Variations in the management of adolescents with blunt splenic trauma in England and Wales: are we preserving enough?

Trauma remains a leading cause of morbidity and mortality in the paediatric population. In blunt abdominal trauma, the spleen is the organ most commonly affected.¹ The management of splenic trauma has undergone a revolution in the past 50 years, with non-operative management now being the accepted standard for children with isolated splenic injury who are haemodynamically stable,² and in the most recent guidance suggests non-operative management being first-line treatment in haemodynamically stable adults with isolated splenic trauma of all grades. Non-operative management aims to reduce the morbidity and potential mortality associated with splenectomy and its potential complications, namely overwhelming post-splenectomy infection. This is estimated to have an incidence of around 0.5% in patients undergoing splenectomy for trauma but has a mortality of up to 50%. Intervention is still mandated in the haemodynamically unstable patient, or those with continuing massive transfusion requirements.

In England and Wales, management of major trauma is organised into trauma networks centred around 27 major trauma centres. Eleven of these only treat adults and five only treat children. In America and Australia, analysis of national trauma statistics has revealed that more children undergo splenectomy for splenic trauma at adult centres than at paediatric trauma centres.^3,4 This difference has also been demonstrated in adolescent (13–18 years of age) patients in the United States.⁵ A 2018 study has assessed the management of the general paediatric population with regards to blunt splenic trauma,⁶ however adolescent patients often represent a ‘grey area’ between paediatric and adult practice and might be at higher risk of disparities in management strategies. The aim of the present study was therefore to assess the management of adolescent splenic trauma at centres in England and Wales and to identify any differences in care between paediatric and adult trauma units.

The Trauma Audit and Research Network (TARN) was set up in 1989 and collects anonymised data from all trauma units and major trauma centres in England and Wales.⁷ Data collected include injuries, pre-hospital, emergency department and inpatient interventions and outcomes. Further information, including the procedures manual, can be viewed at www.tarn.ac.uk.

A request was made to TARN for information pertaining to all cases of non-penetrating splenic trauma reported from centres in England and Wales to TARN between January 2006 and December 2015. Ethical considerations were considered as part of the TARN request. Data were received on patient demographics, mechanism of injury, trauma centre details, injury severity score, grade of splenic injury, associated injuries, blood transfusions, operative management and 30-day mortality outcomes. Patients were classified according to age and separated into cohorts, 11–15 years and 16–20 years.

Statistical analyses were carried out in Stata version 14 and GraphPad. Fisher’s exact test was used to analyse the categorical variables given the low expected cell count of many calculations. Analysis of variance technique was performed to assess for differences in the haemodynamic status of patients.

During the 10-year study period, 5,806 cases of splenic trauma were reported to TARN (Fig 1); 1,277 (22%) were in the 11–20 years cohort, and 511 (40%) of the adolescents studied sustained isolated splenic injuries. Sixty-six of these adolescents did not have a grade of injury uploaded to the database and were excluded from further analysis; 321 (72%) patients underwent computed tomography to establish the diagnosis. Fifty-six 11–15-year-olds were transferred from trauma units to major trauma centres, compared with only 16 16–20-year-olds. There was no mortality from isolated splenic injuries reported during the study period. A summary of injury mechanisms and grades can be seen in Table 1. Analysis showed that 11–15-year-olds were more likely to suffer splenic trauma following falls, and the older adolescents as a result of road traffic collisions (Pearson’s chi-square 0.026).

Systolic blood pressure was comparable in the older age group and in the 11–15-year-olds treated at trauma units, but there was a small but statistically significant difference between those 11–15-year-olds with minor and major trauma treated at major trauma centres (119, 111 vs 132 compared with 115, 103 vs 127; p = 0.028). There was a significant difference in heart rates between those treated at trauma units and major trauma centres. This was apparent across all age groups and grades of injury (81 beats/minute, range 74–93 beats/minute vs 89 beats/minute, range 74–106 beats/minute; p = 0.021).

