The American Journal of Surgery (2015) 210, 345-350
Clinical Science
Contrast blush in pediatric blunt splenic trauma does not warrant the routine use of angiography and embolization Samiksha Bansal, M.D.a, Frederick M. Karrer, M.D.b, Kristine Hansen, D.S.b, David A. Partrick, M.D.b,* a
Department of Pediatric Surgery, Cardinal Glennon Children’s Medical Center, St Louis, MO 63104, USA; bDepartment of Pediatric Surgery, Children’s Hospital Colorado, 13123 East 16th Avenue, Aurora, CO 80045, USA
KEYWORDS: Pediatric; Splenic trauma; Contrast blush; Angiographic embolization
Abstract BACKGROUND: Splenic artery embolization (SAE) in the presence of contrast blush (CB) has been recommended to reduce the failure rate of nonoperative management. We hypothesized that the presence of CB on computed tomography has minimal impact on patient outcomes. METHODS: A retrospective review was conducted of all children (,18 years) with blunt splenic trauma over a 10-year period at a level 1 pediatric trauma center. Data are presented as mean 6 standard error of mean. RESULTS: Seven hundred forty children sustained blunt abdominal trauma, of which 549 had an identified solid organ injury. Blunt splenic injury was diagnosed in 270 of the 740 patients. All patients were managed nonoperatively without SAE. CB was seen on computed tomography in 47 patients (17.4%). There were no significant differences in the need for blood transfusion (12.5% vs 11.1%) or length of stay (3.1 vs 3.3 days) or need for splenectomy when compared in children with or without CB. CONCLUSION: Pediatric trauma patients with blunt splenic injuries can be safely managed without SAE and physiologic response and hemodynamic stability should be the primary determinants of appropriate management. Ó 2015 Elsevier Inc. All rights reserved.
The authors declare no conflicts of interest. There were no relevant financial relationships or any sources of support in the form of grants, equipment, or drugs. This manuscript has been seen and approved by all the authors and the material is previously unpublished. * Corresponding author. Tel.: 11-720-777-6571; fax: 1-720-777-7271. E-mail address: [email protected] Manuscript received March 19, 2013; revised manuscript September 24, 2014 0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2014.09.028
Trauma is the leading cause of childhood death (age , 18 years) with an annual mortality rate of greater than 20,000.1 Blunt trauma accounts for 90% of childhood injuries, resulting most commonly in head and limb injury followed by abdominal trauma in up to 8% of the cases. The spleen is the most commonly injured intra-abdominal organ. The management of pediatric blunt splenic trauma has undergone a major paradigm shift in the last 4 decades. Nonoperative management (NOM) of pediatric splenic trauma was first described in 1968 by Upadhyaya and
346 Simpson.2 It is the current standard of care for hemodynamically stable children, because of high success rates without the morbidity and mortality associated with operative management, and avoiding long-term infectious sequelae from splenectomy. Guidelines for such conservative management of blunt splenic, hepatic, and renal trauma are well established.3,4 Presence of contrast blush (CB) on computed tomography (CT) has been cited as a risk factor for the failure of NOM in the adult literature,5 and splenic artery embolization (SAE) has been recommended and increasingly used in such cases.6 Although few studies have addressed the significance of CB in pediatric splenic trauma in the past,7 an increasing number of institutions continue to adopt a protocol using angiography and embolization in the presence of active extravasation of contrast on initial abdominal CT scan in children. We hypothesized that the presence of CB on abdominal CT has little impact on patient outcomes in the pediatric population. The purpose of our study was to review our management of splenic injuries in children sustaining blunt abdominal trauma and evaluate the frequency and need for SAE in the presence of CB.
Patients and Methods Institutional Review Board approval was obtained before initiation of the study. Records of all children younger than 18 years of age who were admitted to the trauma service at Children’s Hospital Colorado (CHCO), a level I pediatric trauma center, with documented blunt abdominal trauma over a 10-year period (2002 to 2011) were identified using the trauma registry. All patients with splenic injury documented by abdominal CT were included in the study. These patients included those with isolated splenic injury as well as splenic injury associated with multisystem trauma. Data were analyzed separately for isolated splenic injury patients. Patients were divided into 2 groups based on the absence or presence of CB. Only the patients with high-grade (grades 3 to 5) splenic injuries were included for this analysis as CB was only seen with high-grade injuries. Injury grade was determined according to the American Association for the Surgery of Trauma (AAST) solid injury scale.8 CB was reported when a wellcircumscribed area of contrast extravasation, hyperdense with respect to the surrounding parenchyma, was present on CT.9 Demographics, admission, and management parameters were abstracted from the electronic medical record. Current diagnosis and procedural codes were used for the database search. Study data were collected and managed using REDCap electronic data capture tools hosted at CHCO. Data collected included preadmission variables such as age, sex, mechanism of trauma, clinical and laboratory parameters at presentation, associated injuries, injury severity score, radiographic findings including the presence of CB on abdominal CT; management variables such as type of intervention, need for laparotomy, length of
The American Journal of Surgery, Vol 210, No 2, August 2015 intensive care unit (ICU) stay, total hospital stay, need for blood transfusion, and complications including readmissions and mortality. Criteria for laparotomy were hemodynamic instability with evidence of massive bleeding on presentation or children who required transfusion of more than half of their blood volume within 24 hours of injury. The medical records of the pediatric trauma patients identified as requiring laparotomy were reviewed to confirm the details of the operation performed. The need for transfusion was decided by the surgical team members based on the fall in hematocrit and hemodynamic status of the patient. Hemodynamic stability was determined based on age-appropriate ranges for heart rate and blood pressure measurements. At CHCO, injured children are initially evaluated by a team of emergency physicians, general surgery residents, and pediatric surgery fellows directly supervised by pediatric surgery attendings, who provide 24-hour inhospital coverage. An abdomino-pelvic CT was obtained shortly after arrival for all hemodynamically stable patients with suspected blunt abdominal trauma. CTs were interpreted by board-certified pediatric radiologists. Patients were stratified according to their AAST injury grade based on the imaging findings and further management was decided based on an institutional solid organ injury protocol. Management decisions were overseen by the pediatric surgery attending throughout the hospital stay. Statistical significance was determined using Fisher’s exact test, Student t test, and continuous data were compared using analysis of variance. Data are reported as the mean 6 standard error of mean, and P value less than .05 was considered statistically significant.
