Robert W. Letton

Nonoperative management of blunt liver and spleen injury in children: Evaluation of the ATOMAC guideline using GRADE.

BACKGROUND Nonoperative management of liver and spleen injury should be achievable for more than 95% of children. Large national studies continue to show that some regions fail to meet these benchmarks. Simultaneously, current guidelines recommend hospitalization for injury grade + 2 (in days). A new treatment algorithm, the ATOMAC guideline, is in clinical use at many centers but has not been prospectively validated. METHODS A literature review conducted through MEDLINE identified publications after the American Pediatric Surgery Association guidelines using the search terms blunt liver trauma pediatric, blunt spleen trauma pediatric, and blunt abdominal trauma pediatric. Decision points in the new algorithm generated clinical questions, and GRADE [Grading of Recommendations, Assessment, Development, and Evaluations] methodology was used to assess the evidence supporting the guideline. RESULTS The algorithm generated 27 clinical questions. The algorithm was supported by six 1A recommendations, two 1B recommendations, one 2B recommendation, eight 2C recommendations, and ten 2D recommendations. The 1A recommendations included management based on hemodynamic status rather than grade of injury, support for an abbreviated period of bed rest, transfusion thresholds of 7.0 g/dL, exclusion of peritonitis from a guideline, accounting for local resources and concurrent injuries in the management of children failing to stabilize, as well as the use of a guideline in patients with multiple injuries. The use of more than 40 mL/kg or 4 U of blood to define end points for the guideline, and discharging stable patients before 24 hours received 1B recommendations. CONCLUSION The original American Pediatric Surgery Association guideline for pediatric blunt solid organ injury was instrumental in improving care, but sufficient evidence now exists for an updated management guideline. LEVEL OF EVIDENCE Expert opinion, guideline, grades I to IV.

Patterns of power mower injuries in children compared with adults and the elderly.

Power mower trauma remains an alarmingly frequent cause of serious injury in young children. The patterns of mower-related injuries in children < 15 years old (n = 13) were compared with those of adults aged 15-64 (n = 16) and elderly victims > or = 65 years old (n = 6), who were similarly injured over the past 5 years. Children were more likely to be injured in accidents involving high-energy riding mowers. Of those children injured, 69% (9 of 13) were playing in the yard while 31% (4 of 13) were riding on the mower with a guardian when the injury occurred. Amputations in children were more frequent and more extensive than in the adults and included one forearm, two Symes, and three below-knee amputations. The need for transfusion was also significantly increased in children (62% vs. 6% adults, p < 0.005), who were also more likely to require prolonged hospitalization (11.8 days vs. 5 days in adults, p < 0.005). Aggressive efforts to increase public awareness regarding the cause and nature of power mower injuries are warranted to decrease the incidence of this debilitating but preventable trauma in young children.

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

BACKGROUND Blunt intestinal injury (BII) requiring surgical intervention in the pediatric trauma population remains difficult to diagnose. We sought to analyze whether delay in treatment in the event of perforation had an adverse affect on patient outcome. METHODS A multi-institutional retrospective chart review by the members of the American Pediatric Surgical Association Committee on Trauma was initiated after the approval of Institutional Review Board at each of the 18 institutions. All children <or=15 years of age diagnosed with a BII were identified and only those with BII noted during surgery or autopsy from January, 2002, through December, 2007, were included. The data form was designed and approved before chart review and all data were combined into one database. RESULTS Three hundred fifty-eight patients were accrued into the study. Two hundred fourteen patients had sufficient data to analyze the interval between injury and operation. These were divided into six groups (<6 hours, 6-12 hours, and >12 hours) based on time from injury to intervention and whether they had perforation or not. Early and late complications as well as hospital days, injury severity score, and time to full feeds were compared in each group. There were two deaths from an abdominal source in the <6-hour nonperforation group, one in the 6-hour perforation group, and one in the 6-hour to 12-hour nonperforation group. Injury severity score was significantly greater in the <6-hour intervention group regardless of perforation status. There was no correlation between time to surgery and complication rate nor was there a significant increase in hospital days. CONCLUSIONS These data suggest that delay in operative intervention does not have a significant effect on prognosis after pediatric blunt intestinal perforation. Appropriate observation and serial examination rather than repeat computed tomography and/or urgent exploration would appear adequate when the diagnosis is in question.

