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Non-Trauma Centre Management of Pediatric Blunt Abdominal Trauma with Spleen and Liver Injuries: Does One Size Fit All?

Alison M Campbell, Ramnik V Patel, Rejoo D Daniel, Mahmud Fleet, Sanja Besarovic

Department of Pediatric Surgery, Hull Royal Infirmary, Hull, United Kingdom

 

Correspondence:

Alison M Campbell

Department of Pediatric Surgery

Hull Royal Infirmary

Anlaby Road, Hull HU3 2JZ

United Kingdom

Tel: 00441482 875875

Fax: 00441482 675768

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Abstract

Introduction: The abdomen is the most common site of initially unrecognised fatal injury in blunt pediatric trauma. Commonly the spleen and liver are involved. Management is usually conservative. American Pediatric Surgical Association (APSA) guidelines for isolated spleen and liver injury have been validated in large trauma centres. We aimed to review our experience of managing pediatric blunt spleen and liver injury and compare this with APSA guidelines.

Patients and Methods: We retrospectively reviewed all pediatric blunt trauma patients (Grade 2 to Grade 5 spleen or liver injury on imaging) presenting to our department between 2000 and 2011.

Results: Twenty-nice patients (8 girls) with blunt abdominal trauma (spleen 22, liver 6, both 1) were managed conservatively (22) or surgically (7). Three patients died (18 to 72 hours post injury); all had multisystem trauma and underwent surgery. All isolated injuries were successfully managed conservatively (1 embolization). Median hospital stay was 9 days and median bed rest 11 days. Pre-discharge imaging was performed in 20 and post discharge imaging in 13. Failure of conservative management occurred within 72 hours of admission and only with associated injuries.

Conclusion: While our outcomes do not differ from major centres, our follow up is more cautious with increased use of ultrasound and increased length of hospital stay. Non-operative management was successful in all isolated injuries. We further demonstrate that embolization is a useful adjunct in splenic preservation and worth considering.

Keywords: abdomen, blunt trauma, child, embolization, interventional radiology, liver, spleen, ultrasonography, tomography, radiograph, computed axial tomogram (CAT)

 

Introduction

The abdomen is the most common site of initially unrecognised fatal injury in blunt paediatric trauma. The spleen and liver are the most commonly involved organs [1, 2]. Management is usually conservative [3, 4]. American Pediatric Surgical Association (APSA) Trauma Committee’s evidence-based guidelines for the treatment of hemodynamically stable children with isolated liver or spleen injuries were published in 2000 [5], and have been validated in major trauma centres [1].

Trauma is the leading cause of death in children between 1 and 16 years of age. Abdominal trauma has a mortality rate of up to 8.5%. In children with blunt trauma the abdomen is the third most injured region after head and limbs. Injury occurs in isolation or in multisystem trauma. Conservative management has been recognised to be universally successful in stable isolated liver and /or spleen injuries without hollow viscus or multisystem trauma in children. However, a wide variation has been observed in the management algorithms used by individual paediatric surgeons, and between non-trauma centre and major pediatric trauma centres.

We aimed to evaluate our experience of pediatric blunt spleen and liver injury at a non-trauma centre and compare this with APSA guidelines to determine whether they should be routinely applied in our setting.

Patients and Methods

For the ten year period 2002-2012, we reviewed the records to identify all patients less than 16 years who had sustained liver or splenic injury as a result of blunt abdominal trauma. Patients who were transferred to us for specialist management after having had initial management at another hospital were excluded, as were children with penetrating abdominal trauma.

Demographic data and information regarding the mechanism of trauma, primary and secondary survey results, clinical findings, imaging reports, management, resource utilization and outcomes were obtained from emergency department notes, inpatient notes. Radiology and imaging studies department records were also used. Patients were included irrespective of concomitant injuries to other body parts or systems. Data were compiled and analysed using Microsoft Excel.

Results

Twenty nine children were identified for inclusion (8 female and 21 male). Complete data were available for 26 patients. The median age was 9 years 8 months (2.5 years to 15.5 years). Twenty-six had splenic injury, 6 had hepatic injury and one had both combined. The incidence in various calendar months is shown in Fig. 1. The mechanisms of injury are detailed in Fig. 2. While the majority were involved in road traffic collisions; there were a wide variety of mechanisms.

