Table of Contents
Children are more susceptible than adults to serious injury secondary to blunt abdominal trauma. When a pediatric patient presents to the ED following blunt abdominal trauma, the abdominal examination may be unreliable due to the child’s age or developmental level, or due to an associated head injury; a negative abdominal examination and the absence of comorbid injuries do not completely rule out an intra-abdominal injury in these patients. However, the use of diagnostic CT scanning must be weighed against the risks associated with exposure to ionizing radiation in pediatric patients. This supplement provides evidence-based recommendations for the evaluation and management of blunt abdominal injuries in children, including injuries to specific organs. You will learn:
The most common mechanisms of traumatic intra-abdominal injury in children, including motor vehicle crashes, bicycle injuries, sports injuries, and nonaccidental trauma
Why seat-belt sign is an important clinical finding in a child who was involved in a motor vehicle crash
The role of diagnostic laboratory testing in assessing children with intra-abdominal injuries
The applications and limitations of FAST in the evaluation of pediatric patients
How clinical prediction rules can be used to help determine which patients do not need to undergo CT scanning
The appropriate initial management of pediatric blunt trauma patients, including fluid resuscitation for hemodynamically unstable patients
Diagnostic considerations and indications for operative versus nonoperative management of injuries to specific intra-abdominal organs, including splenic, liver, renal, pancreatic, gastrointestinal, and adrenal trauma
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Key Points
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Abstract
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Case Presentations
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Introduction
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Critical Appraisal of the Literature
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Epidemiology and Pathophysiology
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Epidemiology
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Etiology and Pathophysiology
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Common Mechanisms of Injury in Blunt Abdominal Trauma
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Motor Vehicle Crashes
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Seat-Belt Syndrome
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Pedestrian Struck By Motor Vehicle
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Falls
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Bicycle Injuries
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Sports Injuries
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Nonaccidental Trauma
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Prehospital Care
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Emergency Department Evaluation
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Primary Survey
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Focused History
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Secondary Survey
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Physical Examination Findings Suggestive of Abdominal Injury
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Diagnostic Studies
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Laboratory Tests
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Focused Assessment With Sonography in Trauma
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Computed Tomography
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Risks of Computed Tomography in Pediatric Patients
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Determining Which Patients Do Not Need Computed Tomography
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Treatment
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Initial Management
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Management of Specific Organ Injuries
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Splenic Trauma
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Liver Trauma
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Renal Trauma
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Pancreatic Trauma
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Gastrointestinal Trauma
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Adrenal Trauma
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Special Populations/Circumstances
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Nonaccidental Trauma
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Obesity
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Postmenarchal Females/Pregnancy
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Controversies and Cutting Edge
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Massive Transfusion Protocols
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Thromboembolization
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Contrast-Enhanced Ultrasound
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Decreased Time on Bed Rest
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Pediatric Shock Index
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Disposition
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Summary
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Time- and Cost-Effective Strategies
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Risk Management Pitfalls in Blunt Abdominal Trauma in Pediatric Patients
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Case Conclusions
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Clinical Pathway for Management of the Pediatric Patient With Blunt Abdominal Trauma
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Figure
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Figure 1. Seat-Belt Sign
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References
Key Points
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A negative abdominal examination and the absence of comorbid injuries do not completely rule out an intra-abdominal injury.
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A negative FAST examination is not sufficient to rule out the presence of an intra-abdominal injury, but a positive FAST examination should prompt an immediate abdominal CT scan in a hemodynamically stable patient.
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The most useful tests are the complete blood cell count, liver function tests, and urinalysis. However, the physical examination and mechanism of injury should be used to guide the evaluation and choice of diagnostic testing.
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Many pediatric patients with solid-organ injury can be managed nonoperatively.
Abstract
Blunt abdominal trauma is the third most common cause of pediatric deaths from trauma, but it is the most common unrecognized fatal injury. The history and physical examination, combined with the mechanism of injury, should be used to develop a thoughtful and directed diagnostic workup. The mainstays of diagnostic evaluation include laboratory testing, sonography, and computed tomography. However, due to the concern for radiation exposure and other risks, the routine use of these studies may not be necessary, and controversy exists as to which studies are beneficial and which are less valuable. This supplement discusses common mechanisms and injuries seen in children with blunt abdominal trauma and takes a closer look at evaluation and management techniques.
Case Presentations
A 10-year-old girl involved in a motor vehicle crash is brought to your ED. She was restrained in the rear driver’s-side seat of the vehicle with a lap and shoulder belt when the vehicle was struck at high speed on the driver’s side. On arrival to the ED, she is awake and alert, and immobilized with a cervical collar and back board. Her vital signs are as follows: temperature, 37.5°C (99.5°F); heart rate, 130 beats/min; blood pressure, 105/70 mm Hg; respiratory rate, 20 breaths/min; and oxygen saturation, 98% on room air. On examination, she is able to maintain her airway and has clear and equal breath sounds without increased work of breathing, and she has strong distal pulses. She complains of abdominal pain. Her abdomen is soft and nondistended, but she has localized tenderness in the left upper quadrant. There are no bruises or abrasions noted on the abdomen. Several questions are running through your mind: What fluids should I give her, how much, and how fast? What labs should I order? Should I perform a FAST exam, or should I order a CT of the abdomen/pelvis? Do I need contrast for the CT? Or does she need to go emergently to the operating room?
In the next room, a 9-year-old boy has been brought to the ED for epigastric pain and 1 episode of nonbloody, nonbilious vomiting. He is awake and alert, and his vital signs are as follows: temperature, 37°C (98.6°F); heart rate, 110 beats/min; respiratory rate, 24 breaths/min; blood pressure, 95/55 mm Hg; and oxygen saturation, 98% on room air. He has no diarrhea, and there are no known sick contacts. While you are examining him, you note moderate tenderness with voluntary guarding of the epigastric area. On further examination, you notice a faint bruise to the epigastric area and ask the patient how it occurred. He states that he was riding his bicycle the day before, and fell onto the handlebars. You wonder if this could be the cause of his pain and vomiting. For what injuries is he at risk? What tests should you order? Do you need to obtain a surgery consultation? Should he be admitted to the hospital?
Introduction
Trauma remains the leading cause of childhood death and disability in children aged > 1 year.1 While head and thoracic trauma account for most death and disability in children, abdominal injuries constitute the most commonly unrecognized cause of death.2 Blunt injury accounts for 90% of abdominal trauma in children.2 Common mechanisms include motor vehicle crashes (MVCs), falls, pedestrian injuries, bicycle and sports-related injuries, and nonaccidental trauma (NAT). Penetrating injuries are much less common in children than in adults.2
Management of pediatric trauma has unique challenges. The developmental stage of the patient, a lack of verbal skills in younger patients, and a lack of prehospital information create limitations in managing the injured child.3 Similar to their adult counterparts, children can have an unreliable abdominal examination from an associated head injury and a decreased Glasgow Coma Scale (GCS) score. Additionally, children are more likely to have an unreliable abdominal examination secondary to crying and abdominal distension.2
The routine use of trauma panels and computed tomography (CT) scans of the head, neck, chest, abdomen, and pelvis should not be employed in the pediatric patient. Unnecessary radiation exposure in the pediatric patient carries an increased lifetime risk of fatal malignancy, in addition to an increased cost burden.4,5 Instead, a more thoughtful and focused approach to assessing and managing the child with blunt abdominal trauma should be undertaken.
