Non-Op Management of Solid Organ Injuries: An APSA Review

Infographic · Aug 2019 · 1 min read

In brief

APSA systematic review updates 2000 guidelines for pediatric solid organ injuries, recommending physiology-based hospital stays rather than injury grade-based protocols, potentially shorter activity restrictions, selective use of embolization only for ongoing hemorrhage, and elimination of routine follow-up imaging for uncomplicated low-grade injuries.

Hospital length of stay for isolated solid organ injuries should be based on clinical findings, not injury grade, and may be shorter than traditional guidelines.
Activity restriction of injury grade plus two weeks is safe, though shorter restriction periods require further study before recommendation.
Prophylactic embolization is not indicated for stable patients with arterial extravasation; reserve for active ongoing hemorrhage only.
Routine follow-up imaging is unnecessary for asymptomatic low-grade injuries; limited evidence supports imaging for high-grade injuries.
Updated APSA guidelines emphasize physiology-driven care over grade-based protocols, reducing unnecessary interventions and imaging.

Written by the GCMD Library team from the infographic.

Three-panel infographic with blue gradient background. Left panel shows icons for hospital stay and activity restrictions. Center panel displays organ illustrations (liver, kidneys, spleen) above a grading table with ICU days, length of stay, and activity restrictions by injury grade. Right panel illustrates imaging decision criteria with medical icons.

The American Pediatric Surgical Association (APSA) guidelines for the treatment of isolated solid organ injury (SOI) in children were published in 2000 and have been widely adopted. The aim of this systematic review by the APSA Outcomes and Evidence Based Practice Committee was to evaluate the published evidence regarding treatment of solid organ injuries in children.

Methods

A comprehensive search strategy was crafted and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Four principal questions were examined based upon the previously published consensus APSA guidelines regarding length of stay (LOS), activity level, interventional radiologic procedures, and follow-up imaging. A literature search was performed including multiple databases from 1996 to 2016.

Results

LOS for children with isolated solid organ injuries should be based upon clinical findings and may not be related to grade of injury. Total LOS may be less than recommended by the previously published APSA guidelines. Restricting activity to grade of injury plus two weeks is safe but shorter periods of activity restriction have not been adequately studied. Prophylactic embolization of SOI in stable patients with image-confirmed arterial extravasation is not indicated and should be reserved for patients with evidence of ongoing bleeding. Routine follow-up imaging for asymptomatic, uncomplicated, low-grade injured children with abdominal blunt trauma is not warranted. Limited data are available to support the need for follow-up imaging for high grade injuries.

Conclusion

Based upon review of the recent literature, we recommend an update to the current APSA guidelines that includes: hospital length of stay based on physiology, shorter activity restrictions may be safe, minimizing post-injury imaging for lower injury grades and embolization only in patients with evidence of ongoing hemorrhage.

Type of Study

Systematic Review.

Levels of Evidence

Levels 2–4.

Visual abstract created by Alejandra M Casar Berazaluce, MD - Pediatric Surgery Research Fellow at Cincinnati Children's Hospital Medical Center.

The text in the image

Blunt Solid Organ Injuries in Children: An APSA Systematic Review | Length of Stay = Correlate clinically | Activity Restrictions = Grade + 2 weeks | I | II | III | IV | ICU (d) | X | X | X | 1 | LOS (d) | 2 | 3 | 4 | 5 | D/C Imaging | X | X | X | X | F/U Imaging | X | X | X | X | ↓Activity (wk) | 3 | 4 | 5 | 6 | APSA Guidelines (2000) | Role of IR = Arterial blush on imaging + hemodynamic compromise | Follow-up Imaging= Reserved for symptoms | Journal of Pediatric Surgery | Gates et al. Journal of Pediatric Surgery (2019). https://doi.org/10.1016/j.jpedsurg.2019.01.012 | @alejandracasar

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