Nonoperative management of blunt liver and spleen injury in children: Evaluation of the ATOMAC guideline using GRADE

David M. Notrica, James W. Eubanks, David W. Tuggle, Robert Todd Maxson, Robert W. Letton, Nilda M. Garcia, Adam C. Alder, Karla A. Lawson, Shawn D. St Peter, Steve Megison, Pamela Garcia-Filion

Research output: Contribution to journalArticlepeer-review

88 Scopus citations


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, aswell 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 nowexists for an updated management guideline.

Original languageEnglish (US)
Pages (from-to)683-693
Number of pages11
JournalJournal of Trauma and Acute Care Surgery
Issue number4
StatePublished - 2015


  • Blunt liver injury
  • Blunt spleen injury
  • Guideline
  • Nonoperative management
  • Pediatric trauma

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine
  • Surgery


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