D. M. Notrica1,11,12, C. S. Langlais1, M. E. Linnaus1,11, K. A. Lawson2, J. W. Eubanks6, A. C. Alder3, N. M. Garcia2, R. W. Letton5, D. W. Tuggle2, T. Ponsky8, D. Ostlie1, A. Bhatia10, S. D. St. Peter9, C. Leys7, R. T. Maxson4, D. M. Notrica1,11,12 1Phoenix Children’s Hospital,Phoenix, AZ, USA 2Dell Children’s Medical Center,Austin, TX, USA 3Children’s Medical Center Dallas, Part Of Children’s Health,Dallas, TX, USA 4Arkansas Children’s Hospital,Little Rock, AR, USA 5The Children’s Hospital At OU Medical Center,Oklahoma City, OK, USA 6LeBonheur Children’s Hospital,Memphis, TN, USA 7American Family Children’s Hospital,Madison, WI, USA 8Akron Children’s Hospital,Akron, OH, USA 9Children’s Mercy Hospital,Kansas City, MO, USA 10Children’s Healthcare Of Atlanta,Atlanta, GA, USA 11Mayo Clinic,Phoenix, AZ, USA 12University Of Arizona College Of Medicine – Phoenix,Phoenix, AZ, USA
Introduction: Prior guidelines had required bedrest equal to the grade of injury +1 day. The ATOMAC guideline is an evidence-based published guideline for management of pediatric blunt liver and spleen injury (BLSI). The guideline allows for an abbreviated period of bedrest, and provides a detailed algorithm for management. The purpose of this study was to prospectively evaluate the effectiveness of the algorithm to safely guide care and confirm the safety of the abbreviated bedrest included in the algorithm.
Methods: After IRB approval, data was prospectively collected on patients ≤18 years of age admitted with a BLSI identified by Computed Tomography. Data collected included injury details, hospital details, and clinical outcomes. The algorithm was amended during the study to make early recurrent hypotension a failure point. Descriptive statistics are reported. Length of stay (LOS) was compared to a LOS equal to grade + 1 day.
Results: A total of 1008 children were included; 499 liver injuries (50%), 410 spleen injuries (41%), and 99 with both (10%). Median age was 10.3 years [IQR 5.9, 14.2]. At initial presentation, 286 (28%) had recent or ongoing bleeding and were assigned to the bleeding pathway; 242 (24%) were tachycardic and 129 (13%) were hypotensive. Concomitant traumatic brain injury was present in 189 (19%). There were 23 in-hospital deaths (2.5%), 2 due to bleeding. Of the 717 patients clinically assessed and started on the stable pathway, 10 (1.5%) crossed over to the algorithm’s unstable pathway. While minor deviations were common, only 1 patient (0.1%) was at risk of a negative outcome if they followed the original algorithm, resulting in the algorithm amendment. In patients with isolated injuries, median [IQR] lengths of stay by grade of injury (in days) were 0.94 [0.75, 2.17], 1.21 [0.83, 1.89], 1.65 [1.17, 2.08], 2.00 [1.46, 3.29], and 3.23 [2.35, 4.88] for isolated injuries grade 1-5, respectively, totaling 678 days, compared to an expected LOS of 1,211days.
Conclusion:The original ATOMAC guideline was safely applied to 99.9% of 1008 children with BLSI. With the modification for recurrent hypotension in the guideline published last year, the guideline could have safely guided care for 100% of the children with BLSI. Ninety-one (9%) patients reached the algorithm endpoint where continued NOM could no longer be recommended; 22 (24%) of these were still managed nonoperatively at the surgeon’s discretion. Ten patients (1.5%) crossed over from the stable to the unstable pathway. The algorithm saved 533 hospital days over the prior guideline. In the largest prospective study ever conducted of pediatric BLSI, the ATOMAC guideline performed well in guiding non-operative management of patients with BLSI.
