NON-OPERATIVE MANAGEMENT OF PEDIATRIC SOLID ORGAN INJURY 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
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
Exam HOW DOES A CHILD WITH SOLID ORGAN INJURY PRESENT? 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 II Liver Injury Grade V Liver Injury
Grade V Spleen Injury SPLEEN INJURY GRADE 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
ATOMAC 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
DEVELOPED AN ALGORITHM FOR THE TREATMENT OF SOLID ORGAN INJURY 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
PURPOSE Look at the evidence Make new recommendations based on studies already done Find the unanswered question Work together to answer those questions
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