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Introduction: Most children in the US live more than one hour from a Level 1 PTC. The Need For Trauma Intervention (NFTI) score was developed to assess trauma triage criteria and is dependent on whether someone requires one of six urgent interventions (NFTI+). We sought to determine if a novel scoring tool, rSIG, could predict NFTI and facilitate the transfer decision making process., Methods: Children 1-18 years old transferred to our level 1 PTC from 2010 - 2020 with complete vital signs and Glasgow Coma Scale (GCS) score at the transferring facility were included. rSIG was calculated as previously described [(SBP/HR) x GCS], and the following cutoffs were used for each age group: ≤13.1, ≤16.5, and ≤20.1 for 1-6, 7-12, and 13-18 years, respectively. Clinical outcomes upon arrival to the PTC were collected to determine if patients met any NTFI criteria., Results: A total of 456 patients met inclusion criteria. The proportion of patients with an abnormal rSIG was 60.1% (274) and 37.0% (169) were NFTI+. Patients with an abnormal rSIG had an odds ratio of 6.18 (95% CI: 3.90, 10.07), p < 0.001 of being NFTI+ compared to those with a normal rSIG., Conclusion: Children with an abnormal rSIG are more likely to be NFTI+ and require higher levels of care, indicating this scoring tool can identify pediatric trauma patients who may benefit from expedited transfer. Incorporating rSIG into initial evaluation and triage of traumatically injured children may expedite the transfer decision making process and limit delays in transport to a PTC., Type of Study: Retrospective Comparative Study LEVEL OF EVIDENCE: III., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest, financial or otherwise, to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Non-operative management (NOM) is the standard of care for the majority of children with blunt liver and spleen injuries (BLSI). The shock index pediatric age-adjusted (SIPA) was previously shown to predict the need for blood transfusions in pediatric trauma patients with BLSI. We combined SIPA with base deficit (BD) and International Normalized Ratio (INR) to create the BIS score. We hypothesized that the BIS score would predict the need for blood transfusions and/or failure of NOM in pediatric trauma patients with BLSI., Methods: Patients (≤ 18 years) who presented to our Level I pediatric trauma center with BLSI from 2009 to 2019 were identified. BIS scores were calculated by giving 1 point for each of the following: base deficit ≤ -8.8, INR ≥ 1.5, or elevated SIPA. Receiver operating characteristic curves (ROC) were generated for BIS scores ≥ 1, ≥ 2, and ≥ 3. Area under the curve (AUC), sensitivity, and specificity of each score were calculated for ability to predict need for blood transfusions and/or failure of NOM., Results: Of 477 children included, 19.9% required a blood transfusion and 6.7% failed NOM. A BIS score ≥ 1 was the best predictor of the need for blood transfusions with an AUC of 0.81 and a sensitivity of 96.0%. A BIS score ≥ 1 was also the best predictor of failure of NOM with an AUC of 0.72 and a sensitivity of 97.0%., Conclusion: The BIS score is a highly sensitive tool that identifies pediatric patients with BLSI at risk for blood transfusions and/or failure of NOM., Level of Evidence: Level III., Type of Study: Retrospective comparative study., Competing Interests: Declaration of Competing Interest The authors have no financial conflicts of interest to disclose., (Copyright © 2021. Published by Elsevier Inc.)

Background/purpose: The utility of thrombelastography (TEG) in pediatric trauma remains unknown, and differences in coagulopathy between blunt and penetrating mechanisms are not established. We aimed to compare TEG patterns in pediatric trauma patients with blunt solid organ injuries (BSOI) and penetrating injuries to determine the role of mechanism in coagulopathy., Methods: Highest-level pediatric trauma activations with BSOI or penetrating injuries and admission TEG at two pediatric trauma centers were included. TEG abnormalities were defined by each institution's normative values and compared separately by injury mechanism and evidence of shock (elevated SIPA) using Kruskal-Wallis or Fisher's exact tests., Results: Of 118 patients included, 64 had BSOI and 54 had penetrating injuries. There were no significant differences in TEG abnormalities between the BSOI and penetrating injury groups. Patients with shock were more likely to have decreased alpha-angles (30.9% vs. 8.0%, p = 0.01) and decreased maximum amplitude (MA) (44.1% vs. 8.0%, p < 0.001) compared to those without shock, regardless of mechanism of injury., Conclusions: TEG abnormalities were not significantly different between the BSOI and penetrating groups, but there were significant differences in alpha-angle and MA in those with shock, independent of mechanism. Hemodynamic status, rather than mechanism of injury, may be more predictive of coagulopathy in pediatric trauma patients., Level of Evidence/study Type: Level III, retrospective., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest, financial or otherwise, to disclose. No grant funding was used to support this research. Institutional funding was provided by the Colorado Firefighters Endowed Chair for Burn and Trauma Care at Children's Hospital Colorado and the Children's Hospital Center for Research in Outcomes in Children's Surgery., (Copyright © 2021. Published by Elsevier Inc.)

Background: Cardiac injuries are rare in pediatric trauma patients and data regarding this type of injury is limited. There is even less data on traumatic great vessel injuries. This study sought to examine and summarize our recent experience at two pediatric trauma centers, which serve a major metropolitan area and large geographic region., Methods: This is a retrospective review of pediatric (<18 years) patients who sustained cardiac or great vessel injuries and were managed at a Level 1 or Level 2 pediatric trauma center between January 1, 2010 and June 30, 2020. Demographic and clinical characteristics were compared using two-sample t-tests, Wilcoxon Rank-Sum tests, Fisher's exact tests and chi-squared tests for continuous, non-normally distributed continuous, and categorical variables, respectively., Results: A total of 53 patients sustained cardiac and/or great vessel injuries. Of these, 37 (70%) sustained cardiac, 9 (17%) sustained great vessel, and 7 (13%) sustained both types of injuries. The median age was 14.9 years and 74% (n = 39) were male. The median injury severity score (ISS) was 36.0 and the injury mechanism was blunt in 31 (58%) patients. The most common cardiac and great vessel injury locations were left ventricle (n = 9) and thoracic aorta (n = 11), respectively. The overall mortality rate was 53% (n = 28). Mortality was highest among those who sustained great vessel injuries (89%)., Conclusions: There is substantial heterogeneity in cardiac and great vessel injuries. Regardless, they are highly morbid and lethal, despite aggressive surgical and catheter-based interventions., (Copyright © 2021. Published by Elsevier Inc.)

