielding an incidence of 0.21%. Patients were predominately male (69%; mean age, 15 ± 5 years). Injuries were 59% carotid, 13% vertebral, and 28% unspecified, with 15% having bilateral or multivessel BCVI. Although younger patients (

This article describes the different levels of trauma center designation in the United States and focuses on the pediatric trauma centers in the state of Colorado. These urban centers serve a large geographic area that is characterized by rugged mountains, wide open plains and rapidly changing weather patterns. Critical care ground and aeromedical transport are utilized for severely injured children and the quality of care, from initial management in the feld until discharge from the hospital, is critically evaluated by a robust trauma performance improvement (PI) program. The PI program uses audit flters, data analytics and bench-marking to continuously evaluate the network of care to optimize outcomes.

Background/Purpose: Typhlitis is uncommon but can be life-threatening in pediatric cancer patients. The cornerstone is medical management (MM), with surgical intervention reserved for clinical deterioration and/or bowel perforation. We hypothesized that trends in the Shock Index, Pediatric Age-Adjusted (SIPA) and white blood cell (WBC) count could alert practitioners to those patients at greatest risk for surgical intervention and mortality …

The American College of Surgeons (ACS) Committee on Trauma targets undertriage (UT) rates of5% to optimize the chances of survival. The Cribari Matrix (CM) has traditionally been employed to identify undertriage, but it likely overestimates actual undertriage. An innovative tool called "Need For Trauma Intervention" (NFTI), demonstrates a more accurate assessment of undertriage in adults. We hypothesized that using the combination of CM and NFTI would more accurately identify UT in pediatric trauma patients, compared to CM alone.We reviewed undertriage rates using CM and NFTI criteria. Univariate analysis was used to compare the need for surgical management, transfusion requirements, ventilator days, ICU length of stay (LOS), hospital LOS, and hospital costs between CM, NFTI, and the combination of CM and NFTI.Undertriage rates were 8.2% with CM and 4.6% with NFTI. When CM and NFTI were combined, the UT rate was 2.7%. Pediatric patients categorized as UT by the combination of CM and NFTI had significantly longer ICU Length of Stay (LOS) (p 0.001), hospital LOS (p 0.001), higher mortality rates (p = 0.004), and higher hospitalization costs (p 0.001).The combination of CM and NFTI identified UT in children, more accurately than CM or NFTI alone. Injured children who are undertriaged had higher mortality, morbidity, and cost of care. The use of CM in combination with NFTI to evaluate undertriage rates led to the identification of risk factors that may modify the activation criteria for highest and modified level trauma team activations.III STUDY TYPE: Retrospective study without negative criteria (Therapeutic/Care Management).

Background The elevated shock index, pediatric age-adjusted (SIPA) has been found to accurately predict the need for blood transfusion in severely injured children. We sought to determine the utility of monitoring sequential SIPA values from the prehospital setting through the emergency department to identify children with a blunt liver or spleen injury who will require a blood transfusion. Methods We conducted a retrospective review of children 1 to 18 years old admitted to a level-1 pediatric trauma center with any grade blunt liver or spleen injury between 2009 and 2019. Cohorts were stratified into those who received a blood transfusion within the first 24 hours after injury and those who did not. Results A total of 477 children had a blunt liver or spleen injury during the study period, of which 20% (95 of 477) received a blood transfusion within 24 hours of trauma center arrival. Of those who received a blood transfusion, 75% (71 of 95) were transfused within 6 hours of arrival at our center. Nearly 90% (84 of 95) of patients who received blood had at least 1 elevated SIPA score in either setting (prehospital or emergency department). Based on multivariable regression, an elevated SIPA score in either setting was significantly associated with blood transfusion (odds ratio 7.8 (confidence interval 4.7–12.9, P = .002). Conclusion Elevated SIPA values in the prehospital setting and on emergency department arrival are associated with early blood transfusion. The importance of this finding is that after serial SIPA values may assist in the early identification of children with blunt liver or spleen injury who will require a blood transfusion.

