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Schild-Suhren S, Yilmaz E, Biggemann L, Seif A, Torsello GF, Uhlig A, Ghadimi M, Bösch F. [Management of Injuries to the Parenchymal Abdominal Organs]. Zentralbl Chir 2024; 149:359-367. [PMID: 38684170 DOI: 10.1055/a-2301-7951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
The most common organs affected by abdominal trauma are the spleen and the liver, often in combination. Pancreatic injuries are rare. In the case of blunt abdominal trauma, which is much more common, a clinical and laboratory examination as well as sonography should be performed. In the initial assessment, the circulatory situation must be screened. If there is haemodynamic instability and presentation of free fluid, an emergency laparotomy is indicated. If the situation is stable or stabilised and a pathological sonography is present, it is essential to perform triphasic contrast enhanced computed tomography, which is also mandatory in polytraumatised patients. If a renal injury is suspected, a late venous phase should be attached. In addition to the classification of the injury, attention should be paid to possible vascular injury or active bleeding. In this case, angiography with the possibility of intervention should be performed. Endoscopic treatment is possible for injuries of the pancreatic duct. If the imaging does not reveal any intervention target and a circulation is stable, a conservative approach is possible with continuous monitoring using clinical, laboratory and sonographic controls. Most injuries can be successfully treated by non-operative management (NOM).There are various surgical options for treating the injury, such as local and resecting procedures. There is also the option of "damage control surgery" with acute bleeding control and second look. Complex surgical procedures should be performed at centres. Postoperative complications arise out of elective surgery.In the less common case of penetrating abdominal trauma, the actual extent of the injury cannot be estimated from the visible wound. Here again, the circulatory situation determines the next steps. An emergency laparotomy should be carried out in case of instability. If the condition is stable, further diagnostics should be performed using contrast enhanced computed tomography. If penetration through the peritoneum cannot be clearly excluded, diagnostic laparoscopy should be performed.
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Affiliation(s)
- Stina Schild-Suhren
- Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Gottingen, Deutschland
| | - Elif Yilmaz
- Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Gottingen, Deutschland
| | - Lorenz Biggemann
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsmedizin Göttingen, Gottingen, Deutschland
| | - Ali Seif
- Institut für Diagnostische und Interventionelle Radiologie, Georg-August-Universität Göttingen, Gottingen, Deutschland
| | - Giovanni Federico Torsello
- Institut für Diagnostische und Interventionelle Radiologie, Georg-August-Universität Göttingen, Gottingen, Deutschland
| | - Annemarie Uhlig
- Klinik für Urologie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Michael Ghadimi
- Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Gottingen, Deutschland
| | - Florian Bösch
- Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Gottingen, Deutschland
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Erdemir AG, Başaran H, İdilman İS, Onur MR, Akpınar E. Introducing AEM-RADS: A novel reporting and data system for abdominal emergencies. Abdom Radiol (NY) 2024:10.1007/s00261-024-04453-y. [PMID: 38916616 DOI: 10.1007/s00261-024-04453-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/09/2024] [Accepted: 06/12/2024] [Indexed: 06/26/2024]
Abstract
PURPOSE The Reporting and Data System (RADS) has proven successful in various medical settings, but a standardized reporting system for abdominal emergencies is lacking. In this study, the Abdominal Emergency Reporting and Data System (AEM-RADS) for urgent findings on abdominal CT scans is introduced to address the need for consistency in emergency radiology. METHODS In this prospective observational study, conducted over a six-month period, the urgency of abdominal CT scans was assessed using the proposed AEM-RADS scoring system. The committee developed a scale ranging from AEM-RADS 1 (normal) to AEM-RADS 5 (urgent disease). Interobserver agreement between two observers with different experience was evaluated, and robust AEM-RADS reference values were established by radiologists who were not observers. Statistical analysis used mean, standard deviations and Kendall's tau analysis for interobserver agreement. RESULTS Among 2656 patients who underwent CT for abdominal emergencies, the AEM-RADS distribution was 17.50% AEM-RADS 1, 28.57% AEM-RADS 2, 7.22% AEM-RADS 3, 35.61% AEM-RADS 4, and 11.06% AEM-RADS 5. Interobserver agreement was high, especially for urgent and emergent cases (p < 0.0001). Notable discrepancies were observed in AEM-RADS categories 2C-D and 3B-C, emphasizing the influence of radiologists' experience on interpretation. However, the interobserver agreement for both AEM-RADS 2C-D and 3B-C were statistically significant (p < 0.001). CONCLUSIONS AEM-RADS showed promising reliability, particularly in identifying urgent and emergent cases. Despite some inter-observer discrepancies, the system showed potential for standardized emergency workups. AEM-RADS could significantly enhance diagnostic accuracy in abdominal emergencies and provide a structured framework for shared decision-making between clinicians and radiologists.0.