Critical Appraisal of the Literature
A literature search of Ovid, Clinical Key, and PubMed was completed using the terms pediatric blunt abdominal trauma, blunt abdominal trauma, pediatric trauma, and abdominal trauma and specific organs injured. The Cochrane Database of Systematic Reviews and the National Guidelines Clearinghouse were reviewed, but limited information on pediatric abdominal trauma was found. Additionally, ClinicalTrials.gov was reviewed for ongoing studies. The search was limited mostly to the last 20 years. Much research has been completed on trauma and on pediatric trauma, but the literature lacks strong randomized controlled trial data and prospective studies. Many of the studies on which our current evaluation and management strategies are based are retrospective reviews. There are a few prospective observational studies that validate the retrospective studies and an even smaller number of meta-analyses. For injuries with a low incidence of occurrence (such as adrenal injuries), case studies dominate the literature.
Risk Management Pitfalls in Blunt Abdominal Trauma in Pediatric Patients
1. “The patient’s blood pressure was fine, and I thought his elevated heart rate was because he was crying, so I didn’t start fluids.”
Hypotension is a late indicator of hemodynamic instability in children. Although tachycardia may be secondary to pain or fear, it is also the first indicator of blood loss in injured children. Fluids should be initiated in any child who has suffered blunt abdominal trauma and has an elevated heart rate. If pain or fear is thought to be the cause, comforting measures should be implemented. If tachycardia continues, an additional fluid bolus and/or blood products should be given. If the heart rate remains elevated despite these measures, the patient should be considered hemodynamically unstable and undergo immediate surgery consultation.
3. “The FAST was negative, so I didn’t think there was an intra-abdominal injury.”
Several studies in children have shown that the sensitivity of FAST alone is only approximately 50% in detecting intra-abdominal injury. FAST can adequately detect hemoperitoneum; however, up to one-third of intra-abdominal injuries in children do not cause hemoperitoneum and are undetectable by ultrasound. A negative FAST in children is not sufficient to rule out intra-abdominal injury. In any child with a concerning mechanism of injury or examination findings, other diagnostic tests and serial examinations should be obtained to evaluate for intra-abdominal injury further.
8. “I knew the little girl wasn’t properly restrained at the time of the motor vehicle crash, and I saw the lap-belt marks on her abdomen, but her CT scan was normal, so I discharged her home.”
Injuries to the pancreas and gastrointestinal tract require a high index of suspicion, as they may have delayed presentation, and laboratory tests and CT scans may be normal. Therefore, the emergency clinician should be aware of mechanisms that have a higher risk of injury to these organs, including inappropriate restraint with a lap belt only, direct blow to the abdominal wall (such as in handlebar injuries or in some sports injuries), and NAT. If injury to the pancreas or hollow viscus is suspected, surgical consultation should be obtained, and the child should be hospitalized for serial examinations and observation.
References
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.
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Wegner S, Colletti JE, Van Wie D. Pediatric blunt abdominal trauma. Pediatr Clin North Am. 2006;53(2):243-256. (Review)
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Mannenbach M, Spahr C. Pediatric trauma evaluations: current challenges and controversies. Pediatric Emergency Medicine Reports. 2010;15(6):61-75. (Review)
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Sola JE, Cheung MC, Yang R, et al. Pediatric FAST and elevated liver transaminases: An effective screening tool in blunt abdominal trauma. J Surg Res. 2009;157(1):103-107. (Retrospective review; 400 patients)
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Sivit CJ. Contemporary imaging in abdominal emergencies. Pediatr Radiol. 2008;38 Suppl 4:S675-S678. (Review)
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United States Centers for Disease Control and Prevention, Web-based Injury Statistics Query and Reporting System. Leading causes of death reports, national and regional, 1999-2017. 2019. Accessed January 15, 2020. (Government statistical report)
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United States Centers for Disease Control and Prevention, Web-based Injury Statistics Query and Reporting System. Nonfatal injury reports, 2001-2012. 2019. Accessed January 15, 2020. (Government statistical report)
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Baren J. Abdominal Trauma. In: Baren J, Rothrock S, Brennan J, et al, eds. Pediatric Emergency Medicine. Philadelphia, PA: Saunders; 2007:225. (Textbook chapter)
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Rothrock SG, Green SM, Morgan R. Abdominal trauma in infants and children: prompt identification and early management of serious and life-threatening injuries. Part II: Specific injuries and ED management. Pediatr Emerg Care. 2000;16(3):189-195. (Review)
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Wood J, Rubin DM, Nance ML, et al. Distinguishing inflicted versus accidental abdominal injuries in young children. J Trauma. 2005;59(5):1203-1208. (Retrospective chart review; 121 patients)
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American College of Surgeons Committee on Trauma. Advanced Trauma Life Support: Student Course Manual (ATLS). 10th ed. Chicago, IL: American College of Surgeons Committee on Trauma; 2018. (Textbook)
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Potoka D, Saladino R. Blunt abdominal trauma in the pediatric patient. Clin Ped Emerg Med. 2005;6(1):23-31. (Review)
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American Academy of Pediatrics, Committee on Injury and Poison Prevention. Policy statement—child passenger safety. Pediatrics. 2011;127(4):788-793. (Policy statement)
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United States Department of Transportation. Lives saved in 2015 by restraint use and minimum-drinking-age laws. Washington, DC: National Highway Traffic Safety Administration; 2016. (Government statistical report)
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American College of Surgeons. National Trauma Data Bank: Pediatric Report, 2016. 2016. (Statistical report)
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Nance ML, Lutz N, Arbogast KB, et al. Optimal restraint reduces the risk of abdominal injury in children involved in motor vehicle crashes. Ann Surg. 2004;239(1):127-131. (Cross-sectional study of a probability sample; 10,927 crashes involving 17,132 restrained children aged < 16 years)
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Durbin DR, Elliott MR, Winston FK. Belt-positioning booster seats and reduction in risk of injury among children in vehicle crashes. JAMA. 2003;289(21):2835-2840. (Cross-sectional study of a probability sample; 3616 crashes involving 4243 children aged 4-7 years)
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Arbogast KB, Jermakian JS, Kallan MJ, et al. Effectiveness of belt positioning booster seats: an updated assessment. Pediatrics. 2009;124(5):1281-1286. (Longitudinal study; 7151 children aged 4-8 years involved in 6591 crashes, seated in rear rows, and restrained by seat belt or belt-positioning seat)
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Yoganandan N, Pintar FA, Gennarelli TA, et al. Patterns of abdominal injuries in frontal and side impacts. Annu Proc Assoc Adv Automot Med. 2000;44:17-36. (Review of National Automotive Sampling System database)
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Durbin DR, Arbogast KB, Moll EK. Seat belt syndrome in children: a case report and review of the literature. Pediatr Emerg Care. 2001;17(6):474-477. (Review)
