Journal of Trauma and Acute Care Surgery, Publish Ahead of Print

DOI: 10.1097/TA.0000000000001533

Acute Procedural Interventions Following Pediatric Blunt Abdominal

Trauma: A Prospective Multicenter Evaluation

Chase A. Arbra, MD1; Adam M. Vogel, MD2; Jingwen Zhang, MS1; Patrick D. Mauldin, PhD1;

Eunice Y. Huang, MD3; Kate B. Savoie, MD3; Matthew T. Santore, MD4; KuoJen Tsao, MD5;

Tiffany G Ostovar-Kermani, MD5; Richard A. Falcone, MD6; M. Sidney Dassinger, MD7;

D
John Recicar, BSN7; Jeffrey H. Haynes, MD8; Martin L. Blakely, MD9; Robert T. Russell, MD10;

Bindi J. Naik-Mathuria, MD11; Shawn D. St Peter, MD12; David P. Mooney, MD13;

TE
Chinwendu Onwubiko, MD13; Jeffrey S. Upperman, MD14; Christian J. Streck, MD1

1
Department of Surgery, Division of Pediatric Surgery, Medical University of South Carolina,

Charleston, South Carolina, USA.

EP
2
Washington University in St Louis, St. Louis, Missouri
3
Le Bonheur Childrens Hospital, University of Tennessee, Memphis, Tennessee
4
Emory University School of Medicine, Atlanta, Georgia
C

5
University of Texas Health Science Center, Houston, Texas
6
Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio
C

7
Arkansas Childrens Hospital, Little Rock, Arkansas
8
Virginia Commonwealth University, Richmond, Virginia
A

9
Vanderbilt University Medical Center, Nashville, Tennessee
10
Childrens Hospital of Alabama, Birmingham, Alabama
11
Baylor College of Medicine, Texas Childrens Hospital, Houston, Texas
12
Childrens Mercy Hospital, Kansas City, Missouri
13
Boston Childrens Hospital, Boston, Massachusetts
14
Childrens Hospital Los Angeles, Los Angeles, California
1

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

Presented at the 3rd Annual Meeting of the Pediatric Trauma Society, November 11-12, 2016,

Nashville, TN

Corresponding Author:

Chase A. Arbra, MD

Medical University of South Carolina

Department of Surgery

D
96 Jonathan Lucas St., CSB423A

Charleston, SC 29425

TE
Tel:843-792-3072

Fax:843-792-4523

Arbra@musc.edu
EP
The authors have no financial disclosures or conflicts of interest.
C
C
A

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

Background: Pediatric intraabdominal injuries (IAI) from blunt abdominal trauma (BAT) rarely

require emergent intervention. For those children undergoing procedural intervention, our aim

was to understand the timing and indications for operation and angiographic embolization.

Methods: We prospectively enrolled children <16 years following BAT at 14 Level-One

Pediatric Trauma Centers over a 1-year period. Patients with IAI who received an intervention

(IAI-I) were compared to those who did not receive an intervention using descriptive statistics

D
and univariate analysis; p < 0.05 was considered significant.

TE
Results: 261 of 2188 patients (11.9%) had IAI. 45 IAI patients (17.2%) received an acute

procedural intervention (38 operations, 7 angiographic embolization). The mean age for patients

requiring intervention was 7.1+/-4.1 years and not different from the population. The majority of
EP
patients with IAI-I were normotensive (88.9%). IAI-I patients were significantly more likely to

have a mechanism of MVC (66.7% vs. 38.9%), more likely to present as a level I activation

(44.4% vs. 26.9%), more likely to have a GCS < 14 (31.1% vs. 15.5%), and more likely to have

an abnormal abdominal physical exam (93.3% vs. 65.7%) than patients that did not require acute
C

intervention. All patients underwent CT scan before intervention. Operations consisted of

laparotomy (n=21), laparoscopy converted to open (n=11), and laparoscopy alone (n=6). The
C

most common surgical indications were hollow viscus injury (HVI) (11 small bowel, 10 colon, 6

small bowel/colon, 2 duodenum). All interventions for solid organ injury (SOI), including 7
A

angioembolic procedures, occurred within 8 hours of arrival; many had hypotension and received

a transfusion. Procedural interventions were more common for HVI than for SOI (59.2% vs.

7.6%). Post-operative mortality from IAI was 2.6%.

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

Conclusions: Acute procedural interventions for children with IAI from BAT are rare,

predominantly for HVI, are performed early in the hospital course, and have excellent clinical

outcomes.

