Rachael Stottlemyre
Affiliate, Department Funds
Resident in Surgery
All Publications
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Outcomes of Pediatric Blunt Liver and Spleen Injury in 1029 patients using the ATOMAC+ Pediatric Trauma Research Network Guideline.
Journal of pediatric surgery
2026: 163107
Abstract
BACKGROUND: The ATOMAC+ guideline is an evidence-based guideline for management of pediatric blunt liver and/or spleen injury (BLSI) based on clinical signs of bleeding on arrival.METHODS: A prospective multi-institutional study of children aged ≤18 years with BLSI was conducted at 10 pediatric trauma centers. Unstable patients without computed tomography were added retrospectively. Demographic data, interventions, and outcomes were analyzed.RESULTS: Of 1,029 children (median age 10.2 years) with BLSI, 713 (69%) had no signs of clinically significant bleeding upon arrival, and no initially stable patients required surgery for bleeding; 13 (1.8%) required abdominal surgery for other reasons. Of 316 patients with clinical signs of recent bleeding or ongoing bleeding on arrival, 10 patients died in the ED and 17 non-responders underwent surgery directly. Among 168 patients responding initially to transfusion, 22 underwent angiography and 60 went to surgery (9 after angiography). Of the 44 stabilized patients who received >40mL/kg blood products, only 5 (11%) survived without intervention. Additionally, 37 (32%) transfused patients not meeting this threshold also underwent abdominal intervention. Overall mortality was 3.4% including 21% of 42 patients transfused >40mL/kg or 4 units of blood.CONCLUSION: The frequency of laparotomy or laparoscopy in children with BLSI was 8.2%. Children with no clinical signs of bleeding upon arrival did not later bleed, but 1.6% of these patients ultimately required abdominal surgery for other injuries. Transfusion >40mL/kg was strongly associated with intervention or death, but a substantial number of children who received less blood also required intervention.
View details for DOI 10.1016/j.jpedsurg.2026.163107
View details for PubMedID 41887567
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Blunt cerebrovascular injury in children: A prospective multicenter ATOMAC plus study
JOURNAL OF TRAUMA AND ACUTE CARE SURGERY
2025; 99 (2): 245-252
Abstract
The incidence of blunt cerebrovascular injury (BCVI) in children remains largely unknown, with only 16.5% of children receiving appropriate screening. This study sought to determine the impact of a screening guideline on injury detection and outcomes in children with BCVI.This was a prospective, multi-institutional observational study of children younger than 15 years with blunt trauma to the head, face, or neck (Abbreviated Injury Scale score, >0) at any of six level 1 pediatric trauma centers. All patients were screened using the Memphis criteria. Head/neck computed tomography angiogram was recommended for those meeting the criteria. Treatment for BCVI was recommended based on overall trauma burden, with 7- to 10-day follow-up imaging.A total of 2,285 patients met the inclusion criteria. Of those, 520 (23%) (median age, 7.9 years) met the Memphis screening criteria, and 222 (42.5%) received appropriate imaging. A total of 30 BCVIs were identified in 25 patients (1.05%); 22 (88%) had a carotid injury, and 6 (24%) had a vertebral artery injury. Motor vehicle collision was the most common mechanism (42%). Those with BCVIs were older (8.01 years, p = 0.03), with a lower median Glasgow Coma Scale (7.8 vs. 15, p < 0.0001). All but three met the Memphis screening criteria (sensitivity, 88%). Eight (32%) underwent treatment. Six children with BCVI suffered a stroke (24%): two untreated and one treated patient developed a stroke after diagnosis.Similar to adults, BCVI in children screened has an incidence of 1% (overall incidence of 0.33% in all blunt trauma) and carries a significant risk of stroke. Treatment of BCVI in children in this study is inconsistently applied even after diagnosis, and stroke may still occur with treatment.Prognostic and Epidemiological; Level II.
