Trauma II: Solid Organ Injury

ATOMIC consortium started around 2010 as a multi-center prospective study, initially with 5 hospitals expanding to 10, to develop evidence-based algorithms for solid organ injury management

Hypotension is a late finding in pediatric hemorrhagic shock; almost half of patients requiring early transfusion are not hypotensive

When a hypovolemic pediatric patient arrives, you know they have bled but often cannot determine if they are still bleeding until you give them blood and observe their response

Shock index pediatric adjusted (SIPAA) cutoffs: ages 4-6 greater than 1.2, ages 7-12 greater than 1.0, ages 13+ greater than 0.9. Shock index identifies patients NOT in shock with high sensitivity but has lower specificity

After 20 mL/kg of crystalloid, blood transfusion should be initiated if non-operative management is desired and good outcomes are the goal

Viscoelastic assays (TEG/ROTEM) for directed component therapy are theoretically superior to ratio-driven massive transfusion, but definitive pediatric evidence requires a randomized controlled trial comparing the approaches

Angioembolization is safe in pediatric blunt solid organ injury. For splenic injury, no embolized patients in the ATOMIC study went on to fail non-operative management

Many patients with contrast extravasation on CT will stop bleeding spontaneously without angioembolization

Many patients with hepatic injury who underwent angioembolization still required laparoscopy or washout for bile complications or hemoperitoneum management, though embolization was helpful in converting active bleeding to manageable complications

Grade 5 solid organ injuries should be admitted to ICU based on injury grade alone, but grade 1-4 injuries can be managed on the floor if hemodynamically stable

In renal injury, bed rest makes no difference in outcomes whether patients are walking or on strict bed rest

Hemodynamically stable patients with no signs of bleeding can be safely discharged after 18 hours of observation, as patients who fail non-operative management fail early

Serial hemoglobin monitoring is not necessary for stable patients; hemoglobin can decrease due to lab error, dilution from IV fluids, or incorrect blood draw technique. Physical examination and vital signs are superior indicators of ongoing bleeding

Half of patients who fail non-operative management do so because they develop peritonitis, not because of continued bleeding

Telephone follow-up is effective for low-grade injuries; many patients with low-grade injuries never showed for in-person clinic appointments, and telephone follow-up prevents additional missed school days

In-person follow-up visits for solid organ injury have limited utility; patients who needed additional imaging or therapy all presented back to the emergency room with symptoms rather than being identified at routine follow-up

Studies performing routine ultrasounds found many pseudoaneurysms, but the number was discordant with actual delayed bleeding or complications, indicating that asymptomatic pseudoaneurysms rarely lead to clinically significant problems (estimated less than 10%, possibly much lower)

Activity restrictions default to APSA recommendation of grade-plus-two-weeks (e.g., grade 4 injury restricted for 6 weeks), though this is based on expert opinion rather than scientific evidence

Children with solid organ injury can return to school but should change classes 5 minutes before other students to avoid hallway contact and should not participate in gym or physical education

Early recurrent hypotension (patient responds to initial resuscitation, becomes stable, then becomes unstable again before reaching ICU) represents failure of non-operative management and requires operation or angioembolization