Level of Evidence: Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Key Words: Pediatric; Blunt Abdominal Trauma; intra-abdominal injury; surgery; Angiographic

D
embolization

TE
EP
C
C
A

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

Background

Trauma is the leading cause of mortality in children greater than 1 year of age with

greater than 90% of injuries resulting from a blunt traumatic mechanism.1-2 Prior studies have

characterized different subsets of the pediatric blunt abdominal trauma (BAT) population, with

investigators looking primarily at either hollow viscus injuries (HVI) or solid organ injury (SOI).

The management of SOI has evolved from surgical exploration to non-operative management

(NOM), with NOM failure rates at or below 5%.3-5 In addition, angiographic embolization is an

D
option to potentially avoid surgery for severe cases of SOI.6-7 Few have studied the timing of

intervention for children with IAI undergoing angiographic embolization or laparotomy for

TE
failure of NOM.4 In contrast to SOI, treatment of HVI is primarily operative with the main

challenge surrounding identification of injury and the subsequent timing of intervention. In this

regard, recent studies in pediatric trauma patients have shown that some delay in diagnosis does
EP
not ultimately affect morbidity and mortality.5,8 There have been no large, prospective studies

examining pediatric intra-abdominal injury (IAI) as a whole, including both SOI and HVI.

The purpose of this study was to characterize a cohort of patients with IAI who received

acute procedural intervention (surgery or embolization). We hypothesized that the majority of

C

patients requiring surgical intervention were those with suspected HVI. Additionally, we sought

to define the time-course of interventions for HVI as compared to SOI.

C

Methods
A

The study population included patients less than 16 years of age at 14 Level 1 pediatric

trauma centers across the United States over a one-year period that concluded in July 2015.

Institutional review board (IRB) approval was obtained at all 14 institutions prior to study

initiation. The primary purpose of the data collection was to develop a clinical prediction model

to determine which patients were at very low risk for IAI following BAT and could safely avoid

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

abdominal computed tomography (CT) as a component of their initial evaluation. This review to

evaluate the timing and indications for procedural intervention in patients with IAI was a planned

secondary analysis. Pediatric patients were identified by the registrar, trauma service, or

emergency medicine physicians and screened for eligibility. Informed consent in the trauma bay

for data collection was often not practicable due to young patient age, no available caregiver, or a

significantly injured patient, and was waived for this observational study by each institutions

IRB. Exclusion criteria included: presentation greater than 6 hours after injury, abdominal CT

D
imaging prior to arrival to the pediatric trauma center, isolated head or extremity mechanism of

injury, short fall and penetrating/burn/hanging mechanism. The data collection forms included

TE
demographic data (age, race, mechanism of injury), level of trauma activation, initial emergency

department (ED) vital signs, subjective information (complaint of abdominal pain,

nausea/vomiting, abdominal physical exam), laboratory data, abdominal CT timing and results,
EP
ED disposition (ICU/floor admission, OR, discharge), length of stay (LOS), intra-operative data

related to organ injury and treatment, injury severity score (ISS), transfusion requirement

secondary to IAI, and mortality.

Patients with an abdominal wall contusion, seatbelt sign, tenderness to palpation, or

C

abdominal distension were considered to have an abnormal abdominal exam. Intra-abdominal

injury was defined as any injury to one of the following structures: spleen, liver, kidney,
C

mesentery, duodenum, jejunum, ileum, colon, adrenal, pancreas, major intra-abdominal vascular

structure, bladder, ureter, gallbladder, or abdominal wall fascial disruption. Injuries included in
A

the analysis were diagnosed on abdominal CT scan or identified during surgery. Solid organ

injury was defined as injury to the spleen, liver, kidney, adrenal or pancreas. Hollow viscus

injury was defined as injury to the duodenum, jejunum, ileum, colon, or small bowel or colonic

mesentery. Isolated fascial injury was defined as those patients with traumatic fascial disruptions

resulting in acute abdominal wall hernias with no obvious SOI or HVI.

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

 Acute procedural intervention was defined as receiving surgical or angiographic

embolization procedures for management of IAI. Injuries were identified either by CT scan or

intra-operatively. The decision to perform an intervention was at the discretion of the treating

pediatric trauma surgeon. When specifically analyzing the patients who underwent acute

procedural interventions, patients were divided into groups based on the injury necessitating

intervention. These groups include HVI, SOI, and fascial injuries. For patients with injuries in

more than one group, we assigned the patient to the category of injury receiving procedural

D
intervention. Patients managed non-operatively were categorized by the most serious injury

and/or the injury requiring treatment or observation.

