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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: 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: Economic, social, and psychologic stressors are associated with an increased risk for abusive injuries in children. Prolonged physical proximity between adults and children under conditions of severe external stress, such as witnessed during the COVID-19 pandemic with "shelter-in-place orders", may be associated with additional increased risk for child physical abuse. We hypothesized that child physical abuse rates and associated severity of injury would increase during the early months of the pandemic as compared to the prior benchmark period., Methods: We conducted a nine-center retrospective review of suspected child physical abuse admissions across the Western Pediatric Surgery Research Consortium. Cases were identified for the period of April 1-June 30, 2020 (COVID-19) and compared to the identical period in 2019. We collected patient demographics, injury characteristics, and outcome data., Results: There were no significant differences in child physical abuse cases between the time periods in the consortium as a whole or at individual hospitals. There were no differences between the study periods with regard to patient characteristics, injury types or severity, resource utilization, disposition, or mortality., Conclusions: Apparent rates of new injuries related to child physical abuse did not increase early in the COVID-19 pandemic. While this may suggest that pediatric physical abuse was not impacted by pandemic restrictions and stresses, it is possible that under-reporting, under-detection, or delays in presentation of abusive injuries increased during the pandemic. Long-term follow-up of subsequent rates and severity of child abuse is needed to assess for unrecognized injuries that may have occurred., Competing Interests: Declaration of Competing Interest There are no conflicts of interest., (Copyright © 2021. Published by Elsevier Inc.)

Background: The recognition of child physical abuse can be challenging and often requires a multidisciplinary assessment. Deep learning models, based on clinical characteristics, laboratory studies, and imaging findings, were developed to facilitate unbiased identification of children who may have been abused., Methods: Level 1 pediatric trauma center registry data from 1/1/2010-1/31/2020 were queried for abused children and matched participants with non-abusive trauma. Observations were de-identified and divided into training and validation sets. Model 1 used patient demographics (age, gender, and insurance type) and clinical characteristics (vital signs, shock index pediatric age-adjusted, Glasgow Coma Score, lactate, base deficit, and international normalized ratio). Model 2 used the same features as Model 1, but with the text of the radiology reports of head computed tomography, brain MRIs, and skeletal surveys. Google's latest BERT Natural Language Processing (NLP) model, which was pre-trained on a large corpus, was used for fine-tuning Model 2. Accuracy, sensitivity, specificity, F1 scores, and positive predictive values were used to assess performance., Results: Of 1,312 patients, 737 (56.2%) were abused. Model 1 had an accuracy of 86.3%, sensitivity of 87.2%, specificity of 85.1%, F1 score of 0.86, and positive predictive value (PPV) of 88.7% for the validation set with an area under the receiver Operating Curve (ROC AUC) of 0.86. NLP based Model 2 had an accuracy of 93.4%, sensitivity 92.5%, specificity of 94.6%, F1 score of 0.93, and PPV of 95.9% for the validation set, with a ROC AUC of 0.94. Most features had weak individual correlations with abuse (r < 0.3)., Conclusions: Deep learning models accurately distinguished child physical abuse from non-abuse, and NLP further improved the accuracy of the models. Such models could be developed to run in real-time in the electronic medical record and alert clinicians when certain criteria are met, which would prompt them to pursue the diagnosis of abuse., Level of Evidence: III STUDY TYPE: Diagnostic., (Copyright © 2021. Published by Elsevier Inc.)

