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 differences in intervention for pediatric patients.
Lisa Kang, MD: Why was it important to have a statement on how pediatric interventions differ from adult interventions when it comes to endovascular trauma?
Aparna Annam, DO: Over the years, we noticed a difference 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 different? Are children physiologically different from adults? That was the foundation for investigations as to where a pediatric trauma position statement may actually differ 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 defined difference 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 differences in indications for endovascular or operative management for the pediatric patient versus the adult patient?
AA: We just start with CT findings. Sometimes when you have a trauma patient who arrives in an adult hospital, the CT trauma protocol may be different 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 fluid resuscitation. In spite of those imaging findings, the important take-home point is to consider how the patient is doing clinically. Conservative management is often the first 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 different.
Aparna mentioned the spleen, which is one of the most important organs where we see a substantial difference 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 specific 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 find something else bleeding. But again, prophylactic embolization in children is almost never indicated, because persistent hypotension usually 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 find 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 define 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 difference 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?
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 offer 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 notification. 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 fluids or blood but require ongoing blood products. That’s when IR is notified. Yes, that notification period is something that’s important to monitor but it’s less likely than in the adult circumstance, when you’re notified 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 different, so please read the guidelines and the papers that the guidelines are based on because there are different 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 first line.
References:
- 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.
