Modern day nonoperative management of solid organ injury in adults came to be due to its success rate in children. But if you look at the practice guidelines for adults, they frequently include a path for angioembolization in certain patients. In children, embolization is almost never recommended.
But what about that gray zone where children transition to adults? How young is too young to embolize? Or how old is too old not to consider it?
The adult and pediatric trauma groups at Wake Forest looked at this question by reviewing their respective trauma registry data. They looked specifically at patients age 13-18 who presented with a blunt splenic injury over a 8.5 year period. About halfway through this period, adult patients (> 16 years) were sent for embolization not only for pseudoaneurysm or extravasation, but also for high grade injury (> grade 3). Patients under age 16 were managed by the pediatric trauma team, and those 16 and older by the adult team.
Here are the factoids:
- Of the 133 patients studied, 59 were “adolescents” (age 13-15) and 74 were “adults” (16 or older)
- Patients managed by the adult team sent 27 of their 74 patients for angiography
- Those managed by the pediatric team were never sent to angiography
- The failure rate for nonoperative management was statistically identical, about 4% in adults and 0% in adolescents
- For high grade injuries, the adult team sent 27 of 34 patients to IR, whereas the pediatric team sent none of 36. Once again, failure rate was identical.
Bottom line: We already know that too many adult trauma centers send too many younger patients to angiography for solid organ injury. This study tries to tease out when a child becomes an adult, and therefore when angiography should begin to be considered. And basically, it showed that through age 15, they can still be considered as and treated like children, without angiography.
But remember, these numbers are relatively small, so take this work with a grain of salt. If you are managing a younger patient nonoperatively, and they continue to show evidence of blood loss (ongoing fluid/blood requirements, increasing heart rate), angiography may be helpful in avoiding laparotomy as long as your patient remains hemodynamically stable. But consult with your friendly neighborhood pediatric surgeon first.
- Video: how to grade spleen injury
- Solid organ injury tips
- Please, no bedrest after pediatric spleen injury
Reference: The Spleen Not Taken: Differences in management and outcomes of blunt splenic injuries in teenagers cared for by adult and pediatric trauma teams in a single institution. J Trauma, in press, May 2017.