Articles

Multicenter external validation of the Pediatric Emergency Care Applied Research Network rule to identify children at very low risk for intra-abdominal injury requiring acute intervention. [1] Frederick AB et al., J Trauma Acute Care Surg. 2025 Jun 1;98(6):966-972. Epub 2025 Apr 2. PMID: 40170217.

The identification of injuries after blunt trauma is important to effectively treat injured pediatric patients, either with observation or indicated intervention. The development of prediction rules helps guide which of these patients needs a computed tomography (CT), and which patients can be spared a CT without missing injuries. Prediction rules have been developed by multiple groups to try to minimize the number of CT scans while maximizing sensitivity for clinically important injury. The two most commonly used of these rules are those developed by the Pediatric Emergency Care Applied Research Network (PECARN) and by the Pediatric Surgery Research Collaborative (PedSRC). In external validation of the PECARN rule, no previous studies reported the rate of intra-abdominal injury that did not require intervention.

This study used the prospective data collected at 14 Level I Pediatric Trauma Centers during the development of the PedSRC prediction rule to externally validate the PECARN prediction rule. The primary outcome measure was abdominal injury requiring intervention (transfusion, laparotomy or laparoscopy, embolization, IV fluids for 2 or more nights for pancreatic or gastrointestinal injury, or death), and the secondary measure was any abdominal injury. Abdominal CT was performed in 44.2% of patients, the rate of any abdominal injury was 11.9%, and 2.8% of total patients had abdominal injury needing intervention. In this study, for any abdominal injury (even if not requiring intervention) the PECARN rule had a sensitivity of 86.6%, specificity of 49.7% and negative prediction value of 96.5%. The authors concluded that while the PECARN rule works well to identify patients who need acute intervention, it does not identify some children with other, potentially clinically significant abdominal injuries, in that it missed 35 of 261 injuries.

Who needs a tourniquet? And who does not? Lessons learned from a review of tourniquet use in the Russo-Ukrainian war [2] Butler F et al., J Trauma Acute Care Surg. 2024 Aug 1;97(2S Suppl 1):S45-S54. Epub 2024 Jul 12. PMID: 38996420.

Tourniquets have the potential to save limb and life in extremity trauma. Use within the armed forces of the US and other nations have increased over the past two decades. In response to public acts of terrorism and firearm-related mass-casualty events, use of tourniquets has been advocated in the civilian domain. There has been increased advocacy in educating first responders and laypersons in the use of tourniquets, most notably with the American College of Surgeons Stop The Bleed® program. Surgeons have noted increasing frequency of patients arriving to hospitals with tourniquets applied for lesser wounds. Concerns have been raised about whether military application translates directly to civilian use, and also potential harms of tourniquet overuse. This is an issue which affects trauma patients of all ages.

The authors review their observations in the most extensive modern battlefield experience, in which tourniquet use has been widespread. This report is descriptive and firm statistics are withheld for reasons of military security, but authenticity is self-evident. They expand upon a prior publication regarding the ongoing experience in the Russo-Ukrainian war. Examples of morbidity from overzealous tourniquet application are provided, along with recommendations to temper use. The authors comment on studies (both military and civilian) which have shown tourniquets are often applied when not indicated. They describe unnecessary loss of extremities and life-threatening sequela in the Ukranian combat forces. Once applied, the need for ongoing tourniquet use or opportunity for more distal repositioning should reassessed as soon as feasible and not longer than 2 hours after application. On arrival to an urban hospital with multiple personnel and access to advanced care, most tourniquets can likely be removed and hemorrhage control shifted to localized direct pressure if still necessary.

Clinical predictors of major intrathoracic injury in pediatric blunt trauma [3] Gunnink SM et al., Pediatr Emerg Care. 2024 Jan 1;40(1):10-15. PMID: 38157393.

Thoracic injury is a significant cause of death after blunt trauma in children. While there are multiple risk stratification tools that guide radiological evaluation after blunt head, cervical spine, and abdominal trauma, no pediatric guidelines address thoracic imaging. Efforts to minimize pediatric radiation exposure must be balanced by informed decision making regarding the utility of thoracic CT to provide essential diagnostic information.

The authors conducted a retrospective analysis of a pediatric trauma database of patients under 18 years of age seen at a level 1 pediatric trauma center. In 373 patients, 20 patients (5.4%) had major injuries that were missed on chest x-ray. The authors also found that older (>15 years) patients who present with chest pain, abnormal findings on chest auscultation, and age-related tachycardia were at higher risk for major thoracic injuries. While this study was small, retrospective, and limited to a single center, it highlights the importance of developing criteria for the performance of thoracic CT in the evaluation of pediatric patients with blunt chest trauma.

Contemporary management and outcomes of blunt traumatic American Association for the Surgery of Trauma Organ Injury Scale grades III and IV pancreatic injuries in children: A Trauma Quality Improvement Program analysis[4] Rauh JL et al., J Trauma Acute Care Surg. 2024 Sep 1;97(3):365-370. Epub 2024 Jan 29. PMID: 38282245.

Patients with blunt pancreatic injuries can be complex and challenging to care for. It has become standard for AAST grade 1 and 2 injuries to be treated non-operatively but there is debate about the care for grade 3 & 4 injuries with main duct injury. There is a growing body of evidence that these injuries can be successfully treated non-operatively.

This study helps demonstrate how these grade 3 & 4 injuries are being managed. The authors analyzed the TQIP data from 2013 to 2021. They found that 86% of grade 3 injuries were managed non-operatively (NOM) and 84% of grade 4 injuries. In both groups, NOM management trended to be isolated injuries and operative management patients had more severe polytrauma injuries. The study doesn’t necessarily demonstrate superior outcomes with NOM but it demonstrated how centers contributing to TQIP are managing these injuries.

PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study[5] Leonard JC, et al., Lancet Child Adolesc Health. 2024 Jul;8(7):482-490. Epub 2024 Jun 4. PMID: 38843852

Cervical spine injuries in children are rare but timely diagnosis is important for treatment. The use of ionizing radiation in children can increase cancer risk in the future. Though two large studies conducted in adults led to widespread adoption of screening guidelines, these studies included few children and therefore no evidence-based guideline for screening of cervical spine injuries exists for pediatric trauma patients.

In this PECARN, prospective observational study of over 22,000 children presenting with blunt trauma, a prediction rule was derived based on clinical findings alone.  The decision rule has high sensitivity (94%), moderate specificity (64%) and a negative predictive value of 99.9%.

