Pediatric Blunt Abdominal Injury: Age is Irrelevant and Delayed Operation is Not Detrimental

Persistent disparities between trauma center types in the management of children with high-grade blunt splenic injuries

BACKGROUND

In the early 2000s, substantial variations were reported in the management of pediatric patients with blunt splenic injury (BSI). The purpose of this study was to assess the recent trends and disparities between different types of trauma centers. We hypothesized that there would be persistent disparities despite decreased trends in the rate of splenectomy.

METHODS

This is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database. We included patients (age ≤18 years) with high-grade BSI (Abbreviated Injury Scale 3-5) between 2014 and 2021. The patients were divided into three groups based on trauma center types (adult trauma centers [ATCs], mixed trauma centers [MTCs], and pediatric trauma centers [PTCs]). The primary outcome was the splenectomy rate. Logistic regression was performed to evaluate the association between trauma center types and clinical outcomes. Additionally, the trends in the rate of splenectomy at ATCs, MTCs, and PTCs were evaluated.

RESULTS

A total of 6601 patients with high-grade BSI were included in the analysis. Overall splenectomy rates were 524 (17.5%), 448 (16.3%), and 32 (3.7%) in the ATC, MTC, and PTC groups, respectively. ATCs and MTCs had significantly higher splenectomy rates compared to PTCs (ATCs: OR = 5.72, 95%CI = 3.78-8.67, and p < 0.001 and MTCs: OR = 4.50, 95%CI = 2.97-6.81, and p < 0.001), while decreased trends in the splenectomy rates were observed in ATCs and MTCs (ATCs: OR = 0.92, 95%CI = 0.87-0.97, and p = 0.003 and MTCs: OR = 0.92, 95%CI = 0.87-0.98, and p = 0.013).

CONCLUSIONS

This study suggested persistent disparities between different trauma center types in the management of children with high-grade BSI.

Contrast-enhanced ultrasound of blunt abdominal trauma in children

Trauma is the leading cause of morbidity and mortality in children, and rapid identification of organ injury is essential for successful treatment. Contrast-enhanced ultrasound (CEUS) is an appealing alternative to contrast-enhanced CT in the evaluation of children with blunt abdominal trauma, mainly with respect to the potential reduction of population-level exposure to ionizing radiation. This is particularly important in children, who are more vulnerable to the hazards of ionizing radiation than adults. CEUS is useful in hemodynamically stable children with isolated blunt low- to moderate-energy abdominal trauma to rule out solid organ injuries. It can also be used to further evaluate uncertain contrast-enhanced CT findings, as well as in the follow-up of conservatively managed traumatic injuries. CEUS can be used to detect abnormalities that are not apparent by conventional US, including infarcts, pseudoaneurysms and active bleeding. In this article we present the current experience from the use of CEUS for the evaluation of pediatric blunt abdominal trauma, emphasizing the examination technique and interpretation of major abnormalities associated with injuries in the liver, spleen, kidneys, adrenal glands, pancreas and testes. We also discuss the limitations of the technique and offer a review of the major literature on this topic in children, including an extrapolation of experience from adults.

Severe liver trauma among pediatric patients in the Japan Trauma Registry

Background

Limited information exists regarding the clinical characteristics, management practices, and outcomes of pediatric patients with liver injury in Japan. The aim of this study is to evaluate the characteristics, management, and outcome of pediatric patients with liver injury in Japan.

Methods

We conducted a multicenter, retrospective cohort study using data from the Japan Trauma Data Bank between 2004 and 2018. Pediatric patients with liver injury were classified into the following management groups: nonoperative management (NOM); NOM with angioembolization (AE); operative management (OM). The primary outcome was in-hospital survival, and the secondary outcomes were dispositions, hospital length of stay (LOS), and rate of discharge to home.

Results

There were 308 pediatric patients with severe liver injury (organ injury scale grades ≥Ⅲ) during the study period; 135 patients had isolated liver injury and 173 patients had non-isolated liver injury. The rates of NOM, NOM with AE, and OM among all patients were 65%, 23%, and 12%, respectively. AE was highly used both in patients with isolated liver injury (27%) and non-isolated liver injury (22%). In-hospital survival of patients with isolated liver injury and those with non-isolated liver injury were 99% and 88%, respectively. Regarding secondary outcomes among patients with isolated liver injury, 82% were admitted to the intensive care unit. LOS was 11 (8–14) days and 82% were discharged to home.

Conclusions

Our retrospective observational study showed that management of pediatric patients with severe liver injury in Japan was characterized by high utilization of AE. The in-hospital survival rate in Japan was comparable with that of other developed countries.

Variations in the management of adolescents with blunt splenic trauma in England and Wales: are we preserving enough?

INTRODUCTION

Management of blunt splenic injury has changed drastically with non-operative management increasingly used in paediatric and adult patients. Studies from America and Australia demonstrate disparities in care of patients treated at paediatric and adult centres. This study assessed management of splenic injuries in UK adolescents.

MATERIALS AND METHODS

Data were acquired from the Trauma Audit and Research Network on isolated blunt splenic injuries reported 2006-2015. Adolescents were divided into age groups of 11-15 years and 16-20 years, and injuries classified as minor (grades 1/2) or major (3+). Primary outcomes were needed for splenectomy and blood transfusion.

RESULTS

A total of 445 adolescents suffered isolated blunt splenic injuries. Road traffic collisions were the most common mechanism. There were no deaths as a result of isolated blunt splenic injuries, but 49 (11%) adolescents needed transfusions and 105 (23.6%) underwent splenectomies. There was no significant difference observed in the management of adolescents with minor trauma. In major trauma, 11-15-year-olds were more likely to have splenectomies when managed at local trauma units compared with major trauma centres (31% vs 4%, odds ratio 11.5; 95% confidence interval 3.82-34.38, p < 0.0001). Within major trauma centres, older adolescents were more likely to have splenectomies than younger adolescents (35.5% vs 3.8%, odds ratio 14; 95% confidence interval 4.55-43.26, p < 0.0001). There were no significant differences in haemodynamic status, transfusion requirement or embolisation rates.

CONCLUSIONS

There appears to be a large variation in the management of isolated blunt splenic injuries in the UK. The reasons for this remain unclear however non-operative management is safe and should be first line management in the haemodynamically stable adolescent, even with major splenic injuries.