Background: Neutropenic enterocolitis is uncommon but potentially life-threatening, with the cornerstone of treatment being medical management (MM), and surgical intervention reserved for clinical deterioration or bowel perforation. We hypothesized that the Shock Index Pediatric Age-Adjusted (SIPA) is elevated in patients who are at greatest risk for surgical intervention and mortality. We also sought to identify computed tomography (CT) findings associated with surgical intervention and mortality., Methods: A single-center cancer registry was reviewed for neutropenic enterocolitis patients from 2006 -2018. Survival models compared patients with normal versus elevated SIPA throughout their hospitalizations for the time to surgical management (SM), as well as in-hospital mortality., Results: Seventy-four patients with neutropenic enterocolitis were identified; 7 underwent surgery. In-hospital mortality was 12% in MM and 29% in SM; mortality among patients with elevated SIPA was 4.7 times higher compared to those with normal SIPA (95% CI: 1.1, 19.83, p = 0.04). CT findings of bowel obstruction, pneumatosis, and a greater percentage of large bowel involvement were associated with surgical intervention (all ps < 0.05)., Conclusion: Select pre-operative CT findings were associated with need for operative management. Elevated SIPA was associated with increased mortality. Elevated SIPA in pediatric cancer patients with neutropenic enterocolitis may help to identify those with more severe disease and expedite beneficial interventions., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to report. No grant funding was used to support this research. Institutional funding was provided by the Colorado Firefighter Endowed Chair, Children's Hospital Colorado Center for Research in Outcomes in Children's Surgery, and generous support from the Colorado Firefighter Calendar. The funder/sponsor did not participate in the work., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Shock index pediatric age-adjusted (SIPA) is a validated measure to identify severely injured children. Previous literature categorized SIPA as normal or elevated, but the relationship between specific SIPA values and outcomes has not been determined. We sought to determine specific SIPA cut points in the pre-hospital and Emergency Department (ED) settings to identify patients at risk for massive transfusion (MT) and/or mortality., Methods: Patients ≤ 18 years old admitted to our Level I pediatric trauma center following trauma activation were included. Youdin J index was used to define pre-hospital and ED SIPA cut points to identify those at risk of MT and/or mortality for the following age groups: < 1 year, 1-6 years, 7-12 years, and > 12 years old. Sensitivity, specificity, accuracy, and area under the curve (AUC) were calculated to determine SIPA threshold values associated with MT and/or mortality., Results: Of 1,072 patients, 6.3% (n = 68) required MT and 8.4% (n = 90) died. For predicting MT, pre-hospital SIPA cut points performed best in the > 12 year-old age group (AUC = 0.86) and ED SIPA cut points performed best in the 6-12 year-old age group (AUC = 0.87). For predicting mortality, pre-hospital (AUC = 0.78) and ED SIPA cut points (AUC = 0.84) performed best in the > 12 year-old age group., Conclusion: Pre-hospital and ED SIPA cut points performed better at predicting MT and/or mortality in older pediatric patients compared to very young children. Age remains an important factor when determining the validity of SIPA to predict outcomes in pediatric trauma patients., Study Type/level of Evidence: Level III, Retrospective Cohort Study., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to report. No grant funding was used to support this research. Institutional funding was provided by the Colorado Firefighter Endowed Chair and the Children's Hospital Colorado Center for Research in Outcomes in Children's Surgery., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background/purpose: The American College of Surgeons (ACS) Committee on Trauma targets undertriage (UT) rates of <5% to optimize the chances of survival. The Cribari Matrix (CM) has traditionally been employed to identify undertriage, but it likely overestimates actual undertriage. An innovative tool called "Need For Trauma Intervention" (NFTI), demonstrates a more accurate assessment of undertriage in adults. We hypothesized that using the combination of CM and NFTI would more accurately identify UT in pediatric trauma patients, compared to CM alone., Methods: We reviewed undertriage rates using CM and NFTI criteria. Univariate analysis was used to compare the need for surgical management, transfusion requirements, ventilator days, ICU length of stay (LOS), hospital LOS, and hospital costs between CM, NFTI, and the combination of CM and NFTI., Results: Undertriage rates were 8.2% with CM and 4.6% with NFTI. When CM and NFTI were combined, the UT rate was 2.7%. Pediatric patients categorized as UT by the combination of CM and NFTI had significantly longer ICU Length of Stay (LOS) (p < 0.001), hospital LOS (p < 0.001), higher mortality rates (p = 0.004), and higher hospitalization costs (p < 0.001)., Conclusions: The combination of CM and NFTI identified UT in children, more accurately than CM or NFTI alone. Injured children who are undertriaged had higher mortality, morbidity, and cost of care. The use of CM in combination with NFTI to evaluate undertriage rates led to the identification of risk factors that may modify the activation criteria for highest and modified level trauma team activations., Level of Evidence: III STUDY TYPE: Retrospective study without negative criteria (Therapeutic/Care Management)., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Many children with gastric feeding intolerance require postpyloric tube feeding via a gastrojejunal (GJ) tube. Placement or positioning of these tubes is typically a procedure with a low dose of radiation. Although the risk of developing cancer from radiation exposure owing to computed tomography scans is well-documented in children, the risk of cumulative radiation exposure owing to frequent GJ tube replacement often goes unnoticed in the clinical decision-making process. We sought to define the frequency and cost of GJ tube replacement, quantify the radiation doses associated with the initial placement and replacements, and assess the number of conversions to surgical jejunostomies., Methods: All pediatric patients who underwent GJ tube placement or replacement by Interventional Radiology (IR), surgery, and gastroenterology between 2010 and 2018 at a single center were reviewed. We evaluated the total cost of the initial placement and replacement of each GJ tube, the total number of replacements, and the cumulative radiation dose (mGy)., Results: We identified 203 patients who underwent GJ tube placement and/or replacement, of which 150 had radiation data available. Patients underwent a median of five GJ tube replacement procedures, and there was a wide range in the number of replacements per patient, from zero to 88. Patients were exposed to a median cumulative dose of 6.0 mGy (IQR: 2.2, 22.6). Nine percent of patients with available radiation data were exposed to more than 50 mGy, solely from GJ tube replacements. The median cost per replacement was $1170. The sum of the cost of the replacements for dislodged GJs translated to more than $1.4 million during the study period., Conclusions: Overall, the average dose per GJ replacement was 3.50 mGy among all patients with available data. Nine percent of patients (14/150) were exposed to greater than 50 mGy cumulative radiation solely from GJ replacements. Patients who receive more than 50 mGy of cumulative radiation dose, who undergo seven GJ tube replacements in one year, or two consecutive GJ tube replacement procedures with radiation doses exceeding 10 mGy (per replacement) should be considered for a surgical jejunostomy., Level of Evidence: IV TYPE OF STUDY: Treatment study., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The principal triggers for intervention in the setting of pediatric blunt solid organ injury (BSOI) are declining hemoglobin values and hemodynamic instability. The clinical management of BSOI is, however, complex. We therefore hypothesized that state-of-art machine learning (computer-based) algorithms could be leveraged to discover new combinations of clinical variables that might herald the need for an escalation in care. We developed algorithms to predict the need for massive transfusion (MT), failure of non-operative management (NOM), mortality, and successful non-operative management without intervention, all within 4 hours of emergency department (ED) presentation., Methods: Children (≤18 years) who sustained a BSOI (liver, spleen, and/or kidney) between 2009 and 2018 were identified in the trauma registry at a pediatric level 1 trauma center. Deep learning models were developed using clinical values [vital signs, shock index-pediatric adjusted (SIPA), organ injured, and blood products received], laboratory results [hemoglobin, base deficit, INR, lactate, thromboelastography (TEG)], and imaging findings [focused assessment with sonography in trauma (FAST) and grade of injury on computed tomography scan] from pre-hospital to ED settings for prediction of MT, failure of NOM, mortality, and successful NOM without intervention. Sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve (AUC) were used to evaluate each model's performance., Results: A total of 477 patients were included, of which 5.7% required MT (27/477), 7.2% failed NOM (34/477), 4.4% died (21/477), and 89.1% had successful NOM (425/477). The accuracy of the models in the validation set was as follows: MT (90.5%), failure of NOM (83.8%), mortality (91.9%), and successful NOM without intervention (90.3%). Serial vital signs, the grade of organ injury, hemoglobin, and positive FAST had low correlations with outcomes., Conclusion: Deep learning-based models using a combination of clinical, laboratory and