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Management of blunt pancreatic trauma in children: Review of the National Trauma Data Bank.

ABSTRACT: This study aims to examine the current management strategies and outcomes after blunt pancreatic trauma in children using a national patient registry.Using the National Trauma Data Bank (NTDB) from 2007-2011, we identified all patients ?18years old who suffered blunt pancreatic trauma. Patients were categorized as undergoing nonoperative pancreatic management (no abdominal operation, abdominal operation without pancreatic-specific procedure, or pancreatic drainage alone) or operative pancreatic management (pancreatic resection/repair). Patient characteristics, operative details, clinical outcomes, and factors associated with operative management were examined.Of 610,402 pediatric cases in the NTDB, 1653 children (0.3%) had blunt pancreatic injury and 674 had information on specific location of pancreatic injury. Of these 674 cases, 514 (76.3%) underwent nonoperative pancreatic management. The groups were similar in age, gender, and race; however, pancreatic injury grade>3, moderate to severe injury severity, and bicycle accidents were associated with operative management in multivariable analysis. Children with pancreatic head injuries or GCS motor score<6 were less likely to undergo pancreatic operation. Overall morbidity and mortality rates were 26.5% and 5.3%, respectively. Most outcomes were similar between treatment groups, including mortality (2.5% vs. 6.7% in operative vs. nonoperative cohorts respectively; p=0.07).Although rare, blunt pancreatic trauma in children continues to be a morbid injury. In the largest analysis of blunt pancreatic trauma in children, we provide data on which to base future prospective studies. Operative management of pancreatic trauma occurs most often in children with distal ductal injuries, suggesting that prospective studies may want to focus on this group.

SUBMITTER: Englum BR

PROVIDER: S-EPMC5142528 | biostudies-literature | 2016 Sep

REPOSITORIES: biostudies-literature

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Management of blunt pancreatic trauma in children: Review of the National Trauma Data Bank.

Englum Brian R BR Gulack Brian C BC Rice Henry E HE Scarborough John E JE Adibe Obinna O OO

Journal of pediatric surgery 20160531 9

<h4>Purpose</h4>This study aims to examine the current management strategies and outcomes after blunt pancreatic trauma in children using a national patient registry.<h4>Methods</h4>Using the National Trauma Data Bank (NTDB) from 2007-2011, we identified all patients ≤18years old who suffered blunt pancreatic trauma. Patients were categorized as undergoing nonoperative pancreatic management (no abdominal operation, abdominal operation without pancreatic-specific procedure, or pancreatic drainage ...[more]

PMID: 27577183

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Project description:Background/Objective: Traumatic intracranial hemorrhage (tICH) accounts for significant trauma morbidity and mortality. Several studies have developed prognostic models for tICH outcomes, but previous models face limitations, including poor generalizability and limited accuracy. The objective was to develop a prognostic model and determine predictors of mortality using the largest trauma database in the U.S., applying rigorous analytical methodology with true hold-out-set model validation. Methods: We identified 248,536 patients in the National Trauma Data Bank (NTDB) from 2012 to 2016 with a diagnosis code associated with tICH. For each admission, we collected demographic information, systolic blood pressure, blood alcohol level (BAL), Glasgow Coma Score (GCS), Injury Severity Score (ISS), presence of epidural/subdural/subarachnoid/intraparenchymal hemorrhage, comorbidities, complications, trauma center level, and trauma center region. Our final study population was 212,666 patients following exclusion of records with missing data. The dependent variable was patient death. Linear support vector machine (SVM) classification was carried out with recursive feature selection. Model performance was assessed using holdout 10-fold cross-validation. Results: Cross-validation demonstrated a mean accuracy of 0.792 (95% CI 0.783-0.799). Accuracy, precision, recall, and AUC were 0.827, 0.309, 0.750, and 0.791, respectively. In the final model, high ISS, advanced age, subdural hemorrhage, and subarachnoid hemorrhage were associated with increased mortality, while high GCS verbal and motor subscores, current smoker, BAL beyond the legal limit, and level 1 trauma center were associated with decreased mortality. Conclusions: A linear SVM model was developed for tICH, with nine features selected as predictors of mortality. These findings are applicable to multiple hemorrhage subtypes and may benefit the triage of high risk patients upon admission. While many studies have attempted to create models to predict mortality in TBI, we sought to confirm those predictors using modern modeling approaches, machine learning, and true hold-out test sets, using the largest available TBI database in the U.S. We find that while the predictors we identify are consistent with prior reports, overall prediction accuracy is somewhat lower than prior reports when assessed more rigorously.

