1. Management of Spleen/Liver Trauma George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, MO

2. Mechanisms for Intra-abdominal Trauma 1. Motor vehicle collisions 2. Automobile vs pedestrian accidents 3. Falls 4. ATV 5. Handlebar injury from bicycle 6. Sports 7. Non-accidental trauma

3. Frequency of Pediatric Blunt Abdominal Injuries Spleen 27% Kidney 27% Liver 15% Pancreas 2%

4. Splenic Trauma Diagnosis: Plain abdominal film Unreliable and nonspecific Triad of radiographic findings in acute splenic rupture Left diaphragmatic elevation Left lower lobe atelectasis Left pleural effusion Radiograph demonstrates a left pleural effusion, left basilar atelectasis, and inferomedial displacement of the splenic flexure (arrow)

5. Splenic Trauma Diagnosis: FAST Focused Abdominal Sonography for Trauma Bedside study for unstable patient 15% false-negative May miss up to 25% of liver and spleen injuries Compared to CT only 63% sensitive for detecting free fluid Fluid in the subphrenic space and splenorenal recess can be detected. The image shown demonstrates blood (arrow) between the spleen (S) and diaphragm (D).

6. Splenic Trauma Diagnosis: CT with IV contrast Noninvasive, highly accurate, easily identifies and quantifies extent of injury, for stable patient only A: Hemoperitoneum with a liver laceration (arrow) and a shattered spleen is seen.

7. AAST Splenic Injury Scale *Advance one grade for multiple injuries, up to grade III Moore EE, Cogbill TH, Jurkovich GJ, et al

8. AAST Splenic Injury Scale 17-yo boy injured on an ATV. Grade I injury with subcapsular fluid occupying less than 10% of spleen’s surface area.

9. AAST Splenic Injury Scale 17-yo girl injured in an MVC. Grade II injury with laceration involving less than 3 cm of parenchymal depth

10. AAST Splenic Injury Scale 18-yo boy injured playing football. Lacerations involving more than 3 cm of parenchymal depth radiating from splenic hilum -grade III laceration

11. AAST Splenic Injury Scale 16-yo boy injured playing hockey. Fractured spleen involving more than 25%, Grade IV splenic laceration

12. AAST Splenic Injury Scale 12-yo boy pedestrian struck by MV. Fractured spleen with hilar devascularization. Grade V injury.

13. Splenic Trauma Complications Pseudoaneurysms Often asymptomatic and resolve over time If treatment required, angiographic embolization may be used Also occur in liver trauma A.Splenic pseudoaneurysm (arrowheads) after nonoperative treatment of blunt splenic injury. B.Successful angiographic embolization The microcatheter used to deploy the coils is marked by the arrowheads and the embolic coils are marked by the arrows.

14. Splenic Trauma Complications Pseudocysts Rare: 0.44% May become large and painful Tx: laparoscopic excision and marsupialization

15. Splenic Trauma Immunocompetence Vaccination practices vary Adult trauma evidence supports immunocompetence in healed grade IV injuries

16. Splenic Trauma If splenectomy is indicated Pt requires vaccinations prior to discharge Streptococcus pneumoniae Pneumovax 23 Haemophilus influenzae type B Hib vaccine Neisseria meningitidis Quadravalent meningococcal/diphtheria conjugate Prophylactic antibiotics controversial Most centers use penicillin

17. Splenic Trauma Treatment Nonoperative failure rate 2% Risks for increased nonoperative failure rate Bicycle-related injury mechanism More than one solid organ injury Peaks at 4 hrs, declines at 36hrs after admission

18. Contrast Blush - Spleen 216 Pts – 7 yrs 26 Pts – Contrast blush on CT scan Lower HgB More likely to need op (22% vs 4%) Not a definite indication for operation, but indicates subset of pts who have active bleeding and may need transfusion and/or operation Blunt Splenic Injury

19. Liver Trauma Blunt trauma is most common cause of injury to liver High risk due to: Large organ, friable parenchyma, ligamentous attachments