Purpose Early and accurate identification of pediatric trauma patients who will require massive transfusion (MT) remains difficult, and MT activation criteria are not well established. In children, the addition of shock index-pediatric age-adjusted (SIPA) to the ABC score (ABC-S) only modestly improves the sensitivity of the ABC score. We hypothesized that the discriminate ability of the ABC-S score would improve with the addition of elevated serum lactate and base deficit (ABCD score). Methods We identified children between 1 and 18 years old who received a pRBC transfusion between 2008 and 2018 from our trauma registry. We calculated sensitivity, specificity, and accuracy of the ABC, ABC-S, and ABCD scores to determine the need for MT. Results We included 211 children, of which 66 required MT. The best predictor of MT was achieved by adding BD and lactate to the ABC-S score, with an AUC of 0.805. An ABCD score of 3 or greater was 77.4% sensitive and 78.8% specific at predicting the need for MT. Pediatric trauma patients that required MT had higher injury severity score (p = 0.005), lactate (p = 0.002), base deficit (p = Conclusions The ABCD score improves the sensitivity of activating MT in pediatric trauma patients. Study Type Treatment Study. Level of Evidence Level III.

Introduction The rapid response team (RRT) is a multidisciplinary team who evaluates hospitalized patients for concerns of nonemergent clinical deterioration. RRT evaluations are mandatory for children whose Pediatric Early Warning System (PEWS) score (assessment of child's behavior, cardiovascular and respiratory status) is ≥4. We aimed to determine if there were differences in characteristics of RRT calls between children who were admitted primarily to either medical or surgical services. We hypothesized that RRT activations would be called for less severely ill children with lower PEWS score on surgical services compared with children admitted to a medical service. Materials and Methods We performed a retrospective review of all children with RRT activations between January 2008 and April 2015 at a tertiary care pediatric hospital. We evaluated the characteristics of RRT calls and made comparisons between RRT calls made for children admitted primarily to medical or surgical services. Results A total of 2,991 RRT activations were called, and 324 (11%) involved surgical patients. Surgical patients were older than medical patients (median: 7 vs. 4 years; p p p p = 0.412). RRT evaluations did not differ between day and night shifts (52% day vs. 48% night; p = 0.17). All surgical patients and all but one medical patient survived the event; surgical patients were more likely to survive to hospital discharge (97 vs. 91%, p Conclusions RRT activations are rare events among pediatric surgical patients. When compared with medical patients, RRT evaluation is requested for surgical patients with a lower PEWS score and these children are less likely to require transfer to a higher level of care, suggesting that pediatric surgery team, families, and nursing staff may not be as comfortable with clinical deterioration.

BACKGROUND Pediatric trauma centers (PTCs) are concentrated in urban areas, leaving large areas where children do not have access. Although adult trauma centers (ATCs) often serve to fill the gap, disparities exist. Given the limited workforce in pediatric subspecialties, many adult centers that are called upon to care for children cannot sufficiently staff their program to meet the requirements of verification as a PTC. We hypothesized that ATCs in collaboration with a PTC could achieve successful American College of Surgeons (ACS) verification as a PTC with measurable improvements in care. This article serves to provide an initial description of this collaborative approach. METHODS Beginning in 2008, a Level I PTC partnered with three ATC seeking ACS-PTC verification. The centers adopted a plan for education, simulation training, guidelines, and performance improvement support. Results of ACS verification, patient volumes, need to transfer patients, and impact on solid organ injury management were evaluated. RESULTS Following partnership, each of the ATCs has achieved Level II PTC verification. As part of each review, the collaborative was noted to be a significant strength. Total pediatric patient volume increased from 128.1 to 162.1 a year (p = 0.031), and transfers out decreased from 3.8% to 2.4% (p = 0.032) from prepartnership to postpartnership periods. At the initial ATC partner site, 10.7 children per year with solid organ injury were treated before the partnership and 11.8 children per year after the partnership. Following partnership, we found significant reductions in length of stay, number of images, and laboratory draws among this limited population. CONCLUSION The collaborative has resulted in ACS Level II PTC verification in the absence of on-site pediatric surgical specialists. In addition, more patients were safely cared for in their community without the need for transfer with improved quality of care. This paradigm may serve to advance the care of injured children at sites without access to pediatric surgical specialists through a collaborative partnership with an experienced Level I PTC. Further risk-adjusted analysis of outcomes will need to be performed in the future. LEVEL OF EVIDENCE Therapeutic/care management, level IV.