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Sokolove PE, Kuppermann N, Holmes JF. Association between the “seat belt sign” and intra-abdominal injury in children with blunt torso trauma. Acad Emerg Med. 2005;12(9):808-813. (Prospective observational study; 399 children)
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Chakravarthy B, Vaca FE, Lotfipour S, et al. Pediatric pedestrian injuries: emergency care considerations. Pediatr Emerg Care. 2007;23(10):738-744. (Review)
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Peng RY, Bongard FS. Pedestrian versus motor vehicle accidents: an analysis of 5,000 patients. J Am Coll Surg. 1999;189(4):343-348. (Retrospective review of centralized county trauma database; 5000 patients, 38.1% children aged < 15 years)
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Orsborn R, Haley K, Hammond S, et al. Pediatric pedestrian versus motor vehicle patterns of injury: debunking the myth. Air Med J. 1999;18(3):107-110. (Retrospective chart review; 4444 pediatric trauma patients, 465 with pedestrian vs motor vehicle crash)
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Wang MY, Kim KA, Griffith PM, et al. Injuries from falls in the pediatric population: an analysis of 729 cases. J Pediatr Surg. 2001;36(10):1528-1534. (Retrospective review; 729 children)
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Huntimer CM, Muret-Wagstaff S, Leland NL. Can falls on stairs result in small intestine perforations? Pediatrics. 2000;106(2 Pt 1):301-305. (Meta-analysis and literature review; 989 patients)
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Klin B, Rosenfeld-Yehoshua N, Abu-Kishk I, et al. Bicycle-related injuries in children: disturbing profile of a growing problem. Injury. 2009;40(9):1011-1013. (Retrospective review; 142 patients)
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Abu-Kishk I, Vaiman M, Rosenfeld-Yehoshua N, et al. Riding a bicycle: do we need more than a helmet? Pediatr Int. 2010;52(4):644-647. (Retrospective review; 46 patients)
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Alkan M, Iskit SH, Soyupak S, et al. Severe abdominal trauma involving bicycle handlebars in children. Pediatr Emerg Care. 2012;28(4):357-360. (Retrospective review; 8 children)
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Walters BS, Wolf M, Hanson C, et al. Soccer injuries in children requiring trauma center admission. J Emerg Med. 2014;46(5):650-654. (Retrospective review; 20 patients aged < 18 years)
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McCrone AB, Lillis K, Shaha SH. Snowboarding-related abdominal trauma in children. Pediatr Emerg Care. 2012;28(3):251-253. (Retrospective chart review; 213 patients aged 6-21 years)
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Retzlaff T, Hirsch W, Till H, et al. Is sonography reliable for the diagnosis of pediatric blunt abdominal trauma? J Pediatr Surg. 2010;45(5):912-915. (Retrospective analysis; 35 patients)
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Emery KH, McAneney CM, Racadio JM, et al. Absent peritoneal fluid on screening trauma ultrasonography in children: a prospective comparison with computed tomography. J Pediatr Surg. 2001;36(4):565-569. (Prospective observational study; 160 patients)
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Stassen NA, Lukan JK, Carrillo EH, et al. Abdominal seat belt marks in the era of focused abdominal sonography for trauma. Arch Surg. 2002;137(6):718-722. (Retrospective review; 23 patients)
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Suthers SE, Albrecht R, Foley D, et al. Surgeon-directed ultrasound for trauma is a predictor of intra-abdominal injury in children. Am Surg. 2004;70(2):164-167. (Prospective observational study; 120 patients)
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Levy JA, Noble VE. Bedside ultrasound in pediatric emergency medicine. Pediatrics. 2008;121(5):e1404-e1412. (Review)
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Holmes JF, Brant WE, Bond WF, et al. Emergency department ultrasonography in the evaluation of hypotensive and normotensive children with blunt abdominal trauma. J Pediatr Surg. 2001;36(7):968-973. (Prospective observational study; 224 patients)
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Bixby SD, Callahan MJ, Taylor GA. Imaging in pediatric blunt abdominal trauma. Semin Roentgenol. 2008;43(1):72-82. (Review)
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Hom J. The risk of intra-abdominal injuries in pediatric patients with stable blunt abdominal trauma and negative abdominal computed tomography. Acad Emerg Med. 2010;175):469-475. (Meta-analysis; 3 studies, 2596 total patients)
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Brenner D, Elliston C, Hall E, et al. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol. 2001;176(2):289-296. (Estimated risk calculation)
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Rice HE, Frush DP, Farmer D, et al. Review of radiation risks from computed tomography: essentials for the pediatric surgeon. J Pediatr Surg. 2007;42(4):603-607. (Review)
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Holmes JF, Lillis K, Monroe D, et al. Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med. 2013;622):107-116. (Prospective observational cohort study from the Pediatric Emergency Care Applied Research Network [PECARN]; 12,044 patients)
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Streck CJ, Vogel AM, Zhang J, et al. Identifying children at very low risk for blunt intra-abdominal injury in whom CT of the abdomen can be avoided safely. J Am Coll Surg. 2017;224(4):449-458. (Prospective observational study; 2188 patients)
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Arbra CA, Vogel AM, Plumblee L, et al. External validation of a five-variable clinical prediction rule for identifying children at very low risk for intra-abdominal injury after blunt abdominal trauma. J Trauma Acute Care Surg. 2018;85(1):71-77. (Retrospective review; 2435 patients)
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Cook SH, Fielding JR, Phillips JD. Repeat abdominal computed tomography scans after pediatric blunt abdominal trauma: missed injuries, extra costs, and unnecessary radiation exposure. J Pediatr Surg. 2010;45(10):2019-2024. (Retrospective review; 388 patients)
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Stylianos S. Compliance with evidence-based guidelines in children with isolated spleen or liver injury: a prospective study. J Pediatr Surg. 2002;37(3):453-456. (Multicenter prospective study; 312 patients, 16 centers)
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Holmes JH 4th, Wiebe DJ, Tataria M, et al. The failure of nonoperative management in pediatric solid organ injury: a multi-institutional experience. J Trauma. 2005;59(6):1309-1313. (Retrospective study; 1880 patients)
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Gaines BA, Ford HR. Abdominal and pelvic trauma in children. Crit Care Med. 2002;30(11 Suppl):S416-S423. (Review)
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Lynn KN, Werder GM, Callaghan RM, et al. Pediatric blunt splenic trauma: a comprehensive review. Pediatr Radiol. 2009;39(9):904-916. (Review)
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Gaines BA. Intra-abdominal solid organ injury in children: diagnosis and treatment. J Trauma. 2009;67(2 Suppl):S135-S139. (Review)
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Hsiao M, Sathya C, de Mestral C, et al. Population-based analysis of blunt splenic injury management in children: operative rate is an informative quality of care indicator. Injury. 2014;45(5):859-863. (Population-based retrospective cohort study; 3122 patients)
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Davies DA, Pearl RH, Ein SH, et al. Management of blunt splenic injury in children: evolution of the nonoperative approach. J Pediatr Surg. 2009;44(5):1005-1008. (Retrospective review; 486 patients)
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Feigin E, Aharonson-Daniel L, Savitsky B, et al. Conservative approach to the treatment of injured liver and spleen in children: association with reduced mortality. Pediatr Surg Int. 2009;25(7):583-586. (Retrospective trauma registry review; 598 patients)
