TRAUMA COMMITTEE LITERATURE REVIEWS
The Trauma Committee literature reviews provide trauma related content pertinent to pediatric surgeons. The selections are compiled by committee members, but as a group, they are not endorsing the results of these studies as definitive practice.
For general inquiries or questions about any of the articles below, contact John Petty.
Earn MOC CME from the Literature Reviews
Continuing medical education maintenance of certification self-assessment credit is now available for the Cancer, Critical Care, Ethics, Outcomes and Trauma literature reviews.
- ExPERT subscribers: log onto ExPERT, go to Pre-Created courses, look for “Articles” under course type and select the desired course. Remember to use Chrome or Safari.
- Not a subscriber yet? Subscribe to ExPERT and start earning MOC CME*.
*Subscriptions purchased prior to October 1 expired December 31. Subscriptions purchased October 1 or later expire December 31.
Nonaccidental Trauma in Pediatric Patients: Evidence-based Screening Criteria for Ophthalmologic Examination
Ip et al. J Amer Ass Ped Ophth Strabismus 2020 Aug 18:S1091-8531(20)30158-0.
What is known
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.
What this study adds
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.
Other articles you may find interesting
Tranexamic Acid in Pediatric Combat Trauma Requiring Massive Transfusions and Mortality
Hamele et al. J Trauma Acute Care Surg 2020 Aug;89(2S Suppl 2):S242-S245. PMID: 32265388
Guns, Scalpels, and Sutures: The Cost of Gunshot Wounds in Children and Adolescents
Phillips et al. J Trauma Acute Care Surg 2020; 89(3) 558-564. PMID: 32833412
Nationwide Use of REBOA in Adolescent Trauma Patients: An Analysis of the AAST AORTA Registry
Theodorou et al. Injury epub ahead of print, PMID: 32798039
Timing of tracheostomy placement among children with severe traumatic brain injury: A propensity-matched analysis
McLaughlin et al.
J Trauma and Acute Care Surgery 2019;87:818–26.
What is known on this subject:
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.
What this study adds:
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
Rosenfeld et al. J Pediatr Surg. 2019 May;54(5):975-979.
What is known on this subject: 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.
What this study adds: 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.
Other articles you may find inteteresting:
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.
Roden-Foreman et al. J Trauma Acute Care Surg. 2019 Jun 24. [Epub ahead of print] PMID: 31205214
Prevention of Firearm Injuries Among Children and Adolescents Consensus-Driven Research Agenda from the Firearm Safety Among Children and Teens (FACTS) Consortium
Cunningham et al. JAMA Pediatr. 2019 Jun 10. [Epub ahead of print] PMID: 31180470
High Volume Crystalloid Resuscitation Adversely Affects Pediatric Trauma Patients
Coons et al.
J Pediatr Surg 2018 Jul 24. pii: S0022-3468(18)30446-9
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
Leeper et al. J Pediatr Surg 2018 Apr;53(4):775-779.
U.S. Pediatric Burn Patient 30-Day Readmissions
Wheeler et al. J Burn Care Res 2018 Jan 1;39(1):73-81.
Indications and Outcomes of Extracorporeal Life Support in Trauma Patients
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
Kim PT, McCagg J, Dundon A, Ziesler Z, Moody S, Falcone RA.
J Pediatr Surg. 2017. doi: 10.1016/j.jpedsurg.2017.02.014
Questions: What is the overall rate of non-accidental trauma (NAT) among admitted infants less than one year with an unwitnessed head injury? What factors are associated with NAT in this patient population?
Findings: 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.
Meaning: 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
Arbra CA, Vogel AM, Zhang J, Mauldin PD, Huang EY, Savoie KB, Santore MT, Tsao K, Ostovar-Kermani TG, Falcone RA, Dassinger MS, Recicar J, Haynes JH, Blakely ML, Russell RT, Naik-Mathuria BJ, St Peter SD, Mooney DP, Onwubiko C, Upperman JS, Streck CJ.
J Trauma Acute Care Surg. 2017 Oct;83(4):597-602. doi: 10.1097
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?
Cook MR1, Witt CE, Bonow RH, Bulger EM, Linnau KF, Arbabi S, Robinson BRH, Cuschieri J.
J Trauma Acute Care Surg. 2018 Jan;84(1):50-57.
Purpose: 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.
Conclusion: 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
Hamilton EC, Miller CC, Cox CS, Lally KP, Austin MT.
J Trauma Acute Care Surg 2017 Dec 28. Epub ahead of print.
Summary: 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
Calder BW, Vogel AM, Zhang J, Mauldin PD, Huang EY, Savoie KB, Santore MT, Tsao K, Ostovar-Kermani TG, Falcone RA, Dassinger MS, Recicar J, Haynes JH, Blakely ML, Russell RT, Naik-Mathuria BJ, St Peter SD, Mooney DP, Onwubiko C, Upperman JS, Zagory JA, Streck CJ.