Defining pediatric trauma center resource utilization: Multidisciplinary consensus-based criteria from the Pediatric Trauma Society[6]Snyder C. et al. J Trauma and Acute Care Surg. 2024 May 1;96(5):799-804. PMID: 37880842

As injury is the leading cause of death in children, and undertriage is associated with increased morbidity and mortality, there is a need for effective pediatric trauma triage. Current tools are based on mortality risk metrics, which may not fully capture the severity of pediatric injuries. Understanding resource utilization at pediatric trauma centers (PTCs) may provide a more comprehensive basis for triage decisions and more accurately identify the burden of injury. There has been a lack of consensus on what constitutes resource utilization that incorporates all elements of a PTC. This study, led by the Pediatric Trauma Society (PTS) Research Committee, aimed to address this gap by developing consensus-based criteria for defining PTC resource utilization involving experts from various pediatric disciplines.

Using a steering group, a literature review was performed to develop candidate criteria. Each criterion was a statement that completed the sentence: “Pediatric patients with traumatic injuries have used PTC resources if they…” These criteria were then presented to a diverse Delphi panel of experts for initial feedback. Three iterative rounds of Delphi voting were performed with panelists rating each statement using a 5-point Likert scale. Accepted statements had 75% or more of panelists voting agree or strongly agree, and those with 50-75% agreement were revised. Input was also solicited from the members of PTS at the national meeting to evaluate statements not achieving consensus. The final list of consensus statements was reviewed by the PTS Guidelines Committee and had external validation by review by the Society of Pediatric Anesthesiology. The final list of criteria consists of 14 statements that achieved 75% or greater consensus. These statements are comprehensive and cover a range of interventions and services, providing a robust framework to assess the likelihood of PTC resource utilization. The criteria are designed to offer a more comprehensive assessment of injury burden than traditional severity scores, encompassing a broad spectrum of interventions beyond immediate trauma care. While these criteria are not intended to mandate transport to a PTC, they can guide system-level triage decisions and help identify patients who may benefit from PTC resources, potentially reducing unnecessary interfacility transfers. Future research is needed to optimize the clinical application of these criteria, including their incorporation into field triage protocols to improve prediction of PTC resource utilization in pediatric trauma cases. Ultimately, these criteria may inform policy decisions and resource allocation to better align with the demands of pediatric trauma care

Development and validation of a pediatric model predicting trauma-related mortality[7]. Evans M. et al. BMC Pediatr. 2023 Dec 18;23(1):637. PMID: 38110884

As the majority of trauma-related deaths in children are within the first 24 hours of hospital arrival, this creates an initial critical period for accurate assessment and necessary intervention to ensure outcome optimization. In result, several models for mortality assessment in trauma patients have been developed. However, the most well-established were first derived in adults, including the Injury Severity Score (ISS) and the Revised Trauma Score (RTS), and while others are designed for use in pediatric trauma, such as the BIG, it can only be calculated once someone successfully obtains a blood draw and lab result. Although founded on well-established predictors of mortality and preserving a well-intended practical simplicity, these models remain limited in their clinical utility in pediatric trauma patients as they overall fail to capture the clinical picture, such as when the trauma mechanism is a gunshot wound in an eight-year-old.

Using data from the National Trauma Databank (NTDB 2007-2015), Evans et al. developed a novel mortality prediction model intended for use in patients ≤ 18 years-old who experience any trauma mechanism-induced injury. Starting with 80% of the 2007-2014 NTDB patients as their training set, and basic mechanism, clinical and physiologic variables, the authors applied a backwards elimination logistic regression model to factors predictive of mortality on univariate analysis until all covariates were with p < 0.10. This resulted in a final multivariable model consisting of 8 mortality predictors: temperature, race, age, GCS, injury type, systolic blood pressure (cardiac measure) + mechanism of injury and sex, which the authors cleverly named “TRAGIC+”. Receiver operative curve analysis was applied and optimal threshold determined by Youden’s index to optimize sensitivity and specificity for predicting mortality. Using the remaining 20% of the 2007-2014 NTDB patients as their internal validation set and the 2015 NTDB patients as their temporal/external validation set, the TRAGIC+ model demonstrated outstanding predictive performance with area under the curve of 0.964 (95% CI: 0.959-0.969), sensitivity of 92.2% and specificity of 94.4% for mortality prediction. Furthermore, using the same test patients, they applied the ISS and RTS model and found the TRAGIC+ model had superior predictive ability and calibration. To make the TRAGIC+ model usable and accessible for clinicians, the authors then translated the model into a dynamic nomogram located in a simple web-based application. Here a clinician can input their patient’s variables and receive probability of mortality in return. The TRAGIC+ prediction model can be accessed at this link: https://agmoreir.shinyapps.io/TRAGIC/.

Pediatric traumatic hemorrhagic shock consensus conference recommendations [8]. Russell RT. et al. J Trauma Acute Care Surg. 2023 Jan 1;94(1S Suppl 1):S2-S10. Epub 2022 Oct 17.

Hemorrhagic shock in pediatric trauma remains a common and preventable cause of death. Advances in the management of hemorrhagic shock in adults has been largely moved forward by management of combat victims. There is little data in the management of pediatric hemorrhage control. This article is a summation of a 16 multidisciplinary committee of the Pediatric Traumatic Hemorrhagic Shock Consensus Conference. They looked at 6 domains and proposed 21 recommendations on evidence, expert opinion and good practice.

The 6 domains covered: (1) blood products and fluid resuscitation for hemostatic resuscitation, (2) prehospital blood product use, (3) use of tranexamic acid and other hemostatic adjuncts, (4) use of tourniquets, (5) prehospital intubation and blood pressure management, and (6) resuscitation and use of hemostatic monitoring.

The main recommendations are: Prioritize the use of blood products over crystalloids. Use low-titer (< 200 immunoglobulin G) group O whole blood over individual blood components (RBC, plasma, platelets). Target high plasma/red blood cell ratios (1:1) to minimize the plasma deficit. Target high platelet-to-RBC weight-based-ratios (1:1) to minimize platelet deficit. Consider prehospital transfusion by out-of-hospital emergency medical service (EMS) based on product availability and clinical judgment. Consider tranexamic acid (TXA) empirically within 3 hours of injury. Consider TXA over aminocaproic acid as an antifibrinolytic agent. Limited evidence supports the empirical use of prothrombin complex concentrate, fibrinogen supplementation, or viscoelastic monitoring (VEM) for antifibrinolytic therapy. Treat hypofibrogenemia with fibrinogen replacement. Trained Individuals should use commercially available tourniquets for exsanguinating extremity hemorrhage. Avoid permissive hypotension. The resuscitation goals should focus on optimal end-organ perfusion and oxygen delivery. Employ an initial empiric resuscitation with massive transfusion protocols and balanced blood product administration. Utilize a goal-directed resuscitation strategy to optimize hemostasis and correct coagulopathy post-initial resuscitation. When available, incorporate VEM as an adjunct tool. Given the lack of published data, this guideline provides guidance in managing hemorrhagic shock in pediatric trauma patients.