radiographic features can predict the need for emergent intervention (MT, angioembolization, or operative management) and mortality with high accuracy and sensitivity using data available in the first 4 hours of admission. Further research is needed to externally validate and determine the feasibility of prospectively applying this framework to improve care and outcomes., Level of Evidence: III STUDY TYPE: Retrospective comparative study (Prognosis/Care Management)., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background/purpose: Shock index-pediatric age-adjusted (SIPA) is a proven tool to predict outcomes in blunt pediatric trauma. We hypothesized that an elevated SIPA in either the pre-hospital or in the emergency department (ED) would identify children with blunt liver or spleen injury (BLSI) needing a blood transfusion and those at risk for failure of non-operative management (NOM)., Methods: Pediatric patients (1-18 years) in the ACS pediatric-TQIP database (2014-2016) with a BLSI were included. Patients were stratified by the need for a blood transfusion and/or abdominal operation., Results: A total of 3561 patients had BLSI, of which 4% received a blood transfusion, and 4% underwent an abdominal operation. Patients who received blood had higher ISS scores (27.0 vs. 5.0, p < 0.001) and mortality (22% vs. 0.4%, p < 0.001). Those who failed NOM had higher ISS scores (17.0 vs. 5.0, p < 0.001) and mortality (7.9% vs. 0.9%, p < 0.001). On multivariable regression, an elevated SIPA score in either pre-hospital or ED was significantly associated with blood transfusion (odds ratio (OR) 8.2, 95% confidence intervals (CI) 5.8-11.5, p < 0.001) and failure of NOM (OR 2.3, CI 1.5-3.4, p < 0.001)., Conclusions: Hemodynamic instability, represented by an elevated pre-hospital or ED SIPA, accurately identifies children with BLSI who may need blood products or an operative intervention., Type of Study: Retrospective Comparative Study., Level of Evidence: Level III., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Nonoperative management protocols of blunt liver and spleen injury in children usually call for serial monitoring of the child's hemoglobin and hematocrit (H/H) at scheduled intervals. We previously demonstrated that the need for emergent intervention is triggered by changes in vital signs, not the findings of scheduled blood draws and changed our protocol accordingly. The current aim is to evaluate the safety of this change., Methods: We performed a retrospective review of all children admitted following blunt liver or spleen injury during two periods; the historic cohort 1/09-12/13 and the protocol cohort 8/15-7/17. Data evaluated included the need for intervention, number of H/H checks, and outcomes., Results: 330 children were included (216 historic; 114 protocol). Groups did not differ in percentage of male patients, injury severity score, or GCS. Median age in the historic cohort was younger than the protocol cohort (9 vs 12 years; p = 0.02). More children in the protocol group had a grade 5 injury (1% vs 9%; p < 0.0001). Groups did not differ in the number who required intervention or discharge disposition (including mortality). The protocol group had fewer H/H checks (median 5 vs 4, p < 0.0001); the two groups did not differ in their nadir H/H. The historic group had a longer median hospital length of stay (3 days vs 2, p = 0.0007)., Conclusions: Decreasing the number of scheduled blood draws following a blunt liver or spleen injury in children is safe. Additional benefits include a decrease in the number of blood draws and a decrease in length of hospital stay., Study Type: Cost-effectiveness., Level of Evidence: Level III., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Pediatric traumatic vascular injuries are rare. Given the paucity of data to guide anti-coagulation (AC) management of these injuries in children, who have a lower overall risk for thrombosis compared to their adult counterparts, we sought to examine and summarize our recent experience., Method: We conducted a retrospective review of all patients (<18 years old) who sustained traumatic vascular injuries between 2010-2018 at a Level 1 and Level 2 Pediatric Trauma Center., Results: Ninety-nine patients had traumatic vascular injuries. Eighty-four patients sustained a major arterial injury, 26 had a major venous injury, and 11 had both arterial and venous injuries. The arterial injury cohort had a median age of 13.3 years. Most of the arterial injury patients (65/84, 77%) required vascular repair. In-hospital AC management for the arterial injury patients consisted of a post-operative heparin drip (18%, 15/84), aspirin (39%, 26/84), enoxaparin (23%, 19/84), or none (42%, 43/84). Approximately one-half of the patients with arterial injuries (54%, 45/84) were discharged home on AC therapy, most commonly aspirin. Fifty-six patients (66%) followed up post-injury, of which 25% (14/56) had experienced complications., Conclusion: Pediatric traumatic arterial injuries that require surgical intervention other than ligation should be considered for discharge AC - most commonly aspirin - in the absence of contraindications. Pediatric patients with vascular injuries to the aorta, carotid artery, inferior vena cava, portal vein, or lower extremities that are managed non-operatively should also be considered for AC. The preferred AC for pediatric venous injuries is enoxaparin, in the absence of contraindications., Study Type: Treatment Study LEVEL OF EVIDENCE: IV., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Early and accurate identification of pediatric trauma patients who will require massive transfusion (MT) remains difficult, and MT activation criteria are not well established. In children, the addition of shock index-pediatric age-adjusted (SIPA) to the ABC score (ABC-S) only modestly improves the sensitivity of the ABC score. We hypothesized that the discriminate ability of the ABC-S score would improve with the addition of elevated serum lactate and base deficit (ABCD score)., Methods: We identified children between 1 and 18 years old who received a pRBC transfusion between 2008 and 2018 from our trauma registry. We calculated sensitivity, specificity, and accuracy of the ABC, ABC-S, and ABCD scores to determine the need for MT., Results: We included 211 children, of which 66 required MT. The best predictor of MT was achieved by adding BD and lactate to the ABC-S score, with an AUC of 0.805. An ABCD score of 3 or greater was 77.4% sensitive and 78.8% specific at predicting the need for MT. Pediatric trauma patients that required MT had higher injury severity score (p = 0.005), lactate (p = 0.002), base deficit (p = <0.0001). Mortality was higher in the MT group (45.5% vs 15.3%, p = 0.0004)., Conclusions: The ABCD score improves the sensitivity of activating MT in pediatric trauma patients., Study Type: Treatment Study., Level of Evidence: Level III., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Central venous catheters (CVC) are vital to the management of critically ill children. Despite efforts to minimize complications, central line associated bloodstream infection (CLABSI) and venous thromboembolisms (VTE) still occur., Methods: We performed a retrospective review of a prospectively collected database for children admitted to the pediatric intensive care unit (PICU) between November 2013 and December 2016., Results: In total, 2714 CVC were in place, 979 of which were percutaneous CVC. During the study period, 21 CLABSI (1.6/1000 line days) were identified, of which, nearly half (n = 9, 42.9%) were associated with percutaneous CVC (2.6/1000 line days). Poisson regression analysis did not identify a single risk factor for CLABSI when adjusting for line type, anatomic location and laterality of placement, geographic location of placement, length of PICU admission, presence of gastrostomy tube, concurrent mechanical ventilation, age, weight, and height. Forty clinically significant VTE (2.9/1000 line days) were identified, with percutaneous CVC having the highest incidence (7.5/1000 line days, p < 0.001). Of percutaneous CVC, clinically significant VTE were more often associated with femoral vein cannulation (14.8/1000 line days) compared to internal jugular and subclavian vein (2.5 and 2.4/1000 line days, respectively, p < 0.001)., Conclusion: This data suggests that the femoral site may be an important risk factor that should be considered in prevention strategies for catheter-associated VTE in children., Level of Evidence: III., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: In adults, shock index (SI; heart rate/systolic blood pressure) >0.9 predicts injury severity and trauma outcomes. However, age-adjusted shock index (SIPA) out-performs SI in blunt trauma patients 4-16years old. We sought to confirm these findings and expand this tool to include penetrating trauma and children aged 1-4years., Methods: We developed cutoff values for patients 1-3years old using age-based vital signs and queried the 2014 Pediatric Trauma Quality Improvement Program (TQIP) database for patients aged 1-16years sustaining blunt or penetrating trauma. Outcomes measured included injury severity, transfusion within 24h, intensive care unit (ICU) and hospital length of stay (LOS), and mortality. SI and SIPA were compared using Student's t-test and chi-square tests., Results: We identified 22,344 blunt and 613 penetrating trauma patients. SI was elevated in 41.3% and 40.0% of these groups, respectively, whereas SIPA was elevated in 15.6% and 19.4% of patients. SIPA was a significantly better predictor of transfusion needs, injury severity, ICU admission, ventilator use, and mortality for both blunt and penetrating trauma., Conclusion: SIPA identifies severe injury and predicts transfusion needs and mortality more effectively than SI for both blunt and penetrating pediatric trauma. Further investigation should evaluate its use as a triage tool., Type of Study: Prognosis Study., Level of Evidence: II., (Copyright © 2017. Published by Elsevier Inc.)