View details for DOI 10.1097/TA.0000000000004620
View details for Web of Science ID 001543331200015
View details for PubMedID 40269340
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Nationwide Comparison of Epidural and Regional Analgesia versus Intercostal Nerve Cryoablation in Pectus Repair
JOURNAL OF PEDIATRIC SURGERY
2025; 60 (4): 162162
Abstract
Pectus excavatum is the most common congenital chest wall deformity, occurring in 1 in 250-300 live births. Surgical correction of this pathology is traditionally associated with significant pain. We hypothesize intercostal nerve cryoablation is a superior analgesic modality that can improve patient comfort, improve healthcare resource utilization, and reduce opioid exposure in a high-risk population.The most recently published National Readmissions Database (2016-2020) was queried for patient aged 12-21 years old who underwent Nuss Procedure for pectus excavatum. Patient demographics, hospital factors, and patient outcomes including hospital length of stay, opioid-related complications, readmission, post-operative acute pain, respiratory complications, post-operative bleeding, chest tube insertion, pleural effusion, pneumothorax, and hospital costs were analyzed.818 patients were analyzed in this study. 62 % received epidural/regional analgesia and 38 % received intercostal nerve cryoablation. The mean age in the cohort was 16 ± 2 years old. 86 % of the study cohort was male. Intercostal nerve cryoablation was associated with significantly reduced opioid-related complications (4.3 % vs 8.7 %, p = 0.015), hospital length of stay (2 [2-3] vs 4 [3-5] days, p < 0.001), and respiratory failure when compared to epidural analgesia. Intercostal nerve cryoablation was associated with an increased index hospitalization cost when compared to epidural/regional analgesia ($17,656 [15,103-23,346] vs. $15,669 [12,676-20,177], p < 0.001).Intercostal nerve cryoablation for pectus excavatum repair is a safe analgesic modality that is associated with superior pain control while reducing opioid-related complications, respiratory failure, and hospital length of stay.Retrospective Comparative.III.
View details for DOI 10.1016/j.jpedsurg.2025.162162
View details for Web of Science ID 001429110300001
View details for PubMedID 39965427
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Unusual variant of esophageal atresia and tracheo-esophageal fistula: A case report
JOURNAL OF PEDIATRIC SURGERY CASE REPORTS
2024; 110
View details for DOI 10.1016/j.epsc.2024.102886
View details for Web of Science ID 001321889100001
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Preventing Inpatient NP Burnout: The Power of Adequate Staffing and Leadership
JOURNAL OF PEDIATRIC HEALTH CARE
2024; 38 (4): 497-504
Abstract
Nurse practitioner (NP) burnout related to high patient-to-NP ratios needs to be addressed.To survey inpatient pediatric NPs, assess burnout and characterize associated workload and support.Online cross-sectional survey conducted in three phases from March 2022 to August 2023.Inpatient specialty NPs from 32 hospitals.Fisher's exact test and logistic regression were implemented. A patient-to-provider (NP or resident) ratio of more than 5:1 was associated with NP burnout (OR = 3.5, 95% CI 1.0, 12.0 and OR = 4.1, 95% CI 1.1, 16.2, respectively, p < .05). Among NPs without burnout, 100% had organizational NP leadership (p = .012).Though limited by a small convenience sample, a patient-to-provider ratio over 5:1 was associated with NP burnout, and NP leadership was protective. Further research of cost analysis, retention, and patient quality and safety measures are needed.Lower patient-to-NP ratios and NP leadership play a pivotal role in preventing burnout.