Impact of individual components of emergency department pediatric readiness on pediatric mortality in US trauma centers [9]. J Trauma Acute Care Surg. 2023 Mar 1;94(3):417-424. Epub 2022 Sep 1.

The National Pediatric Readiness Project was developed as an initiative to empower all emergency departments to provide effective emergency care to children. The guidelines were published in 2012 and have been used to evaluate individual hospital ED pediatric capabilities. A recent article in the Wall Street Journal published a list of hospitals nationwide that have received state certification of some level of readiness for pediatric emergencies. This showed large areas of the US that do not have EDs that have done this evaluation.

This cohort study used the National Trauma Data Bank and the National Pediatric Readiness Project assessment of adult and pediatric centers taking care of at least 50 injured children. Using a risk adjusted model for trauma, observed to expected mortality ratios were calculated. They looked at 555 trauma centers and found that better than expected survival were found at centers with many components of the pediatric readiness tool in place. These findings agree with other papers showing EDs with pediatric readiness have lower mortality.

The convincing data that ED pediatric readiness is important has led the American College of Surgeons to have this as a requirement for verification in the 2022 Optimal Care document. Since many pediatric trauma patients are seen at non pediatric trauma centers, it should be imperative that all trauma centers and small hospitals become Peds Ready.

Impact of institutional prophylaxis guidelines on rates of pediatric venous thromboembolism following trauma-A multicenter study from the pediatric trauma society research committee [10] Labuz DF et al. J Trauma Acute Care Surg. 2023 Sep 1;95(3):341-346. Epub 2023 Mar 6.

There is substantial morbidity and mortality associated with venous thromboembolism (VTE) in trauma patients. While the incidence of VTE in injured children is much lower than adults (< 1% vs. 10-20%), it is higher (6-10%) in critically injured children and the associated morbidity is still significant. Thromboprophylaxis is variably utilized for pediatric trauma patients, despite joint management guidelines from the Pediatric Trauma Society and the Eastern Association for the Surgery of Trauma being published in 2017. Implementation of these guidelines has been lacking, in part, due to its basis on low-quality evidence and reliance on postinjury metrics like Injury Severity Score that makes it clinically difficult to implement. What VTE prophylaxis strategies benefit critically injured children is controversial, especially in those with a high risk for bleeding. The objective of this study was to perform a multicenter review of injured children to determine the impact of institutional chemoprophylaxis patterns on VTE rates. The authors hypothesized that a reduction in VTE rates would correlate with the implementation of a thromboprophylaxis institutional policy.

Overall 10 pediatric level I or II trauma centers contributed data for pediatric patients < 15 years of age, between Jan 1, 2009 and Dec 31, 201. The majority of data was acquired from each institutional Trauma Registry, following National Trauma Data Standard criteria and data definitions, with additional information for patients with a coded VTE event. VTE diagnosis was confirmed via chart review. Additional information gathered included time to diagnosis, method of diagnosis, prophylaxis use, and timing. Additionally, each center was queried regarding any institutional guideline for selective chemoprophylaxis or screening and, if present, the details of those guidelines and timeframe of implementation was collected.

A total of 45,202 patients were included, of which 28,359 patients (63%) were from the three largest centers (each which had a guideline in place during the study period, Guideline group), and 16,843 children (37%) who were from the 7 other centers (Which did not have guidelines in place, Standard group). Chemoprophylaxis guidelines varied but in general were based on age (over 10–14 years), ICU admission, and presence of two to three other risks factors (lines, BMI, intubation, altered mobility), and all were by administration of low molecular weight heparin.

Overall, there were 30 patients in the Guidelines group that had VTE (0.11%), compared to 33 in the Standard group (0.2%, p-value 0.02) however once accounting for the differences in patient and injury characteristics, there was no difference in VTE rates (0 = 0.05). Overall chemoprophylaxis rates were actually higher at the Standard centers than in centers with a Guideline in place, however, the guidelines centers had higher rates of VTE prophylaxis utilized in children admitted to the ICU. Among children who did get a VTE diagnosis, there was a higher rate of chemoprophylaxis prior to VTE diagnosis in the Standard group (8/33, 24%) than in the Guidelines group (2/30, 6.7%)—although this was not statistically significant.

In the Guidelines group, 17/30 (57%) of patients who developed VTE did not meet institutional metrics for routine chemoprophylaxis. Furthermore, the vast majority of those children (15/17) were deferred based on age alone. The other 2 children were old enough to “qualify” but lacked other risk factors to be started on protocol. Of the remaining 13 children who actually did meet institutional guidelines for chemoprophylaxis, only one patient received prophylaxis; the rest did not per physician discretion. The majority of these children had high risk for bleeding: 9 required early transfusion and 4 were taken to the operating room for craniotomy.

In this multicenter retrospective analysis, among critically injured children, there was no difference in VTE rates between centers with and without guidelines for VTE prophylaxis. The authors conclude that the overall impact of a prophylaxis policy relies on the quality of, and adherence to, the policy/guidelines.

Diagnostic accuracy of screening tools for pediatric blunt cerebrovascular injury: An ATOMAC multicenter study [11] Nickoles TA et al. J Trauma Acute Care Surg. 2023 Sep 1;95(3):327-333. Epub 2023 Jan 25.

Blunt Cerebral Vascular Injury (BCVI) is a rare event in pediatric patients, but is difficult to diagnose on physical exam and carries a risk of stroke as high as 29% and mortality rate estimated between 3-19%. Computed tomography angiography (CTA) is the most commonly used diagnostic test, but requires contrast administration and radiation exposure. There are three sets of screening criteria for BCVI in adults (Denver, Memphis, and EAST criteria) and two sets of criteria in children (Utah and McGovern score) to determine need for CTA imaging, all of which were developed using retrospective single center data. Adequate comparisons of the diagnostic accuracy of these screening tools within a large multi-center pediatric cohort have not been performed.

This study is the first to prospectively evaluate the diagnostic accuracy of each set of BCVI screening criteria using a multi-institutional observational pediatric data set, and the first to include post-discharge follow-up of both imaged and non-imaged patients. Between 2017-2020, children younger than 15 years of age sustaining blunt trauma to the head, neck, or face presenting to six Level 1 pediatric trauma centers were evaluated and data for all 5 BCVI sets of criteria collected. Patients then underwent CTA of the head or neck if the Memphis criteria were met at presentation or if neurologic abnormalities were detected at 2-week follow-up. BCVI patients were treated with systemic heparin (for those with multiple injuries) or low-dose aspirin (for those with isolated BCVI), until follow-up CTA at 7-10 days. If BCVI had resolved at that time, anticoagulation was stopped, while persistent/worsening BCVIs were treated by Biffl grade in consultation with neuro-interventional teams.