21. AAST Liver Injury Grading Grade I Grade IV

22. Types of Injury Parenchymal damage/laceration Subcapsular hematoma/contusion Hepatic vascular disruption – contrast extravasation Bile duct injury

23. Diagnosis Physical exam – ±tachycardia, ±hypotention, peritoneal irritation FAST – better for unstable patients not stable enough for CT 1 CT w contrast determine grade and look for active extravasation 1 Coley et al. J Trauma 2000

24. Contrast Blush - Liver 105 pts – blunt liver injury – 6 yrs 75 pts – Grade III – V 22 pts – Contrast blush transfusion req. mortality (23% vs 4%) ISS also Mortality may be related to the other injuries

25. Indication for Intervention Operate for continued blood loss with hypotension, tachycardia, decreased urine output, decreasing Hg unresponsive to IVF and pRBC Operative rates 3-11% for multiple injuries 0-3% for isolated liver injury Angioembolization – not used as commonly as in adults

26. Bile Duct Injury With nonoperative management, 4% risk of persistent bile leak HIDA with delayed images if bile duct injury suspected ERCP with decompression and stenting – can be diagnostic and therapeutic

27. 72 pts 30 – Liver 44 – Spleen Liver vs spleen – Longer recovery period Nine complications Greater use of resources J Pediatr Surg 43:2264-2267, 2008

28. APSA Guidelines CT GRADEIIIIIIIV Days in ICUNone 1 day Hospital stay2 days3 days4 days5 days Predischarge imaging None Postdischarge imaging None Activity restrictions 3 weeks4 weeks5 weeks6 weeks From Stylianos S, and APSA Trauma Committee: Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. APSA guidelines for hemodynamically stable children with isolated spleen or liver injury J Pediatr Surg 35:164-169, 2000

29. Prospective study all pts with BSLI No exclusions Bedrest :Grade I – II inj – 1 night Grade III – V inj – 2 nights J Pediatr Surg 46:173-177, 2011

30. Prospective Study - BSLI 131 pts (spleen only 72, liver only 55 1 splenectomy (Grade V inj) Transfusions – 24 (18 due to BSLI) Mean injury grade – 2.6 Mean bed rest – 1.6 days Need for bed rest limiting factor in duration of hospital in 86 pts (66%) J Pediatr Surg 46:173-177, 2011

31. Prospective Study – BSLI An abbreviated protocol of 1 night for Grade I – II injuries and 2 nights for Grade III or higher in hemodynamically stable pts is safe and significantly decreases hospitalization c/w previous APSA recommendations.

32. Solid Organ Injury Treatment > 90% of hemodynamically stable pts successfully managed non-operatively Less than 10% require transfusion

33. References Coley BD, Mutabagani KH, Martin LC, Zumberge N, Cooney DR, Caniano DA, Besner GE, Groner JI, Shiels WE 2nd. Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma. J Trauma. 2000 May;48(5):902-6. Holcomb GW III, Murphy JP. Ashcraft’s Pediatric Surgery. 5 th ed. Philadelphia, PA: Saunders An Imprint of Elsevier, 2010. Lynn KN, Werder GM, Callaghan RM, Sullivan AN, Jafri ZH, Bloom DA. Pediatric blunt splenic trauma: a comprehensive review. Pediatr Radiol (2009) 39:904-916. Moore EE, Cogbill TH, Jurkovich GJ, et al: Organ injury scaling: Spleen and liver (1994 revision). J Trauma 38:323-324, 1995 Sabiston DC II, Townsend CM III. Sabiston Textbook of Surgery. 18 th ed. Philadelphia, PA: Saunders An Imprint of Elsevier, 2007. Stylianos S. Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. The APSA Trauma Committee. J Pediatr Surg. 2000 Feb;35(2):164-7. Tataria M, Nance ML, Holmes JH 4 th, Miller CC 3 rd, Mattix KD, Brown RL, Mooney DP, Scherer LR 3 rd, Grooner JI, Scaife ER, Spain DA, Brundage SI. Pediatric blunt abdominal injury: age is irrelevant and delayed operation is not detrimental. J Trauma 2007 Sep;63(3):608-14.

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