Background: Initiatives exist to prevent pediatric injuries, but targeting these interventions to specific populations is challenging. We hypothesized that mapping pediatric injuries by zip code could be used to identify regions requiring more interventions and resources., Methods: We queried the trauma registries of two level I trauma centers for children 0-17years of age injured between 2009 and 2013 with home zip codes in our state. Maps were created to identify outlier zip codes. Multivariate linear regression analysis identified predictors within these zip codes., Results: There were 5380 children who resided in the state and were admitted for traumatic injuries during the study period, with hospital costs totaling more than 200 million dollars. Choropleth mapping of patient addresses identified outlier zip codes in our metro area with higher incidences of specific mechanisms of injury and greater hospital charges. Multivariate analysis identified demographic features associated with higher rates of pediatric injuries and hospital charges, to further target interventions., Conclusions: We identified outlier zip codes in our metro area with higher frequencies of pediatric injuries and higher costs for treatment. These data have helped obtain funding for prevention and education efforts. Techniques such as those presented here are becoming more important as evidence based public health initiatives expand., Level of Evidence: Type of Study: Cost Effectiveness, II., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Following complicated appendicitis, there are limited data available to guide the surgeon regarding antibiotic selection, specifically in regards to route of administration. We hypothesized that among children with appendicitis who are discharged home with antibiotic therapy, the post-discharge readmission and complication rates do not differ between those children who receive IV antibiotics and those who receive PO antibiotics., Methods: We performed a retrospective review of all children discharged home on antibiotics following appendectomy at a single institution between 11/10-10/14. We compared outcomes including ED and hospital readmission rates, and development of postoperative complications, between those children who were discharged on IV antibiotics and those discharged on PO antibiotics., Results: 325 children were discharged with antibiotics following appendectomy (n=291 PO antibiotics group; n=34 IV group). On both univariate and multivariate analysis, rate of each complication did not differ between the two groups including inpatient readmission (5% PO vs. 6% IV; p=0.8), ED readmission (10% vs. 11%; p=0.8), postdischarge complications related to the operation (10% vs. 15%; p=0.4), or abscess development post-discharge (4% vs. 3%; p=1)., Conclusions: Among children with complicated appendicitis who are discharged home with ongoing antibiotic therapy, our data demonstrate no differences in outcomes between those children who receive IV and PO antibiotics. Further data, collected in a prospective fashion, are needed to clarify the role of IV and PO antibiotics among children with perforated appendicitis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background/purpose: Emergency department thoracotomy (EDT) has been proposed to be futile in the pediatric patient population. This extreme procedure has survival rates of 0 to 26% in the nonadult population. When taking into consideration that the mechanism of injury is one of the strongest predictors of survival, we hypothesize that the low survival rate in pediatric patients is attributable to a higher rate of blunt trauma compared to their adolescent counterparts., Methods: Prospective data collected from our level 1 trauma center from 1974 to 2014 on all patients undergoing EDT at our institution were evaluated for age 18years or younger. Patient predictor variables included injury mechanism, injury pattern, and detected cardiac activity in the field. Outcomes included successful resuscitation (reestablish of blood pressure and taken to operating room) and overall survival. Patients were dichotomized by age into pediatric (age≤15years) and adolescent (16-18years) categories., Results: 1691 patients who underwent EDT were evaluated for age of 18years or less, which included 179 patents (11%). Overall survival in the adult population was 6.1%, compared to 3.4% in the nonadult population (p=0.157). Pediatric patients were more likely to sustain blunt injury than adolescents (72% vs 32%, p<0.001). This also corresponded to differences in anatomic injury patterns and more multisystem trauma (52% vs 44%, p=0.001). Adolescents had significantly higher survival rates than pediatric patients (5% vs 0%, p=0.036)., Conclusion: In nonadult patients undergoing EDT, adolescents have a higher survival rate than pediatric patients. The pediatric population had a significantly lower incidence of penetrating trauma and higher incidence of head injury. The discrepancy in survival between adolescent and pediatric patients appears to be attributable to differences in mechanism. Therefore, those pediatric patients with penetrating thoracic injuries may still benefit from EDT., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: We hypothesized that the finding of diffuse slowing on bedside EEG in children with moderate to severe traumatic brain injury (TBI) is associated with prolonged hospital stay and worse functional outcomes., Methods: We reviewed the medical records of all patients admitted to a single level I pediatric trauma center with moderate or severe TBI from 1/10-12/12 (defined by GCS<10 on admission). EEG monitoring results, patient demographics, clinical characteristics, length of stay and postinjury outcomes were recorded. We compared outcomes between patients with and without diffuse slowing on EEG. Data are presented as mean±SEM; p<0.05 was considered statistically significant., Results: 219 children with TBI were identified; 81 had a bedside EEG performed within 48 hours of admission. Diffuse slowing was present in 50 (mean age 5.7+0.7 years) and absent in 31 (n=31, mean age 4.2+0.9 years). Patients with diffuse slowing had a significant increase in ventilator days, ICU LOS, need for rehabilitation, and rehabilitation length of stay., Conclusion: The presence of diffuse slowing on EEG in children with TBI is associated with prolonged patient recovery and poor functional outcomes. This finding should prompt early consideration for rehabilitation and the need for intensive therapy., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Abusive head trauma (AHT) is a significant cause of morbidity and mortality in the pediatric population. We aimed to assess the social and legal outcomes of AHT and determine if the rates of successful prosecution have changed over recent years., Methods: We utilized the trauma database at a single institution to identify all cases of AHT during two time periods: 1996-2001 and 2006-2010 then collected data from the Child Advocacy and Protection Team database. We characterized the social and legal outcomes and compared them between the two cohorts., Results: A total of 254 patients (120 historic and 134 modern cohort) were included. Mortality rate was 19.7% and did not differ between the two cohorts. Thirty-seven percent of patients were discharged to foster care, this rate did not change across the two time periods. Suspected perpetrators pled guilty or were found guilty in only 74 cases (29%). However, when a case involved a fatality, perpetrators pled or were found guilty more often than in cases of a non-fatality (50 vs. 21.5%; p=0.0001)., Conclusions: AHT results in fatality in approximately 1 in 5 cases, perpetrators are identified and found guilty in only 29% of the cases. Trauma surgeons need to be strong advocates for these vulnerable patients and actively participate in legal proceedings., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: Shock index (SI) (heart rate/systolic blood pressure)>0.9 predicts mortality in adult trauma patients. We hypothesized that age adjusted SI could more accurately predict outcomes in children., Methods: Retrospective review of children age 4-16 years admitted to two trauma centers between 1/07 and 6/13 following blunt trauma with an injury severity score (ISS)>15 was performed. We evaluated the ability of SI>0.9 at emergency department presentation and elevated shock index, pediatric age adjusted (SIPA) to predict outcomes. SIPA was defined by maximum normal HR and minimum normal SBP by age. Cutoffs included SI>1.22 (age 4-6), >1.0 (7-12), and >0.9 (13-16)., Results: Among 543 children, 50% of children had an SI>0.9 but this fell to 28% using age adjusted SI (SIPA). SIPA demonstrated improved discrimination of severe injury relative to SI: ISS>30: 37% vs 26%; blood transfusion within the first 24 hours: 27% vs 20%; Grade III liver/spleen laceration requiring blood transfusion: 41% vs 26%; and in-hospital mortality: 11% vs 7%., Conclusion: A pediatric specific shock index (SIPA) more accurately identifies children who are most severely injured, have intraabdominal injury requiring transfusion, and are at highest risk of death when compared to shock index unadjusted for age., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: Excessive crystalloid resuscitation of blunt injured adults is deleterious. We hypothesize that children, unlike adults, are resistant to the adverse effects of high volume resuscitation., Methods: We reviewed the trauma databases at two level-one trauma centers, including all children age 4-16years admitted following blunt trauma with an injury severity score (ISS) ≥15 to determine the relationship between crystalloid volume received and clinical outcomes., Results: A total of 384 children were included. After controlling for age, sex, AIS head, ISS, GCS on presentation, hemoglobin, blood transfusion, and surgical procedures in the first 24hours, crystalloid volume greater than 60ml/kg in the first 24hours was associated with increased length of stay (LOS) and need for mechanical ventilation. On univariate analysis, initial crystalloid volume of >60ml/kg was associated with anemia and thrombocytopenia. Volume of resuscitation was not associated with ARDS, ACS, MOF, urinary tract infection, or blood stream infection. However, these complications were exceedingly rare, with no children developing MOF., Conclusions: Excessive crystalloid resuscitation was associated with increased hospital LOS and need for mechanical ventilation. Increased rates of other complications including ARDS, ACS, and MOF were not observed. Injured children appear relatively resistant to some of the adverse effects of early high volume fluid resuscitation., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Early tracheostomy has been advocated for adult trauma patients to improve outcomes and resource utilization. We hypothesized that timing of tracheostomy for severely injured children would similarly impact outcomes., Methods: Injured children undergoing tracheostomy over a 10-year period (2002-2012) were reviewed. Early tracheostomy was defined as post-injury day ≤ 7. Data were compared using Student's t test, Pearson chi-squared test and Fisher exact test. Statistical significance was set at p<0.05 with 95% confidence intervals., Results: During the 10-year study period, 91 patients underwent tracheostomy following injury. Twenty-nine (32%) patients were < 12 years old; of these, 38% received early tracheostomy. Sixty-two (68%) patients were age 13 to 18; of these, 52% underwent early tracheostomy. Patients undergoing early tracheostomy had fewer ventilator days (p=0.003), ICU days (p=0.003), hospital days (p=0.046), and tracheal complications (p=0.03) compared to late tracheostomy. There was no difference in pneumonia (p=0.48) between early and late tracheostomy., Conclusion: Children undergoing early tracheostomy had improved outcomes compared to those who underwent late tracheostomy. Early tracheostomy should be considered for the severely injured child., Summary: Early tracheostomy is advocated for adult trauma patients to improve patient comfort and resource utilization. In a review of 91 pediatric trauma patients undergoing tracheostomy, those undergoing tracheostomy on post-injury day ≤ 7 had fewer ventilator days, ICU days, hospital days, and tracheal complications compared to those undergoing tracheostomy after post-injury day 7., (© 2014.)

