1 00:00:00,000 --> 00:00:05,000 Global Cast MD, along with Cincinnati Children's Hospital, 2 00:00:05,000 --> 00:00:08,000 sharing knowledge to improve child health around the globe. 3 00:00:08,000 --> 00:00:15,000 Hello, Pediatric Surgery family. 4 00:00:15,000 --> 00:00:20,000 I'm Amgodi, a research fellow from Cincinnati Children's Hospital Medical Center. 5 00:00:20,000 --> 00:00:25,000 Our 11th annual update course in pediatric surgery was held past August. 6 00:00:25,000 --> 00:00:30,000 In this video series, we'll recap the sessions and share the main highlights with you. 7 00:00:30,000 --> 00:00:38,000 In this session, Drs. Katie Russell and Muter Kodagal brought us some rapid fire updates in pediatric trauma. 8 00:00:38,000 --> 00:00:41,000 Today, we'll review updates in solid organ injury. 9 00:00:41,000 --> 00:00:43,000 So this is our case. 10 00:00:43,000 --> 00:00:47,000 So you have a seven-year-old male who was involved in an ATV crash. 11 00:00:47,000 --> 00:00:54,000 Presented to your emergency department with the heart rate of 105, blood pressure of 110 over 75, GCS 15, 12 00:00:54,000 --> 00:00:56,000 and is complaining of abdominal pain. 13 00:00:56,000 --> 00:01:02,000 The patient goes for a CT scan that demonstrates a grade for splenic laceration, hemodynamically normal. 14 00:01:02,000 --> 00:01:06,000 So the question is, what is this patient's disposition? 15 00:01:06,000 --> 00:01:07,000 What do you want to do? 16 00:01:07,000 --> 00:01:10,000 So most of the audience here said floor. 17 00:01:10,000 --> 00:01:17,000 When I work in Uganda, very often these are patients I would put in the ICU just because of monitoring capacity on the floor. 18 00:01:17,000 --> 00:01:22,000 Exactly. In the floor, there's not even a monitor, and there's minimal staff sometimes. 19 00:01:22,000 --> 00:01:28,000 So if we had a way to continually monitor someone, we would send them to the floor. 20 00:01:28,000 --> 00:01:30,000 So I think this is a reflection of resources. 21 00:01:30,000 --> 00:01:34,000 In more resource-constrained settings, the ICU looks very different than the floor. 22 00:01:34,000 --> 00:01:38,000 And actually, when we presented at APSA, it was opposite. 23 00:01:38,000 --> 00:01:42,000 You know, I think it maybe reflects that the people in the room are mostly from academic centers, 24 00:01:42,000 --> 00:01:46,000 and we're not getting that community perspective in this room. 25 00:01:46,000 --> 00:01:48,000 So let's see what the poll says. 26 00:01:48,000 --> 00:01:54,000 According to our poll, between 20 to 30 percent of our audience are sending their patients with a grade for splenic laceration, 27 00:01:54,000 --> 00:01:57,000 who is hemodynamically normal, to the ICU. 28 00:01:57,000 --> 00:02:04,000 So the APSA guidelines are relatively new-ish that came out with revised guidelines around management of patients. 29 00:02:04,000 --> 00:02:11,000 And it includes four basic categories, thinking about where they should be admitted, procedures, when you would discharge them, 30 00:02:11,000 --> 00:02:17,000 and then what you might think about doing after discharge, and particularly in this instance, talking about patients not going to the ICU. 31 00:02:17,000 --> 00:02:23,000 So let's say you got the CT, and it shows an active blush concerning extravasation, hemodynamically normal. 32 00:02:23,000 --> 00:02:25,000 What do you want to do in that instance? 33 00:02:25,000 --> 00:02:32,000 In kids, the data doesn't support the need for angioembolization, even if you see active arterial extravasation on CT. 34 00:02:32,000 --> 00:02:34,000 So these are those APSA guidelines. 35 00:02:34,000 --> 00:02:40,000 Importantly, the last part of this is really about discharge when they're clinically doing well. 36 00:02:40,000 --> 00:02:46,000 No indication for repeat imaging after discharge, and particularly some changes in the activity restrictions. 37 00:02:46,000 --> 00:02:52,000 We used to do much longer than that. If you had a grade for splenic laceration, you were out 12 weeks or things longer than that. 38 00:02:52,000 --> 00:02:56,000 So moving towards a shorter duration, we may even be able to do shorter than that. 39 00:02:56,000 --> 00:02:59,000 We just don't know, and there's no evidence yet to support that. 40 00:02:59,000 --> 00:03:03,000 Here's a guideline from Cincinnati Children's Hospital. They have done a couple of additional things. 41 00:03:03,000 --> 00:03:06,000 Okay, so this is our guideline from Cincinnati now. 42 00:03:06,000 --> 00:03:11,000 These are the patients that say that only the hemodynamically abnormal patients are going to the ICU. 43 00:03:11,000 --> 00:03:14,000 We have started discharging isolated grade 1 or 2 from the ER. 44 00:03:14,000 --> 00:03:20,000 We just presented this at our system level, and the adult surgeons were very uncomfortable with that. 45 00:03:20,000 --> 00:03:25,000 You know, the idea of discharging these pediatric grade 1 and 2 from the ER. But I do think there's a lot of data. 46 00:03:25,000 --> 00:03:32,000 There's a great study looking at this specifically. The grade 1 and 2 injuries with no other major organ that's injured. 47 00:03:32,000 --> 00:03:38,000 Out of that whole group, not a single patient got an intervention during their hospitalization, including transfusion. 