NON-OPERATIVE MANAGEMENT OF PEDIATRIC SOLID ORGAN

INJURYJESSICA A. NAIDITCH, MD

TRAUMA MEDICAL DIRECTOR, DELL CHILDREN’S MEDICAL CENTER OF CENTRAL TEXAS

ASSISTANT PROFESSOR OF SURGERY AND PERIOPERATIVE CARE

UNIVERSITY OF TEXAS – AUSTIN

NO DISCLOSURES

PEDIATRIC TRAUMA IS COMMON

• 22 million children seek medical

care yearly

• 22,000 die annually

• Most common cause of childhood

mortality

• World-wide public health issue

SOLID ORGAN INJURY IS COMMON IN CHILDREN

• Organs closely packaged

• Immature rib cage

• Less soft tissue padding

• Includes:

• Liver

• Spleen

• Kidney

• Pancreas

MECHANISMS OF SOLID ORGAN INJURY

• Falls

• Playground injury

• Motor vehicle collisions

• Pedestrian vs motor vehicle

• Non-accidental trauma

• Recreational activities

• Bicycles

• Scooters

• Skateboards

• Sports

• Dirt bikes

• Hover boards

• ATV

HOW DOES A CHILD WITH SOLID ORGAN INJURY PRESENT?

• History

• Blunt force trauma to the upper abdomen or chest

• Abdominal pain

• Children who can’t tell you

• In the absence of compromised mental status

• Shortness of breath

• Shoulder pain – referred

HOW DOES A CHILD WITH SOLID ORGAN INJURY PRESENT?

• Exam

• Abdominal tenderness

• Abdominal wall findings

• Ecchymosis

• Abrasions

• Seat belt sign

• Handle bar marks

• Signs of shock

• Tachycardia

• Mental status changes

LIVER AND SPLEEN INJURIES ARE THE MOST COMMON, POTENTIALLY LIFE

THREATENING, INTRA-ABDOMINAL INJURIES SUSTAINED IN CHILDREN.

LIVER INJURY GRADE

Grade V Liver

Injury

Grade II Liver

Injury

SPLEEN INJURY GRADE

Grade V Spleen

Injury

Grade III Spleen

Injury

HOW DO WE TREAT THESE INJURIES?

• APSA Guidelines 1999

• Developed by Stylianos as part of APSA Trauma Committee

• Goal of >95% splenic salvage

• More details

• Days of Bed Rest = Injury Grade + 1

• Weeks to return to normal activity = Injury Grade + 2

• Ambitious plan, widely accepted

• Unique aspect of APSA guideline was stratification of patients by CT injury

grade

• Guideline generally considered the standard

• Allowed a decrease in the resources used without a compromise in safety or

outcome

• 44 patients with liver and/or spleen injury

• 40 excluded

• GCS < 13

• Thoracic injury

• Long-bone/pelvic fractures

• Hemodynamically abnormal

• 43 (97.7%) completed the pathway

• 1 developed a biloma

• Protocol driven

• Changed the game

• Hemodynamics mattered more

• ICU utilization was decreased

• Decreased LOS without

complications

THE SELECTION OF PATIENTS FOR NON-OPERATIVE MANAGEMENT SHOULD BE BASED UPON HEMODYNAMIC STABILITY

AND NOT THE GRADE OF INJURY.

CRITERIA FOR NON-OPERATIVE MANAGEMENT OF BLUNT LIVER AND SPLEEN INJURY

• Hemodynamically stable

• Below blood transfusion threshold

• 50% of blood volume or 40cc/kg

• No other indication for an operation

National Trauma Databank

• 413 patients

• High grade splenic injuries

• Non-operative management in

285

• 240 successfully

• 45 underwent delayed

operative management

Attempting non-operative

management is safe.

• Successful most of the time

• When it fails, operative outcomes

are similar to early operative

management.

DOES BEDREST REALLY HELP?

• APSA recommended strict bed rest for Grade+1 days

• Is ambulation associated with bleeding?

