Emergency Department, Inpatient, and ICU Clinical Pathway for Children with Blunt Abdominal Solid Organ Injury

Solid Organ Injury Suspected

Patient Cohort

This pathway is intended to treat children who present to the Emergency Department with suspected solid organ injuries to the liver, spleen, or kidney.

Exclusion Criteria

  • Major multiple trauma when the solid organ injury does not direct the patient’s plan of care
  • Specific findings/Injuries:
    • Peritonitis
    • Pancreatic injuries
    • Penetrating solid organ injury
  • Significant medical comorbidities


Review of history, physical exam, labs, and imaging may help clinicians determine need for further diagnostic imaging.

Abdomen/Pelvis CT with IV Contrast is the preferred modality for hemodynamically stable children. The addition of PO contrast does not improve detection of intra-abdominal injury and should be avoided unless directed by the Trauma Surgical team.

Note: Evaluation, including threshold to image, may change if there is suspicion for inflicted injury. ED Physical Abuse Clinical Pathway

Contraindications to CT:

  • Hemodynamic instability
  • Injury requiring emergent procedures
  • Obvious signs of peritonitis or free air on plain radiograph of the abdomen
  • Mechanism of Injury (MOI)
    • High energy
    • Unrestrained or improperly restrained occupant in MVC
    • Pedestrian or bicyclist vs. Auto
    • Large distance falls
    • Blunt impact to abdomen, flank, back
  • Abdominal pain after injury
  • Emesis after injury
Physical Exam
  • Abdominal tenderness – Particularly diffuse or upper abdomen
  • Abdominal distention
  • Abdominal wall ecchymosis or abrasions (Including seat belt sign)
  • Hematuria
  • Distracting injury
  • GCS < 13 with concerning MOI
  • Signs of Hemorrhagic Shock
    • Tachycardia, poor perfusion
    • Waxing, waning MS
    • Hypotension = Late sign
  • Increasing degrees of abdominal tenderness are associated with increased risk of injury
  • Limitation: Sensitivity of pain and tenderness decreases as GCS decreases
Labs and Imaging
  • CBC
  • LFTs
  • Amylase/Lipase
  • UA
  • Chest XR
  • AST > 200 U/L and ALT > 125 unit/L, UA w/ > 5 RBCs per high-powered field, and initial hematocrit < 30% are associated with intra-abdominal injury
  • An abnormal CXR has been found to be associated with intraabdominal injury