has another cause. So seeking that other source is actually what’s really important.
AA: And not to mention, the pelvic trauma could be venous. Most of the time it is venous. So I’m not sure if a prophylactic arterial embolization would be helpful in that scenario.
SJ: As for wound healing for surgical stabilization afterwards—which is another controversial topic on its own in the orthopedic literature—again, it’s something that we typically would not perform in a pediatric patient.
LK: Who are these guidelines for? Pediatric IRs, or adult IRs who fi nd themselves with pediatric patients? SJ: It’s not uncommon for an adult IR to have to take care of a child, and it’s also hard in pediatrics to defi ne what is pediatric trauma versus what is adult trauma. You may have a 14-year- old who is fully skeletally mature: are they treated the same as a 21-year-old young adult, or are they treated as a skeletally immature 13-year-old? There can be a substantial diff erence in how you respond.
AA: Those of us who work in pediatric centers are very familiar with nonoperative management, but as these children may arrive at adult centers, adult interventionalists may not be as familiar with nonoperative management. The majority of trauma in children isn’t being treated at pediatric trauma centers; it’s primarily done at adult trauma facilities.
SJ: That was one of the key points revealed in this position statement— that when children are treated at adult hospitals and adult trauma centers, they’re more likely to have an intervention, be it embolization or splenectomy, than if they are treated at a pediatric hospital or pediatric trauma center.
The outcome of all of this is the same: nonoperative management in pediatrics is more likely to be successful, despite what the CT shows, so the same rules used for adults cannot be applied to children.
LK: How was this statement produced?
It’s not uncommon for an adult IR to have to take care of a child, and it’s also hard in pediatrics to defi ne what is pediatric trauma vs. what is adult trauma. You may have a 14-year-old who is fully skeletally mature: are they treated the same as a 21-year-old young adult, or are they treated as a skeletally immature 13-year-old? There can be a substantial diff erence in how you respond.
AA:When deciding on the working group for creating this document, it started with SIR and then we reached out to the American Academy of Pediatrics (AAP) to make it a joint venture between our organizations. There was so much to cover that needed multidisciplinary input. The working group started with pediatric IRs and then expanded to include IRs who practice on both adults and children, the surgical team from AAP, an emergency medicine physician and pediatric trauma surgeons. It was very important to keep these guidelines open to a lot of other subspecialties that also handle trauma.
SJ: Once the document was put together, we then submitted it to other societies to off er them the option to concur.
AA:We also brought trainees into some of this process. I think it’s always important when authoring any essential document to include people who will continue to push this forward to the next revision and keep it updated as time goes on.
LK: Do you feel that any of the pearls will be potentially controversial or surprising? SJ: Some of the most controversial points in the guidelines are those based on the recommendations from the trauma societies of the angiographic response within 1 hour of the time of notifi cation. In pediatrics, the one thing we know is that very rarely is the unstable pediatric patient being referred to angiography. You typically have more of a window because the patients who may need angiography are the ones being observed in the intensive care unit, who need ongoing blood
transfusions, who are not hypotensive or unstable and have responded to fl uids or blood but require ongoing blood products. That’s when IR is notifi ed. Yes, that notifi cation period is something that’s important to monitor but it’s less likely than in the adult circumstance, when you’re notifi ed from the emergency room and the patient is bleeding and unstable. So the time requirement is the same, but it’s easier to reach with pediatric patients because it’s a known event.
AA: There are a lot of times when the patient has been in the ICU and transfused already, so IR will get the call when the management team does not see a sustained response.
LK: What is the key point you’d like readers to take away from this statement? SJ: The key is that pediatric patients are diff erent, so please read the guidelines and the papers that the guidelines are based on because there are diff erent algorithms that are present for pediatric solid organ injury in particular—and just because you have a pseudoaneurysm or blush on your CT does not mean that the patient automatically needs to come to angiography to have that treated.
AA: And in most cases, nonoperative management is going to be your fi rst line.
References
1. Padia SA, Ingraham CR, Moriarty JM, Wilkins LR, Bream PR Jr, Tam AL, Patel S, McIntyre L, Wolinsky PR, Hanks SE. Society of Interventional Radiology Position Statement on Endovascular Intervention for Trauma. J Vasc Interv Radiol. 2020 Mar;31(3):363-369.e2. doi: 10.1016/j. jvir.2019.11.012. Epub 2020 Jan 14. PMID: 31948744.
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