• Is bedrest really treatment?

• Limitless numbers of cases treated with bedrest

• No evidence

• 740 children with blunt abdominal trauma

• Blunt splenic injury in 270

• Contrast blush in 47

• No embolizations

• Contrast blush vs absence

• LOS: 5.1 vs 4.1days

• Blood transfusion: 25% vs 21%

• Need for splenectomy: 2% vs 4%

• Mortality: 4% vs 3%

WHY SHOULDN’T WE JUST TAKE OUT THE SPLEEN?

• Overwhelming post-splenectomy infection (OPSI)

• Encapsulated organisms, most often Streptococcus

pneumoniae

• Meningitis and/or septicemia

• Rare, rapidly fatal infection

• 4.4% rate of OPSI with 50% mortality if < 16 years

• 0.9% rate of OPSI with 94% mortality if >16 years

• 2% will get OPSI after trauma splenectomy, half of these will

die

Holdsworth et al. Br. J. Surg. Vol 78 1991

• Formed 7 years ago with 6 Level I Pediatric Trauma Centers

• Purpose was to do multicenter trauma research

• Arizona, Phoenix (PCH) – David Notrica

• Texas, Austin – Nilda Garcia

• Texas, Dallas – Steve Megison

• Oklahoma – Bob Letton and David Tuggle

• Memphis (Le Bonheur) – Trey Eubanks

• Arkansas – Todd Maxson

• Consortium

ATOMAC

• 18 months developing an evidence-based algorithm for SOI

• Modified Delphi method

• Each center reviewed it with retrospective cases

• Started using the algorithm at version 7.4

• Revised it a few more times

• Other centers started asking for it

DEVELOPED AN ALGORITHM FOR THE TREATMENT OF SOLID ORGAN INJURY

• Look at the evidence

• Make new recommendations based on studies already done

• Find the unanswered question

• Work together to answer those questions

PURPOSE

NONOPERATIVE MANAGEMENT OF BLUNT LIVER AND SPLEEN INJURY IN CHILDREN: EVALUATION OF THE ATOMAC GUIDELINE

USING GRADE• 27 clinical questions

• Six 1A recommendations:

• Management based on hemodynamic status rather than grade

• Support for abbreviated period of bed rest

• Transfusion thresholds of 7g/dL

• Exclusion of peritonitis from a guideline

• Accounting for local resources and concurrent injuries in the management of children failing to stabilize

• Use of a guideline in patients with multiple injuries

• Two 1B recommendations

• Use of 40mL/kg of 4 units of blood to define end points for the guideline

• Discharging stable patients before 24 hours

Notrica et al. J Trauma Acute Care Surg 2015

FAILURE OF NONOPERATIVE MANAGEMENT OF PEDIATRIC BLUNT LIVER AND SPLEEN

INJURIES

• 1008 patients

• 499 liver injury

• 410 spleen injury

• 99 both

• 34 (3%) underwent laparotomy or laparoscopy for spleen or liver bleeding

• Patients who failed:

• More likely to receive blood (52/69 vs 162/939; p < 0.001)

• Median time from injury to first blood transfusion: 2.3 hours vs 5.9 hours (p= 0.002)

• Mortality 24% in those who failed NOM due to bleeding

Linnaus et al. J Trauma Acute Care Surg 2017

CONCLUSIONS

• Solid organ injuries, specifically splenic and liver, are common in pediatric

patients

• The vast majority can be managed non-operatively with good outcomes

• The outcomes are similar between those undergoing early operative

management and delayed operative management

• Delayed splenic hemorrhage is rare and not effected by day of mobilization

• Contrast blush is not an indication for operation or angiographic

intervention

QUESTIONS?Jessica A. Naiditch, MD

Trauma Medical Director, Dell Children’s Medical Center of Central Texas

Assistant Professor of Surgery and Perioperative Care

University of Texas – Austin

janaiditch@ascension.org