The spectrum and management of noniatrogenic vascular trauma in the pediatric population

    The Spectrum and Management of Non-Iatrogenic Vascular Trauma in the Pediatric Population Ahmed Kayssi, Maged Metias, Jacob C. Langer, Graham Roche-Nagle, Augusto Zani, Thomas L. Forbes, Paul Wales, Sebastian K. King PII: DOI: Reference:

S0022-3468(17)30256-7 doi: 10.1016/j.jpedsurg.2017.04.015 YJPSU 58144

To appear in:

Journal of Pediatric Surgery

Received date: Revised date: Accepted date:

26 February 2017 22 April 2017 22 April 2017

Please cite this article as: Kayssi Ahmed, Metias Maged, Langer Jacob C., Roche-Nagle Graham, Zani Augusto, Forbes Thomas L., Wales Paul, King Sebastian K., The Spectrum and Management of Non-Iatrogenic Vascular Trauma in the Pediatric Population, Journal of Pediatric Surgery (2017), doi: 10.1016/j.jpedsurg.2017.04.015

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Title: The Spectrum and Management of Non-Iatrogenic Vascular Trauma in the Pediatric Population

RI P

T

Authors: Ahmed Kayssi,a Maged Metias,a Jacob C. Langer,b Graham Roche-Nagle,a Augusto Zani,b Thomas L. Forbes,a Paul Wales,b Sebastian K. Kingb a

SC

Division of Vascular Surgery, University Health Network, 200 Elizabeth Street, Toronto, ON, M5G 2C4 Canada b

NU

Division of General & Thoracic Surgery, Hospital for Sick Children, 555 University Avenue Toronto, ON, M5G 1X8 Canada

Corresponding Author: Dr Jacob C. Langer

ED

Division of General & Thoracic Surgery

PT

Hospital for Sick Children 555 University Avenue

MA

The authors have no conflicts of interest to declare

CE

Toronto, ON, M5G 1X8 Canada

(P): (416) 813-7654 Ext. 202413

AC

(F): (416) 813-7477

(E): [email protected]

1

ACCEPTED MANUSCRIPT

ED

MA

NU

SC

RI P

T

Abstract Background: To describe the spectrum of non-iatrogenic pediatric vascular injuries and their outcomes at a large tertiary pediatric hospital. Methods: Retrospective review of a prospectively-maintained trauma database, identifying children with non-iatrogenic vascular injuries managed between 1994 and 2014. Results: A total of 198 patients were identified. Those patients with a digital or intra-cerebral vascular injury (92/198) were excluded from further analysis. The remaining 106 patients represented 1.2% of all traumas managed at our institution during the 21-year study period. The majority were male (75%), and between 1-12 years of age (71% of all patients). Median time from trauma scene to any hospital was 48 minutes (range 0-132), and most patients were transferred from another hospital (64%). Three patients were declared dead upon arrival (3%). Penetrating injuries accounted for most injuries (72%), while blunt injuries accounted for the remainder. Ulnar, radial, or brachial artery trauma accounted for 47% of injuries. Most vessels were treated operatively, by primary repair (49%), vessel ligation (15%), or interposition graft (12%). Fourteen patients (13%) were managed non-operatively and most patients (74%) experienced no complications in hospital or during follow-up. Conclusion: Non-iatrogenic pediatric vascular injuries are rare and represent a highly heterogeneous population. Most children recover well, with minimal perioperative complications.

PT

Key Words: Vascular Surgery, Pediatric Surgery, Vascular Trauma.

AC

CE

Level of Evidence: IV (Case Series with No Comparison Group).

2

ACCEPTED MANUSCRIPT 1. Introduction Non-iatrogenic vascular injuries in pediatric patients are uncommon. It is estimated that major

T

trauma centers in the United States and Europe treat fewer than five cases annually [1]. Prompt

RI P

diagnosis is important, with a 97% rate of recovery in patients in whom the correct diagnosis is

SC

made [2].

NU

The management of this patient population is complex. Pediatric trauma patients may present with undetected vascular injuries that are masked by vasospasm and the presence of concomitant

MA

multi-system injuries. Furthermore, vascular injuries are usually associated with other lifethreatening, and hence distracting, conditions. Finally, there are no published guidelines for the

PT

ED

management of these patients [3].