Changes in Approach to Solid Organ Injury: What the Radiologist Needs to Know

This review aims to examine the challenges facing radiologists interpreting trauma computed tomography (CT) images in this era of a changing approach to management of solid organ trauma. After reviewing the pearls and pitfalls of CT imaging protocols for detection of traumatic solid organ injuries, we describe the key changes in the 2018 American Association for the Surgery of Trauma Organ Injury Scales for liver, spleen, and kidney and their implications for management strategies. We then focus on the important imaging findings in observed in patients who undergo nonoperative management and patients who are imaged post damage control surgery.

Laparoscopic Management of Pediatric Abdominal Trauma: A National Trauma Data Bank Experience

Purpose: To characterize injury patterns and institutional trends associated with the utilization of laparoscopy in the management of pediatric abdominal trauma. Methods: The National Trauma Data Bank (2010-2014) was queried for encounters involving patients ≤14 years who underwent an open or laparoscopic abdominal operation within 48 hours of emergency department arrival. Patient, injury, and hospital characteristics associated with each approach were identified. Multivariate logistic regression was used to evaluate the influence of patient and hospital characteristics on operative approach. Results: Laparoscopy comprised 7.8% (n = 355) of all abdominal trauma operations. Patients undergoing laparoscopy had lower injury severity scores and higher Glasgow Coma Scale scores on arrival compared with laparotomy subjects (P < .001). Laparoscopic patients also had a shorter length of hospital stay (5.0 versus 8.6 days, P < .001), but longer time to the operating room (9.2 versus 6.3 hours, P < .001) compared with their open counterparts. The proportion of cases managed laparoscopically increased from 6.2% in 2010 to 10.1% in 2014 (P = .013), with increase in utilization primarily driven by university hospitals (P = .026) and level I pediatric trauma centers (P = .043). Conversion to laparotomy was uncommon (18.6%), and mortality in the laparoscopic cohort was low (0.4%). Conclusions: Use of laparoscopy has increased in the pediatric abdominal trauma population, typically in a less injured cohort of patients. As familiarity with and availability of minimally invasive techniques increase, this trend will likely continue.

Non-Operative Management of Blunt Liver Trauma: Safety, Efficacy and Complications of a Standardized Treatment Protocol

Objective:

To evaluate the safety and effectiveness of NOM (non-operative management) in the treatment of blunt liver trauma, following a standardized treatment protocol.

Methods:

All the hemodynamically stable patients with computed tomography (CT) diagnosis of blunt liver trauma underwent NOM. It included strict clinical and laboratory observation, 48-72h contrast enhanced ultrasonography (CEUS) or CT follow-up, a primary angioembolization in case of admission CT evidence of vascular injuries and a secondary angioembolization in presence of vascular injuries signs at follow-up CEUS.

Results:

181 patients (85.4%) [55 (30.4%) women and 126 (69.6%) men, median age 39 (range 14–71)] were included. Of these, 63 patients (34.8%) had grade I, 48 patients (26.5%) grade II, 39 patients (21.5%) grade III, 21 patients (11.6%) grade IV and 10 patients (5.5%) grade V liver injuries. The overall success rate of NOM was 96.7% (175/181). There was not significant difference in the success rate between the patients with different liver injuries grade. Morbidity rate was 7.4% (13/175). Major complications (2 bilomas, 1 liver hematoma and 2 liver abscesses) were successfully treated by CEUS or CT guided drainage. Eighteen (18/181) patients (9.9%) underwent angioembolization with successful results.

Conclusion:

Non-operative management of blunt liver trauma represents a safe and effective treatment for both minor and severe injuries, achieving an high success rate and an acceptable morbidity rate. The angiographic study with embolization, although required only in selected cases of vascular injuries, represents a fundamental therapeutic option in a significant percentage of patients.

Blunt splenic injury in children: haemodynamic status key to guiding management, a 5-year review of practice in a UK major trauma centre

PURPOSE

To review the management of children and adolescents (0-18 years), with blunt splenic injury treated at a single UK major trauma centre over a 5-year period, focusing upon efficacy of non-operative management and the use of haemodynamic stability as a guide to planning treatment strategy, rather than radiological injury grading. To produce a treatment pathway for management of blunt splenic injury in children.

METHODS

Retrospective, cross-sectional study of all paediatric patients admitted with radiologically proven blunt splenic injury between January 2011 and March 2016. Penetrating injuries were excluded. Follow up was for at least 30 days.

RESULTS

30 Patients were included, mean age was 14.5 (SD 3.6), median injury severity score was 16 (IQR 10-31). 6 Patients (20%) had a splenectomy, whilst 22 patients (73%) were successfully treated non-operatively with 100% efficacy at index admission. 5/8 (63%) patients with radiological grade V injuries were managed non-operatively, injury grade was not associated with surgical intervention (p = 1.57). Haemodynamic instability was initially treated with fluid resuscitation leading to successful non-operative management in 5/11 (45%) patients. However, haemodynamic instability is a significant predictor of requirement for surgical intervention (p = 0.03), admission to critical care (p = 0.017), presence of additional injuries (p = 0.015) and increased length of stay (p = 0.038). No such relationships were found to be associated with increased radiological injury grade.

CONCLUSIONS

Non-operative management should be first-line treatment in the haemodynamically stable child with a blunt splenic injury and may be carried out with a high degree of efficacy. It may also be successfully implemented in those initially showing signs of haemodynamic instability that respond to fluid resuscitation. Radiological injury grade does not predict definitive management, level of care, or length of stay; however, haemodynamic stability may be utilised to produce a treatment algorithm and is key to guiding management.

A cohort study to evaluate infection prevention protocol in pediatric trauma patients with blunt splenic injury in a Dutch level 1 trauma center

PURPOSE

Asplenic patients are at increased risk for the development of overwhelming postsplenectomy infection (OPSI) syndrome. It is believed that adequate immunization, antimicrobial prophylaxis, as well as appropriate education concerning risks on severe infection lead to the decreased incidence of OPSI. The aim of this study was to analyze the methods used to prevent OPSI in trauma patients splenectomized before the age of 18.

