Severe blunt hepatic trauma in children

Background: Severe blunt hepatic injury in children is associated with a hi gh mortality rate. Although nonoperative management has become the treatmen t of choice for mild to moderate liver trauma, there is no consensus as to the optimal treatment for the most severe hepatic injuries in children. Methods: A statewide trauma registry was reviewed to identify children (age 18 years or less) treated for a severe blunt liver injury for the period 1 993 to 1998. Only children with an American Association for the Surgery of Trauma grade V (AIS code 541828.5) liver injury were included. Database rec ords were reviewed for demographic information, associated injuries, surviv al rate, length of stay (LOS), intensive care days (ICUD), and treatment re ndered after resuscitation in the emergency department. Results: Thirty children with a grade V liver injury were identified. The m ean age was 11.2 years (range, 1 to 18), and the overall survival rate was 56%. Data for 5 patients were excluded (4 patients died in the emergency de partment, and 1 patient was transferred to another institution after arriva l). Survivors had a trend toward a lower injury severity score (ISS) (36.1 v 44.6; P < .1) and a significantly higher Glasgow Coma Scale (GCS), 12.5 v 6.6; P < .007). Patients with a decreased GCS had a lower overall survival rate (GCS < 8, 30% v GCS > 8, 76%). In the subset of 14 patients taken dir ectly to the operating room, there was no difference between survivors (n = 6, 43%) and nonsurvivors (n = 8, 57%) in ISS (43 v 43; P value, not signif icant) or GCS (8.6 v 8.0; P value, not significant). Of the 11 patients tre ated nonoperatively, 10 (91%) survived with an average ISS of 33 and GCS of 13.8. Nonsurvivors more often had identified associated injuries to other abdominal and retroperitoneal organs. Conclusions: Severe hepatic injury is associated with a very high overall m ortality rate in children. A low GCS is associated with a significant decre ase in survival rate and may be the most important factor in outcome. Patie nts taken directly to the operating room have a slightly greater injury sev erity and a decreased survival rate compared with those treated nonoperativ ely. Thresholds and indications for laparotomy in these patients are not cl ear, and the need for operative management should be guided by the child's physiologic response to resuscitation. For those patients whose physiologic response to resuscitation permitted nonoperative management, a good outcom e was achieved. Copyright (C) 2001 by W.B. Saunders Company.