American Association For The Surgery Of Trauma Research Articles

Complexities of autonomy in military medical ethics: A brief report.

The first Fallen Surgeons Military Educational Symposium was convened in conjunction with the the American Association for the Surgery of Trauma (AAST) 23 meeting, under the guidance of the AAST Military Liaison Committee. The daylong session included a 1.5-hour segment on military medical ethics in combat and its unique challenges. Medical ethical issues arise frequently within the military across a range of varied circumstances, from the day-to-day operations of stateside forces to the complexities of deployed troops in theaters of conflict. Given the scope of these circumstances, preparation and advanced planning are the key to addressing and resolving the ethical issues that occur. The goal of this session was to present illustrative cases, not to prescribe solutions, and to make the attendees aware of some of the challenges they may encounter when deployed.

Successful Non-Operative Management of a Patient with Grade IV Right Renal Trauma Associated with Hepatic and Right Adrenal Trauma – A Case Report

In case of a traumatic event, preservation of the injured renal and kidney function represents the goal of non-operative management (NOM) of renal trauma. The substantial benefits of non-operative management for minor blunt renal injury have already been clearly described in current literature, but its value for major blunt and penetrating renal injuries are still under debate and not clearly highlighted. We hereby fully report a case of a 64 years old male patient with a history of a thoraco-abdominal blunt trauma, victim of aggression caused by a blunt object, which resulted in grade IV injury of the right kidney and associated grade II hepatic injury and right adrenal injury – grading according to the American Association for the Surgery of Trauma (AAST) injury scale guidelines – evaluated through contrast enhanced emergency CT imaging. The patient was hemodynamically stable upon admission to the Emergency Department of Clinical Emergency County Hospital of Brașov, Romania. Non-operative management strategy was chosen, therefore constant and close monitorization and follow-up CT examinations were performed. The patient was subsequently discharged after 8 days, with no further complications reported.

Out with the old, in with the new? The revised AAST grading schema better predicts splenic salvage but not splenectomy

BackgroundThe revised American Association for the Surgery of Trauma (AAST) organ injury scale (OIS) for splenic injury incorporates radiologic features but the implications of this are unknown. We hypothesized that the revised AAST-OIS would better predict outcomes. MethodsPatients with a blunt splenic injury admitted to a Level I trauma center were reviewed from 2016 to 2021. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for splenectomy were calculated for high-grade injuries (AAST-OIS grades IV-V) using both schemas. ResultsOf the 852 patients analyzed, 48.5% were observed, 24.6% were embolized, and the remaining underwent operative intervention. The median AAST-OIS increased from II to III (p ​< ​0.01). Sensitivity (38.0% vs. 73.7%) and NPV (80.9% vs. 88.2%) for splenectomy increased for high-grade injuries but specificity (93.5% vs 70.1%) and PPV (67.5% vs 46.7%) decreased. ConclusionThe revised AAST-OIS better predicted splenic salvage but is less accurate at predicting need for splenectomy.

Management of complex pediatric and adolescent liver trauma: adult vs pediatric level 1 trauma centers.

Management of high-grade pediatric and adolescent liver trauma can be complex. Studies suggest that variation exists at adult (ATC) vs pediatric trauma centers (PTC); however, there is limited granular comparative data. We sought to describe and compare the management and outcomes of complex pediatric and adolescent liver trauma between a level 1 ATC and two PTCs in a large metropolitan city. A retrospective review of pediatric and adolescent (age < 21years) patients with American Association for the Surgery of Trauma (AAST) Grade 4 and 5 liver injuries managed at an ATC and PTCs between 2016 and 2022 was performed. Demographic, clinical, and outcome data were obtained at the ATC and PTCs. Primary outcomes included rates of operative management and use of interventional radiology (IR). Secondary outcomes included packed red blood cell (pRBC) utilization, intensive care unit (ICU) length of stay (LOS), and hospital LOS. One hundred forty-four patients were identified, seventy-five at the ATC and sixty-nine at the PTC. The cohort was predominantly black (65.5%) males (63.5%). Six injuries (8.7%) at the PTC and forty-five (60%) injuries at the ATC were penetrating trauma. Comparing only blunt trauma, ATC patients had higher Injury Severity Score (median 37 vs 26) and ages (20years vs 9years). ATC patients were more likely to undergo operative management (26.7% vs 11.0%, p = 0.016) and utilized IR more (51.9% vs 4.8%, p < 0.001) compared to the PTC. The patients managed at the ATC required higher rates of pRBC transfusions though not statistically significant (p = 0.06). There were no differences in mortality, ICU, or hospital LOS. Our retrospective review of high-grade pediatric and adolescent liver trauma demonstrated higher rates of IR and operating room use at the ATC compared to the PTC in the setting of higher Injury Severity Score and age. While the PTC successfully managed > 95% of Grade 4/5 liver injuries non-operatively, prospective data are needed to determine the optimal algorithm for management in the older adolescent population. Level IV.

