The failure rate of nonoperative management in children with splenic or liver injury with contrast blush on computed tomography: a systematic review

Factores asociados a falla en el manejo no operatorio de lesiones hepáticas o esplénicas secundarias a trauma abdominal cerrado en niños

“…Certain conditions have been associated with this fact, such as severe hepatic or splenic lesions (IV-V), since the more severe the lesion, the greater the probability of hemodynamic instability or association with injury to other organs, the hemoperitoneum abundant (3-4 quadrants), pseudoaneurysms and/or leakage of radiological contrast IV in CAT 1,[12][13][14]24,27,28,36 . However, other series have shown that 61-86% of grade IV lesions and 32-77% of grade V lesions (in the absence of hemodynamic instability) have been treated conservatively 6,7,[12][13][14][15]22 , and it does not matter the age, gender, mechanism of trauma and degree of injury 13,17 , because it is hemodynamic instability the one that does not show improvement after 6 hours of adequate resuscitation, which predicts almost a 100% of correlation between the need for laparotomy and splenectomy in children with closed trauma spleen 29 . The above is clear, a periodic evaluations by trained personnel are necessary in order to allow the early detection of the surgical interventions need and to identify patients at high risk, avoiding failure of NOM 6,7,[12][13][14][15]23,27,[29][30][31] .…”

“…However, other series have shown that 61-86% of grade IV lesions and 32-77% of grade V lesions (in the absence of hemodynamic instability) have been treated conservatively 6,7,[12][13][14][15]22 , and it does not matter the age, gender, mechanism of trauma and degree of injury 13,17 , because it is hemodynamic instability the one that does not show improvement after 6 hours of adequate resuscitation, which predicts almost a 100% of correlation between the need for laparotomy and splenectomy in children with closed trauma spleen 29 . The above is clear, a periodic evaluations by trained personnel are necessary in order to allow the early detection of the surgical interventions need and to identify patients at high risk, avoiding failure of NOM 6,7,[12][13][14][15]23,27,[29][30][31] . The primary indication for surgical intervention in hemodynamically stable children is the requirement for serial transfusions exceeding half the blood volume or 40 cc/kg for 24 hours after injury 1,9,14,15,17 .…”

“…The included patient should present hemodynamic stability, absence of signs of peritoneal irritation 1,4,9,10,12,13,18,19,23,28,29 , whose age were between 0-14 years old, with an initial NOM for hepatic or splenic trauma, no trauma to other solid organs or other voids rather than liver or spleen, which has required to proceed with surgery; patients who present evidence of tomographic images for classification of hepatic or splenic trauma and evidence of clinical and paraclinical data (Hb levels) in clinical history.…”

Focused Assessment with Sonography in Trauma (FAST) Scans Are Not Sufficiently Sensitive to Rule out Significant Injury in Pediatric Trauma Patients

“…However, in our series two grade IV liver and splenic injuries were missed (Figure 1). These patients were successfully managed conservatively, but knowledge of the extent of solid organ injuries and reassurance of no active bleeding (absent contrast blush on CT) [15] is necessary to support the decision to manage these patients conservatively, preferably on a high dependency unit where any clinical deterioration could be immediately detected. In addition quantification of the extent of injury at the time of trauma provides guidance for planning follow-up imaging to assess for significant sequelae of solid organ injuries such as biliary leaks, urinomas and pseudoaneurysms (both hepatic and splenic) [16].…”

Non-Operative Management of Liver Trauma

“…In a direct, single city comparison of adult and paediatric liver injuries, there was no significant difference in the rates of operative intervention or length of hospital stay but adults appeared to require more adjunctive procedures such as ERCP and laparoscopic washouts than children, who had a higher but non-significant mortality rate [124]. More recently a systematic review of SNOM of blunt hepatic (or splenic) trauma in children in whom there is a contrast blush on CT suggests that the failure rate of nonoperative management is much higher -28.2% without the use of embolisation, although the liver specific data records 3/29 failures (10.3%) [125]. A report from Turkey details successful SNOM of penetrating abdominal wounds in children, although it appears that the majority did not injure any intra-abdominal viscera and liver specific data are not reported though it is likely that some of the successful cases of SNOM did have liver involvement [126].…”