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Management of children with solid organ injuries after blunt torso trauma

Wisner, David H. MD; Kuppermann, Nathan MD, MPH; Cooper, Arthur MD, MS; Menaker, Jay MD; Ehrlich, Peter MD; Kooistra, Josh DO; Mahajan, Prashant MD, MPH, MBA; Lee, Lois MD, MPH; Cook, Lawrence J. PhD; Yen, Kenneth MD, MS; Lillis, Kathy MD; Holmes, James F. MD, MPH

Journal of Trauma and Acute Care Surgery: August 2015 - Volume 79 - Issue 2 - p 206–214
doi: 10.1097/TA.0000000000000731
Original Articles
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CME

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.

From 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.

Submitted: January 16, 2015, Revised: March 20, 2015, Accepted: March 23, 2015.

Funding source: This work was supported by a grant from the Centers for Disease Control and Injury Prevention 1 R49CE00100201. This project was also supported in part by the Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB), Emergency Medical Services for Children (EMSC) Network Development Demonstration Program under cooperative agreements U03MC00008, U03MC00001, U03MC00003, U03MC00006, U03MC00007, U03MC22684, and U03MC22685. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

Address for reprints: David H. Wisner, MD, 2221 Stockton Blvd, Room 3112, Sacramento, CA 95817; email: david.wisner@ucdmc.ucdavis.edu.

© 2015 Lippincott Williams & Wilkins, Inc.