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Affiliation(s)
- Ahmet Gürkan Erdemir
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
| | - Hasbi Başaran
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | | | - Mehmet Ruhi Onur
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Erhan Akpınar
- Department of Radiology, Biological Sciences Division, The University of Chicago, Chicago, USA
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Brunese MC, Avella P, Cappuccio M, Spiezia S, Pacella G, Bianco P, Greco S, Ricciardelli L, Lucarelli NM, Caiazzo C, Vallone G. Future Perspectives on Radiomics in Acute Liver Injury and Liver Trauma. J Pers Med 2024; 14:572. [PMID: 38929793 PMCID: PMC11204538 DOI: 10.3390/jpm14060572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/02/2024] [Accepted: 05/09/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Acute liver injury occurs most frequently due to trauma, but it can also occur because of sepsis or drug-induced injury. This review aims to analyze artificial intelligence (AI)'s ability to detect and quantify liver injured areas in adults and pediatric patients. Methods: A literature analysis was performed on the PubMed Dataset. We selected original articles published from 2018 to 2023 and cohorts with ≥10 adults or pediatric patients. Results: Six studies counting 564 patients were collected, including 170 (30%) children and 394 adults. Four (66%) articles reported AI application after liver trauma, one (17%) after sepsis, and one (17%) due to chemotherapy. In five (83%) studies, Computed Tomography was performed, while in one (17%), FAST-UltraSound was performed. The studies reported a high diagnostic performance; in particular, three studies reported a specificity rate > 80%. Conclusions: Radiomics models seem reliable and applicable to clinical practice in patients affected by acute liver injury. Further studies are required to achieve larger validation cohorts.
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Affiliation(s)
- Maria Chiara Brunese
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (M.C.B.)
| | - Pasquale Avella
- Department of Clinical Medicine and Surgery, University of Naples Federico II, 80131 Naples, Italy
- Hepatobiliary and Pancreatic Surgery Unit, Pineta Grande Hospital, 81030 Castel Volturno, Italy
| | - Micaela Cappuccio
- Department of Clinical Medicine and Surgery, University of Naples Federico II, 80131 Naples, Italy
| | - Salvatore Spiezia
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (M.C.B.)
| | - Giulia Pacella
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (M.C.B.)
| | - Paolo Bianco
- Hepatobiliary and Pancreatic Surgery Unit, Pineta Grande Hospital, 81030 Castel Volturno, Italy
| | - Sara Greco
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari “Aldo Moro”, 70124 Bari, Italy
| | | | - Nicola Maria Lucarelli
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari “Aldo Moro”, 70124 Bari, Italy
| | - Corrado Caiazzo
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (M.C.B.)
| | - Gianfranco Vallone
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (M.C.B.)
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Koskinen SK, Alagic Z, Enocson A, Kistner A. The prevalence of early contained vascular injury of spleen. Sci Rep 2024; 14:7917. [PMID: 38575738 PMCID: PMC10995136 DOI: 10.1038/s41598-024-58626-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 04/01/2024] [Indexed: 04/06/2024] Open
Abstract
Contained vascular injuries (CVI) of spleen include pseudoaneurysms (PSA) and arterio-venous fistulae (AV-fistulae), and their reported prevalence varies. Our purpose was to assess the prevalence of early splenic CVI seen on admission CT in patients with splenic trauma admitted to a single level 1 trauma center in 2013-2021, and its detection in different CT protocols. A retrospective, single-center longitudinal cohort study. Nine-year data (2013-2021) of all patients with suspected or manifest abdominal trauma were retrieved. All patients, > 15 years with an ICD code for splenic trauma (S36.0XX) were included. CT and angiographic examinations were identified. Reports and images were reviewed. Splenic CVI CT criterion was a focal collection of vascular contrast that decreases in attenuation with delayed imaging. Number of CVIs and treatment was based on medical records and/or available angioembolization data. Of 2805 patients with abdominal trauma, 313 patients (313/2805; 11.2%) fulfilled the study entry criteria. 256 patients (256/313; 81.8%) had a CT examination. Sixteen patients had splenectomy before CT, and the final study group included 240 patients (240/313; 76.7%). Median New Injury Severity Score (NISS) was 27 and 87.5% of patients had NISS > 15. Splenic CVI was found in 20 patients, which yields a prevalence of 8.3% (20/240; 95% CI 5.2-12.6%). In those cases with both late arterial and venous phase images available, CVI was seen in 14.5% of cases (18/124, 95% CI 8.6-22.0%). None of the patients with CVI died within 30 days of the injury. The prevalence of early splenic CVI in patients with a splenic trauma was 8.3-14.5% (95% CI 5.2-22.0%). Our data suggests that both arterial and venous phase are needed for CT diagnosis. The 30-day outcome in terms of mortality was good.
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Affiliation(s)
- Seppo K Koskinen
- Division for Radiology, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, 171 76, Stockholm, Sweden.
