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 (original) (raw)

. Author manuscript; available in PMC: 2022 Oct 1.

Published in final edited form as: J Trauma Acute Care Surg. 2021 Oct 1;91(4):590–598. doi: 10.1097/TA.0000000000003206

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.

Methods:

A cohort of children (age < 16y) with blunt AAST 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, other major injuries, 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:

1019 children were identified with low-grade blunt SOI and no other major injuries. 986 (96.8%) of these children were admitted to an inpatient unit. Admitted children with low-grade SOI had a median length-of-stay of two days and a 23.9% ICU 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 that underwent angiography was transfused or had an abnormal initial ED shock index.

Conclusions:

Children with low-grade SOI are routinely admitted to the hospital and often to the ICU, 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.

Level of Evidence:

III

Study Type:

Prognostic and Epidemiological

Keywords: Pediatric injury, trauma, blunt abdominal trauma, solid organ injury

Background:

Abdominal injuries are identified in 10–15%1 of pediatric trauma patients and are associated with a 5% case-fatality rate, emphasizing the need to identify patients at risk for death while not over-treating the portion of the population at low-risk for mortality. Abdominal injuries in children most commonly result from a blunt mechanism and commonly involve injury to a solid organ (liver, spleen, or kidney).2, 3 Non-operative management (NOM) of blunt solid organ injury (SOI) was first established over 40-years ago and has since become the standard of care. 4–6 In 2000, the American Pediatric Surgical Association (APSA) published the first practice management guideline (PMG) for NOM of children with SOI,7 which helped standardize the previously highly variable approaches to NOM in pediatric SOI.8 The principles of NOM developed for pediatric SOI quickly spread to the adult trauma community, and by 2003 The Eastern Association for the Surgery of Trauma published the first PMG for NOM of adults with blunt SOI.9, 10 As the understanding of the natural history of children with SOI evolved over the subsequent two decades, operative intervention became exceedingly less common.11

Updated PMGs now emphasize abbreviated bedrest protocols, earlier mobilization, earlier discharge, and management primarily guided by hemodynamics.5, 12–16 Liberalized PMGs have been proven to be safe and effective, and have been associated with a significant reduction in the utilization of healthcare resources and overall cost.17 Patients with SOI and no peritonitis who are admitted without clinical signs of bleeding can safely be managed with abbreviated bedrest and discharged within 24 hours (regardless of grade of injury) if they have minimal abdominal pain, stable vital signs and hematocrit, and do not have an abdominal wall contusion from a seatbelt or handlebar injury.5 While hemodynamic- and symptom-directed management protocols have been shown to be safe and decrease hospital resource utilization for all grades of SOI, the specific subset of low-grade SOI likely has a far lower rate of requiring hospital-based intervention than higher grades of injury. Small observational cohort studies have demonstrated that the need for hospital-based intervention for patients with low-grade SOI in the absence of hollow viscus injury (HVI) is rare (0–4%), but large-scale studies examining intervention rates in this population are lacking.4, 18, 19 Further evidence supporting the low-rate of intervention for low-grade SOI is needed, as a large portion of children with these injuries continue to be admitted to the intensive care unit (ICU) and remain hospitalized for durations consistent with APSA’s original ‘injury grade + 1’ in days guideline.20

The goal of this large retrospective observational cohort study was to use a national database to assess the rate of intervention for low-grade blunt abdominal SOIs in children without other major injuries (OMI). We hypothesized that the need for hospital-based intervention for hemorrhage would be low. The primary objective of this study was to quantify the frequency and timing of hospital-based intervention for hemorrhage. The secondary objective of the study was to describe national practice patterns driving the utilization of hospital resources for nonoperatively managed children with low-grade blunt abdominal SOI.

Methods:

Cohort Selection

We examined a 10-year retrospective cohort of pediatric trauma patients (< 16 years) with abdominal SOI after blunt trauma and no OMIs. ‘Trivial’ extra-abdominal injuries were intentionally not excluded to maximize generalizability of our analysis. Our analysis cohort was derived from the American College of Surgeons Trauma Quality Improvement Program (TQIP) Registry (2007–2017) (Figure 1). The TQIP Registry, previously known as the National Trauma Data Bank (NTDB), includes all patients treated for major traumatic injuries at United States trauma centers who meet inclusion criteria defined by the National Trauma Data Standard (NTDS).21 We included patients with one or more abdominal SOIs (liver, spleen, kidney) as defined by Abbreviated Injury Scale (AIS) pre-dot codes. Patients with a mechanism of injury related to penetrating trauma or burns were excluded to ensure homogeneity of the cohort. Patients were excluded from the analysis if the grade of SOI was not specified (AIS severity ‘Not Further Specified’), or if the full clinical course could not be appreciated, rendering procedural data unavailable, due to transfer to or from another facility or discharge against medical advice. Patients with risk of hemorrhage or need for abdominal operative intervention independent of abdominal SOI were excluded to minimize potential confounding of the indication for intervention for hemorrhage. Patients were considered at independent risk of hemorrhage for the following:

