Importance of a Follow-Up Ultrasound Protocol in Monitoring Posttraumatic Spleen Complications in Children Treated with a Non-Operative Management

Follow-up strategies after non-operative treatment of traumatic splenic injuries: a systematic review

PURPOSE

Blunt trauma often results in splenic injuries, with non-operative management (NOM) being the preferred approach for stable patients. Following NOM, splenic vascular injuries, such as pseudoaneurysms, may arise, prompting radiological follow-up. However, a consensus on optimal radiological follow-up strategies is lacking. This systematic review evaluates existing evidence on radiological follow-up post-NOM for traumatic splenic injuries.

METHODS

Conducting a systematic review following updated PRISMA guidelines, we searched MEDLINE, Embase, The Cochrane Library, and trial registries from January 2010 to March 2023. Inclusion criteria covered studies on radiological follow-up for blunt splenic injuries.

RESULTS

Out of 5794 studies, 17 were included involving 3392 patients. Various radiological modalities were used, with computed tomography (CT) being the most common. Vascular injuries occurred in 4.5% of patients, with most pseudoaneurysms diagnosed on day 2-6 post-trauma, and leading to intervention in 60% of these cases. Thirteen studies recommended routine follow-up, with six favouring CT, and seven supporting radiation-free modalities. Four studies proposed follow-up based on clinical indications, initial findings, or symptoms. Recommendations for specific timing of radiological follow-up ranged from 48 h to seven days post-injury. Regarding AAST grading, nine studies recommended follow-up for injury grade III and higher.

CONCLUSION

Limited high-quality evidence exists on radiological follow-up in isolated blunt splenic injuries, causing uncertainty in clinical practice. However, our review suggests a reasonable need for follow-up, with contrast-enhanced ultrasound emerging as a promising alternative to CT. Specific timing and criteria for follow-up remain unresolved, highlighting the need for high-quality prospective studies to address these knowledge gaps.

Epidemiological profile of patients undergoing non-operative management of solid organ injury and associated factors with mortality

INTRODUCTION

Trauma primarily affects the economically active population, causing social and economic impact. The non-operative management of solid organ injuries aims to preserve organ function, reducing the morbidity and mortality associated with surgical interventions. The aim of study was to demonstrate the epidemiological profile of patients undergoing non-operative management in a trauma hospital and to evaluate factors associated with mortality in these patients.

METHODS

This is a historical cohort of patients undergoing non-operative management for solid organ injuries at a Brazilian trauma reference hospital between 2018 and 2022. Included were patients with blunt and penetrating trauma, analyzing epidemiological characteristics, blood transfusion, and association with the need for surgical intervention.

RESULTS

A total of 365 patients were included in the study. Three hundred and forty-three patients were discharged (93.97%), and the success rate of non-operative treatment was 84.6%. There was an association between mortality and the following associated injuries: hemothorax, sternal fracture, aortic dissection, and traumatic brain injury. There was an association between the need for transfusion and surgical intervention. Thirty-eight patients required some form of surgical intervention.

CONCLUSION

The profile of patients undergoing non-operative treatment consists of young men who are victims of blunt trauma. Non-operative treatment is safe and has a high success rate.

Pseudoaneurysm Screening after Pediatric High Grade Solid Organ Injury

BACKGROUND

High grade solid organ injuries carry risk of complications, including pseudoaneurysms (PSA). The optimal approach to PSA screening among pediatric patients is unknown and may include delayed Computed Tomography Angiography (dCTA) and/or contrast-enhanced ultrasound (CEUS). This study endeavored to define dCTA/CEUS yield in PSA diagnosis after pediatric high grade solid organ injury.

METHODS

Patients <18y presenting to our ACS-verified Level 1 trauma center with ≥1 AAST grade ≥3 abdominal solid organ injury (kidney, liver, and spleen) were included (01/2017-10/2021). Transfers in, death <48h, and immediate nephrectomy/splenectomy were exclusions. PSA screening was pursued selectively based on attending discretion. Demographics, clinical/injury data, and outcomes were collected. Primary outcome was performance of dCTA or CEUS.

RESULTS

Forty-two patients satisfied criteria, with median age 12.5y and ISS 22. Liver injuries were most frequent (48%), followed by spleen (33%) and kidney (19%). Initial management strategy was most commonly nonoperative (liver 60%, spleen 64%, kidney 75%). Overall, 26% underwent PSA screening at a median of hospital day 4, with dCTA (21%) or CEUS (5%). CEUS was only used among liver injuries (10%), with no PSA identified. One PSA was diagnosed on dCTA after splenic injury and was managed with observation.

CONCLUSION

PSA screening occurs infrequently after pediatric high grade solid organ injury, potentially due to concerns about radiation exposure from dCTA which would be mitigated with CEUS. Further delineation of PSA incidence and yield of screening investigations are needed to avoid missing this important diagnosis and to determine the diagnostic accuracy of dCTA and CEUS.

Gunshot Abdominal Injuries: A Report of Two Cases and a Review of the Literature

Abdominal injuries in children caused by guns are a rare clinical entity globally. But, in countries with undefined legal regulations and in war zones, urban violence is a tremendous social problem among older children and adolescents. This manuscript provides details regarding two cases of severe gunshot injuries in young children. The injuries were very complicated and included damage to the parenchymatous and hollow organs and major blood vessels. The clinical presentation on admission was severe and dramatic, but the patients survived. However, one patient developed numerous complications that required repeated surgical interventions and long treatment. This article provides a detailed description of injuries and how to treat them. Patient care requires a multidisciplinary approach, and the initial decision on further treatment depends on the patient's hemodynamic stability.

Splenic Heterogeneity in Focused Assessment With Sonography for Trauma (FAST) Scan Led to the Diagnosis of Grade 2 Splenic Injury in a Pediatric Blunt Abdominal Trauma

Splenic injuries are one of the most common injuries following blunt abdominal trauma. It occurs in 32% of blunt abdominal trauma, with motor vehicle accidents being the most common cause. The patient may present with generalized abdominal pain or left upper quadrant pain associated with left shoulder pain. Hemodynamic instability is one of the most reliable signs of splenic injuries. A focused assessment with sonography for trauma (FAST) scan is the initial imaging used to assess for solid organ injury in the abdomen, followed by computed tomography (CT) scans. Evidence of free fluid in the abdomen in the FAST scan indicates a solid organ injury. However, the absence of the before-mentioned finding does not rule out the presence of solid organ injury. Hereby a case of a 13-year-old Saudi male with left-sided abdominal pain after falling from a motorbike. A set of the investigation was done with insignificant results. However, FAST revealed a heterogenous appearance in the spleen. Thus, the patient subsequently underwent abdominal CT scans. The patient was managed conservatively and then discharged against medical advice (DAMA). Previously documented cases have mentioned the presence of free fluid in the abdomen in FAST scan in a stable patient leading to undergoing a CT scan and further managing trauma victim patients, which was absent in the present case.