- Department of Diagnostic Radiology, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| | - Z Alagic
- Division for Radiology, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, 171 76, Stockholm, Sweden
- Department of Diagnostic Radiology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - A Enocson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76, Stockholm, Sweden
- Department of Trauma, Acute Surgery and Orthopaedics, Karolinska University Hospital, 171 77, Stockholm, Sweden
| | - A Kistner
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76, Stockholm, Sweden
- Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
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5
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Prihadi JC, Hengky A, Lionardi SK. Conservative management in high-grade renal trauma: a systematic review and meta-analysis. BJU Int 2024. [PMID: 38566265 DOI: 10.1111/bju.16343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
OBJECTIVE To systematically investigate and analyse the aggregated data from recent studies to provide a quantitative synthesis for a conservative approach to the management of high-grade kidney trauma, as accumulating evidence supports the favourable outcomes of a conservative approach. METHODS A comprehensive search was performed using databases, including PubMed, EBSCO, ProQuest, Google Scholar, and Cochrane Library, to identify studies relevant to high-grade renal trauma in both adult and paediatric populations. The compare review focused on comparing conservative management interventions, such as observation, rest, resuscitation, transfusion, symptomatic management, and angioembolisation, with operative management interventions. Search strategies incorporated specific medical subject headings and keywords related to conservative management, kidney trauma, mortality, and renal preservation. Random and fixed-effect meta-analyses were conducted to estimate the rates of nephrectomy and mortality, respectively. RESULTS A total of 36 and 29 studies were included for qualitative and quantitative synthesis, respectively. The aggregated data showed a cumulative risk difference of 0.52 (95% confidence interval [CI] 0.38-0.66, P < 0.001), indicating a higher likelihood of nephrectomy in cases where operative management was used instead of conservative management. In terms of mortality, conservative management demonstrated a lower risk difference of 0.09 (95% CI 0.05-0.13, P < 0.001). CONCLUSION The results indicate that opting for conservative management in cases of high-grade renal trauma, particularly for haemodynamically stable patients, presents a lower risk of mortality and reduced probability of requiring nephrectomy when compared to operative management. These findings provide strong evidence in favour of considering conservative management as a viable and effective treatment option for high-grade renal trauma.
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Affiliation(s)
- Johannes Cansius Prihadi
- Division of Urology, Department of Surgery, Atma Jaya Catholic University of Indonesia/Atma Jaya Hospital, Jakarta, Indonesia
| | - Antoninus Hengky
- Center of Health Research, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
- Fatima Hospital, Ketapang Regency, Indonesia
| | - Stevan Kristian Lionardi
- School of Medicine and Health Science, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
- Sultan Syarif Mohamad Alkadrie Hospital, Pontianak, Indonesia
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Khatri H, Kim N, Chuang TY(A, Lamparelli M. A rare presentation of spontaneous splenic rupture from plasma cell leukaemia-a case report. J Surg Case Rep 2024; 2024:rjae223. [PMID: 38605701 PMCID: PMC11007546 DOI: 10.1093/jscr/rjae223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 03/20/2024] [Indexed: 04/13/2024] Open
Abstract
Spontaneous/atraumatic splenic rupture is rare, and often associated with underlying infectious disease, or haematological malignancy. Plasma cell leukaemia (PCL) is a rare and aggressive subtype of multiple myeloma, with a higher prevalence of hepatosplenomegaly with a bleeding diathesis from secondary to thrombocytopaenia. We report the case of an 82-year-old male presenting to the emergency department with altered mentation and complaints of left abdominal pain. He presented with haemorrhagic shock. Imaging revealed a spontaneous splenic rupture. He underwent emergency laparotomy and splenectomy for which the histopathology yielded a diagnosis of PCL as the cause for rupture. He received four courses of bortezomib and hyperCVAD 1A therapy. After a long 64-day admission, he recovered well and was discharged home with outpatient haematology/oncology follow-up.
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Affiliation(s)
- Hershil Khatri
- Department of General Surgery, Ipswich Hospital, Ipswich, QLD 4305, Australia
| | - Nakhyun Kim
- Department of General Surgery, Rockhampton Hospital, Rockhampton, QLD 4700, Australia
| | - Tzu-Yi (Arron) Chuang
- Department of General Surgery, Rockhampton Hospital, Rockhampton, QLD 4700, Australia
| | - Michael Lamparelli
- Department of General Surgery, Rockhampton Hospital, Rockhampton, QLD 4700, Australia
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7
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Cakmak V, Herek D, Oskay A, Güngör G, Çakmak P, Özen M. Pancreatic injury due to blunt trauma on CT: does retropancreatic fat tissue reduce the severity of pancreatic injury? ULUS TRAVMA ACIL CER 2024; 30:263-270. [PMID: 38634850 PMCID: PMC11065974 DOI: 10.14744/tjtes.2024.60622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Pancreatic injuries from blunt abdominal trauma have a high mortality rate, often accompanied by injuries to adjacent organs. This study aims to investigate the relationship between the size of retropancreatic adipose tissue and the severity of pancreatic and adjacent organ injuries in patients with pancreatic trauma. METHODS We retrospectively screened computed tomography (CT) images of 34 patients (25 males, nine females, aged 13-69 years) and 34 controls (28 males, six females, aged 15-66 years) who suffered blunt abdominal trauma. The area of adipose tissue located posterior to the pancreatic body was measured in the axial plane for all subjects. The severity of pancreatic injury was assessed in terms of the injury site, the retropancreatic adipose tissue area, and the degree of other organ injuries. RESULTS Pancreatic injuries were located in the head for 16 patients (23.5%), in the body for four patients (5.9%), and in the tail for 14 patients (20.6%). The retropancreatic fat area was found to be significantly smaller in patients with pancreatic trauma compared to controls (p<0.0001). Furthermore, the ratio of the retropancreatic fat area to the vertebral corpus area differed significantly between patients with and without pancreatic injuries (p=0.014). CONCLUSION Retropancreatic adipose tissue protects the pancreatic body from the impacts of blunt abdominal trauma. An increased amount of retropancreatic adipose tissue is associated with a reduced rate of pancreatic injury.