1. pre-existing diagnosis of a bleeding disorder or active use of anticoagulation at the time of injury, as defined by National Trauma Data Standards pre-existing comorbidity codes, or
2. presence of OMI to the brain, thorax, spine, extremities, pancreas, or hollow viscera that were defined a priori as conferring independent risk for transfusion or abdominal operation unrelated to hemorrhage control (pre-specified AIS injury codes are shown in SDC Appendix 3), or
3. requirement for any major procedures (craniotomy, neck exploration, thoracic procedures, extremity vascular procedures, major orthopedic procedures, or spinal procedures, based on International Classification of Diseases and Related Health Problems (ICD) procedure codes) that were defined a priori to be associated with intra-operative blood loss or as indicative of the presence of significant confounding injuries at risk for hemorrhage (pre-specified ICD procedure codes are shown in SDC Appendix 4).

Figure 1:

STROBE diagram demonstrating cohort selection for pediatric trauma patients with blunt solid organ injury (SOI) without other clinical characteristics independently associated with hospital-based intervention for hemorrhage.

Injury classification was based upon AIS 98 values for 2007–2016 and based upon AIS 05 values for 2017. The 9th revision of ICD (ICD-9) was used for years 2007–2014, either ICD-9 or the 10th revision of ICD (ICD-10) was used for years 2015–2016, and ICD-10 was used for the year 2017.

Classification of Abdominal Solid Organ Injury Grade

Type of SOI and severity of injury were identified using AIS pre- and post-dot codes, respectively. Grade 1 and 2 injuries were grouped together as ‘low-grade’, as they have the same AIS post-dot severity scores and could not be separated (SDC Appendix 1). For sensitivity analyses incorporating high-grade (grade 3–5) injuries, the grades of SOI severity were based on the pre-existing American Association for the Surgery of Trauma (AAST) grading system and were determined using AIS post-dot severity codes. Patients with multiple SOIs were categorized based on the organ injury with the highest severity grade. Patients with a single SOI and patients with multiple SOIs were grouped separately. The low-grade SOI cohort was used to analyze the primary and secondary outcome metrics of the study. A secondary sensitivity analysis of the frequency of hospital-based interventions for hemorrhage was performed on the high-grade (grades 3–5) SOI cohort to assess for reporting bias and validate the reliability of the dataset for capturing the study outcomes.

Patient, Injury, and Treating Center Characteristics

Demographic and clinical variables of interest were defined a priori. They included: age, gender, race, ethnicity, mechanism of injury, trauma center type and verification level, AIS post-dot severity scores by body region (head, face, neck, thorax, upper extremity, lower extremity, external), initial total Glasgow Coma Scale (GCS), initial abnormal pediatric adjusted shock index (SIPA) for children ≥ four years of age, initial age-adjusted hypotension, and initial age-adjusted tachycardia or bradycardia. Age was categorized based on the pediatric age strata defined by the Centers for Disease Control and Prevention.22 Race was classified as White, Black or African American, Asian, American Indian, Native Hawaiian or Other Pacific Islander, or Other. Ethnicity was categorized as Hispanic or Latino, or Not Hispanic or Latino. For patients ≥ four years old, SIPA was calculated using the initial emergency department (ED) heart rate and systolic blood pressure and compared to age-adjusted normative values. Patients were determined to have an abnormal SIPA if their calculated value was greater than their age-adjusted normal range.23 Initial ED systolic blood pressure and heart rate were adjusted for age using Pediatric Advanced Life Support normative threshold values to define dichotomous variables to indicate hypotension, tachycardia, and bradycardia.24 Injury mechanism was determined using ICD external cause codes and were treated as mutually exclusive. Injury mechanisms were grouped according to national standards25 and were categorized as Fall; Motor Vehicle Trauma (MVT) Occupant and Others; Pedestrian Pedal; MVT Motorcyclist; Struck by/Against; and Other.

Trauma centers were classified as an adult trauma center (ATC), pediatric trauma center (PTC), or mixed trauma center (MTC) based primarily on the American College of Surgeons (ACS) verification level. State designation was used only if ACS verification level was not recorded. We defined an ATC as a trauma center with any level of adult ACS or state designation that did not have a pediatric level 1 or 2 ACS or state designation. We defined a freestanding PTC as a trauma center with a pediatric level 1 or 2 ACS or state designation that did not have an adult ACS or state designation of any level. We defined an MTC as a trauma center with an adult ACS or state verification of any level, and a level 1 or 2 pediatric ACS or state designation. Trauma centers were categorized by level of verification based on the highest level of ACS verification or state designation.

