Management of Spleen/Liver Trauma George W. Holcomb, III, M.D., MBASurgeon-in-ChiefChildrens Mercy HospitalKansas City, MO

Mechanisms for Intra-abdominal TraumaMotor vehicle collisionsAutomobile vs pedestrian accidentsFallsATVHandlebar injury from bicycleSportsNon-accidental trauma

Frequency of Pediatric Blunt Abdominal InjuriesSpleen 27%Kidney 27%Liver 15%Pancreas 2%

Splenic TraumaDiagnosis: Plain abdominal filmUnreliable and nonspecificTriad of radiographic findings in acute splenic ruptureLeft diaphragmatic elevationLeft lower lobe atelectasisLeft pleural effusionRadiograph demonstrates a left pleural effusion, left basilar atelectasis, and inferomedial displacement of thesplenic flexure (arrow)

Splenic TraumaDiagnosis: FASTFocused Abdominal Sonography for TraumaBedside study for unstable patient15% false-negativeMay miss up to 25% of liver and spleen injuriesCompared 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).

Splenic TraumaDiagnosis: CT with IV contrastNoninvasive, highly accurate, easily identifies and quantifies extent of injury, for stable patient onlyA: Hemoperitoneum with a liver laceration (arrow) and a shattered spleen is seen.

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

AAST Splenic Injury Scale17-yo boy injured on an ATV. Grade I injury with subcapsular fluid occupying less than 10% of spleens surface area.

AAST Splenic Injury Scale17-yo girl injured in an MVC. Grade II injury with laceration involving less than 3 cm of parenchymal depth

AAST Splenic Injury Scale18-yo boy injured playing football. Lacerations involving more than 3 cm of parenchymal depth radiating from splenic hilum -grade III laceration

AAST Splenic Injury Scale16-yo boy injured playing hockey. Fractured spleen involving more than 25%, Grade IV splenic laceration

AAST Splenic Injury Scale12-yo boy pedestrian struck by MV. Fractured spleen with hilar devascularization. Grade V injury.

Splenic TraumaComplicationsPseudoaneurysmsOften asymptomatic and resolve over timeIf treatment required, angiographic embolization may be usedAlso occur in liver trauma

Splenic pseudoaneurysm (arrowheads) after nonoperative treatment of blunt splenic injury. Successful angiographic embolization The microcatheter used to deploy the coils is marked by the arrowheads and the embolic coils are marked by the arrows.

Splenic TraumaComplicationsPseudocystsRare: 0.44%May become large and painfulTx: laparoscopic excision and marsupialization

Splenic TraumaImmunocompetence Vaccination practices varyAdult trauma evidence supports immunocompetence in healed grade IV injuries

Splenic TraumaIf splenectomy is indicatedPt requires vaccinations prior to dischargeStreptococcus pneumoniaePneumovax 23Haemophilus influenzae type BHib vaccineNeisseria meningitidisQuadravalent meningococcal/diphtheria conjugateProphylactic antibiotics controversialMost centers use penicillin

Splenic TraumaTreatmentNonoperative failure rate 2%Risks for increased nonoperative failure rateBicycle-related injury mechanismMore than one solid organ injuryPeaks at 4 hrs, declines at 36hrs after admission

Contrast Blush - Spleen216 Pts 7 yrs26 Pts Contrast blush on CT scanLower HgBMore 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 operationBlunt Splenic Injury

Liver TraumaBlunt trauma is most common cause of injury to liverHigh risk due to:Large organ, friable parenchyma, ligamentous attachments

AAST Liver Injury GradingGrade IGrade IV

Types of InjuryParenchymal damage/lacerationSubcapsular hematoma/contusionHepatic vascular disruption contrast extravasationBile duct injury

DiagnosisPhysical exam tachycardia, hypotention, peritoneal irritationFAST better for unstable patients not stable enough for CT1CT w contrast determine grade and look for active extravasation1Coley et al. J Trauma 2000

Contrast Blush - Liver105 pts blunt liver injury 6 yrs75 pts Grade III V22 pts Contrast blush transfusion req. mortality (23% vs 4%) ISS alsoMortality may be related to the other injuries

Indication for InterventionOperate for continued blood loss with hypotension, tachycardia, decreased urine output, decreasing Hg unresponsive to IVF and pRBCOperative rates3-11% for multiple injuries0-3% for isolated liver injuryAngioembolization not used as commonly as in adults

Bile Duct InjuryWith nonoperative management, 4% risk of persistent bile leakHIDA with delayed images if bile duct injury suspectedERCP with decompression and stenting can be diagnostic and therapeutic

72 pts30 Liver44 Spleen

Liver vs spleen Longer recovery periodNine complicationsGreater use of resourcesJ Pediatr Surg 43:2264-2267, 2008

APSA GuidelinesFrom 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 injuryJ Pediatr Surg 35:164-169, 2000

CT GRADEIIIIIIIVDays in ICUNoneNoneNone1 dayHospital stay2 days3 days4 days5 daysPredischarge imagingNoneNoneNoneNonePostdischarge imagingNoneNoneNoneNoneActivity restrictions3 weeks4 weeks5 weeks6 weeks

Prospective study all pts with BSLINo exclusionsBedrest :Grade I II inj 1 nightGrade III V inj 2 nights

J Pediatr Surg 46:173-177, 2011

Prospective Study - BSLI131 pts (spleen only 72, liver only 551 splenectomy (Grade V inj)Transfusions 24 (18 due to BSLI)Mean injury grade 2.6Mean bed rest 1.6 daysNeed for bed rest limiting factor in duration of hospital in 86 pts (66%)J Pediatr Surg 46:173-177, 2011

Prospective Study BSLIAn 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.

Solid Organ InjuryTreatment> 90% of hemodynamically stable pts successfully managed non-operativelyLess than 10% require transfusion

ReferencesColey 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. Ashcrafts Pediatric Surgery. 5th 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, 1995Sabiston DC II, Townsend CM III. Sabiston Textbook of Surgery. 18th 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 4th, Miller CC 3rd, Mattix KD, Brown RL, Mooney DP, Scherer LR 3rd, 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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****Finally, until a more efficacious, more cost effective and more efficient (with regard to health care providers and families) antibiotic regimen is identified, this study supports the use of single day dosing of ceftriaxone/metronidazole as the initial treatment regimen in children with perforated appendicitis.