CURRENT MANAGEMENT OF BLUNT SPLENIC TRAUMA IN CHILDREN

Updated APSA Guidelines for the Management of Blunt Liver and Spleen Injuries

BACKGROUND

Non-operative management of blunt liver and spleen injuries was championed initially in children with the first management guideline published in 2000 by the American Pediatric Surgical Association (APSA). Multiple articles have expanded on the original guidelines and additional therapy has been investigated to improve care for these patients. Based on a literature review and current consensus, the management guidelines for the treatment of blunt liver and spleen injuries are presented.

METHODS

A recent literature review by the APSA Outcomes committee [2] was utilized as the basis for the guideline recommendations. A task force was assembled from the APSA Committee on Trauma to review the original guidelines, the literature reported by the Outcomes Committee and then to develop an easy to implement guideline.

RESULTS

The updated guidelines for the management of blunt liver and spleen injuries are divided into 4 sections: Admission, Procedures, Set Free and Aftercare. Admission to the intensive care unit is based on abnormal vital signs after resuscitation with stable patients admitted to the ward with minimal restrictions. Procedure recommendations include transfusions for low hemoglobin (<7 mg/dL) or signs of ongoing bleeding. Angioembolization and operative exploration is limited to those patients with clinical signs of continued bleeding after resuscitation. Discharge is based on clinical condition and not grade of injury. Activity restrictions remain the same while follow-up imaging is only indicated for symptomatic patients.

CONCLUSION

The updated APSA guidelines for the management of blunt liver and spleen injuries present an easy-to-follow management strategy for children.

LEVEL OF EVIDENCE

Level 5.

Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document

Background

In 2017, the World Society of Emergency Surgery published its guidelines for the management of adult and pediatric patients with splenic trauma. Several issues regarding the follow-up of patients with splenic injuries treated with NOM remained unsolved.

Methods

Using a modified Delphi method, we sought to explore ongoing areas of controversy in the NOM of splenic trauma and reach a consensus among a group of 48 international experts from five continents (Africa, Europe, Asia, Oceania, America) concerning optimal follow-up strategies in patients with splenic injuries treated with NOM.

Results

Consensus was reached on eleven clinical research questions and 28 recommendations with an agreement rate ≥ 80%. Mobilization after 24 h in low-grade splenic trauma patients (WSES Class I, AAST Grades I–II) was suggested, while in patients with high-grade splenic injuries (WSES Classes II–III, AAST Grades III–V), if no other contraindications to early mobilization exist, safe mobilization of the patient when three successive hemoglobins 8 h apart after the first are within 10% of each other was considered safe according to the panel. The panel suggests adult patients to be admitted to hospital for 1 day (for low-grade splenic injuries—WSES Class I, AAST Grades I–II) to 3 days (for high-grade splenic injuries—WSES Classes II–III, AAST Grades III–V), with those with high-grade injuries requiring admission to a monitored setting. In the absence of specific complications, the panel suggests DVT and VTE prophylaxis with LMWH to be started within 48–72 h from hospital admission. The panel suggests splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan, irrespective of injury grade. Regarding patients with WSES Class II blunt splenic injuries (AAST Grade III) without contrast extravasation, a low threshold for SAE has been suggested in the presence of risk factors for NOM failure. The panel also suggested angiography and eventual SAE in all hemodynamically stable adult patients with WSES Class III injuries (AAST Grades IV–V), even in the absence of CT blush, especially when concomitant surgery that requires change of position is needed. Follow-up imaging with contrast-enhanced ultrasound/CT scan in 48–72 h post-admission of trauma in splenic injuries WSES Class II (AAST Grade III) or higher treated with NOM was considered the best strategy for timely detection of vascular complications.

Conclusion

This consensus document could help guide future prospective studies aiming at validating the suggested strategies through the implementation of prospective trauma databases and the subsequent production of internationally endorsed guidelines on the issue.

Identical injuries in 2 sisters (victims of motor vehicle collision): Two cases report

BACKGROUND

Children sometimes are victims of motor vehicle collision (MVC) along with their families. Motor vehicle collision can cause several patterns of blunt trauma resulting from the impact itself or penetrating trauma by broken glass or other sharp objects. Most cases can be managed conservatively as long as the hemodynamic parameters are stable & hollow viscera are intact. Usually, cases shared the same accident have different injury patterns. But herein, we present 2 sisters as victims of MVC with same lesions but at variable degrees.

CASE PRESENTATION

Two sisters were referred to our hospital as victims of MVC and presented by nearly identical injuries (left lung injury, left kidney injury, retroperitoneal fluid collection, & left humerus fracture). Both girls were managed non-operatively until improved and became ready for discharge from the hospital in stable good health status.

CONCLUSION

Identical injuries in pediatric trauma victims do occur and should be considered and reported to raise the awareness about the importance of submission to vehicle safety protective rules especially for children.

Non-operative management of solid organ injuries in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee systematic review

PURPOSE

The American Pediatric Surgical Association (APSA) guidelines for the treatment of isolated solid organ injury (SOI) in children were published in 2000 and have been widely adopted. The aim of this systematic review by the APSA Outcomes and Evidence Based Practice Committee was to evaluate the published evidence regarding treatment of solid organ injuries in children.

