Abstract Background/Purpose Although consensus-based guidelines exist for managing pediatric liver/spleen injuries, optimal phlebotomy frequency is unknown. We hypothesize surgeons order more ...phlebotomy than necessary and propose a pathway with one blood draw, early ambulation and discharge, fewer ICU admissions, and physiology-driven interventions. Methods Records of 120 children with solid organ injury from two hospital registries (2008–2012) were analyzed. We compared resource utilization between our current management and management if the proposed pathway were in place. Paired t-test was used for statistical analysis. Results Sixty-one patients were included (35 spleen, 22 liver, 4 combined). Average age was 11.6 (± 4.2) years, injury severity score 9 (± 5), and median injury grade 3. 51% of children were admitted to the ICU. Average phlebotomy per patient was 5 (± 2) and length-of-stay 4.3 (± 1.5) days. Three patients became unstable and required transfusion. No patients required operation or angioembolization. Our pathway would decrease ICU admissions by 65% (p < 0.001), blood draws by 70% (p < 0.001), and length-of-stay by 37% (p < 0.001), while identifying all patients requiring transfusion based on hemodynamic status. Conclusion Our data suggest that clinical parameters could identify patients requiring intervention and decrease resource utilization. This suggests that serial phlebotomy may be unnecessary, and the proposed pathway is worthy of prospective validation.
...with the improvement in prehospital systems, some patients arrive to the ED with life-threatening thoracic wounds while still relatively asymptomatic.2 Second, neither neurological evaluation nor ...GCS score is able to accurately detect which patients have sustained intracranial injury.3 Third, patients with apparently normal cardiovascular function can tolerate a significant blood loss without developing overt signs of shock.4 Indeed, the reported patient maintained hemodynamic stability in the ED despite a very large hemoperitoneum. A series of sonographic evaluations on 313 patients with precordial or transthoracic wounds evaluated by FAST for hemopericardium showed a negative predictive value of 100% and a positive predictive value of 91%.7 Furthermore, a recent multicenter prospective study of 261 patients with penetrating thoracic wounds evaluated by FAST reported 86% true-negative, 11% true- positive, no false-negatives, and 3% false-positive examinations, resulting in 100% sensitivity, 97% specificity, and 97% accuracy.12 In a recent prospective clinical study of penetrating abdominal trauma, FAST was found to have a sensitivity of 46% and a specificity of 94% in the prediction of a therapeutic laparotomy.11
The current study evaluates the need for trauma bay chest radiographs (CXR) in stable blunt-trauma patients who are scheduled for chest computed tomography (CCT). A retrospective review of 157 ...randomly selected, stable, adult blunt-trauma patients who were admitted to a level I trauma center between 2000 and 2002, who underwent both CXR and CCT (GE Light-Speed Scanner), was performed. Stable patients were defined as unintubated, normotensive (SBP > 100 mm Hg), and without hypoxia (O2 saturation > 90%). No interventions were conducted in the trauma bay based on chest radiograph findings. Among 95 patients with a "normal" CXR, 38 patients (40%) were found on CCT to have traumatic injuries. Among 62 patients with an "abnormal" CXR, 18 (29%) were found to be normal on CCT. Of the remaining 44 patients, 34 had additional findings on CCT. In 32 patients, CCT led to changes in management. CCT was more sensitive in diagnosing thoracic injuries and led to significant changes in management. We feel that CXR could be safely eliminated in favor of CCT in stable blunt-trauma patients.