Project description:There have been large changes over the past several decades to patient demographics in those presenting with mild traumatic brain injury (mTBI) with intracranial hemorrhage (ICH; complicated mTBI) with the potential to affect the use of neurosurgical interventions. The objective of this study was to characterize long-term trends of neurosurgical interventions in patients with complicated mTBI using 13 years of the National Trauma Data Bank (NTDB). This was a retrospective cohort study of adult (≥18 years) trauma patients included in the NTDB from 2007 to 2019 who had an emergency department Glasgow Coma Scale score 13-15, an intracranial hemorrhage (ICH), and no skull fracture. Neurosurgical intervention time trends were quantified for each ICH type using mixed-effects logistic regression with random slopes and intercepts for hospitals, as well as covariates for time and 14 demographic, injury, and hospital characteristics. In total, 666,842 ICH patients across 1060 hospitals were included. The four most common hemorrhages were isolated subdural hemorrhage (36%), isolated subarachnoid hemorrhage (24%), multiple hemorrhage types (24%), and isolated unspecified hemorrhages (9%). Overall, 49,220 (7%) patients received a neurosurgical intervention. After adjustment, the odds of neurosurgical intervention significantly decreased every 10 years by the following odds ratios (odds ratio [95% confidence interval]): 0.85 [0.78, 0.93] for isolated subdural, 0.63 [0.51, 0.77] for isolated subarachnoid, 0.50 [0.41, 0.62] for isolated unspecified, and 0.79 [0.73, 0.86] for multiple hemorrhages. There were no significant temporal trends in neurosurgical intervention odds for isolated epidural hemorrhages (0.87 [0.68, 1.12]) or isolated contusions/lacerations (1.03 [0.75, 1.41]). In the setting of complicated mTBI, the four most common ICH types were associated with significant declines in the odds of neurosurgical intervention over the past decade. It remains unclear whether changing hemorrhage characteristics or practice patterns drove these trends.

Project description:The study aims to describe the evidence-based management and controversies in blunt splenic trauma.A shift from operative management to non-operative management (NOM) has occurred over the past decades where NOM has now become the standard of care in haemodynamically stable patients with blunt splenic injury. Splenic artery embolisation (SAE) is generally believed to increase the success rate of NOM. Not all the available evidence is that optimistic about SAE however. A morbidity specifically related to SAE of up to 47% has been reported. Although high-grade splenic injury is a prognostic factor for failure of NOM, an American research group has published a study in which NOM is performed in over half of haemodynamically stable patients with grade IV or V splenic injury without leading to an increased morbidity (in terms of complications) or mortality. Another area of current investigation in the literature is the exact indication for SAE. Although the generally accepted indication is the presence of vascular injury, a topic of current investigation is whether there might be a role for pre-emptive embolisation in patients with high-grade splenic injury. On the other hand, evidence is also emerging that not all blushes require an intervention (small blushes <1 or 1.5 cm do not). Lastly, the available evidence shows that splenic function is preserved after embolisation, and therefore, the routine administration of vaccinations seems not to be necessary. There might be a difference between proximal and distal embolisations; however, with regard to splenic function, in favour of distal embolisation.Nowadays, NOM is the standard of care in haemodynamically stable patients with blunt splenic injury. The available evidence (although with a relatively small number of patients) shows that splenic function is preserved after NOM, a major advantage compared to splenectomy. SAE is used as an adjunct to observation in order to increase the success rate of NOM. Operative management should be applied in case of haemodynamic instability or if associated intra-abdominal injuries requiring surgical treatment are present. Patient selection (which patient can be safely treated non-operatively, does every blush needs to be embolised?, which patients might be better off with direct operative intervention given the patient and injury characteristics) is an ongoing subject of further research. Future studies should also focus on long-term outcomes of patients treated with embolisation (e.g. total number of lifetime infectious episodes requiring antibiotic treatment or hospital admission, quality of life).

Project description:INTRODUCTION: The goal of non-operative management (NOM) for blunt splenic trauma (BST) is to preserve the spleen. The advantages of NOM for minor splenic trauma have been extensively reported, whereas its value for the more severe splenic injuries is still debated. The aim of this systematic review was to evaluate the available published evidence on NOM in patients with splenic trauma and to compare it with the operative management (OM) in terms of mortality, morbidity and duration of hospital stay. METHODS: For this systematic review we followed the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" statement. A systematic search was performed on PubMed for studies published from January 2000 to December 2011, without language restrictions, which compared NOM vs. OM for splenic trauma injuries and which at least 10 patients with BST. RESULTS: We identified 21 non randomized studies: 1 Clinical Controlled Trial and 20 retrospective cohort studies analyzing a total of 16,940 patients with BST. NOM represents the gold standard treatment for minor splenic trauma and is associated with decreased mortality in severe splenic trauma (4.78% vs. 13.5% in NOM and OM, respectively), according to the literature. Of note, in BST treated operatively, concurrent injuries accounted for the higher mortality. In addition, it was not possible to determine post-treatment morbidity in major splenic trauma. The definition of hemodynamic stability varied greatly in the literature depending on the surgeon and the trauma team, representing a further bias. Moreover, data on the remaining analyzed outcomes (hospital stay, number of blood transfusions, abdominal abscesses, overwhelming post-splenectomy infection) were not reported in all included studies or were not comparable, precluding the possibility to perform a meaningful cumulative analysis and comparison. CONCLUSIONS: NOM of BST, preserving the spleen, is the treatment of choice for the American Association for the Surgery of Trauma grades I and II. Conclusions are more difficult to outline for higher grades of splenic injury, because of the substantial heterogeneity of expertise among different hospitals, and potentially inappropriate comparison groups.

Dataset Information

Management of blunt pancreatic trauma in children: Review of the National Trauma Data Bank.

Publications

Management of blunt pancreatic trauma in children: Review of the National Trauma Data Bank.

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