A novel preoperative score to predict severe acute cholecystitis.

In a large multicenter trial, The Parkland Grading Scale (PGS) for acute cholecystitis outperformed other grading scales and has a positive correlation with complications but is limited in its inability to preoperatively predict high-grade cholecystitis. We sought to identify preoperative variables predictive of high-grade cholecystitis (PGS 4 or 5). In a six-month period, patients undergoing cholecystectomy at a single institution with prospectively graded PGS were analyzed. Stepwise logistic regression models were constructed to predict high-grade cholecystitis. The relative weight of the variables was used to derive a novel score, the Severe Acute Cholecystitis Score (SACS). This score was compared with the Emergency Surgery Acuity Score(ESS), American Association for the Surgery of Trauma (AAST) preoperative score and Tokyo Guidelines (TG) for their ability to predict high-grade cholecystitis. Severe Acute Cholecystitis Score was then validated using the database from the AAST multicenter validation of the grading scale for acute cholecystitis. Of the 575 patients that underwent cholecystectomy, 172 (29.9%) were classified as high-grade. The stepwise logistic regression modeling identified seven independent predictors of high-grade cholecystitis. From these variables, the SACS was derived. Scores ranged from 0 to 9 points with a C statistic of 0.76, outperforming the ESS ( C statistic of 0.60), AAST (0.53), and TG (0.70) ( p < 0.001). Using a cutoff of 4 or more on the SACS correctly identifies 76.2% of cases with a specificity of 91.3% and a sensitivity of 40.7%. In the multicenter database, there were 464 patients with a prospectively collected PGS. The C statistic for SACS was 0.74. Using the same cutoff of 4, SACS correctly identifies 71.6% of cases with a specificity of 83.8% and a sensitivity of 52.2%. The Severe Acute Cholecystitis Score can preoperatively predict high-grade cholecystitis and may be useful for counseling patients and assisting in surgical decision making. Diagnostic Test/Criteria; Level III.

Single centre analysis of factors influencing surgical treatment of splenic trauma in children.

This study aims to investigate determinants impacting the surgical management of splenic trauma in paediatric patients by scrutinizing age distribution, etiological factors and concomitant injuries. The analysis seeks to establish a foundation for delineating optimal operative timing. A cohort of 262 paediatric cases presenting with splenic trauma at our institution from January 2011 to December 2021 underwent categorization into either the conservative or operative group. Significantly disparate attributes between the two groups included age, time of presentation, blood pressure, haemoglobin levels, blood transfusion requirements, thermal absorption, American Association for the Surgery of Trauma (AAST) classification and associated injuries. Logistic regression analysis revealed age, haemoglobin levels, AAST classification and blood transfusion as autonomous influencers of surgical intervention (OR = 1.024, 95% CI: 1.011-1.037; OR = 1.067, 95% CI: 1.01-1.127; OR = 0.2760, 95% CI: 0.087-0.875; OR = 7.873, 95% CI: 2.442-25.382; OR = 0.016, 95% CI: 0.002-0.153). The AAST type and age demonstrated areas under the receiver operating characteristic (ROC) curve of 0.782 and 0.618, respectively. Age, haemoglobin levels, AAST classification and blood transfusion independently influence the decision for surgical intervention in paediatric patients with splenic trauma. Age and AAST classification emerge as viable parameters for assessing and prognosticating the likelihood of surgical intervention in this patient cohort.