TE
De-identified data was entered by each individual institution into a central REDCap

database. Univariate descriptive analysis (means, medians, proportions and p-values) of

demographic, clinical, and laboratory variables consisting of chi-square for categorical data, and
EP
independent two-sample (two-sided t test, or Wilcoxon Mann-Whiney U-test for continuous

data) were performed to determine case patients versus control patients. SAS 9.3 (SAS Instituted

Inc. Cary, NC) was used for statistical analyses. A p value <0.05 was used as the criterion for

statistical significance.
C

Results
C

5,787 children who presented as trauma activations or trauma consults were screened

over the one-year study period. Reasons for exclusion were age > 15 years (n=585), penetrating
A

mechanism of injury (n=467), isolated head or extremity mechanism of injury (n=1,289),

delayed presentation or prior abdominal CT (n=1,137), and other (n=121). 2,188 pediatric

patients with mechanism of BAT were included with a mean age of 7.8 +/- 4.6 years. Baseline

characteristics of enrolled patients are described in Table 1. Trauma activations were primarily

level II (67.2%), followed by level I (17.5%), and trauma consults (15.2%). The most common

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

mechanisms of injury were motor vehicle collision (MVC) (46.5%), pedestrian or bicycle struck

by auto (19.7%), all-terrain vehicle (ATV) (8.4%), falls > 10 feet in height (7.2%) and bicycle

crash (3.9%); the remainder included assaults, golf cart related, motorcycle/dirt bike and other

(14.3%). Median ISS was 5 [1,10]. The majority of patients arrived to the trauma bay with GCS

14-15 (83.1%). Thirty-four percent of patients presented with an abnormal abdominal exam.

Overall, 992 (45.3%) patients underwent abdominal CT scan.

The cohort of patients with IAI (n=261, 11.9%) had a mean age of 7.5 +/- 4.4 years,

D
which was not significantly different from those without IAI (p = 0.22). There were 394 organ

injuries among the 261 children with IAI diagnosed by CT or surgery. Liver, spleen, kidney and

TE
small bowel were the most common (Table 2). Patients with IAI were more likely to have an

abnormal abdominal exam (70.5% vs. 29.5%, p < 0.0001), higher ISS scores (median = 16 vs. 4,

p < 0.0001), and present as level I trauma activations (29.9% vs. 15.7%, p < 0.0001) as
EP
compared to the population with no IAI following BAT. Most patients were hemodynamically

stable with GCS > 13 although there were some differences between those patients with and

without IAI [normal systolic blood pressure for age (94.6% vs. 97.6%, p < 0.006), normal heart

rate for age (74.3% vs. 83.5%, p < 0.001), and GCS < 14 (26.5% vs. 14.5%, p < 0.0001)] (Table
C

3). The mechanism of injury, percent motor vehicle collision (43.7% vs. 46.8%, p = 0.34), was

similar between the IAI and no-IAI groups following BAT.

C

The overall rate of procedural intervention for intraabdominal injury (IAI-I) was low,

with 2.1% of all BAT patients and 17.2% of all IAI (n=45) requiring surgery or embolization.
A

There were 38 abdominal operations and 7 angiographic embolization procedures. The mean

age for children with IAI-I was 7.1 +/- 4.1 years and not significantly different from patients that

did not require intervention. As with the IAI group, the majority of patients with IAI-I were

normotensive (88.9%). They were significantly more likely to have a mechanism of MVC

(66.7% vs. 46.0%, p < 0.0001), more likely to present as a level I activation (44.4% vs. 26.9%, p

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

< 0.0001), more likely to have a GCS < 14 (31.1% vs. 15.5%, p < 0.005), and more likely to

have an abnormal abdominal physical exam (93.3% vs. 65.7%, p = 0.002) than patients that did

not require acute intervention (Table 4).

Abdominal procedural interventions for IAI were all therapeutic and included 38

operations, with 21 laparotomies, 11 laparoscopic converted to open cases, and 6 laparoscopies.

