Isolated low-grade solid organ injuries in children following blunt abdominal trauma: Is it time to consider discharge from the emergency department? Plumblee L, Williams R, Vane D, et al. J Trauma Acute Care Surg. 2020 Nov;89(5):887-893.
Take Away: Children with grade I or II solid organ injury (SOI) and no other major injury are unlikely to need acute intervention for their SOI. They should be considered for a period of limited observation or even discharge from the ED.
Summary: The authors performed a secondary analysis of two large multicenter, prospective, observational trials. They identified 517 children (<16 yo) who had grade I-III SOI (liver, spleen, kidney). Approximately half of these children had other major injuries, while the other half did not. Children with other major injuries needed acute intervention for their SOI (transfusion, embolization, or operation) in 12.2% of cases. Children with no other major injuries almost never needed acute intervention. In fact, none of the children with grade I or II injuries needed an acute intervention, if they did not have other major injuries. Despite the fact that none of these children needed intervention, 18.9% were admitted to the pediatric ICU, and the median hospital stay was 4 days. Because children with grade I or II SOI who did not have other major injuries did not need acute interventions, the authors propose that these children should not require ICU admission and could be safely managed with a limited period of observation and possibly even discharge from the emergency department.
Early vasopressor administration in pediatric blunt liver and spleen injury: An ATOMAC+ study. Notrica DM, Sussman BL, Sayrs LW, St. Peter SD, Maxson RT, et al. J Pediatr Surg. 2020 Jul 12;S0022-3468(20)30485-1.
Take Away: In children with blunt liver or spleen injury (BLSI), early vasopressor use for hypotension in the ED was associated with an increased risk of death but did not increase the risk of failure of non-operative management (NOM).
Summary: In this paper, the authors describe a planned secondary analysis of vasopressor use in children with BLSI from 10 centers. Logistic regression was used to assess mortality and failure of NOM following vasopressor administration. Among 1004 children with BLSI, 128 presented with hypotension and 65 received vasopressors. When excluding patients given vasopressors for cardiac arrest, mortality increased 11-fold when vasopressors were used to treat hypotension in the first hour after injury. Vasopressor administration was not associated with failure of NOM.
Whole Blood is Superior to Component Transfusion for Injured Children: A Propensity Matched Analysis. Leeper CM, Yazer MH, Triulzi DJ, Neal MD, Gaines BA. Ann Surg. 2020 Oct;272(4):590-594.
Take Away: Transfusion of cold-stored whole blood may have advantages over the use of blood product component therapy in the initial hemostatic resuscitation in pediatric trauma.
Summary: In this paper, the authors describe a propensity matched study comparing the use of whole blood to component therapy for the initial hemostatic resuscitation of pediatric (age > 1 year) trauma patients. Twenty-eight children who received whole blood (40 ml/kg cold-stored) were matched to 28 children who received component therapy. The authors found that the children who received whole blood therapy had a faster time to resolution of base deficit, a lower posttransfusion INR, and lower transfused volumes of platelets and plasma. On secondary analysis, there was no difference in in-hospital mortality, functional disability, ICU and hospital length of stay, or ventilator days. The study is limited by the small sample size, bias not accounted for by the propensity matching technique, the retrospective collection of transfusion volumes, and the potential evolution/changing of resuscitation practice over time. However, based on these results of the study, whole blood therapy shows improvement in certain clinical aspects of hemostatic resuscitation and may be considered as the initial hemostatic resuscitation agent in injured children.
Timing and volume of crystalloid and blood products in pediatric trauma: An Eastern Association for the Surgery of Trauma multicenter prospective observational study. Polites SF, Moody S, Williams RF, et al. J Trauma Acute Care Surg. 2020;89(1):36-42.
Early transfusion with blood products and limiting crystalloid resuscitation in pediatric trauma patients decreases ventilator days, ICU and hospital length of stay. Early blood transfusion did not affect hospital mortality.
In a prospective, observational, multi-institutional study, injured children who presented in shock (defined by elevated age-adjusted shock index, SIPA) were more likely to require transfusion if they received greater than 1 crystalloid bolus. This study included 712 patients with a mean age of 7.6 years, median ISS of 9 and hospital mortality of 5.3%. Nearly half of the patients received at least one crystalloid bolus and 20% received a blood product transfusion. Though mortality did not increase with increasing crystalloid boluses, secondary outcomes were worse with each incremental crystalloid bolus. On multivariable logistic regression, increase in crystalloid boluses predicted extended ventilator days (>3), extended ICU days (>6) and extended hospital days (>14). These data support a crystalloid-sparing, early transfusion approach for resuscitation of injured children.