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Bond SJ, Eichelberger MR, Gotschall CS, et al. Nonoperative management of blunt hepatic and splenic injury in children. Ann Surg. 1996;223(3):286-289. (Retrospective chart review; 179 patients, 156 of whom did not undergo immediate surgery)
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Lindberg DM, Shapiro RA, Blood EA, et al. Utility of hepatic transaminases in children with concern for abuse. Pediatrics. 2013;1312):268-275. (Retrospective secondary analysis; 2890 patients)
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Landau A, van As AB, Numanoglu A, et al. Liver injuries in children: the role of selective non-operative management. Injury. 2006;37(1):66-71. (Retrospective chart review; 311 patients)
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Inchingolo R, Ljutikov A, Deganello A, et al. Outcomes and indications for intervention in non-operative management of paediatric liver trauma: a 5 year retrospective study. Clin Radiol. 2014;69(2):157-162. (Retrospective observational study; 37 patients)
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Giss SR, Dobrilovic N, Brown RL, et al. Complications of nonoperative management of pediatric blunt hepatic injury: Diagnosis, management, and outcomes. J Trauma. 2006;61(2):334-339. (Retrospective study; 185 patients)
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Eubanks JW 3rd, Meier DE, Hicks BA, et al. Significance of ‘blush’ on computed tomography scan in children with liver injury. J Pediatr Surg. 2003;38(3):363-366. (Retrospective review; 77 patients)
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van der Vlies CH, Saltzherr TP, Wilde JC, et al. The failure rate of nonoperative management in children with splenic or liver injury with contrast blush on computed tomography: a systematic review. J Pediatr Surg. 2010;45(5):1044-1049. (Meta-analysis and review; 117 patients)
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Graziano KD, Juang D, Notrica D, et al. Prospective observational study with an abbreviated protocol in the management of blunt renal injury in children. J Pediatr Surg. 2014;49(1):198-200. (Prospective observational study; 70 patients)
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Umbreit EC, Routh JC, Husmann DA. Nonoperative management of nonvascular grade IV blunt renal trauma in children: meta-analysis and systematic review. Urology. 2009;74(3):579-582. (Review and meta-analysis; 95 patients)
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Fitzgerald CL, Tran P, Burnell J, et al. Instituting a conservative management protocol for pediatric blunt renal trauma: evaluation of a prospectively maintained patient registry. J Urol. 2011;185(3):1058-1064. (Prospective observational study; 39 patients)
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Fraser JD, Aguayo P, Ostlie DJ, et al. Review of the evidence on the management of blunt renal trauma in pediatric patients. Pediatr Surg Int. 2009;25(2):125-132. (Review)
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Jacobs MA, Hotaling JM, Mueller BA, et al. Conservative management vs early surgery for high grade pediatric renal trauma--do nephrectomy rates differ? J Urol. 2012;187(5):1817-1822. (Retrospective review; 419 patients)
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Henderson CG, Sedberry-Ross S, Pickard R, et al. Management of high grade renal trauma: 20-year experience at a pediatric level I trauma center. J Urol. 2007;178(1):246-250. (Retrospective review; 126 patients)
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Sheth S, Casalino D, Expert Panel on Urologic Imaging, et al. ACR Appropriateness Criteria® renal trauma. 2012. Accessed January 15, 2020. (Guideline)
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Abou-Jaoude WA, Sugarman JM, Fallat ME, et al. Indicators of genitourinary tract injury or anomaly in cases of pediatric blunt trauma. J Pediatr Surg. 1996;31(1):86-89. (Retrospective review; 100 patients)
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Buckley JC, McAninch JW. Pediatric renal injuries: management guidelines from a 25-year experience. J Urol. 2004;172(2):687-690. (Retrospective review; 374 patients)
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He B, Lin T, Wei G, et al. Management of blunt renal trauma: an experience in 84 children. Int Urol Nephrol. 2011;43(4):937-942. (Retrospective review; 84 patients)
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Arkovitz MS, Johnson N, Garcia VF. Pancreatic trauma in children: mechanisms of injury. J Trauma. 1997;42(1):49-53. (Retrospective chart review; 26 patients)
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Sutherland I, Ledder O, Crameri J, et al. Pancreatic trauma in children. Pediatr Surg Int. 2010;26(12):1201-1206. (Retrospective chart review; 91 patients)
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Cuenca AG, Islam S. Pediatric pancreatic trauma: trending toward nonoperative management? Am Surg. 2012;78(11):1204-1210. (Retrospective review; 79 patients)
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Abbo O, Lemandat A, Reina N, et al. Conservative management of blunt pancreatic trauma in children: a single center experience. Eur J Pediatr Surg. 2013;23(6):470-473. (Retrospective review; 36 patients)
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Maeda K, Ono S, Baba K, et al. Management of blunt pancreatic trauma in children. Pediatr Surg Int. 2013;29(10):1019-1022. (Review)
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Beres AL, Wales PW, Christison-Lagay ER, et al. Non-operative management of high-grade pancreatic trauma: is it worth the wait? J Pediatr Surg. 2013;48(5):1060-1064. (Retrospective review; 77 patients)
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Bradley EL 3rd, Young PR Jr, Chang MC, et al. Diagnosis and initial management of blunt pancreatic trauma: guidelines from a multiinstitutional review. Ann Surg. 1998;227(6):861-869. (Retrospective chart review; 101 patients)
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Klin B, Abu-Kishk I, Jeroukhimov I, et al. Blunt pancreatic trauma in children. Surg Today. 2011;41(7):946-954. (Retrospective chart review; 10 patients)
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Wood JH, Partrick DA, Bruny JL, et al. Operative vs nonoperative management of blunt pancreatic trauma in children. J Pediatr Surg. 2010;45(2):401-406. (Retrospective review; 43 patients)
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Mattix KD, Tataria M, Holmes J, et al. Pediatric pancreatic trauma: predictors of nonoperative management failure and associated outcomes. J Pediatr Surg. 2007;42(2):340-344. (Multi-institutional chart review; 173 patients)
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Khasawneh R, Ramakrishnaiah RH, Singh S, et al. CT findings in pediatric blunt intestinal injury. Emerg Radiol. 2013;20(6):545-552. (Review)
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Gutierrez IM, Mooney DP. Operative blunt duodenal injury in children: a multi-institutional review. J Pediatr Surg. 2012;47(10):1833-1836. (Retrospective multi-institutional review; 54 patients)
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Clendenon JN, Meyers RL, Nance ML, et al. Management of duodenal injuries in children. J Pediatr Surg. 2004;39(6):964-968. (Retrospective chart review; 42 patients)
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Jerby BL, Attorri RJ, Morton D, Jr. Blunt intestinal injury in children: the role of the physical examination. J Pediatr Surg. 1997;32(4):580-584. (Retrospective chart review; 32 patients)
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Figler BD, Webman R, Ramey C, et al. Pediatric adrenal trauma in the 21st century: Children’s Hospital of Atlanta experience. J Urol. 2011;186(1):248-251. (Retrospective review; 42 patients)
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Lee YS, Jeong JJ, Nam KH, et al. Adrenal injury following blunt abdominal trauma. World J Surg. 2010;34(8):1971-1974. (Retrospective review; 11 patients)