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

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

The impact of morbid obesity on solid organ injury in children using the ATOMAC protocol at a pediatric level I trauma center

INTRODUCTION Obesity is an epidemic in the pediatric population. Childhood obesity in trauma has been associated with increased incidence of long-bone fractures, longer ICU stays, and decreased closed head injuries. We investigated for differences in the likelihood of failure of non-operative management (NOM), and injury grade using a subset of a multi-institutional, prospective database of pediatric patients with solid organ injury (SOI). METHODS We prospectively collected data on all pediatric patients (<18years) admitted for liver or splenic injury from September 2013 to January 2016. SOI was managed based upon the ATOMAC protocol. Obesity status was derived using CDC definitions; patients were categorized as non-obese (BMI <95th percentile) or obese (BMI ≥95th percentile). The ISS, injury grade, and NOM failure rate were calculated among other data points. RESULTS Of 1012 patients enrolled, 117 were identified as having data regarding BMI. Eighty-four percent of patients were non-obese; 16% were obese. The groups did not differ by age, sex, mechanism of injury, or associated injuries. There was no significant difference in the rate of failure of non-operative management (8.2% versus 5.3%). Obesity was associated with higher likelihood of severe (grade 4 or 5) hepatic injury (36.8% versus 15.3%, P=0.048) but not a significant difference in likelihood of severe (grade 4 or 5) splenic injury (15.3% versus 10.5%, P=0.736). Obese patients had a higher mean ISS (22.5 versus 16.1, P=0.021) and mean abdominal AIS (3.5 versus 2.9, P=0.024). CONCLUSION Obesity is a risk factor for more severe abdominal injury, specifically liver injury, but without an associated increase in failure of NOM. This may be explained by the presence of hepatic steatosis making the liver more vulnerable to injury. A protocol based upon physiologic parameters was associated with a low rate of failure regardless of the pediatric obesity status. LEVEL OF EVIDENCE Level II prognosis.

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

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

Letter to the Editor: “Post-traumatic liver and splenic pseudoaneurysms in children: Diagnosis, management, and follow-up screening using contrast enhanced ultrasound (CEUS)” by Durkin et al J Pediatr Surg 51 (2016) 289-292

The recent report by Loux et al. regarding transition to oral antibiotics for perforated appendicitis presents a potential intervention to decrease length of stay in this patient population [1]. It is one of the best papers yet on the subject, since it represents a thorough prospective evaluation of a practice change. This is not easy to accomplish, and the authors are to be congratulated for their efforts. However, I have some serious concerns regarding the data and the outcomes reported, and I would appreciate clarification by the authors. First, the authors report this as “early transition”. In fact, the transition did not occur very early in the course of treatment, since the difference in initial length of stay between those transitioned to oral antibiotics and those who completed an intravenous antibiotic course is 0.5 days for those treated nonoperatively and 1.7 days for those treated operatively. Second, the authors compare their outcomes to their previous relatively aggressive intravenous antibiotic protocol, where patients were continuedon intravenous antibiotics for 48 h aftermeeting criteria for resolved peritonitis and for 5 days if their WBC count was high despite resolved fever, ileus, and pain. We have previously shown that these prolonged antibiotic courses are unnecessary [2,3]. Third, the authors report a very high rate of readmission, almost one in 5 patients, under their new protocol. This constitutes a seriousmorbidity.We have shown that readmission rates can be in the low single digits or prevented completely by adherence to pathways that use strict discharge criteria [3,4]. The authors do recognize this and state that their readmission rates have fallen back to baseline. However, the data provided are difficult to understand, as the difference between initial length of stay and total length of stay (which presumably includes readmission) in operatively treated patients is 0.6 days in their oral antibiotic cohort. Were most patients discharged the same day they were readmitted? How many patients were readmitted with an intraabdominal abscess and how many underwent additional invasive procedures after readmission? Fourth, the authors do not mention any risk stratification or age criteria that may influence their protocol. Would they treat a 3year-old patient the same as a 16-year-old patient and consider oral antibiotics reliable in the former? Would they treat a localized contained perforation the same as one associated with a large abscess, free fecalith, and diffuse fibrinopurulent peritonitis? I do believe there is an important role for oral antibiotics in decreasing the morbidity of perforated appendicitis. However, I am not convinced that it is safe and effective to use this approach nonselectively.

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.

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

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

Reimaging in pediatric blunt spleen and liver injury

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