Due to the rarity of this type of injury, it is unlikely that randomized prospective studies will be

CE

feasible and practice continues to be guided by individual center experiences. The aim of this

AC

study was to identify the spectrum of non-iatrogenic pediatric vascular injuries and their outcomes at a large tertiary pediatric hospital.

2. Methods A retrospective review was performed using a prospectively-maintained trauma database, to identify all pediatric patients (0–17 years inclusive) with non-iatrogenic vascular injuries treated between 1994 and 2014 at the Hospital for Sick Children, Toronto, Canada. The study protocol was approved by the institutional research ethics board at the Hospital for Sick Children (File

3

ACCEPTED MANUSCRIPT Number 1000046556). Patient informed consent was not deemed to be necessary by the research

T

ethics board.

RI P

Individual charts of the identified patients were reviewed. Patient demographics, timing and mechanism of trauma, operative interventions, course in hospital, and post-traumatic follow-up

SC

and complications were analyzed. Descriptive statistics were generated and data analysis was

NU

carried out using the statistical software package SAS 9.3 (Cary, North Carolina).

MA

3. Results

A total of 198 patients were identified. Those with a digital or intra-cerebral vascular injury (92

ED

patients) were excluded from further analysis. The remaining 106 patients represented 1.2% of

PT

all traumas managed at our institution during the study period (Table I). There was no missing demographic data in our patient population. The median prehospital time from trauma scene to

CE

any hospital was 48 minutes (range 0-132). Patients with no prehospital time were those

AC

transported to hospital by private vehicle, rather than by emergency ambulance services. Most patients (64%) were transferred to the Hospital for Sick Children from another hospital, rather than directly from the scene.

The types of injured vessels are listed in Table II. Most patients (85%) presented with a single vessel injury. Glass lacerations to the arteries of the upper extremity were the most common etiology. Venous injuries were infrequent and were present in only 6% of all injuries. The inferior vena cava was the most commonly injured vein.

4

ACCEPTED MANUSCRIPT The hospital services responsible for managing the vascular injury are listed in Table III and the interventions that were performed are listed in Table IV. At our hospital, plastic surgeons

T

manage vascular injuries to the radial, ulnar, and brachial arteries and as such were responsible

RI P

for treating more patients than any other specialists in our series. Most patients (58%) were transferred directly from the emergency department to the operating room, with (49%)

SC

undergoing primary repair. Most patients (64%) required one operative procedure. Those who

NU

required multiple procedures had concurrent abdominal, orthopedic, or intracranial injuries that required several operations. Primary repair with monofilament sutures was successful in treating

MA

most vascular injuries. Interrupted sutures were used to prevent a relative narrowing of the

PT

from using a running suture.

ED

anastomosis associated with growth due to a "purse-string" effect, which would have resulted

Fifteen patients (14%) were managed non-operatively. Of those, all but one presented with blunt

CE

vascular injuries. Three patients were pronounced dead upon arrival to the Hospital for Sick

AC

Children died from intra-cerebral vascular complications and did not undergo any operations. One further patient died following admission to hospital from severe multi-organ injuries that included an inferior vena cava tear sustained during a motor-vehicle accident. That patient was managed non-operatively as well.

The other non-operative patients all underwent imaging

studies with angiography by our interventional radiology colleagues or a CT scan with intravenous contrast. Three patients had evidence of a perihepatic hematoma and were closely monitored for evidence of hemodynamic instability or hemorrhage that would have necessitated an intervention. One of those patients had evidence of hepatic artery laceration on CT scan but there was no evidence of contrast extravasation on angiography so no further intervention was

5

ACCEPTED MANUSCRIPT necessary. Two patients had combined orthopedic injuries with radial or ulnar artery lacerations and were found to have absence of flow in the artery and a well-perfused hand on clinical

T

examination so no arterial repair was attempted. Three patients had dissections in the aorta or

RI P

carotid artery and were managed medically without requiring any surgical interventions. Two patients had lacerations of the brachial or tibial arteries in the setting of a supracondylar humeral