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Roupakias S, Papoutsakis M, Tsikopoulos G. Adrenal injuries following blunt abdominal trauma in children: report of two cases. Ulus Travma Acil Cerrahi Derg. 2012;18(2):171-174. (Case report; 2 patients)
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Maguire SA, Upadhyaya M, Evans A, et al. A systematic review of abusive visceral injuries in childhood--their range and recognition. Child Abuse Negl. 2013;37(7):430-445. (Review; 88 studies)
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Backstrom IC, MacLennan PA, Sawyer JR, et al. Pediatric obesity and traumatic lower-extremity long-bone fracture outcomes. J Trauma Acute Care Surg. 2012;73(4):966-971. (Retrospective cohort study; 356 patients)
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Haricharan RN, Griffin RL, Barnhart DC, et al. Injury patterns among obese children involved in motor vehicle collisions. J Pediatr Surg. 2009;44(6):1218-1222. (Database review, 1997 to 2006 National Automotive Sampling System Crashworthiness Dat a System fo r occupants aged 2 to 17 years involved in an MVC; 3902 obese and 13,517 nonobese children, representing an estimated 1.8 million obese and 7.2 million nonobese children)
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Rana AR, Michalsky MP, Teich S, et al. Childhood obesity: a risk factor for injuries observed at a level-1 trauma center. J Pediatr Surg. 2009;44(8):1601-1605. (Retrospective study; 1314 patients)
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Uppot RN, Sahani DV, Hahn PF, et al. Effect of obesity on image quality: fifteen-year longitudinal study for evaluation of dictated radiology reports. Radiology. 2006;240(2):435-439. (Retrospective study; > 5 million reports reviewed)
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Navarro-Jarabo JM, Ubina-Aznar E, Tapia-Ceballos L, et al. Hepatic steatosis and severity-related factors in obese children. J Gastroenterol Hepatol. 2013;28(9):1532-1538. (Cross-sectional study; 144 children)
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Trifiletti LB, Shields W, Bishai D, et al. Tipping the scales: obese children and child safety seats. Pediatrics. 2006;117(4):1197-1202. (Database review and assessment)
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Fitzharris MP, Bowman DM. Booster seat use by children aged 4-11 years: evidence of the need to revise current Australasian standards to accommodate overweight children. Med J Aust. 2008;189(10):597-598. (Questionnaire survey, convenience sample; 692 respon ses of 3959 questionnaires, total 1500 children)
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Brown HL. Trauma in pregnancy. Obstet Gynecol. 2009;114(1):147-160. (Review)
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Oxford CM, Ludmir J. Trauma in pregnancy. Clin Obstet Gynecol. 2009;52(4):611-629. (Review)
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Petrone P, Talving P, Browder T, et al. Abdominal injuries in pregnancy: a 155-month study at two level 1 trauma centers. Injury. 2011;42(1):47-49. (Retrospective review; 321 patients)
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Mirza FG, Devine PC, Gaddipati S. Trauma in pregnancy: a systematic approach. Am J Perinatol. 2010;27(7):579-586. (Review)
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Wallace GW, Davis MA, Semelka RC, et al. Imaging the pregnant patient with abdominal pain. Abdom Imaging. 2012;37(5):849-860. (Review)
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Hussain ZJ, Figueroa R, Budorick NE. How much free fluid can a pregnant patient have? Assessment of pelvic free fluid in pregnant patients without antecedent trauma. J Trauma. 2011;70(6):1420-1423. (Prospective study; 89 patients)
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Goodwin H, Holmes JF, Wisner DH. Abdominal ultrasound examination in pregnant blunt trauma patients. J Trauma. 2001;50(4):689-693. (Retrospective study; 208 patients)
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Johansson PI, Oliveri RS, Ostrowski SR. Hemostatic resuscitation with plasma and platelets in trauma. J Emerg Trauma Shock. 2012;5(2):120-125. (Meta-analysis; 16 retrospective studies, 3663 patients)
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Nosanov L, Inaba K, Okoye O, et al. The impact of blood product ratios in massively transfused pediatric trauma patients. Am J Surg. 2013;206(5):655-660. (Retrospective study; 105 patients)
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Cannon JW, Johnson MA, Caskey RC, et al. High ratio plasma resuscitation does not improve survival in pediatric trauma patients. J Trauma Acute Care Surg. 2017;83(2):211-217. (Retrospective review; 364 patients)
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Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471-482. (Randomized controlled trial; 680 patients)
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Kiankhooy A, Sartorelli KH, Vane DW, et al. Angiographic embolization is safe and effective therapy for blunt abdominal solid organ injury in children. J Trauma. 2010;68(3):526-531. (Retrospective study; 127 patients with 149 injuries, 7 patients underwent angiographic embolization)
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Vo NJ, Althoen M, Hippe DS, et al. Pediatric abdominal and pelvic trauma: safety and efficacy of arterial embolization. J Vasc Interv Radiol. 2014;25(2):215-220. (Retrospective study; 97 patients undergoing angiography, including 54 requiring emb olization)
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Menichini G, Sessa B, Trinci M, et al. Accuracy of contrast-enhanced ultrasound CEUS) in the identification and characterization of traumatic solid organ lesions in children: a retrospective comparison with baseline US and CE-MDCT. Radiol Med. 2 015;12011) :989-1001. (Retrospective review; 73 patients)
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Ntoulia A, Anupindi SA, Darge K, et al. Applications of contrast-enhanced ultrasound in the pediatric abdomen. Abdom Radiol NY). 2018;434):948-959. (Review)
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McCarville MB. Contrast-enhanced sonography in pediatrics. Pediatr Radiol. 2011;41 Suppl 1:S238-S242. (Review)
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Cagini L, Gravante S, Malaspina CM, et al. Contrast enhanced ultrasound (CEUS) in blunt abdominal trauma. Crit Ultrasound J. 2013;5 Suppl 1:S9. (Review)
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Stylianos S. Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. The APSA Trauma Committee. J Pediatr Surg. 2000;35(2):164-167. (Multi-institutional retrospective chart review; 832 patients)
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St Peter SD, Sharp SW, Snyder CL, et al. Prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Pediatr Surg. 2011;46(1):173-177. (Prospective observational study; 131 patients)
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St Peter SD, Aguayo P, Juang D, et al. Follow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Pediatr Surg. 2013;48(12):2437-2441. (Prospective observational study; 249 patien ts)
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Notrica DM, Eubanks JW 3rd, Tuggle DW, et al. Nonoperative management of blunt liver and spleen injury in children: Evaluation of the ATOMAC guideline using GRADE. J Trauma Acute Care Surg. 2015;79(4):683-693. (Literature review and guideline dev elopment)
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Acker SN, Ross JT, Partrick DA, et al. Pediatric specific shock index accurately identifies severely injured children. J Pediatr Surg. 2015;50(2):331-334. (Retrospective study; 543 patients)
The Glasgow coma scale (GCS) estimates coma severity based on eye, verbal, and motor criteria. The Injury Severity Score (ISS) standardizes the severity of traumatic injury based on the 3 worst injuries from 6 body systems. The SIPA calculates the shock index, adjusted for age, to predict mortality in children.