PATIENTS AND METHODS

A retrospective, single-center study of all pediatric patients sustaining blunt splenic injury (BSI) managed at our level 1 trauma center from January 1979 to March 2012 was performed. A questionnaire was sent to all the included patients to determine the level of knowledge concerning infection risks, the use of antibiotics, and compliance to vaccination recommendations. Furthermore, we investigated whether the implementation of guidelines in 2003 and 2011 resulted in higher vaccination rates.

RESULTS

We included 116 children with BSI. A total of 93 completed interviews were eligible for analysis, resulting in a total response rate of 80% and 1,116 patient years. Twenty-seven patients were splenectomized, and 66 patients were treated by a spleen preserving therapy (including embolization). Only two out of 27 splenectomized patients were adequately vaccinated, five patients without a spleen used prophylactic antibiotics, and about half of the asplenic patients had adequate knowledge of the risk that asplenia entails. A total of 22/27 splenectomized patients were neither adequately vaccinated nor received prophylactic antibiotics. There was no OPSI seen in our study population during the 1,116 follow-up years.

CONCLUSION

The vaccination status, the level of knowledge concerning prevention of an OPSI, and the use of prophylactic antibiotics are suboptimal in pediatric patients treated for BSI. Therefore, we created a new follow-up treatment guideline to have adequate preventive coverage to current standards for these patients.

A comparison of the management of blunt splenic injury in children and young people-A New South Wales, population-based, retrospective study

The importance and safety of non-operative management (NOM) of Blunt Splenic Injury (BSI) has been established in children and adults over recent decades. However, studies have shown higher operation rates in adults. There is international evidence that when children are managed in adult centres, operation rates are higher while adolescents in paediatric centres, are operated on in line with paediatric guidelines. This difference between children and young adults, and the factors responsible, have not been examined in New South Wales (NSW).

OBJECTIVE

To use NSW hospital and mortality data to compare the characteristics of BSI in patients aged 0-16 to those aged 17-25, and determine factors related to operative management (OM) and splenic salvage in each group.

METHODS

Patients age 0-25 between July 2000 and December 2011, with a diagnosis of BSI, were identified in the NSW Admitted Patient Data Collection, and linked to deaths data from Registry of Births Deaths and Marriages and Bureau of Statistics. Operation rate was compared between the two groups. Univariable analysis was used to determine factors associated with OM. Multivariable logistic regression with stepwise elimination was then performed to determine likelihood of OM according to age group, adjusting for potential confounders.

RESULTS

1986 cases were identified, with 422 (21.2%) managed operatively - 101/907 children (11.1%) and321/1079 (29.7%)young adults(p<0.001). Of these, 59 (58%) children underwent splenectomy compared with 233 (73%) young adults (p<0.001). OM increased significantly after the age of 12 (p=0.03), and the percentage almost tripled in the teenage years, coinciding with a higher proportion admitted to adult centres. OM doubled again in young adults(p<0.001), all of whom were managed away from paediatric centres. On multivariable analysis, factors significantly associated with operation included age over 16 (OR 2.82, 95%CI 2.10-3.81), splenic injury severity, associated thoracic, liver, pancreatic and hollow viscus injury, and blood transfusion.

CONCLUSION

While Paediatric Surgeons have wholeheartedly adopted non-operative management, away from paediatric centres, it is possible children and young people in NSW are undergoing operation unnecessarily. Further evaluation of the surgeon attitudes and institutional factors involved in the management of injured children and young people within the broad NSW trauma system is required.

Minimizing variance in Care of Pediatric Blunt Solid Organ Injury through Utilization of a hemodynamic-driven protocol: a multi-institution study

BACKGROUND

An expedited recovery protocol for management of pediatric blunt solid organ injury (spleen, liver, and kidney) was instituted across two Level 1 Trauma Centers, managed by nine pediatric surgeons within three hospital systems.

METHODS

Data were collected for 18months on consecutive patients after protocol implementation. Patient demographics (including grade of injury), surgeon compliance, National Surgical Quality Improvement Program (NSQIP) complications, direct hospital cost, length of stay, time in the ICU, phlebotomy, and re-admission were compared to an 18-month control period immediately preceding study initiation.

RESULTS

A total of 106 patients were treated (control=55, protocol=51). Demographics were similar among groups, and compliance was 78%. Hospital stay (4.6 vs. 3.5days, p=0.04), ICU stay (1.9 vs. 1.0days, p=0.02), and total phlebotomy (7.7 vs. 5.3 draws, p=0.007) were significantly less in the protocol group. A decrease in direct hospital costs was also observed ($11,965 vs. $8795, p=0.09). Complication rates (1.8% vs. 3.9%, p=0.86, no deaths) were similar.

CONCLUSIONS

An expedited, hemodynamic-driven, pediatric solid organ injury protocol is achievable across hospital systems and surgeons. Through implementation we maintained quality while impacting length of stay, ICU utilization, phlebotomy, and cost. Future protocols should work to further limit resource utilization.

TYPE OF STUDY

Retrospective cohort study.

LEVEL OF EVIDENCE

Level II.

Splenic trauma: WSES classification and guidelines for adult and pediatric patients

Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.

Management of paediatric splenic injury in the New South Wales trauma system

Since the 1980's, paediatric surgeons have increasingly managed blunt splenic injury (BSI) in children non-operatively. However, studies in North America have shown higher operation rates in non-paediatric centres and by adult surgeons. This association has not been examined elsewhere.

OBJECTIVE

To investigate the management of BSI in New South Wales (NSW) children, to determine the patient and hospital factors related to the odds of operation. Secondarily, to investigate whether the likelihood of operation varied by year.

METHODS

Children age 0-16 admitted to a NSW hospital between July 2000 and December 2011 with a diagnosis of BSI were identified in the NSW Admitted Patient Data Collection, and linked to deaths data from Registry of Births Deaths and Marriages, and Bureau of Statistics. The operation rate was calculated and compared between different hospital types. Univariable analysis was used to determine patient and hospital factors associated with operative management. The difference in the odds of operation between the oldest data (July 2000-December 2005) and most recent (January 2006-December 2011) was also examined. Multivariable logistic regression with stepwise elimination was then performed to determine likelihood of operative management according to hospital category and era, adjusting for potential confounders.

