Blunt splenic injuries in a Canadian pediatric population: the need for a management guideline
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* Brent Zabolotny
* B.J. Hancock
* Ray Postuma
* Nathan Wiseman

## Abstract

**Objectives:** To review practice patterns in a Canadian pediatric centre and develop a safe and effective care plan for managing children with splenic injuries.

**Design:** A chart review.

**Setting:** Winnipeg Children’s Hospital.

**Patients:** All patients with splenic injuries under the age of 17 years admitted to the hospital between December 1994 and April 1999.

**Outcome measures:** These included patient demographics, length of stay, location of care, grade of splenic injury (American Association for the Surgery of Trauma Organ Injury Scale), imaging tests performed in hospital and after discharge, follow-up care and time to return to full activity.

**Results:** Forty-four patients received nonoperative management. The mean age of the patients was 10.4 years. The average grade of splenic injury was 2.8. Sixteen patients (36%) were admitted to the intensive care unit for an average of 1.9 days. Mobilization was allowed after a mean of 5.2 days. Average length of hospital stay was 9.2 days. At the time of admission 98% of the patients underwent computed tomography, but at follow-up only 20% of patients underwent this investigation. None of the follow-up imaging studies altered the postdischarge management plan. The median time to full activity was 12 weeks (range from 0–17 wk). One patient had a delayed hemorrhage and required splenectomy.

**Conclusions:** Reduced admissions to the intensive care unit, shorter overall stays, omission of follow-up imaging and an earlier return to full activity should be considered in the management of children with blunt splenic injuries. Standardization of nonoperative care for such children would result in safe and more efficient delivery of health care.

The management of children with blunt splenic injury has evolved over time, and currently nonoperative care is the standard initial management. Operative intervention, however, is mandatory for children who show delayed evidence of splenic bleeding. The reported rate of delayed intervention ranges from 2% to 16%.1–3 The objective of post-trauma management is prevention of delayed complications that require intervention. This goal is achieved by restricting activity and assessing splenic healing with repeated imaging. Recently, however, the utility of follow-up imaging has been questioned.4–6 A review of surgeon practice patterns has revealed a wide variance in care plans, particularly the time recommended before resuming full activities.7 A lack of consensus has resulted in multiple approaches to the post-trauma care of children with blunt splenic injuries. The Trauma Committee of the American Pediatric Surgical Association (APSA) is the first body to address this situation, having published an evidence-based guideline for managing solid organ injury.8

We reviewed local practice patterns in an attempt to determine a Canadian perspective on post-trauma management of blunt splenic injuries and to establish a care plan that would simplify the management of these children without compromising patient safety.

## Materials and methods

A chart review was conducted of all patients admitted to the Children’s Hospital, Winnipeg, from December 1994 to April 1999. The Medical Records Department identified and included in the study charts with the diagnosis of “splenic laceration” and “blunt splenic injury.” All 3 local pediatric general surgeons use the hospital clinic for follow-up, allowing this information to be accessed from the chart. We are confident that no delayed splenic hemorrhages would be missed as the Children’s Hospital of Winnipeg is the only pediatric centre for the entire province of Manitoba — all major pediatric illness is referred to this centre. Data collected included: patient demographics; length of stay; location of care (pediatric intensive care unit [PICU] v. standard ward bed); grade of splenic injury (according to the American Association for the Surgery of Trauma scoring criteria);9 pediatric trauma score (PTS); imaging tests performed in hospital and at follow-up; number of follow-up visits; and time to return to full activity. Where appropriate, Student’s *t*-test was applied for statistical analysis; a *p* value of 0.05 was considered significant.

## Results

### Patient demographics

Forty-eight children with blunt splenic injuries were identified, 4 of whom sustained multisystem trauma. One chart was unavailable. Two children underwent laparotomy and splenectomy immediately and 1 at 48 hours after injury. The remaining 44 children successfully completed a course of nonoperative management. The mean age of children was 10.4 years (range from 5–17 yr). The patient population was predominantly male (37 boys, 7 girls).

### Grade of splenic injury and pediatric trauma scores

Table 1 shows the distribution of splenic injury grades. No child sustained a grade 5 injury. The average grade of injury was 2.8. The mean pediatric trauma score was 11.3 (range from 6–12). The mean grade of splenic injury for patients treated in the PICU was 3.1; the mean PTS was 11.2. Those treated on the ward exclusively had an average grade of injury of 2.6 and an average PTS of 11.4. Both the grade of splenic injury and the PTS did not differ significantly between PICU and ward patients.

View this table:
[Table 1](http://canjsurg.ca/content/45/5/358/T1)

Table 1 
Distribution of Grades of Splenic Injury in 48 Children

### Location of care

Sixteen of the children were admitted to the PICU for observation. The average length of stay in the PICU was 1.9 days. The average overall length of stay for all patients was 9.2 days (range from 1–56 d). When analyzed by admission to the PICU, it was observed that those admitted to the PICU had an overall mean length of stay of 12.7 days, whereas those treated on the ward exclusively were hospitalized an average of 7.1 days. This difference was not significant (*p* = 0.057). When children with multiple injuries were excluded, those admitted to the PICU (8.2 d) stayed significantly longer in hospital than those treated on the ward (6 d; *p* = 0.03). In none of the children admitted to PICU was delayed hemorrhage diagnosed while in the unit. One child had a delayed hemorrhage at 48 hours, after transfer to the ward.

