INTRODUCTION:Current guidelines recommend nonoperative management (NOM) of low-grade (American Association for the Surgery of Trauma-Organ Injury Scale Grade I-II) pancreatic injuries (LGPIs), and drainage rather than resection for those undergoing operative management, but they are based on low-quality evidence. The purpose of this study was to review the contemporary management and outcomes of LGPIs and identify risk factors for morbidity. METHODS:Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018. The primary outcome was pancreas-related complications (PRCs). Predictors of PRCs were analyzed using multivariate logistic regression. RESULTS:Twenty-nine centers submitted data on 728 patients with LGPI (76% men; mean age, 38 years; 37% penetrating; 51% Grade I; median Injury Severity Score, 24). Among 24-hour survivors, definitive management was NOM in 31%, surgical drainage alone in 54%, resection in 10%, and pancreatic debridement or suturing in 5%. The incidence of PRCs was 21% overall and was 42% after resection, 26% after drainage, and 4% after NOM. On multivariate analysis, independent risk factors for PRC were other intraabdominal injury (odds ratio [OR], 2.30; 95% confidence interval [95% CI], 1.16-15.28), low volume (OR, 2.88; 1.65, 5.06), and penetrating injury (OR, 3.42; 95% CI, 1.80-6.58). Resection was very close to significance (OR, 2.06; 95% CI, 0.97-4.34) (p = 0.0584). CONCLUSION:The incidence of PRCs is significant after LGPIs. Patients who undergo pancreatic resection have PRC rates equivalent to patients resected for high-grade pancreatic injuries. Those who underwent surgical drainage had slightly lower PRC rate, but only 4% of those who underwent NOM had PRCs. In patients with LGPIs, resection should be avoided. The NOM strategy should be used whenever possible and studied prospectively, particularly in penetrating trauma.

Trauma is the leading cause of mortality and hemorrhagic shock in pediatric patients, and sustained injuries are one of the most common causes of preventable mortality in these patients. 1 An estimated 1000 to 2000 preventable traumatic deaths in children per year occur after injury in the US because of inadequate or delayed care. 2 Some of these deaths may represent pediatric patients with unrecognized hemorrhagic shock who are not promptly treated with hemorrhage control and appropriate hemostatic resuscitation. The 30-day mortality in children with traumatic hemorrhagic shock is estimated to be 36% to 50% compared with the 25% reported mortality in similar adults. 3,4 A retrospective review of the Pennsylvania statewide trauma database by Morgan et al 5 aimed to determine if the utilization of prehospital transfusion (PHT) in injured children leads to decreased mortality.Adult data have left no question as to whether prehospital blood transfusions improve mortality. Retrospective military and civilian studies in addition to randomized clinical trials have demonstrated improved 6-hour, 24-hour, and 30-day mortality rates in traumatically injured adults receiving PHT. In addition, these studies have demonstrated improvement in the patient's physiological status on arrival at the hospital, less need for crystalloid administration, and minimal blood product wastage. [6][7][8][9] The Pediatric Traumatic Hemorrhagic Shock Consensus Conference determined, based on the current literature, that it is reasonable to consider PHT for pediatric patients with hemorrhagic shock, but this is a critical research priority. 10,11 Prior to this study, the best available pediatric literature suggests that clinicians should try to limit the use of crystalloid boluses in children with hemorrhagic shock. Increasing the use of crystalloids in children exhibiting signs of shock has led to increased odds of mechanical ventilation and longer intensive care unit and hospital stays. [12][13][14] In addition, small single-center studies have demonstrated that PHT is safe and feasible and improves physiologic measures of coagulopathy and shock. However, owing to the limited sample size of these studies, to our knowledge, no study has demonstrated an improvement in mortality. [15][16][17][18][19] This evaluation of the Pennsylvania Trauma Systems Foundation registry by Morgan et al 5 provides critical data to suggest that PHT in pediatric trauma patients improves mortality. From their 10-year retrospective cohort of more than 14 000 pediatric trauma patients, 559 (4.0%) received a blood product transfusion and 70 (0.5%) received a PHT. As expected, there were significant differences between patients receiving emergency department transfusions (EDT) and PHT. To address potential selection bias, they developed 3:1 propensity