Mehall et al developed an algorithm for the management of a pediatric patient who is hemodynamically stable after blunt injury to the liver and/or spleen. The premise is that hemodynamic stability is a better predictor of clinical outcome than the injury grade on CT scan. The authors are from the Arkansas Children's Hospital in Little Rock.


Patient selection:

(1) pediatric age group

(2) hemodynamically normal

(3) liver and/or spleen injury on CT scan

(4) no other injury requiring admission to the pediatric ICU (closed head injuries, long bone fractures, pelvic fractures, etc.)


Heart Rate

Systolic Blood Pressure

0 to 2 years

< 130 beats per minute

> 70 mm Hg

3 to 10 years

< 110 beats per minute

> 80 mm Hg

11 to 18 years

< 90 beats per minute

> 90 mm Hg

from Table 1, page 348


Initial management - Admit to floor:

(1) NPO.

(2) Infuse D5 half normal saline with 20 mEq/L KCl at maintenance rate.

(3) Bedrest

(4) Morphine sulfate 0.05 to 0.10 mg/kg IV q2h PRN for pain.


Time from Admission


Vital Signs

0 hours



2 hours



4 hours



6 hours



10 hours



12 hours



14 hours



18 hours




Exit from pathway if one of the following is identified:

(1) peritonitis

(2) hemodynamically abnormal

(3) hematocrit < 21% despite transfusion of packed RBCs at 10 mL/kg, with abdominal tenderness.


If hemodynamically stable with hematocrit > 21% and no abdominal tenderness at 18 hours after injury, then the patient was continued on the protocol:

(1) Start regular diet.

(2) Discontinue IV fluids when tolerating oral intake.

(3) Allowed out of bed with activity ad lib.

(4) Tylenol for pain at a dosage for age and weight.

(5) Monitor hematocrit in 24 hours (42 hours after starting protocol).


Discharge home at 48 hours (I interpret this as 66 hours after starting protocol, although it could be 6 hours after doing the hematocrit) if:

(1) Tolerating regular diet

(2) No abdominal tenderness

(3) Stable hematocrit > 21%.


Discharge instructions:

(1) Routine activity with no contact sports.

(2) Followup at 4 weeks with ultrasound examination of the abdomen.


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