Glasgow Coma Scale
Introduction
The Glasgow coma scale (GCS) estimates coma severity based on eye, verbal, and motor criteria.
Points & Pearls
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The Glasgow coma scale (GCS) allows providers in multiple settings and with varying levels of training to communicate succinctly about a patient’s mental status.
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The GCS has been shown to have a statistical correlation with a broad array of adverse neurologic outcomes, including brain injury, need for neurosurgery, and mortality.
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The GCS has been incorporated into numerous guidelines and assessment scores (eg, ACLS, ATLS, APACHE I-III, TRISS, and the WNS SAH grading scale).
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In some patients, it may be impossible to assess 1 or more of the 3 components of the GCS. The reasons for this include, but are not limited to:
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Eye: local injury and/or edema
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Verbal: intubation
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All (eye, verbal, motor): sedation, paralysis, and ventilation that eliminates all responses
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If a component of the GCS is untestable, a score of 1 should not be assigned (Teasdale 2014). In this circumstance, summation of the components for a total GCS score is invalid.
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The 3 parts of the GCS are charted independently, and a component can be recorded as NT (not testable), with an option of indicating the reason (eg, C for eye closure and T for intubation).
Points to keep in mind:
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Correlation with outcome and severity is most accurate when applied to an individual patient over time; the patient’s trend is important.
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A GCS score of 8 should not be used in isolation to determine whether or not to intubate a patient, but does suggest a level of obtundation that should be evaluated carefully.
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Reproducibility is usually good (Reith 2016). If individual institutions have concerns about agreement among providers, training and education are available from the GCS creators.
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Simpler scores that have been shown to perform as well as the GCS in the prehospital and emergency department setting (for initial evaluation); these are often contracted versions of the GCS itself. For example, the Simplified Motor Score (SMS) uses the motor portion of the GCS only. The SMS and other contracted scores are less well studied than the GCS for outcomes like long-term mortality, and the GCS has been studied as trended over time, while the SMS has not.
Why and When to Use, and Next Steps
Why to Use
The GCS score is an adopted standard for mental status assessment in the acutely ill trauma and nontrauma patient and assists with predictions of neurological outcomes (complications, impaired recovery) and mortality.
When to Use
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The GCS is designed for use in serial assessments of patients with coma from either medical or surgical causes and is widely applicable.
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The GCS is commonly used in the prehospital and acute care setting as well as over a patient’s hospital course to evaluate for mental status assessment in both traumatic and nontraumatic presentations.
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In the care of an individual patient, the scoring for each of the 3 components of the GCS (eye, verbal, motor) should be assessed, monitored, reported, and communicated separately.
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The combined GCS score is an index of the net severity of impairment and is useful as a summary of a pa-tient’s condition, in classifying groups of different severity, for triage, and in research. A GCS score should not be calculated if 1 or more of the components cannot be assessed.
Next Steps
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The GCS can indicate the level of critical illness.
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Trauma patients presenting with a GCS score < 15 warrant close attention and reassessment.
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A declining GCS score is concerning in any setting, and should prompt airway assessment and possible intervention.
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Conversely, a GCS score of 15 should not be taken as an indication that a patient (trauma or medical) is not critically ill. Decisions about the aggressiveness of management and treatment plans should be made based on clinical presentation and context, and should not be overridden in any way by the GCS score.
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Clinical management decisions should not be based solely on the GCS score in the acute setting.
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If a trauma patient has a GCS score < 8 and there is clinical concern that the patient is unable to protect his/her airway or there is an expected worsening clinical course based on exam or imaging findings, then intubation can be considered.
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In any patient, a rapidly declining or waxing and waning GCS score is concerning and intubation should be considered in the context of the patient's overall clinical picture.
Abbreviation: GCS, Glasgow coma scale.
Calculator Review Authors
Daniel Runde, MD
Department of Emergency Medicine, University of Iowa
Hospitals and Clinics, Iowa City, IA
Critical Actions
Although it has been adopted widely and in a variety of settings, the GCS score is not intended for quantitative use. Clinical management decisions should not be based solely on the GCS score in the acute setting.
Evidence Appraisal
The modified GCS (the 15-point scale that has been widely adopted, including by the original unit in Glasgow, as opposed to the 14-point original GCS) was developed to be used in a repeated manner in the inpatient setting to assess and communicate changes in mental status and to measure the duration of coma (Teasdale 1974).
The evidence presented in 53 published reports on the reproducibility of the GCS was synthesized in a systematic review by Reith et al in 2016. Eighty-five percent of the findings in the studies identified as high quality showed substantial reliability of the GCS as judged by the standard criterion of a kappa statistic > 0.6. Reproducibility of the total GCS score was also high, with kappa > 0.6 in 77% of the observations. Education and training on usage of the GCS resulted in a clear beneficial effect on reliability (Reith 2016).