These data suggest that there is a large variation in the management of major blunt splenic trauma in England and Wales. While it remains beyond doubt that the haemodynamically unstable patient with continuing transfusion requirements warrants surgical exploration, the management of the haemodynamically stable patient has undergone a remarkable paradigm shift in the past 50 years. Initially in the paediatric population, and subsequently in adult practice, non-operative management has been increasingly adopted, and a 2013 systematic review proposed non-operative management as the gold standard for grade I or 2 splenic lesions in adults.⁸ The same review found that non-operative management was a valid first-line therapy in more severe injuries, but management should be decided on an individual patient basis. The more recent development of angioembolisation has been shown to lead to a decrease in splenectomy rates in England and Wales and combined with the use of topical haemostatic agents more spleens might be preserved in the future.^9–11

Reassuringly, there is no discernible difference in the management of adolescents with minor isolated splenic injuries. The low numbers of minor trauma are likely representative of underdiagnosis but the clinical impact of this is likely low. Significantly, however, this study demonstrates two differences in the management of major trauma in adolescents. First, as previously shown,⁶ in the 11–15 years age group there was a significantly higher rate of splenectomy in the patients treated at trauma units compared with major trauma centres. However, in the trauma units group, systolic blood pressure was not significantly lower, and heart rate was slightly higher in major trauma centres, so there does not appear to be a reason for this practice haemodynamically. Similarly, if there was no increase in the transfusion requirements of these children, why was the splenectomy rate so high? One explanation is that as these children are being managed by general surgeons who may be applying adult general surgical principles to these patients. It has previously been shown that when posed with the same clinical scenario, adult trauma surgeons were less likely to undertake non-operative management than paediatric surgeons, and this may well be the reason for the unusually high rate of adolescent splenectomies at local trauma centres.¹² Another possibility is that some trauma units might not have the confidence or provision for monitoring of these patients (for example a high-dependency setting). If this were to be the case and the child was haemodynamically stable, it is the authors’ opinion that a supervised transfer to a centre with that provision might be preferential to a splenectomy.

The second, and particularly surprising, difference is the large variation observed in the management of adolescent patients with blunt splenic trauma within major trauma centres. Despite similar grades of splenic injury and overall injury severity score, splenectomy rates more than doubled in the 16–20-year-olds compared with the 11–15 years age group. As with the trauma units–major trauma centres comparison, there was no significant increase in transfusion requirements between the groups and heart rate was not significantly different between age groups within major trauma centres. Furthermore, the lack of a significant difference in embolisation rates suggests the low splenectomy rates at major trauma centres looking after younger adolescents are not being masked by other forms of intervention.

This raises the question, do we really need to be performing as many splenectomies are in the older adolescent group? It is widely recognised that children are not just small adults, and this is particularly evident in trauma. It has previously been shown that children suffer blunt splenic trauma through different mechanisms to adults,¹³ and children are known to have a different physiological response to trauma than adults. That being said, the authors consider that the physiological differences between the age groups studied should be minimal and is unlikely to account for the differences observed. The differences in haemodynamic parameters seen in our study, while statistically significant, is not considered to have much impact clinically, given the numbers shown.

This study demonstrates that variance in practice exists and demonstrates that the benchmarking of standards for the management of splenic trauma in the adolescent population is required. It is not possible to absolutely be sure as to why this variance exists due to limitations in the study. Importantly, the data analysed were not patient-level data and, as such, in-depth multivariate analysis was impossible. Further prospective studies are needed to further explore trends in the management of splenic trauma and optimise outcomes.

In conclusion, there is a large disparity in the management of isolated major splenic trauma in adolescent patients in England and Wales. Young adolescents treated at major trauma centres have a much lower rate of splenectomy compared with those treated at trauma units or older adolescents treated at adult major trauma centres, despite comparable overall transfusion requirements. Splenectomy has associated morbidity and should not be undertaken lightly. Most importantly, there is up to a 5% lifetime risk of overwhelming post-splenectomy infection. We advocate that non-operative management should be the first-line management in the haemodynamically stable adolescent patient.