CURRENT MANAGEMENT OF BLUNT SPLENIC TRAUMA IN CHILDREN

ANZ J. Surg. 2006; 76: 48–52 doi: 10.1111/j.1445-2197.2006.03647.x ORIGINAL ARTICLE CURRENT MANAGEMENT OF BLUNT SPLENIC TRAUMA IN CHILDREN STEPHEN ...
Author: Sherman Wells
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ANZ J. Surg. 2006; 76: 48–52

doi: 10.1111/j.1445-2197.2006.03647.x

ORIGINAL ARTICLE

CURRENT MANAGEMENT OF BLUNT SPLENIC TRAUMA IN CHILDREN STEPHEN R. THOMPSON AND ANDREW J. A. HOLLAND Department of Academic Surgery, The Children’s Hospital at Westmead, The University of Sydney, Sydney, New South Wales, Australia Background: Non-operative management of the great majority of blunt splenic injuries in children has become routine. Debate continues on the need for intensive care unit (ICU) admission, follow-up imaging and the duration of physical activity restrictions following injury. The purpose of this study was to review the recent experience of an Australian Paediatric Trauma Centre with splenic trauma to define current practice. Methods: A retrospective chart review of patients with splenic trauma admitted to the Children’s Hospital at Westmead between November 1995 and December 2003. Results: A total of 39 patients with blunt splenic trauma were identified: 20 (51%) were multiply injured. Thirty-three (85%) children were managed non-operatively. The most common initial imaging method was computed tomography (n = 28, 72%). Fourteen patients (36%) were admitted to the ICU with a mean length of stay (LOS) of 4.1 days (range 1–13 days). The overall mean LOS was 10.8 days (range 1–43 days). Nineteen patients (50%) had imaging studies performed after diagnosis but before discharge. Further post-discharge imaging was carried out in 21 cases (54%). There were no deaths, but 10 patients developed complications. The mean documented activity restriction was 7.4 weeks (range 1–16 weeks). Conclusion: The majority of children who had suffered blunt splenic trauma were safely managed non-operatively outside an ICU. In stable patients, there appeared to be no benefits associated with repeated imaging following the diagnosis of splenic trauma. Physical activity restriction in excess of 3–4 weeks did not appear to be warranted. Key words: children, non-operative management, radiological imaging, splenic trauma.

Abbreviations: AAST, American Association for the Surgery of Trauma; APSA, American Pediatric Surgical Association; CHW, Children’s Hospital at Westmead; CT, computed tomography; ICU, intensive care unit; ISS, injury severity score; LOS, length of stay; MVI, motor vehicle injuries; NM, nuclear medicine; OIS, organ injury scale; PTC, Paediatric Trauma Centre; US, ultrasound.

INTRODUCTION It has been said that the preservation of the spleen in trauma should not be in formalin but in the peritoneal cavity.1 Until the late 1960s, however, splenectomy was routinely carried out in children who had sustained a blunt splenic injury. Computed tomography (CT) has enabled definitive diagnosis of blunt splenic trauma without the need for invasive diagnostic and operative measures. Non-operative management for all but the most severe of splenic injuries is now routinely, effectively and safely used, regardless of the magnitude of splenic injury on CT scans.1–5 Reviews of clinical management by surgeons have shown that management algorithms and practice patterns vary widely.6,7 Debatable issues include the need for intensive care admission, pre-discharge and post-discharge imaging and the duration of restricted physical activity following injury. American Pediatric Surgical Association (APSA) guidelines are based on severity of injury according to CT grade.8 As CT injury severity score (ISS) increases from I to IV, the length of hospital stay S. R. Thompson MSc; A. J. A. Holland PhD, FRACS. Correspondence: Associate Professor Andrew J. A. Holland, Department of Academic Surgery, The Children’s Hospital at Westmead, The University of Sydney, Locked Bag 4001, Westmead, NSW 2145, Australia. Email: [email protected] Accepted for publication 11 August 2005 Ó 2006 Royal Australasian College of Surgeons

