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    7 Liver - Spleen Trauma

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    sanjay
    This document discusses spleen and liver trauma in pediatric patients. It covers mechanisms of injury, frequency of injuries by organ, diagnostic tools like CT scans and their accuracy, complications, treatments, and guidelines for management based on injury grade. For stable pediatric patients with isolated spleen or liver injuries, non-operative management is successful over 90% of the time with a hospital stay of 1-5 days depending on injury grade. Operative intervention is rarely needed at less than 10%.

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    7 Liver - Spleen Trauma

    Uploaded by

    sanjay
    200 views34 pages
    This document discusses spleen and liver trauma in pediatric patients. It covers mechanisms of injury, frequency of injuries by organ, diagnostic tools like CT scans and their accuracy, complications, treatments, and guidelines for management based on injury grade. For stable pediatric patients with isolated spleen or liver injuries, non-operative management is successful over 90% of the time with a hospital stay of 1-5 days depending on injury grade. Operative intervention is rarely needed at less than 10%.

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    This document discusses spleen and liver trauma in pediatric patients. It covers mechanisms of injury, frequency of injuries by organ, diagnostic tools like CT scans and their accuracy, complications, treatments, and guidelines for management based on injury grade. For stable pediatric patients with isolated spleen or liver injuries, non-operative management is successful over 90% of the time with a hospital stay of 1-5 days depending on injury grade. Operative intervention is rarely needed at less than 10%.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    200 views34 pages

    7 Liver - Spleen Trauma

    Uploaded by

    sanjay
    This document discusses spleen and liver trauma in pediatric patients. It covers mechanisms of injury, frequency of injuries by organ, diagnostic tools like CT scans and their accuracy, complications, treatments, and guidelines for management based on injury grade. For stable pediatric patients with isolated spleen or liver injuries, non-operative management is successful over 90% of the time with a hospital stay of 1-5 days depending on injury grade. Operative intervention is rarely needed at less than 10%.

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    of 34

    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

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