Outcome Variables

The primary study outcome was acute hospital-based intervention for hemorrhage. Children were considered to have undergone an intervention for hemorrhage if they were transfused with any blood component or product, underwent angiography with or without embolization, or underwent an abdominal operation. Interventions were identified by individual ICD procedure codes (SDC Appendix 2). Interventions of different categories were not considered mutually exclusive. Only the first intervention from each category was reported. If a patient underwent ≥ 2 interventions from different categories, the first intervention from each category was reported. The TQIP variable ‘time to procedure’, reported as days or hours to procedure, was used to determine the time to intervention. If ‘time to procedure’ was reported in hours, it was converted to days. Interventions that occurred within 24-hours of presentation were considered to occur on hospital day 1 and all values were rounded up to the nearest whole number as is practice when reporting hospital days.

The secondary study outcome was hospital-based resource utilization, as indicated by hospital admission, ICU admission, hospital length of stay (LOS), and ICU LOS. A recorded hospital LOS > 0 indicated admission to the hospital, and an ICU LOS > 0 indicated admission to the ICU.

Statistical Analyses

A descriptive analysis of the study population was performed. Continuous variables were reported as the median with IQR. Categorical variables were reported as frequency and percentage. All statistical analysis was completed in SAS version 9.4.

Results:

Overall, 18,680 patients with blunt abdominal SOI were identified, and 15,998 patients were subsequently excluded. A total of 2,682 patients with SOI without OMI were included in the study cohort, with 1019 (38%) of these patients having low-grade injuries (Figure 1). The most common low-grade SOI was the liver, and multi-organ SOI was uncommon overall (Table 1a). Low-grade SOIs occurred more commonly in younger patients (Table 1a) and as a result of motor vehicle collision (Table 1b). Extra-abdominal injuries were seen in > 20% of low-grade SOI patients, all of which had only minor or moderate AIS post-dot severity scores (SDC Table 1).

Table 1a:

Characteristics of pediatric (<16 years) trauma patients with blunt SOI, comparing patients with low-grade SOI to patients with high-grade SOI

Table 1b:

Injury mechanism and treating center characteristics of pediatric (<16 years) trauma patients with blunt SOI, comparing patients with low-grade SOI to patients with high-grade SOI

There were no deaths among patients with low-grade SOI. Inpatient admission was used for 96.8% of patients with low-grade injuries of which 23.9% were admitted to the ICU. Only 17 patients (1.7%) with low-grade SOI underwent an intervention for hemorrhage. Angioembolization was the most common intervention, with a median time to intervention of hospital day 1 (Table 2). None of the patients who underwent angioembolization had an abnormal initial ED SIPA or received a blood transfusion (Table 3). The only patient with low-grade injury that underwent intervention with an abnormal initial ED SIPA required suture repair of a small bowel injury (as defined by a documented procedure code despite lack of an associated AIS code for intestinal injury) at the time of abdominal operation (Table 3). All interventions for hemorrhage except for one abdominal operation occurred in patients admitted to ATCs or MTCs (SDC Table 2). Patients with low-grade kidney injury were less likely to be admitted to the ICU than patients with low-grade liver, spleen, or multi-organ SOIs. The majority of interventions for hemorrhage (14/17) in the low-grade SOI cohort occurred in patients with isolated spleen and liver injuries (Table 2). All patients with low-grade SOI that underwent intervention were ultimately discharged to home.

Table 2:

Outcomes and hospital resource utilization for low-grade (grade 1–2) injuries by organ injured

Table 3:

Descriptive analysis of patients with low-grade SOI that underwent hospital-based intervention for hemorrhage

The rate of ICU admission in patients with low-grade SOI was higher at ATCs and MTCs than PTCs (SDC Table 2). The overall hospital admission rate of patients with low-grade SOI was equivalent between trauma center types.

Our sensitivity analysis to assess for reporting bias included 1,663 patients with SOIs of grade 3 severity or higher, without OMIs (SDC Table 1). In the high-grade SOI group, there were 11 deaths, 3 of which occurred in the ED, and 8 of which occurred after admission (SDC Table 3). High-grade SOI patients were demonstrated to have the expected higher rate of intervention for hemorrhage and longer median hospital LOS and ICU LOS (SDC Table 3).