There were 7 angio-embolic procedures. All patients in this review underwent abdominal CT

scans prior to procedural intervention. The IAI-I patients were subdivided further into HVI, SOI,

D
and isolated major fascial injury groups. Hollow viscous injury accounted for the majority of

IAI requiring acute procedural intervention (64%). Intra-operative findings in the 29 patients

TE
included: 11 small bowel, 10 colon, 6 combined small bowel/colon and 2 duodenal injuries with

all HVI necessitating repair. Among the SOI patients (n=14), there were 7 surgeries and 7

angiographic embolizations. Among the 7 patients that underwent laparotomy for solid organ
EP
injury there were 4 major liver injuries, 2 major spleen injuries and 2 major kidney injuries.

Among the 7 patients receiving angiographic embolization there were 5 major liver injuries, 4

major spleen injuries and 2 major kidney injuries. Eleven of the 14 patients that underwent acute

intervention for SOI had active contrast extravasation on abdominal CT. There were two cases
C

where the primary surgery involved repair of isolated fascial injuries. The vast majority of

patients requiring acute procedural interventions for IAI presented with abnormal abdominal
C

physical exams. The majority of patients in each group were normotensive for age although

patients with SOI were more commonly hypotensive on initial systolic BP in the emergency
A

department than HVI (28.6% vs. 3.4%, p = 0.016). The SOI group also showed a higher

proportion receiving transfusions compared to HVI (42.9 vs. 10.3%, p < 0.015). Patients with

SOI tended to be more significantly injured than those with HVI with a median ISS of 35 [34,38]

vs. 12 [5,17], p < 0.001 (Table 5).

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

 The median time to intervention was 4 hours or less for all injury groups; however, there

was a broader interquartile range amongst those with HVI (4 [2,10] vs. SOI 4 [2,5], p = 0.74).

All procedural interventions for SOI occurred within 8 hours of presentation. The vast majority

of SOI patients were admitted to the ICU following surgery or angiography (93%), compared to

HVI (44.8%, p < 0.003) and fascial injury. Median length of stay in days was similar between

solid and hollow viscus injury (8 [6,24] and 8 [6,12]) and slightly shorter in the fascia group

(4.5[1,8]). When looking at the entire population of patients with IAI (n=261), the likelihood of

D
receiving a procedural intervention was markedly higher for HVI than for SOI (59.2% vs. 7.6%,

p < 0.0001). The 40.8% of HVI patients not undergoing procedural intervention included 11

TE
small bowel mesenteric injuries, 11 small bowel injuries (7 duodenum, 4 jejunum/ileum) with

associated hematomas, and 2 colon injuries with pericolonic hematomas. In this group, all

injuries were identified by CT and there were no definite radiographic signs of perforation.
EP
Mortality within 30 days of injury occurred in 42 of 2,188 children (1.9%), with the

majority attributed to traumatic brain injury (TBI). Of those that died, 81% were diagnosed with

TBI on head CT, 31% had invasive ICP monitoring, and 98% presented with a GCS<8. Only 1

death (0.05%) was attributed to IAI, with an overall post-operative mortality rate for surgical
C

intervention of 2.6%.
C

Discussion

Our review of this large, prospective, multi-institutional cohort of pediatric trauma patients found
A

an overall incidence of IAI of 12%, with only 17% of abdominal injury patients (2.1% of all

patients following BAT) receiving an acute procedural intervention. Our incidence of IAI is

similar to the estimated incidence of 10-15% in the current literature.8-9 A recent study from the

Pediatric Emergency Care Applied Research Network (PECARN) documented a similar ratio of

patients with IAI undergoing surgery or angiography. The study included 12,044 children with

10

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

6.3% of children diagnosed with intraabdominal injuries, 16.4% of which underwent an acute

procedural intervention.10 Comparisons of injury severity between the PECARN study

population and this current study are not possible as details of the PECARN study populations

associated injuries, level of trauma activation, need for ICU admission, length of stay or ISS

were not published. It is possible that the incidence of IAI was much higher in the current study

because patients with isolated mechanism of injury to the head and extremity were excluded or a

greater proportion of patients presented as a Trauma Activation. Our study had a greater

D
proportion of patients that presented following MVC (46% vs. 32%) and a similar percentage

that presented as pedestrian or bicyclist struck by car (20% vs. 19%) and may represent a more

TE
injured population. Patients in both studies underwent a similar rate of abdominal CT (45.3% vs.

44.7%).