48 00:03:38,000 --> 00:03:43,000 So if you watch them for four hours, they're able to tolerate a PO challenge, then we discharge those patients from the ED. 49 00:03:43,000 --> 00:03:49,000 Sometimes I get the feeling with all these new changes that we're only getting a CT to grade the injury, you know. 50 00:03:49,000 --> 00:03:55,000 So we're not actually acting on grade. We're not acting on the blush on the angio. 51 00:03:55,000 --> 00:04:04,000 And there's actually good data from the Atomac study on whom to do ACT, on whom to avoid ACT. But what's your opinion on that? 52 00:04:04,000 --> 00:04:10,000 So I think there's two reasons to think about CT. One is just making a diagnosis overall, right? 53 00:04:10,000 --> 00:04:19,000 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 54 00:04:19,000 --> 00:04:22,000 and also what recommendations you give them post discharge. 55 00:04:22,000 --> 00:04:33,000 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. 56 00:04:33,000 --> 00:04:37,000 That's the reason. I think it's less about grade severity and more about diagnosis. 57 00:04:37,000 --> 00:04:47,000 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. 58 00:04:47,000 --> 00:04:51,000 So, but I will be convinced every year I change my practice at this course. 59 00:04:51,000 --> 00:05:00,000 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. 60 00:05:00,000 --> 00:05:06,000 I can send them home. Correct. Would anyone change to now send home grade twos after this? Because I would. 61 00:05:06,000 --> 00:05:09,000 OK, so two people, three, three people, four. 62 00:05:09,000 --> 00:05:13,000 Some of that to me is about counseling and having the family understand that. 63 00:05:13,000 --> 00:05:24,000 And I think there's a big difference at 2 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. 64 00:05:24,000 --> 00:05:35,000 And I guess that's where some of my hesitation would come in is that particular scenario and making sure because really about do they understand what could happen if what the level of activity we're talking about. 65 00:05:35,000 --> 00:05:45,000 Yes, 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 E.D. so that people know. 66 00:05:45,000 --> 00:05:50,000 They also have every one of these patients that gets discharged seen in their trauma clinic within the week. 67 00:05:50,000 --> 00:05:59,000 In order to make sure, A, that the kid's still doing well and B, that we do continue to give that counseling around what it is they can and can't do. 68 00:05:59,000 --> 00:06:03,000 So I think the system is an important part of making that effective and safe. 69 00:06:03,000 --> 00:06:07,000 And the last change that they made was about hemoglobin checks after admissions. 70 00:06:07,000 --> 00:06:12,000 Let's say you admit a kid who has a great force, plain laceration and hemodynamically normal. 71 00:06:12,000 --> 00:06:15,000 How often do you check their CBC or hemoglobin afterwards? 72 00:06:15,000 --> 00:06:19,000 They're going to get one. They practice out in Utah and 80 percent of our kids are transfers. 73 00:06:19,000 --> 00:06:24,000 Most likely they've already had a CBC at the other hospital, but we do not repeat it. 74 00:06:24,000 --> 00:06:29,000 If it's a hemodynamically normal child, they will go to the floor and not get a repeat credit. 75 00:06:29,000 --> 00:06:32,000 Perfect. That's what we're doing, too. And there's actually data to support that. 76 00:06:32,000 --> 00:06:35,000 That we know there is some degree of hemodilution. 77 00:06:35,000 --> 00:06:42,000 The data suggests that the patients who are more likely to fail, not up for the management, have an initial hemoglobin less than 9.25. 78 00:06:42,000 --> 00:06:48,000 We use that data to update our protocol. So if your hemoglobin is less than 9.25, you get one repeat hemoglobin. 79 00:06:48,000 --> 00:06:54,000 If it's greater than 9.25, you don't get any repeats unless you clinically appear that you need to. 80 00:06:54,000 --> 00:07:00,000 Has there been anything new on ultrasound or contrast enhanced ultrasound for grading to avoid radiation? 81 00:07:00,000 --> 00:07:03,000 We haven't been doing it routinely because they come in at two in the morning. 82 00:07:03,000 --> 00:07:09,000 The radiologists and the ultrasonographer who are comfortable doing contrast enhanced ultrasound aren't there, and so it becomes a challenge. 83 00:07:09,000 --> 00:07:15,000 But I think there is going to be some evidence about it. We just haven't found that it's very reliable yet. 84 00:07:15,000 --> 00:07:19,000 In summary, management of splenic lacerations varies based on resources. 85 00:07:19,000 --> 00:07:25,000 In limited settings, ICU admission might be preferred due to monitoring capabilities. 86 00:07:25,000 --> 00:07:32,000 Contrary to past practice, active arterial extravasational CT doesn't mandate angiomyelization in kids. 87 00:07:32,000 --> 00:07:41,000 Recent trends show safe discharge of low-grade injuries directly from the ER. CT scans more for diagnosis than injury grading. 88 00:07:41,000 --> 00:07:47,000 Effective patient care requires standardized discharge instructions and trauma clinic follow-ups. 89 00:07:47,000 --> 00:07:51,000 Hemoglobin checks post-admission are guided by initial values. 90 00:07:51,000 --> 00:07:57,000 The reliability of contrast enhanced ultrasound as a CT alternative remains uncertain. 91 00:07:57,000 --> 00:08:01,000 Don't forget to subscribe to the Stay Current MD YouTube channel. 92 00:08:01,000 --> 00:08:08,000 Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. 93 00:08:08,000 --> 00:08:22,000 Global CAST MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.