Managing Pediatric Solid Organ Injury

Abstract

We read the article by Mehall et al with interest. In their article “Prospective Results of a Standardized Algorithm Based on Hemodynamic Status for Managing Pediatric Solid Organ Injury,” the authors present preliminary data that suggest that pediatric patients with blunt spleen and liver injuries can be managed on the basis of physiologic rather than anatomic parameters. We agree completely with this premise and have previously published data on the use of our management guideline for the acute care of children with blunt splenic injuries, stressing this important principle. But we do not agree that the article provides adequate data leading to an algorithm for all solid organ injuries. We disagree that this very preliminary data, based on only 10 patients with AAST grade 3 and 4 injuries and no patients with grade 5 injuries, can be used to present a management algorithm that suggests defining the standard of care for injured children with blunt splenic and hepatic injuries. The authors state that all children with solid organ injuries and initial “hemodynamic stability” can be observed out of the intensive care unit and suggest that subsequent instability based on ongoing blood loss or hollow viscus injury can be reliably identified in the surgery ward environment. We disagree with this statement based on our large experience, which strongly suggests that markedly injured children (AAST grade 3) benefit from observation for 24 hours in a closely monitored pediatric ICU environment. The authors further state that all injured children can immediately return to normal activities without contact sports after discharge. Again, our experience strongly suggests that injured children need more than three days of monitored activities before returning to an unmonitored school environment. Finally, the authors state that all children with solid organ injuries should have followup at 1 month with an ultrasonographic study used “as a safeguard given the short period of observation.” The logic of this statement is unclear at best and differs with a substantial body of evidence from large studies that no imaging study is required if the child is clinically well at subsequent outpatient evaluation. We applaud the authors’ attempt to define the care of injured children with solid organ injuries, but we strongly disagree with the conclusions of this very preliminary study and worry about its presentation as the lead article in this prestigious journal and its inclusion as a selected article in the journal’s continuing medical education program. The authors suggest substantial changes in the postinjury care of children with liver and spleen injuries; we would suggest that these recommendations need further study before adoption as accepted guidelines for care of injured children.