Pediatric Blunt Solid Organ Injury Management Note (Nonoperative)

Encounter Details

Date/Time: [Date and time of documentation]
Author/Service: [Author name and role / Service]
Location: [ED / ICU / Ward]
Hospital Day / Post-Injury Day: [Hospital day number] / [Post-injury day number]
Protocol Status: [On pathway / Off pathway / Exception] (If off pathway or exception, state reason.)
Note Type: [Admission / Daily Progress]

(Do not copy-forward prior exam findings; document today's assessment explicitly. Omit sections and organs not applicable to this patient.)

Injury Summary

[Mechanism and approximate time of injury]

• Spleen: [Imaging modality and date] — AAST Grade [I / II / III / IV / V]; [Key qualifiers: active extravasation, hemoperitoneum volume, vascular injury] (Include only if spleen injured.)
• Liver: [Imaging modality and date] — AAST Grade [I / II / III / IV / V / VI]; [Key qualifiers: active extravasation, hemoperitoneum volume, vascular injury] (Include only if liver injured.)
• Kidney: [Imaging modality and date] — AAST Grade [I / II / III / IV / V]; [Key qualifiers: vascular injury, collecting system involvement, urinary extravasation] (Include only if kidney injured.)
• Associated injuries: [Relevant injuries affecting monitoring or disposition: TBI, fractures, thoracic injury, coagulopathy] (Include only if present.)
• Pending: [Pending item and expected timing] (Include only if results are pending.)

Subjective

[Clinical trajectory narrative: pain location, severity, and trend; symptoms suggesting bleeding such as dizziness, weakness, or pallor; nausea and vomiting; oral intake tolerance; for renal injuries include hematuria status and urinary symptoms; family questions or concerns if raised]

Objective

Vitals: [HR, BP, RR, SpO2, Temp with units] — [Trend since last assessment] (Flag values abnormal for age.)

Exam: [General appearance]; [Abdomen: distension, tenderness location, guarding, rebound, peritoneal signs]; [Flank/CVA tenderness if renal injury]; [Perfusion if relevant]

Labs/Data: [Hgb/Hct with timestamps]; [UA results if renal injury]; [Other decision-relevant labs] (State "No new labs since [date]" if none obtained.)

Imaging: [New imaging with key findings] (State "No new imaging since [date]" if none obtained.)

Assessment

[One-sentence synthesis: age, organ and grade, hemodynamic status, pain trend, bleeding concern present or absent]

• [Solid organ injury by organ and grade]
• [Hemodynamic status] (Include if unstable or recently resuscitated.)
• [Pain control]
• [Nutrition and mobility]
• [Associated injuries] (Include only if present.)
• [Psychosocial or family concerns] (Include only if relevant.)

Plan

(Organize by problem, highest acuity first. Document explicit if/then escalation thresholds.)

Hemodynamic Status

• Current status: [stable / improving / worsening]
• Monitoring: [Vital sign frequency]; [Abdominal exam frequency]
• Resuscitation to date: [Crystalloid mL/kg]; [Blood products mL/kg and types] (Include on admission note or if recently resuscitated.)
• Transfusion trigger: [Hgb threshold or clinical criteria]
• Escalation criteria:
  • [If sustained tachycardia or hypotension beyond age-adjusted threshold despite specified resuscitation volume → notify attending]
  • [If Hgb drop exceeds threshold over specified timeframe or ongoing transfusion requirement → consider IR vs OR]
  • [If concern for massive hemorrhage → activate MTP]

Spleen Injury — Nonoperative Management

(Include only if spleen injured.)

• Status: [stable / improving / worsening]
• Monitoring: [VS frequency]; [Exam frequency]; [CBC strategy with rationale]
• Diet: [NPO / Clear liquids / Regular]
• Activity: [Bedrest / Bathroom privileges / Ambulate] (Specify duration and progression criteria.)
• Escalation: [If specified threshold → action]

Liver Injury — Nonoperative Management

(Include only if liver injured.)

• Status: [stable / improving / worsening]
• Monitoring: [VS frequency]; [Exam frequency]; [CBC strategy with rationale]
• Diet: [NPO / Clear liquids / Regular]
• Activity: [Bedrest / Bathroom privileges / Ambulate] (Specify duration and progression criteria.)
• Escalation: [If specified threshold → action]

Kidney Injury — Nonoperative Management

(Include only if kidney injured.)

• Status: [stable / improving / worsening]
• Hematuria: [none / microscopic / gross] — [improving / stable / worsening]
• Monitoring: [VS frequency]; [Exam frequency]; [CBC strategy if indicated]; [UA frequency if indicated]
• Foley: [in place / not present] — [plan and criteria for removal or insertion]
• Urology: [consulted / not consulted] — [criteria for consultation: collecting system injury, urinary extravasation, worsening hematuria]
• BP surveillance: [Inpatient frequency]; [Outpatient plan and duration]
• Diet: [NPO / Clear liquids / Regular]
• Activity: [Bedrest / Bathroom privileges / Ambulate] (Specify duration and progression criteria.)
• Escalation: [If specified threshold → action]

Associated Injuries

(Include only if present.)

• [Injury]: [Status, management plan, monitoring, consultations]

Shared Plan Elements

• Pain management: [Multimodal analgesia approach]
• VTE prophylaxis: [mechanical / pharmacologic / deferred] — [rationale based on bleeding risk and patient factors]
• IV fluids: [Type and rate]; [PO advancement goal]
• Consultations: [Services consulted and status]
• Family communication: [Key points discussed] (Include only if significant discussion occurred.)

Disposition

• Current plan: [Continue ICU / Transfer to ward / Discharge] — [Criteria supporting decision]
• Anticipated timeline: [Expected disposition and prerequisites]

Discharge Planning

(Include on discharge day or as anticipatory guidance.)

• Readiness criteria met: [Stable vitals; pain controlled on oral medications; tolerating diet; ambulatory; no bleeding concern]
• Activity restrictions: [No contact sports or strenuous activity for specified weeks] (Use most restrictive timeline if multiple organs injured. Include staged return-to-play guidance.)
• Discharge medications: [Analgesics and other medications with dosing]
• Follow-up: [Clinic service and timing]; [Imaging if planned: modality and timing]; [BP monitoring schedule for renal injuries]
• Return precautions: [Worsening abdominal pain; dizziness or syncope; vomiting; fever; hematuria; decreased urine output; signs of bleeding] (Tailor to specific injuries.)
• Documentation provided: [School/sports restriction letter; discharge instructions to family]