SC

fracture or a proximal tibial fracture but no clinical evidence of distal ischemia. One patient had

NU

evidence of unilateral thrombosis of the internal carotid artery in the setting of a skull fracture and subdural hematoma secondary to a motor vehicle accident. It was unclear whether there

MA

would have been any benefit to revascularizing the thrombosed internal carotid artery in that patient since it occluded prior to presentation to hospital. Finally, one patient had evidence of a

ED

right external iliac artery laceration and retroperitoneal hematoma in the setting of a closed

PT

comminuted right iliac wing fracture. The patient was hemodynamically stable on presentation

CE

with no evidence of distal ischemia and was successfully observed non-operatively.

AC

Most of the patients who did not die in the emergency department and were managed nonoperatively developed no complications. Of the three non-operative patients with complications, one developed abdominal compartment syndrome and required a decompressive laparotomy, one developed purulent otorrhea unrelated to his vascular injury, and the third developed posttraumatic genu valgum of left proximal tibia and medial physeal arrest of the tibial growth plate that resulted in subsequent growth retardation and pain with ambulation.

Endovascular repair was attempted in two patients.

Interventional radiology attempted to

cannulate and exclude an extravasating branch of the left hepatic artery of a 9 year-old passenger

6

ACCEPTED MANUSCRIPT involved in a motor-vehicle accident.

The procedure was abandoned after numerous

unsuccessful attempts and evidence of tamponade of the bleeding vessel. The patient was

T

observed in hospital and developed no complications. The second patient was an 11 year-old

RI P

passenger in a motor-vehicle accident who presented with multi-system trauma and thoracic aortic dissection. Interventional cardiology successfully placed a covered NuMed Cheatham

SC

Platinum 8-Zig 50mm stent (Hopkinton, NY) in the thoracic aorta. The patient was discharged

NU

after a long course in hospital because of non-vascular injuries and was followed by the cardiologist for two years without any evidence of vascular complications, but was subsequently

MA

lost to follow-up.

ED

Thirteen patients (12%) underwent an interposition graft procedure to replace the native artery.

PT

Of those, six were brachial, axillary, and subclavian artery repairs with a reversed great saphenous or ipsilateral forearm vein interposition graft. Four were lower extremity popliteal to

CE

popliteal or common femoral to superficial femoral interposition grafts with reversed great

AC

saphenous vein. In the case of the common femoral to superficial femoral artery interposition graft procedure, the profunda artery was re-implanted onto the vein graft. Two repairs of traumatic aortic ruptures were performed using 18 mm Dacron tube interposition grafts (Maquet, Rastatt, Germany) in 14 and 11 year-old patients.

Six patients (6%) underwent a bypass graft procedure. Of those, five were lower-extremity femoro-popliteal, femoro-tibial, or popliteo-tibial bypasses with reversed great saphenous vein, and all were performed in patients 12 years or older. A seven-year-old boy underwent a bypass from the aorta to the brachiocephalic artery with a 7 mm Gore-Tex graft (W. L. Gore and

7

ACCEPTED MANUSCRIPT Associates, Newark, DE) for rupture of the brachiocephalic artery sustained in a Go-Kart

T

accident.

RI P

One patient (1%) required an amputation. The patient was a 7 year-old boy who was struck, and subsequently crushed, by a dump-truck and presented with a mangled extremity. He sustained

SC

multiple open fractures and profound ischemia of the right lower extremity that necessitated an

NU

above-knee amputation.

MA

Eighty-seven patients (82%) had concomitant injuries in addition to their vascular traumatic injuries. Of those, 38% were orthopedic and 34% were neurological injuries, including

ED

peripheral nerve or intracranial injuries. A further 10% had injuries to the gastrointestinal tract

PT

and 3% had lung and diaphragmatic injuries. In the cases where neuro- or orthopedic surgery was the primary admitting service because of more urgent concomitant traumatic injuries, non-

CE

operative management of the vascular injuries was pursued. If possible, concomitant injuries

AC

were otherwise repaired at the same operation or as soon as possible afterwards. The decision to operate on a vascular or other injury first was typically made according to the patient’s condition and after discussion between the involved surgical services. Unfortunately, our database search did not identify the anticoagulation management of those patients.