View details for DOI 10.1016/j.pedhc.2024.02.005
View details for Web of Science ID 001263377300001
View details for PubMedID 38703177
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The use and timing of angioembolization in pediatric blunt liver and spleen injury
JOURNAL OF TRAUMA AND ACUTE CARE SURGERY
2024; 96 (6): 915-920
Abstract
Nonoperative management (NOM) is the standard of care for the management of blunt liver and spleen injuries (BLSI) in the stable pediatric patient. Angiography with embolization (AE) is used as an adjunctive therapy in the management of adult BLSI patients, but it is rarely used in the pediatric population. In this planned secondary analysis, we describe the current utilization patterns of AE in the management of pediatric BLSI.After obtaining IRB approval at each center, cohort data was collected prospectively for children admitted with BLSI confirmed on CT at 10 Level I pediatric trauma centers (PTCs) throughout the United States from April 2013 to January 2016. All patients who underwent angiography with or without embolization for a BLSI were included in this analysis. Data collected included patient demographics, injury details, organ injured and grade of injury, CT finding specifics such as contrast blush, complications, failure of NOM, time to angiography and techniques for embolization.Data were collected for 1004 pediatric patients treated for BLSI over the study period, 30 (3.0%) of which underwent angiography with or without embolization for BLSI. Ten of the patients who underwent angiography for BLSI failed NOM. For patients with embolized splenic injuries, splenic salvage was 100%. Four of the nine patients undergoing embolization of the liver ultimately required an operative intervention, but only one patient required hepatorrhaphy and no patient required hepatectomy after AE. Few angiography studies were obtained early during hospitalization for BLSI, with only one patient undergoing angiography within 1 hour of arrival at the PTC, and 7 within 3 hours.Angioembolization is rarely used in the management of BLSI in pediatric trauma patients with blunt abdominal trauma and is generally used in a delayed fashion. However, when implemented, angioembolization is associated with 100% splenic salvage for splenic injuries.Therapeutic/Care Management; Level IV.
View details for DOI 10.1097/TA.0000000000004228
View details for Web of Science ID 001229278200019
View details for PubMedID 38189680
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Admission to a Verified Pediatric Trauma Center is Associated With Improved Outcomes in Severely Injured Children
JOURNAL OF PEDIATRIC SURGERY
2024; 59 (3): 488-493
Abstract
Previous studies have shown improved survival for severely injured adult patients treated at American College of Surgeons verified level I/II trauma centers compared to level III and undesignated centers. However, this relationship has not been well established in pediatric trauma centers (PTCs). We hypothesize that severely injured children will have lower mortality at verified level I/II PTCs compared to centers without PTC verification.All patients 1-15 years of age with ISS >15 in the 2017-2019 American College of Surgeons Trauma Quality Programs (ACS TQP) dataset were reviewed. Patients with pre-hospital cardiac arrest, burns, and those transferred out for ongoing inpatient care were excluded. Logistic regression models were used to assess the effects of pediatric trauma center verification on mortality.16,301 patients were identified (64 % male, median ISS 21 [17-27]), and 60 % were admitted to verified PTCs. Overall mortality was 6.0 %. Mortality at centers with PTC verification was 5.1 % versus 7.3 % at centers without PTC verification (p < 0.001). After controlling for injury mechanism, sex, age, pediatric-adjusted shock index (SIPA), ISS, arrival via interhospital transfer, and adult trauma center verification, pediatric level I/II trauma center designation was independently associated with decreased mortality (OR 0.72, 95 % CI 0.61-0.85).Treatment at ACS-verified pediatric trauma centers is associated with improved survival in critically injured children. These findings highlight the importance of PTC verification in optimizing outcomes for severely injured pediatric patients and should influence trauma center apportionment and prehospital triage.Level IV - Retrospective review of national database.
View details for DOI 10.1016/j.jpedsurg.2023.10.064
View details for Web of Science ID 001171825600001
View details for PubMedID 37993397
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Single-center comparison of outcomes between laparoscopic appendectomy and transumbilical laparoscopic assisted appendectomy
JOURNAL OF PEDIATRIC SURGERY
2023; 58 (5): 838-843
Abstract
Appendectomy is the most common pediatric emergency surgery performed to date. This study compared outcomes between laparoscopic appendectomy (LA) and transumbilical laparoscopic assisted appendectomy (TULAA) for 1154 uncomplicated patients across 5 years at a single institution. Primary outcomes include length of stay (LOS), post-operative complications, pain score, and operating room (OR) time.Demographic and clinical data was collected for 1154 eligible patients treated for uncomplicated appendicitis between August 2014-October 2019, with 830 patients in the LA group, and 324 in the TULAA group. Mixed effects modeling procedure using logistic and linear regression examined the effect of surgery type on the four primary outcomes after adjustment for potential clustering effect of surgeon and confounding factors.Of 1154 patients, 62.7% were male, and mean (SD) age was 10.9 (3.6) years. Median [IQR] LOS was 28.0 h [22.0, 36.0], mean (SD) OR time was 29.0 (10.0) minutes, and median [IQR] pain at maximum level was 5.5 (2.7). The complication rate overall was <5.0% and did not differ between TULAA and LA groups (p > 0.05). OR time was reduced by an average of 5.2 min in the TULAA group (p < 0.001), pain did not differ between groups overall (p > 0.05), and patients were more likely to be discharged within 24 h in patients who underwent TULAA (OR = 5.3 [1.6, 17.4], p = 0.007).Retrospective analysis of 1154 pediatric appendectomies, found no difference in complications between single- and three-incision laparoscopic procedures (TULAA vs. LA). Findings suggest TULAA is a safe procedure for acute appendicitis in pediatrics.IV.