RESULTS

955 cases were identified, with 101(10.6%) managed operatively. On multivariable analysis, factors associated with operation included age (OR 1.11, 95% CI 1.01-1.18, p<0.05), massive splenic disruption (OR 3.10, 95% CI 1.61-6.19, p<0.001), hollow viscus injury (OR 11.03, 95% CI 3.46-34.28, p<0.001) and transfusion (OR 7.70, 95% CI 4.54-13.16, p<0.001). Management outside a paediatric trauma centre remained significantly associated with operation, whether it be metropolitan adult trauma centre (OR 4.22 95% CI 1.70-10.52, p<0.01), rural trauma centre (OR 3.72 95% CI 1.83-7.83, p<0.001) or metropolitan local hospital (OR 5.23, 95% CI 1.22-18.93 p<0.05). Comparing the 2 eras, the overall operation rate fell, although not significantly, from 12.9% to 8.7% (OR 1.3, 95% CI 0.89-243 p=0.13) CONCLUSION: While Paediatric Surgeons have wholeheartedly adopted non-operative management, away from paediatric centres, children in NSW are still being operated on for BSI unnecessarily. While the factors at play may be complex, further evaluation of the management and movement of injured children within the broad NSW trauma system is required.

Management of blunt pancreatic trauma in children: Review of the National Trauma Data Bank

PURPOSE

This study aims to examine the current management strategies and outcomes after blunt pancreatic trauma in children using a national patient registry.

METHODS

Using the National Trauma Data Bank (NTDB) from 2007-2011, we identified all patients ≤18years old who suffered blunt pancreatic trauma. Patients were categorized as undergoing nonoperative pancreatic management (no abdominal operation, abdominal operation without pancreatic-specific procedure, or pancreatic drainage alone) or operative pancreatic management (pancreatic resection/repair). Patient characteristics, operative details, clinical outcomes, and factors associated with operative management were examined.

RESULTS

Of 610,402 pediatric cases in the NTDB, 1653 children (0.3%) had blunt pancreatic injury and 674 had information on specific location of pancreatic injury. Of these 674 cases, 514 (76.3%) underwent nonoperative pancreatic management. The groups were similar in age, gender, and race; however, pancreatic injury grade>3, moderate to severe injury severity, and bicycle accidents were associated with operative management in multivariable analysis. Children with pancreatic head injuries or GCS motor score<6 were less likely to undergo pancreatic operation. Overall morbidity and mortality rates were 26.5% and 5.3%, respectively. Most outcomes were similar between treatment groups, including mortality (2.5% vs. 6.7% in operative vs. nonoperative cohorts respectively; p=0.07).

CONCLUSION

Although rare, blunt pancreatic trauma in children continues to be a morbid injury. In the largest analysis of blunt pancreatic trauma in children, we provide data on which to base future prospective studies. Operative management of pancreatic trauma occurs most often in children with distal ductal injuries, suggesting that prospective studies may want to focus on this group.

Management of Abdominal Solid Organ Injury After Blunt Trauma

Injury to the solid abdominal organs-liver, spleen, kidney, and pancreas-is one of the most common injury patterns in pediatric blunt trauma. Pediatric trauma centers are becoming increasingly successful in managing these injuries without operative intervention. Well-validated guidelines have been established for liver and spleen injury management, and operative intervention is reserved for patients who show evidence of active bleeding after resuscitation. No such guidelines yet exist for the management of traumatic injury of the kidney or pancreas. Exploratory laparotomy remains the treatment of choice in patients suffering hemodynamic collapse, but interventional radiologic or endoscopic procedures are increasingly used to manage all but the most devastating solid organ injuries. [Pediatr Ann. 2016;45(7):e241-e246.].

Pediatric solid organ injury operative interventions and outcomes at Harborview Medical Center, before and after introduction of a solid organ injury pathway for pediatrics

BACKGROUND

Although nonoperative management has become the standard of care for solid organ injury, variability exists in the care patients receive, and there are limited data regarding nonoperative management in patients with high grades of organ injury and substantial overall injury. We aimed to evaluate operative intervention frequency, including splenectomy, and patient outcomes before and after institution of the pediatric solid organ injury pathway at Harborview Medical Center (HMC) in 2005.

METHODS

This is a retrospective cohort study conducted at HMC for all pediatric solid organ injury patients from 2001 to 2012. Patients were identified in the Harborview Trauma Registry via DRG International Classification of Diseases-9th Rev. (ICD-9) codes for the presence of liver and spleen injuries. Demographic information, clinical characteristics, and ICD-9 procedure codes were also obtained from the trauma registry. Outcomes including splenectomy, a related abdominal surgery (exploratory laparotomy, spleen or liver repair, or splenectomy), mortality, and length of stay were compared between periods before and after 2005, adjusted for Injury Severity Score (ISS).

RESULTS

The pediatric solid organ injury population at HMC (n = 712) has a high frequency of high-grade injury (35% Grade IV or V) and a high level of overall injury severity (median ISS, 21). Splenectomy was rare and remained stable over time despite an increase in severity of injury (from 2.4% to 0.8%, p = 0.44, among patients with isolated injury and from 4.0% to 3.3%, p = 0.78, among patients with nonisolated injury). Other abdominal surgeries also remained stable over time. Mortality decreased among patients with nonisolated injury (from 11.2% to 4.8%, p = 0.01). Length of stay decreased among patients with isolated organ injury, from a median of 4 days (interquartile range, 3-5 days) to 2 days (interquartile range, 2-3 days) (p < 0.0005) as well as within the lower ISS strata among patients with nonisolated organ injury (from a median of 4 days to 2 days among ISS < 12, p = 0.007; from 5 days to 3 days among ISS of 12-20, p = 0.0001; and from 7 days to 4 days among ISS of 21-33, p = 0.003).

CONCLUSION

Care in the recent period (2005-2012) was associated with a stable, low frequency of splenectomy; decreased mortality for patients with nonisolated injury; and decreased hospital length of stay among most subsets of patients, suggesting improved care despite an increase in patients' severity of injury.

LEVEL OF EVIDENCE

Therapeutic study, level IV; epidemiologic study, level III.