The median length of stay was 5 days (range 1-99), and the majority of patients (74%) experienced no complications in hospital or on follow-up (Table V). Follow-up clinic visit notes did not document any clinical evidence of leg malperfusion or failure of the vascular repair. Three patients (3%) developed ipsilateral growth retardation of the affected limb on follow-up.

8

ACCEPTED MANUSCRIPT Two of those had concomitant femoral and tibial fractures and popliteal artery injuries and one had a displaced distal radial, ulnar, and supracondylar humeral fracture and brachial artery injury

RI P

T

that resulted in growth plate arrest of the distal radius.

The median length of time between discharge and the first follow-up clinic visit was 11 days

SC

(range 2-837). Patients typically underwent Doppler ultrasound studies to assess the status of

NU

their vascular repairs or bypass surgeries. Patients followed-up with the service that attended to their vascular injuries in hospital, and most frequently had two outpatient appointments (range 0-

MA

21) before either being discharged back to their pediatrician or being lost to follow-up. The

ED

median duration of follow-up was 10 months (range 0.2-131).

PT

4. Discussion

This study has shown that non-iatrogenic traumatic vascular injuries are uncommon in pediatric

AC

CE

patients, and that most patients do well following admission to hospital.

Most patients in our series sustained penetrating trauma to the arteries of the upper extremities with shattered glass, utensils, knives, or tools. This is consistent with findings reported by other investigators [2, 4-6]. While firearm injuries account for up to 20% of vascular traumas in the United States, our series only identified one patient who presented with a gunshot vascular trauma [7]. This difference is most likely explained by the lesser availability of firearms in our hospital’s catchment area compared with many pediatric trauma centers in the United States [8].

9

ACCEPTED MANUSCRIPT Non-operative management was reserved for patients who were hemodynamically stable because of their vascular injuries, and who did not demonstrate any hard signs of vascular trauma,

T

including pulselessness, active extravasation, expanding hematoma, or a thrill or bruit in the

RI P

proximity of the injured vessel. This approach to management complements the findings of a recent review of limb ischemia management at our institution, in which non-operative

SC

management and therapeutic anticoagulation was a safe option in selected pediatric vascular

NU

injuries [9, 10]. Unfortunately, our database search did not identify which patients had soft or hard signs of vascular injury on presentation, but rather their management once a diagnosis of

MA

vascular injury was made. There is no evidence that the diagnosis of vascular injury was delayed

ED

due to any diagnostic challenges.

PT

While endovascular stent deployment has not been studied prospectively in pediatric vascular trauma, case reports have described the efficacy of this approach in select patients [11, 12].

CE

Furthermore, the Coarctation of the Aorta Stent Trial (COAST) examined the safety of stent

AC

placement in children and adults with aortic coarctation, and enrolled children 8 years of age or older [13]. The published two-year results reported a success rate of 90% with minimal complications, whilst the five-year follow-up results are forthcoming [14].

Most of the patients (74%) developed no post-traumatic complications at follow-up. The most common complication was post-operative infection in those patients who underwent operative repair. Nerve injuries, neuropathic pain, and paraesthesia were also common, especially in patients with extremity injuries. Only one patient required an amputation. The incidence of post-traumatic complications in our series is lower than in the published literature, possibly

10

ACCEPTED MANUSCRIPT because few patients presented with major crush or penetrating injuries of the limbs. Mommsen et al. and Rozycki et al. both reported an 18% incidence of amputations in pediatric patients with

T

blunt or penetrating injuries of the extremities [1, 15]. Conversely, Corneille et al. reported a

RI P

limb salvage rate of 97% in pediatric patients with upper or lower extremity trauma [3]. Anderson et al. described no post-traumatic complications in pediatric patients presenting with

SC

abdominal aortic trauma or thoracic aortic trauma managed non-operatively [16]. However, the

NU

incidence of growth retardation in a small number of our patients suggests that vascular injuries

late sequelae of growth retardation.

MA

that are not immediately limb-threatening should be repaired when clinically safe to prevent the

ED

Our analysis was limited by the sample size and considerable heterogeneity in the patient

PT

population. Furthermore, a number of patients in our series were transferred from other hospitals or regions and may have opted to follow-up closer to home after discharge. We were unable to

AC

specialists.

