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
Fluid in the subphrenic space and
• Compared to CT only 63% splenorenal recess can be detected.
sensitive for detecting free The image shown demonstrates blood
fluid (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 spleen’s 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 A. Splenic pseudoaneurysm
used (arrowheads) after nonoperative
treatment of blunt splenic injury.
• Also occur in liver
B. Successful angiographic
trauma 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
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
APSA guidelines for hemodynamically stable children with isolated
spleen or liver injury

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 None None None None
imaging
Postdischarge None None None None
imaging
Activity 3 weeks 4 weeks 5 weeks 6 weeks
restrictions

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. Ashcraft’s 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