Blunt Trauma in Paediatric Patients - Experience from a Small Centre

OBJECTIVE

Despite great prevention efforts, blunt abdominal trauma still remains a leading cause of injury, especially in the paediatric population. Abdominal trauma is the main culprit of serious children's injury and the most common area of initially missed diagnosis with a fatal outcome.

AIM

The purpose of this study was to determine the incidence, aetiology, grades of abdominal organ injuries, diagnosis, management and outcome of blunt abdominal trauma in a paediatric population.

METHOD

This is a retrospective study of 31 patients with isolated parenchymatous abdominal organs, treated in a single centre. Stable patients with no signs of peritonitis and insignificant changes in laboratory findings were managed conservatively. Unstable patients received surgery.

RESULTS

The leading cause of injuries were traffic accidents (64.5%), followed by fall from a height (22.5%), bicycle handlebar injuries (6.45%), contact sport and child abuse (3.22% each). The majority of injured children (90.32%) were managed conservatively. Only three patients (9.68%) were operated on due to complete avulsion and organ smash, or devascularization of the injured organs. Diagnostic computed tomography (CT) scan examination was performed on 93.5% of patients. Few patients had grade I and grade V injuries, while the largest proportion of patients had grade III and IV injuries. The most frequently injured organs were the spleen and kidney. There was no mortality.

CONCLUSION

The results emphasize that conservative treatment was appropriate for all stable patients with blunt abdominal trauma regardless of organ injury grade. The success of non-operative management depends upon proper patient selection. The choice of non-operative treatment should be based predominantly on physiological response, rather than grade injury on CT scan.

Blunt Spleen and Liver Trauma

Blunt abdominal trauma is an important cause of pediatric morbidity and mortality. The spleen and liver are the most common abdominal organs injured. Trauma to either organ can result in life-threatening bleeding. Controversy exists regarding which patients should be imaged and the correct imaging modality depending on the level of clinical suspicion for injury. Nonoperative management of blunt abdominal trauma is the standard of care for hemodynamically stable patients. However, the optimal protocol to maximize patient safety while minimizing resource utilization is a matter of debate. Adjunctive therapies for pediatric spleen and liver trauma are also an area of ongoing research. A review of the current literature on the diagnosis, management, and follow-up of pediatric spleen and liver blunt trauma is presented.

Benchmarks for splenectomy in pediatric trauma: how are we doing?

BACKGROUND/PURPOSE

Following publication of American Pediatric Surgical Association (APSA) hospital benchmarks for the operative management of blunt splenic trauma in specialized centers, it was found that most hospitals exceeded these benchmarks. We sought to determine if benchmarks were being met a decade later and to identify factors associated with splenectomy in injured children.

METHODS

Rates of splenic procedures were calculated for children≤19 with a blunt splenic injury (ICD-9 865) using the 2010-2011 National Trauma Data Bank. Multivariable analysis was performed to determine independent predictors of splenectomy.

RESULTS

Of 8597 children, 24.3% received care at pediatric trauma centers (PTC), 34.6% at adult trauma centers (ATC), and the remaining 41.2% at other centers (OTC). The overall operative rate was 9.2% (3.9% if age≤14, 6.7% if ≤17). Operative rates were higher in children treated at ATC and OTC when compared to PTC. On multivariable analysis, age>14, coexisting injuries, severity of splenic injury, and care at ATC or OTC were predictive of undergoing operative treatment.

CONCLUSIONS

Operative rates for splenic injuries meet APSA benchmarks at PTC yet remain high at other centers. Care at an ATC or OTC is associated with greater odds of operative management after adjustment for age and injury severity.

Splenic injury after blunt abdominal trauma during a soccer (football) game

The spleen is the most commonly injured abdominal organ in children who sustain blunt abdominal trauma, and pediatric splenic injury may result from minor mechanisms of injury, including sports participation. We present 2 cases of splenic injury in soccer goalies because of blunt abdominal trauma sustained during game play. Although abdominal organ injuries are uncommon in soccer, emergency medicine and primary care physicians must be aware of the possibility. A high index of suspicion and careful physical examination are key in making the diagnosis.

Non-operative management attempted for selective high grade blunt hepatosplenic trauma is a feasible strategy

Background

There is growing evidence of clinical data recently for successful outcomes of non-operative management (NOM) for blunt hepatic and spleen injuries (BHSI). However, the effectiveness of NOM for high-grade BHSI remains undefined. The aim of the present study was to review our experience with NOM in high-grade BHSI and compare results with the existing related data worldwide.

Methods

In this retrospectively protocol-driven study, 150 patients with grade 3–5 BHSI were enrolled during a 3-year period. Patients were divided into immediate laparotomy (immediate OP) and initial non-operative (initial NOM) groups according to hemodynamic status judged by duty trauma surgeon. Patients who received initial NOM were divided into successful NOM (s-NOM) and failed NOM (f-NOM) subgroups according to conservative treatment failure. We analyzed the clinical characteristics and the outcomes of patients.

Results

Twenty-eight (18.7%) patients underwent immediate operations, and the remaining 122 (81.3%) were initially treated with NOM. Compared with the initial NOM group, the immediate OP group had significantly lower hemoglobin levels, a higher incidence of tube thoracostomy, contrast extravasation and large hemoperitoneum on computed tomography, a higher injury severity score, increased need for transfusions, and longer length of stay (LOS) in the intensive care unit (ICU) and hospitalization. Further analysis of the initial NOM group indicated that NOM had failed in 6 (4.9%) cases. Compared with the s-NOM subgroup, f-NOM patients had significantly lower hemoglobin levels, more hospitalized transfusions, and longer ICU LOS.

Conclusions

NOM of high-grade BHSI in selected patients is a feasible strategy. Notwithstanding, patients with initial low hemoglobin level and a high number of blood transfusions in the ICU are associated with a high risk for NOM failure.

Introduction of a simple technique for partial splenectomy in multiple trauma patients

Background:

The spleen is the most commonly injured intraperitoneal organ in multiple trauma patients. Total splenectomy results in immunodeficiency and predisposes patients to certain infections.

Objectives:

Performing partial splenectomy with a safe, simple, and definite technique in trauma patients with hemodynamic instability and accompanying intra-abdominal injury could play an important role in the preservation of immune function and reducing morbidity.