Figure 1: Incidence per months of the year

fig 1 

Figure 2: Mechanism of injury (RTA – Road Traffic Accidents)

fig 2

Injury severity score (ISS) ranged from 9 to 75, mean being 22.4. Survivors had injury severity score ranging from 9 to 43 while the non survivors had injury severity score ranged from 57 to 75. Sixteen children had isolated injury out of which 14 were hemodynamically stable. Six patients had associated thoraco-abdominal injuries and 5 children had multi- system injury. There were 3 deaths (all in the multisystem injury group).

Delay in presentation has been shown in the Fig. 3. Admission location has been demonstrated in Fig. 4. A significant associated non-abdominal injury was sustained by 7 (28%), of whom the majority were involved in a road traffic accident (RTA). These injuries included traumatic brain injury, long bone fractures, bilateral pneumothorax and pulmonary contusions.

Figure 3: Delay in presentation (A&E – Accident and Emergency Department) 

fig 3

Figure 4: Admission location (ICU – Intensive Care Unit, PHDU – Pediatric High Dependency Unit)

fig 4

Conservative treatment was applied in 22 patients and one patient required embolization for splenic injury with ongoing bleeding (Fig. 5). The Injury Severity Score (ISS) scores ranged between 9 -26 with a median of 16. Four transfusions were needed: 2 by 2 units packed red cells (PRC), 2 by 1unit PRC in patients with ISS score 16 -17. Those who did not require transfusion had their ISS between 9 -26. One patient with ISS of 9 with a deranged prothrombin time needed vitamin K. The conservative group of patients’ hospital stay ranged from 4 to 22 days with a median of 9 days.

Figure 5: Management – the number of patients requiring conservative, interventional or operative treatment

fig 5

There were 3 deaths (Fig. 6). The age range was 6 -13. All patients were pedestrians involved in RTA (1 pushed in front of vehicle). The ISS range was 57 -75 and all of them needed laparotomy. They died between 18 and 72 hours post injury. The causes of death in these three patients were as follows: (1) Bleeding from avulsion of liver, ( 2) Intracranial injury and (3) Uncertain (family refused post mortem, bilateral pneumothorax and open femur fracture as well as grade 4 splenic injury – died 48 hrs post laparotomy).

Figure 6: Outcome

fig 6

The median length of follow-up was 24 months (range 9-128 months). At the time the data for this study was collected, none of the children in this cohort had been readmitted to hospital following their initial stay as a result of morbidity related to any abdominal injuries (Fig.7). Pre-discharge follow up imaging was carried out in 20 patients out of 23. Post discharge follow up imaging was performed in 13 of the 23 patients (Fig. 7). Six children had laparotomies out of which 3 died. One child had splenic artery embolization. A total of 9 patients required blood products.

Figure 7: Pre-discharge imaging (USS – ultrasound, CT – computer tomography)

fig 7

The bed rest ranged from 4 to 33 days with a median of 11 days. The range of duration of absence from school was 2 -4 weeks and contact sports ranged from 4-26 weeks. With regards to the resource utilization, mean hospital stay was 10.8 days, with a range from 4 to 22 (Fig. 8).

Seven patients required surgical intervention. None had an isolated injury; all had associated intra-abdominal or multisystem trauma. ISS ranged from 21 -75, three patients (with ISS 57-75) died. All 7 patients were operated on within 48 hours of admission. Three of the 4 survivors in this group underwent splenectomy (1 Grade 3, 2 Grade 4) the other patient undergoing laparotomy had surgicel applied to the spleen (Grade 2). The ISS in this group was 21 – 43. The hospital stay ranged from 5-22 days with a median stay of 14 days. Bed rest ranged from 3-20 days. The duration of absence from school ranged 0 - 4 weeks and that of restriction from contact sport ranged 0 - 4 months. One patient with ISS score of 25 and grade 4 splenic injury required 8 units PRC, 4 units fresh frozen plasma (FFP). His hospital stay was for 12 days with bed rest for 3 weeks at home and remained off contact sports for 3 months.