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/purpose: There remains a lack of data on the utility of viscoelastic tests in managing abused patients. We hypothesize that abnormalities on admission thrombelastography (TEG) will differ in abused patients compared to those accidentally injured., Methods: Pediatric trauma patients (≤10 years old) who had an admission TEG at a Level I pediatric trauma center (2010-2020) were included and stratified into two cohorts: abuse versus accidental trauma. TEG abnormalities were based on the institution's normative values and compared between the groups., Results: Of 41 children included, 21 sustained abuse. Five abused patients and three accidentally injured patients died. Abused children showed a hypercoagulable pattern on viscoelastic testing with TEG when compared to those accidentally injured, as demonstrated by a short R-time (67% vs. 30%, p = 0.040) and an increased alpha angle (47% vs. 0%, p = 0.001). There was no significant difference in the MA and LY30 values between the two groups. In a multivariable model, only an abnormal alpha angle remained associated with abuse [odds ratio (OR) 0.17 (confidence intervals (CI) 0.02-0.92)]. In a separate multivariable model, only an abnormal MA was associated with mortality [OR 18.97 (CI 1.93-475.47), p = 0.025]., Conclusions: Our data suggest that hemostasis is significantly different in abused children relative to those who are accidentally injured., Type of Study: Retrospective Comparative Study., Level of Evidence: Level III., (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: Child physical abuse (CPA) is a significant cause of morbidity and mortality. Children who sustain CPA consume significant healthcare resources. We hypothesized that the costs to care for children who sustain for children with CPA-type injuries are greater than the costs to care for children who sustain accidental injuries., Methods: All confirmed CPA patients between the ages of 0 and 19 years old, who were admitted to a level 1 pediatric trauma center between January 2010 and September 2018, were retrospectively reviewed. We compared outcomes, including mortality, length of stay (LOS), diagnostic work-up, and overall cost using propensity matching between CPA and accidentally injured trauma patients. Patients were matched based on injury severity score (ISS)., Results: The CPA cohort (n = 595) was younger (1.31 +/- 1.96 years, p < 0.0001) than the accidental trauma patients (8.6 +/-5.54 years). The majority of the CPA patients had Medicaid coverage (75.1%), when compared to accidental trauma patients (37.5%; p < 0.0001). CPA patients had longer ICU LOS (2.43 days; p < 0.0001), increased ventilation days (2.57 days; p < 0.0001), and longer hospital LOS (6.56 days; p = 0.0004). The overall mortality rate for CPA patients was higher than accidental trauma patients (9.9% vs. 1.2%; p < 0.0001). The median hospital cost was significantly higher for those with CPA ($18,000) than accidental trauma ($10,100; p < 0.0001)., Conclusion: The costs to care for children who sustain CPA-type injuries are significantly greater than the costs to care for children who sustain accidental trauma. Better screening tools, more provider education and broader community outreach efforts are needed to reduce the societal and economic costs associated with child physical abuse., Study Type: Treatment., 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.)

Introduction: Accurate, real-time technology is needed to predict which newborns with congenital diaphragmatic hernia (CDH) will require ECMO. The Compensatory Reserve Index (CRI) is a noninvasive monitoring technology that continuously trends an individual's capacity to compensate from normovolemia (CRI = 1) to decompensation (CRI = 0). We hypothesized that postnatal CRI values would be lower in CDH newborns that required ECMO than those who did not require ECMO., Methods: Newborns with a CDH were prospectively monitored with a CipherOx® CRI M1 device. We compared CRI values from delivery to ECMO (ECMO group) versus delivery to clinical stabilization (non-ECMO group)., Results: Postnatal CRI values were available from 26 newborns. Eight underwent ECMO within 33 h of delivery, and median CRI prior to ECMO was 0.068 (IQR: 0.057, 0.078). Eighteen did not require ECMO. Median CRI from birth to 48 h was 0.112 (IQR: 0.082, 0.15). CRI values were significantly lower in newborns that required ECMO versus those who did not (p = 0.0035). Postnatal CRI had the highest AUC (0.85) compared to other prenatal prognostic measures., Conclusion: Humans from newborns to adults share elemental features of the pulsatile waveform that are associated with progression to decompensation. CRI may be helpful when deciding when to initiate ECMO., Level of Evidence: Level III., Type of Study: Diagnostic test., (Copyright © 2019 Elsevier Inc. All rights reserved.)