The Blunt Liver and Spleen Trauma (BLAST) audit: national survey and prospective audit of children with blunt liver and spleen trauma in major trauma centres

Every year in the United Kingdom (UK) approximately 130 children experience blunt abdominal trauma with solid organ injury [1]. A significant proportion of these children require a hospital stay and potentially surgery [2]. There has been a shift in the management of blunt liver and spleen injuries (BLSI) over the past 40 years [3‐7], primarily after the release of the American Pediatric Surgery Association (APSA) guidelines in 2000 [8]. This guidance highlighted that the majority of paediatric BLSI could be managed conservatively, and recommended a period of observation based on grade of injury + 1 day, with no requirement for follow-up imaging [8, 9].

Since then, large collaboratives in the United States of America have developed management protocols based primarily on haemodynamic status rather than the grade of injury [10, 11]. However, late complications of trauma including pseudoaneurysm formation and delayed bleeding have been reported as the majority of children are now managed conservatively [12]. There appears to be a higher risk of vascular abnormality (pseudoaneurysm) in higher grade injury but the evidence to support recommendations for routine imaging or intervention are weak [5, 12].

Recently APSA published a systematic review considering the length of stay and level of care, restriction of activity, the role of interventional radiology (IR) and follow-up imaging studies for children managed non-operatively after BLSI [5]. Subsequently new APSA 2019 guidelines for the management of BLSI have been released [13]. Understanding the application of these ‘best-practice’ guidelines by surgeons in the UK is important, particularly as there are no UK or European guidelines and as management varies between specialist and non-specialist centres [14].

The evidence supporting the APSA guidance on acute assessment and management immediately after BLSI is strong [5, 10]. If UK surgeons routinely keep children in hospital for longer than is necessary, or have a lower threshold for intensive care admission, then applying the APSA guidance may enable early discharge and appropriate allocation of resources [10]. Additionally, the variability in management and outcomes that has previously been demonstrated within the UK [14] may be improved by employing evidence based pathways. However, questions remain about the utilisation of additional imaging to identify complications such as pseudoaneurysm after BLSI and the timing of return to activity and contact sport after injury. Assessment of UK clinicians’ approach and variation from APSA guidance is therefore important since it demonstrates what specialist UK surgeons feel is a safe approach and may help to identify evidence gaps and areas of equipoise which could inform future research into these more contentious areas.

The aim of this study is to describe the current approach to paediatric BLSI management by UK paediatric trauma specialists and compare this to the APSA 2019 guidance.

The STROBE and CHERRIES checklist were used to describe the relevant methodology for the e-survey and the observational, prospective audit (Supplementary Information) [15, 16].

One-hundred and thirty one children with BLSI were reported to the audit during the year of data collection. Road traffic injuries were the most common cause of injury (41, 31%), followed by cycling injuries (37, 28%), fall from a height (22, 17%) and horse-riding injuries (10, 8%). One patient did not survive their multiple injuries and died before leaving the emergency department. 52 (40%) children had a liver injury (18 (14%) isolated liver injury), 66 (50%) had a splenic injury (34 (26%) isolated splenic injury) and 13 (10%) had both liver and spleen injury (without additional concomitant injuries in 2 (2%)). The most common sites of concomitant injuries were the lungs (41, 31%), chest wall (27, 20%) and the kidney (23, 17%) (Table 1). For all patients, the median grade of splenic injury was III (IQR II–IV) and of liver injury was III (IQR II–III) The Injury Severity Score (ISS) was recorded in 59 patients who had a median ISS of 16 (IQR 7.5–24, range 4–57). Four children, all with grade IV and V injury and haemodynamic instability, underwent splenic vessel embolization and all avoided subsequent laparotomy. Seven children had an early laparotomy: 2 had a splenectomy, 2 had packing and preservation of the spleen and oversewing of a gastric perforation, 2 had packing of the liver and one had repair of an aortic bleed. Two patients had a delayed bile leak.

In this report we demonstrate that there is variability in the intended and given care for children with blunt liver and spleen injury (BLSI) in UK paediatric major trauma centres. Current UK practice deviates from recently published guidance from APSA in key areas of management including duration of bed rest, criteria for discharge and follow-up imaging.