Discussion:

This retrospective study examining outcomes and hospital resource utilization in pediatric blunt trauma patients with low-grade SOI without OMI confirmed that children with low-grade SOI rarely require hospital-based intervention for hemorrhage. Despite this low rate of needing intervention, over 96% of patients with low-grade SOI were admitted to the hospital with a median hospital LOS of 2 days. To our knowledge, this is the largest cohort of children with blunt SOI without OMI analyzed to date and is the first large national database study seeking specifically to evaluate the need and timing of intervention in patients with low-grade SOI. Our observed intervention rate of 1.7% in children with low-grade SOI is consistent with the results of published studies (0–4% rate of intervention). Previously, the body of literature supporting the low rate of intervention in children with low-grade SOI was limited to evidence based on small subset analyses of observational research cohorts.4, 19 Our findings, based on US trauma center registry data, add to the generalizability of the otherwise narrow existing body of evidence for the low rate of intervention in low-grade SOI.

Closer investigation of the patients with low-grade SOI who did undergo intervention suggests that our reported 1.7% intervention rate likely overestimates necessary intervention for hemorrhage. The majority of interventions occurred in patients with only one low-grade SOI indicating the presence of more than one SOI did not impact the need for intervention. Of all interventions observed, angiography with embolization was the most common in patients with low-grade SOI. All angiographic procedures were completed on the first hospital day despite no patient presenting with abnormal ED SIPA or receiving a blood transfusion. No angiographic procedures were performed at a freestanding PTC, with all patients undergoing angiography while at MTCs or ATCs. The necessity of angiographic interventions in this cohort can be seen as particularly uncertain as previous studies have reported that the rate of angiography in children with SOI is almost 9 times higher at ATCs or MTCs when compared to PTCs, with no difference in outcomes.26 Furthermore, many centers have treated arterial contrast extravasation on CT (‘blush’) as an indication for angioembolization regardless of hemodynamics. We were unable to capture CT findings such as arterial contrast extravasation in the TQIP dataset, but would argue that embolization for ‘blush’ in the absence of hemodynamic changes or clinical evidence of ongoing bleeding, has been demonstrated to be unnecessary as the significant majority of children with blush on initial CT imaging do not ultimately require an intervention for hemorrhage.5, 27

Only four patients underwent an abdominal operative intervention. The only patient with an abnormal ED SIPA was admitted directly to the operating room where procedure codes indicate she underwent repair of a small bowel laceration. This patient was not excluded from our analysis cohort as there was no documented AIS injury code reflecting intestinal injury and the procedure code for repair of the small bowel was noted only on post hoc exploratory manual review of the records of patients that underwent intervention. Unlike the three other patients that underwent an abdominal operation, this patient did not have a documented procedure code to indicate she required operative control of hemorrhage or a surgical intervention to address her low-grade liver SOI. The small bowel injury, as opposed to the low-grade liver injury, was likely the primary cause of the patient’s abnormal SIPA and, ultimately, the need for operative intervention. Only one patient underwent operative intervention at a freestanding PTC, with the intervention defined as ‘excision of right lobe of liver, percutaneous approach, diagnostic’ by ICD-10. Furthermore, the intervention occurred on hospital day 2, in a patient presenting after nonaccidental trauma, who did not receive a blood transfusion. It is unclear if this reflects a delayed presentation of the patient’s injury, but the conflicting clinical descriptors and atypical procedure obscure what actually happened to this patient. Both patients that underwent splenectomy were at adult trauma centers.

All patients who received a blood transfusion without operative intervention or angiography were admitted to the ICU. Three patients were transfused on hospital day 2 or 3, all had multiple injuries (which may have been more severe than how they were coded) and required ICU admission for 3 or more days. Conversely, one patient was transfused on hospital day 1 but did not have an abnormal ED SIPA and remained in the ICU for only 1 day. The clinical indications for intervention are questionable in the majority of the low-grade SOI patients due to the lack of other clinical variables consistent with hemorrhage. Taking into consideration that several of the interventions may have been clinically unnecessary, the true rate of hospital-based intervention for hemorrhage in patients with low-grade SOI is likely even less than the 1.7% we have reported.