Results During the study period from 2002 to 2011, there were 740 pediatric patients who sustained blunt abdominal trauma, of which 549 (74%) had an identified solid organ injury. Blunt splenic injury was diagnosed in 270 (49%) patients, of whom 143 had isolated splenic trauma and 127 sustained multiorgan injuries. Forty-three percent of our patients were transferred from outside hospitals. Time from injury to presentation to our hospital varied between 3 and 16 hours with an average of 5.6 hours. Mean age of the study patients was 9.5 6 .3 years; 193 (71%) were boys and the mean injury severity score of all patients was 17.8 6 .7. The mechanism of injury for the entire patient population is depicted in Fig. 1. Sports-related injury was the most common mechanism of injury (22%), followed closely by motor vehicle collision (21%), falls (15%), and pedestrian-related injuries (11%). Although sports-related mechanisms were responsible for most of the isolated splenic injuries (34%), motor vehicle collisions were the leading cause of splenic injury in multisystem trauma patients (38%). Associated extra-abdominal injuries included 42 patients with traumatic brain injury (41%), 32 with thoracic (31%), and 39 with
S. Bansal et al.
Figure 1
Contrast blush in pediatric splenic injuries
Mechanism of injury for the entire study population.
extremity injuries (38%). Patients were divided into AAST splenic injury grades, and various admission and outcome parameters were analyzed as shown in Table 1. Grade 5 splenic injuries were only seen in multisystem trauma patients and motor vehicle collision was the mechanism of injury in all these cases. Length of stay was directly related to the grade of injury in isolated splenic trauma patients and was significantly higher for patients with grade 3 and 4 splenic injuries. There were no significant differences in length of intensive care unit stay and total hospital stay for multisystem trauma patients; for these patients, the associated traumatic brain injury and/or traumatic pulmonary insult dictated level of care and the length of stay. Blood transfusion was used in 6.3% of isolated splenic injury
Table 1
347 patients compared with 34.6% of multisystem trauma patients; for the majority of these patients, the transfusion need was driven by injuries other than splenic trauma. We had 12 deaths in the study population, all of which were unrelated to the splenic injury. Nine patients died secondary to traumatic brain injury; 2 patients died because of chest trauma and 1 child died from a high-grade liver injury with cardiopulmonary arrest. Admission and outcome parameters were further analyzed in 160 (59%) high-grade3–5 splenic injury patients to determine if the presence of CB was associated with worse outcomes (Table 2). CB was seen in 47 patients (25 in grade 3, 19 in grade 4, and 3 in grade 5 injuries) comprising 17.4% of the study population. Of the 47 patients with CB, only 7 patients were age 14 or greater. Among all the patients with CB, 28 had presence of intraparenchymal blush, 19 patients had free peritoneal extravasation, and none were found to have presence of pseudoaneurysm. Additionally, of the 47 patients with CB, 6 had small amount of hemoperitoneum, 17 had moderate, and 24 were found to have large amount of hemoperitoneum. Patients were managed based on their grade of splenic injury and hemodynamic stability, irrespective of the type of CB and amount of hemoperitoneum. Of the 160 patients with high-grade splenic injuries, 19 patients were hemodynamically unstable on initial presentation. Nine of these patients were brought to the operating room for an emergent exploratory laparotomy. Splenectomy was performed in 6 patients, one of which was performed at an outside institution before patient transfer. CB was present in only one of these 6 patients and the decision for
Demographics and outcome measure comparison for patients based on splenic injury grade
Grade of splenic injury
I
II
III
IV
V
No. of patients (n 5 270) Age (years) Men (%) ICU LOS (days) Isolated Multiorgan Total LOS (days) Isolated Multiorgan Mortality (%) Isolated Multiorgan Blood transfusion (%) Isolated Multiorgan Splenectomy (%) Isolated Multiorgan Presence of multiorgan injuries
34 8.7 6 .8 21 (62)
76 8.9 6 .9 53 (69)
88 9.6 6 .3 63 (71)
66 9.7 6 1.1 54 (81)
6 8.2 6 .7 4 (67)
.1 6 .02 2.7 6 .8
.1 6 .03 3.1 6 .7
.3 6 .07 3.2 6 1.1
1.1 6.4* 2.7 6 1.2
N/A 3.3 6 1.7
1.8 6 .6 7.3 6 1.9
1.6 6 .4 6.9 6 1.1
2.4 6 .6 6.6 6 1.1
4.2 6 .3* 5.9 6 1.2
N/A 6.2 6 1.6
0 2 (9)
0 4 (10)
0 2 (6)
0 2 (8)
N/A 2 (33)
0 12 (54)
0 15 (36)
4 (7) 6 (18)
5 (12)* 8 (32)
N/A 3 (50)
0 0 22 (65)
0 0 41 (54)
0 1 (3) 33 (37)
1 (2) 1 (4) 25 (38)
N/A 3 (50)* 6 (100)
ICU 5 intensive care unit; LOS 5 length of stay; NA 5 not applicable. *P , .05.