View details for DOI 10.1016/j.jpedsurg.2023.01.033
View details for Web of Science ID 000984990300001
View details for PubMedID 36805141
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Hemodilution in pediatric trauma: Defining the expected hemoglobin changes in patients with liver and/or spleen injury: An ATOMAC plus secondary analysis
JOURNAL OF PEDIATRIC SURGERY
2023; 58 (2): 325-329
Abstract
Many children with blunt liver and/or spleen injury (BLSI) never bleed intraperitoneally. Despite this, decreases in hemoglobin are common. This study examines initial and follow up measured hemoglobin values for children with BLSI with and without evidence of intra-abdominal bleeding.Children ≤18 years of age with BLSI between April 2013 and January 2016 were identified from the prospective ATOMAC+ cohort. Initial and follow up hemoglobin levels were analyzed for 4 groups with BLSI: (1) Non bleeding; (2) Bleeding, non transfused (3) Bleeding, transfused, and (4) Bleeding resulting in non operative management (NOM) failure.Of 1007 patients enrolled, 767 were included in one or more of four study cohorts. Of 131 non bleeding patients, the mean decrease in hemoglobin was 0.83 g/dL (+/-1.35) after a median of 6.3 [5.1,7.0] hours, (p = 0.001). Follow-up hemoglobin levels in patients with and without successful NOM were not different. For patients with an initial hemoglobin >9.25 g/dL, the odds ratio (OR) for NOM failure was 14.2 times less, while the OR for transfusion was 11.4 times less (p = 0.001).Decreases in hemoglobin are expected after trauma, even if not bleeding. A hemoglobin decrease of 2.15 g/dL [0.8 + 1.35] would still be within one standard deviation of a non bleeding patient. An initial low hemoglobin correlates with failure of NOM as well as transfusion, thereby providing useful information. By contrast, subsequent hemoglobin levels do not appear to guide the need for transfusion, nor correlate with failure of NOM. These results support initial hemoglobin measurement but suggest a lack of utility for routine rechecking of hemoglobin.Level II Prognostic Study.