Patients and Methods:

From 2006 to 2009, a total of 20 patients underwent partial splenectomy, at Mobasher and Be’sat hospitals. Patients with splenic injuries of up to stage IV and grade 3 shocks underwent partial splenectomy. The operations were performed without vascular isolation and by wedge resection of the injured splenic tissue and repair with chromic 2/0 sutures in two rows. Three months later, patients were evaluated by a Tc99 liver-spleen scan, complete blood count, and blood smear.

Results:

There were 16 male and four female patients with an age range of 4 to 54 years old. Ten patients had additional intra and extra abdominal injuries. The salvaged spleen tissue was approximately 30% in nine patients, 40 to 50% in two, and more than 50% in another nine patients. The operation time was less than three hours and hospital stay was 3 to 15 days for 90% of the patients. No complications occurred after the surgery or during the follow up. For all patients, the complete blood count, peripheral smear, and liver-spleen scan were normal after six months.

Conclusions:

Partial splenectomy with preserving at least 30% of the splenic tissue can be performed for trauma patients using wedge resection of the injured splenic tissue and repair by chromic 2/0 sutures in two rows. Using this technique, there is no need for vascular isolation or hemostatic materials. Splenic function is presented and associated intra and extra abdominal injuries are not contraindications for partial splenectomy.

Follow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children

OBJECTIVE

Current APSA recommendations for blunt spleen/liver injury (BSLI) entail bedrest equal to grade of injury plus one. We reported our experience 3 years ago with a prospectively implemented abbreviated protocol, one concern of which was that more numbers would be needed to support the safety of such a protocol. We are now reporting the final experience with this protocol as we move forward with further investigation.

METHODS

Following IRB approval, data were collected prospectively in all patients with BSLI up to 8 weeks after discharge. There were no exclusion criteria, and patient accrual was consecutive. Bedrest was restricted to one night for Grade I & II injuries and two nights for Grade ≥ III.

RESULTS

Between 11/2006 and 10/2012, 249 patients were admitted with BSLI. Mean age and weight were 10.3±4.8 years and 40.1±19.8 kg, respectively. Injuries included isolated spleen in 130 (52%), liver only in 107 (43%), and both in 12 (5%). One splenectomy was required for a grade V injury. Transfusions were used in 40 patients (16%), with 28 (11%) due to the injured solid organ. Bedrest for solid organ injury was applicable to 199 patients (80%), for which the mean grade of injury was 2.7±1.0 and mean bedrest was 1.6±0.6 days, resulting in 2.5±1.9 days of hospitalization. The need for bedrest was the limiting factor for length of stay in 155 patients (62%), for which mean grade of injury was 2.5±1.0 and mean bedrest was 1.6±0.6 days, resulting in 1.7±0.8 days of hospitalization. There were 4 deaths, 3 from brain injury and 1 from grade V liver injury. There were no patients readmitted for complications of solid organ injury.

CONCLUSIONS

These data further validate that an abbreviated protocol of one night of bedrest for grade I and II injuries and two nights for grade ≥ III can be safely employed, resulting in dramatic decreases in hospitalization compared to the current APSA recommendations.

Traumatic hepatic artery laceration managed by transarterial embolization in a pediatric patient

While blunt abdominal trauma with associated liver injury is a common finding in pediatric trauma patients, hepatic artery transection with subsequent treatment by transarterial embolization has rarely been reported. We present a case of a child who suffered from a hepatic artery injury which was successfully managed by supraselective transarterial microcoil embolization, discuss management strategies in these patients, and provide a review of currently available literature.

Validation of rules to predict emergent surgical intervention in pediatric trauma patients

BACKGROUND

Trauma centers use guidelines to determine when a trauma surgeon is needed in the emergency department (ED) on patient arrival. A decision rule from Loma Linda University identified patients with penetrating injury and tachycardia as requiring emergent surgical intervention. Our goal was to validate this rule and to compare it with the American College of Surgeons' Major Resuscitation Criteria (MRC).

STUDY DESIGN

We used data from 1993 through 2010 from 2 level 1 trauma centers in Denver, CO. Patient demographics, injury severity, times of ED arrival and surgical intervention, and all variables of the Loma Linda Rule and the MRC were obtained. The outcome, emergent intervention (defined as requiring operative intervention by a trauma surgeon within 1 hour of arrival to the ED or performance of cricothyroidotomy or thoracotomy in the ED), was confirmed using standardized abstraction. Sensitivities, specificities, and 95% confidence intervals were calculated.

RESULTS

There were 8,078 patients included, and 47 (0.6%) required emergent intervention. Of the 47 patients, the median age was 11 years (interquartile range [IQR] 7 to 14 years), 70% were male, 30% had penetrating mechanisms, and the median Injury Severity Score (ISS) was 25 (IQR 9 to 41). At the 2 institutions, the Loma Linda Rule had a sensitivity and specificity of 69% (95% CI 45% to 94%) and 76% (95% CI 69% to 83%), respectively, and the MRC had a sensitivity and specificity of 80% (95% CI 70% to 92%) and 81% (95% CI 77% to 85%), respectively.

CONCLUSIONS

Emergent surgical intervention is rare in the pediatric trauma population. Although precision of predictive accuracies of the Loma Linda Rule and MRC were limited by small numbers of outcomes, neither set of criteria appears to be sufficiently accurate to recommend their routine use.

Pediatric Pancreatic Trauma: Trending toward Nonoperative Management?

Pancreatic trauma is rare in children and optimal care has not been defined. We undertook this study to review the cumulative experience from three centers. After obtaining Institutional Review Board approval at each site, the trauma registries of three institutions were searched for pancreatic injuries. The charts were reviewed and data pertaining to demographics, hospital course, and outcome were obtained and analyzed. During the study period, a total of 79 pancreatic injuries were noted. The most common mechanism of injury was motor vehicle crash (44%) followed by child abuse (11%) and bicycle crashes (11%). Computed tomographic (CT) scans were obtained in 95 per cent with peripancreatic fluid the most common finding. Median Injury Severity Score (ISS) was 9, whereas median organ injury score was 2, and a higher grade correlated with need for operation ( P = 0.001). Pancreatic operations were performed in 32 patients, whereas non-operative management was noted in 47 cases. We noted no differences in length of stay, age, ISS, or initial blood pressure in operative versus nonoperatively managed cases. Pancreatic injuries were rare in children with trauma. CT scans were the most common method of diagnosis. Nonoperative management appeared to be safe and was more common, especially for the lower grade injuries.

