title: Contrast extravasation predicts the need for operative intervention in children with blunt splenic trauma.
abstract: BACKGROUND
  Although the presence of a contrast blush (CB) on computed tomographic (CT) scan is associated with an increased failure rate of nonoperative management in adults with blunt splenic injury, little information is available for the pediatric population, where nonoperative management is the standard of care. Our aim was to determine whether the finding of CB on CT scan could predict failure of nonoperative therapy in children with blunt splenic injury.
  
  
  METHODS
  A retrospective analysis of 343 patients admitted with blunt splenic injury to our Level I pediatric trauma center over a 7-year period was performed. All CT scans were reviewed by a radiologist who was blinded to the patient outcome. We excluded 127 patients who either underwent immediate laparotomy without a CT scan or whose CT scans were unavailable at the time of this review. We divided the patients into two groups on the basis of the presence or absence of CB on the updated reading of the CT scan. Demographic variables analyzed included age, sex, mechanism of injury, Injury Severity Score, Glasgow Coma Scale score, initial hemoglobin and hematocrit, and emergency department pulse rate and systolic blood pressure. Outcome measures compared include length of stay, length of intensive care unit stay, the need for splenic intervention, and mortality. Continuous variables were compared using Student's t test for normally distributed data and the Mann-Whitney test for skewed data. Categorical data were compared using chi2 analysis or Fisher's exact test. Statistical significance was assigned to values of p < 0.05.
  
  
  RESULTS
  Among the study population (N = 216), 27 patients (12.5%) had CB on CT scan. Patients with CB had significantly lower hematocrit (p = 0.0004) and required operative intervention more frequently than those without CB (22% vs. 4%;p = 0.0008). Among patients with CB, mean pulse rate at presentation was higher in those that required splenic intervention (SI) (129 +/- 20.1) compared with those who underwent successful nonoperative therapy (100.4 +/- 23.1; p = 0.01). Only grade V injuries correlated with the need for laparotomy.
  
  
  CONCLUSIONS
  Children with blunt splenic injury who have CB on CT scan are more likely to require SI than those without CB. However, because the majority of patients with CB did not require SI, in the absence of hemodynamic instability, this finding may be insufficient to determine the need for SI. CB is a specific marker of active bleeding that may predict the need for early splenic intervention in a specific subset of patients at presentation.
authors.affiliation: Department of Surgery, Children's Hospital of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, PA 15213, USA.
authors.forename: Benedict C
authors.initials: BC
authors.lastname: Nwomeh
authors.forename: Evan P
authors.initials: EP
authors.lastname: Nadler
authors.forename: Manuel P
authors.initials: MP
authors.lastname: Meza
authors.forename: Kerry
authors.initials: K
authors.lastname: Bron
authors.forename: Barbara A
authors.initials: BA
authors.lastname: Gaines
authors.forename: Henri R
authors.initials: HR
authors.lastname: Ford
mesh_terms: D000007:Abdominal Injuries / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000601:surgery*; D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005119:Extravasation of Diagnostic and Therapeutic Materials / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000601:surgery*; D005260:Female; D006400:Hematocrit; D006801:Humans; D007223:Infant; D015601:Injury Severity Score; D008297:Male; D020380:Needs Assessment / Q000706:statistics & numerical data; D011237:Predictive Value of Tests; D011379:Prognosis; D012189:Retrospective Studies; D013154:Spleen / Q000000981:diagnostic imaging / Q000293:injuries*; D013156:Splenectomy; D013161:Splenic Rupture / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000601:surgery; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data; D014193:Trauma Centers / Q000706:statistics & numerical data; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000601:surgery*