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European Journal of Trauma and Emergency Surgery

, Volume 45, Issue 5, pp 791–799 | Cite as

Blunt splenic injury in children: haemodynamic status key to guiding management, a 5-year review of practice in a UK major trauma centre

  • Rohan ArdleyEmail author
  • Laura Carone
  • Stella Smith
  • Stephen Spreadborough
  • Patrick Davies
  • Adam Brooks
Original Article

Abstract

Purpose

To review the management of children and adolescents (0–18 years), with blunt splenic injury treated at a single UK major trauma centre over a 5-year period, focusing upon efficacy of non-operative management and the use of haemodynamic stability as a guide to planning treatment strategy, rather than radiological injury grading. To produce a treatment pathway for management of blunt splenic injury in children.

Methods

Retrospective, cross-sectional study of all paediatric patients admitted with radiologically proven blunt splenic injury between January 2011 and March 2016. Penetrating injuries were excluded. Follow up was for at least 30 days.

Results

30 Patients were included, mean age was 14.5 (SD 3.6), median injury severity score was 16 (IQR 10–31). 6 Patients (20%) had a splenectomy, whilst 22 patients (73%) were successfully treated non-operatively with 100% efficacy at index admission. 5/8 (63%) patients with radiological grade V injuries were managed non-operatively, injury grade was not associated with surgical intervention (p = 1.57). Haemodynamic instability was initially treated with fluid resuscitation leading to successful non-operative management in 5/11 (45%) patients. However, haemodynamic instability is a significant predictor of requirement for surgical intervention (p = 0.03), admission to critical care (p = 0.017), presence of additional injuries (p = 0.015) and increased length of stay (p = 0.038). No such relationships were found to be associated with increased radiological injury grade.

Conclusions

Non-operative management should be first-line treatment in the haemodynamically stable child with a blunt splenic injury and may be carried out with a high degree of efficacy. It may also be successfully implemented in those initially showing signs of haemodynamic instability that respond to fluid resuscitation. Radiological injury grade does not predict definitive management, level of care, or length of stay; however, haemodynamic stability may be utilised to produce a treatment algorithm and is key to guiding management.

Keywords

Spleen Splenic Injury Trauma Paediatric 

Notes

Compliance with ethical standards

Conflict of interest

The author(s) declare that they have no competing interests.

Human and animal rights

No research was conducted using human or animal participants

Informed consent

None required.