348
The American Journal of Surgery, Vol 210, No 2, August 2015
Table 2 injuries
Association between clinical and outcome parameters in the presence and absence of contrast blush in high-grade splenic
High-grade splenic injuries (n 5 160)
Presence of contrast blush (n 5 47)
Absence of contrast blush (n 5 113)
P value
Age Hemodynamically unstable (%) ISS Hematocrit at presentation Drop in hematocrit ICU LOS (days) Total LOS (days) Blood transfusion (%) Splenectomy (%) Mortality (%)
8.6 6 1.6 5 (11) 20.2 6 2.3 34 6 2.8 7.3 6 1.2 1.8 6 .5 5.1 6 .8 12 (25) 1 (2) 2 (4)
9.4 6 1.2 14 (12) 18.0 6 4.2 35 6 1.7 6.8 6 1.3 1.4 6 .7 4.1 6 1.3 24 (21) 5 (4) 4 (3)
NS NS NS NS NS NS NS NS ,.05 NS
ICU 5 intensive care unit; ISS 5 injury severity score; LOS 5 length of stay; NS 5 not significant.
laparotomy was made because of hemodynamic instability and the presence of associated injuries. One patient, whose splenectomy was performed at an outside institution, did not show the presence of CB on abdominal CT and splenectomy was performed before long-distance transfer, because of the presence of grade 5 splenic injury. All other patients were managed nonoperatively using a blunt splenic injury protocol without SAE irrespective of the presence or absence of CB. There were no statistically significant differences in the average drop in hematocrit, need for blood transfusion, and length of hospital stay between CB and no CB groups. Table 3 represents outcome parameters for isolated highgrade injury patients only in the presence and absence of CB. Again, as seen for the whole group, we did not see any statistically significant difference in the average drop in hematocrit, need for blood transfusion, and length of hospital stay between CB and no CB groups in isolated splenic trauma patients. Presence of contrast extravasation did not result in increased need for splenectomy. No patient experienced delayed splenic rupture and there were no delayed failures of NOM following initial resuscitation. There were no spleen-related deaths. Three patients were readmitted secondary to abdominal pain. Repeat abdominal CT in these patients found no evidence of rebleeding. One of these patients, whose initial scan did not show CB, was later
diagnosed with a splenic artery pseudoaneurysm; this was conservatively managed and self-resolved.
Comments Prior to 1960s, splenectomy was considered the standard treatment for blunt splenic injuries. The first reported series of children with blunt splenic trauma managed nonoperatively was published by Upadhyaya and Simpson in 1948. This idea persevered because of the documented risks of overwhelming postsplenectomy sepsis, because of known operative morbidity and mortality, and with the observation by surgeons that most splenic bleeding had ceased by the time of operative intervention.10 Douglas et al in 1971 and later Ein et al in 1978 reported their initial series suggesting a decrease in blood transfusion requirement and decreased mortality associated with nonoperative protocols, further supporting the nonoperative approach to blunt splenic trauma.11,12 These initial experiences led to the implementation of NOM protocols for solid organ injuries in children by the American Pediatric Surgical Association trauma committee in 2000. Today, NOM is the standard of care with success rates approaching 90% in most series.13 The higher success rate of NOM in children, when compared
Table 3 Association between clinical and outcome parameters in the presence and absence of contrast blush in isolated high-grade splenic injuries High-grade isolated splenic injuries (n 5 96)
Presence of contrast blush (n 5 24)
Absence of contrast blush (n 5 72)
P value
Age Hemodynamically unstable (%) ISS Hematocrit at presentation Drop in hematocrit ICU LOS (days) Total LOS (days) Blood transfusion (%) Splenectomy
9.3 6 .8 1 (4) 12.5 6 1.7 36 6 1.1 5.3 6 .9 .6 6 .5 3.1 6 .8 3 (12) 0
10.7 6 1.7 4 (5) 12.6 6 1.3 35 6 .9 4.8 6 1.1 .4 6 .1 3.3 6 .5 8 (11) 1 (1%)
NS NS NS NS NS NS NS NS ,.05
ICU 5 intensive care unit; ISS 5 injury severity score; LOS 5 length of stay; NS 5 not significant.
