Case 4 A biking injury
George, a 12-year-old boy, is BMX biking on a purpose-built track on a Saturday afternoon and falls off his bike as he is riding downhill; he lands on top of his bike. George is wearing a helmet, but no other protective clothing. By the time his friend reaches him, George is awake and orientated but complains of a painful left shoulder and stomach area. An ambulance is called and he is taken to hospital.
His observations at triage show a mild tachycardia of 110/min, but other observations are within normal parameters. He has a bruise over the left upper quadrant of his abdomen but no other visible injuries. George is given a Manchester Triage Score assessment of Urgent (i.e. that full assessment take place within 60 minutes).
What is your opinion of this initial assessment?
Thirty minutes after his arrival in ED, George’s parents arrive. They find him complaining of increasing abdominal pain and looking pale. A repeat set of observations show that his tachycardia has worsened to 120/min and his blood pressure is now a little low at 95/58 mm Hg.
What course of action is appropriate at this stage?
George is moved from his cubicle to the resuscitation area and a paediatric trauma call is put out. The full trauma team attend and the call is led by the ED middle grade. George has no problems with his airway or breathing, but has signs of clinical shock. He is given 10 ml/kg of 0.9% saline. George shows no response to the first fluid bolus, but after a second bolus of 10 ml/kg his pulse and blood pressure return to normal. Trauma bloods are sent while a bedside FBC shows a Hb of 10g/dl (normal 12.1–16.6 g/dl).
A bedside FAST (Focused Assessment with Sonography for Trauma) ultrasound scan is performed by the ED middle grade and shows free fluid in the left upper quadrant but does not show any obvious splenic injury. A CT abdomen is performed while George is still in the ED, and shows a grade IV splenic injury (where grade I is least severe and grade V is most severe).
As George remains stable, the surgical registrar does not want to operate, but asks for George to be admitted to the general paediatric ward for observation. The surgical registrar confirms this plan with the on-call general surgical consultant and George is admitted.
George is transferred to the ward where he has routine 4-hourly observations. The first set of observations after his transfer to the ward is within normal limits.
Do you think this is an appropriate management plan?
Two hours after George is transferred to the ward, his parents call the nurses as they are concerned that he is looking pale again. His observations now show a pulse of 130/min and a blood pressure of 90/55 mmHg. A full paediatric arrest call is put out. George is given a further 2 boluses of 10 ml/kg of 0.9% saline, but achieves only partial haemodynamic stabilization, with a persistent tachycardia.
George is taken to theatre immediately, while the on-call general surgical consultant comes in from home. A repeat FBC shows a Hb of 8 g/dl and George requires a transfusion of O-Negative blood prior to the operation. At operation, attempts are made to preserve the spleen by splenorrhaphy, but these prove inadequate to control the bleeding and George has a splenectomy.
After discharge George’s parents make a formal complaint, stating that he received inadequate care both in ED and on the ward and that this led to his spleen being removed unnecessarily.
Expert opinion
Splenic injury is a common consequence of blunt trauma in children. The most common mechanism is a biking injury, followed by a motorbike injury. Abdominal wall bruising in the presence of blunt trauma is highly significant with one in nine children having a significant intra-abdominal injury. Left shoulder pain is a recognized referred pain phenomenon in splenic injury, caused by blood irritating the diaphragm. In this case, the ED staff failed to recognize the potential seriousness of this presentation as well as the early warning signs of shock. A paediatric trauma call should have been activated following triage.
Current best practice is that most splenic injuries can be successfully managed nonoperatively with even grade IV lacerations healing well without surgery. With more severe injuries there remains considerable clinical variation in practice.
However, a well-recognized indication for changing from nonoperative to operative intervention is the presence of haemodynamic instability. It is therefore imperative that patients with splenic injury who are being nonoperatively managed are closely observed. The American Pediatric Surgical Association recommends that patients with grade IV splenic injury are observed in a paediatric intensive care unit. Implicit in this recommendation is the requirement for frequent routine observations (at least hourly) as opposed to the 4-hourly observations given to George. It would have been best practice to transfer him either to a recognized trauma centre or to a paediatric surgical centre where he could have been more appropriately nonoperatively managed.
It is impossible to say whether the substandard care George received led directly to the need for splenectomy as even in specialist centres splenectomy remains necessary in some cases. However, there is clear evidence that children managed in nonpaediatric surgical centres have higher rates of splenectomy than patients managed in specialist centres.
Legal comment
It seems that the paediatric trauma team should have been called half an hour earlier than it was. It also seems that arrangements should have been made for much closer observation of George. It is only by luck that his parents noticed a change in his condition.
So there seem to have been two likely breaches of duty of care to George. But even so, it is very doubtful whether the parents will be able to successfully sue the hospital. The reason is that, while those breaches may have caused some delay, they probably did not obviate the need for surgery. Arguments that the delay and/or failure to refer to a specialist centre had led to a more radical surgery than would otherwise have taken place would also be very difficult for the parents to prove.
George’s parents have made a formal complaint. This should prompt an investigation of the systems in place for the treatment of children with a ruptured spleen. As a result, the paediatric department should be made aware of the need for frequent observations in patients such as George.