CE

determine whether patients who transitioned into adult medicine were followed by vascular

One patient (1%) died from post-traumatic complications following admission to hospital. It is possible that the true mortality rate secondary to vascular trauma is higher in our region, as our series does not capture patients who died on the scene or in another hospital. Conversely, Bramparas et al. described a 13% mortality rate in an analysis of pediatric vascular traumas in the American College of Surgeons National Trauma Data Bank [7]. That report, however, included more firearm traumas, which were associated with a 20% mortality, and many of those patients may have been treated at facilities not verified as high level pediatric trauma centers by

11

ACCEPTED MANUSCRIPT the American College of Surgeons. Hamner et al. [17] similarly used the National Trauma Data Bank and described a 16% mortality rate in their analysis of blunt intra-abdominal arterial

RI P

T

injuries

Our institution is the only Level I trauma hospital serving pediatric patients in the greater

SC

Toronto area. It is possible that some pediatric patients with minor vascular injuries in our

NU

catchment area might have been treated at other hospitals rather being transferred to our institution, and as such our paper might underestimate the true incidence of pediatric vascular

MA

patients treated in our area. Trauma patients who present to our hospital are managed according to a multi-disciplinary, team-based trauma protocol that combines clinical examination with

ED

imaging studies, as needed. Vascular injuries that are identified during this work-up are then

PT

referred to the appropriate service for management, as determined by the trauma team leader.

CE

Vascular surgery coverage at our hospital is provided by surgeons who work at an adult hospital

AC

across the street and who have operating privileges at our hospital. While there is no official protocol in place for activating the vascular surgery service, if the trauma team leader requires a vascular surgery consultation, then the on-call vascular surgeon at the adult hospital is paged and requested to be physically present as soon as possible. The vascular surgeons would likely be commuting from home if they are not in hospital at the time of the consultation. To date, we have not encountered any difficulty in reaching our vascular surgery colleagues or getting prompt support whenever it has been required.

12

ACCEPTED MANUSCRIPT Despite the small number of patients in our study, it is one of the largest series in the literature to date. Indeed, the rarity of pediatric non-iatrogenic vascular injuries makes it unlikely that large

T

randomized prospective studies will be possible to better characterise this patient population.

RI P

However, like all retrospective database studies, ours is somewhat limited by selection and recall

SC

bias and confounding that limits the inferences that can be drawn to help guide future practice.

NU

Pediatric vascular trauma outside of war zones is infrequent, which makes it difficult to study. Long-term follow-up studies are required to better understand the natural history of vascular

MA

injuries in pediatric patients. In addition, educational initiatives may be useful in training

ED

frontline providers on the soft signs of vascular trauma to expedite definitive management.

PT

5. Conclusions

Pediatric non-iatrogenic pediatric vascular injuries are rare and represent a highly heterogeneous

CE

population. There is a significant amount of variability in how pediatric trauma patients present

AC

and in how they are best managed. In many cases, a multidisciplinary approach involving several surgical specialties, including vascular, plastic, and general surgery, as well as interventional radiology is necessary. Most children do well, with minimal perioperative and short-term complications.

6. Acknowledgements The authors would like to thank Ms. Margaret Kreller for her assistance with compiling the data for this study.

13

ACCEPTED MANUSCRIPT 7. Funding Sources This research did not receive any specific grant from funding agencies in the public, commercial,

AC

CE

PT

ED

MA

NU

SC

RI P

T

or not-for-profit sectors.