Purpose: Head injury secondary to abusive head trauma (AHT) is a major cause of morbidity and mortality in susceptible young infants and children. Diagnosing AHT remains challenging and is often complicated by a questionable mechanism of injury. Concern of ionizing radiation risk to children undergoing head CT imaging warrants a selective approach. We aimed to evaluate initial findings that could direct further investigation of AHT., Methods: A retrospective review of the trauma databases at a two level one pediatric trauma centers was performed. We reviewed all patients age five years and under with a diagnosis of traumatic brain injury (TBI) from 2002-2011., Results: A total of 1129 patients (mean age 1.7 ± 1.7 years; 64% male) with TBI were identified, 429 (38%) of which were the result of AHT. Complete data was available for 921 patients (82%) and were included in statistical evaluation. Forty-eight percent of patients in the AHT group had a hematocrit ≤ 30% on presentation compared to 19% of patients in the non-AHT group. On univariate analysis, a hematocrit of ≤ 30% was predictive of AHT as the cause of injury (P<.0001), as was a platelet count of greater than 400,000 (P<.0001). After controlling for age, sex, ISS, GCS on presentation, need for CPR, and survival to hospital discharge, hematocrit of ≤ 30% and platelets of greater than 400,000 were predictive of AHT as the cause of TBI (P<.05)., Conclusions: In the setting of head injury and unclear history of trauma, a hematocrit of ≤ 30% on presentation increases the likelihood of abusive head trauma in children up to the age of 5 years., (© 2014.)