The literature is in agreement that overall children with blunt SOI infrequently require interventions for hemorrhage and that children with high-grade SOI require intervention at a much higher frequency.4, 18, 19, 28 The growing body of evidence supporting the low failure rate of NOM in patients with SOI has helped catalyze the modernization of historically conservative NOM practices. Liberalized PMGs emphasizing abbreviated bedrest protocols with early mobilization, and even hospital discharge in less than 24-hours, have been demonstrated to be safe without any associated increase in the rate of acute or delayed bleeding complications.5, 12, 29–31 Furthermore, the implementation of abbreviated PMGs have been associated with significant reduction in the utilization of hospital resources, with the resulting annual savings estimated to be as high as 19 million dollars.11

The clear benefits of adopting modernized NOM practices and the low rate of hospital-based interventions in children with low-grade SOI has caused several groups to question the necessity of inpatient observation in this cohort of patients.19, 32 Furthermore, the low rate of intervention has caused the necessity of transfer to a PTC to come under scrutiny and the elimination of unnecessary transfers has been identified as an additional opportunity for significant cost savings.33 However, national practice patterns have historically been reported to be slow to adopt new liberal practices despite their safety having been established.4, 11, 34–36 Abbreviated bedrest and accelerated discharge protocols are appropriate for asymptomatic patients, but in practice, the need for antiemetics and intravenous pain medications may be unappreciated important drivers behind inpatient admission and longer hospital length of stay.32 The findings of this study support the feasibility of ambulatory management and elimination of unnecessary transfers to PTCs in a select cohort of children with low-grade SOI without OMI. However, conventional NOM practices are unlikely to change until the risk profile for events related to hemorrhage and reliable clinical indicators for inpatient admission have been defined.

We would urge caution interpreting these results in the context of hollow viscus injury (HVI). As the primary goal of this paper was to assess the need for intervention for hemorrhage related to blunt SOI, we a priori excluded patients with HVI, as this would mandate laparotomy and confound our ‘surgery for hemorrhage’ findings. It is possible that HVI was diagnosed later in a child’s hospitalization as a result of admission for serial abdominal exams in the context of a Grade 1 or 2 SOI. As the risk of missed intestinal injury in the low-grade SOI population was not characterized in our cohort, we recommend maintaining a high index of suspicion for occult HVI in patient with high-risk signs or symptoms. The presence of peritonitis on exam should prompt consideration for surgical exploration. Admission for serial exams should be considered regardless of SOI grade for any child with signs of abdominal wall trauma including a seatbelt sign or bruising, subjective symptoms such as nausea or pain, secondary signs of intestinal injury on CT scan such as free fluid or bowel wall thickening, or a high-risk mechanism such as a handlebar injury.37

Our results should be considered in light of several key limitations. The retrospective nature of the data introduces bias secondary to unmeasured confounding. The TQIP dataset does not include information on pain medication, antiemetic medication, or need for admission related to social factors (parent or family member injured in the same accident, long distance from home, etc.) which may be important drivers of need for inpatient admission and length of stay. Our assessment of hemodynamic stability is limited to the first set of vital signs and we cannot measure the delayed development of hypotension or tachycardia that may have prompted some of the observed interventions, nor can we objectively quantify bleeding due to the lack of laboratory values in the dataset. Our observed rate of intervention may be suppressed secondary to reporting bias, but we did perform a sensitivity analysis on the cohort of patients with high-grade SOI which demonstrated capture of the study’s main outcome variables in the dataset at the expected higher frequency. Similarly, our rate of discharge from the ED may also be subject to reporting bias, as TQIP does not reliably capture patients discharged from the emergency department due to significant variability in how individual trauma centers identify patients for registry inclusion. As a result, we may have underestimated the number of patients with SOI discharged from the emergency department.

The TQIP dataset does not capture readmissions and therefore we were unable to quantify readmissions or the development of delayed complications, such as pseudoaneurysm or hemorrhage. However, the need to capture readmissions, particularly in children with low-grade SOI, may ultimately be unwarranted as recent studies have demonstrated the low risk of complications and delayed bleeding in children with SOI.38, 39 The most important clinically relevant limitation was our inability to capture ‘bedrest’ as a treatment for SOI. We cannot, therefore, investigate the impact of bedrest, or inpatient observation without activity restrictions, on the low rate of intervention in our study, and ultimately cannot make definitive conclusions about the safety of ambulatory management. We would argue, however, that bedrest (if an effective therapy) can be prescribed at home.

The results of this study indicate that the majority of children with low-grade SOI and no OMI will not require hospital-based intervention. However, it remains crucial to recognize that a certain subset of children do likely mandate admission, but a more granular dataset is needed to better define factors that are associated with intervention or other indicators for inpatient admission. Surgical consultation for patients with abdominal trauma should remain the gold standard, especially given considerations for risk factors for occult HVI. We suspect that further liberalized management practices, with reduced transfers to PTCs and outpatient ambulatory management for the majority of these patients, are likely safe. Standardized pathways for low-grade SOI management outside of PTCs in conjunction with a local general surgeon would need to be developed and disseminated to prevent both 1) over-treatment with unnecessary procedures, and 2) under-recognition of patients with associated HVI risk that should be observed at a PTC. Further prospective investigation of the safety of ambulatory management in patients with low-grade SOI without OMI is necessary to identify predictors for needing hospital-based intervention as we cannot fully support these claims with our analysis. After appropriate prospective risk factor identification, it is likely that a majority of these patients could be safely managed in an ambulatory setting as long as the families are reliable and have access to a hospital with a general surgeon.