References

  1. 1.
    Godbole P, Stringer MD. Splenectomy after paediatric trauma: could more spleens be saved? Ann R Coll Surg Engl. 2002;84(2):106–8.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Gaines AB, Ford RH. Abdominal and pelvic trauma in children. Crit Care Med. 2002;30(11):416–23.CrossRefGoogle Scholar
  3. 3.
    Costa G, Tierno SM, Tomassini F, Venturini L, Frezza B, Cancrini G, et al. The epidemiology and clinical evaluation of abdominal trauma. An analysis of a multidisciplinary trauma registry. Ann Ital Chir. 2010;81(2):95–102.PubMedGoogle Scholar
  4. 4.
    Bond JS, Eichelberger MR, Gotschall CS, Sivit CJ, Randolph JG. Nonoperative management of blunt hepatic and splenic injury in children. Ann Surg. 1996;223(3):286–9.CrossRefGoogle Scholar
  5. 5.
    Boam T, Sellars P, Isherwood J, Hollobone C, Pollard C, Lloyd DM, et al. Adherence to vaccination guidelines post splenectomy: a five year follow up study. J Infect Public Health. 2017;10(6):803–8.CrossRefGoogle Scholar
  6. 6.
    Holdsworth RJ, Cuschieri A, Irving AD. Postsplenectomy sepsis and its mortality rate: actual versus perceived risks. Br J Surg. 1991;78(9):1031–8.CrossRefGoogle Scholar
  7. 7.
    Schwartz PE, Sterioff S, Mucha P, Melton LJ, Offord KP. Postsplenectomy sepsis and mortality in adults. JAMA. 1982;248(18):2279–83.CrossRefGoogle Scholar
  8. 8.
    Elbadawi O, Ali SR, Waheed A, Khan S. An overwhelming post-splenectomy infection (OPSI). J Emerg Med 2012.  https://doi.org/10.5339/jemtac.2012.13.CrossRefGoogle Scholar
  9. 9.
    Adams SE, Holland A, Brown J. Management of paediatric splenic injury in the New South Wales trauma system. Injury. 2017;48(1):106–13.CrossRefGoogle Scholar
  10. 10.
    Lee J, Moriarty KP, Tashjian DB. Less is more: management of pediatric splenic injury. Arch Surg. 2012;147(5):437–41.CrossRefGoogle Scholar
  11. 11.
    Zarzaur B, Kozar RA, Fabian TC, Coimbra R. A survey of American Association for the Surgery of Trauma member practices in the management of blunt splenic injury. J Trauma Injury Infect Crit Care. 2011;70(5):1026–31.CrossRefGoogle Scholar
  12. 12.
    Davis DH, Localio AR, Stafford PW, Helfaer MA, Durbin DR. Trends in operative management of pediatric splenic injury in a regional trauma system. Pediatrics. 2005;115(1):89–94.CrossRefGoogle Scholar
  13. 13.
    Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Organ injury scaling: spleen and liver (1994 revision). J Trauma Acute Care Surg. 1995;38(3):323–4.CrossRefGoogle Scholar
  14. 14.
    Velmahos GC, Chan LS, Kamel E, Murray JA, Yassa N, Kahaku D, et al. Nonoperative management of splenic injuries: have we gone too far? Arch Surg. 2000;135(6):674–81.CrossRefGoogle Scholar
  15. 15.
    Smith SR, Morris L, Spreadborough S, Al-Obaydi W, D’Auria M, White H, et al. Management of blunt splenic injury in a UK major trauma centre and predicting the failure of non-operative management: a retrospective, cross-sectional study. European journal of trauma emergency surgery. 2017.  https://doi.org/10.1007/s00068-017-0807-5.CrossRefPubMedGoogle Scholar
  16. 16.
    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(2):164–9.CrossRefGoogle Scholar
  17. 17.
    McVay MR, Kokoska ER, Jackson RJ, Smith SD. Throwing out the “grade” book: management of isolated spleen and liver injury based on hemodynamic status. J Pediatr Surg. 2008;43(6):1072–6.CrossRefGoogle Scholar
  18. 18.
    Notrica MD, Eubanks JW, Tuggle DW, Maxson RT, Letton RW, Garcia NM, et al. Nonoperative management of blunt liver and spleen injury in children: evaluation of the ATOMAC guideline using GRADE. J Trauma Acute Care Surg. 2015;79(4):683–93.CrossRefGoogle Scholar
  19. 19.
    Gandhi RR, Keller MS, Schwab CW, Stafford PW. Pediatric splenic injury: pathway to play? J Pediatr Surg. 1999;34(1):55–9.CrossRefGoogle Scholar
  20. 20.
    Leung E, Wong L, Taylor J. Non- operative management for blunt splenic trauma in children: an updated literature review. Surg Pract. 2007;11(1:29–35.CrossRefGoogle Scholar
  21. 21.
    Pearl RH, Wesson DE, Spence LJ, Filler RM, Ein SH, Shandling B, et al. Splenic injury: a 5-year update with improved results and changing criteria for conservative management. J Pediatr Surg. 1989;24(5):428–31.CrossRefGoogle Scholar
  22. 22.
    Baker SP, O’Neill B, Haddon W, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma-Injury Infect Crit Care. 1974;14(3):187–96.CrossRefGoogle Scholar
  23. 23.
    Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol. 1996;49(12):1373–9.CrossRefGoogle Scholar
  24. 24.
    Tataria M, Nance ML, Holmes JH, Miller CC, Mattix KD, Brown RL, et al. Pediatric blunt abdominal injury: age is irrelevant and delayed operation is not detrimental. J Trauma Acute Care Surg. 2007;63(3):608–14.CrossRefGoogle Scholar
  25. 25.
    Bowman SM, Zimmerman FJ, Christakis DA, Sharar SR, Martin DP. Hospital characteristics associated with the management of pediatric splenic injuries. JAMA. 2005;294(20):2611–7.CrossRefGoogle Scholar
  26. 26.
    Peitzman AB, Heil B, Rivera L, Federle MB, Harbrecht BG, Clancy KD, et al. Blunt splenic injury in adults: multi-institutional study of the Eastern Association for the Surgery of Trauma. J Trauma. 2000;49(2):177–87.CrossRefGoogle Scholar
  27. 27.
    Watson G, Hoffman M, Peitzman A. Nonoperative management of blunt splenic injury: what is new? Eur J Trauma Emerg Surg. 2015;41(3):219–28.CrossRefGoogle Scholar
  28. 28.
    Jim J, Leonardi MJ, Cryer HG, Hiatt JR, Shew S, Cohen M, et al. Management of high-grade splenic injury in children. Am Surg. 2008;74(10):988–92.PubMedGoogle Scholar
  29. 29.
    Potoka DA, Schall LC, Ford HR. Risk factors for splenectomy in children with blunt splenic trauma. J Pediatr Surg. 2002;37(3):294–9.CrossRefGoogle Scholar
  30. 30.
    Kirkegard J, Avlund TH, Amanavicius N, Mortensen FV, Kissmeyer-Nielsen P. Non-operative management of blunt splenic injuries in a paediatric population: a 12-year experience. Dan Med J. 2015;62(2):A4998.PubMedGoogle Scholar
  31. 31.
    Fick AE, Raychaudhuri P, Bear J, Roy G, Balogh Z, Kumar R. Factors predicting the need for splenectomy in children with blunt splenic trauma. ANZ J Surg. 2011;81(10):717–9.CrossRefGoogle Scholar
  32. 32.
    Notrica DM. Pediatric blunt abdominal trauma: current management. Curr Opin Crit Care. 2015;21(6):531–7.CrossRefGoogle Scholar
  33. 33.
    Kaufman EJ, Wiebe DJ, Martin ND, Pascual JL, Reilly PM, Holena DN. Variation in intensive care unit utilization and mortality after blunt splenic injury. J Surg Res. 2016;203(2):338–47.CrossRefGoogle Scholar
  34. 34.
    Keller MS, Vane DW. Management of pediatric blunt splenic injury: comparison of pediatric and adult trauma surgeons. J Pediatr Surg. 1995;30(2):221–5.CrossRefGoogle Scholar
  35. 35.
    Li D, Yanchar N. Management of pediatric blunt splenic injuries in Canada—practices and opinions. J Pediatr Surg. 2009;44(5):997–1004.CrossRefGoogle Scholar
  36. 36.
    Matsushima K, Schaefer EW, Won EJ, Nichols PA, Frankel HL. Injured adolescents, not just large children: differences in care and outcome between adult and pediatric trauma centers. Am Surg. 2013;79(3):267–73.PubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.East Midlands Major Trauma Centre, Queens Medical CentreNottinghamUK
  2. 2.LNR deaneryNottinghamUK

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