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Pediatric Trauma With Dr. Richard Falcone
With Dr. Richard Falcone · hosted by Dr. Todd Ponsky
Chapter 4 of 9 · Surgical Management
Pancreatic injury
Pancreatic Trauma Management
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Cincinnati Children's Hospital is a Level 1 pediatric trauma center verified since 1993, seeing approximately 2000 trauma patients per year.
At Cincinnati Children's Hospital, the ED physician serves as team leader for all trauma activations because they are present when the patient arrives.
The ultimate risk of C-spine injury in pediatric trauma is actually pretty low.
Approximately 90% of children admitted in C-collars can be clinically cleared the next morning when they are less distracted and not in the trauma bay.
Some children are sent home in C-collars with follow-up in trauma clinic in one week where nurse practitioners clear them clinically.
Flexion-extension films obtained early when a child is still tender and scared often yield inadequate images.
Getting CT early in children with normal neurologic exam is not useful because clinicians will not feel comfortable removing the collar based on imaging alone if the child still has tenderness.
There is sufficient evidence that awake children without distracting injuries and no midline tenderness do not require X-rays for C-spine clearance.
For severe TBI patients, MRI is obtained before C-spine clearance because a normal exam for clinical clearance will not be available within days or even a week.
Most pediatric centers obtain both CT (for bony abnormalities) and MRI (for soft tissue and ligaments) before clearing the C-spine in obtunded patients, though adult literature suggests CT alone may be sufficient.
For severe TBI patients, C-spine CT is not obtained during initial resuscitation but is deferred until the follow-up head CT in the next 24 hours when the patient is more stable.
The challenge in pancreatic trauma is determining whether there is a pancreatic duct injury.
There is increasing evidence that true pancreatic duct disruption is better treated with early distal pancreatectomy, ideally spleen-preserving.
Some children can have significant-appearing pancreatic injuries on CT, but ERCP or MRCP shows the duct is intact, and these children will heal without surgery.
ERCP has the advantage of being potentially therapeutic (stent placement) but the disadvantage of injecting dye that can cause pancreatic inflammation.
MRCP does not carry the risk of causing pancreatic inflammation that ERCP does.
Conservative management of pancreatic duct disruption can work and pseudocysts are manageable and drainable, but this approach results in longer TPN time and longer hospital length of stay compared to early pancreatectomy.
Centers that report good outcomes with distal pancreatectomy for pancreatic trauma are those with surgeons who are very comfortable operating on the pancreas and do it frequently.
Surgeons who rarely operate on the pancreas may put patients at more complication risk by attempting distal pancreatectomy, and non-operative management may be in the patient's best interest at such centers.
Being indecisive about pancreatic trauma management and operating around day 3 leads to worse outcomes than either early surgery or committed non-operative management.
More literature is trending toward operating on pancreatic duct injuries more frequently, and if surgery is chosen, it should be done within the first 24 hours.
The decision to operate on pancreatic trauma should be made within the 24-hour window after obtaining ERCP or MRCP to confirm duct disruption.
If intraoperative findings show parenchymal pancreatic injury without ductal disruption, the appropriate management is drainage rather than distal pancreatectomy.
Cincinnati Children's Hospital data showed that before implementing standardized screening, low socioeconomic status and minority children with head injuries were much more likely to receive skeletal surveys and social services evaluation than middle/upper class non-minority families.
Abuse occurs in all races and all socioeconomic groups, though economic stress may add some risk.
Cincinnati Children's Hospital implemented a protocol where all children under 2 admitted with head injuries from mechanisms not witnessed publicly receive skeletal survey and social work evaluation.
Publicly witnessed mechanisms are defined as events seen by unrelated parties (e.g., fall from grocery cart at supermarket, motor vehicle collision), not events witnessed only by family members or caregivers.
After implementing standardized screening criteria, the percentage of positive abuse cases remained at 50% despite evaluating more children, indicating previously undetected abuse was being identified.
The 50% positive abuse rate in screened children represents a biased population because they had injuries severe enough to require hospital admission.