14

ACCEPTED MANUSCRIPT

AC

CE

PT

ED

MA

NU

SC

RI P

T

References 1. Mommsen P, Zeckey C, Hildebrand F, Frink M, Khaladj N, Lange N, et al. Traumatic extremity arterial injury in children: epidemiology, diagnostics, treatment and prognostic value of Mangled Extremity Severity Score. J Orthop Surg Res 2010; 5: 25. 2. Evans WE, King DR, and Hayes JP. Arterial trauma in children: diagnosis and management. Ann Vasc Surg 1988; 2(3): 268-70. 3. Corneille MG, Gallup TM, Villa C, Richa JM, Wolf SE, Myers JG, et al. Pediatric vascular injuries: acute management and early outcomes. J Trauma 2011; 70(4): 823-8. 4. Whitehouse WM, Coran AG, Stanley JC, Kuhns LR, Weintraub WH, and Fry WJ. Pediatric vascular trauma. Manifestations, management, and sequelae of extremity arterial injury in patients undergoing surgical treatment. Arch Surg 1976; 111(11): 1269-75. 5. Klinkner DB, Arca MJ, Lewis BD, Oldham KT, and Sato TT. Pediatric vascular injuries: patterns of injury, morbidity, and mortality. J Pediatr Surg 2007; 42(1): 178-82; discussion 1823. 6. Shah SR, Wearden PD, and Gaines BA. Pediatric peripheral vascular injuries: a review of our experience. J Surg Res 2009; 153(1): 162-6. 7. Barmparas G, Inaba K, Talving P, David JS, Lam L, Plurad D, et al. Pediatric vs adult vascular trauma: a National Trauma Databank review. J Pediatr Surg 2010; 45(7): 1404-12. 8. Hackam DJ, Mazzioti MV, Pearl RH, Mazziotti GM, Winthrop AL, and Langer JC. Mechanisms of pediatric trauma deaths in Canada and the United States: the role of firearms. J Trauma 2004; 56(6): 1286-90. 9. Kayssi A, Shaikh F, Roche-Nagle G, Brandao LR, Williams SA, and Rubin BB. Management of acute limb ischemia in the pediatric population. J Vasc Surg 2014; 60(1): 106-10. 10. Lazarides MK, Georgiadis GS, Papas TT, Gardikis S, and Maltezos C. Operative and nonoperative management of children aged 13 years or younger with arterial trauma of the extremities. J Vasc Surg 2006; 43(1): 72-6; discussion 76. 11. Milas ZL, Milner R, Chaikoff E, Wulkan M, and Ricketts R. Endograft stenting in the adolescent population for traumatic aortic injuries. J Pediatr Surg 2006; 41(5): e27-30. 12. Gunabushanam V, Mishra N, Calderin J, Glick R, Rosca M, and Krishnasastry K. Endovascular stenting of blunt thoracic aortic injury in an 11-year-old. J Pediatr Surg 2010; 45(3): E15-8. 13. Ringel RE, Gauvreau K, Moses H, and Jenkins KJ. Coarctation of the Aorta Stent Trial (COAST): study design and rationale. Am Heart J 2012; 164(1): 7-13. 14. Torok RD, Campbell MJ, Fleming GA, and Hill KD. Coarctation of the aorta: Management from infancy to adulthood. World J Cardiol 2015; 7(11): 765-75. 15. Rozycki GS, Tremblay LN, Feliciano DV, and McClelland WB. Blunt vascular trauma in the extremity: diagnosis, management, and outcome. J Trauma 2003; 55(5): 814-24. 16. Anderson SA, Day M, Chen MK, Huber T, Lottenberg LL, Kays DW, et al. Traumatic aortic injuries in the pediatric population. J Pediatr Surg 2008; 43(6): 1077-81. 17. Hamner CE, Groner JI, Caniano DA, Hayes JR, and Kenney BD. Blunt intraabdominal arterial injury in pediatric trauma patients: injury distribution and markers of outcome. J Pediatr Surg 2008; 43(5): 916-23.

15

ACCEPTED MANUSCRIPT

Table I: Demographics of the patients.

T

Table II: Injured blood vessels in patients (stratified by patient age group). The percentage of injuries is presented as a proportion of injuries within the same age group.

RI P

Table III: Service responsible for managing the vascular injury (stratified by patient age group). The percentage of services is presented as a proportion of services within the same age group.

SC

Table IV: Management of vascular injuries (stratified by patient age group). The percentage of interventions is presented as a proportion of interventions within the same age group.

AC

CE

PT

ED

MA

NU

Table V: Concomitant injury or post-traumatic complications (stratified by patient age group). The percentage of injuries or complications is presented as a proportion of injuries or complications within the same age group.