### Transfusion requirements

Of the 44 children who successfully completed the course of non-operative treatment, only 4 (9%) required a blood transfusion, (average volume 23.2 mL/kg). This is in contrast to the children who underwent operative management for their injury, all of whom required a transfusion (average volume 32.1 mL/kg).

### Imaging studies

Of the imaging studies performed at the time of admission (Table 2) only 1 child (2%) did not undergo CT. Follow-up imaging studies are depicted in Table 3. CT was used in only 20% of children at follow-up, and none of the follow-up imaging modalities resulted in a change in patient management.

View this table:
[Table 2](http://canjsurg.ca/content/45/5/358/T2)

Table 2 
Imaging Modalities Used for Diagnosis of Blunt Splenic Injury at the Time of Admission to Hospital

View this table:
[Table 3](http://canjsurg.ca/content/45/5/358/T3)

Table 3 
Imaging Modalities Used for Diagnosis of Blunt Splenic Injury at Follow-up

### Mobilization and follow-up

While in hospital, children were advanced to quiet activities in a mean of 5.2 days. Fig. 1 shows the breakdown of time before patients were allowed to participate in full, unrestricted activity. The average time to return to full activity after injury was 10 weeks (median 12 wk). Thirty-five percent of children had activity restrictions removed in less than 8 weeks after the injury, 20% in less than 6 weeks.

![FIG. 1](http://canjsurg.ca/https://www.canjsurg.ca/content/cjs/45/5/358/F1.medium.gif)

[FIG. 1](http://canjsurg.ca/content/45/5/358/F1)

FIG. 1 
Total time elapsed after blunt splenic injury before activity restrictions were lifted in the study population.

Patients were seen in follow-up an average of 1.4 times; 16% were lost to follow-up. One patient was readmitted for observation in the follow-up period because of abdominal pain unrelated to the spleen. No other patients required readmission to the Children’s Hospital of Winnipeg.

## Discussion

Although nonoperative management of blunt splenic injuries is well accepted, management guidelines and follow-up care have not been standardized. Post-trauma care is directed at preventing delayed splenic hemorrhage. The current literature suggests a delayed bleeding rate of approximately 2%;1,2,10,11 however, delayed operative rates as high as 16% have been recorded.3 In our local experience, a similar delayed hemorrhage rate was observed, with only 1 of 45 (2%) patients who had no evidence of active bleeding at presentation requiring splenectomy after 48 hours.

A low rate of delayed hemorrhage may not warrant the level of vigilance currently employed. Post-trauma care could be modified. One such modification would concern the use of the PICU for monitoring isolated splenic injuries. Our experience has shown that children with similar grades of splenic injury did equally well regardless of admission to the ward or PICU. Furthermore, admission to the PICU with an isolated splenic injury was associated with a longer hospital stay. Several authors including Lynch and associates12 and Siplovich and Kawar13 have also questioned the need for intensive care monitoring. In these studies, none of the patients admitted to the ICU required therapeutic intervention. Stylianos8 also concluded that PICU admission is warranted only for the most severe (grade 4) splenic injuries.

The use of imaging studies could also be modified. Initial confirmation should be made by one imaging modality alone. In our centre, CT scan was the most popular choice, with 98% of patients undergoing preadmission scanning. Computed tomography is considered the “gold standard” in the current literature for evaluation of blunt abdominal trauma.14,15 Computed tomography provides an excellent assessment and is readily available in most major centres. Surgeons should be cautioned, however, against using CT findings in the decision to operate. Kohn and associates16 showed that splenic injury grading by CT did not correlate with the need for an operation. We found that more than 50% of children admitted for observation had grade 3 or 4 splenic injuries. All of these patients successfully completed a course of nonoperative therapy. For those requiring operative intervention, the decision to proceed with splenectomy should be based on clinical evaluation.

Routine follow-up imaging has also been questioned.4–6,8 In our local experience, a variety of imaging modalities were used, yet none altered the course of management. The 32% of patients who did not have follow-up imaging all had a good final outcome.

Restriction of activity is common after splenic injury. The necessary duration of that restriction, however, has not been established. The majority of surgeons advise 3 months.17 A recent survey of practice patterns in the management of blunt solid organ injuries suggests that a significant proportion of patients safely return to full activity levels in less than 3 months.7 The APSA Trauma Committee has shown that it is safe for surgeons to be even more aggressive in allowing patients to return to full activity levels. Their research suggests that all injuries require no more than 6 weeks of restricted activity, and they have linked the length of activity restriction to the grade of splenic injury. These numbers were devised by determining the minimum number of days that at least 25% of the patients were safely treated.8 Applying this to our data, we found that activity level restrictions could be lifted between 6 and 8 weeks. We found that activity levels were safely liberalized at 8 weeks in 35% of patients and at 6 weeks in 20%. Our patient population is too small to comment on grade-specific activity restrictions.

This study suggests that routine admission to the PICU, follow-up imaging studies and lengthy restriction of activities are not necessary. A care map based on the findings of our study is depicted in Fig. 2. Standardization of nonoperative care should ensure safe care for children with splenic injuries while allowing for more efficient resource utilization, reducing nonessential costs in health care delivery.

![FIG. 2](http://canjsurg.ca/https://www.canjsurg.ca/content/cjs/45/5/358/F2.medium.gif)

[FIG. 2](http://canjsurg.ca/content/45/5/358/F2)

FIG. 2 
Care map for patients with blunt splenic injuries.

*   Accepted January 28, 2002.

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