increases from 2 to 5 days, and the activity restriction increases from 3 to 6 weeks. The guidelines further suggest that routine predischarge and post-discharge imaging should not be carried out, regardless of injury severity. These guidelines have been validated9 in the USA with documented reductions in duration of intensive care unit (ICU) admission and use of routine follow-up imaging. Proposed Canadian guidelines make no recommendations concerning the need for ICU admission and have suggested activity restriction between 6 and 8 weeks for all patients.10 Guidelines, although useful especially once validated, have practical limitations. Foremost, the guidelines assume haemodynamic stability9 and provide little information to guide the less experienced clinician when to operate. The guidelines also assume an isolated splenic injury, although some allowance has been made for children with minor remote injuries including non-comminuted fractures and soft tissue injuries. There remain no national paediatric guidelines in Australia. Moreover, preliminary research has shown that nonoperative management may still be possible in selected multiply injured patients.11,12 Lastly present APSA guidelines exclude grade V injuries, the most severe form of splenic injury. The purpose of this study was to review a contemporary 8 year 1 month experience with splenic trauma at the Children’s Hospital at Westmead (CHW). The review sought to define an Australian perspective on the current management of blunt splenic injury in a paediatric population, examine how this experience compared with current American practice guidelines and propose appropriate regional management guidelines.

MANAGEMENT OF BLUNT SPLENIC TRAUMA

METHODS The paediatric trauma registry at the CHW was used to identify patients who had been admitted to the hospital between November 1995, when the hospital opened at its current location, and December 2003. Relevant cases were identified by ICD9, 9CM and 10AM codes as having suffered a blunt splenic traumatic injury. Data were collected in several categories: general patient information included age, sex, length of stay (LOS), duration in the ICU, mechanism of injury, associated injuries, type of management and operative findings if applicable. Haemodynamic data included arrival heart rate, blood pressure, haemoglobin, haematocrit, haematocrit 24 h following arrival and blood transfusion requirements during admission. Imaging data included type of initial diagnostic imaging and findings, pre-discharge imaging, post-discharge imaging, and specific reporting of contrast extravasation on CT scans. Follow-up data included laboratory findings during admission, complications, documented activity restriction on discharge, death and post-mortem findings. The American Association for the Surgery of Trauma (AAST) Organ Injury Scale13 was assigned to all splenic injuries based on CT scans, ultrasound (US) scans or operative findings. All CT and US scans were initially reported by consultant paediatric radiologists or fellow using a teleradiology facility. ISS were assigned to each patient using the Abbreviated Injury Scale: 1990 revision, update 98.14 Statistical analysis was carried out using the Student’s t-test and v2-test. A P-value of less than 0.05 was considered significant. The CHW Research Ethics Committee approved this study.

RESULTS

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grades of splenic injury13 were identified (Table 1), with grade III injuries representing almost half of all injuries (44%) and grade II injuries representing one-third (36%). Level I, IV and V injuries were much less common. The overall median ISS was 12 (mean 14.5). Associated injuries were common (Table 2), occurring in 20 children (51%). Intra-abdominal and orthopaedic injuries occurred in half of those multiply injured (50%), followed by intrathoracic (45%), head (25%) and soft tissue (10%) injuries. There was one instance of a large bowel perforation, which was immediately diagnosed and treated through laparotomy. Multiply injured patients had a significantly (P = 0.0004) higher mean ISS of 20.2 (median 18) compared with a mean ISS of 8.5 (median 9) found in isolated injury patients (Table 2). Vehicle versus pedestrian injuries resulted in the largest ISS, with a median ISS of 25 (mean 29.2, range 17–50). All children who had injuries as a result of pedestrian accidents also sustained multiple injuries. Of the splenic injuries, two were of grade II, whereas the other two were of grade III and V. MVI were the cause of 13 injures (33%) and resulted in a median ISS of 13 (mean 17.8, range 9–43). Nine of these children (69%) sustained multiple injuries. MVI were the only categories to produce all five grades of splenic injury and accounted for three of the five severe (grades IV and V) splenic injuries. Falls accounted for 18 injuries (46%) and were associated with a median ISS of 9 (mean 10.2, range 4–34). Multiple injuries were found in six (33%) of these patients. There were eight cases each of grade II and III splenic injuries resulting from falls, and one case each of grade I and IV injuries. Sporting and bicycle injuries resulted in two cases each, with a respective median ISS of 4 and 12.5. One bicycle injury resulted in multiple injuries, whereas both sporting injures resulted only in isolated, mild (grades I and II) blunt splenic injuries.

