S. N. Acker1, D. A. Partrick1, L. R. Hill1, D. D. Bensard1,2 1Children’s Hospital Colorado,Pediatric Surgery,Aurora, CO, USA 2Denver Health Medical Center,Department Of Surgery,Denver, CO, USA
Introduction: Among adult patients who suffer blunt solid organ injury, the presence of contrast blush (CB) on initial screening CT scan is associated with a 22 to 24 times greater likelihood of failure of non operative management (NOM) than if no CB is present. Current Western Trauma Association guidelines recommend that all adults with the presence of a blunt splenic injury and contrast blush should be considered for angioembolization. Currently, rate of splenectomy and failure of NOM of blunt organ injury is used as a quality indicator to assess trauma centers caring for injured children. We hypothesized that children with a CB represent a higher risk group and the use of splenectomy rate alone may not be an accurate measure of quality.
Methods: We performed a retrospective review of all children admitted to either of two academic pediatric trauma centers following blunt trauma with any grade liver or spleen injury from 1/09-12/13. Data evaluated included presence of CB on initial CT, need for intervention, and timing of intervention.
Results:245 children were admitted with blunt liver or spleen injury. 45 children were excluded due to lack of radiology report. 183 children had no CB (91%); 17 children had either a definite CB or CB could not be ruled out (9%) and were included in the CB group. Of those with CB, 3 required splenectomy (18%); all three were taken directly from the ED to the OR due to hemodynamic instability that failed to respond to packed red blood cell (PRBC) transfusion. Three additional children in the CB group received a PRBC transfusion within 12 hours of injury. One child had an avulsed kidney and underwent laparotomy, one child received PRBC transfusion during an orthopedic procedure, and the last child was hypotensive and thus received a transfusion. Each of the remaining 11 children with CB remained hemodynamically stable throughout their hospital stay; none required intervention in the form of laparotomy, angioembolization (AE), or PRBC transfusion. No children in either group underwent AE. Children with a CB were more likely to require splenectomy than children with no CB (n=3 (18%) vs n=1 (1%); p<0.01). CB was associated with a higher injury grade than lack of CB (3.4 vs 2.7; p <0.001).
Conclusion:
Contrast blush is rare among children with blunt solid organ injury, but does identify a higher risk group. The presence of CB alone did not precipitate splenectomy, however children with CB were more likely to be hemodynamically unstable, requiring intervention. If splenectomy rates are to be utilized as a quality measure for pediatric trauma care, the presence of vascular blush should also be considered as it represents a 5x higher risk of need for emergent intervention. The need for splenectomy can be used as a quality indicator, however this should not include children with a vascular blush.