Pediatric liver lacerations and intensive care: evaluation of ICU triage strategies.

OBJECTIVE

To compare PICU admission criteria following blunt traumatic liver laceration based on CT grade and/or physiologic instability with actual practice to improve efficiency of ICU admission.

DESIGN

Retrospective cohort study.

SETTING

Patients with grade 3-6 liver lacerations, 2002-2010.

PATIENTS

Hundred seventy-one infants and children, ages 1 month to 17 years.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Preadmission signs of physiologic instability (i.e., coma and cardiac arrest), liver CT grading, and outcomes including length of stay and packed RBC transfusion after admission to ICU were collected. Multiple body region severe trauma was defined as more than or equal to 1 extra-abdominal body area abbreviated injury score more than or equal to 4. Actual ICU admissions were compared with predicted. Two patients died before ICU admission and five (3%) died afterward. Of 169 patients, 52 (31%) were initially admitted to the inpatient ward. Five percent received surgical care for liver injury. Twenty percent received packed RBCs emergently for shock, whereas 5% received their first packed RBCs after admission. Compared with ICU admissions, ward patients were significantly older, had lower Injury Severity Scores, and less operative care. Among ICU patients, transfusion for hemorrhagic shock was significantly associated with more severe injury scores. Sixty percent of ICU patients were not transfused. ICU triage determined by signs of physiologic instability predicted 53 admissions (31%) including seven of nine patients (78%) treated with transfusions after admission. Predicted ICU admission for nontransfused patients was lower-9%. Adding CT laceration grade more than or equal to 4 increased ICU admissions to 129 (76%). Among surviving ICU patients, 37 of 62 patients (60%) with isolated severe abdominal trauma and no systemic instability had ICU length of stay less than 1 day.

CONCLUSIONS

Children with isolated abdominal injury and no physiologic instability can generally be treated without ICU admission. Adding grade more than or equal to 4 to usual ICU admission criteria resulted in excessive admission of stable patients.