Aetiology and epidemiology A total of 39 cases of blunt splenic trauma were identified (Table 1). The majority were male children (69%) and less than 9 years of age (59%), with a mean age of 7.8 years. There were no patients older than 15 years. Injury was most frequently the result of a fall (46%), followed by passenger motor vehicle injuries (MVI) (33%) and then pedestrian MVI (10%). Bicycle injuries and sports injuries accounted for the remainder. All five AAST

Table 1.

Initial investigations The initial imaging method used in the diagnosis of blunt splenic injury at presentation to CHW was CT in 28 patients (72%). US

Table 2.

Comparison of patients with isolated and multiple injuries All patients (%)

Patient and splenic injury details All patients Non-operative Operative (%) (% within group)(% within group)

Age 0–9 years 23 (59) 21 (63.6) 5 (83.3) 10–15 years 16 (41) 12 (36.7) 1 (16.7) Mean 7.8 8.5 4.4* Sex 27 males (69) 22 males (66.7) 5 males (83.3) AAST grade I 3 (7.7) 3 (9.1) 0 II 14 (35.9) 13 (39.4) 1 (16.7) III 17 (43.6) 16 (48.5) 1 (16.7) IV 2 (5.1) 1 (3) 1 (16.7) V 3 (7.7) 0 3 (50) Mean injury 14.5 11.9 29* severity score *Student’s t-test, P < 0.05. AAST, American Association for the Surgery of Trauma. Ó 2006 Royal Australasian College of Surgeons

Age 0–9 years 10–15 years Mean Total

Isolated injury† (% within group)

Multiple injuries (% within group)

11 (57.9) 15 (75) 8 (42.1) 5 (25) 8.9 6.8 19 (48.7% of 20 (51.3% all patients) of all patients) 27 males (69) 14 males (73.7) 13 males (65)

Sex AAST grade I II III IV V Mean injury severity score

23 (59) 16 (41) 7.8 39

3 (7.7) 14 (35.9) 17 (43.6) 2 (5.1) 3 (7.7) 14.5

2 (10.5) 6 (31.6) 9 (47.4) 1 (5.3) 1 (5.3) 8.5

1 (5) 8 (40) 8 (40) 1 (5) 2 (10) 20.2*

*Student’s t-test, P < 0.05. †Patients with soft tissue or non-comminuted limb fractures, which did not alter management, were considered as having an isolated injury. AAST, American Association for the Surgery of Trauma.

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was used initially in seven children (18%). In five of these seven patients (71%), subsequent CT scans were carried out to confirm the diagnosis. All US scans showed signs consistent with splenic injury. In two cases (5%), plain abdominal radiology was carried out. In neither case were the findings used to diagnose blunt splenic trauma. In one child, the radiograph showed large amounts of free-air under the diaphragm, indicating a bowel perforation, subsequently repaired during a laparotomy. A grade II injured spleen was diagnosed at the time of operation. In the second patient, radiography showed distension of the abdomen. As the patient was haemodynamically unstable, with a pulse rate of 201 and decreasing systolic blood pressure, laparotomy was undertaken. A grade V splenic injury was found at operation. Two patients (5%), both with grade V splenic injuries, had their splenic trauma diagnosed during laparotomy without any imaging method being used. There were no cases in which a nuclear medicine (NM) scan or diagnostic peritoneal lavage had been used for diagnosis. Two patients in whom CT scan was the initial imaging method had subsequent abdominal US scans carried out within the initial day of hospitalization. In one instance, the US scan failed to show a grade II splenic injury documented by CT scan. Management Overall, 33 children (85%) were managed non-operatively. Laparotomy was carried out in six children (15%); three of these resulted in splenectomy, two in splenorrhaphy and one procedure was carried out for a hollow viscus perforation. All three splenectomies were carried out in cases of grade V splenic trauma. Splenorrhaphy was carried out in patients with a grade III and a grade IV splenic injury. There were no deaths in the present series. Four of the six children (67%) who were managed operatively sustained their injuries as a result of passenger MVI, whereas in the other two children, injuries occurred following a pedestrian MVI and a fall. Patients who underwent operative management had a significantly (P = 0.029) higher mean pulse rate of 144 than pulse rate of 112 found in patients who underwent non-operative management. Operated patients were also significantly (P = 0.0001) more likely to receive a blood transfusion (Table 3). Mean systolic blood pressure, initial haemoglobin and haematocrit values were not significantly different between those who underwent laparotomy and those treated conservatively. Haematocrit values obtained 24 h after admission were also not significantly (P > 0.05) different. Table 3. patients