METHODS

A comprehensive search strategy was crafted and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Four principal questions were examined based upon the previously published consensus APSA guidelines regarding length of stay (LOS), activity level, interventional radiologic procedures, and follow-up imaging. A literature search was performed including multiple databases from 1996 to 2016.

RESULTS

LOS for children with isolated solid organ injuries should be based upon clinical findings and may not be related to grade of injury. Total LOS may be less than recommended by the previously published APSA guidelines. Restricting activity to grade of injury plus two weeks is safe but shorter periods of activity restriction have not been adequately studied. Prophylactic embolization of SOI in stable patients with image-confirmed arterial extravasation is not indicated and should be reserved for patients with evidence of ongoing bleeding. Routine follow-up imaging for asymptomatic, uncomplicated, low-grade injured children with abdominal blunt trauma is not warranted. Limited data are available to support the need for follow-up imaging for high grade injuries.

CONCLUSION

Based upon review of the recent literature, we recommend an update to the current APSA guidelines that includes: hospital length of stay based on physiology, shorter activity restrictions may be safe, minimizing post-injury imaging for lower injury grades and embolization only in patients with evidence of ongoing hemorrhage.

TYPE OF STUDY

Systematic Review.

LEVELS OF EVIDENCE

Levels 2-4.

Results of non-operative management of splenic trauma and its complications in children

Introduction:

Non-operative management (NOM) of splenic trauma in children is currently the treatment of choice.

Purpose:

We report a series of 83 cases in order to compare our results with literature data.

Patients and Methods:

For this, we conducted a retrospective study of 13 years and collected 83 cases of children with splenic trauma contusion, managed at Lapeyronie Montpellier Hospital in Visceral Pediatric Surgery Department. The studied parameters were age, sex, circumstances, the blood pressure (BP), hematology, imaging, associated injuries, transfusion requirements, treatment, duration of hospital stay, physical activity restriction and evolution.

Results:

NOM was successful in 98.7% of cases. We noted 4 complications including 3 pseudo aneurysms (PSA) of splenic artery and 1 pseudocyst spleen with a good prognosis. There was no mortality in our series.

Conclusion:

NOM is the treatment of choice for splenic trauma in children with a success rate of over 90%. Complications are rare and are dominated by the PSA of splenic artery.

Traumatic pseudoaneurysms of the liver and spleen in children: is routine screening warranted?

BACKGROUND

Although blunt injury to the spleen and liver can lead to pseudoaneurysm formation, current surgical guidelines do not recommend follow-up imaging. Controversy exists regarding the clinical implications of these traumatic pseudoaneurysms as well as their management.

METHODS

Retrospective review of children treated nonoperatively for isolated blunt liver and spleen trauma between 1991 and 2008 was undertaken. Patient demographics, grade of injury, and follow-up Doppler ultrasound results were obtained.

RESULTS

Three hundred sixty-two children were identified. One hundred eighty-six of them had splenic injuries, and 10 (5.4%) developed pseudoaneurysms. They were associated with grade III (3/39 [8%]) and grade IV (7/41 [17%]) injuries. In 7 patients, the pseudoaneurysm thrombosed spontaneously. Angiographic embolization was required in 2 children, and one underwent emergency splenectomy for delayed hemorrhage. Of the 176 patients who had liver injuries, 3 (1.7%) developed pseudoaneurysms. All 3 were associated with grade IV injuries (3/11 [27%]). One child underwent early embolization, while 2 developed delayed hemorrhage requiring emergent treatment.

CONCLUSIONS

Pseudoaneurysm development after blunt abdominal trauma is associated with high-grade splenic and liver injuries. Routine screening of this group of patients before discharge from hospital may be warranted because of the potential risk of life-threatening hemorrhage.

Long-term follow-up of children with nonoperative management of blunt splenic trauma

BACKGROUND

: The effectiveness of nonoperative management (NOM) of blunt splenic injuries (BSIs) in children is established; however, only limited data of their long-term follow-up exist. We hypothesize that long-term follow-up verifies that NOM of BSI in children is safe and effective.

METHODS

: From 1993 to 2008, 153 children (1-17 years, mean = 12) with BSI were admitted. Patients were contacted by telephone and answered a standardized questionnaire. Medical records were reviewed to validate injury grade, hospital stay, and complications.

RESULTS

: Eighty patients (52%) participated; 18 were excluded (8 splenectomies, 2 splenorraphies, 3 comatose, 2 language barriers, and 3 with unavailable records). Mean follow-up of the remaining 62 patients was 74 months (range, 5-165 months). There were 9 grade I, 9 grade II, 22 grade III, 20 grade IV, and 2 grade V injuries. Mechanism of injury was motor vehicle crashes (14), falls (11), all terrain vehicle (ATV) crashes (10), snow recreation related (14), and other recreation (13). Two patients were readmitted for spleen complications (splenic cyst and hematoma), but neither required additional treatment. Seven patients reported potential spleen-related complications: six immunologic (asthma, rashes, and increased illness), two abdominal pain, and two psychiatric related to fear of reinjuring their spleen. Three children sustained a second BSI, and none required surgical intervention.

