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Multiple trauma: liver and spleen injury
1Children's Hospital-Boston, Boston, Massachusetts, USA. david.mooney@tch.harvard.edu
Insights
Pediatric nonoperative management for liver and spleen injuries is now standard, though optimal care protocols are still being refined. Research clarifies risks and guides best practices for treating these childhood traumatic injuries.
Area of Science:
- Pediatric surgery
- Trauma management
- Abdominal injuries
Background:
- Management of pediatric hepatic and splenic injuries has shifted from operative to nonoperative approaches over 30 years.
- Nonoperative management strategies are becoming standardized, but areas for refinement remain.
- Falls from greater heights are a significant cause of solid organ injury in children.
Purpose of the Study:
- To review and refine nonoperative management strategies for pediatric hepatic and splenic injuries.
- To address ongoing debates regarding optimal care settings (adult vs. pediatric trauma centers).
- To clarify the risk of post-splenectomy sepsis.
Main Methods:
- Analysis of the Pennsylvania Trauma Systems Foundation dataset for children with severe liver injuries.
- Literature review to clarify the risk of post-splenectomy sepsis.
- Examination of factors influencing nonoperative management, including ICU/acute care length of stay, laboratory draws, activity restriction, and radiographic healing evidence.
Main Results:
- Nonoperative management is now the predominant strategy for the majority of pediatric hepatic and splenic injuries.
- Specific parameters of nonoperative care, such as length of stay and activity restrictions, require further study.
- The risk of post-splenectomy sepsis has been further elucidated.
Conclusions:
- Nonoperative management is the established standard for pediatric hepatic and splenic injuries.
- Continued research is necessary to optimize intensive care unit (ICU) and acute care unit lengths of stay, laboratory testing frequency, activity restriction duration, and radiographic healing criteria.
- Understanding the risks associated with splenectomy remains crucial.
Abstract:
The management of hepatic and splenic injuries in childhood has evolved over the past 30 years from prompt operation upon recognition of injury to nonoperative management in the large majority of children. Many aspects of nonoperative management have become increasingly standardized and efforts continue to further refine this strategy. The appropriate intensive care unit and acute care unit length of stay, the number of laboratory draws, the length of activity restriction and the need for radiographic evidence of healing prior to release from activity restriction remain areas of study. Previously demonstrated variation in the management and outcome of injured children between adult and pediatric surgeons has led to debate over which type of facility should best care for injured children. The Pennsylvania Trauma Systems Foundation dataset was used to derive a series of children with severe liver injuries. Finally, the risk of post-splenectomy sepsis, a stimulus for the initial development of nonoperative management, has been further clarified by a literature review. While falls from a low height may infrequently lead to a significant injury, falls from greater heights are more likely to induce a solid organ injury.