Supplementary Material

Supplemental Digital Content Tables and Appendixes

SDC Table 1: AIS score of associated injuries by body region for pediatric (< 16 years) patients with SOI without major injuries independently associated with hospital-based intervention for hemorrhage

SDC Table 2: Outcomes and hospital resource utilization for low-grade (grade 1-2) solid organ injuries by trauma center type

SDC Table 3: Outcomes and hospital resource utilization for high-grade (grade 3-5) SOI by grade of injury

SDC Appendix 1: List of diagnostic coding used to determine type and severity of solid organ injury

SDC Appendix 2: List of ICD procedure codes used to identify hospital-based interventions for hemorrhage

SDC Appendix 3: List of diagnostic coding used to identify injuries independently associated with hemorrhage or need for operative intervention for intra-abdominal pathology

Acknowledgments

Funding:

This project was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through UCSF-CTSI Grant Number #UL1 TR001872.

Footnotes

Conflict of Interest Statement:

None of the authors have any personal or financial conflicts of interest to disclose.

References:

• 1.National Trauma Data Bank Annual Report and Pediatric Annual Report 2016. Chicago, IL; 2016. https://www.facs.org/~/media/files/quality%20programs/trauma/ntdb/ntdb%20annual%20report%202016.ashx. Last accessed March 13, 2021. [Google Scholar]
• 2.Gaines BA. Intra-abdominal solid organ injury in children: diagnosis and treatment. J Trauma Acute Care Surg. 2009;67(2 Suppl):135. [DOI] [PubMed] [Google Scholar]
• 3.Holmes JF, Sokolove PE, Brant WE, Palchak MJ, Vance CW, Owings JT, Kuppermann N. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med. 2002;39(5):500–9. [DOI] [PubMed] [Google Scholar]
• 4.Wisner DH, Kuppermann N, Cooper A, Menaker J, Ehrlich P, Kooistra J, Mahajan P, Lee L, Cook LJ, Yen K, et al. Management of children with solid organ injuries after blunt torso trauma. J Trauma Acute Care Surg. 2015;79(2):206–14. [DOI] [PubMed] [Google Scholar]
• 5.Notrica DM, Eubanks JW, Tuggle DW, Maxson RT, Letton RW, Garcia NM, Alder AC, Lawson KA, St Peter SD, Megison S, et al. Nonoperative management of blunt liver and spleen injury in children: Evaluation of the ATOMAC guideline using GRADE. J Trauma Acute Care Surg. 2015;79(4):683–93. [DOI] [PubMed] [Google Scholar]
• 6.Aronson DZ, Scherz AW, Einhorn AH, Becker JM, Schneider KM. Nonoperative management of splenic trauma in children: a report of six consecutive cases. Pediatrics. 1977;60(4):482–5. [PubMed] [Google Scholar]
• 7.Stylianos S Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. The APSA Trauma Committee. J Pediatr Surg. 2000;35(2):164–9. [DOI] [PubMed] [Google Scholar]
• 8.Stylianos S Compliance with evidence-based guidelines in children with isolated spleen or liver injury: a prospective study. J Pediatr Surg. 2002;37(3):453–6. [DOI] [PubMed] [Google Scholar]
• 9.Stassen NA, Bhullar I, Cheng JD, Crandall M, Friese R, Guillamondegui O, Jawa R, Maung A, Rohs TJ Jr., Sangosanya A, et al. Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S288–93. [DOI] [PubMed] [Google Scholar]
• 10.Stassen NA, Bhullar I, Cheng JD, Crandall ML, Friese RS, Guillamondegui OD, Jawa RS, Maung AA, Rohs TJ Jr., Sangosanya A, et al. Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S294–300. [DOI] [PubMed] [Google Scholar]
• 11.Dodgion CM, Gosain A, Rogers A, St Peter SD, Nichol PF, Ostlie DJ. National trends in pediatric blunt spleen and liver injury management and potential benefits of an abbreviated bed rest protocol. J Pediatr Surg. 2014;49(6):1004–8. [DOI] [PubMed] [Google Scholar]
• 12.St Peter SD, Aguayo P, Juang D, Sharp SW, Snyder CL, Holcomb GW 3rd, Ostlie DJ. Follow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Pediatr Surg. 2013;48(12):2437–41. [DOI] [PubMed] [Google Scholar]
