FEATURE When to wait
Nonoperative management for pediatric trauma By Lisa Kang, MD, Aparna Annam, DO, and Shellie C. Josephs, MD, FSIR
A
new SIR position statement on endovascular trauma intervention for pediatric patients will provide
guidance and insight into nonmedical management options. This position statement has been endorsed by the American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Pediatric Orthopaedic Society of North America, Pediatric Trauma Society, Society for Pediatric Interventional Radiology and Society for Pediatric Radiology, and will be available soon via the Journal of Vascular and Interventional Radiology.
Lisa Kang, MD, spoke to two of the authors, Aparna Annam, DO (lead author), and Shellie C. Josephs, MD, FSIR, on the creation of the document, key takeaways and crucial diff erences in intervention for pediatric patients.
Lisa Kang, MD: Why was it important to have a statement on how pediatric interventions diff er from adult interventions when it comes to endovascular trauma? Aparna Annam, DO: Over the years, we noticed a diff erence in how pediatric trauma is handled versus adult trauma. There has been so much work done on the relevance of CT scans in adult trauma as well as the actual methods and techniques for treatment, and there has always been the question of whether we can extrapolate this guidance to children. Should we follow the same criteria, or should it be something diff erent? Are children physiologically diff erent from adults? That was the foundation for
18 IRQ | WINTER 2024
investigations as to where a pediatric trauma position statement may actually diff er from the adult side.
During the creation of the SIR position on adult trauma, the authors noted what some of us suspected: not only is there a defi ned diff erence between how children respond in trauma, but also when there is an actual need for intervention. Given this, it was clear there was an independent need for guidelines for the pediatric population.
LK: Can you go into a little more detail about the diff erences in indications for endovascular or operative management for the pediatric patient versus the adult patient? AA: We just start with CT fi ndings. Sometimes when you have a trauma patient who arrives in an adult hospital, the CT trauma protocol may be diff erent from that in pediatric hospitals. In pediatrics, we try to limit our scanning to one phase to conserve radiation dose. You may see a triple phase scan in adult centers, but it’s really not indicated in children. In pediatrics, you may start with that CTA, and even if there is contrast extravasation or a splenic laceration, it doesn’t necessarily mean that the patient should go directly to endovascular management or splenectomy. We have to then evaluate where the patient is overall in terms of their vital signs, need for transfusion and fl uid resuscitation. In spite of those imaging fi ndings, the important take-home point is to consider how the patient is doing clinically. Conservative management is often the fi rst line of
therapy with pediatric patients unless they are unstable.
Shellie C. Josephs, MD, FSIR: Also consider that when it comes to infants and small children, cerebrovascular trauma is much more common than solid organ injury. So those cases where you have someone less than 2 years old needing embolization are extremely rare. The more likely patient that people will see is 10 years of age or older. We also must remember that most procedures are done with anesthesia rather than moderate sedation, and we do worry about a patient’s body temperature, contrast amounts, etc. Also, the amount of blood loss related to your procedure is substantially diff erent.
Aparna mentioned the spleen, which is one of the most important organs where we see a substantial diff erence between pediatrics and adult. Adult protocols are well established: a splenic artery pseudoaneurysm and a splenic laceration in a stable patient is going to come to IR. In pediatrics, that patient is observed, and there are very specifi c criteria for blood transfusion requirements at which the patient is considered to have failed nonoperative management. A blood transfusion requirement beyond 40 cc/kg or 4 units of pRBCs would be considered for either angiography or surgery depending on which is available and which is better for the patient based on other underlying injuries.
There was a conversation on SIR Connect regarding pelvic trauma in pediatrics where someone did a prophylactic embolization on a patient who had intermittent hypotension. And most of us who practice pediatric IR exclusively would know that, especially in a growing patient who has nonfused epiphyses, we are not going to do a prophylactic embolization. That is when you do your “angiographic laparotomy” or angiography to look around and see if you fi nd something else bleeding. But again, prophylactic embolization in children is almost never indicated, because persistent hypotension usually
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