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Guidelines in Focus: Blunt Liver and Spleen Injury
Byron D. Hughes MD MPH, Nathaniel Kreykes MD, Shannon Longshore MD, and John Petty, MD

Key Guideline Reference:

Notrica, D. M., Eubanks, J. W., Tuggle, D. W., Maxson, R. T., Letton, R. W., Garcia, N. M., et al. (2015). Nonoperative management of blunt liver and spleen injury in children: Evaluation of the ATOMAC guideline using GRADE. The Journal of Trauma and Acute Care Surgery, 79(4), 683–693.

Link to guideline: Evaluation of ATOMAC BLS guideline

The Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium (ATOMAC) consists of a group of Level I pediatric trauma centers from across the United States dedicated to performing clinical and preclinical studies aimed at optimizing management and functional outcomes for injured children. This study attempted to bring together the current research on pediatric blunt liver and spleen injury management and analyze the literature using the GRADE approach. The results of this analysis guides our current and future research and potentially will provide a platform of evidence for other centers to consider.

For ATOMAC

David Tuggle MD FACS FAAP
Associate Trauma Medical Director
Dell Children's Medical Center of Central Texas
Dell Medical School, the University of Texas at Austin

Guideline Highlights:

This recent guideline was developed by the ATOMAC pediatric trauma consortium to update the practice management guidelines for treating blunt liver and spleen injuries (BLSI).

Pervious management guidelines were largely based on expert opinion. This review subjects the guideline to analysis based on Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology to rate the level of evidence associated with the practice management guideline.

The previous practice management guideline gave rise to 27 clinical questions on blunt liver and spleen injury management. Relevant earlier publications were identified and evidence reviewed using the GRADE system. The evidence was then assigned a grade, A (very confident) to D (little confidence) and clinical recommendations graded as 1 (strongly recommended) or 2 (weak or conditional recommendation).

Strongly supported recommendation include:

  1. Management of pediatric BLSI may be based on hemodynamic status, rather than injury grade.
  2. A shortened period of bed rest of 1 day or less for stable children with unchanged hemoglobin levels.
  3. A transfusion threshold of 7.0 g/dl is reasonable for children undergoing non-operative management.
  4. Unstable patients should be considered for surgery, urgent embolization, or continued non-operative management, depending on other injuries and the center's resources

Finally, this guideline provides a treatment algorithm supported by the consortium's exhaustive review of the blunt trauma literature and thorough analysis using the GRADE methodology.

What's New?

Three recent publications contribute to our understanding of pediatric solid organ injuries.

Article 1: Wisner DH, Kuppermann N, Cooper A, Menaker J, Ehrlich P, Kooistra J, Mahajan P, Lee L, Cook LJ, Yen K, Lillis K, Holmes JF. Management of children with solid organ injuries after blunt torso trauma. J Trauma Acute Care Surg. 2015 Aug; 79(2):206-14.

Link to article: PECARN_Solid_Organ_Injury

The Pediatric Emergency Care Applied Research Network (PECARN) collects prospective data across twenty participating hospitals (14 freestanding and 6 non-freestanding children’s hospitals). This analysis of care delivered to children with solid organ injury (liver, spleen, kidney) revealed considerable variation in practice. Overall rates of intervention were 4.1% laparotomy, 1.4% angioembolization, and 11% transfusion. Intervention rates were lower at freestanding children's hospitals than at non-freestanding children's hospitals (2.8% vs. 5.4%). Utilization of the ICU admission was high at 34% for Grade I or II injuries, compared to published American Pediatric Surgical Association (APSA) 2002 guidelines. These findings suggest that management of solid organ injuries varies widely across centers, and the presence of a widely endorsed guideline does not necessarily result in standardization of practice.

Article 2: Linnaus, M. E., Langlais, C. S., Garcia, N. M., Alder, A. C., Eubanks, J. W., III, Maxson, R. T., et al. (2017). Failure of nonoperative management of pediatric blunt liver and spleen injuries. Journal of Trauma and Acute Care Surgery, 1–22.

