One-hundred and thirty one children with BLSI were reported to the audit during the year of data collection. Road traffic injuries were the most common cause of injury (41, 31%), followed by cycling injuries (37, 28%), fall from a height (22, 17%) and horse-riding injuries (10, 8%). One patient did not survive their multiple injuries and died before leaving the emergency department. 52 (40%) children had a liver injury (18 (14%) isolated liver injury), 66 (50%) had a splenic injury (34 (26%) isolated splenic injury) and 13 (10%) had both liver and spleen injury (without additional concomitant injuries in 2 (2%)). The most common sites of concomitant injuries were the lungs (41, 31%), chest wall (27, 20%) and the kidney (23, 17%) (Table 1). For all patients, the median grade of splenic injury was III (IQR II–IV) and of liver injury was III (IQR II–III) The Injury Severity Score (ISS) was recorded in 59 patients who had a median ISS of 16 (IQR 7.5–24, range 4–57). Four children, all with grade IV and V injury and haemodynamic instability, underwent splenic vessel embolization and all avoided subsequent laparotomy. Seven children had an early laparotomy: 2 had a splenectomy, 2 had packing and preservation of the spleen and oversewing of a gastric perforation, 2 had packing of the liver and one had repair of an aortic bleed. Two patients had a delayed bile leak.
One hundred and fifty two surgeons were invited to participate and 100 completed surveys were returned (66% response rate). All 21 pMTCs/specialist units were represented in the responses, including the 3 specialist UK liver units. Trauma was reported as a subspecialist interest by 27/100 (27%) and 4/100 (4%) reported trauma as their only subspecialty area. 7/100 (7%) respondents were hepatobiliary specialists. One respondent only reviews patients in the acute phase of the admission and therefore was not included in follow-up responses.
APSA guidance: admission to ICU is indicated if there are abnormal vital signs after initial resuscitation.
Thirty four (26%) children were admitted to the Intensive Care Unit (ICU) on the first day of admission, 21 (62%) of whom had required resuscitation prior to admission (fluid bolus or blood products). Children admitted to ICU requiring resuscitation did not have a significantly different grade of injury to those not requiring resuscitation (resuscitation given: 3 (IQR 2–4) vs no resuscitation given: 3.5 (IQR 2.8–4.3), p 0.53). 16/21 (76%) of those admitted to ICU and given fluid resuscitation had injury of at least one other organ and 10/13 (77%) not given resuscitation had injury to another organ. 3 patients who had neither multiple injuries nor required resuscitation were admitted to ICU, all of whom had a grade III injury or above.
45/100 (45%) of survey respondents report placing children on ICU based on haemodynamic features of instability without using injury grade as an indication. 10/100 (10%) use grade in combination with haemodynamic status and the majority of these respondents also report using concomitant injuries as an additional factor in determining whether ICU admission is indicated.
Grade of injury was reported as the sole determinant of ICU admission for 15/100 (15%) of respondents. For those who admit to ICU based on grade, 2/15 (13%) do so for Grade III and above, 8/15 (53%) do so for Grade IV and above and 5/15 (33%) do so for Grade V.
The remaining respondents did not give a description of the indications which they use for admission.
APSA guidance: Bedrest on ICU until all vitals are normal. No restriction of activity on the ward.
Bed rest was employed in 114/126 (90%) of children in whom location was reported on the first day of admission, despite only 34/126 (27%) being admitted to ICU (Table 2). By day 5 after injury only 5/73 (7%) patients who remained in hospital were cared for in ICU but 42/73 (58%) remained on bed rest (Fig. 1). A significant variation in practice around bed rest is evident, even in patients with isolated injury (Fig. 1D). Four patients on the ward were tachycardic on day 5, two of whom required a fluid bolus, demonstrating that a small number of children who are potentially unstable may be cared for in a ward rather than ICU setting.
62 (63%) respondents use radiological grade of injury all of the time to determine the duration of prescribed bed rest after BLSI. 16 (16%) use the grade of injury some of the time to determine the duration of bed rest and most commonly these are injuries grade III or above (8/16, 50%) or grade IV or above (5/16, 31%) but 3/16 (19%) only used it for low grades of injury. 2 (2%) respondents use the same duration of best rest for all patients. The remaining 19 (19%) respondents use a combination of haemodynamic status (most commonly), pain, age, Haemoglobin level, other injuries and imaging findings (other than grade) to determine the duration of bed rest. No respondents report using location of care (i.e. ICU vs ward) as a determinant of bed rest.
APSA guidance: discharge should be based on clinical condition, not injury severity. This includes haemodynamic stability, minimal abdominal pain and tolerating diet.
Level III–IV evidence, grade C recommendation 
Table 3 displays the criteria that were documented in children’s records as forming a decision in their readiness for discharge and those which respondents use to determine readiness for discharge. Grade of injury and repeat imaging were frequently reported to be an important determinant of readiness for discharge.
APSA guidance: restricting activity to grade plus 2 weeks is safe. Shorter restrictions may be safe but there is inadequate data to support decreasing these recommendations.
Level III–IV evidence, grade C recommendation 
25/99 (25%) of survey respondents report using grade of injury plus 2 weeks to determine the duration of restricted activity, although this advice was only given to 12/131 (9%) of patients. 28/99 (28%) reported restricting activity for 6 weeks for all patients and this advice was given to 34/131 (26%) of patients. 22/99 (22%) survey respondents report restricting activity until they have reviewed them as an outpatient and this advice was given to 7/131 (5%) of patients. 55 (42%) patients did not have any documented advice about return to activity. The remaining 23 patients received a variety of advice ranging between limiting activity for between 2 weeks and 3 months, with a restriction due to concomitant injury in 5 patients.
APSA guidance: consider imaging for symptomatic patients with prior high grade injuries.
Level IV evidence, grade C recommendation 
Table 4 displays the reported approach to routine imaging (subsequent to the initial CT) after BLSI, describing the timing and modality that is used. Respondents could select more than one response if they routinely image more than once. Some respondents noted that they specifically look for pseudoaneurysm prior to discharge.
56/130 (43%) patients had further imaging after their initial CT to reassess their liver or spleen injury before discharge from hospital. The grade of injury was significantly higher in those who had any re-imaging before discharge compared to those who did not (3 (IQR 2–4) vs 2.5 (IQR 2–4), p 0.02). At the time of the first (and in many, only) re-imaging, 28 (50%) patients were asymptomatic, 15 (27%) had mild abdominal pain without other symptoms, 9 (16%) had moderate abdominal pain, some with additional symptoms and 2 (4%) had severe pain and/or additional symptoms at the time of imaging. Overall 41 doppler ultrasound scans (d-USS), 8 contrast enhanced ultrasound scans (CE-USS), 21 CT scans and 4 other scans (HIDA or MRI) were used to re-assess the liver or spleen before discharge. One pseudoaneurysm was detected and treated by interventional radiology in a mildly symptomatic patient with a grade II injury. After discharge 43 (33%) patients underwent further imaging of their liver or spleen—d-USS was performed in 37 and CT or CE-USS in the other 5. Overall, 74 (56%) had a least one further radiological assessment of their liver or spleen injury after the initial diagnostic CT.