Central venous catheters (CVC) are vital to the management of critically ill children. Despite efforts to minimize complications, central line associated bloodstream infection (CLABSI) and venous thromboembolisms (VTE) still occur.We performed a retrospective review of a prospectively collected database for children admitted to the pediatric intensive care unit (PICU) between November 2013 and December 2016.In total, 2714 CVC were in place, 979 of which were percutaneous CVC. During the study period, 21 CLABSI (1.6/1000 line days) were identified, of which, nearly half (n = 9, 42.9%) were associated with percutaneous CVC (2.6/1000 line days). Poisson regression analysis did not identify a single risk factor for CLABSI when adjusting for line type, anatomic location and laterality of placement, geographic location of placement, length of PICU admission, presence of gastrostomy tube, concurrent mechanical ventilation, age, weight, and height. Forty clinically significant VTE (2.9/1000 line days) were identified, with percutaneous CVC having the highest incidence (7.5/1000 line days, p 0.001). Of percutaneous CVC, clinically significant VTE were more often associated with femoral vein cannulation (14.8/1000 line days) compared to internal jugular and subclavian vein (2.5 and 2.4/1000 line days, respectively, p 0.001).This data suggests that the femoral site may be an important risk factor that should be considered in prevention strategies for catheter-associated VTE in children.III.

The utility of EDT in the adult trauma population, using well-defined guidelines, is well established, especially for penetrating injuries. Since the introduction of these guidelines, reports on the use of EDT for pediatric trauma have been published, and these series reveal a dismal, almost universally fatal, outcome for EDT following blunt trauma in the child. This report reviews the clinical outcomes of EDT in the pediatric population. We performed a review of EDT in the pediatric population using the published data from 1980 to 2017. Variables extracted included mechanism of injury and mortality. To minimize bias, single case reports were not included in the review. Upon review of four decades of published literature on the use of emergency department thoracotomy (EDT) in the pediatric population, mortality rates are comparable between adults and pediatric patients for penetrating thoracic trauma. In contrast, in pediatric patients sustaining blunt trauma, no patient under the age of 15 has survived. In patients between 0 and 14 years of age presenting with no signs of life following blunt trauma, withholding EDT should be considered. Patients between the ages of 15 and 18 should be treated in accordance with adult ATLS principles for the management of thoracic trauma. Level IV

Current management protocols for children with blunt solid organ injury to the liver and spleen call for serial monitoring of the child's hemoglobin and hematocrit every 6, 12, or 24 hours, depending on the injury grade. We hypothesized that children who require emergent intervention in the form of laparotomy, angioembolization, or packed red blood cell (PRBC) transfusion because of bleeding from a solid organ injury will have changes in their vital signs that alert the clinician to the need for intervention, making scheduled laboratory evaluation unnecessary.We performed a retrospective review of all children admitted to either of two pediatric trauma centers following blunt trauma with any grade liver or spleen injury from January 2009 to December 2013. Data evaluated include a need for intervention, indication for intervention, and timing of intervention.A total of 245 children were admitted with blunt liver or spleen injury. Six patients (2.5%) underwent emergent exploratory laparotomy for hypotension a median of 4 hours after injury (range, 2-4 hours), four of who required splenectomy. No child required laparotomy for delayed bleeding from a solid organ injury. One child (0.4%) underwent angioembolization for blunt splenic injury. Forty-one children (16.7%) received a PRBC transfusion during hospitalization, 32 of whom did not undergo laparotomy or angioembolization. Children who underwent an intervention had a lower nadir hematocrit (median, 22.9 vs. 32.8; p0.0001), longer time from injury to nadir hematocrit (median, 35.5 vs. 16 hours; p0.0001), and more total blood draws for hemoglobin and hematocrit monitoring (median, 20 vs. 5; p0.0001).Among children with blunt liver or spleen injury, a need for emergent intervention in the form of laparotomy or PRBC transfusion for hemorrhagic shock occurs within the first 24 hours of injury. Ongoing, scheduled monitoring of serum hemoglobin and hematocrit values may not be necessary.Retrospective study with no negative criteria, prognostic study, level III.

We have previously demonstrated that a shock index, pediatric age adjusted (SIPA) accurately identifies severely blunt injured children. We aimed to determine if SIPA could more accurately identify children with severe traumatic brain injury (TBI) than hypotension alone. We performed subset analysis of those children with TBI among a cohort of children age 4–16 years with blunt trauma and injury severity score ≥15 from 1/07 to 6/13. We evaluated the ability of four markers to identify the most severely brain injured children. Markers included hypotension, elevated SIPA, abnormal GCS motor score (GMS), and elevated SIPA or abnormal GMS. We aimed to determine which of these four markers had the highest sensitivity in identifying severely injured children. Three hundred and ninety-two (392) children were included. Hypotension was present in 24 patients (6 %); elevated SIPA in 106 (27 %), abnormal GMS in 172 (44 %), and elevated SIPA or abnormal GMS in 206 (53 %). All markers were able to accurately identify severely injured children with TBI. Elevated SIPA or abnormal GMS identified a greater percentage of patients with each of seven complications with higher sensitivity than each of the three other markers. Among blunt injured children with TBI, elevated SIPA or abnormal GMS identifies severely brain injured children.