Traumatismo renal secundario a accidente en patinete eléctrico

Introduction: the e-scooter has become a common transportation method which use has been rising in the last few years. Most lesions reported secondary to e-scooter accidents are traumatic brain injury (TBI), bone fractures and in a lower percentage abdominal visceral trauma. Methods: retrospective review of renal traumatisms cases secondary to e-scooter accidents presented to the emergency room (ER) of the Hospital Universitari Doctor Peset in Valencia, Spain since December 2021 to December 2022. A literature review on PubMed database was performed to investigate injuries caused by electric scooter use. Results: a total of five patients were included with a mean age of 34 years, being one woman and four men. A contrasted abdominopelvic computerized tomography (CT) scan was performed in all cases as a diagnosis method. The American Association for the Surgery of Trauma (AAST) renal injury scale was used to classify each case and determine the correct treatment. As a result, one case of AAST grade I, one case of AAST grade III, two cases of AAST grade IV and one AAST grade V were obtained; three of which were managed conservatively and two required invasive procedures. Conclusions: the rising use of the e-scooter as a transportation method has become a new cause and mechanism of renal traumatism to have in mind in polytraumatized patients in this context.

Repeat imaging increases detection of delayed pseudoaneurysms in patients with high-grade solid organ injury following abdominal trauma.

Nonoperative management of abdominal trauma can be complicated by the development of delayed pseudoaneurysms. Early intervention reduces the risk of rupture and decreases mortality. The objective of this study is to determine the utility of repeat computed tomography (CT) imaging in detecting delayed pseudoaneurysms in patients with abdominal solid organ injury. A retrospective cohort study reviewing Montreal General Hospital registry between 2013 and 2019. Patients with The American Association for the Surgery of Trauma (AAST) grade 3 or higher solid organ injury following abdominal trauma were identified. A chart review was completed, and demographics, mechanism of injury, Injury Severity Score (ISS) score, AAST injury grade, CT imaging reports, and interventions were collected. Descriptive analysis and logistic regression model were completed. We identified 195 patients with 214 solid organ injuries. The average age was 38.6years; 28.2% were female, 90.3% had blunt trauma, and 9.7% had penetrating trauma. The average ISS score was 25.4 (SD 12.8) in patients without pseudoaneurysms and 19.5 (SD 8.6) in those who subsequently developed pseudoaneurysms. The initial management was nonoperative in 57.0% of the patients; 30.4% had initial angioembolization, and 12.6% went to the operating room. Of the cohort, 11.7% had pseudoaneurysms detected on repeat CT imaging within 72h. Grade 3 represents the majority of the injuries at 68.0%. The majority of these patients underwent angioembolization. In patients with high-grade solid organ injury following abdominal trauma, repeat CT imaging within 72h enabled the detection of delayed development of pseudoaneurysms in 11.7% of injuries. The majority of the patients were asymptomatic.

Machine Learning Detection and Characterization of Splenic Injuries on Abdominal Computed Tomography.

Multi-detector contrast-enhanced abdominal computed tomography (CT) allows for the accurate detection and classification of traumatic splenic injuries, leading to improved patient management. Their effective use requires rapid study interpretation, which can be a challenge on busy emergency radiology services. A machine learning system has the potential to automate the process, potentially leading to a faster clinical response. This study aimed to create such a system. Using the American Association for the Surgery of Trauma (AAST), spleen injuries were classified into 3 classes: normal, low-grade (AAST grade I-III) injuries, and high-grade (AAST grade IV and V) injuries. Employing a 2-stage machine learning strategy, spleens were initially segmented from input CT images and subsequently underwent classification via a 3D dense convolutional neural network (DenseNet). This single-centre retrospective study involved trauma protocol CT scans performed between January 1, 2005, and July 31, 2021, totaling 608 scans with splenic injuries and 608 without. Five board-certified fellowship-trained abdominal radiologists utilizing the AAST injury scoring scale established ground truth labels. The model achieved AUC values of 0.84, 0.69, and 0.90 for normal, low-grade injuries, and high-grade splenic injuries, respectively. Our findings demonstrate the feasibility of automating spleen injury detection using our method with potential applications in improving patient care through radiologist worklist prioritization and injury stratification. Future endeavours should concentrate on further enhancing and optimizing our approach and testing its use in a real-world clinical environment.