Background/purpose: Children suffering from abusive head trauma (AHT) have worse outcomes compared to non-AHT, but the reasons for this are unclear. We hypothesized that delayed medical care associated with AHT causes prolonged pre-hospital hypotension and hypoxia as measured by admission base deficit (BD), and that this would correlate with outcome., Methods: We performed a 10-year retrospective chart review of children admitted for AHT at two academic level-I trauma centers. Statistics were performed using Student's t test, chi-square analysis, and multivariate logistic regression, and considered significant at p < 0.05., Results: Four-hundred twelve children with AHT were identified, and admission BD was drawn for 148/412 (36%) children, including 104 survivors and 44 non-survivors. Non-survivors had significantly higher BD compared to survivors (12.6 ± 1.6 versus 5.3 ± 0.6, p < 0.001). Non-survivors were more likely to be intubated pre-hospital and get cardiopulmonary resuscitation (CPR) (p < 0.001). Mortality increased with rising BD, according to CPR status. There was no difference in patterns of brain injury between survivors and non-survivors (p > 0.05)., Conclusions: BD correlates with mortality in children suffering severe AHT. Non-survivors are also more likely to be intubated pre-hospital and require CPR, with no difference in pattern of brain injury, suggesting that secondary injury is a major determinant of outcome in severe AHT., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background/purpose: Early postinjury death after packed red blood cell (pRBC) transfusion is attributed to uncontrolled hemorrhage and coagulopathy. The adverse immunomodulatory effects of blood transfusion are implicated in subsequent morbidity. We hypothesized that injured children requiring pRBC transfusion demonstrate patterns in outcome similar to those observed in adults., Methods: Our prospectively collected trauma registry was queried for demographics, treatment, and outcome (2006-2009). Outcomes of children who received pRBC transfusion were compared with those of age- and Injury Severity Score (ISS)-matched children who did not receive pRBC transfusion by both univariate and multivariable analysis., Results: Eight percent (43/512) of injured children received a pRBC transfusion: 20 early and 23 late. The likelihood of pRBC transfusion increased with increasing ISS (ISS <15, 2%; ISS 16-25, 17%; ISS >25, 72%). One-half of injured children who received an early pRBC transfusion died; however, most deaths were because of central nervous system injury. Both ventilator and intensive care unit days were increased in children who received pRBC transfusion as compared with those who did not., Conclusion: Early pRBC transfusion is associated with a high mortality in children. Late blood transfusion is associated with worse outcomes, although this relationship may not be causal. This pilot study provides evidence of an association between pRBC transfusion, morbidity, and mortality among injured children that warrants refinement in larger, prospective investigations., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Introduction: We have developed a collaborative approach to pediatric thyroid surgery, with operations performed at a children's hospital by a pediatric surgeon and an endocrine surgeon. We hypothesize that this strategy minimizes specialist-specific limitations and optimizes care of children with surgical thyroid disease., Methods: Data from all partial and total thyroidectomies performed by the pediatric-endocrine surgery team at a tertiary children's hospital between 1995 and 2009 were collected and analyzed retrospectively. Statistical analyses were performed with IBM SPSS software (SPSS, Chicago, IL)., Results: Thirty-five children met the inclusion criteria (69% female; median age, 13 years; median follow-up, 1119 days). The indications for operation were thyroid nodule (71%), genetic abnormality with predisposition to thyroid malignancy (17%), multinodular goiter (5.7%), Grave disease (2.9%), and Hashimoto thyroiditis (2.9%). Sixteen children (46%) underwent thyroid lobectomy, and 19 children (54%) underwent total thyroidectomy. Median length of stay was 1 day (1 day after lobectomy vs 2 days after total thyroidectomy, P < .0001). There were 4 cases of transient hypocalcemia after total thyroidectomy, but there were no nerve injuries or other in-hospital complications in either group (overall complication rate, 11%)., Conclusions: For pediatric thyroidectomy and thyroid lobectomy, collaboration of high-volume endocrine and pediatric surgeons as well as pediatric endocrinologists at a dedicated pediatric medical center provides optimal surgical outcomes., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Traumatic injuries are a major cause of morbidity and mortality in children. The purpose of the present study was to determine the incidence of nonaccidental trauma (NAT) and to compare the outcomes of accidental trauma (AT) patients with NAT patients at a large pediatric trauma center., Methods: A retrospective chart review of 6186 trauma patients younger than 18 years evaluated during the period of 1996 to 2004., Results: During the period of study, NAT accounted for 7.3% (n = 453) of trauma evaluations (n = 6186). Compared to AT, the NAT patient was younger, 12 vs 76 months (P < .05); were more severely injured, injury severity score 18 vs 9 (P < .05); and required both longer intensive care unit stay, 2 vs 1 day (P < .05), and overall hospital stay, 6 vs 3 days (P < .05). Craniotomy was required in 4.4% of NAT patients compared with 2.7 % of AT patients (P < .05). Abdominal exploration was necessary in 3.5% of NAT patients compared to 1.6% of AT patients. The mortality rate for NAT was 9.7% compared to 2.2% for AT (P < .05)., Conclusions: The surgeon caring for children must appreciate the high incidence of NAT with its increased morbidity and mortality relative to AT patients. A surgical evaluation should be performed promptly in NAT patients because of their frequent need for emergent intervention.