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Affiliation(s)
- Vefa Cakmak
- Department of Radiology, Faculty of Medicine, Pamukkale University, Denizli-Türkiye
| | - Duygu Herek
- Department of Radiology, Faculty of Medicine, Pamukkale University, Denizli-Türkiye
| | - Alten Oskay
- Department of Emergency Medicine, Faculty of Medicine, Pamukkale University, Denizli-Türkiye
| | - Gülay Güngör
- Department of Radiology, Faculty of Medicine, Pamukkale University, Denizli-Türkiye
| | - Pınar Çakmak
- Department of Radiology, Faculty of Medicine, Pamukkale University, Denizli-Türkiye
| | - Mert Özen
- Department of Emergency Medicine, Faculty of Medicine, Pamukkale University, Denizli-Türkiye
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Spoor K, Cull JD, Otaibi BW, Hazelton JP, Chipko J, Reynolds J, Fugate S, Pederson C, Zier LB, Jacobson LE, Williams JM, Easterday TS, Byerly S, Mentzer C, Hawke E, Cullinane DC, Ontengco JB, Bugaev N, LeClair M, Udekwu P, Josephs C, Noorbaksh M, Babowice J, Velopulos CG, Urban S, Goldenberg A, Ghobrial G, Pickering JM, Quarfordt SD, Aunchman AF, LaRiccia AK, Spalding C, Catalano RD, Basham JE, Edmundson PM, Nahmias J, Tay E, Norwood SH, Meadows K, Wong Y, Hardman C. Failure rates of nonoperative management of low-grade splenic injuries with active extravasation: an Eastern Association for the Surgery of Trauma multicenter study. Trauma Surg Acute Care Open 2024; 9:e001159. [PMID: 38464553 PMCID: PMC10921525 DOI: 10.1136/tsaco-2023-001159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 12/25/2023] [Indexed: 03/12/2024] Open
Abstract
Objectives There is little evidence guiding the management of grade I-II traumatic splenic injuries with contrast blush (CB). We aimed to analyze the failure rate of nonoperative management (NOM) of grade I-II splenic injuries with CB in hemodynamically stable patients. Methods A multicenter, retrospective cohort study examining all grade I-II splenic injuries with CB was performed at 21 institutions from January 1, 2014, to October 31, 2019. Patients >18 years old with grade I or II splenic injury due to blunt trauma with CB on CT were included. The primary outcome was the failure of NOM requiring angioembolization/operation. We determined the failure rate of NOM for grade I versus grade II splenic injuries. We then performed bivariate comparisons of patients who failed NOM with those who did not. Results A total of 145 patients were included. Median Injury Severity Score was 17. The combined rate of failure for grade I-II injuries was 20.0%. There was no statistical difference in failure of NOM between grade I and II injuries with CB (18.2% vs 21.1%, p>0.05). Patients who failed NOM had an increased median hospital length of stay (p=0.024) and increased need for blood transfusion (p=0.004) and massive transfusion (p=0.030). Five patients (3.4%) died and 96 (66.2%) were discharged home, with no differences between those who failed and those who did not fail NOM (both p>0.05). Conclusion NOM of grade I-II splenic injuries with CB fails in 20% of patients. Level of evidence IV.
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Affiliation(s)
- Kristen Spoor
- Prisma Health Upstate, Greenville, South Carolina, USA
| | - John David Cull
- Surgery, Prisma Health Upstate, Greenville, South Carolina, USA
| | - Banan W Otaibi
- Pennsylvania State University, Hershey, Pennsylvania, USA
| | | | - John Chipko
- Research Medical Center, Kansas City, Missouri, USA
| | | | - Sam Fugate
- University of Kentucky HealthCare, Lexington, Kentucky, USA
| | | | - Linda B Zier
- Medical Center of the Rockies, Loveland, Colorado, USA
| | - Lewis E Jacobson
- Trauma Department, St. Vincent Indianapolis Hospital, Indianapolis, Indiana, USA
| | - Jamie M Williams
- Trauma Department, St. Vincent Indianapolis Hospital, Indianapolis, Indiana, USA
| | | | | | - Caleb Mentzer
- Department of Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Edward Hawke
- Spartanburg Regional Health System, Spartanburg, South Carolina, USA
| | | | | | | | | | - Pascal Udekwu
- Surgery, WakeMed Health and Hospitals, Raleigh, North Carolina, USA
| | | | | | | | | | - Shane Urban
- Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Anna Goldenberg
- Trauma, Acute Care Surgery, and Surgical Critical Care, Cooper University Hospital Regional Trauma Center, Camden, New Jersey, USA
| | | | | | | | - Alia F Aunchman
- University of Vermont Medical Center, Burlington, Vermont, USA
| | | | - Chance Spalding
- Trauma and Acute Care Surgery, Grant Medical Center, Columbus, Ohio, USA
| | - Richard D Catalano
- Loma Linda University Adventist Health Sciences Center, Loma Linda, California, USA
| | | | | | | | - Erika Tay
- Texas Health Presbyterian Hospital, Dallas, Texas, USA
| | | | | | - Yee Wong
- Premier Health Partners Inc, Dayton, Ohio, USA
| | - Claire Hardman
- Wright State Physicians, Department of Surgery, Dayton, Ohio, USA