The Role of Dual-Energy CT in Solid Organ Injury.

The liver, spleen, and kidneys are the commonest injured solid organs in blunt and penetrating trauma. The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) is the most widely accepted system for categorizing traumatic injuries. Grading systems allow clear communication of findings between clinical teams and assign a measurable severity of injury, which directly correlates with morbidity and mortality. The 2018 revised AAST OIS emphasizes reliance on CT for accurate grading; in particular regarding vascular injuries. Dual-Energy CT (DECT) has emerged as a promising tool with multiple clinical applications already demonstrated. In this review article, we summarize the basic principles of CT attenuation to refresh the minds of our readers and we scrutinize DECT's technology as opposed to conventional Single-Energy CT (SECT). This is followed by outlining the benefits of various DECT postprocessing techniques, which authors of this article refer to as the 3Ms (Mapping of Iodine, Material decomposition, and Monoenergetic virtual imaging), in aiding radiologists to confidently assign an OIS as well as problem solve complex injury patterns. In addition, a thorough discussion of changes to the revised AAST OIS focusing on definitions of key terms used in reporting injuries is described.

Survival Secrets: Unmasking the Factors Predicting Failure of Non-operative Management (NOM) in Splenic Injuries.

Splenic injuries are common solid organ injuries resulting from blunt abdominal trauma in road traffic accidents. Very often, splenic injuries can be life-threatening. Earlier, splenic injuries were often dealt with surgical intervention, such as splenectomy. With the recognition of the immunological function of the spleen and possible complications of splenectomy surgery, such as overwhelming post-splenectomy infections (OPSI), there has been a recent trend for non-operative management (NOM). To study the variables predicting failure of NOM in blunt abdominal trauma patients with splenic injury. This is a retrospective study that includes 235 patients who presented to the Safdarjung Hospital emergency room (New Delhi, India) with blunt trauma abdomen and splenic injuries with or without associated injuries between January 2019 and December 2021. The data was entered in a Microsoft Excel spreadsheet (Microsoft Corp., Redmond, WA, USA). Categorical variables were expressed as frequencies and percentages. Pearson's chi-square test of association was used to determine if there is a relationship between two variables. A p-value of <0.05 was considered statistically significant. Out of 235 patients with blunt abdominal trauma and splenic injuries, 82 were hemodynamically unstable despite resuscitation and were taken up for emergency laparotomy. The remaining 153 patients, who were either hemodynamically stable or stabilized after adequate resuscitation, were managed on the lines of NOM. The number of patients with splenic injury in AAST grades 1, 2, 3, 4, and 5 was 36, 50, 40, 24, and three, respectively. Out of 153 patients, 130 (85%) were successfully managed by NOM, while eight (5%) had to discontinue NOM as they required surgical intervention. The failure of NOM (fNOM) is seen mostly with grade 5 injuries (2/2, 100%, p<0.01), followed by grade 4 (4/20, 20%) and grade 3 (2/37, 5.7%). The mean age in fNOM was 58.3 years, as compared to 42.2 years in the success of NOM (sNOM). All eight patients had multiple concomitant injuries, with femur fracture being the most common association in up to six patients (p<0.01), followed by liver injury in four patients. There were 15 mortalities, irrespective of AAST severity grade. All of these patients had associated concomitant injuries, with intracranial bleeding (n = 10, 32%, p<0.01) being the most common association, followed by femur fracture (n = 6, 20%) and liver injury (n = 5, 16%). Also, the cause of death was unrelated to splenic trauma (p = 0.67), with pulmonary embolism (n = 6, 40%, p<0.01) being the most common cause, followed by brain stem herniation (n = 5, 34%). Non-operative management is a safe and efficient method for treating patients with splenic injuries who are hemodynamically stable or stabilized. The factors associated with fNOM include elderly age, a higher American Association for the Surgery of Trauma(AAST) grade of splenic injury, and associated concomitant injuries. Femur fracture was the most common concomitant injury present in cases where NOM failed, followed by liver injury. The presence of intracranial bleeds in these patients was a common association with mortality, irrespective of the grade of splenic injury.

