Update Course Rewind: Updates in Solid Organ Injury Management 2023

Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello pediatric surgery family. I'm M. Godi, a research fellow from Cincinnati Children's Hospital Medical Center. Our 11th annual update course in pediatric surgery was held past August. In this video series, we'll recap the sessions and share the main highlights with you. In this session, Dr. Katie Russell and Mira Khaddage brought us some rapid-fire updates in pediatric trauma. Today, we'll review updates in solid organ injury. So this is our case. You have a 7-year-old male who was involved in an ATV crash. Presented to your emergency department with a heart rate of 105, blood pressure of 110 over 75, GCS 15 and is complaining of abdominal pain. The patient goes for a CT scan that demonstrates a grade four splenic laceration. Hemodynamically normal. So the question is, what is this patient's disposition? What do you want to do? So most of the audience here said floor. When I work in Uganda, very often these are patients I would put in the ICU just because of monitoring capacity on the floor. Exactly. In the floor, there's not even a monitor and there's minimal staff sometimes. So if we had a way to continue to monitor someone, we would send them to the floor. So I think this is a reflection of resources. In more resource constrained settings, the ICU looks very different than the floor. And actually, when we presented at ABSA, it was opposite. You know, I think it maybe reflects that the people in the room are mostly from academic centers and we're not getting that community perspective in this room. So let's see what the poll says. According to our poll, between 20 to 30% of our audience are sending their patients with a grade four splenic laceration who is hemodynamically normal to the ICU. So the ABASA guidelines are relatively new-ish that came out with revised guidelines around management of patients. And it includes four basic categories, thinking about where they should be admitted, procedures, when you would discharge them, and then what you might think about doing after discharge, and particularly in this instance, talking about patients not going to the ICU. So let's say you got the CT and it shows an active blush concerning extravasation, hemodynamically normal. What do you want to do in that instance? In kids, the data doesn't support the the need for angioembolization, even if you see active arterial extravasation on CT. So these are those ABASA guidelines. Importantly, the last part of this is really about discharge when they're clinically doing well. No indication for repeat imaging after discharge and particularly some changes in the activity restrictions. We used to do much longer than that. If you had a grade force spleen lac, you were out 12 weeks or things longer than that. So moving towards a shorter duration. We may even be able to do shorter than that. We just don't know and there's no evidence yet to support that. Here's a guideline from Cincinnati Children's Hospital. They've done a couple of additional things. Okay, so this is our guideline from Cincinnati. So now, these are the patients that say that only the hemodynamically abnormal patients are going to the ICU. We have started discharging isolated grade one or two from the ER. We just presented this at our system level. Yeah. And the adult surgeons were very uncomfortable with that. You know, the idea of discharging these pediatric grade one and two from the ER. But I do think there's a lot of data. There's a great study looking at this specifically, the grade one and two injuries with no other major organ that's injured. Out of that whole group, not a single patient got an intervention during their hospitalization, including transfusion. So if you watch them for four hours, they're able to tolerate a PO challenge, then we discharge those patients from the ED. Sometimes I get the feeling with all these new changes that we're only getting a CT to grate the injury, you know? So we're not actually acting on grade. We're not acting on the blush on the angio. And there's actually good data from the Atomac study on whom to do a CT on, whom to avoid a CT, but what's your opinion on that? So I think there's two reasons to think about CT. One is just making a diagnosis overall, right? You may have a patient who has abdominal pain and trying to decide is that a small bowel contusion or a splenic laceration can impact how you watch them and also what recommendations you give them post discharge. If you have a splenic laceration, your discharge activity restrictions are going to be different than a small bowel contusion in terms of how you might discharge them and with what restrictions. That's the reason. I think it's less about grade severity and more about diagnosis. But in our blunt abdominal trauma guideline, we don't scan everybody. We look at kids and we get an AST and a lipase and use that to decide who needs a scan. So, but I will be convinced every year I change my practice at this course. You feel comfortable with the data that I can safely and within standard of care that a grade two injury that's normal vitals looks good. I can send them home. Correct. Would anyone change to now send home grade twos after this? Cuz I would. Okay, so two people, three, three people, four. Some of that to me is about counseling and having the family understand that and I think there's a big difference at 2:00 a.m. when it's a resident who's overnight talking to the patient versus like the ability to talk to the family and have them understand that. And I guess that's where some of my hesitation would come in is that particular scenario and making sure because really it's about do they understand what could happen if? What the level of activity we're talking about? Yeah, two things. One, we've created standardized discharge instructions, so we give everybody the same discharge instructions and we do that in collaboration with our EDs so that people know. They also have every one of these patients that gets discharged seen in their trauma clinic within the week in order to make sure A that the kids' still doing well and B that we do continue to give that counseling around what it is they can and can't do. So the I think the system is an important part of making that effective and safe. And the last change that they made was about hemoglobin checks after admissions. Let's say you admit a kid who has a grade four spleen laceration and hemodynamically normal. How often do you check their CBC or hemoglobin afterwards? They're going to get one. I practice out in Utah and 80% of our kids are transfers. Most likely they've already had a CBC at the other hospital, but we do not repeat it. If it's a hemodynamically normal child, they will go to the floor and not get a repeat crit. Perfect. That's what we're doing too and there's actually data to support that that we know there is some degree of hemo dilution. The data suggests that the patients who are more likely to fail non-operative management have an initial hemoglobin less than 9.25. We use that data to update our protocol. So if your hemoglobin's less than 9.25, you get one repeat hemoglobin. If it's greater than 9.25, you don't get any repeats unless you clinically appear that you need to. Has there been anything new on ultrasound or contrast enhanced ultrasound for grading to avoid radiation? We haven't been doing it routinely because they come in at 2:00 in the morning and the radiologists and the ultrasonographer who are comfortable doing contrast enhanced ultrasound aren't there and so it becomes a challenge. But I think there is going to be some evidence about it. We just haven't found that it's very reliable yet. In summary, management of splenic lacerations varies based on resources. In limited settings, ICU admission might be preferred due to monitoring capabilities. Contrary to past practice, active arterial extravasation on CT doesn't mandate angioembolization in kids. Recent trends show safe discharge of low grade injuries directly from the ER. CT scans more for diagnosis than injury grading. Effective patient care requires standardized discharge instructions and trauma clinic follow-ups. Hemoglobin checks post admission are guided by initial values. The reliability of contrast enhanced ultrasound as a CT alternative remains uncertain. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.