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?
Brown JB, Gestring ML, Leeper CM, Sperry JL, Peitzman AB, Billiar TR, Gaines BA.
J Trauma Acute Care Surg. 2017 Jun;82(6):995-1001
PMID: 28328674 PMCID: PMC5464600 [Available on 2018-06-01]
Evaluation of guidelines for injured children at high risk for venous thromboembolism: A prospective observational study
Landisch RM, Hanson SJ, Cassidy LD, Braun K, Punzalan RC, Gourlay DM.
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
Escobar MA Jr1, Auerbach M, Flynn-O’Brien K, Tiyyagura G, Borgman MA, Duffy SJ, Falcone K, Burke R, Cox JM, Maguire S.
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
Arbuthnot M, Mooney DP.
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
Grool AM, Aglipay M, Momoli F, Meehan WP 3rd, Freedman SB, Yeates KO, Gravel J, Gagnon I, Boutis K, Meeuwisse W, Barrowman N, Ledoux AA, Osmond MH, Zemek R; Pediatric Emergency Research Canada (PERC) Concussion Team.
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
Mahajerin A, Petty JK, Hanson SJ, Thompson AJ, OʼBrien SH, Streck CJ, Petrillo TM, Faustino EV.
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
Rakes L, King M, Johnston B, Chesnut R, Grant R, Vavilala M.
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
Leeper CM, Neal MD, McKenna C, Sperry JL, Gaines BA.
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
Hanson SJ1, Faustino EV, Mahajerin A, O’Brien SH, Streck CJ, Thompson AJ, Petrillo TM, Petty JK.
J Trauma Acute Care Surg. 2016 May;80(5):695-701. doi: 10.1097/TA.0000000000000962. PMID: 26881487
Management of pediatric blunt renal trauma: A systematic review
LeeVan E, Zmora O, Cazzulino F, Burke RV, Zagory J, Upperman JS.
J Trauma Acute Care Surg. 2016 Mar;80(3):519-28. doi: 10.1097/TA.0000000000000950. Review. PMID: 26713980
Acute traumatic coagulopathy in a critically injured pediatric population: Definition, trend over time, and outcomes
Leeper CM1, Kutcher M, Nasr I, McKenna C, Billiar T, Neal M, Sperry J, Gaines BA.
J Trauma Acute Care Surg. 2016 Jul;81(1):34-41. doi: 10.1097/TA.0000000000001002. PMID: 26886002
Operative vs Nonoperative Management of Pediatric Blunt Pancreatic Trauma: Evaluation of the National Trauma Data Bank
Mora MC1, Wong KE2, Friderici J2, Bittner K2, Moriarty KP3, Patterson LA2, Gross RI2, Tirabassi MV3, Tashjian DB3.
J Am Coll Surg. 2016 Jun;222(6):977-82. doi: 10.1016/j.jamcollsurg.2015.12.005. Epub 2015 Dec 18. PMID: 26776354
Return on investment: Thirty years of commitment to the injured child has become a pathway to success
Tepas JJ 3rd.
J Trauma Acute Care Surg. 2016 May;80(5):689-94. doi: 10.1097/TA.0000000000001018. PMID: 26910235
Post-traumatic liver and splenic pseudoaneurysms in children: Diagnosis, management, and follow-up screening using contrast enhanced ultrasound (CEUS)
Durkin N, Deganello A, Sellars ME, Sidhu PS, Davenport M, Makin E.
J Pediatr Surg. 2016 Feb;51(2):289-92. doi: 10.1016/j.jpedsurg.2015.10.074. Epub 2015 Nov 10. PMID: 26656617
The value of official reinterpretation of trauma computed tomography scans from referring hospitals
Onwubiko C, Mooney DP.
J Pediatr Surg. 2016 Mar;51(3):486-9. doi: 10.1016/j.jpedsurg.2015.08.006. Epub 2015 Aug 10. PMID: 26342629
Operative vs Nonoperative Management of Pediatric Blunt Pancreatic Trauma: Evaluationof the National Trauma Data Bank
Mora MC, Wong KE, Friderici J, Bittner K, Moriarty KP, Patterson LA, Gross RI, Tirabassi MV, Tashjian DB.
J Am Coll Surg. 2015 Dec 18. pii:S1072-7515(15)01775-5 doi: 10.1016/j.jamcollsurg.2015.12.005. [Epub ahead of print]
Risk factors for venous thromboembolism after pediatric trauma
Allen CJ, Murray CR, Meizoso JP, Ray JJ, Neville HL, Schulman CI, Namias N, Sola JE, Proctor KG.
J Pediatr Surg. 2016 Jan;51(1):168-71. doi:
A Clinical Tool for the Prediction of Venous Thromboembolism in Pediatric Trauma Patients
Connelly CR, Laird A, Barton JS, Fischer PE, Krishnaswami S, Schreiber MA, Zonies DH, Watters JM.