S. Bansal et al.
Contrast blush in pediatric splenic injuries
with adults, is thought to be because of a higher proportion of myoepithelial cells within the spleen, more efficient contraction and retraction of splenic arterioles, and a thicker splenic capsule.14,15 In our study, 12% of the high-grade splenic injuries presented with initial hemodynamic instability; however, splenectomy was performed in only one third of these patients, when the criteria for NOM were not met at the time of presentation. NOM was uniformly successful in our series. We believe that this is because of strict protocol adherence, close supervision, and involvement of the attending surgeons in clinical decision making. Lower success rates for successful NOM of adult splenic injuries has led to a body of experience using angiographic embolization (AE) to control hemorrhage and its use has been advocated in the presence of CB on abdominal CT scan.16 AE seems to be a useful adjunct for splenic preservation because the trabecular distribution of the intraparenchymal splenic vessels allows for targeted embolization, while preserving blood flow to uninjured areas of the organ.17 In 1995, Sclafani et al17 published the first series of SAE in 172 adult patients with blunt splenic injury, with a splenic salvage rate of 98.5%. Based on this and other adult experiences, many have advocated for its use in the pediatric population, despite varied consensus. According to the American College of Surgeons trauma quality improvement program database, angiography is being used in 3.2% (0% to 19%) of pediatric patients with blunt splenic trauma. Thus, adolescents, those with associated closed head injury, and children being treated at adult trauma centers are more likely to undergo an AE procedure.18,19 Kiankhooy et al20 in 2010 published their series of blunt solid organ injury and advocated its use, although AE was used in only 2 patients with splenic trauma. Several others have associated the presence of CB in children with the failure of NOM. Cox et al21 reviewed 5 cases of solid organ injuries and suggested that the blush sign might be an early indicator of the need for laparotomy. Taylor et al22 in their series of thoracoabdominal trauma had 7 children with radiographic evidence of CB, 6 of whom underwent surgical intervention; however, only one child suffered from splenic trauma. Van der Vlies et al23 suggested that management of splenic injuries should include consideration of the presence of a CB. However, their review included a small case series and many children treated at adult trauma centers with no established pediatric trauma protocols. Lutz et al and Cloutier et al suggested that the presence of CB in children does not affect patient outcomes and AE is not necessary.24,25 However, CB was only seen in a small number of patients in both series making it difficult to draw any conclusions. In our current series, CB was seen in 17.4% of cases and was associated with higher grades of injury. The presence of CB did not result in increased need for blood transfusion or prolonged length of stay. We have previously published data supporting decreased need for blood transfusion with NOM of blunt solid organ injuries in children, compared with operative management.26 This
349 study similarly supports the conclusion that children with spleen injuries managed nonoperatively require fewer blood transfusions compared with the operative group. One can argue that this is simply because the patients undergoing laparotomy were more severely injured with multiorgan injuries and thus, not surprisingly, had higher transfusion requirements. AE was not part of our treatment algorithm and the success rate of NOM in isolated splenic injuries with CB was 100%; thus, it can be concluded that AE is rarely necessary because of the already high success rate of NOM in children. Another consideration is that the smaller size of pediatric vessels creates technical challenges and raises concerns regarding procedure-related safety and complications. Potential complications from angiography and embolization in children are similar (or possibly higher) compared with adults and include arterial puncture site hematoma, catheter, or guidewire-related arterial injury, contrast nephropathy, target organ ischemia, and nontarget organ embolization.20 These complications, although uncommon, may threaten organ or limb function.27 The limitations of our study include the technique used for contrast injection and subjective reader variability with abdominal CT interpretation. Half of our patient population was transferred from an outside hospital with the CT done before transfer. These studies were frequently read by adult radiologists, which could affect the CT attenuation values and variability in the diagnosis of CB. Based on our current series, we conclude that the presence of CB does not mandate any additional intervention, although it certainly warrants intensive observation. Patients should be managed based on their hemodynamic status and their physiological response to resuscitation, rather than the radiologic appearance of the injury. The use of clinical practice guidelines and familiarity with pediatric splenic injury management play important roles in achieving high NOM success rates.
References 1. Ramenofsky ML. Pediatric abdominal trauma. Pediatr Ann 1987;16: 318–26. 2. Upadhyaya P, Simpson JS. Splenic trauma in children. Surg Gynecol Obstet 1968;126:781–90. 3. Stylianos S. Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. The APSA Trauma Committee. J Pediatr Surg 2000;35:164–9. 4. Stylianos S, Egorova N, Guice KS, et al. Variation in treatment of pediatric spleen injury at trauma centers versus nontrauma centers: a call for dissemination of American Pediatric Surgical Association benchmarks and guidelines. J Am Coll Surg 2006;202:247–51. 5. Schurr MJ, Fabian TC, Gavant M, et al. Management of blunt splenic trauma: computed tomographic contrast blush predicts failure of nonoperative management. J Trauma 1995;39:507–12. 6. Alonso M, Brathwaite C, Garcia V, et al, EAST Practice Management Guidelines Work Group. Practice Management Guidelines for the Nonoperative Management of Blunt Injury to the Liver and Spleen. Chicago, IL: Eastern Association for the Surgery of Trauma; 2003.
350 7. Nwomeh BC, Nadler EP, Meza MP, et al. Contrast extravasation predicts the need for operative intervention in children with blunt splenic trauma. J Trauma 2004;56:537–41. 8. Moore EE, Shackford SR, Pachter HL, et al. Organ injury scaling: spleen, liver, and kidney. J Trauma 1989;29:1664–8. 9. Shanmuganathan K, Mirvis SE, Sover ER. Value of contrast enhanced CT in detecting active hemorrhage in patients with blunt abdominal or pelvic trauma. AJR Am J Roentgenol 1993;161:65–9. 10. Balfanz JR, Nesbit ME, Jarvis C, et al. Overwhelming sepsis following splenectomy for trauma. J Pediatr 1976;88:458–60. 11. Douglas GJ, Simpson JS. The conservative management of splenic trauma. J Pediatr Surg 1971;6:565–70. 12. Ein SH, Shandling B, Simpson JS, et al. Nonoperative management of traumatized spleen in children: how and why. J Pediatr Surg 1978;13: 117–9. 13. Davies DA, Pearl RH, Ein SH, et al. Management of blunt splenic injury in children: evolution of the nonoperative approach. J Pediatr Surg 2009;44:1005–8. 14. Muehrcke DD, Kim SH, MacCabe CJ. Pediatric splenic trauma: predicting the success of nonoperative therapy. Am J Emerg Med 1987; 5:109–12. 15. Gross P. Subcutaneous spleen rupture, a complication of the indirect, traumatic diaphragmatic rupture. Chirurg 1967;38:564–7. 16. Dent D, Alsabrook G, Erickson BA, et al. Blunt splenic injuries: high nonoperative management rate can be achieved with selective embolization. J Trauma 2004;56:1063–7. 17. Sclafani SJ, Shaftan GW, Scalea TM, et al. Nonoperative salvage of computed tomography diagnosed splenic injuries: utilization of angiography for triage and embolization for hemostasis. J Trauma 1995; 39:818–27.
