III. MANAGEMENT
A. Liver and Spleen
The contemporary approach for managing blunt spleen and liver injuries
is primarily non-operative; more than 95% of all spleen and liver are managed
with expectant observation. In order to be a candidate for non-operative
management, the child must have normal hemodynamic parameters, and be in
a facility where there is close monitoring for signs of on-going hemorrhage.
The recommended period of observation was initially proposed by the APSA
Committee on Trauma, and is based on the American Association for the
Surgery of Trauma (AAST) grade of injury as determined by CT [12-15]. A
recent paper has challenged these recommendations, finding that abbreviated
periods of bedrest (a single night for injuries with Grades 1&2 and two nights for
Grades 3-5) do not result in delayed bleeding, return to the hospital. With this
approach, the authors found a decrease the length of hospitalization by two
days when compared to the APSA recommendations [16]. Routine repeat
imagin is not recommened regardless of the grade. Patients should be allowed
to return to contact sports 4 - 6 weeks after the injury.
Nearly all children with spleen or liver injuries experience complete
recovery and excellent long -erm outcomes without the need for operative
intervention. However, a few patients may still require operative intervention for
ongoing hemorrhage. Tachycardia, not responsive to fluid resuscitation,
decreased end-organ perfusion (low urine output, changes in mental status),