The evaluation of blunt abdominal injury in children continues to evolve in order to better
EP
identify children with injuries that will benefit from acute procedural intervention. In this study,

an abnormal abdominal exam was found in the majority of children that received an acute

intervention. These findings emphasize the continued importance of an accurate and complete

physical exam. In the literature, the role of diagnostic imaging, particularly CT, in the diagnosis
C

and management of pediatric blunt abdominal injury remains controversial. In this series, all of

the patients that received an intervention underwent an abdominal CT scan compared to 45% of
C

the overall patient population. Abdominal CT has been found to be highly reliable in ruling out

intra-abdominal pathology, with recent studies showing negative predictive rates of > 99% after
A

normal CT.11-12 In this study limited to children with blunt mechanism of injury, who were

largely hemodynamically stable, approximately 3 of every 4 abdominal CT scans was negative.

Clearly, CT is a valuable tool for the diagnosis and management of patients with IAI following

BAT. A reliable, validated clinical prediction model is still needed for children following

pediatric BAT to avoid unnecessary radiation and cost from CT in this population. FAST was

11

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

not routinely applied or performed in a standardized fashion among centers. Further research

efforts are needed to clarify the role of FAST in the pediatric blunt trauma evaluation.

While the overall rate of acute procedural intervention for patients with IAI was 17%, the

rate for the subset with SOI was significantly lower (8%) with only half of these receiving an

operation. Approximately 4% of patients with SOI underwent surgery at a pediatric trauma

center, which is consistent with the largest prior studies that show operative rates in the range of

2.5%-5%.3-4,6-7 However, our angiographic embolization rate was higher (3.8%,) compared to

D
two other recent studies (1.0-1.4%). Both of these studies focused solely on SOI patients, which

resulted in a larger sample of SOI patients.6-7 The small sample of SOI patients in the current

TE
study may overestimate the true rate of angiographic embolization for pediatric SOI or may

reflect institutional treatment biases. Several recent studies have called into question the benefit

of angiographic embolization in the management of pediatric solid organ injury.13-15 Not

EP
surprisingly, SOI patients requiring intervention were more likely to be hypotensive upon arrival

to the ED (29%) compared with other intra-abdominal injury types. Classically, abnormal

hemodynamics suggest hemorrhage in the trauma population, which necessitates intervention.9

Although relatively more SOI patients with IAI-I had a low BP as compared to HVI, initial
C

systolic blood pressure was normal for age for most, perhaps reflecting the significant ability of

children to compensate physiologically until late in hypotensive shock.

C

In this study, median time to intervention for SOI was 2 hours for surgery and 5 hours for

angiographic embolization. When procedural intervention occurs for SOI, it is almost always
A

within 6 hours of the injury. Tataria et al. showed no difference in mortality, transfusion

requirements, ICU or hospital LOS when comparing children who underwent immediate

laparotomy vs delayed surgery >3 hours for blunt SOI.3 A short delay of a few hours appears not

to adversely affect outcomes.

12

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

 The proportion of patients with HVI requiring intervention was much higher than SOI

with 59% requiring operative intervention. Similar to prior studies, small bowel injury was the

most common surgical indication.5,16 The somewhat longer delay to surgery, with a median time

of 4 hours and almost one fourth delayed at least 10 hours, can be explained by several potential

factors. These patients were largely normotensive, with normal mental status, and fewer

concomitant injuries, presenting a population with an opportunity for serial abdominal

examination for those patients with initially equivocal findings for perforation on exam and

D
imaging. Several previous papers have shown that a delay to intervention in children with blunt

HVI is not associated with increased complications or length of stay.5,8 Letton et al. showed that

TE
the HVI victims requiring intervention soonest were those with the highest ISS scores,

suggesting the more significantly injured patients will declare themselves as appropriate

operative candidates more expeditiously.8

EP
Regardless of the intervention performed, the clinical outcomes in children are generally

excellent. The overall mortality rate was less than 2% and largely secondary to traumatic brain

injury (TBI), with only one death attributed to intra-abdominal injury. The single death from IAI

involved a teenager with hypotension and active extravasation of contrast on abdominal CT scan
C

secondary to a Grade V liver laceration. The extremely low rate of death as a result of IAI in this

study is similar to that of 0.1% seen in the recent PECARN study.10 TBI as the leading cause of
C

death following pediatric BAT has been well described.5,16 Until recently, few studies have

demonstrated that following blunt abdominal injury, death is exceedingly rare from intra-
A

abdominal injuries in children.8

There are several limitations associated with the study design and analysis of our cohort.

This was a planned secondary analysis of a prospective, observational cohort study designed to

identify a prediction rule to optimize CT utilization in pediatric blunt abdominal trauma. There

were clearly variations in trauma center practices amongst the different participating trauma

13

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

centers. In particular, there was variation regarding oldest age of patient treated; however, all

centers treated patients less than 16 years of age which allowed for a consistent population

among centers. This decision to exclude patients age 16 years and older was determined a priori.