The American Journal of Surgery, Vol 210, No 2, August 2015 18. Mayglothling JA, Haan JM, Scalea TM. Blunt splenic injuries in the adolescent trauma population: the role of angiography and embolization. J Emerg Med 2011;41:21–8. 19. Sims CA, Wiebe DJ, Nance ML. Blunt solid organ injury: do adult and pediatric surgeons treat children differently? J Trauma 2008;65:698–703. 20. Kiankhooy A, Sartorelli KH, Vane DW, et al. Angiographic embolization is safe and effective therapy for blunt abdominal solid organ injury in children. J Trauma 2010;68:526–31. 21. Cox Jr CS, Geiger JD, Liu DC, et al. Pediatric blunt abdominal trauma: role of computed tomography vascular blush. J Pediatr Surg 1997;32:1196–200. 22. Taylor GA, Kaufman RA, Sivit CJ. Active hemorrhage in children after thoracoabdominal trauma: clinical and CT features. AJR Am J Roentgenol 1994;162:401–4. 23. Van der Vlies CH, Saltzherr TP, Wilde JCH, et al. The failure rate of nonoperative management in children with splenic or liver injury with contrast blush on computed tomography: a systematic review. J Pediatr Surg 2010;45:1044–9. 24. Lutz N, Mahboubi S, Nance ML, et al. The significance of contrast blush on computed tomography in children with splenic injuries. J Pediatr Surg 2004;39:491–4. 25. Cloutier DR, Baird TB, Gormley P, et al. Pediatric splenic injuries with a contrast blush: successful nonoperative management without angiography and embolization. J Pediatr Surg 2004;39:969–71. 26. Partrick DA, Bensard DD, Moore EE, et al. Nonoperative management of solid organ injuries in children results in decreased blood utilization. J Pediatr Surg 1999;34:1695–9. 27. Drooz A, Lewis C, Allen S, et al. Quality improvement guidelines for percutaneous transcatheter embolization. J Vasc Interv Radiol 2003; 14:S237–42.
Clinical Science
Contrast blush in pediatric blunt splenic trauma does not warrant the routine use of angiography and embolization Samiksha Bansal, M.D.a, Frederick M. Karrer, M.D.b, Kristine Hansen, D.S.b, David A. Partrick, M.D.b,* a
Department of Pediatric Surgery, Cardinal Glennon Children’s Medical Center, St Louis, MO 63104, USA; bDepartment of Pediatric Surgery, Children’s Hospital Colorado, 13123 East 16th Avenue, Aurora, CO 80045, USA
KEYWORDS: Pediatric; Splenic trauma; Contrast blush; Angiographic embolization
Abstract BACKGROUND: Splenic artery embolization (SAE) in the presence of contrast blush (CB) has been recommended to reduce the failure rate of nonoperative management. We hypothesized that the presence of CB on computed tomography has minimal impact on patient outcomes. METHODS: A retrospective review was conducted of all children (,18 years) with blunt splenic trauma over a 10-year period at a level 1 pediatric trauma center. Data are presented as mean 6 standard error of mean. RESULTS: Seven hundred forty children sustained blunt abdominal trauma, of which 549 had an identified solid organ injury. Blunt splenic injury was diagnosed in 270 of the 740 patients. All patients were managed nonoperatively without SAE. CB was seen on computed tomography in 47 patients (17.4%). There were no significant differences in the need for blood transfusion (12.5% vs 11.1%) or length of stay (3.1 vs 3.3 days) or need for splenectomy when compared in children with or without CB. CONCLUSION: Pediatric trauma patients with blunt splenic injuries can be safely managed without SAE and physiologic response and hemodynamic stability should be the primary determinants of appropriate management. Ó 2015 Elsevier Inc. All rights reserved.
The authors declare no conflicts of interest. There were no relevant financial relationships or any sources of support in the form of grants, equipment, or drugs. This manuscript has been seen and approved by all the authors and the material is previously unpublished. * Corresponding author. Tel.: 11-720-777-6571; fax: 1-720-777-7271. E-mail address: [email protected] Manuscript received March 19, 2013; revised manuscript September 24, 2014 0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2014.09.028
Trauma is the leading cause of childhood death (age , 18 years) with an annual mortality rate of greater than 20,000.1 Blunt trauma accounts for 90% of childhood injuries, resulting most commonly in head and limb injury followed by abdominal trauma in up to 8% of the cases. The spleen is the most commonly injured intra-abdominal organ. The management of pediatric blunt splenic trauma has undergone a major paradigm shift in the last 4 decades. Nonoperative management (NOM) of pediatric splenic trauma was first described in 1968 by Upadhyaya and
346 Simpson.2 It is the current standard of care for hemodynamically stable children, because of high success rates without the morbidity and mortality associated with operative management, and avoiding long-term infectious sequelae from splenectomy. Guidelines for such conservative management of blunt splenic, hepatic, and renal trauma are well established.3,4 Presence of contrast blush (CB) on computed tomography (CT) has been cited as a risk factor for the failure of NOM in the adult literature,5 and splenic artery embolization (SAE) has been recommended and increasingly used in such cases.6 Although few studies have addressed the significance of CB in pediatric splenic trauma in the past,7 an increasing number of institutions continue to adopt a protocol using angiography and embolization in the presence of active extravasation of contrast on initial abdominal CT scan in children. We hypothesized that the presence of CB on abdominal CT has little impact on patient outcomes in the pediatric population. The purpose of our study was to review our management of splenic injuries in children sustaining blunt abdominal trauma and evaluate the frequency and need for SAE in the presence of CB.