Of 2284 patients evaluated, 1461 cases had CTA and/or 2-week clinical follow-up and sufficient data for analysis. There were 24 cases total of BCVI (1.6%), 76.0% were grade I or II and 24.0% were grade IV or V. Sensitivity, specificity, positive predictive value, and negative predictive value for each set of criteria were calculated. The Memphis criteria had the highest sensitivity (91.7%), meaning it would have missed the fewest BCVIs, and required approximately 20 CTAs to detect one BCVI. The Utah score had the highest specificity, requiring 6.5 CTAs to detect 1 BCVI, but had the lowest sensitivity (45.8%) and would have missed more than half of BCVI injuries. A tool that narrows the Memphis criteria, while maintaining its sensitivity, is needed for application in pediatric patients.

Balanced Resuscitation with whole blood versus component therapy in critically injured pre-adolescent children: getting there faster with fewer exposures [12] McLoughlin RJ et al. J Trauma Acute Care Surg. 2023 Sep 6. Epub ahead of print

It is well-known in adult trauma literature that balanced component therapy (CT) in hemorrhagic shock improves survival. More recently, use of whole blood resuscitation (WB) expedites resuscitation and decreases volume required to achieve a balanced resuscitation.

The authors used TQIP database to evaluate pediatric trauma patients requiring balanced resuscitation comparing CT vs WB. They found children receiving WB achieved balanced resuscitation faster with less transfusion exposures and less volume received. This finding should encourage whole blood resuscitation when available over the use of component therapy.

Hemodilution in pediatric trauma:  Defining the expected hemoglobin changes in patients with liver and/or spleen injury: An ATOMAC+ secondary analysis[13]. Stottlemyre RL, et al. J Pediatr Surg. 2023 Feb;58(2):325-329. Epub 2022 Oct 23.

In 2000, the American Pediatric Surgery Association (APSA) Trauma Committee developed guidelines to standardize the care of children with blunt liver and splenic injuries (BLSI) which were largely based on the American Association for the Surgery of Trauma Organ Injury Grading scales with subsequent great improvements in outcomes for this patient population1. Since, there has been an evidence-based evolution of practice toward hemodynamic status as the main determinant of BLSI management2-4. In 2015, the Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium (ATOMAC) debuted its BLSI practice management guidelines which were largely founded on the principles of non-operative management (NOM) and intervention based on physiologic state5. In 2019, an update to the APSA Blunt Liver/Spleen Guidelines reflected the accruing evidence supporting management based on hemodynamic state over radiologic grade6. However, despite it being known that most patients with BLSI do not experience delayed intraperitoneal bleeding, serial hemoglobin monitoring remains an important part of this management guideline. Moreover, ATOMAC wasn’t the only group to demonstrate that most pediatric patients who fail NOM due so due to hemodynamic instability and necessitate a trip to the operating room within the first five hours of injury7, 8. Therefore, it is worth questioning if routine serial hemoglobin monitoring in pediatric BLSI is utilizing unnecessary resources without informing clinical management.

In February of 2023, JPS published an ATOMAC+ planned secondary analysis which directly questions the utility of serial hemoglobin monitoring in pediatric BLSI9. In this study, 716 patients ≤ 18 years-old who presented to one of 10 Level I pediatric trauma centers between April 2013 and January 2016 with CT evidence of BLSI, hemodynamic stability and ≥ 1 repeat hemoglobin measurement within 10 hours of the initial hemoglobin level were classified into one of four groups: 1) non-bleeding (18.3%), 2) bleeding, not requiring transfusion (67.9%), 3) bleeding requiring transfusion within 24 hours (17.9%), and 4) bleeding resulting in a failure of NOM (3.1%). They found that serial hemoglobin measurements offered little insight into clinical bleeding. Initial hemoglobin trends for the group that was transfused within 24 hours and the group that failed NOM were well above the normal transfusion threshold of 7 g/dL. Furthermore, even non-bleeding patients had a 9% hemoglobin drop in the first 24 hours (as compared to 15% drop for those bleeding, non-transfused; 7% drop followed by stabilization for those bleeding and transfused; 9% increase followed by stabilization for those that failed NOM) which they attribute to an expected physiologic and iatrogenic hemodilution. Conversely, significant differences were observed for initial-hemoglobin levels between non-bleeding patients and patients who were transfused or failed NOM. Based on ROC curve analysis, a cut point of 9.25 g/dL was associated with failed NOM and by logistic regression, an initial hemoglobin of > 9.25 g/dL was associated with an 11-fold decreased risk of requiring transfusion within the first 24 hours and a 14-fold decreased risk of failure of NOM. This suggests that although the serial evaluation of hemoglobin may not be informing management, a hemoglobin < 9.25 g/dL at time of presentation for hemodynamically stable children with BLSI may be an important indicator of patients who warrant closer attention and potentially further intervention.

Clinical and radiographic predictors of the need for facial CT in pediatric blunt trauma: a multi-institutional study[14]. Nguyen BN, et al. Trauma Surg Acute Care Open. 2022 Apr 24;7(1):e000899. eCollection 2022.

Facial fractures are relatively rare events in pediatric blunt trauma. Like other rare events, there is currently insufficient data to generate guidelines. CT head is commonly obtained in blunt trauma, but there is uncertainty about when to add a dedicated facial CT which carries the benefits of thinner image slicing and extension through the mandible. Smaller studies have suggested that a CT head will capture a majority of clinically significant facial fractures in patients without evidence of mandibular or dental trauma.

This five center, retrospective study is the largest study to date on the topic of CT head as a sufficient screening tool for facial fractures. These results support that, absent exam findings of dental, alveolar, or mandibular trauma, CT head can effectively exclude clinically significant injuries and further reduce radiation exposure in pediatric trauma patients. The authors note that institution specific CT reconstruction techniques impact the ability of a CT head to detect facial fractures, as well as whether or not a facial reconstruction can be obtained from a combined CT head and neck.

Isolated low-grade solid organ injuries in children following blunt abdominal trauma: Is it time to consider discharge from the emergency department [15]? Plumblee L, et al. J Trauma Acute Care Surg 2020;89(5):887-93.

