Initial trial of conservative management of splenic injury [Pediatrics Classics Series]

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1. The conservative, symptomatic management of 16 patients following assumed splenic injury from blunt abdominal trauma resulted in normalization of hemodynamic stability within 2 days of hospital admission, complete normalization of clinical examination by 2 weeks post-discharge, and no hospital readmissions.

2. This approach to splenic injury management was later supported by future investigations, eventually leading to the acceptance of conservative management as standard of care.

Original Date of Publication: October 1971

Study Rundown: The spleen is particularly susceptible to blunt abdominal trauma and, prior to this study, splenectomy was routine following abdominal injury. However, potential nonoperative management had been linked to positive outcomes in the past based on anecdotal experience of the authors. With the potential for spleen salvage and a reduction in surgical and post-operative risks, this study investigated the outcomes of children who were not treated surgically for their splenic injuries. The study was limited by its small sample size, lack of a control group, and use of descriptive statistics as the only method for analysis. In addition, conclusions drawn from the study may be inaccurate as patients were assumed to have splenic injury from clinical examination as no method, apart from surgical exploration, could confirm injury. At the time of its publication, the proposed conservative treatment investigated in the study differed radically from expected surgical intervention. Conservative management is now considered the preferred method of management for children with splenic injury secondary to blunt trauma. Improved imaging techniques and technology for monitoring patient hemodynamic status now allow for better assessment of the need for surgical intervention. A relatively recent retrospective study of the evolution of splenic injury management was published in 2009 in the Journal of Pediatric Surgery and can be found at the link below. This updated analysis found hospital length of stay, transfusion requirements, and mortality decreased as conservative management of splenic injury became widely accepted.

Click to read the study in the Journal of Pediatric Surgery

Click to read the updated study in the Journal of Pediatric Surgery

In-Depth [observational descriptive study]: A total of 32 children admitted to the hospital during 1948-1955 following blunt abdominal trauma with potential splenic involvement were included for the study. Six patients underwent splenectomy, 1 patient died as a result of a crush injury, and the remaining 25 underwent nonoperative management. Of these patients, 16 were included in the study (mean age = 10 years, 69% male) as their presentation indicated likely splenic involvement, although this was not confirmed by surgical intervention. Patients underwent standard examinations with researchers reporting close monitoring of patient vitals. All patients were conscious upon presentations with a complaint of abdominal pain and all had significant abdominal tenderness. Three children had ecchymoses overlying the site of trauma and 3 had potential intraperitoneal fluid  detected on physical exam. Patient pulses ranged from 100-140/min and 4 patients had blood pressures < 90/50 mmHg. Complete blood counts had hemoglobin values ranging from 7.9-11.4 g/100 mL (mean = 9.5 g/100 mL) and white blood cell counts ranging from 8000-27 000 mm3 (mean = 17 000 mm3). Patient temperatures ranged from 100˚F-104˚F (mean = 102˚F).

In terms of injury management, 9 children received whole blood transfusions for hemodynamic instability, 2 received plasma. All patients received intravenous fluids. Patients were hemodynamically stable within 2 days of admission. Resolution of abdominal tenderness was noted to correlate with normalization of heart rate and body temperature. Total length of stay ranged from 4 to 42 days (mean = 16 days). Two weeks after discharge, all patients’ physical examinations normalized and no patient underwent readmission.

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