I recently wrote about this journal article from a couple of pediatric trauma programs in New York. The article tried to focus on reducing the rate of phlebotomy in children who are being observed for solid organ injury. I was more excited about the overall protocol being used to manage liver and spleen injury, as it was a great advance over the original APSA guideline. But let’s look at the phlebotomy part as well.
This is an interestingly weird study, and you’ll see what I mean shortly. Two New York trauma hospitals that take care of pediatric patients pooled 4 years of registry records on children with isolated blunt liver and/or spleen injuries. Then they did a tabletop excercise, looking at “what if” they had applied the APSA guideline, and “what if” they had applied their new, proposed guideline.
Interestingly, this implies that they were using neither! I presume they are trying to justify (and push all their partners) to move to the new protocol from (probably) random, individual choice.
Here are the factoids:
- 120 records were identified across the 2 hospitals that met criteria
- Late presentation to the hospital, contrast extravasation, comorbidities, lack of imaging, operative intervention at an outside hospital excluded 59 patients, leaving 61 for analysis. Three of those patients became unstable and were also excluded.
- None of the remaining patients required operation or angioembolization
- Use of the “new” (proposed) protocol would reduce ICU admissions by 65%, reduce blood draws by 70%, and reduce hospital stay by 37%
- Conclusion: use of the protocol would eliminate the need for serial phlebotomy (huh?)
Bottom line: Huh? All this to justify decreasing blood draws? I know, kids hate needles, but the data on decreased length of stay in the hospital and ICU is much more important! We’ve been using a protocol similar to their “new” one at Regions Hospital, which I’ve shared below. We’ve been enjoying decreased resource utilization, blood draws, and very short lengths of stay for over a decade. And our analysis showed that we save $1000 for every patient entering the protocol, compared to the old-fashioned and inefficient way we used to manage them.
Reference: Reducing scheduled phlebotomy in stable pediatric patients with liver or spleen injury. J Ped Surg 49(5):759-762, 2014.
FAST is a helpful adjunct to the initial evaluation of adult trauma patients. Unfortunately, due to small numbers the usefulness is not as clear in children. In part, this is due to the fact that many children (particularly small children < 10 years old) have a small amount of fluid in the abdomen at baseline. This makes interpreting a FAST exam after trauma more difficult.
Despite this, use of FAST in children is widespread. A survey of 124 US trauma hospitals in 2007 showed an interesting pattern of ultrasound usage. In adult-only institutions 96% use FAST, and at hospitals that see both adults and kids, 85% use it. Most of these centers that use FAST have no lower age limit, and the physician most commonly performing the exam was a surgeon. However, only 15% of children’s hospitals do FAST exams, and they were usually done by nonsurgeons! The reasons for this are not clear. It appears that the pediatric surgeons have not embraced this technology as much as their adult counterparts.
What about that confusing bit of fluid found in kids? Several groups have looked at this (retrospectively). Fluid in the pelvis alone appears to be okay, but fluid anywhere else is a good predictor of solid organ injury. Fluid seen outside the pelvis had a 90% sensitivity and 97% specificity for injury, and positive and negative predictive values were 87% and 97% respectively.
Bottom line: FAST exam is useful in pediatric victims of blunt abdominal trauma. Fluid in the pelvis alone is normal in most children, but fluid seen anywhere else indicates a high probability of solid organ injury.
- Use of focused abdominal sonography for trauma at pediatric and adult trauma centers: a survey. J Pediatric Surgery 44:1746-1749, 2009.
- Minimal pelvic fluid in blunt abdominal trauma in children: the significance of this sonographic finding. J Pediatric Surgery 36(9):1387-1389, 2001.
- Clinical importance of ultrasonographic pelvic fluid in pediatric patients with blunt abdominal trauma. Ulus Travma Acil Cerrahi Derg 16(2):155-159, 2010.
Nonoperative management of solid organ injury is the norm, and has reduced the operative rate significantly. At the same time, the recognition that development of deep venous thrombosis (DVT) in trauma patients is commonplace creates uncertainty? Is it safe to give chemical prophylaxis with low molecular weight heparin (LMWH)? How soon after injury?
The trauma group at USC+LAC recently published the findings of a retrospective review of 312 patients undergoing nonoperative management for their liver, spleen or kidney injuries. They looked at chemical prophylaxis administration and its relationship to failure of nonop management of solid organ injury.
As expected, as the grade of the solid organ injury increased, so did the failure rate of nonoperative management. Administration of low molecular weight heparin, such as enoxaparin, did not increase failure rate in this study. All but one failure occurred in patients who had not yet received the injections. Likewise, two DVT and two pulmonary embolisms occurred, but only in patients who had not yet received prophylaxis.
Bottom line: This small study offers some assurance that early prophylaxis is okay, and a few prospective studies do exist. UCSF / San Francisco General is comfortable beginning chemical prophylaxis 36 hours postop, regardless of solid organ injury. Look for more guidance on this issue in the coming year or so. Until then, consider starting LMWH prophylaxis early to avoid complications from DVT or PE.
Reference: Thromboembolic prophylaxis with low-molecular-weight heparin in patients with blunt solid abdominal organ injuries undergoing nonoperative management: current practice and outcomes. J Trauma 70(1): 141-147, 2011.
It’s always interesting to review the trauma literature of days gone by to see where we’ve been and how it impacts where we are today in trauma care. Here are a few articles from the Jan 1990 Journal of Trauma (Volume 30 Number 1) worth commenting on:
Efficacy of Liver Wound Healing by Secondary Intent. Dulchavsky et al, page 44-48. This paper compared wound healing using tensile strength in pigs and dogs. The authors compared primary operative closure, closure with an omental buttress, and healing by secondary intention. They found that the strength of secondary healing equaled or exceeded that in both types of operative repair by 6 weeks post-injury. This paper and several similar ones laid the groundwork for our understanding of solid organ healing and lend weight to the somewhat arbitrary guidelines of resuming full physical activity after 6 weeks.
Intestinal Injuries Missed by Computed Tomography. Sherck et al, page 1-7. The authors retrospectively looked at 10 CT scans done over a 9 year period that were done in patients who eventually were found to have an intestinal injury. The injury became apparent in 2 hours to 3 days after the traumatic event. Even when the authors knew that a bowel injury was present, they could definitively diagnose the problem on the initial CT in only 2. The authors concluded that CT could not reliably detect these injuries. Little has changed since this paper was published, even though the scan technology has improved greatly (1 or 2 slice scanners in 1990, 16-64 slices now). We have gotten better at detecting bowel injury with better resolutions, but the diagnosis still remains a clinical one.
Techniques of Splenic Preservation Using Fibrin Glue. Shoemaker et al, page 97-101. The senior author first described the use of fibrin glue in splenic injury in 1983, and continued to investigate it over the next 7 years. This paper was the largest human series at the time. The authors found that it limited blood loss and transfusions, although there was no actual control group. They found that it increased splenic salvage rates to 86% in operative cases, and repeat CT did not show rebleeding or abscess formation. This study added a new technique to the trauma surgeon’s armamentarium in dealing with solid organ injury. Although later studies did find a modest increase in abscess formation, the technique remains a viable alternative when operatively managing solid organ injury. Overall, it is not used as much now because nonoperative management has become quite refined, with a success rate of about 93%.