Haemodynamic status of operative and non-operative Non-operative management

Operative management

Total patients 33 (84.6%) 6 (15.4%) OIS 11.9 29* Heart rate 112 144* Systolic blood pressure 116 118 Haemoglobin 12.1 11 Haematocrit (initial) 36.2 35.4 Haematocrit (24 h after arrival) 32.7 32.8 Transfused 4 (12% 5 (83% of group) of group)** *Student’s t-test, P < 0.05. **v2, P < 0.001. OIS, organ injury scale.

The mean LOS in all patients was 10.8 days (range 1–43 days). Those who underwent operative management had a longer course in hospital, with a mean stay of 15.8 days compared with the nonoperative LOS of 7.7 days. This difference was not statistically significant. Fourteen patients (36%) were admitted to ICU: the mean unit LOS was 4.1 days (range 1–13). A significantly (P = 0.009) higher proportion of those patients managed operatively were admitted to the ICU (five of six, 83%) compared with those managed non-operatively (9 of 33, 27%), although nonoperative patients accounted for more admissions to the ICU. Multiply injured patients were significantly (P = 0.011) more likely to be admitted to ICU and comprised 11 of the 14 cases (78%). They also had a significantly (P = 0.019) longer mean length of admission in hospital than patients who suffered isolated injuries. There were no other significant differences between multiple and isolated injury patients. All grade V injured patients were admitted to the ICU and had a significantly (P = 0.026) longer mean LOS of 21.7 days. All grade V patients received blood transfusions and underwent laparotomy. As injury severity decreased, so too did frequency of admission to the ICU. Fifty per cent (1) of grade IV injured patients, 35% (6) of grade III injured patients and 29% (4) of grade II injured patients were admitted to the ICU. No grade I injured patients were admitted to the ICU.

Follow-up imaging In 19 patients (48%) imaging studies were carried out before discharge. US was carried out in 17 cases, whereas NM scans were carried out in the remaining two cases. In 20 patients documented imaging was not carried out before discharge. In all cases, pre-discharge imaging showed either no change or improvement in the appearance of the splenic injury. There was no single documented change of management as a result of pre-discharge imaging. In four cases (21% of those undergoing pre-discharge imaging), the spleen was reported as either completely healed or normal before discharge. Post-discharge imaging was carried out in 21 cases (48% of total patients). The most commonly used imaging method was US, accounting for 17 (81%) of the 21 imaging studies obtained. CT scan was used for follow-up imaging in two cases (10%), and NM scans were repeated in the two patients (10%) who had them before discharge. In four patients serial post-discharge ultrasonography was carried out. The mean time to post-discharge imaging was 4.7 weeks (range 1–16 weeks). All scans showed a degree of resolution of the original injury, and seven scans showed complete healing, including that of one patient which already showed a healed spleen before discharge. In 10 patients (26%), no imaging studies were carried out before or following discharge from hospital. There was no single documented change in management as a result of post-discharge imaging.

Activity restriction Specific activity restriction was documented in 21 cases (54%), with a further three instances (8%) of documented activity restriction without a specific duration. The mean documented activity restriction was 7.4 weeks (range 1–16 weeks). There were no statistically significant differences in activity restriction between AAST grade of injury, operative and non-operative management, isolated and multiple injury. Ó 2006 Royal Australasian College of Surgeons

MANAGEMENT OF BLUNT SPLENIC TRAUMA

Outcome There were no deaths. Ten patients (25%) suffered complications of their injury, of which respiratory were most common. Five patients (50% of those developing complications) developed a pulmonary lower lobe collapse. One patient, treated non-operatively, developed Streptococcal sp. and Haemophilus sp. bacteraemia following admission for multisystem trauma sustained after being crushed by a forklift. Another patient, with a history of prematurity, suffered a grand mal seizure, which developed into status epilepticus and required intubation. One patient developed a urinary tract infection and another developed severe mouth ulceration restricting oral nutrition. One patient suffered extensive complications due to head injury, including raised intracranial pressure and temporary paralysis, but no complications were due to grade II splenic injury. None of the patients who underwent operative management developed complications. Only two of the three patients who underwent splenectomy had documented administration of vaccination against Streptococus pneumoniae.

