Management of Spleen/Liver

Trauma
George W. Holcomb, III, M.D., MBA
Surgeon-in-Chief
Childrens Mercy Hospital
Kansas City, MO
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-yo boy injured on an ATV. Grade I injury with subcapsular fluid
occupying less than 10% of spleens surface area.
AAST Splenic Injury Scale
17-yo girl injured in an MVC. Grade II injury with laceration involving
less than 3 cm of parenchymal depth
AAST Splenic Injury Scale
18-yo 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-yo boy injured playing hockey. Fractured spleen involving
more than 25%, Grade IV splenic laceration
AAST Splenic Injury Scale
12-yo 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
216 Pts 7 yrs
26 Pts Contrast blush on CT scan
Lower HgB
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
Blunt Splenic Injury
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 CT
1
CT w contrast
determine grade and look for
active extravasation
1
Coley 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
CT GRADE I II III IV
Days in ICU None None None 1 day
Hospital stay 2 days 3 days 4 days 5 days
Predischarge
imaging
None None None None
Postdischarge
imaging
None None None None
Activity
restrictions
3 weeks 4 weeks 5 weeks 6 weeks
From Stylianos S, and APSA Trauma Committee: Evidence-based guidelines for resource
utilization in children with isolated spleen or liver injury.
APSA guidelines for hemodynamically stable 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. 5
th
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. 18
th
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 4
th
, Miller CC 3
rd
, Mattix KD, Brown RL, Mooney DP,
Scherer LR 3
rd
, 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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