Many children admitted with low grade solid organ injuries (SOI) are admitted, receive little or no treatment, and are then discharged. The authors used 2 large data sets from prior prospective studies to see if some of the children could have been safely discharged from the emergency department (ED) after low grade SOI. The databases were from the prior PECARN study, and a study done by the PedSRC. 517 children had a grade I, II, or III injury, and 262 had no other major injuries. Of the 262 patients, none of the grade I or grade II SOIs required any interventions. Only about 3% of the grade III injuries needed an intervention. These findings are not too dissimilar from a follow-up study done by some of the same authors using TQIP data and presented at the Pediatric Trauma Society where they found a slightly higher 1.7% of the grade I or II injuries underwent an intervention [16].

This study is important because it attempts to identify a significant number of avoidable hospital admissions. The major limitation is that the studies excluded 56 patients with hollow viscus injuries. Moreover, these intestinal injuries may not have been clinically apparent in the emergency department. Additionally, the author acknowledges that some of the patients may have had other injuries requiring admission not captured in the two databases. Overall, it is clearly time to start the discussion about discharging isolated grade I and II solid organ injuries from the emergency department.

Mass Shootings in America: Consensus Recommendations for Healthcare Response [17]. Goolsby C, et al. JACS July 18, 2022 - Volume - Issue - 10.1097/XCS.0000000000000312.

In 2021, 702 people have died in Mass Shooting Incidents in the US. Trauma center responses to MSIs should be coordinated as no one hospital can be the sole provider of care. Preparedness for the inevitable MSI event is crucial. Articles regarding this subject in the past have touched on taking lessons from the battlefield and applying to the emergency room. Local, regional and federal agencies have provided tools to aid in disaster preparedness emphasizing a multi-disciplinary approach. Every trauma center is mandated to have a mass casualty plan and perform drills.

This article tries to address healthcare needs in response to MSIs. The process brought representatives from 6 recent MSI sites around the country to make recommendations for other health care settings to improve outcomes. They made recommendations regarding readiness training, public education, triage, communication, patient tracking, medical records, family reunification, and mental health services for responders. This article emphasizes pearls from those who have experienced MSIs first hand.

The small (14 Fr) percutaneous catheter (P-CAT) versus large (28-32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial [18]. Kulvatunyou N, et al. J Trauma Acute Care Surg. 2021 Nov 1;91(5):809-813.

The traditional treatment of a hemothorax involved open placement of a large-bore (36- or 40-Fr) chest tube in adults or adult-sized teens. Previous studies have shown that smaller tubes are effective for hemothorax evacuation, and recently a single-center randomized trial showed that a 14-Fr percutaneous catheter (PC), or “pigtail” was just as efficacious for evacuation of blood and air in traumatic hemothorax or hemopneumothorax. Previous studies suggest less pain and discomfort for patients in placement of the PC versus a larger tube. These data are in adults without any similar randomized data in the pediatric population.

The authors organized a multicenter randomized trial to evaluate the use of either 14-Fr PC’s or 28- to 32- Fr chest tubes for patients 18 or older with traumatic hemothorax or hemopneumothorax. 120 patients at 5 institutions were randomized with primary outcome measure of failure rate for catheter drainage (defined as persistent radiographically evident hemothorax requiring additional intervention). Secondary outcome measures included amount of drainage by time interval, ventilator days, hospital and ICU length of stay, and a non-validated insertion perception experience (IPE) score to measure pain and tolerability of procedure. The study found the two arms similar in all but the IPE score, where the PC group had better tolerance of the procedure. While this study was conducted in adults, not children, this may be generalizable to adult-sized teens presenting with hemothorax.

Urine Leaks in Children Sustaining Blunt Renal Trauma [19]. Ghani MOA, et al. J Trauma Acute Care Surg. 2022 Jan 4. Online ahead of print.

Urinary leak occurs in 30-50% of adults with a high-grade renal injury, but the frequency of this complication in pediatric patients is less clear. Observational management is the standard of care, even with high grade injuries. Also, there are no guidelines establishing the criteria for – and optimal timing of – follow up imaging after injury to evaluate for urine leak.

This is a large single-institution retrospective review of 347 patients with blunt renal trauma, 44 (12.4%) of whom developed a urine leak after their injury. The median age of patients studied was 16, but urine leak was more frequent in younger patients (median age 13). The most frequent presenting symptoms were fever (59%) and hematuria (70.5%) on arrival. Admission vitals and injury severity were not significantly different for patients who developed a urine leak. Patients who did not receive on-table delayed CT on presentation were more likely to have a non-diagnostic scan and require repeat imaging later in the hospitalization. Injury patterns associated with leak included: isolated renal trauma, injury to the upper lateral quadrant of the kidney, and grade of injury 3 or above. Based on these results, patients with a blunt renal injury of grade 3 or higher should receive delayed phase CT imaging during the initial workup, which has been implemented into practice at the authors’ institution.

It is time for TEG in pediatric trauma: unveiling meaningful alterations in children who undergo massive transfusion [20]. Phillips R, et al. Pediatr Surg Int. 2021. Nov;37(11):1613-1620. Epub 2021 Sep 17.

Thromboelastography (TEG) initially was used for monitoring coagulation in cardiac surgery and starting in the 1990s was used as a research tool in trauma patients. TEG then was described for use in guiding massive transfusion protocols in adult trauma patients which has allowed for more goal directed resuscitation. Use of TEG to direct massive transfusion in pediatric trauma patients has not been as broadly accepted as in adult trauma patients. There is little information on use of TEG directed pediatric resuscitation and if there are any differences in TEG results that may be of clinical importance.

This study retrospectively reviewed pediatric trauma patients at two pediatric trauma centers who had admission TEGs obtained and they compared those who received massive transfusions versus those who did not. They reviewed differences in the TEG results between these cohorts. Patients that received massive transfusion had TEG findings consistent with low fibrinogen and abnormal platelet function. The authors conclude that using TEG would alter the resuscitation by earlier cryoprecipitate and platelet transfusion. Albeit as a small retrospective study, it does demonstrate how TEG directed resuscitation may impact product usage and ultimately morbidity and mortality in pediatric patients requiring massive transfusion.

The small (14 Fr) percutaneous catheter (P-CAT) versus large (28-32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial [18]. Kulvatunyou N, et al. J Trauma Acute Care Surg. 2021 Nov 1;91(5):809-813.

The traditional treatment of a hemothorax involved open placement of a large-bore (36- or 40-Fr) chest tube in adults or adult-sized teens. Previous studies have shown that smaller tubes are effective for hemothorax evacuation, and recently a single-center randomized trial showed that a 14-Fr percutaneous catheter (PC), or “pigtail” was just as efficacious for evacuation of blood and air in traumatic hemothorax or hemopneumothorax. Previous studies suggest less pain and discomfort for patients in the placement of the PC versus a larger tube. These data are in adults without any similar randomized data in the pediatric population.