Patients and Methods Institutional Review Board approval was obtained before initiation of the study. Records of all children younger than 18 years of age who were admitted to the trauma service at Children’s Hospital Colorado (CHCO), a level I pediatric trauma center, with documented blunt abdominal trauma over a 10-year period (2002 to 2011) were identified using the trauma registry. All patients with splenic injury documented by abdominal CT were included in the study. These patients included those with isolated splenic injury as well as splenic injury associated with multisystem trauma. Data were analyzed separately for isolated splenic injury patients. Patients were divided into 2 groups based on the absence or presence of CB. Only the patients with high-grade (grades 3 to 5) splenic injuries were included for this analysis as CB was only seen with high-grade injuries. Injury grade was determined according to the American Association for the Surgery of Trauma (AAST) solid injury scale.8 CB was reported when a wellcircumscribed area of contrast extravasation, hyperdense with respect to the surrounding parenchyma, was present on CT.9 Demographics, admission, and management parameters were abstracted from the electronic medical record. Current diagnosis and procedural codes were used for the database search. Study data were collected and managed using REDCap electronic data capture tools hosted at CHCO. Data collected included preadmission variables such as age, sex, mechanism of trauma, clinical and laboratory parameters at presentation, associated injuries, injury severity score, radiographic findings including the presence of CB on abdominal CT; management variables such as type of intervention, need for laparotomy, length of
The American Journal of Surgery, Vol 210, No 2, August 2015 intensive care unit (ICU) stay, total hospital stay, need for blood transfusion, and complications including readmissions and mortality. Criteria for laparotomy were hemodynamic instability with evidence of massive bleeding on presentation or children who required transfusion of more than half of their blood volume within 24 hours of injury. The medical records of the pediatric trauma patients identified as requiring laparotomy were reviewed to confirm the details of the operation performed. The need for transfusion was decided by the surgical team members based on the fall in hematocrit and hemodynamic status of the patient. Hemodynamic stability was determined based on age-appropriate ranges for heart rate and blood pressure measurements. At CHCO, injured children are initially evaluated by a team of emergency physicians, general surgery residents, and pediatric surgery fellows directly supervised by pediatric surgery attendings, who provide 24-hour inhospital coverage. An abdomino-pelvic CT was obtained shortly after arrival for all hemodynamically stable patients with suspected blunt abdominal trauma. CTs were interpreted by board-certified pediatric radiologists. Patients were stratified according to their AAST injury grade based on the imaging findings and further management was decided based on an institutional solid organ injury protocol. Management decisions were overseen by the pediatric surgery attending throughout the hospital stay. Statistical significance was determined using Fisher’s exact test, Student t test, and continuous data were compared using analysis of variance. Data are reported as the mean 6 standard error of mean, and P value less than .05 was considered statistically significant.
Results During the study period from 2002 to 2011, there were 740 pediatric patients who sustained blunt abdominal trauma, of which 549 (74%) had an identified solid organ injury. Blunt splenic injury was diagnosed in 270 (49%) patients, of whom 143 had isolated splenic trauma and 127 sustained multiorgan injuries. Forty-three percent of our patients were transferred from outside hospitals. Time from injury to presentation to our hospital varied between 3 and 16 hours with an average of 5.6 hours. Mean age of the study patients was 9.5 6 .3 years; 193 (71%) were boys and the mean injury severity score of all patients was 17.8 6 .7. The mechanism of injury for the entire patient population is depicted in Fig. 1. Sports-related injury was the most common mechanism of injury (22%), followed closely by motor vehicle collision (21%), falls (15%), and pedestrian-related injuries (11%). Although sports-related mechanisms were responsible for most of the isolated splenic injuries (34%), motor vehicle collisions were the leading cause of splenic injury in multisystem trauma patients (38%). Associated extra-abdominal injuries included 42 patients with traumatic brain injury (41%), 32 with thoracic (31%), and 39 with
S. Bansal et al.
Figure 1
Contrast blush in pediatric splenic injuries
Mechanism of injury for the entire study population.