JAMA Surg. 2016 Jan 1;151(1):50-7. doi: 10.1001/jamasurg.2015.2670.
The use of an institutional pediatric abdominal trauma protocol improves resource use
Fallon SC1, Delemos D, Akinkuotu A, Christopher D, Naik-Mathuria BJ.
J Trauma Acute Care Surg. 2016 Jan;80(1):57-63. doi:
Implementation of pediatric cervical spine clearance guidelines at a combined trauma center: Twelve-month impact
Rosati SF, Maarouf R, Wolfe L, Parrish D, Poppe M, Manners R, Brown K, Haynes JH.
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
Hale DF, Fitzpatrick CM, Doski JJ, Stewart RM, Mueller DL.
J Trauma Acute Care Surg. 2015 May;78(5):943-8
Benchmarks for splenectomy in pediatric trauma: How are we doing?
Polites SF, Zielinski MD, Zarroug AE, Wagie AE, Stylianos S, Habermann EB.
J Pediatr Surg. 2015 Feb;50(2):339-42
Managing moderately injured pediatric patients without immediate surgeon presence: 10 years later
Boomer LA, Nielsen JW, Lowell W, Haley K, Coffey C, Nuss KE, Nwomeh BC, Groner JI.
J Pediatr Surg. 2015 Jan;50(1):182-5
Pediatric emergency department thoracotomy: A large case series and systematic review
Allen CJ, Valle EJ, Thorson CM, Hogan AR, Perez EA, Namias N, Zakrison TL, Neville HL, Sola JE.
J Pediatr Surg. 2015 Jan;50(1):177-81
Pediatric trauma and the Pediatric Trauma Society: Our time has come
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)
Eckert MJ, Wertin TM, Tyner SD, Nelson DW, Izenberg S, Martin MJ.
J Trauma Acute Care Surg. 2014 Dec;77(6):852-8; discussion 858. doi: 10.1097/TA.0000000000000443.
Validation of a clinical prediction rule for pediatric abusive head trauma
Hymel KP, Armijo-Garcia V, Foster R, Frazier TN, Stoiko M, Christie LM, Harper NS, Weeks K, Carroll CL, Hyden P10, Sirotnak A, Truemper E, Ornstein AE, Wang M, Pediatric Brain Injury Network (PediBIRN) Investigators.
Pediatrics. 2014 Dec;134(6):e1537-44. doi: 10.1542/peds.2014-1329. Epub 2014 Nov 17.
Operative vs nonoperative management for blunt pancreatic transection in children: multi-institutional outcomes.
Iqbal CW, St Peter SD, Tsao K, Cullinane DC, Gourlay DM, Ponsky TA, Wulkan ML, Adibe OO; Pancreatic Trauma in Children (PATCH) Study Group.
J Am Coll Surg. 2014 Feb;218(2):157-62PMID: 24440062
Children are safer in states with strict firearm laws: a National Inpatient Sample study.
Safavi A, Rhee P, Pandit V, Kulvatunyou N, Tang A, Aziz H, Green D, O’Keeffe T, Vercruysse G, Friese RS, Joseph B.
J Trauma Acute Care Surg. 2014 Jan;76(1):146-50; discussion 150-1. PMID:24368370
Improving ATLS performance in simulated pediatric trauma resuscitation using a checklist.
Parsons SE, Carter EA, Waterhouse LJ, Fritzeen J, Kelleher DC, Oʼconnell KJ, Sarcevic A, Baker KM, Nelson E, Werner NE, Boehm-Davis DA, Burd RS.
Ann Surg. 2014 Apr;259(4):807-13.PMID: 24096751
National trends in pediatric blunt spleen and liver injury management and potential benefits of an abbreviated bed rest protocol.
Dodgion CM, Gosain A, Rogers A, St Peter SD, Nichol PF, Ostlie DJ.
J Pediatr Surg. 2014 Jun;49(6):1004-8; discussion 1008. PMID:24888852
Management of children with mild traumatic brain injury and intracranial hemorrhage.
Greenberg JK, Stoev IT, Park TS, Smyth MD, Leonard JR, Leonard JC, Pineda JA, Limbrick DD.
J Trauma Acute Care Surg. 2014 Apr;76(4):1089-95
Trauma remains a surgical disease from cradle to grave.
Acker SN, Stovall RT, Moore EE, Partrick DA, Burlew CC, Bensard DD.
J Trauma Acute Care Surg. 2014 Aug;77(2):219-25.PMID: 25058245
Routine repeat brain computed tomography in all children with mild traumatic brain injury may result in unnecessary radiation exposure.
Howe J, Fitzpatrick CM, Lakam DR, Gleisner A, Vane DW.
J Trauma Acute Care Surg. 2014 Feb;76(2):292-5; discussion 295-6. PMID: 24458036