title: The impact of morbid obesity on solid organ injury in children using the ATOMAC protocol at a pediatric level I trauma center.
abstract: BACKGROUND
  Obesity is an epidemic in the pediatric population. Childhood obesity in trauma has been associated with increased incidence of long-bone fractures, longer ICU stays, and decreased closed head injuries. We investigated for differences in the likelihood of failure of non-operative management (NOM), and injury grade using a subset of a multi-institutional, prospective database of pediatric patients with solid organ injury (SOI).
  
  
  METHODS
  We prospectively collected data on all pediatric patients (<18years) admitted for liver or splenic injury from September 2013 to January 2016. SOI was managed based upon the ATOMAC protocol. Obesity status was derived using CDC definitions; patients were categorized as non-obese (BMI <95th percentile) or obese (BMI ≥95th percentile). The ISS, injury grade, and NOM failure rate were calculated among other data points.
  
  
  RESULTS
  Of 1012 patients enrolled, 117 were identified as having data regarding BMI. Eighty-four percent of patients were non-obese; 16% were obese. The groups did not differ by age, sex, mechanism of injury, or associated injuries. There was no significant difference in the rate of failure of non-operative management (8.2% versus 5.3%). Obesity was associated with higher likelihood of severe (grade 4 or 5) hepatic injury (36.8% versus 15.3%, P=0.048) but not a significant difference in likelihood of severe (grade 4 or 5) splenic injury (15.3% versus 10.5%, P=0.736). Obese patients had a higher mean ISS (22.5 versus 16.1, P=0.021) and mean abdominal AIS (3.5 versus 2.9, P=0.024).
  
  
  CONCLUSIONS
  Obesity is a risk factor for more severe abdominal injury, specifically liver injury, but without an associated increase in failure of NOM. This may be explained by the presence of hepatic steatosis making the liver more vulnerable to injury. A protocol based upon physiologic parameters was associated with a low rate of failure regardless of the pediatric obesity status.
  
  
  METHODS
  Level II prognosis.
authors.affiliation: Children's Medical Center Dallas, Dallas, TX 75235.
authors.forename: Nathan
authors.initials: N
authors.lastname: Vaughan
authors.affiliation: Children's Medical Center Dallas, Dallas, TX 75235.
authors.forename: Jeff
authors.initials: J
authors.lastname: Tweed
authors.affiliation: Children's Medical Center Dallas, Dallas, TX 75235.
authors.forename: Cynthia
authors.initials: C
authors.lastname: Greenwell
authors.affiliation: Phoenix Children's Hospital, Phoenix, AZ 85016.
authors.forename: David M
authors.initials: DM
authors.lastname: Notrica
authors.affiliation: Phoenix Children's Hospital, Phoenix, AZ 85016.
authors.forename: Crystal S
authors.initials: CS
authors.lastname: Langlais
authors.affiliation: Children's Mercy Hospital, Kansas City, MO 64108.
authors.forename: Shawn D St
authors.initials: SD
authors.lastname: Peter
authors.affiliation: American Family Children's Hospital, Madison, WI 53792.
authors.forename: Charles M
authors.initials: CM
authors.lastname: Leys
authors.affiliation: Phoenix Children's Hospital, Phoenix, AZ 85016; American Family Children's Hospital, Madison, WI 53792.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Ostlie
authors.affiliation: Arkansas Children's Hospital, Little Rock, AR 72202.
authors.forename: R Todd
authors.initials: RT
authors.lastname: Maxson
authors.affiliation: Akron Children's Hospital, Akron, OH 44308.
authors.forename: Todd
authors.initials: T
authors.lastname: Ponsky
authors.affiliation: Dell Children's Medical Center, Austin, TX 78723.
authors.forename: David W
authors.initials: DW
authors.lastname: Tuggle
authors.affiliation: Le Bonheur Children's Hospital, Memphis, TN 38103.
authors.forename: James W
authors.initials: JW
authors.lastname: Eubanks
authors.affiliation: Hughes Spalding Children's Hospital, Atlanta, GA 30303.
authors.forename: Amina
authors.initials: A
authors.lastname: Bhatia
authors.affiliation: Children's Medical Center Dallas, Dallas, TX 75235.
authors.forename: Cynthia
authors.initials: C
authors.lastname: Greenwell
authors.affiliation: Dell Children's Medical Center, Austin, TX 78723.
authors.forename: Nilda M
authors.initials: NM
authors.lastname: Garcia
authors.affiliation: Dell Children's Medical Center, Austin, TX 78723.
authors.forename: Karla A
authors.initials: KA
authors.lastname: Lawson
authors.affiliation: The Children's Hospital at OU Medical Center, Oklahoma City, OK 73104.
authors.forename: Prasenjeet
authors.initials: P
authors.lastname: Motghare
authors.affiliation: The Children's Hospital at OU Medical Center, Oklahoma City, OK 73104.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Letton
authors.affiliation: Children's Medical Center Dallas, Dallas, TX 75235. Electronic address: Adam.Alder@childrens.com.
authors.forename: Adam C
authors.initials: AC
authors.lastname: Alder
mesh_terms: D000007:Abdominal Injuries / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols; D016208:Databases, Factual; D005260:Female; D006776:Hospitals, Pediatric; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015601:Injury Severity Score; D008099:Liver / Q000293:injuries*; D008297:Male; D009767:Obesity, Morbid / Q000150:complications*; D063766:Pediatric Obesity / Q000150:complications*; D011379:Prognosis; D011446:Prospective Studies; D012307:Risk Factors; D013154:Spleen / Q000293:injuries*; D014193:Trauma Centers; D014949:Wounds, Nonpenetrating / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*
keywords: Abdominal; Blunt; Guideline; Obesity; Pediatric; Trauma