extremity injuries (38%). Patients were divided into AAST splenic injury grades, and various admission and outcome parameters were analyzed as shown in Table 1. Grade 5 splenic injuries were only seen in multisystem trauma patients and motor vehicle collision was the mechanism of injury in all these cases. Length of stay was directly related to the grade of injury in isolated splenic trauma patients and was significantly higher for patients with grade 3 and 4 splenic injuries. There were no significant differences in length of intensive care unit stay and total hospital stay for multisystem trauma patients; for these patients, the associated traumatic brain injury and/or traumatic pulmonary insult dictated level of care and the length of stay. Blood transfusion was used in 6.3% of isolated splenic injury
Table 1
347 patients compared with 34.6% of multisystem trauma patients; for the majority of these patients, the transfusion need was driven by injuries other than splenic trauma. We had 12 deaths in the study population, all of which were unrelated to the splenic injury. Nine patients died secondary to traumatic brain injury; 2 patients died because of chest trauma and 1 child died from a high-grade liver injury with cardiopulmonary arrest. Admission and outcome parameters were further analyzed in 160 (59%) high-grade3–5 splenic injury patients to determine if the presence of CB was associated with worse outcomes (Table 2). CB was seen in 47 patients (25 in grade 3, 19 in grade 4, and 3 in grade 5 injuries) comprising 17.4% of the study population. Of the 47 patients with CB, only 7 patients were age 14 or greater. Among all the patients with CB, 28 had presence of intraparenchymal blush, 19 patients had free peritoneal extravasation, and none were found to have presence of pseudoaneurysm. Additionally, of the 47 patients with CB, 6 had small amount of hemoperitoneum, 17 had moderate, and 24 were found to have large amount of hemoperitoneum. Patients were managed based on their grade of splenic injury and hemodynamic stability, irrespective of the type of CB and amount of hemoperitoneum. Of the 160 patients with high-grade splenic injuries, 19 patients were hemodynamically unstable on initial presentation. Nine of these patients were brought to the operating room for an emergent exploratory laparotomy. Splenectomy was performed in 6 patients, one of which was performed at an outside institution before patient transfer. CB was present in only one of these 6 patients and the decision for
Demographics and outcome measure comparison for patients based on splenic injury grade
Grade of splenic injury
I
II
III
IV
V
No. of patients (n 5 270) Age (years) Men (%) ICU LOS (days) Isolated Multiorgan Total LOS (days) Isolated Multiorgan Mortality (%) Isolated Multiorgan Blood transfusion (%) Isolated Multiorgan Splenectomy (%) Isolated Multiorgan Presence of multiorgan injuries
34 8.7 6 .8 21 (62)
76 8.9 6 .9 53 (69)
88 9.6 6 .3 63 (71)
66 9.7 6 1.1 54 (81)
6 8.2 6 .7 4 (67)
.1 6 .02 2.7 6 .8
.1 6 .03 3.1 6 .7
.3 6 .07 3.2 6 1.1
1.1 6.4* 2.7 6 1.2
N/A 3.3 6 1.7
1.8 6 .6 7.3 6 1.9
1.6 6 .4 6.9 6 1.1
2.4 6 .6 6.6 6 1.1
4.2 6 .3* 5.9 6 1.2
N/A 6.2 6 1.6
0 2 (9)
0 4 (10)
0 2 (6)
0 2 (8)
N/A 2 (33)
0 12 (54)
0 15 (36)
4 (7) 6 (18)
5 (12)* 8 (32)
N/A 3 (50)
0 0 22 (65)
0 0 41 (54)
0 1 (3) 33 (37)
1 (2) 1 (4) 25 (38)
N/A 3 (50)* 6 (100)
ICU 5 intensive care unit; LOS 5 length of stay; NA 5 not applicable. *P , .05.
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The American Journal of Surgery, Vol 210, No 2, August 2015
Table 2 injuries
Association between clinical and outcome parameters in the presence and absence of contrast blush in high-grade splenic
High-grade splenic injuries (n 5 160)
Presence of contrast blush (n 5 47)
Absence of contrast blush (n 5 113)
P value
Age Hemodynamically unstable (%) ISS Hematocrit at presentation Drop in hematocrit ICU LOS (days) Total LOS (days) Blood transfusion (%) Splenectomy (%) Mortality (%)
8.6 6 1.6 5 (11) 20.2 6 2.3 34 6 2.8 7.3 6 1.2 1.8 6 .5 5.1 6 .8 12 (25) 1 (2) 2 (4)
9.4 6 1.2 14 (12) 18.0 6 4.2 35 6 1.7 6.8 6 1.3 1.4 6 .7 4.1 6 1.3 24 (21) 5 (4) 4 (3)
NS NS NS NS NS NS NS NS ,.05 NS
ICU 5 intensive care unit; ISS 5 injury severity score; LOS 5 length of stay; NS 5 not significant.
laparotomy was made because of hemodynamic instability and the presence of associated injuries. One patient, whose splenectomy was performed at an outside institution, did not show the presence of CB on abdominal CT and splenectomy was performed before long-distance transfer, because of the presence of grade 5 splenic injury. All other patients were managed nonoperatively using a blunt splenic injury protocol without SAE irrespective of the presence or absence of CB. There were no statistically significant differences in the average drop in hematocrit, need for blood transfusion, and length of hospital stay between CB and no CB groups. Table 3 represents outcome parameters for isolated highgrade injury patients only in the presence and absence of CB. Again, as seen for the whole group, we did not see any statistically significant difference in the average drop in hematocrit, need for blood transfusion, and length of hospital stay between CB and no CB groups in isolated splenic trauma patients. Presence of contrast extravasation did not result in increased need for splenectomy. No patient experienced delayed splenic rupture and there were no delayed failures of NOM following initial resuscitation. There were no spleen-related deaths. Three patients were readmitted secondary to abdominal pain. Repeat abdominal CT in these patients found no evidence of rebleeding. One of these patients, whose initial scan did not show CB, was later
diagnosed with a splenic artery pseudoaneurysm; this was conservatively managed and self-resolved.
