Spleen/Liver Trauma

Mechanisms for Intra-abdominal Trauma

1. Motor vehicle collisions 2. Automobile vs pedestrian accidents 3. Falls

4. ATV
5. Handlebar injury from bicycle 6. Sports 7. Non-accidental trauma

Frequency of Pediatric Blunt Abdominal Injuries

Spleen 27% Kidney 27% Liver 15%

Pancreas 2%

Splenic Trauma
Diagnosis:
Plain abdominal film Unreliable and nonspecific
Triad of radiographic findings in acute splenic rupture
Left diaphragmatic elevation Left lower lobe atelectasis Left pleural effusion
Radiograph demonstrates a left pleural effusion, left basilar atelectasis, and inferomedial displacement of the splenic flexure (arrow)

Splenic Trauma
Diagnosis:
FAST
Focused Abdominal Sonography for Trauma Bedside study for unstable patient 15% false-negative May miss up to 25% of liver and spleen injuries Compared to CT only 63% sensitive for detecting free fluid

Fluid in the subphrenic space and splenorenal recess can be detected. The image shown demonstrates blood (arrow) between the spleen (S) and diaphragm (D).

Splenic Trauma
Diagnosis:
CT with IV contrast
Noninvasive, highly

accurate, easily identifies and quantifies extent of injury, for stable patient only
A: Hemoperitoneum with a liver laceration (arrow) and a shattered spleen is seen.

AAST Splenic Injury Scale

*Advance one grade for multiple injuries, up to grade III Moore EE, Cogbill TH, Jurkovich GJ, et al

AAST Splenic Injury Scale

17-yr boy injured on an rta. Grade I injury with subcapsular fluid occupying less than 10% of spleens surface area.

AAST Splenic Injury Scale

17-yrgirl injured in an rta. Grade II injury with laceration involving less than 3 cm of parenchymal depth

AAST Splenic Injury Scale

18-yr boy injured playing football. Lacerations involving more than 3 cm of parenchymal depth radiating from splenic hilum -grade III laceration

AAST Splenic Injury Scale

16-yr boy injured playing hockey. Fractured spleen involving more than 25%, Grade IV splenic laceration

AAST Splenic Injury Scale

12-yr boy pedestrian struck by MV. Fractured spleen with hilar devascularization. Grade V injury.

Splenic Trauma
Complications
Pseudoaneurysms Often asymptomatic and resolve over time
If treatment required, angiographic embolization may be used Also occur in liver trauma
A. Splenic pseudoaneurysm (arrowheads) after nonoperative treatment of blunt splenic injury. B. Successful angiographic embolization The microcatheter used to deploy the coils is marked by the arrowheads and the embolic coils are marked by the arrows.

Splenic Trauma
Complications
Pseudocysts
Rare: 0.44% May become large and painful Tx: laparoscopic excision and marsupialization

Splenic Trauma
Immunocompetence
Vaccination practices vary Adult trauma evidence supports

immunocompetence in healed grade IV injuries

Splenic Trauma
If splenectomy is indicated Pt requires vaccinations prior to discharge Streptococcus pneumoniae Pneumovax 23
Haemophilus influenzae type B Hib vaccine Neisseria meningitidis Quadravalent meningococcal/diphtheria

conjugate
Prophylactic antibiotics controversial

Most centers use penicillin

Splenic Trauma
Treatment
Nonoperative failure rate 2% Risks for increased nonoperative failure rate

Bicycle-related injury mechanism More than one solid organ injury

Peaks at 4 hrs, declines at 36hrs after admission

Contrast Blush - Spleen

Blunt Splenic Injury

216 Pts 7 yrs 26 Pts Contrast blush on CT scan
Lower Hb More likely to need op (22% vs 4%)
Not a definite indication for operation, but indicates subset of pts who have active bleeding and may need transfusion and/or operation

Liver Trauma
Blunt trauma is most common cause of injury to liver High risk due to:
Large organ, friable

parenchyma, ligamentous attachments

AAST Liver Injury Grading

Grade I

Grade IV

Types of Injury
Parenchymal damage/laceration
Subcapsular hematoma/contusion Hepatic vascular disruption contrast extravasation Bile duct injury