Additionally, level I and II trauma activation criteria were not standardized across institutions.

Although the activation criteria were not standardized, inclusion of this activation information is

still relevant and allows for important comparisons to other institutions and trauma practices. The

variability in age of patients evaluated and activation criterion highlights an opportunity to

D
potentially seek some standardization of practice following future study.

Although the overall number of patients was high, only a small proportion of the cohort had an

TE
intra-abdominal injury and an even smaller portion received an acute procedural intervention.

With the relatively small sample size, this study was not adequately powered to identify

predictors of acute interventions or to detect differences of outcomes between various

EP
interventions for both solid organ and hollow viscus injuries. Additionally, the study design did

not identify or account for specific clinical indications leading to the specific acute procedural

interventions. In many cases, particularly in the subset of patients with HVI, the exact reasoning

behind a decision for observation or operative intervention is unclear. The decision to operate
C

was likely based on all of the available clinical information, in most cases a combination of

abdominal physical exam and CT imaging findings. These and other confounding variables, such
C

as specific trauma center protocols, or individual trauma surgeon treatment bias, could introduce

selection bias into the analysis and interpretation of the results. Finally, the prospective
A

observational nature of the study does not allow the assessment of the impact of less frequent

injuries that could require procedural interventions. Despite these limitations, this study cohort

represents a unique opportunity to describe and assess, in a prospective multicenter fashion, the

use of acute procedural interventions in pediatric blunt abdominal trauma.

14

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

Conclusions

Children with intraabdominal injuries requiring acute procedural intervention are rare following

blunt abdominal trauma. The small proportion of patients that require surgery or angiography

will typically receive intervention early following trauma, particularly those who require

intervention for solid organ injury. Those patients requiring acute procedural intervention

typically exhibit an abnormal abdominal exam, are initially normotensive and will likely receive

an abdominal CT scan prior to surgery or angiographic embolization. Patients with hollow viscus

D
injury are relatively more likely to undergo surgery than those with solid organ injury and

account for the majority of patients requiring operation. Mortality secondary to intra-abdominal

TE
injury is exceedingly rare following blunt abdominal trauma.
EP
Authorship:
C

C.J.S, A.M.V., D.P.M, E.Y.H, M.T.S, K.T., T.G.O, R.A.F, M.S.D., J.H.H, M.L.B, R.T.R.,

B.J.N., S.D.S., and J.S.U. were involved in conception of the study and the study design. C.J.S,
C

A.M.V., D.P.M, E.Y.H, M.T.S, K.T., J.R., T.G.O, R.A.F, M.S.D., J.H.H, M.L.B, R.T.R., B.J.N.,

S.D.S., J.S.U., C.O., and K.B.S were involved in acquisition of the data. P.D.M., J.Z., C.J.S, and
A

C.A.A. performed the data analysis and interpreted the data, C.A.A. drafted the manuscript. All

authors participated in critical review and revision of the final manuscript.

15

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

References:

1. Borse NN, Gilchrist J, Dellinger AM, Rudd RA, Ballesteros MF, Sleet DA. CDC

childhood injury report: patterns of unintentional injury among 0-19 year olds in the

united states, 2000-2006. Atlanta (GA): Centers for disease control and prevention,

National center for injury prevention and control; 2008.

2. Gaines BA, Ford HR. Abdominal and pelvic trauma in children. Crit Care Med. 2002

Nov; 30(11 Suppl): S416-23.

D
3. Tataria M, Nance ML, Holmes JH 4th, Miller CC 3rd, Mattix KD, Brown RL, Mooney

DP, Scherer LR 3rd, Groner JI, Scaife ER, et al. Pediatric blunt abdominal injury: age is

TE
irrelevant and delayed operation is not detrimental. J Trauma. 2007 Sep; 63(3): 608-14.

4. Holmes JH 4th, Wiebe DJ, Tataria M, Mattix KD, Mooney DP, Scaife ER, Brown RL,

Groner JI, Brundage SI, Sherer LR, et al: The failure of nonoperative management in
EP
pediatric solid organ injury: a multi-institutional experience. J Trauma. 2005 Dec; 59(6):

1309-13.