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Katsura M, Fukuma S, Kuriyama A, Kondo Y, Yasuda H, Matsushima K, Shiraishi A, Kusaka A, Nakabayashi Y, Yagi M, Ito F, Tanikawa A, Kushimoto S. Association of Contrast Extravasation Grade With Massive Transfusion in Pediatric Blunt Liver and Spleen Injuries: A Multicenter Retrospective Cohort Study. J Pediatr Surg 2024; 59:500-508. [PMID: 37996348 DOI: 10.1016/j.jpedsurg.2023.10.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 10/18/2023] [Accepted: 10/25/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND This study aimed to assess whether the grade of contrast extravasation (CE) on CT scans was associated with massive transfusion (MT) requirements in pediatric blunt liver and/or spleen injuries (BLSI). METHODS This multicenter retrospective cohort study included pediatric patients (≤16 years old) who sustained BLSI between 2008 and 2019. MT was defined as transfusion of all blood products ≥40 mL/kg within the first 24 h of admission. Associations between CE and MT requirements were assessed using multivariate logistic regression analysis with cluster-adjusted robust standard errors to calculate the adjusted odds ratio (AOR). RESULTS A total of 1407 children (median age: 9 years) from 83 institutions were included in the analysis. Overall, 199 patients (14 %) received MT. CT on admission revealed that 54 patients (3.8 %) had CE within the subcapsular hematoma, 100 patients (7.1 %) had intraparenchymal CE, and 86 patients (6.1 %) had CE into the peritoneal cavity among the overall cohort. Multivariate analysis, adjusted for age, sex, age-adjusted shock index, injury severity, and laboratory and imaging factors, showed that intraparenchymal CE and CE into the peritoneal cavity were significantly associated with the need for MT (AOR: 2.50; 95 % CI, 1.50-4.16 and AOR: 4.98; 95 % CI, 2.75-9.02, respectively both p < 0.001). The latter significant association persisted in the subgroup of patients with spleen and liver injuries. CONCLUSION Active CE into the free peritoneal cavity on admission CT was independently associated with a greater probability of receiving MT in pediatric BLSI. The CE grade may help clinicians plan blood transfusion strategies. LEVEL OF EVIDENCE Level 4; Therapeutic/Care management.
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Affiliation(s)
- Morihiro Katsura
- Department of Surgery, Okinawa Chubu Hospital, Okinawa, Japan; Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Shingo Fukuma
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, Okayama, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA
| | | | - Akari Kusaka
- Critical Care Medical Center, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Yosuke Nakabayashi
- Advanced Medical Emergency Department and Critical Care Center, Maebashi Red Cross Hospital, Gunma, Japan
| | - Masayuki Yagi
- Department of Emergency Medicine and Acute Care Surgery, Matsudo City General Hospital, Chiba, Japan
| | - Fumihito Ito
- Department of Emergency and Critical Care Medicine, Ohta Nishinouchi Hospital, Fukushima, Japan
| | - Atsushi Tanikawa
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan
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Adams-McGavin RC, Tafur M, Vlachou PA, Wu M, Brassil M, Crivellaro P, Lin HM, Gomez D, Colak E. Interrater Agreement of CT Grading of Blunt Splenic Injuries: Does the AAST Grading Need to Be Reimagined? Can Assoc Radiol J 2024; 75:171-177. [PMID: 37405424 DOI: 10.1177/08465371231184425] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023] Open
Abstract
Introduction: The Revised Organ Injury Scale (OIS) of the American Association for Surgery of Trauma (AAST) is the most widely accepted classification of splenic trauma. The objective of this study was to evaluate inter-rater agreement for CT grading of blunt splenic injuries. Methods: CT scans in adult patients with splenic injuries at a level 1 trauma centre were independently graded by 5 fellowship trained abdominal radiologists using the AAST OIS for splenic injuries - 2018 revision. The inter-rater agreement for AAST CT injury score, as well as low-grade (IIII) versus high-grade (IV-V) splenic injury was assessed. Disagreement in two key clinical scenarios (no injury versus injury, and high versus low grade) were qualitatively reviewed to identify possible sources of disagreement. Results: A total of 610 examinations were included. The inter-rater absolute agreement was low (Fleiss kappa statistic 0.38, P < 0.001), but improved when comparing agreement between low and high grade injuries (Fleiss kappa statistic of 0.77, P < .001). There were 34 cases (5.6%) of minimum two-rater disagreement about no injury vs injury (AAST grade ≥ I). There were 46 cases (7.5%) of minimum two-rater disagreement of low grade (AAST grade I-III) versus high grade (AAST grade IV-V) injuries. Likely sources of disagreement were interpretation of clefts versus lacerations, peri-splenic fluid versus subcapsular hematoma, application of adding multiple low grade injuries to higher grade injuries, and identification of subtle vascular injuries. Conclusion: There is low absolute agreement in grading of splenic injuries using the existing AAST OIS for splenic injuries.
