Interventional Radiology in Unstable Pediatric Patients with Solid Organ Injury
Interventional radiology (IR) is rarely indicated in hemodynamically unstable pediatric patients with solid organ injury, as these patients should undergo immediate operative management rather than IR procedures.
Hemodynamic Status Determines Management Pathway
Unstable Patients
- In pediatric patients with solid organ injury who are hemodynamically unstable (non-responders to resuscitation), immediate operative management is the standard of care 1
- According to WSES guidelines, hemodynamically unstable patients should undergo operative management rather than any attempt at non-operative management (NOM) or IR procedures 1
- The primary surgical intention should be to control hemorrhage and initiate damage control resuscitation as soon as possible 1
Limited Role for IR in Unstable Patients
- IR procedures require time for setup, patient transport to the angiography suite, and procedure execution—time that an unstable patient cannot afford
- WSES guidelines specifically state that angioembolization should be considered only in hemodynamically stable patients or as an adjunct after non-hemostatic or damage control procedures 1
Specific Scenarios Where IR May Be Considered
Post-Operative Adjunct
- IR may be used as a second-line intervention after damage control surgery if persistent arterial bleeding is identified 1
- In this scenario, the patient would typically be stabilized first through operative intervention
Transient Responders
- In patients considered "transient responders" with moderate to severe injuries, non-operative management (which might include IR) should only be considered in highly selected settings with:
- Immediate availability of trained surgeons
- Operating room accessibility
- Continuous monitoring in ICU/ER
- Immediate access to angiography/embolization
- Ready availability of blood products
- Quick transfer capability to higher level care 1
Splenic Injuries - Special Considerations
- For pediatric splenic trauma specifically, the vast majority of pediatric patients do not require angiography/angioembolization even for moderate to severe injuries 1
- The WSES guidelines note that "AG/AE may be considered in patients undergone to NOM, hemodynamically stable with signs of persistent hemorrhage not amenable of NOM" 1
Age-Specific Considerations
- Patients older than 15 years should be managed according to adult protocols for angiography/angioembolization 1
- For younger children, the threshold for operative management versus IR should be lower due to:
- Smaller blood volume and less physiologic reserve
- Technical challenges of catheterization in smaller vessels
- Higher success rates of non-operative management in pediatric solid organ injuries
Contrast Blush on CT Scan
- In hemodynamically stable children, the presence of contrast blush on CT scan is not an absolute indication for angiography/angioembolization, unlike in adults 1
- This is an important distinction from adult trauma protocols
Common Pitfalls to Avoid
- Delaying definitive treatment: Attempting IR in an unstable pediatric patient can delay life-saving operative intervention
- Misinterpreting contrast blush: Unlike in adults, contrast extravasation on imaging may not require acute surgical or interventional management in pediatric patients 2
- Overlooking the value of splenic preservation: While immediate surgery may be necessary in unstable patients, the long-term immunologic benefits of splenic preservation should be considered in the overall management plan
Conclusion
While interventional radiology has an expanding role in pediatric trauma management 3, 2, its use in hemodynamically unstable pediatric patients with solid organ injury remains extremely limited. The priority in these cases should be rapid operative intervention to control hemorrhage and stabilize the patient, with IR potentially serving as an adjunctive therapy after initial stabilization.