5. Canty TG Sr, Canty TG Jr, Brown C: Injuries of the gastrointestinal tract from blunt

trauma in children: a 12-year experience at a designated pediatric trauma center. J

C

Trauma. 1999; 46(2): 234-40.

6. Safavi A, Skarsgard ED, Rhee P, Zangbar B, Kulvatunyou N, Tang A, OKeefe T, Friese

C

RS, Joseph B. Trauma center variation in the management of pediatric patients with

blunt abdominal solid organ injury: a national trauma data bank analysis. J Pediatr Surg.
A

2016 Mar; 51(3):499-502.

7. Wisner DH, Kuppermann N, Cooper A, Menaker J, Ehrlich P, Kooistra J, Mahajan P,

Lee L, Cook LJ, Yen K, et al. Management of children with solid organ injuries after

blunt torso trauma. J Trauma Acute Care Surg. 2015 Aug; 79(2): 206-14.

16

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

8. Letton RW, Worrell V, APSA Committee on Trauma Blunt Intestinal Injury Study

Group: Delay in diagnosis and treatment of blunt intestinal injury does not adversely

affect prognosis in the pediatric trauma patient. J Pediatr Surg. 2010; 45(1): 161-5.

9. Gaines, BA. Intra-abdominal solid organ injury in children: diagnosis and treatment. J

Trauma. 2009 Aug; 67 (2 Suppl):S135-9.

10. Holmes JF, Lillis K, Monroe D, Borgialli D, Kerrey BT, Mahajan P, Adelgais K, Ellison

AM, Yen K, Atabaki S, et al. Identifying children at very low risk of clinically important

D
blunt abdominal injuries. Ann Emerg Med. 2013 Aug; 62(2):107-116.e2

11. Hom J. The risk of intra-abdominal injuries in pediatric patients with stable blunt

TE
abdominal trauma and negative abdominal computed tomography. Acad Emerg Med.

2010 May; 17(5):469-75.

12. Kerrey BT, Rogers AJ, Lee LK, Adelgais K, Tunik M, Blumberg SM, Quayle KS,
EP
Sokolove PE, Wisner DH, Miskin ML, et al. A multicenter study of the risk of intra-

abdominal injury in children after normal abdominal computed tomography scan results

in the emergency department. Ann Emerg Med. 2013 Oct; 62(4):319-26.

13. Bansal S, Karrer FM, Hansen K, Partrick DA. Contrast Blush in pediatric blunt splenic
C

trauma does not warrant the routine use of angiography and embolization. Am J Surg.

2015 Aug; 210(2):345-50.

C

14. Ingram MC, Siddharthan RV, Morris AD, Hill SJ, Travers CD, McKracken CE, Heiss

KF, Raval MV, Santore MT. Hepatic and splenic blush on computed tomography in
A

children following blunt abdominal trauma: Is intervention necessary? J Trauma Acute

Care Surg. 2016 Aug; 81(2):266-70.

15. Notrica DM, Eubanks JW 3rd, Tuggle DW, Maxson RT, Letton RW, Garcia NM, Alder

AC, Lawson KA, St Peter SD, Megison S, et al. Nonoperative management of blunt liver

17

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

 and spleen injury in children: Evaluation of the ATOMAC guideline using GRADE. J

Trauma Acute Care Surg. 2015 Oct; 79(4): 683-93.

16. Ciftci AO, Tanyel FC, Salman AB, Buyukpamukcu N, Hicsonmez A. Gastrointestinal

tract perforation due to blunt abdominal trauma. Pediatr Surg Int. 1998 Apr; 13(4):259-

64.

D
TE
EP
C
C
A

18

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

Pediatric Blunt Abdominal Trauma (BAT) Manuscript Tables and Figures

Table 1: Baseline characteristics of study population

Characteristic BAT population IAI no intervention IAI undergoing
(n=2,188) (n= 216) intervention (n=45)
Age (mean +/- SD), years 7.8 +/- 4.6 7.5 +/- 4.5 7.1 +/- 4.1
Race/Ethnicity (%):
White 48.3% 51.0% 71.1%
Black 34.9% 31.0% 15.5%
Hispanic 14.5% 11.9% 4.4%
Other 2.3% 6.1% 9.0%
Mechanism of Injury:
Motor Vehicle Crash 46.5% 38.9% 66.7%

