Building an "Abdomen-First" multidisciplinary system for pediatric polytrauma with major abdominal injuries: A decade of surgical evolution and outcomes.

BACKGROUND

The management of pediatric abdominal-dominant polytrauma, where life-threatening abdominal injuries coexist with other system injuries, lacks a standardized, surgery-led decision-making framework. This study aimed to evaluate the evolution and impact of a structured "Abdomen-First" Multidisciplinary Trauma Protocol (AF-MTP) developed at a high-volume pediatric trauma center.

METHODS

A retrospective cohort study was conducted on children (age <16 years) with severe polytrauma (Injury Severity Score ≥25) and major abdominal injuries (Abbreviated Injury Scale ≥3) admitted between 2014 and 2023. Patients were stratified into three epochs reflecting system evolution: Traditional Care (2014-2016), Protocol Transition (2017-2020), and Integrated Maturation (2021-2023). The AF-MTP featured general surgery-led team activation, a "one-stop" whole-body CT strategy, a defined decision algorithm prioritizing abdominal intervention, objective damage control surgery (DCS) criteria, and a standardized postoperative care bundle. Process metrics and clinical outcomes were compared across epochs.

RESULTS

Among 120 included patients, injury severity increased significantly across epochs (median ISS: 30 vs. 36 vs. 41, p < 0.001). Concurrently, AF-MTP implementation was associated with marked improvements: time from emergency department arrival to surgical incision decreased by 52 % (130 vs. 62 min, p < 0.001), DCS application increased from 22.5 % to 85.0 % (p < 0.001), and non-therapeutic laparotomy decreased from 17.5 % to 2.5 % (p = 0.036). Despite higher injury burden, abdominal injury-related 30-day mortality decreased by 75 % (20.0 %-5.0 %, p = 0.045 for trend). Multivariable analysis confirmed treatment in the mature protocol epoch (Epoch III) as an independent protective factor against abdominal-related mortality (aOR 0.18, 95 % CI 0.03-0.95).

CONCLUSION

The systematic implementation of a general surgery-led, protocol-driven "Abdomen-First" multidisciplinary system significantly improved the efficiency of care and survival for children with severe abdominal-dominant polytrauma, even as injury complexity increased. This model provides a replicable framework for optimizing trauma resuscitation where abdominal injury is the primary physiological threat.