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Published on: July 28, 2020
Management of children with solid organ injuries after blunt torso trauma
David H Wisner1, Nathan Kuppermann, Arthur Cooper
1From the Departments of Surgery (D.H.W.), and Emergency Medicine (N.K., J.F.H.), University of California-Davis, Sacramento, California; Department of Surgery (A.C.), Columbia University, New York; Department of Surgery (J.M.) University of Maryland, Baltimore, Maryland; Department of Surgery (P.E.) University of Michigan, Ann Arbor, Michigan; Department of Emergency Medicine (J.K.) Helen DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics (P.M.) Wayne State University, Detroit, Michigan; Department of Pediatrics (L.L.) Harvard University, Boston, Massachusetts; Department of Pediatrics (L.J.C.) University of Utah, Salt Lake City, Utah; Department of Pediatrics (K.Y.) Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Pediatrics (K.L.) State University of New York, Buffalo, Buffalo, New York.
Insights
Most children with blunt abdominal trauma and solid organ injuries are managed non-operatively. Observation is common, with blood transfusions being the most frequent intervention, while surgery and embolization are rare. Management varies significantly across hospitals.
Area of Science:
- Pediatric Surgery
- Trauma Management
- Abdominal Injuries
Background:
- Management of pediatric intra-abdominal solid organ injuries has evolved.
- This study describes current management practices for children with these injuries following blunt trauma.
Purpose of the Study:
- To analyze current management strategies for children with blunt abdominal trauma and solid organ injuries.
- To identify trends in interventions and patient disposition.
Main Methods:
- Secondary analysis of a prospective, multicenter observational study.
- Included children (<18 years) with spleen, liver, or kidney injuries identified via imaging or autopsy.
- Outcomes assessed included disposition and interventions like transfusion, angiography, and laparotomy.
Main Results:
- 605 of 12,044 children had intra-abdominal solid organ injuries.
- Spleen, liver, and kidney were the most commonly injured organs.
- Observation was the primary management; blood transfusion (11%) was most common intervention, while laparotomy (4.1%) and embolization (1.4%) were infrequent.
Conclusions:
- Most children with solid organ injuries are managed non-operatively.
- Blood transfusion is the most frequent intervention, with surgery and embolization being uncommon.
- Disposition for isolated Grade I-II injuries varies widely, often deviating from guidelines.
Background:
Management of children with intra-abdominal solid organ injuries has evolved markedly. We describe the current management of children with intra-abdominal solid organ injuries after blunt trauma in a large multicenter network.
Methods:
We performed a planned secondary analysis of a prospective, multicenter observational study of children (<18 years) with blunt torso trauma. We included children with spleen, liver, or kidney injuries identified by computed tomography, laparotomy/laparoscopy, or autopsy. Outcomes included disposition and interventions (blood transfusion for intra-abdominal hemorrhage, angiography, laparotomy/laparoscopy). We performed subanalyses of children with isolated injuries.
Results:
A total of 12,044 children were enrolled; 605 (5.0%) had intra-abdominal solid organ injuries. The mean (SD) age was 10.7 (5.1) years, and injured organs included spleen 299 (49.4%), liver 282 (46.6%), and kidney 147 (24.3%). Intraperitoneal fluid was identified on computed tomography in 461 (76%; 95% confidence interval [CI], 73-80%), and isolated solid organ injuries were present in 418 (69%; 95% CI, 65-73%). Treatment included therapeutic laparotomy in 17 (4.1%), angiographic embolization in 6 (1.4%), and blood transfusion in 46 (11%) patients. Laparotomy rates for isolated injury were 11 (5.4%) of 205 (95% CI, 2.7-9.4%) at non-freestanding children's hospitals and 6 (2.8%) of 213 (95% CI, 1.0-6.0%) at freestanding children's hospitals (difference, 2.6%; 95% CI, -7.1% to 12.2%). Dispositions of the 212 children with isolated Grade I or II organ injuries were home in 6 (3%), emergency department observation in 9 (4%), ward in 114 (54%), intensive care unit in 73 (34%), operating suite in 7 (3%), and transferred in 3 (1%) patients. Intensive care unit admission for isolated Grade I or II injuries varied by center from 9% to 73%.
Conclusion:
Most children with solid organ injuries are managed with observation. Blood transfusion, while uncommon, is the most frequent therapeutic intervention; angiographic embolization and laparotomy are uncommon. Emergency department disposition of children with isolated Grade I to II solid organ injuries is highly variable and often differs from published guidelines.
Level Of Evidence:
Prognostic/epidemiologic study, level III; therapeutic study, level IV.
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