BACKGROUND: Abusive head trauma (AHT) is a significant cause of morbidity and mortality in the pediatric population. We aimed to assess the social and legal outcomes of AHT and determine if the rates of successful prosecution have changed over recent years. METHODS: We utilized the trauma database at a single institution to identify all cases of AHT during two time periods: 1996-2001 and 2006-2010 then collected data from the Child Advocacy and Protection Team database. We characterized the social and legal outcomes and compared them between the two cohorts. RESULTS: A total of 254 patients (120 historic and 134 modern cohort) were included. Mortality rate was 19.7% and did not differ between the two cohorts. Thirty-seven percent of patients were discharged to foster care, this rate did not change across the two time periods. Suspected perpetrators pled guilty or were found guilty in only 74 cases (29%). However, when a case involved a fatality, perpetrators pled or were found guilty more often than in cases of a non-fatality (50 vs. 21.5%; p=0.0001). CONCLUSIONS: AHT results in fatality in approximately 1 in 5 cases, perpetrators are identified and found guilty in only 29% of the cases. Trauma surgeons need to be strong advocates for these vulnerable patients and actively participate in legal proceedings. Language: en

Introduction Shock index (SI) (heart rate/systolic blood pressure) >0.9 predicts mortality in adult trauma patients. We hypothesized that age adjusted SI could more accurately predict outcomes in children. Methods Retrospective review of children age 4–16years admitted to two trauma centers between 1/07 and 6/13 following blunt trauma with an injury severity score (ISS) >15 was performed. We evaluated the ability of SI >0.9 at emergency department presentation and elevated shock index, pediatric age adjusted (SIPA) to predict outcomes. SIPA was defined by maximum normal HR and minimum normal SBP by age. Cutoffs included SI >1.22 (age 4–6), >1.0 (7–12), and >0.9 (13–16). Results Among 543 children, 50% of children had an SI>0.9 but this fell to 28% using age adjusted SI (SIPA). SIPA demonstrated improved discrimination of severe injury relative to SI: ISS>30: 37% vs 26%; blood transfusion within the first 24hours: 27% vs 20%; Grade III liver/spleen laceration requiring blood transfusion: 41% vs 26%; and in-hospital mortality: 11% vs 7%. Conclusion A pediatric specific shock index (SIPA) more accurately identifies children who are most severely injured, have intraabdominal injury requiring transfusion, and are at highest risk of death when compared to shock index unadjusted for age.

BACKGROUND Acute appendicitis is the most common emergent surgical procedure performed among children in the United States, with an incidence exceeding 80,000 cases per year. Appendectomies are often performed by both pediatric surgeons and adult general/trauma and acute care (TACS) surgeons. We hypothesized that children undergoing appendectomy for acute appendicitis have equivalent outcomes whether a pediatric surgeon or a TACS surgeon performs the operation. METHODS A retrospective chart review was performed for patients 6 to 18 years of age, who underwent appendectomy at either a regional children's hospital (Children's Hospital of Colorado [CHCO], n = 241) or an urban safety-net hospital (n = 347) between July 2010 and June 2015. The population of patients operated on at the urban safety-net hospital was further subdivided into those operated on by pediatric surgeons (Denver Health Medical Center [DHMC] pediatric surgeons, n = 68) and those operated on by adult TACS surgeons (DHMC TACS, n = 279). Baseline characteristics and operative outcomes were compared between these patient populations utilizing one-way analysis of variance and χ test for independence. RESULTS When comparing the CHCO and DHMC TACS groups, there were no differences in the proportion of patients with perforated appendicitis, operative time, rate of operative complications, rate of postoperative infectious complications, or rate of 30-day readmission. Length of stay was significantly shorter for the DHMC TACS group than that for the CHCO group. CONCLUSIONS Our data demonstrate that among children older than 5 years undergoing appendectomy, length of stay, risk of infectious complications, and risk of readmission do not differ regardless of whether they are operated on by pediatric surgeons or adult TACS surgeons, suggesting resources currently consumed by transferring children to hospitals with access to pediatric surgeons could be allocated elsewhere. LEVEL OF EVIDENCE Therapeutic/Care management, level III.