The authors organized a multicenter randomized trial to evaluate the use of either 14-Fr PC’s or 28- to 32- Fr chest tubes for patients 18 or older with traumatic hemothorax or hemopneumothorax. 120 patients at 5 institutions were randomized with primary outcome measure of failure rate for catheter drainage (defined as persistent radiographically evident hemothorax requiring additional intervention). Secondary outcome measures included amount of drainage by time interval, ventilator days, hospital and ICU length of stay, and a non-validated insertion perception experience (IPE) score to measure pain and tolerability of procedure. The study found the two arms similar in all but the IPE score, where the PC group had better tolerance of the procedure. While this study was conducted in adults, not children, this may be generalizable to adult-sized teens presenting with hemothorax.

Evaluation of Emergency Department Pediatric Readiness and Outcomes Among US Trauma Centers [21], Newgard CD, et al. JAMA Pediatr. 2021 Sep 1;175(9):947-956.

All pediatric surgeons recognize that trauma is the leading cause of mortality for children. Children receiving post-injury care at pediatric trauma centers are known to have lower mortality rates and lower rates of splenectomy after blunt trauma when compared to non-pediatric centers. Timely access to pediatric trauma centers for all children, however, is geographically limited. Only 43% of children live within a 60-minute drive to a pediatric trauma center, and it is estimated that as high as 80% of children receive initial post-injury care outside of a pediatric trauma center. The National Pediatric Readiness Project (NPRP) is a quality improvement initiative that aims to ensure that emergency departments have the essential guidelines and resources in place to provide effective emergency care to children, regardless of pediatric designation status. Emergency Department Pediatric Readiness scores for individual facilities are measured by facility-level self-reported survey. While pediatric trauma centers have been shown to have high Pediatric Readiness scores, adult trauma centers are known to have pediatric readiness scores that are similar to non-pediatric general hospitals nationally. Mortality outcomes for pediatric critical illness have been shown to be improved at centers with higher Pediatric Readiness scores, but this relationship has not been shown within trauma centers.

This retrospective cohort study of 832 trauma center emergency departments with known pediatric readiness scores derived from the 2013 National Pediatric Readiness Assessment, examined center-specific risk-adjusted mortality as a function of initial receiving center weighted pediatric readiness scores. This study examined in-hospital risk-adjusted mortality of over 370,000 children, and demonstrated that children that were initially treated at an emergency department with weighted pediatric readiness score (wPRS) in the top quartile were less likely to die than children initially treated in EDs with a wPRS in the lowest quartile (adjusted odds ratio 0.58; 95% CI, 0.45-0.75). This study highlights the importance of pediatric trauma centers partnering with outlying referring centers to promote pediatric readiness within community and critical access hospitals, as well as in neighboring adult freestanding centers. As the majority of children receive initial post-injury stabilization outside of pediatric trauma centers, collaborative efforts to improve pediatric readiness in these referring centers have the potential to impact mortality for patients eventually transferred to pediatric trauma centers for definitive care.

Nonaccidental Trauma in Pediatric Patients: Evidence-based Screening Criteria for Ophthalmologic Examination [22], Ip et al J Amer Ass Ped Ophth Strabismus 2020 Aug 18:S1091-8531(20)30158-0.

Ophthalmologic examination is a standard component of the evaluation of nonaccidental trauma (NAT) in children. Previous studies of children being evaluated have demonstrated that intracranial hemorrhage is associated with the presence of retinal hemorrhage (RH) and that retinal hemorrhage is rare in the absence of intracranial hemorrhage.

This single institution, retrospective study reviewed patients who received a NAT evaluation that included an ophthalmologic examination over a four-year period. The study included 192 children between six days and six years of age with neuroimaging obtained in 171 of these evaluations. Only 15 (eight percent) of patients had RH – all of whom had positive neuroimaging (defined as any abnormality other than scalp hematoma). Positive neuroimaging was associated with the presence of RH with odds ratio of 21.0. Other findings associated with RH included subdural hemorrhage (OR=54), extra-axial hemorrhage (OR=28.3), seizures (OR=15.8), altered mental status including seizure (OR=8.3), brain parenchymal hypoxia/ischemia/infarct (OR=10.1) and vomiting (OR=4.4). The authors concluded that neuroimaging is an effective screening tool and that an ophthalmologic examination should not be routinely performed in the absence of abnormal findings on neuroimaging.

Tranexamic Acid in Pediatric Combat Trauma Requiring Massive Transfusions and Mortality [23], Hamele et al J Trauma Acute Care Surg 2020 Aug;89(2S Suppl 2):S242-S245.

Guns, Scalpels, and Sutures: The Cost of Gunshot Wounds in Children and Adolescents [24], Phillips et al J Trauma Acute Care Surg 2020; 89(3) 558-564.

Nationwide Use of REBOA in Adolescent Trauma Patients: An Analysis of the AAST AORTA Registry [25], Theodorou et al Injury

Timing of tracheostomy placement among children with severe traumatic brain injury: A propensity-matched analysis [26], McLaughlin et al J Trauma Acute Care Surg 2019;87:818–26.

Adult intensive care has moved towards early performance of tracheostomy in patients requiring prolonged mechanical ventilation as it is associated with less frequent complications and possibly also lower mortality. The timing, necessity and appropriateness of tracheostomy in critically ill children is more complex. There is a natural tendency to wait longer before broaching the subject of tracheostomy with parents. This dilemma is especially relevant for children with traumatic brain injury (TBI) in which the long term neurologic prognosis is frequently uncertain.

The data presented by McLaughlin et al provide more robust support for early timing of tracheostomy in critically injured pediatric patients. Specifically, they focused on 361 children with severe TBI with early tracheostomy defined as sooner than 15 days after injury. Although their data is retrospective (from the National Trauma Data Bank), they attempted to account for critical confounders by matching patients based on propensity scores. While early timing of tracheostomy was not associated with lower mortality, it was significantly associated with fewer ventilator days, time in the intensive care unit, lower odds of pneumonia and higher odds of discharge to home. Finally, this study had a notable finding that 95% of children not receiving tracheostomy were on the ventilator for 18 days or less suggesting that few children with severe TBI will be successfully extubated beyond this point.

Defining Massive Transfusion in Civilian Pediatric Trauma [27], Rosenfeld et al J Pediatr Surg 2019 May;54(5):975-979.

Massive transfusion protocols (MTP) are intended to rapidly deliver predefined volumes of blood products in specific ratios to critically ill patients in hemorrhagic shock. Currently, there is a lack of data validating existing pediatric MTP triggers.

