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

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

History	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

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.