Purpose In adults, shock index (SI; heart rate/systolic blood pressure) >0.9 predicts injury severity and trauma outcomes. However, age-adjusted shock index (SIPA) out-performs SI in blunt trauma patients 4–16years old. We sought to confirm these findings and expand this tool to include penetrating trauma and children aged 1–4years. Methods We developed cutoff values for patients 1–3years old using age-based vital signs and queried the 2014 Pediatric Trauma Quality Improvement Program (TQIP) database for patients aged 1–16years sustaining blunt or penetrating trauma. Outcomes measured included injury severity, transfusion within 24h, intensive care unit (ICU) and hospital length of stay (LOS), and mortality. SI and SIPA were compared using Student's t-test and chi-square tests. Results We identified 22,344 blunt and 613 penetrating trauma patients. SI was elevated in 41.3% and 40.0% of these groups, respectively, whereas SIPA was elevated in 15.6% and 19.4% of patients. SIPA was a significantly better predictor of transfusion needs, injury severity, ICU admission, ventilator use, and mortality for both blunt and penetrating trauma. Conclusion SIPA identifies severe injury and predicts transfusion needs and mortality more effectively than SI for both blunt and penetrating pediatric trauma. Further investigation should evaluate its use as a triage tool. Type of study Prognosis Study. Level of evidence II.

Introduction Excessive crystalloid resuscitation of blunt injured adults is deleterious. We hypothesize that children, unlike adults, are resistant to the adverse effects of high volume resuscitation. Methods We reviewed the trauma databases at two level-one trauma centers, including all children age 4–16years admitted following blunt trauma with an injury severity score (ISS) ≥15 to determine the relationship between crystalloid volume received and clinical outcomes. Results A total of 384 children were included. After controlling for age, sex, AIS head, ISS, GCS on presentation, hemoglobin, blood transfusion, and surgical procedures in the first 24hours, crystalloid volume greater than 60ml/kg in the first 24hours was associated with increased length of stay (LOS) and need for mechanical ventilation. On univariate analysis, initial crystalloid volume of >60ml/kg was associated with anemia and thrombocytopenia. Volume of resuscitation was not associated with ARDS, ACS, MOF, urinary tract infection, or blood stream infection. However, these complications were exceedingly rare, with no children developing MOF. Conclusions Excessive crystalloid resuscitation was associated with increased hospital LOS and need for mechanical ventilation. Increased rates of other complications including ARDS, ACS, and MOF were not observed. Injured children appear relatively resistant to some of the adverse effects of early high volume fluid resuscitation.

Our aim was to define the radiographic findings that help differentiate abusive head trauma (AHT) from accidental head injury. Our trauma registry was queried for all children ≤5 years of age presenting with traumatic brain injury (TBI) from 1996–2011. Of 2,015 children with TBI, 71 % had accidental injury and 29 % had AHT. Children with AHT were more severely injured (ISS 22.1 vs 14.4; p

BACKGROUND: A dramatic rise in nonoperative management of many blunt and some penetrating traumatic injuries has occurred during the past four decades. This trend has lead some to suggest that trauma is no longer a surgical disease. We questioned what role the trauma surgeon plays in the care of the injured patient. We hypothesized that surgical intervention and judgment are still often required in both injured children and adults. METHODS: We queried the trauma databases at two academic Level I trauma centers (adult and pediatric) for all patients admitted for trauma who underwent an inpatient operation between July 1, 2009, and June, 31, 2013, as well as those patients with ‘‘potentially operative injury.’’ Potentially operative injury was defined as the presence of liver or splenic laceration of any grade or hemothorax in patients who did not undergo an inpatient operation. For analysis, we divided patients into groups based on age. We differentiated infants (0Y1 years), toddlers (2Y5 years), school-aged children (6Y12 years), adolescents (13Y15 years), young adults (16Y21 years), adults (22Y40 years), middle-aged adults (41Y50 years), late middle-aged adults (51Y64 years), and elderly (965 years). Data collected included demographic information and number of operations performed in each patient based on surgical service (neurosurgery, trauma surgery, orthopedic surgery, and other surgical services). RESULTS: During this 4-year study period, 11,611 patients were admitted to the trauma service, 6,334 (54.6%) of whom underwent an inpatient operation and another 492 (4.2%) of whom had potentially operative injury. Across all age groups, orthopedic procedures accounted for the greatest percentage of inpatient procedures (970% of inpatient operations performed). Neurosurgical intervention accounted for less than 10% of inpatient surgical interventions, and general surgical procedures performed by trauma surgeons accounted for 17.1%. More than half of all general surgical procedures were performed in the patients who required a hospital stay of more than 7 days (67.2% among all patients). CONCLUSION: More than half of patients admitted following traumatic injury require operative intervention. This rate remains stable across all age groups. Our data emphasize the continued need for surgeons to stay engaged in the care of the trauma patient, particularly those most critically injured patients who will require prolonged hospital stay. (J Trauma Acute Care Surg. 2014;77: 219Y225. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Epidemiologic study, level III. Care management study, level IV.

