Solid Organ Injury Rapid Fire Session: Update Course 2015

Organ injuries. Well, it's good you have wit there because I'm going to be quoting Witt's Witt's institution quite a, quite a bit on this. So, um, so here, here we go, and this actually is a case of mine that came in about 4 months ago. Uh, the 15-year-old, uh, involved in a collision with a teammate during a baseball game. Uh, I think he was a second baseman, fly ball in between, right fielder coming in. And not only did they collide, but the right fielder landed on top of the second baseman, kind of knee to left upper quadrant. Um, comes in, and I'll show you guys a CT scan in a second. It was read as a grade 5 injury with a blush, and the vital signs as they were read to me over the phone was 125/80. Well, you can read them there. Pulse of only 85, which was amazing to me. But uh this, this is the CT scan. Um. And you can see it's a complete crush injury of the spleen involving down to the hilum. And uh the blush, while not uh overly impressive, you know, I put an arrow in there and this was read as a as a definite blush by the radiologist. You can also see there's blood around the liver, so, so there's blood in the abdomen as well. So, the phone call I got was um Doctor Azaro, we're on our way to the angio suite. OK, that was the phone call I got in the middle of the night. So. My question to the panel is, Uh, what would you guys do? How many of you would meet the patient in the angio suite, stop that, do something else? Um, where would you go at this point in time? I'd say turn around. Treat the patient, not the, not the blush. I'm going to the angio suite to block the door. to the ICU. So you guys are right on target. That's exactly what I did. I actually went in the hospital um and essentially grabbed the stretcher and got them en route and and rerouted them. And so really there there are a couple couple of papers you notice the 4th 1 down is from Wits Institution. Um, the, the one that I, I really like the title of the best is the top one by McVeigh. Basically throwing out the grade book, uh, in the management of isolated spleen and liver injuries. So, what we're really doing now is we're, we're looking at the patients, and we're, we're looking at the hemodynamics, and we're treating based on hemodynamics. And the offshot of that is we are actually able to get these patients in and out of the hospital much quicker than we used to, um, cos, you know, we were all uh raised watching these patients, you know, several days in in. In ICU several days in bed, several weeks at home, and you, you have children with just isolated spleen injuries, and it's all you can do, and you, you tell them not to do anything. And, and the parents called you up saying these kids are driving them crazy. And so, really managing based on hemodynamics is the current trend across the country. Exactly how we do that is different in almost every institution. So what I'm gonna show you is our is our current protocol. We just had our fellows draw this up this year, and this is again for hemodynamically stable patients. So these are ones with no blood pressure changes and uh you can argue whether the tachycardia that we're gonna discuss makes them hemodynamically unstable or not. But for the most part, normal blood pressure, normal respiratory rate, uh, not, not in extremists at all. And then uh. We're trying to get away from looking at the CT scan. It does tell you how badly injured things are, and um, and then you can just follow it down. Um, the hard part is determining whether your tachycardia is due to pain, uh, whether it's due to an overlying broken rib, or whether it's just due to blood in the abdomen and the splenic injury. So, you really have to do give a little bit of pain control in order to make this work. And then if you have a tachycardia due to a low hematocrit. You know, that's a patient who's in the ICU that you're gonna uh potentially need to transfuse, maybe not depending upon how low. But uh for the ones with normal vital signs and not tachycardic, we get them up to the ward fairly quickly, and for the ones that, that are not injured that severely, they are literally out of our hospital in 20, in less than 24 hours. For the ones like this particular child. This child was uh was discharged within 48 hours from the hospital. And given that degree of injury, that's something that never would have happened even last year at our place uh with without an algorithm like this. Now, the other caveat is we take patients from all over the state, and we would not somebody, send somebody across the state with this. These are for folks who are who are are local in the community. You know, parents are now, you know, educated by us and can get back fairly quickly if they need to, but you know, you can follow this down and we get them up, we get them eating, and we get them home. Let me stop you, Ken. Let me go through here and see. We do the same protocol early discharge. Does anyone here still follow Stilanos' recommendations? I think we've tightened it up, but you still keep them long. Oh, you've shortened it but