Impact of operative intervention delay on pediatric trauma outcomes

BACKGROUND

Establishing quality indicators is an essential step in improving mortality and disability among pediatric patients with trauma. We hypothesized that timing of craniotomy, intracranial pressure (ICP) monitoring for traumatic brain injury, and abdominal operation for solid organ injury correlates with a reduced risk of death, shorter stay, and reduced risk of requiring assistance at discharge.

METHODS

This was a retrospective cohort study of 99,513 pediatric patients with trauma, using the National Trauma Data Bank.

RESULTS

For patients who had an ICP monitor placed within 4 hours compared with those whose ICP monitor was delayed, there was no difference in mortality; however, there was a shorter stay in the hospital (relative risk [RR], 0.84; 95% confidence interval (CI), 0.72-0.97) and in the intensive care unit (ICU) (RR, 0.76; 95% CI, 0.66-0.86) in those that survived to discharge. Patients who had craniotomy within 4 hours had higher mortality (RR, 1.98; 95% CI, 1.11-3.51) compared with those that were delayed. After excluding those that died, there was a shorter overall stay (RR, 0.69; 95% CI, 0.59-0.81) and ICU stay (RR, 0.69; 95% CI, 0.57-0.83). Similar length of stay results were seen in pediatric patients with solid organ injuries. Excluding those that died, length of stay (RR, 0.58; 95% CI, 0.47-0.73) and ICU stay (RR, 0.52; 95% CI, 0.37-0.74) were shorter.

CONCLUSION

Early intervention in those who survive their initial operation is associated with shorter ICU and hospital stay for traumatic brain and solid organ injuries.

LEVEL OF EVIDENCE

Therapeutic study, level III.

In-Hospital Treated Pediatric Injuries are Increasing in Finland — A Population Based Study between 1997 AND 2006

Background and Aims:

Injuries are an important public health problem as well as the leading cause of death and disability among children. Our aim was to longitudinally explore the incidence of in-hospital treated traumas, their operative treatment and related mortality among pediatric patients in Finland.

Methods:

The National Hospital Discharge Register and the Official Cause-of-Death Statistics data of in-hospital treated pediatric trauma patients between 1997 and 2006 in Finland were evaluated for hospitalizations, treatment modality and mortality.

Results:

Fractures (69%) and head injuries (28%) were the most common in-hospital treated traumas (477/100 000 persons/year). These were followed by injuries of intra-abdominal (1.4%), thoracic (1.2%) and urological organs (0.6%). Head traumas constituted 67% of injury-related deaths. During the ten-year follow-up period, the annual incidence (per 100 000 persons) of head injuries decreased by 13.6% (152 in 1997 vs. 131 in 2006, p < 0.0001) mainly contributing to a 30% decrease in overall injury-related mortality incidence (from 5.7 in 1997 to 4.0 in 2006, p = 0.0519). The overall trauma incidence, and incidence of fractures and abdominal injuries significantly increased by 5.0% (p < 0.0001), 13.5% (p < 0.0001) and 37% (p < 0.05), respectively, while the incidence of thoracic and urological injuries remained unchanged. Up to 15% of spleen injuries lead to splenectomy.

Conclusions:

Although overall and head trauma-related mortality is decreasing, the increasing incidence of fractures and abdominal injuries has amplified the overall incidence of severe injuries among children in Finland. A significant number of unnecessary splenectomies are still performed among children.

Prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children

PURPOSE

The aim of this study was to validate the safety, and quantify the impact of, an abbreviated protocol for blunt spleen/liver injury (BSLI), we instituted a prospective study with early ambulation.

METHODS

Following institutional review board approval, data were collected prospectively in all patients with BSLI up to 8 weeks after discharge. There were no exclusion criteria, and patient accrual was consecutive. Bedrest was restricted to 1 night for grade I and II injuries and 2 nights for grade III or higher.

RESULTS

A total of 131 patients with BSLI were enrolled. Injuries included isolated spleen in 72 (55%), liver only in 55 (42%), and both in 4 (3%). One splenectomy was required for a grade 5 injury. Transfusions were used in 24 patients, with 18 patients undergoing transfusion because of injured solid organ. Bedrest was applicable to 110 patients (84%), for which the mean grade of injury was 2.6 and mean bedrest was 1.6 days. The need for bedrest was the limiting factor for length of stay in 86 patients (66%). There were 2 deaths, and no patients were readmitted.

CONCLUSIONS

An abbreviated protocol of 1 night of bedrest for grade I and II injuries and 2 nights for grade III or higher can be safely used, resulting in dramatic decreases in hospitalization compared with the current American Pediatric Surgical Association recommendations.

The failure rate of nonoperative management in children with splenic or liver injury with contrast blush on computed tomography: a systematic review

PURPOSE

Nonoperative management (NOM) is the treatment of choice for hemodymically stable pediatric patients with spleen or liver trauma. The aim of this study was to assess the failure rate of NOM in children with blunt liver and/or splenic injury when a contrast blush is present on a computed tomography (CT) scan.

METHODS

A systematic review of the literature published between 1985 and 2009 was performed by searching the EMBASE and MEDLINE database for English and German articles. Articles were eligible if they reported the failure rate of NOM with or without angioembolization (AE) in pediatric patients with splenic and/or liver injuries with a contrast blush on CT and included 2 or more trauma patients. Two reviewers independently assessed the eligibility and the quality of the articles and performed the data extraction. Interrater differences were resolved by discussion.

RESULTS

Nine studies were included describing 117 pediatric patients. The median sample size was 5 (range, 2-44). Seven studies (including 71 patients) reported a total of 16 patients with failure after NOM without AE. Failure rates across these studies ranged from 4.5% to 100%; the pooled percentage was 28.2% (95% confidence interval, 8.9%-61.3%). The failure percentages after NOM with or without AE ranged from 0 to 100%; the pooled percentage was 21% (95% confidence interval, 7.5%-46.8%). Two studies (including 46 patients) reported a total of 3 patients (6.5%) with failure after NOM with primary AE.

