Blunt splenic trauma in children: are we too careful?

Abstract

Introduction: There has been a shift from operative treatment (OT) to non-operative treatment (NOT) of splenic injury. We evaluated the outcomes of treatment of pediatric patients with blunt splenic trauma in our hospital, with special focus on the outcomes after NOT.

Patients and methods: The data of all patients <18 years with radiologically proven blunt splenic injury admitted between 1988 and 2007 were retrospectively analyzed. Mechanism of injury, type of treatment, ICU stay, total hospital stay, morbidity and mortality were assessed. Patients suffering isolated splenic injuries were assessed separately from patients with multiple injuries. Patients were subsequently divided into those admitted before and after 2000.

Results: There were 64 patients: 49 males and 15 females with a mean age of 13 years (range 0-18). 3 patients died shortly after admission due to severe neurological injury and were excluded. In the remaining 61 patients concomitant injuries, present in 62%, included long bone fractures (36%), chest injuries (16%), abdominal injuries (33%) and head injuries (30%). Mechanisms of injury were: car accidents (26%), motorcycle (20%), bicycle (19%), fall from height (17%) and pedestrians struck by a moving vehicle (8%). A change in treatment strategy was evident for the pre- and post-2000 periods. Significantly more patients had NOT after 2000 in both the isolated splenic injury group and the multi-trauma group [4/11 (36%) before vs. 10/11 (91%) after (p=0.009); 15/19 (79%) before vs. 8/20 (40%) after 2000 (p=0.03)]. There was also a significant shift to spleen-preserving operations. All life-threatening complications occurred within <24 h after injury. Mortality for the entire cohort was 7%; all of these patients were treated operatively. When comparing the median ICU and hospital stay before and after 2000 it was found to be significantly higher in the isolated injury group and remained statistically the same in the multi-trauma group.

Conclusion: Splenic injury in children is associated with substantial mortality. This is due to concomitant injuries and not to the splenic injury. Non-operative treatment is increasingly preferred to operative procedures when treating splenic injuries in hemodynamically, stable children. ICU and hospital stay have, despite the change from OT to NOT, remained the same. Complications after NOT are rare. We are still observing children in hospital for a longer period than is necessary.