 Figure 8Resource utilization (in hemodynamically stable patients with isolated injury) 

CT Grade

II (n=6) *

III (n=6)

IV (n=2)

ICU stay

0

0

0 (both admitted in PHDU for 24hrs)

Hospital days

10 (4 -15)

8 (4-11)

12 -19

Pre discharge Imaging

1 (0-2)

1 (0-2)

1

Post discharge Imaging

0 (0-2)

1 (0-2)

1

Activity restriction (weeks)

6 (4-12)

6 (4-16)

4-6

*1 both liver and spleen injury

PHDU – Pediatric High Dependency Unit


Discussion

Non-operative management of haemodynamicaly stable isolated liver/spleen injuries in children has evolved and been fine-tuned. It is an accepted evidence based practice and widely used in paediatric surgical centres. The guidelines published by the APSA with regards to the site of their care, intensive care unit admission, pre-discharge and post-discharge imaging, number of days of hospital admission and number of restricted days activities were validated in large trauma centres with large volumes of trauma [5]. The incidence of pediatric blunt abdominal trauma in the UK is low but is a cause of significant morbidity and mortality [1-2, 6-8].

In our series, failure of non-operative management was not seen in isolated hepatic or splenic injury. In those with associated thoraco-abdominal injury 2 out of 6 failed conservative management (there were no deaths or long term sequelae in this cohort). In the patients with multisystem trauma, all 5 required exploratory laparotomy (3 with higher ISS died). Our patients presented due to a wide range of mechanisms. The majority resulted from road traffic accidents and bicycle riding in keeping with the published literature [9-12].

Non-operative management is successful in the majority of children presenting with blunt spleen and liver injury especially if they are haemodynamicaly stable and have no associated intra-abdominal or multisystem trauma. Conservative management of splenic injury is more resource and labour intensive than the operative approach. These children have to be managed in centres with appropriate expertise. Applying the APSA guidelines has been shown to safely decrease hospital stay and use of imaging in large tertiary centres.

Although non-operative management of isolated spleen and liver injury in children is successful in hemodynamically stable patients, this is more likely to fail in hemodynamically unstable patients. Non-operative failure rate for splenic injury is approximately 2%, it peaks at 4 hours and declines at 36 hours after admission. Non-operative failure rate is higher in bicycle-related injuries, and where there is more than one solid organ injury.

Failure of non-operative management occurred early in our patients, therefore we should consider implementation of APSA guidelines in isolated blunt liver and spleen trauma for hemodynamically stable patients. Our audit has shown that this is feasible, effective and safe in this group of selected patients.

Failure rate for non-operative management in pediatric liver injury is 3-11 % in polytrauma and 0-3% for isolated liver injury. Angioembolization is a distinct interventional modality which is helpful in patients in the grey zone but is not used as commonly as in adults. This may be due to non-availability of equipment and expertise in pediatric surgical centers. In our series one patient underwent embolization to allow splenic salvage. We would conclude that embolization is a useful adjunct to aid conservation of the spleen.

In a child who has sustained blunt abdominal trauma, isolated liver and /or spleen injury can be treated conservatively even in a non-designated paediatric surgical trauma centre. However, multiple intra-abdominal injuries and multisystem injuries with higher ISS are more complicated and may need interventional radiological expertise and operative management. Multisystem paediatric trauma victims are a very high risk group with higher morbidity and mortality. These challenging patients’ need extra attention and resources.

Successful conservative management of blunt spleen and liver trauma is labour intensive. This approach involves close observations, serial physical examinations, consideration of further imaging if required and appropriately timed surgical or radiological intervention in the event of clinical deterioration. It may not be realistic to apply the APSA guidelines and recommendations in all centres. In smaller centres, with lower volumes of trauma, follow up ultrasound scans and slightly longer hospital stays may provide the reassurance to safely manage these patients, in spite of higher resource utilization.

Conclusion

While our outcomes do not differ from major centres, our follow up is more cautious with increased use of ultrasound and increased length of hospital stay. Non-operative management was successful in all isolated injuries. We further demonstrate that embolization is a useful adjunct in splenic preservation and worth considering.



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