BACKGROUND: The diagnosis of blunt abdominal trauma can be challenging and resource intensive. Observation with serial clinical assessments plays a major role in the evaluation of these patients, but the time required for intra-abdominal injury to become clinically apparent is unknown. The purpose of this study was to determine the amount of time required for an intra-abdominal injury to become clinically apparent after blunt abdominal trauma via physical examination or commonly followed clinical values. METHODS: A retrospective review of patients who sustained blunt trauma resulting in intra-abdominal injury between June 2010 and June 2012 at a Level 1 academic trauma center was performed. Patient demographics, injuries, and the amount of time from emergency department admission to sign or symptom development and subsequent diagnosis were recorded. All diagnoses were made by computed tomography or at the time of surgery. Patient transfers from other hospitals were excluded. RESULTS: Of 3,574 blunt trauma patients admitted to the hospital, 285 (8%) experienced intra-abdominal injuries. The mean (SD) age was 36 (17) years, the majority were male (194 patients, 68%) and the mean (SD) Injury Severity Score (ISS) was 21 (14). The mean (SD) time from admission to diagnosis via computed tomography or surgery was 74 (55) minutes. Eighty patients (28%) required either surgery (78 patients, 17%) or radiographic embolization (2 patients, 0.7%) for their injury. All patients who required intervention demonstrated a sign or symptom of their intra-abdominal injury within 60 minutes of arrival, although two patients were intervened upon in a delayed fashion. All patients with a blunt intra-abdominal injury manifested a clinical sign or symptom of their intra-abdominal injury, resulting in their diagnosis within 8 hours 25 minutes of arrival to the hospital. CONCLUSION: All diagnosed intra-abdominal injuries from blunt trauma manifested clinical signs or symptoms that could prompt imaging or intervention, leading to their diagnosis within 8 hours 25 minutes of arrival to the hospital. All patients who required an intervention for their injury manifested a sign or symptom of their injury within 60 minutes of arrival. (J Trauma Acute Care Surg. 2014;76:1020Y1023. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Therapeutic study, level IV. Epidemiologic study, level III.

BACKGROUND Blood transfusion has been associated with worse outcomes in adult trauma patients with traumatic brain injury (TBI). However, the effects in injured children have not been evaluated. We hypothesize that blood transfusion is also associated with worse outcomes in children with TBI. METHODS A retrospective review of the trauma database at two Level I pediatric trauma centers was performed. We reviewed all patients 18 years and younger with TBI, who survived at least 24 hours, from 2002 to 2011. Exclusion criteria include those who underwent craniotomy, thoracotomy, exploratory laparotomy, and any orthopedic procedure. RESULTS A total of 1,607 children with TBI were included in the study population (mean age, 6.4 [5.7] years; 65% male), 178 of whom received a blood transfusion. Mean Injury Severity Score (ISS) was 16.5 (9.1). Patients who received a transfusion had a higher ISS than those who did not (26.7 vs. 15.3). After controlling for age, sex, ISS, Glasgow Coma Scale (GCS) score on presentation, and mechanism of injury, patients who received a blood transfusion were more likely to be admitted to the intensive care unit (p < 0.0001), less likely to survive to hospital discharge (p = 0.02), more likely to be discharged to a rehabilitation facility (p = 0.01) and be dependent on caretakers at follow-up (p < 0.0001), as well as more likely to develop urinary tract infection (p = 0.02) and bacteremia (p = 0.02) during their hospital stay. These differences in outcomes among those who did and did not receive a blood transfusion began to disappear in patients with a nadir hemoglobin of less than 8.0 g/dL. CONCLUSION Pediatric patients sustaining TBI who receive blood transfusion and do not require operative intervention have worse outcomes compared with patients who do not receive transfusion. This includes an increased risk of death. These data suggest that a transfusion trigger of hemoglobin level at 8.0 g/dL in injured children with TBI may be beneficial. LEVEL OF EVIDENCE Epidemiologic study, level III. Therapeutic study, level IV.

