A. De Roulet1, K. Matsushima1, K. Beetham1, K. Inaba1, D. Demetriades1 1University Of Southern California,Division Of Acute Care Surgery,Los Angeles, CA, USA
Introduction: Nonoperative management (NOM) of penetrating solid organ injuries (SOI) has not been well described in the pediatric population. The objective of this study is to characterize the epidemiology, injury patterns, and patient-level factors associated with trial of NOM and failure of NOM.
Methods: This is a retrospective cohort analysis of the National Trauma Data Bank (NTDB) for the period of 2007-2014. The population under study includes patients ≤18 with penetrating injury to the liver, spleen, or kidney. Patients with severe concomitant injuries (abbreviated injury scale [AIS] ≥3 in other body regions) were excluded. Trial of NOM was defined as no operative intervention (exploratory laparotomy or operation involving the liver, spleen, or kidney) within 4 hours of emergency department (ED) arrival. Failed NOM was defined as operative intervention >4 hours after ED arrival. Multivariate logistic regression analysis interrogated factors potentially associated with trial of NOM and failed NOM.
Results: Of the 943,000 pediatric trauma patients included in the NTDB, 7,330 (0.7%) sustained penetrating SOI. After excluding patients with severe concomitant injuries in other body regions, 3,005 patients were analyzed. Median age was 17.0 (IQR 15-18) years; the majority (88.0%) were male. Gunshot wounds (GSW) accounted for 71.7% of injury mechanisms and cutting instruments accounted for the remaining 28.3%. Median injury severity score (ISS) was 9 (IQR 5-13); ED hemodynamics included mean heart rate 97.0 (23.1) and systolic blood pressure 129.8 (24.3). 2,121 (70.6%) patients sustained kidney injury, 1,795 (58.7%) liver injury, and 159 (5.3%) splenic injury. NOM was pursued in 667 (22.5%) patients. Factors significantly associated with trial of NOM included mechanism of injury (GSW OR: 0.51, 95% CI: 0.42-0.63, p<0.001), multiple SOI (OR: 0.74, 95% CI: 0.55-0.99, p=0.04), hollow viscus injury (OR: 0.24, 95% CI: 0.20-0.30, p<0.001), and ED hypotension (OR: 0.35, 95% CI: 0.18-0.70, p=0.003). Failed NOM was identified in 234 (34.6%) of the 677 patients that initially underwent NOM. Factors significantly associated with failed NOM included age 10-13 years (vs. 14-18 years) (OR: 2.99, 95% CI:1.37-6.53, p=0.006), mechanism of injury (GSW OR: 2.15, 95% CI: 1.42-3.24, p<0.001), hollow viscus injury (OR: 6.93, 95% CI: 4.64-10.33, p<0.001), and Grade IV/V SOI (OR: 2.26, 95% CI: 1.13-4.48, p=0.02).
Conclusion: NOM can be performed in a carefully selected group of pediatric patients with penetrating SOI. Future prospective studies are warranted to validate its feasibility.