Mobility and Sporting Activity After Renal Trauma: A Survey Regarding Best Clinical Practice During the Recovery Stage

To evaluate strategies that are followed after pediatric renal trauma during the recovery stage, with an emphasis on mobility and involvement in subsequent sporting activities. Renal trauma is the most common urogenital trauma in children. The American Association for the Surgery of Trauma (AAST) scale is most commonly used to stratify the severity of injury. There is no consensus in the existing literature with respect to the recovery stage following renal trauma. A survey was constructed by the European Association of Urology (EAU) - Young Academic Urologists (YAU) Pediatric Urology Working Group and then made digitally available on SurveyMonkey. The survey consists of 15 questions exploring relevant factors and timing to start again with mobility and activity. In total 153 people responded, of whom 107 completed the entire survey. The presence of pain and severity of trauma were acknowledged as most important factors to commence mobilization, whereas presence of hematuria was identified as an additional factor for sporting activity. Regardless of severity of trauma a minimum of 90% of respondents recommend return to noncontact sports within 12weeks. For contact sports, a minimum of 33% of respondents advised >12weeks minimum before starting again. A small number of respondents would never allow sporting activities again. The time to allow sporting activity shows high variation among the respondents, some even restricting sporting activities completely. This survey highlights the need for a standardized protocol based on multicenter follow-up data.

Renal Arteriovenous (AV) Fistula after High-Grade Blunt Renal Trauma Caused by Traffic Accidents.

To report a series of three patients with traumatic renal AV fistulas after blunt renal laceration. We retrospectively analyzed the renal trauma cases treated in the Department of Urology of Salzburg University Clinic during a time period of 10 years concerning traumatic AV fistula formation and other clinical parameters. In total, 3 cases of traumatic AV fistula formation were identified in 106 blunt renal trauma patients (2.8%), with a mean age of 39 (17-56) years. All renal traumas were classified as American Association for the Surgery of Trauma (AAST) grade IV. Two patients were primarily treated with ureteral stent; one was managed conservatively. All AV fistulas were diagnosed after a mean time of 7 (1-13) days. Two patients were symptomatic with gross hematuria, and the mean time between trauma and onset of symptoms was 11 (9-13) days. All cases were managed via coil embolization after a mean of 10 (8-13) days. Two patients received a second intervention after a mean of 18 (11-25) days. The mean AV fistula size was 18.7 (12-24) mm. Mean hemoglobin loss was 3.6 g/dL. One patient received one erythrocyte concentrate. Discharge was after a mean time of 13.3 (7-12) days, with the mean time of intensive care treatment being 2.3 (1-3) days. Traumatic renal AV fistula is a rare but severe complication associated with higher-grade renal trauma. It can become evident through hematuria or blood loss several days after the initial trauma. The availability of coil embolization in a trauma center can help kidney preservation management.

Comparison of Pediatric Acute Appendicitis Before and During the COVID-19 Pandemic in New York City.

Background: Acute appendicitis (AA) is the most common abdominal surgical emergency in children and adolescents. In the year immediately following the declaration of the coronavirus disease 2019 (COVID-19) pandemic by the World Health Organization (WHO), there was a precipitous decline in emergency department (ED) visits especially for surgical conditions and infectious diseases. Fear of exposure to severe acute respiratory coronavirus 2 infection resulted in delay in presentation and time to surgery, and a shift toward more conservative management. Objective: Our goal was to compare the incidence and severity of AA before and during the COVID-19 pandemic. Methods: Patients aged 2-18years admitted with the diagnosis of AA to Flushing Hospital Medical Center or Jamaica Hospital Medical Center in Queens, New York, were selected for chart review. Data extracted from electronic health records included demographics, clinical findings, imaging studies, and operative and pathological findings. We calculated the Alvarado score (AS) for incidence and the American Association for the Surgery of Trauma (AAST) grade for severity. We compared patients admitted between March 1, 2018-February 29, 2020 (pre-pandemic) to patients admitted between March 1, 2020-February 28, 2021 (pandemic). We then compared pre-pandemic and pandemic groups to determine differences in pediatric AA incidence and severity. Results: Of 239 patients diagnosed with AA, 184 (77%) were in the pre-pandemic group and 55 (23%) in the pandemic group. Incidence (number per year) of AA declined by 40%. The pandemic group had significantly greater overall AS of ≥7, indicating increased likelihood to require surgery, (P = 0.04) and higher AAST grade demonstrating increased severity (P = 0.02). Conclusion: There was a decline in the number of AA cases seen in our pediatric EDs and admitted during the first year of the pandemic. Clinicians need to be aware of increased severity of AA at time of presentation during public health emergencies such as a pandemic, possibly due to modified patient behavior.

