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Published on: July 28, 2020
Prospective results of a standardized algorithm based on hemodynamic status for managing pediatric solid organ injury
J R Mehall1, J S Ennis, D A Saltzman
1Department of Pediatric Surgery, Arkansas Children's Hospital, Little Rock 72202, USA.
Insights
Pediatric blunt trauma patients with stable hemodynamics can avoid intensive care unit admission and prolonged hospitalization. These children can safely resume school activities upon discharge, focusing on clinical status over imaging severity.
Area of Science:
- Pediatric Surgery
- Trauma Management
- Emergency Medicine
Background:
- Management of pediatric blunt trauma, specifically liver or spleen injuries, lacks consensus regarding ICU admission, bed rest, and activity restrictions.
- Adult trauma literature suggests prioritizing hemodynamic stability over imaging (CT) grade for patient management.
Purpose of the Study:
- To evaluate a standardized management algorithm for hemodynamically normal pediatric patients with blunt liver or spleen injuries.
- To determine if clinical status, rather than CT grade, can guide safe nonoperative management and discharge criteria.
Main Methods:
- A 3-year prospective study enrolled hemodynamically normal pediatric patients with blunt liver/spleen injury, excluding those needing ICU for other reasons.
- Patients were admitted to a surgical ward, monitored with serial hematocrit, and discharged after 48 hours if stable and tolerating diet.
- Activity restrictions were limited to noncontact activities, including school, post-discharge, with 1-month follow-up ultrasonography.
Main Results:
- 44 pediatric patients with blunt liver/spleen injury were managed nonoperatively without transfusion, predominantly due to motor vehicle collisions.
- All patients completed the algorithm, with a mean observation of 55.2 hours. One patient experienced a complication, with no delayed bleeding observed at 1-month follow-up.
Conclusions:
- Hemodynamic status, not CT grade, should guide the management of pediatric solid organ injuries.
- Hemodynamically normal children with blunt liver/spleen injury can be safely managed without ICU monitoring or prolonged hospitalization.
- These children can safely resume school activities upon discharge, indicating successful nonoperative management.
Background:
Controversy surrounds the need for ICU admission, prolonged bed rest, and the duration of activity restrictions for children sustaining blunt trauma. Adult literature supports management based on hemodynamic status, not CT grade.
Study Design:
A 3-year prospective study of a standardized management algorithm for hemodynamically normal pediatric patients with blunt liver or spleen injury was performed. Patient selection was based on vital signs, irrespective of injury grade on CT. Patients requiring ICU admission for nonliver or nonspleen injury were excluded. Patients were admitted to a surgical ward with serial hematocrit levels. Discharge occurred 48 hours postinjury if patients had no abdominal tenderness, tolerated a regular diet, and had a stable hematocrit. Patients were allowed noncontact activity, including school, after discharge. Patients were followed up at 1 month with ultrasonographic imaging.
Results:
Eighty-nine patients sustained blunt liver or spleen injury. Forty-five patients were excluded for other injuries (Glasgow Coma Scale < 13, 32 of 45); the remaining 44 patients had a mean age of 8.9 years (range 2 to 17 years), Injury Severity Score 10.6 (range 4 to 33), liver grade 2.1, and splenic injury grade 2.3. Mechanisms of injury were predominately motor vehicle collisions (59%). All patients were managed nonoperatively without transfusion; 43 of 44 patients completed the algorithm. Mean observation was 55.2 +/- 12.3 hours. One-month followup occurred in 33 of 44 patients, with one complication detected and no delayed bleeding.
Conclusion:
Management of pediatric solid organ injury should be guided by hemodynamic status and not injury grade on CT. Hemodynamically normal children can be safely managed without intensive care monitoring, do not need prolonged hospitalization, and can resume school on discharge.