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Affiliation(s)
- R Chris Adams-McGavin
- Department of Surgery, Temetry Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Monica Tafur
- Department of Medical Imaging, Unity Health Toronto, St Michael's Hospital, Toronto, ON, Canada
- Department of Medical Imaging, Temetry Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Paraskevi A Vlachou
- Department of Medical Imaging, Unity Health Toronto, St Michael's Hospital, Toronto, ON, Canada
- Department of Medical Imaging, Temetry Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Matthew Wu
- Department of Medical Imaging, Unity Health Toronto, St Michael's Hospital, Toronto, ON, Canada
- Department of Medical Imaging, Temetry Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Michael Brassil
- Department of Medical Imaging, Unity Health Toronto, St Michael's Hospital, Toronto, ON, Canada
- Department of Medical Imaging, Temetry Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Priscila Crivellaro
- Department of Medical Imaging, Unity Health Toronto, St Michael's Hospital, Toronto, ON, Canada
- Department of Medical Imaging, Temetry Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Hui-Ming Lin
- Department of Medical Imaging, Unity Health Toronto, St Michael's Hospital, Toronto, ON, Canada
| | - David Gomez
- Department of Surgery, Temetry Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
- Division of General Surgery, Unity Health Toronto, St Michael's Hospital, Toronto, ON, Canada
| | - Errol Colak
- Department of Medical Imaging, Unity Health Toronto, St Michael's Hospital, Toronto, ON, Canada
- Department of Medical Imaging, Temetry Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
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11
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Lanier MH, Mellnick VM. Invited Commentary: Agreement for Blunt Splenic Injuries Has Room for Improvement. Can Assoc Radiol J 2024; 75:26-27. [PMID: 37531212 DOI: 10.1177/08465371231189681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
Affiliation(s)
- M Hunter Lanier
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
| | - Vincent M Mellnick
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
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12
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Radding S, Harfouche MN, Dhillon NK, Ko A, Hawley KL, Kundi R, Maddox JS, Radowsky JS, DuBose JJ, Feliciano DV, Kozar RA, Scalea TM. A pseudo-dilemma: Are we over-diagnosing and over-treating traumatic splenic intraparenchymal pseudoaneurysms? J Trauma Acute Care Surg 2024; 96:313-318. [PMID: 37599423 DOI: 10.1097/ta.0000000000004117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
BACKGROUND Splenic embolization for traumatic vascular abnormalities in stable patients is a common practice. We hypothesize that modern contrast-enhanced computed tomography (CT) over diagnoses posttraumatic splenic vascular lesions, such as intraparenchymal pseudoaneurysms (PSA) that may not require embolization. METHODS We reviewed the experience at our high-volume center with endovascular management of blunt splenic injuries from January 2016 to December 2021. Multidisciplinary review was used to compared initial CT findings with subsequent angiography, analyzing management and outcomes of identified vascular lesions. RESULTS Of 853 splenic injuries managed overall during the study period, 255 (29.9%) underwent angiography of the spleen at any point during hospitalization. Vascular lesions were identified on 58% of initial CTs; extravasation (12.2%) and PSA (51.0%). Angiography was performed a mean of 22 hours after admission, with 38% done within 6 hours. Embolization was performed for 90.5% (231) of patients. Among the 130 patients with PSA on initial CT, 36 (27.7%) had no visible lesion on subsequent angiogram. From the 125 individuals who did not have a PSA identified on their initial CT, 67 (54%) had a PSA seen on subsequent angiography. On postembolization CT at 48 hours to 72 hours, persistently perfused splenic PSAs were seen in 41.0% (48/117) of those with and 22.2% (2/9) without embolization. Only one of 24 (4.1%) patients with PSA on angiography observed without embolization required delayed splenectomy, whereas 6.9% (16/231) in the embolized group had splenectomy at a mean of 5.5 ± 4 days after admission. CONCLUSION There is a high rate of discordance between CT and angiographic identification of splenic PSAs. Even when identified at angiogram and embolized, close to half will remain perfused on follow-up imaging. These findings question the use of routine angioembolization for all splenic PSAs. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Sydney Radding
- From the Department of Surgery (S.R.), Virginia Commonwealth University, Richmond, VA; R Adams Cowley Shock Trauma Center (M.N.H., N.K.D., K.L.H., R.K., J.S.M., J.S.R., D.V.F., R.A.K., T.M.S.), University of Maryland Medical System, Baltimore, Maryland; Department of Surgery (A.K.), Stanford University, Stanford, California; and Department of Surgery (J.J.DB.), University of Texas at Austin, Austin, Texas
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13
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Visconti D, Parini D, Mariani D, Biloslavo A, Bellio G, Ceolin M, Cozza V, Musetti S, Pivetta E, Kurihara H, Zago M, Santarelli M, Chiarugi M. Spread and feasibility of non-operative management (NOM) of traumatic splenic injuries in adults: a national survey. Updates Surg 2024; 76:245-253. [PMID: 38103166 DOI: 10.1007/s13304-023-01718-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 11/23/2023] [Indexed: 12/17/2023]
Abstract
In hemodynamically stable adults sustaining a splenic trauma, non-operative management (NOM) represents the standard approach even in high-severity injuries. However, knowledge, structural, and logistic limitations still reduce its wider diffusion. This study aims to identify such issues to promote the safe and effective management of these injuries.A survey was developed using the SurveyMonkey® software and spread nationally in Italy. The survey was structured into: (1) Knowledge of classification systems; (2) Availability to refer patients; (3) Patients monitoring and follow-up; (4) Center-related.The survey was filled in by 327 surgeons, with a completeness rate of 63%. Three responders out of four are used to manage trauma patients. Despite most responders knowing the existing classifications, their use is still limited in daily practice. If a patient needs to be centralized, the concern about possible clinical deterioration represent the main obstacle to achieving a NOM. The lack of protocols does not allow standardization of patient surveillance according to the degree of injury. The imaging follow-up is not standardized as well, varying between computed tomography, ultrasound, and contrast-enhanced ultrasound.The classification systems need to be spread to all the trauma-dedicated physicians, to speak a common language. A more rational centralization of patients should be promoted, ideally through agreements between peripheral and reference centers, both at regional and local level. Standardized protocols need to be shared nationally, as well as the clinical and imaging follow-up criteria should be adapted to the local features.
