Trauma of the spleen and liver in children

Evolution of non-operative management for blunt splenic trauma in children

Until the late 1960s, splenectomy was routinely performed in children who had sustained blunt splenic injury. There was based on the ability to perform splenectomy without obvious consequence; the cited 90-100% mortality for splenic trauma and the possibility of delayed rupture of the spleen. In contrast, contemporary findings in immunology and surgery demonstrated that non-operative management was not only feasible but desirable in view of the potential for overwhelming post-plenectomy infection. The history of universal splenectomy following blunt splenic trauma has been reviewed and we outline the findings that have resulted in the current standard of non-operative management following blunt splenic trauma.

Conservative management of splenic trauma: history and current trends

Evolution of the present-day policy of conservative management of ruptured spleen has been hailed as one of the most notable advances in pediatric surgery. Until 1971, routine splenectomy used to be the sacrosanct treatment for splenic trauma. It was universally believed that non-operative management carried a high mortality of 90 to 100%. Sporadic reports of successful conservative treatment appeared in the early twentieth century, but regrettably, these were ignored. Likewise, experimental studies pointing to the danger of post-splenectomy sepsis were also disregarded. Dominant surgical opinion continued to practice removal of the injured spleen. In 1968, Upadhyaya and Simpson, based on a well-designed clinical analysis of 52 children made a convincing plea for conservative management. In 1971, Upadhyaya et al. presented results of a corroborative experimental study, which provided the conclusive evidence that isolated splenic tears are well tolerated and heal spontaneously by first intention. Seeing the surge of publications that followed this presentation, it becomes apparent that this study constituted the real turning point that changed the world opinion in favour of salvage of the ruptured spleen. By 1979, numerous authors had reported the safety of non-operative management in hundreds of children all over the world. Currently, the policy of routine splenectomy has been universally abandoned; and the reported salvage rate of ruptured spleen is more than 90%. This paper traces the historical perspectives in the management of injured spleen from the times of Aristotle to the present day.

Injuries from falls in the pediatric population: an analysis of 729 cases

BACKGROUND/PURPOSE

Falls are classified as low or high level for triage purposes. Because triage criteria dictate less urgency for low-level falls, this classification scheme has important implications for pediatric emergency care.

METHODS

Retrospective analysis was conducted of 729 (393 low-level and 336 high-level) pediatric patients treated for fall-related trauma (1992 through 1998). Falls were classified as low (<15 feet) or high-level (> or =15 feet). All falls were reported as accidental or unintentional.

RESULTS

The overall mortality rate was 1.6% (2.4% for high-level falls compared with 1.0% for low-level falls). All 4 patients who died of a low-level fall had an abnormal head computed tomography (CT) scan and intracranial hypertension. Half of deaths from high-level falls were attributable to intracranial injuries, and half were caused by severe extracranial injuries. Common extracranial injuries were upper extremity fracture (6.2%), lower extremity fracture (5.6%), pulmonary contusion (1.8%), pneumothorax (1.1%), liver laceration (1.1%), bowel injury (1.0%), and splenic injury (2.1%). Orthopedic and thoracic injuries resulted more commonly from high-level falls, whereas abdominal injuries were as likely to occur after a low-level fall.

CONCLUSIONS

Intracranial injury accounts for the majority of deaths from falls. Children suffering low-level falls were at similar risk for intracranial and abdominal injuries compared with those who fell from greater heights. Pediatric trauma triage criteria should account for these findings.

Ligation of the splenic artery; effects on the injured spleen and its function

Treatment of splenic trauma by ligating the splenic artery was studied on 28 dogs. Bleeding was arrested, and the animals under experimentation tolerated the ligation of the splenic artery without complications. The histology of the spleen showed no abnormalities 2 mo after the experiment. The traumatized area of the spleen had healed. The platelets and reticulocytes were temporarily increased. The hemotocrit values, WBC counts, and serum immunoglobulin M, remained within normal levels. Bone marrow smears, and scintigrams of the spleen were normal. Ligation of the splenic artery, combined with splenorrhaphy, was also successfully used in children with splenic trauma involving major segmental vessels.

Jejunal perforation occurring in contact sports

Two cases of jejunal rupture following blunt trauma, occurring in participants of contact sports, have been reported. Additionally, a possible mechanism of injury is described.

The non-operative management of splenic trauma

Non-operative management of splenic trauma is not a widely accepted method of treatment. During the period 1964 to 1976, 39 children were treated in the Adelaide Children's Hospital for splenic trauma. Twenty-four were managed without operation, while 15 were treated by splenectomy. Recently, splenic scan has helped in the diagnosis and management of splenic injuries. From our observations, it appears that non-operative treatment of a proven splenic injury is safe and the ideal initial treatment in the paediatric age group, when the spleen is the only intraabdominal organ injured, and the vital signs are stable with the application of adequate resuscitative measures.