Building an "Abdomen-First" multidisciplinary system for pediatric polytrauma with major abdominal injuries: A decade
Lijian Chen1, Chunyi Ji1, Miaoxian Yuan1
1Department of General Surgery I, Affiliated Children's Hospital of Xiangya School of Medicine, Central South University (Hunan Children's Hospital), Changsha 410007, China.
Insights
A new "Abdomen-First" protocol improved care for critically injured children with abdominal trauma. This surgery-led approach reduced surgical delays and mortality, enhancing survival rates in pediatric polytrauma patients.
Area of Science:
- Trauma Surgery
- Pediatric Critical Care
- Surgical Protocol Development
Background:
- Management of pediatric abdominal-dominant polytrauma lacks a standardized, surgery-led decision-making framework.
- Life-threatening abdominal injuries often coexist with other severe system injuries in pediatric polytrauma.
- This study evaluates the impact of a structured "Abdomen-First" Multidisciplinary Trauma Protocol (AF-MTP).
Purpose of the Study:
- To assess the evolution and effectiveness of the AF-MTP in a high-volume pediatric trauma center.
- To determine if the protocol improves care efficiency and patient outcomes in severe pediatric polytrauma.
- To establish a replicable model for trauma resuscitation prioritizing abdominal injury.
Main Methods:
- Retrospective cohort study of children (<16 years) with severe polytrauma (ISS ≥25) and major abdominal injuries (AIS ≥3) from 2014-2023.
- Patients stratified into three epochs: Traditional Care, Protocol Transition, and Integrated Maturation (AF-MTP).
- Key protocol elements: surgery-led activation, whole-body CT, abdominal intervention prioritization, damage control surgery (DCS) criteria, and postoperative care bundle.
Main Results:
- Despite increasing injury severity (ISS 30 to 41), AF-MTP implementation significantly reduced time to surgical incision (130 to 62 min).
- DCS application increased (22.5% to 85.0%), while non-therapeutic laparotomy decreased (17.5% to 2.5%).
- Abdominal injury-related 30-day mortality decreased by 75% (20.0% to 5.0%), with mature protocol use being protective (aOR 0.18).
Conclusions:
- A systematic, surgery-led, protocol-driven "Abdomen-First" approach significantly enhanced care efficiency and survival in pediatric abdominal-dominant polytrauma.
- The protocol demonstrated effectiveness even with increasing injury complexity.
- This model offers a replicable framework for optimizing trauma resuscitation when abdominal injury is the primary threat.
Background:
The management of pediatric abdominal-dominant polytrauma, where life-threatening abdominal injuries coexist with other system injuries, lacks a standardized, surgery-led decision-making framework. This study aimed to evaluate the evolution and impact of a structured "Abdomen-First" Multidisciplinary Trauma Protocol (AF-MTP) developed at a high-volume pediatric trauma center.
Methods:
A retrospective cohort study was conducted on children (age <16 years) with severe polytrauma (Injury Severity Score ≥25) and major abdominal injuries (Abbreviated Injury Scale ≥3) admitted between 2014 and 2023. Patients were stratified into three epochs reflecting system evolution: Traditional Care (2014-2016), Protocol Transition (2017-2020), and Integrated Maturation (2021-2023). The AF-MTP featured general surgery-led team activation, a "one-stop" whole-body CT strategy, a defined decision algorithm prioritizing abdominal intervention, objective damage control surgery (DCS) criteria, and a standardized postoperative care bundle. Process metrics and clinical outcomes were compared across epochs.
Results:
Among 120 included patients, injury severity increased significantly across epochs (median ISS: 30 vs. 36 vs. 41, p < 0.001). Concurrently, AF-MTP implementation was associated with marked improvements: time from emergency department arrival to surgical incision decreased by 52 % (130 vs. 62 min, p < 0.001), DCS application increased from 22.5 % to 85.0 % (p < 0.001), and non-therapeutic laparotomy decreased from 17.5 % to 2.5 % (p = 0.036). Despite higher injury burden, abdominal injury-related 30-day mortality decreased by 75 % (20.0 %-5.0 %, p = 0.045 for trend). Multivariable analysis confirmed treatment in the mature protocol epoch (Epoch III) as an independent protective factor against abdominal-related mortality (aOR 0.18, 95 % CI 0.03-0.95).
Conclusion:
The systematic implementation of a general surgery-led, protocol-driven "Abdomen-First" multidisciplinary system significantly improved the efficiency of care and survival for children with severe abdominal-dominant polytrauma, even as injury complexity increased. This model provides a replicable framework for optimizing trauma resuscitation where abdominal injury is the primary physiological threat.
