The incidence of delayed splenic bleeding in pediatric blunt trauma

Notrica, David M.; Sayrs, Lois W.; Bhatia, Amina; Letton, Robert W.; Alder, Adam C.; Peter, Shawn D. St.; Ponsky, Todd A.; Eubanks, James W.; Lawson, Karla A.; Ostlie, Daniel J.; Tuggle, David W.; Garcia, Nilda M.; Maxson, R. Todd; Leys, Charles; Greenwell, Cynthia

doi:10.1016/j.jpedsurg.2017.10.005

Cited by 23 publications

(11 citation statements)

References 21 publications

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“…The Injury Severity Score (ISS), hospital length of stay, and ICU length of stay of our study population are elevated compared to prior studies. 5,11 It is important to note that Center 2 serves as a tertiary referral center for pediatric trauma patients and therefore may represent a more severely injured population. Given the small sample size, patients were not excluded based on other organ systems injured.…”

Section: Discussionmentioning

confidence: 99%

Routine Repeat Imaging of Pediatric Blunt Solid Organ Injuries Is Not Necessary

Fletcher

Meagher

Spencer

et al. 2021

The American Surgeon™

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Introduction Nonoperative management of hemodynamically stable patients with blunt splenic and/or hepatic injury has been widely accepted in the pediatric population. However, variability exists in the utilization and timing of repeat imaging to assess for delayed complications during index hospitalization. Recent level-IV evidence suggests that repeat imaging in children should be performed based on a patient’s clinical status rather than on a routine basis. The aim of this study is to examine the rate of delayed complications and interventions in pediatric trauma patients with blunt splenic and/or hepatic injuries who undergo repeat imaging prompted either by a clinical change (CC) or non-clinical change (NCC). Methods A 9-year (2011-2019), retrospective, dual-institution study was performed of children (0-17 years) with blunt splenic and/or hepatic injuries. Patients were grouped based on reason for repeat imaging: CC or NCC. The rate of organ-specific delayed complications and interventions was examined by reason for scan. Results A total of 307 injuries were included in the study period (174 splenic, 113 hepatic, and 20 both). Of 194 splenic injuries, 30(15.5%) underwent repeat imaging (CC = 19; NCC = 11). Of 133 hepatic injuries, 27(20.3%) underwent repeat imaging (CC = 21; NCC = 6). There was no difference in the incidence of organ-specific delayed complications between the CC and NCC groups. Of the 4 patients with complications necessitating intervention, only one was identified based on NCC. Conclusions Our data suggest routine repeat imaging is unnecessary in children with blunt splenic and/or hepatic injuries; therefore, practitioners may rely on a patient’s clinical change.

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Section: Discussionmentioning

confidence: 99%

Routine Repeat Imaging of Pediatric Blunt Solid Organ Injuries Is Not Necessary

Fletcher

Meagher

Spencer

et al. 2021

The American Surgeon™

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“…The standard procedure for managing isolated blunt splenic injuries for hemodynamically stable pediatric patients is NOM [ 2 , 3 ]. The success rate of NOM has been reported at 90–100% [ 4 – 6 ]. However, delayed complications have been reported, including pseudocysts, abscess, pseudoaneurysms, and delayed rupture [ 1 , 8 ].…”

Section: Discussionmentioning

confidence: 99%

“…Nonoperative management (NOM) has been established as the standard treatment for isolated blunt organ injuries in hemodynamically stable pediatric patients [ 2 , 3 ]. The high success rate of NOM in isolated blunt splenic injuries has been reported [ 4 – 6 ]. Although delayed splenic rupture or bleeding is a rare complication [ 4 – 7 ], it is a potential problem that requires careful observation, both during hospital stays and after discharge [ 3 , 7 ].…”

Section: Introductionmentioning

confidence: 99%

A rare mechanism of delayed splenic rupture following the nonoperative management of blunt splenic injury in a child