DISCUSSION Non-operative management for blunt splenic trauma in the paediatric sample is universally acknowledged. Aspects of nonoperative management, such as need for ICU admission, length of hospitalization, need for follow-up imaging and length of activity restriction, remain variable.6,15 In this series, we have characterized an Australian Paediatric Trauma Centre’s experience with these issues. Again, the safety and efficacy of non-operative management for blunt splenic trauma have been shown. There were no deaths, and the majority of patients experienced an uncomplicated recovery. Our findings show some important differences between one Australian PTC’s current management practices and validated American evidence-based guidelines for isolated splenic injury.9 In our series, in eight patients with isolated injury, routine predischarge imaging was carried out, and in 13 patients with isolated injury (68% of total patients with isolated injury), routine post-discharge imaging was carried out. There was no evidence that the results of these studies changed the management of patients. Other studies have largely come to the same conclusion that routine follow-up imaging is unnecessary16–19 in patients with isolated blunt splenic injury. Pranikoff et al. found that half of all splenic injuries, regardless of severity, had CT evidence of complete healing within 6 weeks of injury.16 Some of the less severe (grade I–II) injuries, however, as well as the severe injuries, were still not completely healed at this point. This might suggest that the concept of a 3-month activity restriction on all patients suffering splenic injury was reasonable, although radiological ‘healing’ does not necessarily eliminate the risk of delayed rupture. Pranikoff et al. further noted that in none of the cases did CT results alter clinical management, thereby raising the question of the utility of routine scanning. Shafi et al., in their 5-year retrospective study, found that the appearance of splenic injury on CT scans remained unchanged or improved in 95% of the imaging studies obtained.17 Rovin et al. found that almost all splenic injuries show complete healing on CT scans by 3 months after injury, with more minor splenic injuries being healed slightly before 3 months.18 Last, in a decision analysis paper by Huebner and Reed,19 their model extracted data from 26 cohort studies and found that the risk of delayed splenic rupture was so low that rates Ó 2006 Royal Australasian College of Surgeons

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of detecting it would be unaffected by imaging protocols. Consequently, in the evidence-based guidelines established by the APSA,8 it has been recommended that there be no routine follow-up imaging regardless of injury severity and that imaging occur in a focused manner based on clinical symptoms. The APSA guidelines suggest an activity restriction of 6 weeks for the more severe grade IV injuries and a progressive 1 week decrease in the duration of restriction for subsequently less severe injury grades. Although previous findings have shown that most spleens are not radiologically ‘healed’ before 6 weeks,16 the guideline authors have observed that radiographic demonstration of healing does not necessarily equate with anatomical integrity. Using their retrospective findings, these guidelines reduce the duration of activity restriction in patients with grade I injuries to only 3 weeks, with 4-week restriction for grade II injuries and 5-week restriction for grade III injuries. Their prospective findings evaluating the compliance with these guidelines showed that mean activity restriction for each grade of injury was slightly higher than proposed.9 Nevertheless, actual mean activity restriction remained within a week of guideline recommendations. Further, their study failed to show any adverse outcomes associated with reduced activity restrictions. Our findings suggest that despite these well researched recommendations, traditional practice patterns of imposing a blanket 6-week activity restriction in all patients with blunt splenic injury continues at CHW.1,8 This was disappointing and may reflect the need for clinical guidelines at our institution. The introduction of the APSA guidelines as clinical practice has been shown to be effective at other institutions.20 It is difficult to understand why there was such a high rate of routine imaging and extended duration of activity restriction occurring in our series. Consultant paediatric surgeons were involved in the treatment of all patients. Although studies have shown that injury grade cannot be used to predict operative or non-operative management,5,21 the current APSA guidelines suggest that once operative or non-operative management has been determined, the injury grade can be used to facilitate appropriate hospital stay, aid in discharge planning and guide recommended activity restriction. In our present series, there was only one instance of AAST splenic injury grade provided in the radiological report. It might be suggested that in the absence of grading, the splenic injury was overestimated by clinicians and compensatory increases in LOS and activity restriction resulted. Another possible explanation for our data remains the relatively large proportion of multiply injured children. Their combined injuries may have resulted in increased caution among the surgeons in recommending return to physical activity. The majority of patients in our series (51%) suffered multiple injuries. Originally, the safety of non-operative management of blunt splenic trauma was established only in isolated injuries of patients who were haemodynamically stable.22,23 Non-operative management occurred in an expectant fashion, with conversion of non-operative to operative management a function of the haemodynamic stability. Should the child become haemodynamically unstable, with a persistent tachycardia, or require ongoing blood transfusions resulting in greater than half their blood volume of 40 mL/kg being transfused over a 4-h period, operative management was indicated.1 Consequently, accurate determination of haemodynamic parameters remains of paramount importance when attempting to assess changes in the presence of a confounding injury such as a pelvic fracture. As a result, nonoperative management of blunt splenic injury remains less frequent

