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Everyone:

I've just been reviewing the literature on non-operative management of
blunt pediatric abdominal injury, and have found some interesting numbers.

When pooling the only three series I could find from the past decade that
specified both the total number of laparotomies and the denominator of
children evaluated (summary at bottom of this note), the laparotomy rate
averages 9% for identified solid organ injury. This is 0.3% of consecutive
blunt trauma admissions (excluding those additional children evaluated and
discharged), or roughly 1 in every 333 admissions. Even in these three
major pediatric trauma centers, this translates to an amazingly low average
of one laparotomy every 7 months.

While this now-established safety of non-operative management is a great
success for the children we treat, it also raises questions about the need
to routinely summon a surgeon for every trauma alert when actual laparotomy
will occur perhaps twice per year. What hospitals out there have their
surgeons more on a standby or delayed response basis for blunt pediatric
trauma?

Steve Green, MD, FACEP
Professor of Emergency Medicine & Pediatrics
Director, Emergency Medicine Residency Program
Loma Linda University Medical Center & Children's Hospital
Loma Linda, California

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Reference: Bond SJ, Eichelberger MR, Gotschall CS, et al. Nonoperative
management of blunt hepatic and splenic injuries in children. Ann Surg
1996; 223:286-289.
Pediatric Trauma Center: Children's National Medical Center, Washington, DC
Age: <=14 years
Patients: 3,577 admissions over 67 months
Solid Organ Injury: 179 liver or spleen (no others mentioned)
Laparotomy (% of admits): 7 directly from ED (0.2%), 4 delayed from floor
(0.1%)
Laparotomy Frequency: 1 from ED per 10 months; 1 delayed per 17 months

Reference: Haller JA, Papa P, Drugas G, Colombani P. Nonoperative
management of solid organ injuries in children. Is it safe? Ann Surg 1994;
219(6): 625-628.
Pediatric Trauma Center: Johns Hopkins Children's Center, Baltimore, MD
Age: <=14 years
Patients: 2,887 admissions over 33 months
Solid Organ Injury: 53 liver or spleen, 18 renal, 7 pancreatic
Laparotomy (% of admits): 9 (0.3%) It is not specified how many went
directly to laparotomy and how many had delayed intervention.
Laparotomy Frequency: 1 every 4 months

Reference: Hall JR, Reyes HM, Meller JL, Loeff DS, Dembek R. The outcome
for children with blunt trauma is best at a pediatric trauma center. J
Pediatr Surg 1996; 31(1): 72-76.
Pediatric Trauma Center: Cook County Hospital Pediatric Trauma Center,
Chicago IL
Age: <=15 years
Patients: 1,337 admissions over 84 months
Solid Organ Injury: 48 liver or spleen (no others mentioned)
Laparotomy (% of admits): 6 (0.4%) It is not specified how many went
directly to laparotomy and how many had delayed intervention.
Laparotomy Frequency: 1 every 14 months

DATA ABOVE POOLED
Patients: 7,801 admissions over 184 months
Solid Organ Injury: 305 total
Laparotomy (% of admits): 26 (0.3%) It is not clear how many went directly
to laparotomy and how many had delayed intervention.
Laparotomy Frequency: 1 every 7 months

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