et al. 2018

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BackgroundNonoperative management (NOM) has been established as the standard treatment for isolated blunt organ injury in hemodynamically stable pediatric patients. Although delayed splenic rupture or bleeding is a rare complication in NOM, it is an issue that many pediatric surgeons are greatly concerned about. We herein report a rare pediatric case concerning the mechanisms involved in delayed splenic rupture after NOM.Case presentationA 9-year-old boy with severe abdominal pain was transferred to our hospital. Twenty-one hours before the admission, he had been kicked in the region of his left lateral abdomen. Contrast-enhanced abdominal computed tomography revealed a severe intra-parenchymal hematoma and multiple lacerations of the spleen with a large amount of hemoperitoneum without active bleeding. His condition was diagnosed as a grade III injury on the AAST splenic injury scale. After fluid resuscitation, his vital signs became stable. The patient was treated with NOM in our intensive care unit. However, suddenly after defecation (72 h after the injury), he started complaining of severe abdominal pain and left shoulder pain. His blood pressure dropped to 70/35 mmHg, and he started to lose consciousness. Abdominal ultrasonography (US) revealed increased ascites. Fluid resuscitation and blood transfusion were performed. His symptoms and abdominal US findings suggested that splenic re-bleeding had caused delayed splenic rupture to occur. Emergency splenectomy was performed. The resected spleen was enlarged with a large parenchymal hematoma. The posterior-lateral side of the splenic capsule was ruptured.ConclusionsThe mechanism of delayed splenic rupture in our case was considered to be the result of a tear in the subcapsular hematoma caused by stretching the splenocolic ligament related to a bowel movement during defecation. Although delayed splenic rupture or bleeding is unpredictable, it is very important to understand the mechanisms and to educate the family of the children with splenic injuries of the warning signs of delayed rupture or bleeding.

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“…No definitive data exist regarding complications rate and short and long-term follow-up strategies for pediatric splenic trauma patients undergoing NOM. Notrica et al [ 116 ] reported, in their prospective study, conducted on 509 pediatric patients with blunt abdominal trauma, a 0.2% incidence of delayed splenic bleeding. Huebner et al [ 117 ] conducted a literature review concerning the role of follow-up imaging of blunt splenic trauma in children.…”

Section: Methodsmentioning

confidence: 99%

“…In pediatric splenic injury, current guidelines advocate a "less is more" approach to imaging studies with radiation exposure during admission and follow-up [ 89 ]. A recent prospective multi-center study looking at pediatric blunt liver or spleen injury concluded that “a selective re-imaging strategy appears safe, and even re-imaging symptomatic patients rarely results in intervention” [ 116 ]. This can be seen in conjunction with previous reviews on the matter, which do not support the use of routine follow-up imaging of all children with blunt splenic trauma [ 117 , 150 ].…”

Section: Methodsmentioning

confidence: 99%

Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document

et al. 2022

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Background In 2017, the World Society of Emergency Surgery published its guidelines for the management of adult and pediatric patients with splenic trauma. Several issues regarding the follow-up of patients with splenic injuries treated with NOM remained unsolved. Methods Using a modified Delphi method, we sought to explore ongoing areas of controversy in the NOM of splenic trauma and reach a consensus among a group of 48 international experts from five continents (Africa, Europe, Asia, Oceania, America) concerning optimal follow-up strategies in patients with splenic injuries treated with NOM. Results Consensus was reached on eleven clinical research questions and 28 recommendations with an agreement rate ≥ 80%. Mobilization after 24 h in low-grade splenic trauma patients (WSES Class I, AAST Grades I–II) was suggested, while in patients with high-grade splenic injuries (WSES Classes II–III, AAST Grades III–V), if no other contraindications to early mobilization exist, safe mobilization of the patient when three successive hemoglobins 8 h apart after the first are within 10% of each other was considered safe according to the panel. The panel suggests adult patients to be admitted to hospital for 1 day (for low-grade splenic injuries—WSES Class I, AAST Grades I–II) to 3 days (for high-grade splenic injuries—WSES Classes II–III, AAST Grades III–V), with those with high-grade injuries requiring admission to a monitored setting. In the absence of specific complications, the panel suggests DVT and VTE prophylaxis with LMWH to be started within 48–72 h from hospital admission. The panel suggests splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan, irrespective of injury grade. Regarding patients with WSES Class II blunt splenic injuries (AAST Grade III) without contrast extravasation, a low threshold for SAE has been suggested in the presence of risk factors for NOM failure. The panel also suggested angiography and eventual SAE in all hemodynamically stable adult patients with WSES Class III injuries (AAST Grades IV–V), even in the absence of CT blush, especially when concomitant surgery that requires change of position is needed. Follow-up imaging with contrast-enhanced ultrasound/CT scan in 48–72 h post-admission of trauma in splenic injuries WSES Class II (AAST Grade III) or higher treated with NOM was considered the best strategy for timely detection of vascular complications. Conclusion This consensus document could help guide future prospective studies aiming at validating the suggested strategies through the implementation of prospective trauma databases and the subsequent production of internationally endorsed guidelines on the issue.

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The incidence of delayed splenic bleeding in pediatric blunt trauma

Cited by 23 publications

References 21 publications

Routine Repeat Imaging of Pediatric Blunt Solid Organ Injuries Is Not Necessary

Routine Repeat Imaging of Pediatric Blunt Solid Organ Injuries Is Not Necessary

A rare mechanism of delayed splenic rupture following the nonoperative management of blunt splenic injury in a child

Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document

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