A screening test with nearly 50% positive rate is more productive than most screening tests used for other conditions.
Families find standardized non-accidental trauma screening more reassuring because it can be explained as standard protocol for all families with this injury type, not a judgment about the specific family.
Ophthalmologic examination is not part of routine non-accidental trauma screening at Cincinnati Children's Hospital but is obtained if skeletal survey is positive or there are other concerning findings.
Abnormal liver function tests greater than 150-200 indicate good chance of some abdominal injury, but normal LFTs provide very little evidence of safety.
Cincinnati Children's Hospital has moved away from routine LFTs, amylase, and lipase in trauma patients, obtaining them only when other indications for CT scan already exist.
FAST examination has low sensitivity and is very user-dependent, providing false sense of security in stable patients.
FAST remains useful for hypotensive patients to rapidly determine if there is blood in the abdomen, which was the original indication for its development.
Laboratory tests may be useful as one additional screening test for children with vague symptoms and mechanisms who are being considered for discharge, with positive labs prompting CT and negative labs supporting discharge.
Cincinnati Children's Hospital has not used angioembolization for solid organ injury in approximately 4-5 years despite high trauma volume.
Angioembolization is used more frequently at adult trauma centers that routinely perform the procedure for adult patients.
CT blush on imaging puts patients at higher risk for needing intervention or transfusion but does not mandate intervention.
In small children, angioembolization may put them at more risk of injury and may eliminate most of the spleen anyway, losing the benefit of splenic preservation.
Pediatric surgeons' approach to solid organ injury management was subsequently adopted by adult trauma surgeons.
Children with solid organ injuries can be mobilized much more quickly than originally recommended, without the slow progression from bed to bathroom to ambulation.
Very few grade 1 solid organ injuries require transfusion, so routine serial lab draws as outlined in original Stylianos protocol are probably unnecessary.
There is growing support for less frequent lab draws and shorter length of stay for pediatric solid organ injuries.
Isolated grade 1 splenic injuries may not require hospital admission because they never require transfusion and never have problems.
Cincinnati Children's Hospital protocol for grade 1 solid organ injuries includes one 12-hour lab check only.
Grade 2 solid organ injuries receive two lab checks, and grade 3 injuries may receive two or three checks based on clinical exam.
There is evidence supporting tiered trauma activation systems with different levels of team response.
Cincinnati Children's Hospital uses a 3-level activation system: lowest level is ED only with surgery called if needed, mid-level includes ED and surgery resident, highest level includes attending surgeon, OR staff, anesthesia, and ICU.
Centers often add multiple additional activation criteria based on individual cases, resulting in 10-20 criteria that cause confusion.
The optimal number of activation criteria is around 8-9, as more criteria lower under-triage but significantly increase over-triage.
The Trauma Association of Canada Pediatric Subcommittee published evidence-based C-spine clearance recommendations in the Journal of Trauma 2-3 years ago emphasizing clinical examination as the first test.
For children greater than 8 years old with normal X-rays and normal neurologic exam, re-examination allows clinical clearance without CT if the repeat exam is normal.
CT or MRI of the C-spine should be considered only when there is an abnormal neurologic exam, requiring involvement of spine surgeons.
A multi-site study published in Journal of Trauma around 2009 developed a scoring system for C-spine injury risk in children under 3: 3 points for GCS <14, 2 points for GCS injury score of 1, 2 points for motor vehicle collision, 1 point for age 2-3 years.
Children under 3 with a C-spine risk score of 0 or 1 have 0.0% chance of C-spine injury and do not need imaging.
Children under 3 with a C-spine risk score of 7 or 8 have approximately 21% chance of C-spine injury and clearly need imaging.
In the multi-site study, pediatric Level 1 centers obtained C-spine CTs only 17% of the time compared to adult centers which obtained them 24-45% of the time.
The Pediatric Emergency Care Research Network published criteria in Annals of Emergency Medicine in 2013 for identifying children at very low risk of clinically important blunt abdominal injuries.