D
Pedestrian or bicyclist
struck by car 19.7% 24.5% 13.3%
ATV 8.4% 6.9% 2.2%

TE
Fall from > 10 feet 7.2% 6.0% 4.4%
Fall from bicycle 3.9% 3.7% 0%
Assault 2.6% 2.8% 6.7%
Other 11.7% 17.2% 9.8%
Activation Level:
One 17.5% 26.9% 44.4%
EP
Two 67.2% 50.9% 42.2%
Consult 15.2% 21.3% 13.3%
Key: BAT = blunt abdominal trauma, IAI = Intra-abdominal injury, SD = standard deviation, ATV = all-terrain vehicle
C
C
A

19

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

 Table 2: Incidence of Intraabdominal Injury
Organ % of Total % of IAI % of IAI-I
(n=2188) (n=261) (n=45)
Liver 5.7% 47.5% 28.9%
Spleen 3.2% 26.4% 22.2%
Kidney 1.8% 14.9% 11.1%
Jejunum/Ileum 1.1% 9.6% 40.0%
Mesentery 1.1% 8.8% 22.2%
Colon 0.9% 7.7% 37.8%
Duodenum 0.8% 6.5% 17.8%
Pancreas 0.6% 5.0% 6.7%
Abdominal wall fascia 0.6% 5.0% 11.1%

D
Major Intra-abdominal Vessels 0.4% 3.4% 11.1%
Bladder 0.4% 3.4% 6.7%
Ureter 0.05% 0.4% 0.0%

TE
Key: IAI = intra-abdominal Injury patients, IAI-I = intra-abdominal Injury patients requiring procedural intervention
EP
C
C
A

20

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

 Table 3: Comparison of patients with IAI vs. those without IAI
Characteristics No IAI IAI
(n=1927) (n=261)
Level One Activation 15.7% 29.9%*
Normal BP on arrival for age 97.6% 94.6%*
GCS < 14 14.5% 26.5%*
Abnormal Abdominal Exam 29.5% 70.5%*
Mean Starting Hematocrit (%) 36.6 34.7
Median ISS [IQR] 4 [1,10] 16 [9,26]*
Key: IAI = intra-abdominal injury, BP = systolic blood pressure, GCS = glascow coma scale, ISS = injury severity score, IQR =
interquartile range, *=denotes statistically significant difference, p<0.05

D
TE
EP
C
C
A

21

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

 Table 4: Comparison of patients with IAI (no intervention) vs. those
IAI receiving intervention
Characteristics IAI no I IAI-I
(n=216) (n=45)
Level One Activation 26.9% 44.4%*
Normal BP on arrival for age 95.8% 88.9%*
GCS < 14 15.5% 31.1%*
Abnormal Abdominal Exam 65.7% 93.3%*
Mean Starting Hematocrit (%) 35.1 (5.0) 33.2 (6.3)
Median ISS [IQR] 17 [9,22] 15 [10,34]*
Key: IAI = intra-abdominal injury, IAI-I = intra-abdominal injury patients requiring intervention BP = systolic blood pressure, GCS =
glascow come scale, ISS = injury severity score, *=denotes statistically significant difference, p<0.05

D
TE
EP
C
C
A

22

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

Table 5: Comparison of Patients Undergoing Acute Procedural Interventions by Injury
Category
Injury Type HVI (n=29) SOI (n=14) Isolated Fascia (n=2)
Age (mean +/- SD), 6.2 +/- 3.6 8.8 +/- 4.9 7 +/- 1.4
years
Mechanism (% MVC) 83% 36%* 50%
Level One Activation 41% 50% 50%
Normal arrival BP for 97% 71%* 100%
age
GCS<14 31% 36% 0%
Abnormal Abdominal 100% 79%* 100%
Exam (%)
Mean Hematocrit (%) 35.1 (4.7) 29.3 (7.6)* 35.8 (8.6)

D
Transfused 10% 43%* 0%
Median Time to OR 4 [2,10] OR 2 [2,4] OR 2 [2,3]
Intervention (hours) Angio 5 [4,6]

TE
ICU Admission (%) 45% 93%* 50%
Median LOS (days) 8 [6,12] 8 [6,24] 4.5 [1,8]
Median ISS [IQR] 12 [5,17] 35 [34,38]* 8.5 [4,13]
Key: ISS = Injury Severity Score, SD = standard deviation, GCS = Glascow Coma Scale, HVI = Hollow viscus injuries,
SOI = Solid organ injury, MVC = motor vehicle collision, BP = systolic blood pressure, ICU = intensive care unit, LOS
= length of stay, IQR = interquartile range, *=denotes statistically significant difference, p<0.05
EP
C
C
A

23

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.