Xanthogranulomatous pyelonephritis is a rare condition in children. A 7-year-old boy developed right flank pain and tenderness 1 month after an appendectomy. Abdominal computed tomography scan documented a right renal mass. A right nephrectomy was performed. The pathological report documents xanthogranulomatous pyelonephritis. He experienced an uneventful recovery. Xanthogranulomatous pyelonephritis should be included in the differential diagnosis of children with fever, weight loss, flank tenderness, and a renal mass.

Background/purpose: The minimally invasive Nuss procedure is emerging as the preferred technique for repair of pectus excavatum. Original methods of pectus bar placement have been modified to improve safety and efficacy and avoid cardiothoracic complications. The currently reported modifications to facilitate retrosternal pectus bar placement include routine use of right thoracoscopy or a subxiphoid incision. The purpose of this article is to describe additional modifications of the Nuss procedure to improve safety and efficacy., Methods: A retrospective analysis was performed on 51 patients who have had a thoracoscopic-assisted Nuss procedure at The Children's Hospital, Denver, Colo, between 1999 and 2002. Technical modifications included patient positioning, routine use of left thoracoscopy, and an Endo-kittner., Results: Fifty-one patients have successfully undergone the Nuss procedure using the new modifications. Surgical time ranged from 45 to 120 minutes. There have been no intraoperative or postoperative bleeding complications. There have been 2 large pneumothoraces requiring needle thoracenteses in the operating room before extubation. No chest tubes were required postoperatively. Subjectively, all patients have been satisfied with their surgical correction. Average length of hospital stay was 4 to 6 days., Conclusions: By using left chest thoracoscopy and Endo-kittner dissectors, the risk of cardiothoracic injury can be eliminated. Moreover, other methods to ensure safe substernal dissection are unnecessary.

Background: Sentinel lymph node (SLN) status is the strongest predictor of survival in adult melanoma. However, the prognostic value of SLN status in children and adolescents with melanoma is unknown., Methods: Records of 327 patients aged 12 to 86 years undergoing SLN biopsy for melanoma or other melanocytic lesions were reviewed. A literature search identified additional patients younger than 21 years undergoing SLN biopsy for the same indications and these patients were combined with our series for meta-analysis., Results: Sentinel lymph node metastases were found in 8 (40%) of 20 patients aged 12 to 20 years compared with 55 (18%) of 307 adults (P < .05). Median follow-up was 35 and 17 months for the groups, respectively. Sentinel lymph node-positive pediatric patients did not recur, whereas 14 (25%) adults recurred within this period. Of the 55 adults, 5 (9.1%) have died of disease. Of the combined SLN-positive children and adolescents from the literature (total n = 25), only a single (4%) child recurred at 6 months. The difference in survival for adult and pediatric patients was significant., Conclusion: Pediatric patients have a higher incidence of SLN metastases than adults yet have a lower incidence of recurrence. Sentinel lymph node status does not predict early recurrence in pediatric patients with melanoma or atypical Spitz nevi.

Background: Children have a lower incidence of postinjury multiple organ failure (MOF) compared with adults with equivalent injury severity. Because MOF appears to be the end result of systemic hyperinflammation, children may have either an attenuated proinflammatory response or an augmented antiinflammatory response compared with adults. The purpose of this study was to determine the lipopolysaccharide (LPS)-induced pro- and antiinflammatory cytokine response of pediatric versus adult peritoneal macrophages (PM). The authors hypothesized that pediatric PMs would have an enhanced antiinflammatory response compared with adults., Methods: Human PMs were collected during elective laparoscopic procedures and stimulated with LPS. (Pediatric cohort: n = 9 [mean, 5.4 years], adult cohort: n = 8 [mean, 41.6 years]). P less than.05 was accepted as significant., Results: LPS-induced a 50-fold increase in interleukin-10 (IL-10) antiinflammatory cytokine production in pediatric versus adult PMs. LPS-induced tumor necrosis factor-alpha (TNF-alpha) production was also increased in pediatric versus adult PMs. The anti-proinflammatory cytokine ratio (IL-10 to TNF-alpha) was 20-fold higher in pediatric versus adult PMs., Conclusions: LPS-induced macrophage production of both IL-10 and TNF-alpha was increased in children. The anti-proinflammatory cytokine ratio (IL-10 to TNF-alpha) was strikingly higher in pediatric versus adult PMs. These data suggest that the age-related balance of anti- and proinflammatory cytokines in resident macrophages is different in children compared with adults.

Background/purpose: pulmonary (PPT) and extrapulmonary pseudotumors (EPPT) are uncommon benign tumors, which, in general, do not recur after complete resection. Recurrence rates for both types of pseudotumors are undocumented in a large population of children, and the salient features of potential recurrences are unspecified., Methods: This is a report of 15 children with PPT and EPPT; 3 children had a recurrence. These pseudotumors recurred despite adequate primary resection of all gross disease at first presentation. The literature was reviewed to determine rate of recurrence for PPT and EPPT and also to document features common to recurrent pseudotumors., Results: Overall recurrence rate for pseudotumors was 14%. PPT and EPPT, which were not confined to a single organ, had a high chance of recurrence (46% and 30%, respectively) compared with PPT and EPPT, which were confined to a single organ (1.5% and 8%, respectively). Recurrences have appeared between 3 months and 7 years. Intraabdominal EPPT accounts for more than 75% of the EPPT recurrences., Conclusions: PPT and EPPT recur more frequently than anticipated. All pseudotumors, which on initial presentation extend beyond the confines of a single organ, have a high chance of recurrence despite what appears to be adequate resection. Children with pseudotumors that extend beyond a single organ, require frequent postoperative evaluation for recurrence and may be candidates for chemotherapy or radiotherapy at the time of initial resection.

Purpose: The aim of this study was to determine in a pediatric population whether a routine chest x-ray after central venous access is necessary when the central venous catheter is placed with intraoperative fluoroscopy., Methods: This was a retrospective review of the charts of all patients at Children's Hospital in Denver, Colorado who underwent subclavian or internal jugular central venous catheter placement from January 1, 1998 through December 31, 2001. Age, sex, primary reason for access, access site, number of venipuncture attempts, type of catheter, intraoperative fluoroscopy results, chest x-ray results, location of the tip of the catheter, and complications were analyzed., Results: There were 1,039 central venous catheters placed in 824 patients, 92.6% in the subclavian vein and 7.4% in the internal jugular vein. There were 604 (58.1%) children who had both fluoroscopy and a postprocedure chest x-ray, there were 308 (29.6%) who had only fluoroscopy, there were 117 (11.3%) who had only a postprocedure chest x-ray, and there were 10 (1.0%) who had neither fluoroscopy nor chest x-ray. On completion of the procedure, there were 12 (1.1%) children with misplaced central venous catheters, only 1 (0.1%) when intraoperative fluoroscopy was used. There were 17 (1.6%) complications; 9 (0.9%) were pulmonary (pneumothorax, hemothorax, or an effusion). All children with pulmonary complications experienced clinical signs and symptoms suggestive of the complication after their central venous catheter insertion but before their postprocedure chest x-ray., Conclusions: The number of complications encountered in children who had central venous access of the subclavian vein or internal jugular central vein with intraoperative fluoroscopy was infrequent, the number of misplaced catheters was minimized with intraoperative fluoroscopy, and all children with pulmonary complications showed clinical signs suggestive of pulmonary complications before postoperative chest x-ray. Therefore, children who have had central venous access of the subclavian and internal jugular vein with intraoperative fluoroscopy do not appear to require a routine chest x-ray after catheter placement unless clinical suspicion of a complication exists.