CONCLUSION

Despite the current low level of evidence on failure rate of NOM when a contrast blush is present on CT, we emphasize that there is a significant number of patients in whom NOM fails. We therefore recommend that the management of splenic and hepatic injury in children should not only be based on the physiologic response but should include consideration of the presence of a contrast blush.

The nature and characteristics of abdominal injuries sustained during children's sports

OBJECTIVE

To increase the evidence base by characterizing various features of pediatric sports-related abdominal injuries.

DESIGN

A review of the trauma database at The Children's Hospital at Westmead was undertaken for all abdominal injuries presenting to the emergency department between 2001 and 2006.

SETTING

The Children's Hospital at Westmead is a tertiary-level pediatric trauma center servicing Sydney's west. It sees approximately 50,000 patients a year.

PARTICIPANTS

Only those injuries occurring during an organized sport were included for analysis. Thirty-three of the original 513 patients were eligible for inclusion.

MAIN OUTCOME MEASURES

The data collected included basic demographics, mechanism of injury, sport injury, time to presentation, length of stay, diagnoses, treatment, and complications. Injury severity scores were assigned retrospectively.

RESULTS

Males sustained more injuries than females. Collisions and falls were the most common modes of injury. Rugby was the most common sport for injury. Most patients presented within 12 hours, and most presented with musculoskeletal injuries. Injury severity was usually mild; treatment, conservative; length of stay, short; and complications, uncommon. When characteristics were compared by sex, males had mostly collision injuries in high-impact/contact sports, with females having more falls in other sports. When characteristics were compared by age, the only statistically significant difference was in the organ injured: older children had more single solid organ injuries, and younger children had more multiple and hollow viscus injuries.

CONCLUSIONS

Sports-related abdominal injuries in children are mostly minor and not as common as other injury mechanisms. Despite this, they can be serious, with early diagnosis often delayed because of their subtle nature. Sports-related abdominal injuries in children require a high index of suspicion in the part of the clinician if they are to be recognized early and managed effectively.

Pediatric blunt splenic trauma: a comprehensive review

Abdominal trauma is a leading cause of death in children older than 1 year of age. The spleen is the most common organ injured following blunt abdominal trauma. Pediatric trauma patients present unique clinical challenges as compared to adults, including different mechanisms of injury, physiologic responses, and indications for operative versus nonoperative management. Splenic salvage techniques and nonoperative approaches are preferred to splenectomy in order to decrease perioperative risks, transfusion needs, duration/cost of hospitalization, and risk of overwhelming postsplenectomy infection. Early and accurate detection of splenic injury is critical in both adults and children; however, while imaging findings guide management in adults, hemodynamic stability is the primary determinant in pediatric patients. After initial diagnosis, the primary role of imaging in pediatric patients is to determine the level and duration of care. We present a comprehensive literature review regarding the mechanism of injury, imaging, management, and complications of traumatic splenic injury in pediatric patients. Multiple patients are presented with an emphasis on the American Association for the Surgery of Trauma organ injury grading system. Clinical practice guidelines from the American Pediatric Surgical Association are discussed and compared with our experience at a large community hospital, with recommendations for future practice guidelines.

[Thoracic and abdominal trauma in children]

Knowledge of the characteristics of thoraco-abdominal trauma in children is important to optimize the imaging work up while keeping radiation exposure to a minimum. Because of the plasticity of the pediatric rib cage, rib fractures are infrequent, and severe parenchymal injuries may be present in the absence of rib fracture. Mediastinal injuries are unusual. The increased mobility of solid intraabdominal organs combined with a weaker abdominal wall are specific to pediatric patients. First-line imaging typically includes chest radiograph and abdominal US with Doppler imaging. Contrast-material enhanced CT is used as a second-line technique, with delayed imaging in patients with urinary tract lesions. Dedicated pediatric acquisition protocols are mandatory. Follow-up is obtained mainly with US.

Review of the evidence on the management of blunt renal trauma in pediatric patients

Due to the size and location within the pediatric patient, the kidneys are susceptible to injury from blunt trauma. While it is clear that the goal of management of blunt renal trauma in children is renal preservation, the methods of achieving this goal have not been well established in the current literature. Therefore, we have set out to summarize and clarify the current published information on the management strategies for blunt renal trauma in children. While there is extensive literature available, it consists mostly of retrospective series documenting widely varied management styles. The purpose of this review is to display the current information available and delineate the role for future studies that may allow us to develop consistent management strategies of pediatric patients, who have sustained blunt renal trauma, in a safe and cost-effective manner.

Pediatric transfusion medicine: development of a critical mass

Many significant events have occurred in the recent past that beg a broad audience to address the question "What is pediatric transfusion medicine?" Herein, we list some of these events and their relevance below and attempt to provide an answer for this question. Indeed, several issues regarding the subspecialty of pediatric transfusion medicine (PTM) are particularly timely, and it appears that a critical mass, or a nidus capable of becoming a critical mass, is developing in PTM.

Management of High-Grade Splenic Injury in Children

Using the National Trauma Databank, we identified 413 children (age ≤ 14 years) who sustained high-grade blunt splenic injury (Abbreviated Injury Scale scores ≥4) from 2001 to 2005. Overall mortality was 13.5 per cent. Early operation within 6 hours of injury (EOM) was performed in 128 patients (31%). Patients not undergoing EOM (n = 285) were assumed to have been treated with initial nonoperative management (NOM). NOM was successful in 84 per cent of patients. Operative intervention was necessary in 42 per cent of cases with 74 per cent of these undergoing early operation (EOM). Total splenectomy was the most common procedure (83%). EOM and failure of NOM were both associated with lower systolic blood pressure and lower Glasgow Coma Scale score at admission, higher Injury Severity Score, longer hospital stay, and higher mortality. Need for surgery was independent of patient age and gender. Failure of NOM was associated with increased mortality compared with successful NOM, but had similar mortality and length of hospital or intensive care unit stay compared with EOM. We conclude that operative treatment is necessary in nearly half of pediatric patients with high-grade splenic injury. With careful selection, nonoperative management is usually successful but must include close monitoring, because 16 per cent required delayed operation.