16

ACCEPTED MANUSCRIPT Table I Characteristic

Frequency (%)

Age

Male Timing of Trauma

T

9 (8) 33 (31) 25 (24) 39 (37)

71 (68) 33 (32)

58 (55) 17 (16) 1 (1) 13 (12) 3 (3) 13 (12) 1 (1)

AC

CE

PT

ED

MA

NU

SC

5am-12pm 12pm-6pm 6pm-12am 12am-5am Mode of Transport to Hospital Land Ambulance Private Vehicle Mechanism of Injury Penetrating Glass Utensil, knife, or tool Gunshot Blunt Motor-vehicle passenger Fall Crush Pedestrian struck by vehicle

1 (1) 75 (71) 30 (28) 80 (75)

RI P

<12 months 1-12 years ≥13 years

17

ACCEPTED MANUSCRIPT Table II

T

RI P

SC

NU

MA

≥13 years (n=30) 10 (33) 2 (7) 2 (7) 5 (17) 2 (7) 1 (3) 1 (3) 0 1 (3) 0 1 (3) 0 0 0 2 (7) 0 0 1 (3) 0 0 1 (3) 1 (3)

AC

CE

PT

Ulnar artery Radial artery Brachial artery Popliteal artery Aorta Posterior tibial artery Superficial femoral artery Common carotid artery Inferior vena cava Superior mesenteric artery Axillary artery Common iliac artery Internal carotid artery Internal jugular vein Internal mammary artery External iliac artery Hepatic artery Omental vessel Posterior tibial vein Renal artery Subclavian artery Vertebral artery

Frequency (%) <12 months (n=1) 1-12 years (n=75) 1 (100) 12 (16) 0 13 (17) 0 10 (13) 0 6 (8) 0 6 (8) 0 4 (5) 0 4 (5) 0 4 (5) 0 2 (3) 0 3 (4) 0 1 (1) 0 2 (3) 0 2 (3) 0 2 (3) 0 0 0 1 (1) 0 1 (1) 0 0 0 1 (1) 0 1 (1) 0 0 0 0

ED

Vessel

18

ACCEPTED MANUSCRIPT Table III

T

RI P

≥13 years (n=30) 14 (47) 4 (13) 4 (13) 7 (23) 0 1 (3) 0 0

AC

CE

PT

ED

MA

NU

Plastic Surgery Vascular Surgery General Surgery Cardiac Surgery Neurosurgery Orthopedic Surgery Interventional Cardiology Interventional Radiology

Frequency (%) <12 months (n=1) 1-12 years (n=75) 1 (100) 40 (53) 0 17 (23) 0 10 (13) 0 3 (4) 0 2 (3) 0 1 (1) 0 1 (1) 0 1 (1)

SC

Service

19

ACCEPTED MANUSCRIPT Table IV

Management

<12 months (n=1)

Frequency (%) 1-12 years (n=75)

1 (100) 0 0 0 0 0 0

38 (51) 10 (13) 7 (9) 2 (3) 3 (4) 1 (1) 14 (19)

RI P SC

13 (43) 6 (20) 6 (20) 4 (13) 0 0 1 (3)

AC

CE

PT

ED

MA

NU

Primary Repair Vessel ligation Interposition graft Bypass graft Patch angioplasty Endovascular stent placement Non-Operative

T

Operative

≥13 years (n=30)

20

ACCEPTED MANUSCRIPT Table V

Frequency (%) 1-12 years (n=75)

0 0 0 0 0 0 0 0 0 0 0 0

7 (9) 4 (5) 2 (3) 1 (1) 3 (4) 2 (3) 1 (1) 1 (1) 0 1 (1) 1 (1) 1 (1)

RI P SC

≥13 years (n=30) 0 2 (7) 4 (13) 2 (7) 0 0 0 0 1 (3) 0 0 0

AC

CE

PT

ED

MA

Post-operative infection Nerve injury Neuropathic pain Parasthesia Growth retardation Foot drop Amputation Small bowel obstruction Pulmonary embolism Tracheo-esophageal fistula Renal failure Death

T

<12 months (n=1)

NU

Concomitant Injury or PostTraumatic Complication

21