View details for DOI 10.1016/j.jpedsurg.2022.10.044
View details for Web of Science ID 000926383700001
View details for PubMedID 36428184
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Meningitis secondary to rectothecal fistula associated with congenital anterior meningocele
JOURNAL OF PEDIATRIC SURGERY CASE REPORTS
2022; 84
View details for DOI 10.1016/j.epsc.2022.102343
View details for Web of Science ID 000877582100007
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Evaluating abusive head trauma in children <5 years old: Risk factors and the importance of the social history
JOURNAL OF PEDIATRIC SURGERY
2021; 56 (2): 390-396
Abstract
Abusive head trauma (AHT) is the leading cause traumatic death in children ≤5 years of age. AHT remains seriously under-surveilled, increasing the risk of subsequent injury and death. This study assesses the clinical and social risks associated with fatal and non-fatal AHT.A single-institution, retrospective review of suspected AHT patients ≤5 years of age between 2010 and 2016 using a prospective hospital forensic registry data yielded demographic, clinical, family, psycho-social and other follow-up information. Descriptive statistics were used to look for differences between patients with AHT and accidental head trauma. Logistic regression estimated the adjusted odds ratios (AOR) for AHT. A receiver operating characteristic (ROC) curve was created to calculate model sensitivity and specificity.Forensic evaluations of 783 children age ≤5 years with head trauma met the inclusion criteria; 25 were fatal with median[IQR] age 23[4.5-39.0] months. Of 758 non-fatal patients, age was 7[3.0-11.0] months; 59.5% male; 435 patients (57.4%) presented with a skull fracture, 403 (53.2%) with intracranial hemorrhage. Ultimately 242 (31.9%) were adjudicated AHT, 335(44.2%) were accidental, 181 (23.9%) were undetermined. Clinical factors increasing the risk of AHT included multiple fractures (Exp(β) = 9.9[p = 0.001]), bruising (Expβ = 5.7[p < 0.001]), subdural blood (Exp(β) = 5.3[p = 0.001]), seizures (Exp(β) = 4.9[p = 0.02]), lethargy/unresponsiveness (Exp(β) = 2.24[p = 0.02]), loss of consciousness (Exp(β) = 4.69[p = 0.001]), and unknown mechanism of injury (Exp(β) = 3.9[p = 0.001]); skull fracture reduced the risk of AHT by half (Exp(β) = 0.5[p = 0.011]). Social risks factors included prior police involvement (Exp(β) = 5.9[p = 0.001]), substance abuse (Exp(β) = 5.7[p = .001]), unknown number of adults in the home (Exp(β) = 4.1[p = 0.001]) and intimate partner violence (Exp(β) = 2.3[p = 0.02]). ROC area under the curve (AUC) = 0.90([95% CI = 0.86-0.93] p = .001) provides 73% sensitivity; 91% specificity.To improve surveillance of AHT, interviews should include and consider social factors including caregiver/household substance abuse, intimate partner violence, prior police involvement and household size. An unknown number of adults in home is associated with an increased risk of AHT.Prognostic, Level III.
View details for DOI 10.1016/j.jpedsurg.2020.10.019
View details for Web of Science ID 000616821600033
View details for PubMedID 33220974
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Intimate Partner Violence, Clinical Indications, and Other Family Risk Factors Associated With Pediatric Abusive Head Trauma
JOURNAL OF INTERPERSONAL VIOLENCE
2022; 37 (9-10): NP6785-NP6812
Abstract
Over half of fatal pediatric traumatic brain injuries are estimated to be the result of physical abuse, i.e., abusive head trauma (AHT). Although intimate partner violence (IPV) is a well-established risk for child maltreatment, little is known about IPV as an associated risk factor specifically for AHT. We performed a single-institution, retrospective review of all patients (0-17 years) diagnosed at a Level 1 pediatric trauma center with head trauma who had been referred to an in-hospital child protection team for suspicion of AHT between 2010 and 2016. Data on patient demographics, hospitalization, injury, family characteristics, sociobehavioral characteristics, physical examination, laboratory findings, imaging, discharge, and forensic determination of AHT were extracted from the institution's forensic registry. Descriptive statistics (mean, median), chi-square and Mann-Whitney U tests were used to compare patients with fatal head injuries to patients with nonfatal head injuries by clinical characteristics, family characteristics, and forensic determination. Multiple logistic regression was used to estimate adjusted odds ratios for the presence of IPV as an associated risk of AHT while controlling for other clinical and family factors. Of 804 patients with suspicion for AHT in the forensic registry, there were 240 patients with a forensic determination of AHT; 42 injuries were fatal. There were 101 families with a reported history of IPV; 64.4% of patients in families with reported IPV were <12 months of age. IPV was associated with a twofold increase in the risk of AHT (Exp(β) = 2.3 [p = .02]). This study confirmed IPV was an associated risk factor for AHT in a single institution cohort of pediatric patients with both fatal and nonfatal injuries. Identifying IPV along with other family factors may improve detection and surveillance of AHT in medical settings and help reduce injury, disability, and death.
View details for DOI 10.1177/0886260520967151
View details for Web of Science ID 000657906600001
View details for PubMedID 33092447