Solid Organ Injury: ATOMAC Guidelines
Guideline · Oct 2018 · 1 min read
In brief
In brief
Updated ATOMAC guidelines for pediatric blunt liver and spleen injuries shift management focus from injury grade to hemodynamic status, supporting abbreviated bed rest and earlier discharge. Evidence-based recommendations include transfusion thresholds of 7.0 g/dL and accounting for local resources in treatment decisions.
- Manage pediatric solid organ injuries based on hemodynamic status, not injury grade—over 95% can be managed nonoperatively
- Abbreviated bed rest is supported; stable patients can be discharged before 24 hours with appropriate follow-up
- Transfusion threshold of 7.0 g/dL is recommended; >40 mL/kg or 4 units defines failure of nonoperative management
- ATOMAC guideline updates APSA recommendations using GRADE methodology with strong evidence for hemodynamic-based protocols
- Local resources and concurrent injuries must guide management decisions for children failing to stabilize
Written by the GCMD Library team from the guideline.
BACKGROUND:
Nonoperative management of liver and spleen injury should be achievable for more than 95% of children. Large national studies continue to show that some regions fail to meet these benchmarks. Simultaneously, current guidelines recommend hospitalization for injury grade + 2 (in days). A new treatment algorithm, the ATOMAC guideline, is in clinical use at many centers but has not been prospectively validated.
METHODS:
A literature review conducted through MEDLINE identified publications after the American Pediatric Surgery Association guidelines using the search terms blunt liver trauma pediatric, blunt spleen trauma pediatric, and blunt abdominal trauma pediatric. Decision points in the new algorithm generated clinical questions, and GRADE [Grading of Recommendations, Assessment, Development, and Evaluations] methodology was used to assess the evidence supporting the guideline.
RESULTS:
The algorithm generated 27 clinical questions. The algorithm was supported by six 1A recommendations, two 1B recommendations, one 2B recommendation, eight 2C recommendations, and ten 2D recommendations. The 1A recommendations included management based on hemodynamic status rather than grade of injury, support for an abbreviated period of bed rest, transfusion thresholds of 7.0 g/dL, exclusion of peritonitis from a guideline, accounting for local resources and concurrent injuries in the management of children failing to stabilize, as well as the use of a guideline in patients with multiple injuries. The use of more than 40 mL/kg or 4 U of blood to define end points for the guideline, and discharging stable patients before 24 hours received 1B recommendations.
CONCLUSION:
The original American Pediatric Surgery Association guideline for pediatric blunt solid organ injury was instrumental in improving care, but sufficient evidence now exists for an updated management guideline.
LEVEL OF EVIDENCE:
Expert opinion, guideline, grades I to IV.
Statements in this guideline
Nonoperative management of liver and spleen injury should be achievable for more than 95% of children.
Current guidelines recommend hospitalization for injury grade plus 2 days.
Management should be based on hemodynamic status rather than grade of injury.
An abbreviated period of bed rest is supported.
Transfusion thresholds of 7.0 g/dL should be used.
Peritonitis should be excluded from a guideline.
Local resources and concurrent injuries should be accounted for in the management of children failing to stabilize.
A guideline should be used in patients with multiple injuries.
More than 40 mL/kg or 4 units of blood should be used to define end points for the guideline.
Stable patients may be discharged before 24 hours.
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