• 13.Acker SN, Hill LRS, Bensard DD, Moulton S, Partrick DA. The benefits of limiting scheduled blood draws in children with a blunt liver or spleen injury. J Pediatr Surg. 2019;55(7):1219–1223. [DOI] [PubMed] [Google Scholar]
• 14.Mehall JR, Ennis JS, Saltzman DA, Chandler JC, Grewal H, Wagner CW, Jackson RJ, Smith SD. Prospective results of a standardized algorithm based on hemodynamic status for managing pediatric solid organ injury. J Am Coll Surg. 2001;193(4):347–53. [DOI] [PubMed] [Google Scholar]
• 15.McVay MR, Kokoska ER, Jackson RJ, Smith SD. Throwing out the “grade” book: management of isolated spleen and liver injury based on hemodynamic status. J Pediatr Surg. 2008;43(6):1072–6. [DOI] [PubMed] [Google Scholar]
• 16.Graziano KD, Juang D, Notrica D, Grandsoult VL, Acosta J, Sharp SW, Murphy JP, St Peter SD. Prospective observational study with an abbreviated protocol in the management of blunt renal injury in children. J Pediatr Surg. 2014;49(1):198–200. [DOI] [PubMed] [Google Scholar]
• 17.Katz MG, Kastenberg ZJ, Taylor MA, Bolinger CD, Scaife ER, Fenton SJ, Russell KW. Reduction of resource utilization in children with blunt solid organ injury. J Pediatr Surg. 2019;54(2):354–7. [DOI] [PubMed] [Google Scholar]
• 18.Arbra CA, Vogel AM, Zhang J, Mauldin PD, Huang EY, Savoie KB, Santore MT, Tsao K, Ostovar-Kermani TG, Falcone RA, et al. Acute procedural interventions after pediatric blunt abdominal trauma: A prospective multicenter evaluation. J Trauma Acute Care Surg. 2017;83(4):597–602. [DOI] [PubMed] [Google Scholar]
• 19.Plumblee L, Williams R, Vane D, Zhang J, Jensen A, Naik-Mathuria B, Evans L, Streck CJ. Isolated Low-Grade Solid Organ Injuries in Children Following Blunt Abdominal Trauma: Is It Time to Consider Discharge from the Emergency Department? J Trauma Acute Care Surg. 2020;89(5):887–893. [DOI] [PubMed] [Google Scholar]
• 20.Gates RL, Price M, Cameron DB, Somme S, Ricca R, Oyetunji TA, Guner YS, Gosain A, Baird R, Lal DR, et al. Non-operative management of solid organ injuries in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee systematic review. J Pediatr Surg. 2019;54(8):1519–1526.. [DOI] [PubMed] [Google Scholar]
• 21.The American College of Surgeons Committee on Trauma. National Trauma Data Standard Data Dictionary 2017 Admissions. 2017. https://www.facs.org/-/media/files/quality-programs/trauma/ntdb/ntds/data-dictionaries/ntdsdatadictionary2017admissions.ashx. Last accessed March 13, 2021.
• 22.Borse N, Sleet DA. CDC Childhood Injury Report: Patterns of Unintentional Injuries Among 0- to 19-Year Olds in the United States, 2000–2006. Fam Community Health. 2009;32(2):189. [DOI] [PubMed] [Google Scholar]
• 23.Acker SN, Ross JT, Partrick DA, Tong S, Bensard DD. Pediatric specific shock index accurately identifies severely injured children. J Pediatr Surg. 2015;50(2):331–4. [DOI] [PubMed] [Google Scholar]
• 24.de Caen AR, Berg MD, Chameides L, Gooden CK, Hickey RW, Scott HF, Sutton RM, Tijssen JA, Topjian A, van der Jagt ÉW, et al. Part 12: Pediatric Advanced Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(18 Suppl 2):S526–42. [DOI] [PMC free article] [PubMed] [Google Scholar]
• 25.Pediatric TQIP Benchmark Report Cycle Reference Report. American College of Surgeons. Chicago, IL; 2019. [Google Scholar]
• 26.Swendiman RA, Goldshore MA, Fenton SJ, Nance ML. Defining the role of angioembolization in pediatric isolated blunt solid organ injury. J Pediatr Surg. 2020;55(4):688–92. [DOI] [PubMed] [Google Scholar]
• 27.St Peter SD, Keckler SJ, Spilde TL, Holcomb GW, Ostlie DJ. Justification for an abbreviated protocol in the management of blunt spleen and liver injury in children. J Pediatr Surg. 2008;43(1):191–4. [DOI] [PubMed] [Google Scholar]