Comments Prior to 1960s, splenectomy was considered the standard treatment for blunt splenic injuries. The first reported series of children with blunt splenic trauma managed nonoperatively was published by Upadhyaya and Simpson in 1948. This idea persevered because of the documented risks of overwhelming postsplenectomy sepsis, because of known operative morbidity and mortality, and with the observation by surgeons that most splenic bleeding had ceased by the time of operative intervention.10 Douglas et al in 1971 and later Ein et al in 1978 reported their initial series suggesting a decrease in blood transfusion requirement and decreased mortality associated with nonoperative protocols, further supporting the nonoperative approach to blunt splenic trauma.11,12 These initial experiences led to the implementation of NOM protocols for solid organ injuries in children by the American Pediatric Surgical Association trauma committee in 2000. Today, NOM is the standard of care with success rates approaching 90% in most series.13 The higher success rate of NOM in children, when compared
Table 3 Association between clinical and outcome parameters in the presence and absence of contrast blush in isolated high-grade splenic injuries High-grade isolated splenic injuries (n 5 96)
Presence of contrast blush (n 5 24)
Absence of contrast blush (n 5 72)
P value
Age Hemodynamically unstable (%) ISS Hematocrit at presentation Drop in hematocrit ICU LOS (days) Total LOS (days) Blood transfusion (%) Splenectomy
9.3 6 .8 1 (4) 12.5 6 1.7 36 6 1.1 5.3 6 .9 .6 6 .5 3.1 6 .8 3 (12) 0
10.7 6 1.7 4 (5) 12.6 6 1.3 35 6 .9 4.8 6 1.1 .4 6 .1 3.3 6 .5 8 (11) 1 (1%)
NS NS NS NS NS NS NS NS ,.05
ICU 5 intensive care unit; ISS 5 injury severity score; LOS 5 length of stay; NS 5 not significant.
S. Bansal et al.
Contrast blush in pediatric splenic injuries
with adults, is thought to be because of a higher proportion of myoepithelial cells within the spleen, more efficient contraction and retraction of splenic arterioles, and a thicker splenic capsule.14,15 In our study, 12% of the high-grade splenic injuries presented with initial hemodynamic instability; however, splenectomy was performed in only one third of these patients, when the criteria for NOM were not met at the time of presentation. NOM was uniformly successful in our series. We believe that this is because of strict protocol adherence, close supervision, and involvement of the attending surgeons in clinical decision making. Lower success rates for successful NOM of adult splenic injuries has led to a body of experience using angiographic embolization (AE) to control hemorrhage and its use has been advocated in the presence of CB on abdominal CT scan.16 AE seems to be a useful adjunct for splenic preservation because the trabecular distribution of the intraparenchymal splenic vessels allows for targeted embolization, while preserving blood flow to uninjured areas of the organ.17 In 1995, Sclafani et al17 published the first series of SAE in 172 adult patients with blunt splenic injury, with a splenic salvage rate of 98.5%. Based on this and other adult experiences, many have advocated for its use in the pediatric population, despite varied consensus. According to the American College of Surgeons trauma quality improvement program database, angiography is being used in 3.2% (0% to 19%) of pediatric patients with blunt splenic trauma. Thus, adolescents, those with associated closed head injury, and children being treated at adult trauma centers are more likely to undergo an AE procedure.18,19 Kiankhooy et al20 in 2010 published their series of blunt solid organ injury and advocated its use, although AE was used in only 2 patients with splenic trauma. Several others have associated the presence of CB in children with the failure of NOM. Cox et al21 reviewed 5 cases of solid organ injuries and suggested that the blush sign might be an early indicator of the need for laparotomy. Taylor et al22 in their series of thoracoabdominal trauma had 7 children with radiographic evidence of CB, 6 of whom underwent surgical intervention; however, only one child suffered from splenic trauma. Van der Vlies et al23 suggested that management of splenic injuries should include consideration of the presence of a CB. However, their review included a small case series and many children treated at adult trauma centers with no established pediatric trauma protocols. Lutz et al and Cloutier et al suggested that the presence of CB in children does not affect patient outcomes and AE is not necessary.24,25 However, CB was only seen in a small number of patients in both series making it difficult to draw any conclusions. In our current series, CB was seen in 17.4% of cases and was associated with higher grades of injury. The presence of CB did not result in increased need for blood transfusion or prolonged length of stay. We have previously published data supporting decreased need for blood transfusion with NOM of blunt solid organ injuries in children, compared with operative management.26 This
349 study similarly supports the conclusion that children with spleen injuries managed nonoperatively require fewer blood transfusions compared with the operative group. One can argue that this is simply because the patients undergoing laparotomy were more severely injured with multiorgan injuries and thus, not surprisingly, had higher transfusion requirements. AE was not part of our treatment algorithm and the success rate of NOM in isolated splenic injuries with CB was 100%; thus, it can be concluded that AE is rarely necessary because of the already high success rate of NOM in children. Another consideration is that the smaller size of pediatric vessels creates technical challenges and raises concerns regarding procedure-related safety and complications. Potential complications from angiography and embolization in children are similar (or possibly higher) compared with adults and include arterial puncture site hematoma, catheter, or guidewire-related arterial injury, contrast nephropathy, target organ ischemia, and nontarget organ embolization.20 These complications, although uncommon, may threaten organ or limb function.27 The limitations of our study include the technique used for contrast injection and subjective reader variability with abdominal CT interpretation. Half of our patient population was transferred from an outside hospital with the CT done before transfer. These studies were frequently read by adult radiologists, which could affect the CT attenuation values and variability in the diagnosis of CB. Based on our current series, we conclude that the presence of CB does not mandate any additional intervention, although it certainly warrants intensive observation. Patients should be managed based on their hemodynamic status and their physiological response to resuscitation, rather than the radiologic appearance of the injury. The use of clinical practice guidelines and familiarity with pediatric splenic injury management play important roles in achieving high NOM success rates.
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