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in multiply injured patients,8 with no clear published guidelines. Nevertheless, one study found no difference in morbidity, mortality or ICU length in multiply injured patients despite equal ISS.11 Our findings support the safety of managing multiply injured patients non-operatively with no difference in morbidity or mortality. In conclusion, following the definitive diagnosis of blunt splenic trauma, further routine imaging during admission or following discharge did not appear to alter the management of patients with isolated or multiple injuries. Admission to the ICU can be safely restricted to patients who are haemodynamically unstable (and may require operative intervention), who are multiply injured, or in whom a high dependency unit bed is unavailable to provide adequate analgesia and chest physiotherapy. Physical activity restriction in excess of 4 weeks may not be indicated, but further prospective validation appears warranted to identify the optimal duration of activity restriction.

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Trauma Committee. J. Pediatr. Surg. 2000; 35: 164–7; (discussion 167–9). Stylianos S. Compliance with evidence-based guidelines in children with isolated spleen or liver injury: a prospective study. J. Pediatr. Surg. 2002; 37: 453–6. Zabolotny B, Hancock BJ, Postuma R, Wiseman N. Blunt splenic injuries in a Canadian pediatric population: the need for a management guideline. Can. J. Surg. 2002; 45: 358–62. Coburn MC, Pfeifer J, DeLuca FG. Nonoperative management of splenic and hepatic trauma in the multiply injured pediatric and adolescent patient. Arch. Surg. 1995; 130: 332–8. Keller MS, Sartorelli KH, Vane DW. Associated head injury should not prevent nonoperative management of spleen or liver injury in children. J. Trauma 1996; 41: 471–5. Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Organ injury scaling: spleen and liver (1994 revision). J. Trauma 1995; 38: 323–4. Association for the Advancement of Automotive Medicine. The Abbreviated Injury Scale. 1990 revision. Update 98. Des Plaines, IL: Association for the Advancement of Automotive Medicine, 2001. Mooney DP, Forbes PW. Variation in the management of pediatric splenic injuries in New England. J. Trauma 2004; 56: 328–33. Pranikoff T, Hirschl RB, Schlesinger AE, Polley TZ, Coran AG. Resolution of splenic injury after nonoperative management. J. Pediatr. Surg. 1994; 29: 1366–9. Shafi S, Gilbert JC, Irish MS, Glick PL, Caty MG, Azizkhan RG. Follow-up imaging studies in children with splenic injuries. Clin. Pediatr. (Phila.) 1999; 38: 273–7. Rovin JD, Alford BA, McIlhenny TJ, Burns RC, Rodgers BM, McGahren ED. Follow-up abdominal computed tomography after splenic trauma in children may not be necessary. Am. Surg. 2001; 67: 127–30. Huebner S, Reed MH. Analysis of the value of imaging as part of the follow-up of splenic injury in children. Pediatr. Radiol. 2001; 31: 852–5. Leinwand MJ, Atkinson CC, Mooney DP. Application of APSA evidence-based guidelines for isolated liver or spleen injuries: a single institution experience. J. Pediatr. Surg. 2004; 39: 487–90. Powell M, Courcoulas A, Gardner M et al. Management of blunt splenic trauma: significant differences between adults and children. Surgery 1997; 122: 654–60. Upadhyaya P, Simpson JS. Splenic trauma in children. Surg. Gynecol. Obstet. 1968; 126: 781–90. Douglas GJ, Simpson JS. The conservative management of splenic trauma. J. Pediatr. Surg. 1971; 6: 565–70.

Ó 2006 Royal Australasian College of Surgeons

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