In its most common usage, the 3 sections of the scale are often combined to provide a summary of severity. The authors themselves have explicitly objected to the score being used in this way, and analysis has shown that patients with the same total score can have huge variations in outcomes, specifically mortality. A GCS score of 4 predicts a mortality rate of 48% if calculated 1 + 1 + 2 for eye, verbal, and motor components, respectively, and a mortality rate of 27% if calculated 1 + 2 + 1, but a mortality rate of only 19% if calculated 2 + 1 + 1 (Healey 2014).
The modified GCS provides a nearly universally-accepted method of assessing patients with acute brain damage. Summation of its components into a single overall score loses information and provides only a rough guide to severity. In some circumstances, such as early triage of severe injuries, assessment of only a contracted version of the motor component of the scale (as in the SMS) can perform as well as the GCS and is less complicated. However, the scores like the SMS may be less informative in patients with lesser injuries.
Calculator Creator
Sir Graham Teasdale, MBBS, FRCP
References
Original/Primary Reference
Validation References
Other References
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Teasdale G, Jennett B. Assessment of coma and severity of brain damage. Anesthesiology. 1978;49(3):225-226.
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Teasdale G, Jennett B, Murray L, et al. Glasgow coma scale: to sum or not to sum. Lancet. 1983;2(8351):678.
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Healey C, Osler TM, Rogers FB, et al. Improving the Glasgow Coma Scale score: motor score alone is a better predictor. J Trauma. 2003;54(4):671-678.
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Green SM. Cheerio, laddie! Bidding farewell to the Glasgow Coma Scale. Ann Emerg Med. 2011;58(5):427-430.
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Middleton PM. Practical use of the Glasgow Coma Scale; a comprehensive narrative review of GCS methodology. Australas Emerg Nurs J. 2012;15(3):170-183.
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Yeh DD. Glasgow Coma Scale 40 years later: in need of recalibration?. JAMA Surg. 2014;149(7):734.
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Teasdale G. Forty years on: updating the Glasgow Coma Scale. Nurs Times. 2014;110(42):12-16.
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Gill M, Windemuth R, Steele R, et al. A comparison of the Glasgow Coma Scale score to simplified alternative scores for the prediction of traumatic brain injury outcomes. Ann Emerg Med. 2005;45(1):37-42.
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Haukoos JS, Gill MR, Rabon RE, et al. Validation of the Simplified Motor Score for the prediction of brain injury outcomes after trauma. Ann Emerg Med. 2007;50(1):18-24.
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Thompson DO, Hurtado TR, Liao MM, et al. Validation of the Simplified Motor Score in the out-of-hospital setting for the prediction of outcomes after traumatic brain injury. Ann Emerg Med. 2011;58(5):417-425.
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Teasdale G, Maas A, Lecky F, et al. The Glasgow Coma Scale at 40 years: standing the test of time. Lancet Neurol. 2014;13(8):844-854.
Injury Severity Score (ISS)
Introduction
The Injury Severity Score (ISS) standardizes the severity of traumatic injury based on the 3 worst injuries from 6 body systems.
Points & Pearls
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The Injury Severity Score (ISS) was initially derived in patients with blunt traumatic injury from motor vehicle accidents.
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The ISS is not intended to be used for bedside decision-making for a single patient in the emergency department setting, but rather as a tool to standardize the study of trauma patients.
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Due to the nature of the score, multiple combinations of Abbreviated Injury Scale (AIS) scores may result in the same ISS, each of which may indicate a different mortality rate. For example, an ISS of 17 can be calculated from patients with a combination of points based on the 3 most severe injuries, such as (4, 1, 0) or (3, 2, 2). The ISS assigns equal value to each body region.
Why and When to Use, and Next Steps
Why to Use
Due to the heterogeneous nature of trauma patients, standardizing the severity of traumatic injuries allows for comparison of much larger sample populations in trauma research studies.
When to Use
The ISS attempts to standardize the severity of injuries sustained during trauma. This standardization allows for more accurate study and prediction of morbidity and mortality outcomes after traumatic injuries.
Next Steps
As the ISS is intended primarily as a research tool, the score should not affect the initial management of a patient with traumatic injuries.
Abbreviation: ISS, Injury Severity Score.
Calculator Review Authors
Max Berger, MD
Ronald O. Perelman Department of Emergency
Medicine, NYU Langone Health, New York, NY
Alexandra Ortego, MD
Ronald O. Perelman Department of Emergency
Medicine, NYU Langone Health, New York, NY
Instructions
First, the most severe injury from each of 6 body systems is assigned an AIS score on a scale of 0 (no injury) to 6 (unsurvivable injury). Next, those scores are used to determine the 3 most injured body systems. Finally, the ISS is calculated by squaring the AIS score for each of the 3 most injured body systems, then adding up the 3 squared numbers (A2 + B2 + C2 = ISS, where A, B, and C are the AIS scores of the most severe injury in each of the 3 most severely injured body systems). Patients with an AIS of 6 in any body system are automatically assigned an ISS of 75, the maximum possible score.
The ISS is used primarily in research settings, so calculation of the score should not delay initial management of patients with traumatic injuries.
Critical Action
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In all trauma patients, the initial treatment strategy should focus on the primary and secondary survey, and assessing and stabilizing the patient.
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Although the ISS score is intended primarily for research purposes, it may have broader clinical use in the intensive care unit for prognostication following the initial stabilization of traumatic injuries.
Evidence Appraisal
The ISS was derived by Baker et al (1974) by taking the previously used AIS (American Medical Association Committee on Medical Aspects of Automotive Safety 1971) and adding the squared value of each of the 3 most severely injured body systems, in an effort to add increasing importance to the most severe injuries. The top 3 most severe injuries were used to calculate the final score because it had been shown that injuries that would not necessarily be life-threatening in isolation could have a significant effect on mortality when they occurred in combination with other severe injuries. The derivation study included only injuries sustained from motor vehicle collisions, including the occupants of the vehicles and any pedestrians involved.
Further studies have validated the ISS to include other mechanisms of injury. A study by Beverland et al (1983) of 875 patients with gunshot wounds showed that an increasing ISS was associated with increasing mortality (chi-squared = 83.31, P < .001). A study by Bull (1978) confirmed the correlation between increasing ISS and increasing mortality in road traffic accidents, and showed correlation between increasing ISS and increasing mean hospital length of stay.
In a study of 8852 trauma patients from the Illinois Trauma Program (including both vehicular and nonvehicular trauma), Semmlow et al (1976) had similar findings to Baker et al regarding the relationship between ISS and mortality. They also found that the ISS correlated with hospital length of stay.
Calculator Creator
Susan P. Baker, MPH
References
Original/Primary Reference
Validation References
Shock Index, Pediatric Age-Adjusted (SIPA)
Introduction
The SIPA calculates the shock index, adjusted for age, to predict mortality in children.
Points & Pearls
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The shock index, pediatric age-adjusted (SIPA) should be calculated upon the patient’s presentation to the emergency department (ED).