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Affiliation(s)
- Diego Visconti
- Città della Salute e della Scienza University Hospital, Turin, Italy.
| | - Dario Parini
- Ospedale Santa Maria della Misericordia ULSS 5 Polesana, Rovigo, Italy
| | | | | | - Gabriele Bellio
- Ospedale di Piove di Sacco, ULSS 6 Euganea, Piove di Sacco, Padua, Italy
| | - Martina Ceolin
- IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy
| | - Valerio Cozza
- Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | | | - Emanuele Pivetta
- University of Turin and Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Hayato Kurihara
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mauro Zago
- Ospedale A. Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - Mauro Santarelli
- Città della Salute e della Scienza University Hospital, Turin, Italy
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14
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Barah A, Elmagdoub A, Aker L, M. Alahmad Y, Jaleel Z, Ahmed Z, Kaassamali R, Hasani AA, Al-Thani H, Omar A. The predictive value of CTSI scoring system in non-operative management of patients with splenic blunt trauma: The experience of a level 1 trauma center. Eur J Radiol Open 2023; 11:100525. [PMID: 37771658 PMCID: PMC10522900 DOI: 10.1016/j.ejro.2023.100525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/08/2023] [Accepted: 09/20/2023] [Indexed: 09/30/2023] Open
Abstract
Background The spleen is one of the most injured organs following blunt abdominal trauma. The management options can be either operative or non-operative management (NOM) with either conservative management or splenic artery embolization. The implementation of CT in emergency departments allowed the use of CT imaging as a primary screening tool in early decision-making. Consecutively, new splenic injury scoring systems, such as the CT severity index (CTSI) reported was established. Aim The main aim of this study is to evaluate the effect of the implementation of CTSI scoring system on the management decision and outcomes in patients with blunt splenic trauma over 8 years in a level 1 trauma center. Methods This is a retrospective study including all adult patients with primary splenic trauma, having NOM and admitted to our hospital between 2013 and 2021. Results The analyses were conducted on ninety-nine patients. The average sample age was 32.7 ± 12.3 years old. A total of (63/99) patients had splenic parenchyma injury without splenic vascular injury. There is a statistically significant association between CTSI grade 3 injury and the development of delayed splenic vascular injury (p < 0.05). There is an association between severity of initial CTSI score and the risk of NOM/clinical failure (p = 0.02). Conclusion Our findings suggest implementing such a system in a level 1 trauma center will further improve the outcome of treatment for splenic blunt trauma. However, CTSI grade 3 is considered an increased risk of NOM failure, and further investigations are necessary to standardize its management.
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Affiliation(s)
- Ali Barah
- Radiology Department, Hamad Medical Corporation, Doha, Qatar
| | - Ayman Elmagdoub
- Radiology Department, Hamad Medical Corporation, Doha, Qatar
| | - Loai Aker
- Radiology Department, Hamad Medical Corporation, Doha, Qatar
| | | | - Zeyad Jaleel
- Radiology Department, Hamad Medical Corporation, Doha, Qatar
| | - Zahoor Ahmed
- Radiology Department, Hamad Medical Corporation, Doha, Qatar
| | | | | | | | - Ahmed Omar
- Radiology Department, Hamad Medical Corporation, Doha, Qatar
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15
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Dixe de Oliveira Santo I, Sailer A, Solomon N, Borse R, Cavallo J, Teitelbaum J, Chong S, Roberge EA, Revzin MV. Grading Abdominal Trauma: Changes in and Implications of the Revised 2018 AAST-OIS for the Spleen, Liver, and Kidney. Radiographics 2023; 43:e230040. [PMID: 37590162 DOI: 10.1148/rg.230040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
According to the Centers for Disease Control and Prevention, trauma is the leading cause of fatal injuries for Americans aged 1-44 years old and the fourth leading overall cause of death. Accurate and early diagnosis, including grading of solid organ injuries after blunt abdominal trauma (BAT), is crucial to guide management and improve outcomes. The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) is the most widely accepted BAT scoring system at CT both within the United States and internationally, and its uses include stratification of injury severity, thereby guiding management, and facilitation of clinical research, billing, and coding. Furthermore, this system also plays a role in the credentialing process for trauma centers in the United States. The newly revised 2018 OIS provides criteria for grading solid organ damage into three groups: imaging, operation, and pathology. The final grade is based on the highest of the three criteria. If multiple lower-grade (I or II) injuries are present in a single organ, one grade is advanced to grade III. The most substantial change in the revised 2018 AAST-OIS is incorporation of multidetector CT findings of vascular injury, including pseudoaneurysm and arteriovenous fistula. The authors outline the main revised aspects of grading organ injury using the AAST-OIS for the spleen, liver, and kidney after BAT, particularly the role of multidetector CT and alternative imaging in organ injury detection, the importance of vascular injuries in grade change, and the impact of these changes on patient management and in prediction of operative treatment success and in-hospital mortality. ©RSNA, 2023 Supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Quiz questions for this article are available through the Online Learning Center.