The purpose of this study was to identify an optimal definition of massive transfusion in civilian trauma. Severely injured children (< =18-years old, ISS >=25) in the Trauma Quality Improvement Program research datasets 2014-2015 that received blood products were identified. Children with traumatic brain injury and non-survivable injuries were excluded. Using receiver operator curves and sensitivity and specificity analysis in this cohort of 270 patients, sensitivity and specificity for early mortality was optimized at a 4-hour transfusion volume of 37mL/kg. This threshold predicted the need for a hemorrhage control procedure (OR 8.60; 95% CI 4.25-17.42; p < 0.01) and early mortality (OR 4.24; 95% CI 1.96-9.16; p < 0.01).
The threshold of 37mL/kg/4h for defining massive transfusion in the civilian pediatric trauma population accurately predicts early mortality and the need for hemorrhage control operations. This marker can provide clinicians with a timely prognostic indicator, improve research methodology, and resource utilization.

Rethinking the Definition of Major Trauma: The Need For Trauma Intervention Outperforms InjurySeverity Score and Revised Trauma Score in 38 Adult and Pediatric Trauma Centers [28], Roden-Foreman et al J Trauma Acute Care Surg 2019 Jun 24.

Prevention of Firearm Injuries Among Children and Adolescents Consensus-Driven Research Agenda from the Firearm Safety Among Children and Teens (FACTS) Consortium [29], Cunningham et al JAMA Pediatr. 2019 Jun 10.

High Volume Crystalloid Resuscitation Adversely Affects Pediatric Trauma Patients [30], Coons et al J Pediatr Surg 2018 Jul 24.

Current research in adult trauma resuscitation has emphasized lower volumes of crystalloid fluid in order to decrease adverse outcomes (e.g. ventilator days, intensive care unit (ICU) stay, ongoing hemorrhage, abdominal compartment syndrome). The relationship between volume of crystalloid resuscitation and outcome in pediatric trauma has not been well described.

The authors retrospectively evaluated outcomes of pediatric trauma patients associated with differing volumes of crystalloid resuscitation. They analyzed patient cohorts based on volume of crystalloid resuscitation at 24 and 48 hrs: less than 20 mL/kg/day, 20 to 40 mL/kg/day, 40 to 60 mL/kg/day and greater than 60 mL/kg/day. They evaluated the incidence of adverse outcomes in each of these cohorts. They discovered that administration of high volumes of crystalloid fluid (i.e. greater than 60 mL/kg/day) in the first 48 hours was associated with significantly increased ICU length of stay, overall length of stay, days on the ventilator and time spent NPO. These findings held true when adjusting for patient age, weight, Glascow coma scale and Injury Severity Score.

Critically injured children should receive judicious fluid resuscitation with crystalloid, as high volume fluid resuscitation (i.e. greater than 60 mL/kg/day) is associated with worse pulmonary outcome and length of stay.

Implementation of Clinical Effectiveness Guidelines for Solid Organ Injury after Trauma: 10-year Experience at a Level 1 Pediatric Trauma Center [31], Leeper et al J Pediatr Surg 2018 Apr;53(4):775-779.

U.S. Pediatric Burn Patient 30-Day Readmissions [32], Wheeler et al J Burn Care Res 2018 Jan 1;39(1):73-81.

Indications and Outcomes of Extracorporeal Life Support in Trauma Patients [33], Swol et al. J Trauma Acute Care Surg 2018 Jun;84(6):831-837.

Consistent Screening of Admitted Infants with Head Injuries Reveals High Rate of Non-Accidental Trauma [34], Kim et al J Pediatr Surg 2017.

Use of a screening guideline has eliminated screening disparities in evaluating for NAT in infants admitted with an unwitnessed head injury. Retrospective review of 563 infants admitted with an unwitnessed head injury and screened for NAT had an overall rate of NAT of 25.6% (n = 144). Screening for NAT was consistent across race and insurance status in this patient population. Logistic regression analysis showed that NAT was associated with a higher ISS (p < 0.0001), positive skeletal survey (p< 0.0001), and no insurance or government insurance (p = 0.0047). Age, race and sex did not correlate with NAT.
There is a high rate of NAT in infants admitted after a head injury not witnessed in a public situation. Victims of NAT admitted with an unwitnessed head injury have a higher ISS, positive skeletal survey and no insurance or government insurance than those with accidental injury.

Acute Procedural Interventions after Pediatric Blunt Abdominal Trauma: A Prospective Multicenter Evaluation [35], Arbra et al J Trauma Acute Care Surg 2017 Oct;83(4):597-602.

This is a secondary analysis of a 14 center prospective evaluation of pediatric patients presenting to the emergency center with suspected blunt abdominal trauma. Of 2,188 patients, 261 had abdominal injury identified on CT. 17% of these received an acute intervention (surgery or angioembolization). The most common reason for surgery was hollow viscus injury (59%). Patients who required acute intervention were more commonly hypotensive, had a lower GCS, and abnormal abdominal physical exam at presentation than those that did not require intervention.

A Cohort Study of Blunt Cerebrovascular Injury Screening in Children: Are They Just Little Adults? [36], Cook et al J Trauma Acute Care Surg 2018 Jan;84(1):50-57.

To evaluate the efficacy of blunt cerebrovascular injury (BCVI) screening criteria in children, the Denver criteria (DC), EAST guidelines, and Utah score (US) were retrospectively applied to 558 children (age less than 18 years) who sustained blunt trauma at a single center from 2005 through 2015 and received neck imaging (96% CTA; 4% MRA). The primary outcome was the false-negative rate (Type II error) of the screening tests.

Ninety-six patients with 128 BCVIs for an incidence of 1.3%. The patient population were primarily adolescent, male, were injured following a motor vehicle crash and were severely injured. In-hospital mortality was 9% and the overall incidence of CVA in children with a diagnosis of a BCVI was 18%. Aspirin was most common treatment used (59%). With respect to the primary outcome, the false-negative rates for the DC was 2%, EAST was 17%, and US was 17% and the difference was statistically significant. With respect to the clinically meaningful false-negative rate (patients who did not meet clinical screening criteria and developed a CVA); the DC was 0%, EAST was 12%, and US was 6%; the differences were not statistically significant. The authors comment that under their current practice 6 CTAs of the neck would need to be order to identify 1 BCVI and 33 CTAs to identify 1 patient with neurologic sequelae of their BCVI. The study has several limitations including a significantly higher incidence of BCVI in their cohort as well as limitations associated with a retrospective cohort design, particularly with respect to the fact that clinically silent injuries were not identified and additional screening test characteristics such as sensitivity, specificity, or the negative and positive predictive values could bot be evaluated.

The 3 most commonly used clinical screening criteria have a sizeable false-negative rate, although the most liberal criteria, the DC, performed the best. These findings support the recommendations to screen children according to adult guidelines and support the use of a liberal approach to clinical screening and imaging for BCVI

Variability of Child Access Prevention Laws and Pediatric Firearm Injuries [37], Hamilton et al J Trauma Acute Care Surg 2017 Dec 28.