not quite this short. Uh, anyone here have a difference of opinion? Is there anyone here that's opposed to this early discharge protocol? who died from a football injury in New Jersey and then the report was a splenic injury. Obviously we have no idea. So on the one hand, yes, it makes sense, and I know our trauma team is very aggressive about moving patients through, but on the other side, you know, there is consequence to these injuries. OK, Ken. So the question is, is, you know, I think most places around the country have aggressive discharge protocols, but the question I have for, for the panel and, and for the audience is, is then what? So once they're home, how long do you keep them out of school? How long? Or they can go back to, to, you know, full activities. I think the literature is fairly clear. They don't need to be imaged any further. But um but I think we all do different things as to what you do when you send them home. So I'd be interested to hear what folks' opinions are with that. Um, I do, for that part, I still follow the old rules, uh, because unlike the fact that we keep, I mean, I don't give any restrictions after surgery. I tell people that if it hurts, don't do it, they can do anything, but for this, I give restrictions because I've seen rebleeds. Uh, so I do, I think it's 2 plus the grade, grade plus 2, yeah, so I still do that. Uh, does anyone have a longer or shorter time frame? No, it looks like we're all in agreement there on that, Ken. So, um, so my guess is, is what's going to happen in the future is uh the reason why we're all in agreement is because we really haven't started looking closely at what we do when we send them home. I think once this gets to be common practice with the early discharge, my guess is we're gonna be looking more aggressively at um at at getting folks back to at least doing, maybe not playing contact football or or or wrestling practice, but at least getting them back to uh. Some semblance of normal activity, um, because if this is like any other injury, you know, once you have a stable clot for about 3 weeks. That's probably more stable than the remaining spleen. So we'll, you know, we'll have to see what happens long-term, but I think that's where we're moving in the future. This is just very interesting. This is one of those things that, as you all know, this has changed several times within our careers, and I think it's gonna continue to change in the next, uh, in the next 10 years. So, uh, this was great, and I'll tell you, I think that today I'm getting kind of excited here because I think that each time we do one of these, there's like. Even each year, it's amazing to me how there's new trends that are coming out, and this is one that I'm glad you brought to the attention of everyone watching. This is definitely a, a, a new trend that is, is really taking, taking over everywhere, I think. What else you got? Is that it? That's it. It's all I got for you today, Todd. Ken, thank you, wish, wish you were here, but, uh, we'll take you virtually. Thank you for, for spending the time. If you can, as much as you could stay online and participate in the rest of the discussion, we'd love to have you, but if you gotta go, uh, we understand, and we'll, we'll talk to you another time. All right, thanks for inviting me. Have a great day, everyone. You too. Thank you. All right, so can I ask you a panel of questions. Uh, Ken said, and we all know that there's good literature that says that these patients do not need to be reimaged after their solid organ injury. What do y'all do if, if, for example, a child is reimaged and it's found to have a pseudoaneurysm? know. Pseudoaneurysm in the vessel, you could, I mean, if it's a big pseudoaneurysm you probably coil it, I was gonna say I guess pseudoaneurysms in this day and age, the interventional radiologists, uh, vascular. Interventional radiologists, vascular surgeons have a lot more alternatives. We have had to deal with some of these in some of our kids with massive spleens where they have aneurysmal weaknesses, and you can stent them, you can coil them. You can also, and so on occasion though, you still have to deal with it because if they start to grow, you're in a position you're going to have to deal with it. Would you ever consider just If it's small, following it and yeah, absolutely, absolutely start with following, but if they get bigger, and again, I don't know what the number is, clearly in adults, you know, 2 centimeters for a mesenteric vessel is the cutoff that which you know everybody's going to get nervous, but how does that factor in a 10-year-old or a 12-year-old we've had some of those kids, right. gives to childbearing women, I mean, I think that may be a small subset of patients and many to have very, very active follow-up if you're not going to toilet, right? It's just interesting that we don't really know the denominator of how many of these kids do have pseudoaneurysms because they're not getting imaged. Well, a lot of them don't have hilar vessel injuries either, right? I mean, that you can see that on their initial scans. All right