Background/purpose: Appendicitis continues to present a diagnostic dilemma in children of all ages leading to increased utilization of radiographic studies. Focused computed tomography (CT) scanning has become the diagnostic test of choice in many hospitals. The purpose of this study was to critically evaluate the use of radiographic studies for the evaluation of acute appendicitis in children and to determine if diagnostic accuracy has improved., Methods: Children undergoing appendectomy for acute appendicitis were reviewed from 1997 to 2001. Diagnostic workup (CT scan, ultrasound [US], or no radiographic study) was recorded as were the final pathology results., Results: Six hundred sixteen appendectomies were performed. Mean age was 10.4 +/- 4.1 years, and 60% were boys. Overall, 184 children (30%) underwent CT scanning, 104 (17%) had US performed, and 310 (50%) had no radiographic study (18 patients had both CT and US performed). A pathologically normal appendix was removed in 7% (14 of 202) of CT patients, 11% (14 of 122) of US patients, and 8% (26 of 310) of patients without a study. The frequency of CT scanning increased from 1.3% of all children in 1997 to 58% in 2001, whereas utilization of US decreased from 40% to 7%. Over the same period, the overall negative appendectomy rate did not change significantly from 8% to 7%., Conclusions: With increased utilization of focused CT scanning, the negative appendectomy rate has remained unchanged. History and physical examination by an experienced surgeon is as accurate as CT in correctly diagnosing acute appendicitis in children., (Copyright 2003 Elsevier Inc. All rights reserved.)

Background/purpose: The literature lacks a concise description of the anorectal anomalies encountered in pygopagus twins., Methods: This is a retrospective literature review of 34 pygopagus twins highlighting their anorectal malformations., Results: Overall pygopagus twins represent 17% of all conjoined twins. Live-birth pygopagus twins are more commonly female (86%), whereas stillborns are commonly male (80%). Half of the twins had nonfused rectums, and half had fused rectums. The nonfused had 2 rectums (80%) or one rectum and one rectovaginal fistula (20%). The fused had high (46%) or low (54%) rectal junctions. All reported living male pygopagus twins have had nonfused rectums. All can be managed applying the principles of posterior sagittal anorectoplasty., Conclusions: In general, live-born male pygopagus twins are likely to survive with a nonfused rectum and good bowel function, whereas live-born female pygopagus twins have a good chance of surviving with a fused rectum (high or low), which requires appropriate operative reconstruction., (Copyright 2003, Elsevier Science (USA). All rights reserved.)

Background/purpose: Neutrophils (PMNs) are well known effectors of lung injury after sepsis. The accumulation of PMNs into the lung is dependent on a complex cascade of events that includes the local production of chemokines. Interestingly, neonates are protected from lung injury after zymosan-induced sepsis. The authors hypothesized that this protection was caused by either altered PMN function or diminished lung chemokine production compared with the adult., Methods: Sepsis was induced in neonatal and adult rats by an intraperitoneal injection of zymosan. Animals were killed 24 hours later and lungs examined for PMN accumulation and function, chemokine production, and lung injury., Results: Septic neonates (SN) were protected from pulmonary edema when compared with septic adults (SA). Lung PMN number and chemokine (MIP-2) production increased in both septic neonates and adults when compared with vehicle (V) treated animals. Conversely, PMN function was decreased significantly in neonates when compared with adults., Conclusions: Despite equivalent lung PMN accumulation and chemotactic protein production, PMN function and lung injury in septic neonates was diminished when compared with that of adults. These findings suggest that neonates may be relatively protected from sepsis-induced lung injury caused by immature PMN function., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Background/purpose: Although thoracoscopy in children is a well-accepted technique, there are limitations to this approach. Small lung nodules or those not located on the pleural surface often require an open thoracotomy. The purpose of this report is to evaluate the utility of computed tomography (CT) guided needle localization of lung nodules in children followed by thoracoscopic resection., Methods: From 1997 to 2000, 13 thoracoscopic procedures were performed on 12 children who presented with small pulmonary nodules (<1 cm) or nodules deep to the pleural surface. Preoperative needle localization was performed by injecting methylene blue under CT guidance. Patients then were taken directly to the operating room for thoracoscopic resection., Results: All 13 procedures were completed successfully thoracoscopically. Twelve yielded diagnostic pathologic findings as well as therapeutic resections in 7. All patients underwent extubation in the operating room, and chest tubes were removed within 36 hours. No thoracotomies were performed, and there were no complications., Conclusions: Preoperative localization utilizing CT guidance is safe and beneficial in children with pulmonary nodules less than 1 cm in size and those located deep to the pleural surface. This technique allows the surgeon to perform thoracoscopy for diagnosis and therapeutic resection of these lesions rather than submitting patients to the morbidity of a thoracotomy., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Purpose: Injury is the leading cause of cardiac arrest in children older than 1 year. Previous findings suggest that children who require cardiopulmonary resuscitation (CPR) administered by paramedics for any reason rarely survive to hospital discharge. The authors evaluated the outcome of children sustaining cardiac arrest after blunt trauma in a Regional Pediatric Trauma Center., Methods: Children (age < 16) who underwent CPR in the field or in the emergency department (ED) after blunt trauma were identified from the trauma registry of a regional pediatric trauma center over a 3-year period (1997 to 2000). Patient demographics, rate of survival to discharge, factors influencing survival, and organ donation data were obtained from the trauma registry and medical record. Probability of survival (Ps) was calculated by TRISS analysis., Results: Twenty-five children were identified with a history of cardiac arrest after blunt injury (mean age; 3.3 years; range, 0.1 to 10; mean ISS, 30.7; range, 13-75; mean RTS, 1.58). Mean calculated Ps was 22.7%. However, only 2 (8%) survived. Death in the majority (91%) of the 23 patients who died occurred secondary to brain or spinal cord injury, and only 2 (9%) occurred as the result of exsanguinating hemorrhage. CPR was first performed in the field in 10 patients (40%), en route in 6 (24%), and in the ED in 9 (36%). Of the children who survived, both had vitals in the field, and CPR was administered initially in the ED. Mean length of ED resuscitation before death was 80 minutes. Of the children who died, organ donation occurred in only 3 (13%). The 2 survivors had no head injury and were discharged within 3 weeks of injury., Conclusions: Cardiopulmonary resuscitation after blunt injury in children rarely results in survival. The majority of deaths occur as a result of isolated intracranial injury and not exsanguinating hemorrhage. Although all children should receive aggressive resuscitation after injury, the need for CPR in the field portends a poor outcome. Furthermore, these data would suggest that prolonged or heroic efforts for children sustaining cardiac arrest in the field are not indicated.