There is now a strong evidence base for basing the location of care on haemodynamic stability rather than grade of injury [5, 10] and this is reflected in both the survey and prospective data collection. Clinicians reported that their main criteria for ICU admission was haemodynamic stability alone or in combination with other factors, rather than grade of injury alone. This approach was generally reflected in patient management, with almost 2/3 of those admitted to ICU requiring fluid resuscitation and 70% having multiple injuries. A small number of patients were admitted to ICU without either of these indications, suggesting that there is still scope to improve ICU utilisation further in this group of patients.

APSA guidance recommends bed-rest on ICU until vital signs are normal, then no further bed rest. All but one respondent report using bed-rest within their management plan after BLSI and for the majority, the duration was determined by radiological grade of injury. Haemodynamic stability was the main factor for bed-rest duration in those respondents not using grade and this may be a more appropriate determinant for mobilisation, given that there are many factors which affect whether a child is admitted to ICU. The use of therapeutic bed rest within clinical practice is prevalent, with almost 60% of those in hospital on day 5 after injury remaining on bed rest in a ward setting. The reasons for this may be multi-factorial: thresholds for step-down from ICU may differ in the UK compared to the USA, where the majority of studies have been undertaken; the decision to moblise may be determined by patients’ symptoms; and it may be impacted by their concomitant injuries. Whilst there is a growing evidence base for early mobilisation after blunt liver and spleen injury [21‐23], studies have not followed the protocol recommended by the APSA guidance.

The reported and observed approach to imaging after initial CT differs significantly from the APSA guidance which notes that delayed splenic bleeding has a low reported incidence of 0.2–0.3% [24, 25] and that complications rarely arise in asymptomatic individuals [5]. Despite this, over 50% of respondents report that they routinely image patients after injury and a similarly high proportion of patients underwent further imaging. This may be because the rate of pseudoaneurysm after BLSI is reported to be as high as 22% [5, 26], because pseudoaneurysms have been detected after grade II splenic injuries [27] and patients have suddenly decompensated with bleeding 10 days after injury, having previously being well [26, 28]. Respondents reported that they image at two main times—within the first week and within 3 months of injury—suggesting that complications are looked for prior to discharge from hospital and before discharge from follow-up.

There was no clear approach from respondents about the advice given for returning to normal activity, with practice varying and a surprisingly high proportion of patients not receiving documented advice about this. A recent article showed that when using the APSA guidelines of grade of injury + 2 weeks to return to sport in a cohort of 1005 patients there were no episodes of re-bleeding, whether patients followed the guidance or not [29]. Knowledge and experience of significant complications, particularly delayed bleeding after trauma, may be major factors for clinicians not following APSA guidance. Further systematic research is needed to determine a safe, stratified approach to the modality and timing of imaging. Furthermore, developing evidence to guide standardised advice for safe return to activity and contact sports is important for many children with BLSI, some of whom play sport competitively [30].

Adherence to trauma guidance in general has been shown to be variable and in some cases based on the strength of the evidence behind the recommendations [31]. Proven evidence based best-practice after trauma have also been demonstrated to occur more frequently in larger hospitals and level I trauma centres [32]. Mortality rates after paediatric blunt abdominal trauma are very low, as demonstrated in the results of this study, making mortality a poor indicator of high quality care on which to determine the impact of the guidance. A core outcome set (COS) has been developed for the evaluation of outcomes after damage control laparotomy [33] but a COS does not exist for children (or adults) managed conservatively for abdominal trauma. The results of this paper highlight key areas where future research should be focussed to advance the evidence base and therefore guidance. A COS as a first step towards this would determine the important outcomes to be reported in publications regarding blunt abdominal trauma.

The management of paediatric BLSI in the UK deviates from the APSA guidance in many areas. There is common ground on the indications for admission to ICU and the use of clinical features to determine readiness for discharge, demonstrating strong support for this aspect of the guidance with further scope to improve adherence to this aspect of the guidance in UK practice.

UK surgeons continue to place significant emphasis on radiological grade of injury to determine duration of bed rest yet there is a good evidence base that an abbreviated bed rest duration is safe. The majority of UK specialists routinely re-image children after BLSI using ultrasound scan and guidance about return to activity is variable. These deviations from the guidance occur where the evidence base is weak, highlighting that further robust research focussing on the natural history of pseudoaneurysm and return to activity is warranted.