Purpose To compare the reported and observed management of UK children with blunt liver or spleen injury (BLSI) to the American Pediatric Surgical Association (APSA) 2019 BLSI guidance. Methods UK Paediatric Major Trauma Centres (pMTCs) undertook 1 year of prospective data collection on children admitted to or discussed with those centres with BLSI and an online questionnaire was distributed to all consultants who care for children with BLSI in those centres. Results All 21/21 (100%) pMTCs participated; 131 patients were included and 100/152 (65%) consultants responded to the survey. ICU care was reported and observed to be primarily determined using haemodynamic status or concomitant injuries rather than injury grade, in accordance with APSA guidance. Bed rest was reported to be determined by grade of injury by 63% of survey respondents and observed in a similar proportion of patients. Contrary to APSA guidance, follow-up radiological assessment of the injured spleen or liver was undertaken in 44% of patients before discharge and 32% after discharge, the majority of whom were asymptomatic. Conclusions UK management of BLSI differs from many aspects of APSA guidance. A shift towards using clinical features to determine ICU admission and readiness for discharge is demonstrated, in line with a strong evidence base. However, routine bed rest and re-imaging after BLSI is common, contrary to APSA guidance. This disparity may exist due to concern that evidence around the incidence, presentation and natural history of complications after conservatively managed BLSI, particularly bleeding from pseudoaneurysms, is weak.

Background At its inception, there was no formal provision for children within the English major trauma network. There are now combined and stand-alone centres, but the scarcity of paediatric trauma facilities in some regions can result in long patient transfers and impact patient outcomes. The objective of this study was to determine the proportion of paediatric trauma patients who may benefit from input by adult services or may be safely managed within the local adult MTC, either because of patient physiology or injury patterns. Methods All trauma presentations to our urban MTC aged ≤16 over a 3-year period were retrospectively identified and grouped, based on age and weight. ‘Young adult’ mechanisms of trauma and patient destinations (whether paediatric or adult wards) were determined. Results There were 847 paediatric trauma cases recorded with a mean age of 9 and a male preponderance. Based on age and weight, 10–45% of cases could be considered physiologically adult-like, and 22–28% pubertal. Almost all penetrating trauma occurred in males, increasing with age. 14% of all admissions were managed on adult wards, with frequency increasing with patient age and with mechanism of actions (MOIs) relating to interpersonal violence. Conclusion In this dataset, nearly half of paediatric trauma was ‘pubertal’ or ‘adult’ in their physiology and of these most presented with ‘young adult’ MOIs. These children likely benefit from combined paediatric and adult trauma services; where these do not exist, some older patients may be safely managed within local adult MTCs.

BackgroundTension pneumothorax following trauma is a life-threatening emergency and radiological investigation is normally discouraged prior to treatment in traditional trauma doctrines such as ATLS. Some trauma patients may be physiologically stable enough for diagnostic imaging and occult tension pneumothorax is discovered radiologically. We assessed the outcomes of these patients and compared them with those with clinical diagnosis of tension pneumothorax prior to imaging.MethodsA multicentre civilian–military collaborative network of six major trauma centres in the UK collected observational data from adult patients who had a diagnosis of traumatic tension pneumothorax during a 33-month period. Patients were divided into ‘radiological’ (diagnosis following CT/CXR) or ‘clinical’ (no prior CT/CXR) groups. The effect of radiological diagnosis on survival was analysed using multivariable logistic regression that included the covariates of age, gender, comorbidities and Injury Severity Score.ResultsThere were 133 patients, with a median age of 41 (IQR 24–61); 108 (81%) were male. Survivors included 49 of 59 (83%) in the radiological group and 59 of 74 (80%) in the clinical group (p=0.487). Multivariable logistic regression showed no significant association between radiological diagnosis and survival (OR 2.40, 95% CI 0.80 to 7.95; p=0.130). There was no significant difference in mortality between the groups.ConclusionRadiological imaging may be appropriate for selected trauma patients at risk of tension pneumothorax if they are considered haemodynamically stable. Trauma patients may be physiologically stable enough for radiological imaging but have occult tension pneumothorax because they did not have the typical clinical presentation. The historical dogma of the ‘forbidden scan’ no longer applies to such patients.

Introduction Optimal management of anterior penetrating abdominal injuries (A-PAI) is an area of ongoing debate. Randomised controlled trials are missing and guidelines are based on expert opinion. The accuracy of computerised tomography (CT) is challenged, and hence diagnostic laparoscopies are still widely used. Method We retrospectively reviewed the TARN database identifying patients presenting with A-PAI to a London Major Trauma Centre between 01/19/2015-31/03/2018 and reviewed their clinical notes. Results 143 patients were identified (79% male, mean age = 30). Non-operative management (NOM) took place without complication in 15% (n = 12) of cases, despite 38% (n = 8) showing a potential peritoneal breach on CT, and 19% (n = 4) a definitive intra-abdominal injury. Of the 37% (n = 53) of patients undergoing laparoscopy, half revealed no intra-abdominal injury. When comparing CT consultant reports to intra-operative findings, the accuracy of CT in identifying peritoneal breach was calculated to be 93% and sensitivity at 95%. Negative predictive value was 62%. Conclusions We concluded that a significant number of patients have unnecessary laparoscopies, which are not without risk. CT is an excellent resource, but negative predictive value is poor. NOM with serial abdominal examination remains a valid clinical option in the stable non-peritonitic patient and in the absence of definitive viscous perforation on CT.

BackgroundPenetrating gluteal injuries (PGIs) are an increasingly common presentation to major trauma centers (MTCs) in the UK and especially in London. PGIs can be associated with mortality and significant morbidity. There is a paucity of consistent guidance on how best to investigate and manage these patients.MethodsA retrospective cohort study was performed by interrogating prospectively collected patient records for PGI presenting to a level 1 MTC in London between 2017 and 2019.ResultsThere were 125 presentations with PGI, accounting for 6.86% of all penetrating injuries. Of these, 95.2% (119) were male, with a median age of 21 (IQR 18–29), and 20.80% (26) were under 18. Compared with the 3 years prior to this study, the number of PGI increased by 87%. The absolute risk (AR) of injury to a significant structure was 27.20%; the most frequently injured structure was a blood vessel (17.60%), followed by the rectum (4.80%) and the urethra (1.60%). The AR by anatomic quadrant of injury was highest in the lower inner quadrant (56%) and lowest in the upper outer quadrant (14%). CT scanning had an overall sensitivity of 50% and specificity of 92.38% in identifying rectal injury.DiscussionThe anatomic quadrant of injury can be helpful in stratifying risk of rectal and urethral injuries when assessing a patient in the emergency department. Given the low sensitivity in identifying rectal injury on initial CT, this data supports assesing any patients considered at high risk of rectal injury with an examination under general anesthetic with or without rigid sigmoidoscopy . The pathway has created a clear tool that optimizes investigation and treatment, minimizing the likelihood of missed injury or unnecessary use of resources. It therefore represents a potential pathway other centers receiving a similar trauma burden could consider adopting.Level of evidence2b.