American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma: Clinical protocol for damage-control resuscitation for the adult trauma patient.

Damage-control resuscitation in the care of critically injured trauma patients aims to limit blood loss and prevent and treat coagulopathy by combining early definitive hemorrhage control, hypotensive resuscitation, and early and balanced use of blood products (hemostatic resuscitation) and the use of other hemostatic agents. This clinical protocol has been developed to provide evidence-based recommendations for optimal damage-control resuscitation in the care of trauma patients with hemorrhage.

Successful nonoperative management of a simultaneous high-grade splenic injury and devascularized kidney in Australia: a case report

Severe blunt injuries to isolated solid abdominal viscera have been previously managed nonoperatively; however, management algorithms for simultaneous visceral injuries are less well defined. We report a polytrauma case of a 33-year-old man involved in a motorbike collision who presented with left-sided chest and abdominal pain. Initial imaging demonstrated multiple solid organ injuries with American Association for the Surgery of Trauma (AAST) grade V splenic injury and complete devascularization of the left kidney. The patient underwent urgent angioembolic coiling of the distal splenic artery with successful nonoperative management of simultaneous grade V solid organ injuries.

Grading Abdominal Trauma: Changes in and Implications of the Revised 2018 AAST-OIS for the Spleen, Liver, and Kidney.

According to the Centers for Disease Control and Prevention, trauma is the leading cause of fatal injuries for Americans aged 1-44 years old and the fourth leading overall cause of death. Accurate and early diagnosis, including grading of solid organ injuries after blunt abdominal trauma (BAT), is crucial to guide management and improve outcomes. The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) is the most widely accepted BAT scoring system at CT both within the United States and internationally, and its uses include stratification of injury severity, thereby guiding management, and facilitation of clinical research, billing, and coding. Furthermore, this system also plays a role in the credentialing process for trauma centers in the United States. The newly revised 2018 OIS provides criteria for grading solid organ damage into three groups: imaging, operation, and pathology. The final grade is based on the highest of the three criteria. If multiple lower-grade (I or II) injuries are present in a single organ, one grade is advanced to grade III. The most substantial change in the revised 2018 AAST-OIS is incorporation of multidetector CT findings of vascular injury, including pseudoaneurysm and arteriovenous fistula. The authors outline the main revised aspects of grading organ injury using the AAST-OIS for the spleen, liver, and kidney after BAT, particularly the role of multidetector CT and alternative imaging in organ injury detection, the importance of vascular injuries in grade change, and the impact of these changes on patient management and in prediction of operative treatment success and in-hospital mortality. ©RSNA, 2023 Supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Quiz questions for this article are available through the Online Learning Center.

