Hospital-based intervention is rarely needed for children with low-grade blunt abdominal solid organ injury: An analysis of the Trauma Quality Improvement Program registry

Abstract

BACKGROUND:Children with low-grade blunt solid organ injury (SOI) have historically been admitted to an inpatient setting for monitoring, but the evidence supporting the necessity of this practice is lacking. The purpose of this study was to quantify the frequency and timing of intervention for hemorrhage and to describe hospital-based resource utilization for low-grade SOI in the absence of other major injuries (OMIs). METHODS:A cohort of children (aged <16 years) with blunt American Association for the Surgery of Trauma grade 1 or 2 SOI from the American College of Surgeons Trauma Quality Improvement Program registry (2007-2017) was analyzed. Children were excluded if they had confounding factors associated with intervention for hemorrhage (comorbidities, OMIs, or extra-abdominal surgical procedures). Outcomes included frequency and timing of intervention (laparotomy, angiography, or transfusion) for hemorrhage, as well as hospital-based resource utilization. RESULTS:A total of 1,019 children were identified with low-grade blunt SOI and no OMIs. Nine hundred eighty-six (96.8%) of these children were admitted to an inpatient unit. Admitted children with low-grade SOI had a median length-of-stay of 2 days and a 23.9% intensive care unit admission rate. Only 1.7% (n = 17) of patients with low-grade SOI underwent an intervention, with the median time to intervention being the first hospital day. No child who underwent angiography was transfused or had an abnormal initial ED shock index. CONCLUSION:Children with low-grade SOI are routinely admitted to the hospital and often to the intensive care unit but rarely undergo hospital-based intervention. The most common intervention was angiography, with questionable indications in this cohort. These data question the need for inpatient admission for low-grade SOI and suggest that discharge from the emergency room may be safe. Prospective investigation into granular risk factors to identify the rare patient needing hospital-based intervention is needed, as is validation of the safety of ambulatory management.

Analysis of the efficacy and safety of conservative treatment of blunt abdominal trauma in children: retrospective study. Conservative treatment of blunt abdominal trauma in children

“…The first report of conservative management of blunt abdominal trauma came from Toronto, between 1956-1965, of 12 children with splenic trauma treated without surgery. Revision of published series showed that 8-12% of children with blunt abdominal trauma have an internal organ damage and more than 90% of them survive 9 , 12 , 18 - 21 .…”

“…Currently, the global trend is towards the conservative treatment of blunt abdominal trauma, often with prolonged hospitalization and aggressive hemodynamic monitoring of affected children, as well as the intense use of imaging methods to follow-up these children [11][12][13][14][15] .…”

“…As for the ISS there was an apparent correlation with the need for operation, although not statistically significant: none of the three that were classified as mild trauma (ISS from 1-15) needed surgery; however, 14,2% of the 14 classified as moderate trauma (ISS 16-24) and, 40% of the 10 included as severe trauma (ISS equal or above 25) required surgery.The present series showed that the initial conservative treatment of blunt abdominal trauma had an efficacy of 96%.DISCUSSIONThe first report of conservative management of blunt abdominal trauma came from Toronto, between 1956-1965, of 12 children with splenic trauma treated without surgery. Revision of published series showed that 8-12% of children with blunt abdominal trauma have an internal organ damage and more than 90% of them survive9,12,[18][19][20][21] .More flexible ribs, thinner abdominal wall, smaller size of the abdomen and a higher relative volume of the parenchymal organs predispose to the occurrence of multiple injuries in children. However, the thicker and resilient capsule of organs also cause bleeding to cease spontaneously more often, facilitating the non-operative treatment of those injuries7 .A few factors may increase the risk of failure in non-surgical treatment: bicycle trauma, isolated pancreatic injury, more than one solid organ or isolated 5th degree lesions of any solid organ and traumatic brain injury patients with Glasgow less or equal to 8.…”

Análise de eficácia e segurança do tratamento conservador do trauma abdominal contuso em crianças: estudo retrospectivo. Tratamento conservador de trauma abdominal contuso em crianças

“…Até 20 anos atrás, acreditava-se que o tratamento cirúrgico deveria ser instituído o mais precocemente possível a fim de diminuir a morbimortalidade do trauma. Atualmente, a tendência mundial é de tratamento conservador do trauma abdominal contuso, muitas vezes com internação prolongada e monitorização hemodinâmica agressiva das crianças acometidas, bem como uso intenso de métodos de imagem para acompanhamento desses pacientes [11][12][13][14][15] .…”

“…Quanto ao ISS, houve correlação aparente com a necessidade de cirurgia, embora não estatisticamente significativa: nenhum dos três traumas classificados como leves (ISS de 1 a 15) precisou de cirurgia; entretanto, 14,2 % dos 14 traumas classificados como moderados (ISS 16-24) e 40% dos 10 graves (ISS ≥25) necessitaram de cirurgia.A presente série mostrou que o tratamento conservador inicial do trauma abdominal contuso teve eficácia de 96%.DISCUSSÃOO primeiro relato de manejo conservador de trauma abdominal contuso veio de Toronto, entre 1956-1965, de 12 crianças com trauma esplênico tratadas sem cirurgia. A revisão de séries publicadas mostrou que 8-12% das crianças com trauma abdominal contuso apresentam lesão de órgão interno e mais de 90% delas sobrevivem9,12,[18][19][20][21] . Costelas mais flexíveis, parede abdominal mais fina, menor tamanho do abdome e maior volume relativo dos órgãos parenquimatosos predispõem à ocorrência de lesões múltiplas em crianças.…”