• 28.Acker SN, Petrun B, Partrick DA, Roosevelt GE, Bensard DD. Lack of utility of repeat monitoring of hemoglobin and hematocrit following blunt solid organ injury in children. J Trauma Acute Care Surg. 2015;79(6):991–4. [DOI] [PubMed] [Google Scholar]
• 29.London JA, Parry L, Galante J, Battistella F. Safety of early mobilization of patients with blunt solid organ injuries. Arch Surg. 2008;143(10):972–6. [DOI] [PubMed] [Google Scholar]
• 30.Daodu O, Brindle M, Alvarez-Allende CR, Lockyer L, Weber B, Lopushinsky SR. Outcomes of an accelerated care pathway for pediatric blunt solid organ injuries in a public healthcare system. J Pediatr Surg. 2017;52(5):826–31. [DOI] [PubMed] [Google Scholar]
• 31.Cunningham AJ, Lofberg KM, Krishnaswami S, Butler MW, Azarow KS, Hamilton NA, Fialkowski EA, Bilyeu P, Ohm E, Burns EC, et al. Minimizing variance in Care of Pediatric Blunt Solid Organ Injury through Utilization of a hemodynamic-driven protocol: a multi-institution study. J Pediatr Surg. 2017;52(12):2026–30. [DOI] [PubMed] [Google Scholar]
• 32.Walsh J, Schmit P, Yanchar N. Should grade of solid organ injury determine need for hospitalization in children? J Trauma Acute Care Surg. 2017;82(1):109–13. [DOI] [PubMed] [Google Scholar]
• 33.Tessler RA, Graves JM, Vavilala MS, Goldin A, Rivara FP. Hospital factors associated with higher costs in pediatric blunt abdominal trauma: A national study. J Pediatr Surg. 2019; 54(8):1621–1627. [DOI] [PMC free article] [PubMed] [Google Scholar]
• 34.Bowman SM, Bulger E, Sharar SR, Maham SA, Smith SD. Variability in pediatric splenic injury care: results of a national survey of general surgeons. Arch Surg. 2010;145(11):1048–53. [DOI] [PubMed] [Google Scholar]
• 35.Sokolove PE, Kuppermann N, Vance CW, Lee MO, Morris BA, Holmes JF. Variation in specialists’ reported hospitalization practices of children sustaining blunt abdominal trauma. West J Emerg Med. 2013;14(1):37–46. [DOI] [PMC free article] [PubMed] [Google Scholar]
• 36.Yung N, Solomon D, Schuster K, Christison-Lagay E. Closing the Gap in Care of Blunt Solid Organ Injury in Children. J Trauma Acute Care Surg. 2020;November;89(5):894–899. [DOI] [PubMed] [Google Scholar]
• 37.Awasthi S, Mao A, Wooton-Gorges SL, Wisner DH, Kuppermann N, Holmes JF. Is hospital admission and observation required after a normal abdominal computed tomography scan in children with blunt abdominal trauma? Acad Emerg Med. 2008;15(10):895–9. [DOI] [PubMed] [Google Scholar]
• 38.Notrica DM, Sussman BL, Garcia NM, Leys CM, Maxson RT, Bhatia A, Letton RW, Ponsky T, Lawson KA, Eubanks JW 3rd, et al. Reimaging in pediatric blunt spleen and liver injury. J Pediatr Surg. 2019;54(2):340–4. [DOI] [PubMed] [Google Scholar]
• 39.Notrica DM, Sayrs LW, Krishna N, Ostlie DJ, Letton RW, Alder AC, St Peter SD, Ponsky TA, Eubanks JW 3rd, Tuggle DW, et al. Adherence to APSA activity restriction guidelines and 60-day clinical outcomes for pediatric blunt liver and splenic injuries (BLSI). J Pediatr Surg. 2019;54(2):335–9. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplemental Digital Content Tables and Appendixes

SDC Table 1: AIS score of associated injuries by body region for pediatric (< 16 years) patients with SOI without major injuries independently associated with hospital-based intervention for hemorrhage

SDC Table 2: Outcomes and hospital resource utilization for low-grade (grade 1-2) solid organ injuries by trauma center type

SDC Table 3: Outcomes and hospital resource utilization for high-grade (grade 3-5) SOI by grade of injury

SDC Appendix 1: List of diagnostic coding used to determine type and severity of solid organ injury

SDC Appendix 2: List of ICD procedure codes used to identify hospital-based interventions for hemorrhage

SDC Appendix 3: List of diagnostic coding used to identify injuries independently associated with hemorrhage or need for operative intervention for intra-abdominal pathology