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An upward trending SIPA between the field and the ED may predict a poor outcome, but this was not examined by the original study authors.
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The original study authors indicated that the age-specific cutoffs they chose will require further validation in a second cohort (Acker 2017).
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The use of the SIPA to predict patient morbidity and mortality following admission has not yet been validated. However, a prognostic study by Vandewalle et al (2018) found that patients who developed an elevated SIPA within the first 24 hours of admission were at an increased risk for complications compared to those whose SIPA remained normal throughout the first 48 hours of admission. In addition, the time to normalize SIPA directly correlated with the length of hospital stay and length of stay in the intensive care unit.
Why and When to Use, and Next Steps
Why to Use
The SIPA is more accurate than the SI at differentiating severely injured children from children with mild injury. In the original study (Acker 2015), an elevated SIPA was shown to identify approximately 25% of the most severely injured children, regardless of age, while an SI > 0.9 has been shown to identify anywhere from 32% to 71% of injured children, depending on age. Being able to accurately identify severely injured children is critical in reducing the overtriage of children who have sustained injuries. An elevated SIPA is associated with the following outcomes (Acker 2015; Nordin, Coleman, Shi, et al 2017):
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Higher injury severity
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Need for blood transfusion in the first 24 hours
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Longer intensive care unit and hospital length of stay
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Higher number of ventilator days
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Discharge to a rehabilitation facility
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Increased risk of mortality
When to Use
The SIPA can be used for patients aged 4 to 16 years who have sustained blunt trauma. The SIPA should not be used for young infants, toddlers, or patients with penetrating trauma.
Next Steps
The general management of pediatric blunt abdominal trauma includes performing the primary and secondary surveys and determining the extent, type, and severity of injury.
A thorough abdominal examination is ex-tremely important because abdominal injuries are often not apparent on physical examination. Depending on the examination findings, the use of imaging may be warranted.
Abbreviations: SI, shock index; SIPA, shock index, pediatric age-adjusted.
Calculator Review Authors
Christian Hietanen, DO
Department of Primary Care, Touro College of
Osteopathic Medicine, Middletown, NY
Advice
Patients who present with an elevated SIPA for age have a higher risk of morbidity and mortality following blunt trauma. Early recognition and treatment of these patients, including a possible decision to transfer to a higher level of care, will improve outcomes.
Critical Action
There is no value or finding that necessarily defines shock, and children can compensate more readily than adults. Hypotension is often a late finding in children with hypovolemic shock.
Evidence Appraisal
The SIPA was originally developed by researchers at the Children’s Hospital of Colorado to help identify severely injured children following blunt trauma (Acker 2015). Mechanism alone has been found to be a poor predictor of injury severity in children (Qazi 1998). Clinical and physiologic parameters are better indicators (Wang 2001) and previous studies (Rousseaux 2013; Yasaka 2013) have shown that the shock index (SI) helps identify a higher risk of mortality versus using heart rate and blood pressure alone. The SIPA furthers builds on those findings by using specific vital sign cutoffs by age group.
Realizing that pediatric vital signs vary with age and that the SI might not be as useful in children, Acker et al (2015) sought and defined maximum normal heart rate and minimum normal systolic blood pressure using reference ranges from 2 pediatric textbooks and the United States Department of Health and Human Services’ Pediatric Basic and Advanced Life Support guidelines. The authors used these numbers to determine the maximum normal SI for 3 age groups, and then conducted a retrospective review of 543 children aged 4 to 16 years who had been admitted between January 2007 and June 2013 to 2 Colorado trauma centers following blunt trauma and with injury severity scores > 15.
An elevated SI was present in 49% of the children, while an elevated SIPA was present in only An elevated SI was present in 49% of the children, while an elevated SIPA was present in only 27.6% of the children, all of whom had the same adverse outcomes that were identified by using the SI. The SIPA demonstrated improved discrimination of severe injury compared to the SI in the following categories:
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Injury severity score > 30: 37% versus 26%
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Blood transfusion within first 24 hours: 27% versus 20%
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Grade III liver/spleen laceration requiring blood transfusion: 41% versus 26%
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Inhospital mortality: 11% versus 7%
The authors concluded that the SIPA misses fewer children with severe injury while also minimizing overtriage.
A multicenter prospective observational study of 386 patients aged 4 to 16 years (Linnaus 2017) validated the original study with level II-quality evidence.
In 2017, Nordin, Coleman, and Shi, et al, developed SIPA cutoff values for patients aged 1 to 3 years and found the SIPA to be a significantly better predictor than the SI of transfusion needs, injury severity, intensive care unit admission, ventilator use, and mortality following blunt and penetrating trauma.
The authors of the original SIPA study conducted a follow-up study (Acker 2017) and found the SIPA to be superior to age-adjusted hypotension in identifying injured children who required trauma team activation. The criteria used as indicators included early blood transfusion, endotracheal intubation, and emergency operation.
A comparison of the accuracy of the SIPA, SI, and the revised trauma score for predicting outcomes in pediatric trauma patients was presented at the 2017 annual meeting of the Pediatric Trauma Society; the presenters found that the SIPA outperformed the SI and compared favorably to the revised trauma score (Nordin, Shi, Wheeler 2017).
Calculator Creator
Manuel Mutschler, MD
References
Original/Primary Reference
Validation Reference
Other References
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Vandewalle RJ, Peceny JK, Dolejs SC, et al. Trends in pediatric adjusted shock index predict morbidity and mortality in children with severe blunt injuries. J Pediatr Surg. 2018;53(2):362-366.
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Qazi K, Wright MS, Kippes C. Stable pediatric blunt trauma patients: is trauma team activation always necessary? J Trauma. 1998;45(3):562-564.
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Wang MY, Kim KA, Griffith PM, et al. Injuries from falls in the pediatric population: an analysis of 729 cases. J Pediatr Surg. 2001;36(10):1528-1534.
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Rousseaux J, Grandbastien B, Dorkenoo A et al. Prognostic value of shock index in children with septic shock. Pediatr Emerg Care. 2013;29(10):1055-1059.
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Yasaka Y, Khemani RG, Markovitz BP. Is shock index associated with outcome in children with sepsis/septic shock? Pediatr Crit Care Med. 2013;14(8):e372-e379.
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Nordin A, Coleman A, Shi J, et al. Validation of the age-adjusted shock index using pediatric trauma quality improvement program data. J Pediatr Surg. 2017;53(1):130- 135.
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Acker SN, Bredbeck B, Partrick DA, et al. Shock index, pediatric age-adjusted (SIPA) is more accurate than age-adjusted hypotension for trauma team activation. Surgery. 2017;161(3):803-807.
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Nordin A, Shi J, Wheeler K. A comparison of trauma scoring systems using pediatric TQIP data. Paper presented at: 4th Annual Meeting of the Pediatric Trauma Society, November 3, 2017; Charleston, SC.
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