BackgroundThe optimal time to initiate venous thromboembolism pharmacoprophylaxis after blunt abdominal solid organ injury is unknown.MethodsPostinjury coagulation status was characterized using thromboelastography (TEG) in trauma patients with blunt abdominal solid organ injuries; TEG was divided into 12-hour intervals up to 72 hours.ResultsForty-two of 304 patients (13.8%) identified underwent multiple postinjury thromboelastographic studies. Age (P = .45), gender (P = .45), and solid organ injury grade (P = .71) were similar between TEG and non-TEG patients. TEG patients had higher Injury Severity Scores compared with non-TEG patients (33.2 vs 18.3, respectively, P < .01). Among the TEG patients, the shear elastic modulus strength and maximum amplitude values began in the normal range within the first 12-hour interval after injury, increased linearly, and crossed into the hypercoagulable range at 48 hours (15.1 ± 1.9 Kd/cs and 57.6 ± 1.6 mm, respectively; P < .01, analysis of variance).ConclusionsPatients sustaining blunt abdominal solid organ injuries transition to a hypercoagulable state approximately 48 hours after injury. In the absence of contraindications, pharmacoprophylaxis should be considered before this time for effective venous thromboembolism prevention.

The liberal use of computed tomographic (CT) scanning during the evaluation of injured children has increased their exposure to the risks of ionizing radiation. We hypothesized that CT imaging performed for mechanism of injury alone is unnecessary and that serious or life-threatening injury is rarely identified.All pediatric blunt trauma team evaluations (age15 years) at a pediatric Level 2 trauma center over 72 months were reviewed. CT findings in patients with normal Glasgow Coma Scale (GCS) score, vital signs (VS), and physical examination (PE) (Group I) were compared with Group II (GCS score15), Group III (abnormal VS/PE), and Group IV (abnormal GCS score, VS/PE). Variables associated with any positive finding were entered into a multiple logistic regression model to assess for independent contributions. Each patient's total effective radiation dose from CT scans in millisieverts was calculated using an age-adjusted scale.A total 174 children met trauma team activation criteria (mean [SD] age, 7 [5] years; 63% male; mean [SD] Injury Severity Score [ISS], 10 [10]). A total of 153 (88%) were imaged by CT (I, 54 of 66; II, 25 of 25; III, 49 of 57; IV, 25 of 26). No patient in Group I had a serious finding on CT compared with Group II (17 of 77), III (25 of 111), and IV (18 of 72). Mortality was 4%. Radiation dose (mSv) from CT was not different among the groups (I, 17 [14]; II, 29 [13]; III, 21 [16]; IV, 27 [17]). By univariate analysis, GCS score of less than 15 (p0.01) and respiratory rate of greater than 30 (p = 0.09) were associated with a positive CT finding. By logistic regression analysis, GCS score of less than 15 remained the only variable associated significantly with a positive finding (odds ratio, 6.7; 95% confidence interval, 3-14; p0.01).In children imaged based only on mechanism, no patient had a serious positive finding but was subjected to radiation doses associated with an increased risk of future malignancy. The use of CT imaging in injured children in the absence of a physiologic or anatomic abnormality does not seem to be justified.Care management study, level IV.

A child's risk of developing cancer from radiation exposure associated with computed tomography (CT) imaging is estimated to be as high as 1/500. Chest CT (CCT), often as part of a "pan-scan," is increasingly performed after blunt trauma in children. We hypothesized that routine CCT for the initial evaluation of blunt injured children does not add clinically useful information beyond chest radiograph (CXR) and rarely changes management.Pediatric (15 y) trauma team evaluations over 6 y at an academic Level I trauma center were reviewed. Demographic data, injuries, imaging, and management were identified for all patients undergoing CT. Effective radiation dose in milliSieverts (mSv) was calculated using age-adjusted scales.Fifty-seven of 174 children (33%) undergoing CT imaging had a CCT; 55 (97%) of these had a CXR. Pathology was identified in significantly fewer CXRs compared with CCTs (51% versus 83%, P0.001). All 7/57 (12%) emergent or urgent chest interventions were based on information from CXR. In 53 children (93%), the CCT was ordered as part of a pan-scan, resulting in a radiation dose of 37.69 ± 7.80 mSv from initial CT scans. Radiation dose was significantly greater from CCT than from CXR (8.7 ± 1.1 mSv versus 0.017 ± 0.002 mSv, P0.001).Clinically useful information found on CCT had good correlation to information obtained from CXR and did not change patient management, however, did add significantly to the radiation exposure of initial imaging. We recommend selective use of CCT, particularly in the presence of an abnormal mediastinal silhouette on CXR after a significant deceleration injury.