CONCLUSIONS

: Long-term follow-up indicates that our protocol for NOM of BSI in children is safe, including secondary injuries. However, this study indicates that children who sustain BSI may require more counseling than presently provided. With an intact spleen, fear of immunologic dysfunction is irrational and indicates a lack of understanding at discharge. In addition, more intensive investigation and interventions for families that may suffer from posttraumatic stress disorder or related disorders appears indicated.

Management of pediatric blunt splenic injuries in Canada--practices and opinions

PURPOSE

The aim of the study was to compare the self-reported practice patterns of Canadian general surgeons (GSs) and pediatric general surgeons (PGSs) in treating blunt splenic injuries (BSIs) in children.

METHODS

Forty-five PGSs and 690 GSs were surveyed (internet and hard copy). chi(2) was used to compare groups; logistic regression was performed to determine independent factors influencing management variables.

RESULTS

Thirty-three PGSs and 191 GSs completed the survey, for a response rate of 30%. Pediatric general surgeons are more likely than GSs to follow American Pediatric Surgical Association guidelines (52% vs 11%; P < .0001). In diagnosing BSIs, PGSs and GSs are equally likely to use computed tomography (CT) over ultrasound for initial imaging. Pediatric general surgeons are less likely to consider CT injury grade in deciding on nonoperative management (NOM) (odds ratio [OR], 0.2; confidence interval [CI], 0.07-0.5; P = .002) and are more likely to continue NOM for patients with contrast blush on CT (OR, 6.5; CI, 2.5-17; P = .0002). Pediatric general surgeons report more selective intensive care unit use, hospital stay, follow-up imaging, and activity restrictions. No differences were found in the management of splenic artery pseudoaneurysms.

CONCLUSION

Differences exist between PGSs and GSs in the management of pediatric BSIs, resulting in higher operative rates, use of resources, and radiation exposure. Further education of GSs in NOM and establishment of management guidelines are indicated.

Conservative management of splenic injury in the tropics

We undertook this study in order to determine whether the conservative management of splenic injuries is a safe practice in a low-volume tropical hospital. We evaluated 69 consecutive patients with splenic injury prospectively. The outcome measures were morbidity and mortality rates, overall hospital stay and blood transfusion requirements. Spleen preservation was achieved in 85% (59) of cases. Of the 16 patients who underwent splenic surgery, six had splenorraphy (38%). The overall mortality was 4.3% (3) and the deaths were not related to the conservative management. Our findings suggest that not only is the conservative management of splenic injuries safe, but also that the repair of an enlarged spleen (splenorrhaphy) is safe and feasible in tropical hospital settings. The findings in this study provide further evidence that the conservative management of splenic injury in a tropical hospital without computed tomography scan is a safe practice.

Justification for an abbreviated protocol in the management of blunt spleen and liver injury in children

OBJECTIVE(S)

The current management of blunt spleen/liver injury in children requires a number of days of bed rest equal to the grade of injury plus 1. This protocol is used even when there is no clinical indication of ongoing bleeding. To establish a prospective protocol with an abbreviated period of bed rest, we conducted a retrospective review of our blunt spleen and liver trauma experience to examine the safety of such an attenuated protocol.

METHODS

A retrospective analysis of our most recent 10-year experience (January 1996 to December 2005) with blunt spleen or liver injury was performed. Patient demographics, vital signs, hemoglobin levels, need for transfusion, operations, and outcomes were measured. An abbreviated protocol using 1 night of bed rest for grades 1 and 2 injuries and 2 nights of bed rest for higher grades was designed. This protocol was then applied to our patient population to assess its safety. Data are expressed as mean +/- SD.

RESULTS

During the study period, 243 patients were admitted with blunt spleen and/or liver injury. The mean patient age was 9.0 +/- 4.6 years, and the mean weight was 35.3 +/- 19.3 kg. Sixty-three percent were male. The spleen was injured in 148 (61.2%) patients and the liver in 121 (50.0%), and 26 (10.6%) had both. The mean grade was 2.0 +/- 1.1, for which the mean bed rest was 3.5 +/- 1.1 days. This resulted in 5.6 +/- 6.5 days of hospitalization. There were 9 patients who died, 7 with severe brain injury and 2 with massive liver hemorrhage on presentation. No patient required an operation or transfusion after 2 nights of observation who did not have clinically obvious signs of ongoing blood loss. Implementation of the abbreviated protocol would have affected 65.8% of our patients and would have saved a mean of 2.0 +/- 1.5 hospital days per patient.

CONCLUSIONS

According to our data, an abbreviated trauma protocol with overnight bed rest for grades 1 and 2 injuries and 2 nights for higher grades could be safely used. This protocol would immensely improve current resource use. Based on these retrospectively collected data, we have initiated a prospective consecutive controlled series to assess the safety of such an attenuated protocol.