Pancreatic and Duodenal Injuries: Experience at A Single Trauma Centre

Background: Pancreatic and duodenal injuries are uncommon due to relative protection by their posterior anatomical position and have an incidence of less than 1% of all hospital admissions for trauma. Auckland City Hospital is a tertiary referral hospital in New Zealand with Trauma and Hepatopancreatobiliary units and admits approximately 384 patients with major trauma per year, predominantly from blunt mechanisms. This study is used to assess the incidence, diagnosis and clinical management of pancreatic and duodenal injuries in trauma patients at a single trauma centre. Method: A retrospective study was undertaken using data from a prospectively collected trauma registry. Inpatient notes including all patients admitted from 2007 to 2020 were reviewed. Pancreatic and duodenal injuries were graded using the American Association for the Surgery of Trauma (AAST) organ injury scale (OIS) grading system. Investigations including radiology and biochemistry and clinical management were noted. Results: A total of 45 trauma patients admitted to Auckland City Hospital had sustained pancreatic or duodenal injuries. Six patients had combined pancreaticoduodenal injuries, 16 had duodenal and 23 had pancreatic injuries. Grade I organ injuries were the most common in pancreatic (19/29) and duodenal injuries (9/22). Majority of patients underwent laparotomy (33/45) for associated haemodynamic instability. All organ specific indications for surgery occurred in Grade II and higher injuries. 10/45 patients were managed non-operatively, of which the majority had Grade I or II organ injuries (9/45). 3/45 patients died. Conclusion: The incidence of pancreaticoduodenal injuries is rare (45 patients in 13 years) and in keeping with trauma literature. In our series, haemodynamically stable patients with Grade I - II pancreatic and Grade I - II (non-laceration type) duodenal injuries did not require operative management. Endoscopic pancreatic stenting may facilitate selective non-operative management in some patients with pancreatic injury or complications.

Blunt pancreatic injury in children: Lessons from 11-year experience in a pediatric center

ObjectiveTo study the diagnosis, management strategies, and outcomes of pediatric patients with blunt pancreatic injury. MethodsThe clinical data of patients with blunt pancreatic injury at Children's Hospital, Zhejiang University School of Medicine from January 2011 to September 2022 were collected and analyzed retrospectively. ResultsA total of 51 patients were enrolled. According to the American Association for the Surgery of Trauma (AAST) classification of pancreatic injury, 41 patients were categorized in the low-grade and nine in the high-grade groups. On admission, serum amylase and lipase levels in the high-grade group were significantly higher than in the low-grade group (P = 0.025 and P = 0.021, respectively). The peak levels of serum amylase and lipase in the high-grade group were considerably higher than in the low-grade group (P = 0.017 and P = 0.038, respectively). Two patients received surgical treatment, but none experienced pancreatectomy. The remaining 49 patients were successfully treated with conservative methods. The incidence of pancreatic pseudocysts in patients was 47.1% (24/51), and half required external drainage. ConclusionConservative management is safe for most children with blunt pancreatic injury, surgical intervention should be adopted in patients with hemodynamic instability or multiple organ failure.

Can we predict failure of non-operative management of blunt splenic injuries on arrival? A comparison of predictors of immediate splenectomy versus splenectomy secondary to non-operative management failure

Aims and Background The spleen is the most frequently injured solid organ after blunt trauma and a trial non-operative management (NOM) has become the standard of care in hemodynamically stable patients. It remains uncertain which patients are at increased risk of non-operative management failure (NOMF) at initial presentation. We explored whether clinical variables including the contemporary rotational thromboelastography (ROTEM) parameters are predictive of NOMF. Materials and Methods Data for all adult patients with a blunt splenic injury was collected retrospectively at St. Michael’s Hospital in Toronto, Canada between 2005 and 2021. Those who underwent a splenectomy within 4 hours of presentation were classified as direct operative management (OM), while those who had a splenectomy after 4 hours of observation were classified as NOM failure. Vital signs on arrival and injury characteristics were collected. Logistic regression was used to identify predictors of OM and predictors of NOM failure. Results Seven hundred and seventeen patients were identified with splenic injury during our study period. The median Injury Severity Score (ISS) was 27 (IQR 17–36), and 19% ( n = 134) had a shock index of 1 or more. One hundred and eleven (15.5%) underwent direct operative management. A shock index above 1 and increasing spleen injury severity were strong predictors of patients undergoing direct OM. The remaining 606 patients underwent NOM of which 59% ( n = 357) of these were admitted to the ICU. NOM failure occurred in 7.4% ( n = 45) with a median time to NOM failure of 23 (IQR 8–72) hours. The American Association for the Surgery of Trauma (AAST) spleen injury severity was the major factor significantly associated with NOM failure. Conclusions The only major predictor of NOMF available on arrival is increased spleen injury grade. Other clinical variables such as age, vital signs on arrival, and bloodwork were not significantly able to predict NOM failure. Additional investigation is required to identify novel predictors of NOM failure.