Link to article: Failure of NOM of BLS injuries

This study attempts to determine the frequency and clinical characteristics of failure of NOM in pediatric BLSI patients. A prospective observational study was conducted on patients ?18 years presenting to any of ten level 1 pediatric trauma centers over a recent 3 year period with BLSI on computed tomography. Management of BLSI was based on the ATOMAC pediatric guideline. Failure of NOM was defined as needing laparoscopy or laparotomy.? A total of 1008 patients met inclusion criteria. A total of 69 (7%) underwent laparotomy or laparoscopy, but only 34 (3%) underwent surgery for spleen or liver bleeding. Other operations were for 21 intestinal injuries; 15 hematoma evacuations, washouts, or drain placements; 9 pancreatic injuries; 5 mesenteric injuries; 3 diaphragm injuries; and 2 bladder injuries. Patients who failed NOM were more likely to receive blood. Overall mortality rate was 24% (8/34) in those who failed NOM due to bleeding. The authors conclude that NOM fails in 7% of children with BLSI, but only 3% of patients failed for bleeding due to liver or spleen injury. For children failing NOM due to bleeding, the mortality was 24%.

Article 3: Vaughn N, Tweed J, Greenwell D, Notrica DM, Langlais CS, St Peter SD, Leys CM, Ostlie DJ, Maxson RT, Ponsky T, Tuggle DW, Eubanks JW, Bhatia A, Greenwell C, Garcia NM, Lawson KA, Motghare P, Letton RW, Alder AC. The impact of morbid obesity on solid organ injury in children using the ATOMAC protocol at a pediatric level 1 trauma center. J Pediatr Surg. 2017 Feb; 52(2):345-348.

Link to article: Impact of morbid obesity on solid organ injury

This article is a multi-center, prospective database study that compared obese versus non-obese pediatric trauma patients admitted for liver or splenic laceration. All patients were managed based upon the ATOMAC protocol. The study cohort had 117 patients, and 16% were obese. Though obesity was associated with a higher grade liver laceration, it was not associated with failure in non-operative management. There was no difference in severity of splenic injury. It was theorized hepatic steatosis in the obese patients may make the liver more vulnerable to injury. The ATOMAC protocol was associated with a low rate of failure regardless of the obesity status.

What Next?
Link to care pathways: Solid organ injury care pathways on PTS site

The solid organ care pathways submitted on the website represent a lot of hard work from some of our member institutions. Overall, they are structured for care based on anatomic grade of injury, though most are more progressive than the "classic" approach to nonoperative management of liver and spleen injuries. They each use physiologic instability as a trigger for intervention. Example #1 provides some nice background for care of these injuries. This example also builds in a psychosocial assessment as part of its care pathway. Wouldn't it be great if we all did that? Example #2 is the flow chart from the key guideline reviewed above. It is great to have this "just a click away" on the website if you need a quick refresher. Example #3 has an interesting flow chart at the beginning to guide clinicians on which patients should have imaging, and which patients probably do not need imaging at all. It also has a thorough set of home instructions for families after hospital discharge. Example #4 provides some direction on caring for a child after splenectomy. Yikes! We hope we don't have to do that very often, but it is a good reminder that not every patient can be managed nonoperatively. Example #5 is a care pathway for isolated liver and spleen injury, but it also provides the grading system for kidney and pancreas injuries. Some of the same principles of nonoperative management could be applied to kidney and pancreas injuries, too. This example also provides a table of the evidence at the end, rather than merely a bibliography.

What do you think? Does your institution treat children according to the anatomic grade? Physiology only? Combination of both?

PTS would love to hear from you. If you want to submit your solid organ injury management pathway, email it to guidelines@pediatrictraumasociety.org.

If you want to join the conversation, become part of the ListServ: http://members.pediatrictraumasociety.org/forms/ListServ-SignUp.cgi

Keep an eye on the PTS website for new ideas and ways to make the care of injured kids better.