Child access prevention (CAP) laws impart criminal liability to adults who allow children access to firearms. CAP laws are not federally mandated and therefore there is variability in the laws across states. Strong CAP laws require safe storage of firearms while weak CAP laws only impose criminal liability if a child gains access to a gun. This study utilized the KID (Kids’ Inpatient Database) to find that strong CAP laws were associated with a significant reduction in all (70%), self-inflicted (46%) and unintentional (56%0 pediatric firearm injuries. There was no association with intentional firearm injuries, which were more common in teenagers (14-17 years) and may not be related to gun access in the home.

Focused assessment with sonography for trauma in children after blunt abdominal trauma: A multi-institutional analysis [38], Calder et al J Trauma Acute Care Surg 2017 Aug;83(2):218-224.

The value of the injury severity score in pediatric trauma: Time for a new definition of severe injury? [39], Brown et al J Trauma Acute Care Surg 2017 Jun;82(6):995-1001.

Evaluation of guidelines for injured children at high risk for venous thromboembolism: A prospective observational study [40], Landisch et al J Trauma Acute Care Surg 2017 May;82(5):836-844

The association of non-accidental trauma with historical factors, exam findings and diagnostic testing during the initial trauma evaluation [41], et al J Trauma Acute Care Surg 2017 Jun 23;82(6):1147-57

The Sensitivity and Negative Predictive Value of a Pediatric Cervical Spine Clearance Algorithm that Minimizes Computerized Tomography [42], Arbuthnot et al J Pediatr Surg 2017 Jan;52(1):130-135.

Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents [43], Grool et al JAMA Pediatr 2016 Dec 20; 316(23):2504-2514

Prophylaxis Against Venous Thromboembolism in Pediatric Trauma: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society [44], Mahajerin et al J Trauma Acute Care Surg 2016 Dec 23.

Development and Implementation of a Standardized Pathway in the Pediatric Intensive Care Unit for children with Severe Traumatic Brain Injuries [45], Rakes et al BMJ Qual Improv Rep 2016 Nov 22;5(1).

Abnormalities in Fibrinolysis at the Time of Admission are Associated with Deep Vein Thrombosis, Mortality, and Disability in a Pediatric Trauma Population [31], Leeper et al J Trauma Acute Care Surg 2017 Jan;82(1):27-34.

Recommendations for venous thromboembolism prophylaxis in pediatric trauma patients: A national, multidisciplinary consensus study [46], Hanson et al J Trauma Acute Care Surg 2016 May;80(5):695-701.

Management of pediatric blunt renal trauma: A systematic review [47], LeeVan et al J Trauma Acute Care Surg 2016 Mar;80(3):519-28.

Acute traumatic coagulopathy in a critically injured pediatric population: Definition, trend over time, and outcomes [48], Leeper et al J Trauma Acute Care Surg 2016 Jul;81(1):34-41.

Operative vs Nonoperative Management of Pediatric Blunt Pancreatic Trauma: Evaluation of the National Trauma Data Bank [49], Mora et al J Am Coll Surg 2016 Jun;222(6):977-82.

Return on investment: Thirty years of commitment to the injured child has become a pathway to success [50], Tepas J Trauma Acute Care Surg 2016 May;80(5):689-94.

Post-traumatic liver and splenic pseudoaneurysms in children: Diagnosis, management, and follow-up screening using contrast enhanced ultrasound (CEUS) [51], Durkin et al J Pediatr Surg 2016 Feb;51(2):289-92.

The value of official reinterpretation of trauma computed tomography scans from referring hospitals [52], Onwubiko et al J Pediatr Surg 2016 Mar;51(3):486-9.

Risk factors for venous thromboembolism after pediatric trauma [53], Allen et al J Pediatr Surg 2016 Jan;51(1):168-71.

A Clinical Tool for the Prediction of Venous Thromboembolism in Pediatric Trauma Patients [54], Connelly et al JAMA Surg 2016 Jan 1;151(1):50-7.

The use of an institutional pediatric abdominal trauma protocol improves resource use [55], Fallon et al J Trauma Acute Care Surg. 2016 Jan;80(1):57-63.

Implementation of pediatric cervical spine clearance guidelines at a combined trauma center: Twelve-month impact [56], Rosati et al J Trauma Acute Care Surg 2015 Jun;78(6):1117-21.

Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger [57], Hale et al J Trauma Acute Care Surg 2015 May;78(5):943-8.

Benchmarks for splenectomy in pediatric trauma: How are we doing? [58], Polites et al J Pediatr Surg 2015 Feb;50(2):339-42.

Managing moderately injured pediatric patients without immediate surgeon presence: 10 years later [59], Boomer et al J Pediatr Surg 2015 Jan;50(1):182-5.

Pediatric emergency department thoracotomy: A large case series and systematic review [60], Allen et al J Pediatr Surg 2015 Jan;50(1):177-81.

Pediatric trauma and the Pediatric Trauma Society: Our time has come [61], Gaines J Trauma Acute Care Surg 2015 Jun;78(6):1111-6.

Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma andtranexamic acid study (PED-TRAX) [62], Eckert et al J Trauma Acute Care Surg 2014 Dec;77(6):852-8.

Validation of a clinical prediction rule for pediatric abusive head trauma [63], Hymel et al Pediatrics 2014 Dec;134(6):e1537-44.

Operative vs nonoperative management for blunt pancreatic transection in children: multi-institutional outcomes [64], Iqbal et al J Am Coll Surg 2014 Feb;218(2):157-62.

Children are safer in states with strict firearm laws: a National Inpatient Sample study. [65], Safavi et al J Trauma Acute Care Surg 2014 Jan;76(1):146-50.

Improving ATLS performance in simulated pediatric trauma resuscitation using a checklist [66], Parsons et al Ann Surg 2014 Apr;259(4):807-13.

National trends in pediatric blunt spleen and liver injury management and potential benefits of an abbreviated bed rest protocol [67], Dodgion et al J Pediatr Surg 2014 Jun;49(6):1004-8.

Management of children with mild traumatic brain injury and intracranial hemorrhage [68], Greenberg et al J Trauma Acute Care Surg 2014 Apr;76(4):1089-95.

Trauma remains a surgical disease from cradle to grave [69], Acker et al J Trauma Acute Care Surg 2014 Aug;77(2):219-25.

Routine repeat brain computed tomography in all children with mild traumatic brain injury may result in unnecessary radiation exposure [70], Howe et al J Trauma Acute Care Surg 2014 Feb;76(2):292-5.

References