Diagnosis
Physical exam
tachycardia, hypotention,

peritoneal irritation

FAST
better for unstable patients

not stable enough for CT1

CT w contrast
determine grade and look for

active extravasation
1Coley

et al. J Trauma 2000

Contrast Blush - Liver

105 pts blunt liver injury 6 yrs 75 pts Grade III V 22 pts Contrast blush
transfusion req. mortality (23% vs 4%) ISS also Mortality may be related to the other injuries

Indication for Intervention

Operate for continued blood loss with hypotension, tachycardia, decreased urine output, decreasing Hg unresponsive to IVF and pRBC Operative rates
3-11% for multiple injuries 0-3% for isolated liver injury

Angioembolization not used as commonly as in adults

Bile Duct Injury

With nonoperative management, 4% risk of persistent bile leak
HIDA with delayed images if bile duct injury suspected ERCP with decompression and stenting can be diagnostic and therapeutic

 72 pts 30 Liver 44 Spleen Liver vs spleen

Longer recovery period Nine complications Greater use of resources
J Pediatr Surg 43:2264-2267, 2008

APSA Guidelines
APSA guidelines for hemodynamically stable children with isolated spleen or liver injury

CT GRADE
Days in ICU
Hospital stay Predischarge imaging Postdischarge imaging Activity restrictions

I
None
2 days None None 3 weeks

II
None
3 days None None 4 weeks

III
None
4 days None None 5 weeks

IV
1 day
5 days None None 6 weeks

From Stylianos S, and APSA Trauma Committee: Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury.

J Pediatr Surg 35:164-169, 2000

 Prospective study all pts with BSLI No exclusions Bedrest : Grade I II inj 1 night Grade III V inj 2 nights
J Pediatr Surg 46:173-177, 2011

Prospective Study - BSLI

131 pts (spleen only 72, liver only 55 1 splenectomy (Grade V inj) Transfusions 24 (18 due to BSLI)

Mean injury grade 2.6

Mean bed rest 1.6 days

Need for bed rest limiting factor in duration of hospital in 86 pts (66%)
J Pediatr Surg 46:173-177, 2011

Prospective Study BSLI

An abbreviated protocol of 1 night for Grade I
II injuries and 2 nights for Grade III or higher in hemodynamically stable pts is safe and significantly decreases hospitalization c/w previous APSA recommendations.

Solid Organ Injury

Treatment
> 90% of hemodynamically stable pts

successfully managed non-operatively

Less than 10% require transfusion

References
Coley BD, Mutabagani KH, Martin LC, Zumberge N, Cooney DR, Caniano DA, Besner GE, Groner JI, Shiels WE 2nd. Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma. J Trauma. 2000 May;48(5):902-6. Holcomb GW III, Murphy JP. Ashcrafts Pediatric Surgery. 5th ed. Philadelphia, PA: Saunders An Imprint of Elsevier, 2010. Lynn KN, Werder GM, Callaghan RM, Sullivan AN, Jafri ZH, Bloom DA. Pediatric blunt splenic trauma: a comprehensive review. Pediatr Radiol (2009) 39:904-916. Moore EE, Cogbill TH, Jurkovich GJ, et al: Organ injury scaling: Spleen and liver (1994 revision). J Trauma 38:323-324, 1995 Sabiston DC II, Townsend CM III. Sabiston Textbook of Surgery. 18th ed. Philadelphia, PA: Saunders An Imprint of Elsevier, 2007. Stylianos S. Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. The APSA Trauma Committee. J Pediatr Surg. 2000 Feb;35(2):164-7. Tataria M, Nance ML, Holmes JH 4th, Miller CC 3rd, Mattix KD, Brown RL, Mooney DP, Scherer LR 3rd, Grooner JI, Scaife ER, Spain DA, Brundage SI. Pediatric blunt abdominal injury: age is irrelevant and delayed operation is not detrimental. J Trauma 2007 Sep;63(3):608-14.

QUESTIONS