Background Urinary tract infection (UTI) in trauma patients is associated with increased mortality. Whether the urinalysis (UA) is an adequate test for a urinary source of fever in the ICU trauma patient has not been demonstrated. We hypothesized that the UA is a valuable screen for UTI in the febrile, critically ill trauma patient. Study Design All trauma ICU patients in our surgical ICU who had a fever (temperature >38.0°C), urinary catheter, UA, and a urine culture between January 1, 2011 and December 13, 2011 were reviewed. A positive UA was defined as positive leukocyte esterase, positive nitrite, WBC > 10/high power field, or presence of bacteria. A positive urine culture was defined as growth of ≥10 5 colony forming units (cfu) of an organism irrespective of the UA result or ≥10 3 cfu in the setting of a positive UA. A UTI was defined as positive urine culture without an alternative cause of the fever. Results There were 232 UAs from 112 patients that met criteria. The majority (75%) of patients were men; the mean age was 40 (±16) years. Of the 232 UAs, 90 (38.7%) were positive. There were 14 UTIs. The sensitivity, specificity, positive predictive value, and negative predictive value of the UA for UTI were 100%, 65.1%, 15.5%, and 100%, respectively. Conclusions A negative UA reliably excludes a catheter-associated UTI in the febrile, trauma ICU patient with a 100% negative predictive value, and it can rapidly direct the clinician toward more likely sources of fever and reduce unnecessary urine cultures.

Analogous to organ injury scales developed for trauma, a scoring system is needed for acute care surgery. The purpose of this study was to develop a disease severity score (DSS) for acute appendicitis, the most common surgical emergency.A panel of acute care surgery experts reviewed the literature and developed a DSS for acute appendicitis as follows: grade 1, inflamed; Grade 2, gangrenous; Grade 3, perforated with localized free fluid; Grade 4, perforated with a regional abscess; and Grade 5, perforated with diffuse peritonitis. We applied the DSS to 1,000 consecutive patients undergoing appendectomy from 1999 to 2009 and examined its association with outcomes (mortality, length of hospital stay, incidence of in-hospital, and postdischarge complications). Of the 1,000 patients, 82 were excluded owing to negative or interval appendectomy or advanced end-stage renal disease.Among 918 eligible patients, the DSS distribution was Grade 1 at 62.4%, Grade 2 at 13.0%, Grade 3 at 18.7%, Grade 4 at 4.4%, and Grade 5 at 1.5%. Statistical analyses indicated a stepwise risk increase in adverse outcomes with higher DSS grades (c statistics ≥ 0.75 for all outcomes). Covariates (age, sex, and type of surgical access) did not add to the predictive power of DSS.Based on this single-institution study, the proposed appendicitis DSS seems to be a useful tool. This DSS can inform future, national efforts, which can build on the knowledge provided by the present investigation. This DSS may be useful for comparing therapeutic modalities, planning resource use, improving programs, and adjusting reimbursementEpidemiologic study, level III.

Introduction In the adult population, assessment of blood consumption (ABC) score [penetrating mechanism, positive focused assessment sonography for trauma (FAST), systolic blood pressure 120] ≥2 identifies trauma patients who require massive transfusion (MT) with sensitivity and specificity of 75 and 86%. We hypothesized that the adult criteria cannot be applied to children, as the vital sign cut-offs are not age-adjusted. We aimed to determine if the use of a shock index, pediatric age-adjusted (SIPA) would improve the discriminate ability of the ABC score in children. Materials and Methods A retrospective review of children age 4 to 15 who received a packed red blood cell (PRBC) transfusion during admission for trauma between 2008 and 2014 was performed. We compared the sensitivity and specificity of ABC score ≥ 2, elevated SIPA, and age-adjusted ABC score (ABC-S) utilizing SIPA in place of HR and BP, to determine the need for MT. Results A total of 50 children were included, 31 received PRBC transfusion within 6 hours of injury, 7 children had a positive FAST, and 3 suffered penetrating trauma, all in the early transfusion group. ABC score ≥ 2 is 29% sensitive and 100% specific at predicting need for MT while ABC-S score ≥ 1 is 65% sensitive and 84% specific. Conclusions Adult-based criteria for activation of MT perform poorly in the pediatric population. The use of SIPA modestly improves the sensitivity of the ABC score in children; however, the sensitivity and specificity of this score are still worse than when used in an adult population. This suggests the need to develop a new score that takes into account the low rate of penetrating trauma and positive FAST in the pediatric population.