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Affiliation(s)
- Irene Dixe de Oliveira Santo
- From the Section of Interventional Radiology (I.D.d.O.S., A.S.), Department of Radiology and Biomedical Imaging (I.D.d.O.S., A.S., N.S., R.B., J.C., J.T., M.V.R.), Yale School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520; Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Ind (S.C.); and Department of Radiology, University of Washington School of Medicine, Seattle, Wash (E.A.R.)
| | - Anne Sailer
- From the Section of Interventional Radiology (I.D.d.O.S., A.S.), Department of Radiology and Biomedical Imaging (I.D.d.O.S., A.S., N.S., R.B., J.C., J.T., M.V.R.), Yale School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520; Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Ind (S.C.); and Department of Radiology, University of Washington School of Medicine, Seattle, Wash (E.A.R.)
| | - Nadia Solomon
- From the Section of Interventional Radiology (I.D.d.O.S., A.S.), Department of Radiology and Biomedical Imaging (I.D.d.O.S., A.S., N.S., R.B., J.C., J.T., M.V.R.), Yale School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520; Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Ind (S.C.); and Department of Radiology, University of Washington School of Medicine, Seattle, Wash (E.A.R.)
| | - Riddhi Borse
- From the Section of Interventional Radiology (I.D.d.O.S., A.S.), Department of Radiology and Biomedical Imaging (I.D.d.O.S., A.S., N.S., R.B., J.C., J.T., M.V.R.), Yale School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520; Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Ind (S.C.); and Department of Radiology, University of Washington School of Medicine, Seattle, Wash (E.A.R.)
| | - Joe Cavallo
- From the Section of Interventional Radiology (I.D.d.O.S., A.S.), Department of Radiology and Biomedical Imaging (I.D.d.O.S., A.S., N.S., R.B., J.C., J.T., M.V.R.), Yale School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520; Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Ind (S.C.); and Department of Radiology, University of Washington School of Medicine, Seattle, Wash (E.A.R.)
| | - Jason Teitelbaum
- From the Section of Interventional Radiology (I.D.d.O.S., A.S.), Department of Radiology and Biomedical Imaging (I.D.d.O.S., A.S., N.S., R.B., J.C., J.T., M.V.R.), Yale School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520; Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Ind (S.C.); and Department of Radiology, University of Washington School of Medicine, Seattle, Wash (E.A.R.)
| | - Suzanne Chong
- From the Section of Interventional Radiology (I.D.d.O.S., A.S.), Department of Radiology and Biomedical Imaging (I.D.d.O.S., A.S., N.S., R.B., J.C., J.T., M.V.R.), Yale School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520; Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Ind (S.C.); and Department of Radiology, University of Washington School of Medicine, Seattle, Wash (E.A.R.)
| | - Eric A Roberge
- From the Section of Interventional Radiology (I.D.d.O.S., A.S.), Department of Radiology and Biomedical Imaging (I.D.d.O.S., A.S., N.S., R.B., J.C., J.T., M.V.R.), Yale School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520; Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Ind (S.C.); and Department of Radiology, University of Washington School of Medicine, Seattle, Wash (E.A.R.)
| | - Margarita V Revzin
- From the Section of Interventional Radiology (I.D.d.O.S., A.S.), Department of Radiology and Biomedical Imaging (I.D.d.O.S., A.S., N.S., R.B., J.C., J.T., M.V.R.), Yale School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520; Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Ind (S.C.); and Department of Radiology, University of Washington School of Medicine, Seattle, Wash (E.A.R.)
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Alqtishat B, Hodali A, Abukeshek T, Al-Shobaki T. Delayed splenic rupture presenting 8 days following blunt abdominal trauma due to a motor vehicle accident. Int J Surg Case Rep 2023; 109:108474. [PMID: 37437328 PMCID: PMC10362288 DOI: 10.1016/j.ijscr.2023.108474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/23/2023] [Accepted: 06/27/2023] [Indexed: 07/14/2023] Open
Abstract
INTRODUCTION Hemodynamic instability in previously stable trauma patients carries rather not a wide differential diagnosis. Delayed Splenic Rupture is certainly not on the top of the list. CASE PRESENTATION We present a patient with delayed splenic rupture eight days after a blunt abdominal trauma caused by a motor vehicle accident. The patient's initial full-body trauma protocol CT scan was negative for internal injuries and rib fractures. He was discharged after 48 h of uneventful observation. Returning eight days with grade III subcapsular splenic hematoma; with negative history of strenuous activities or a second trauma. A trial of non-operative management was opted for after stabilizing the patient. However, the patient's hemodynamic status deteriorated and he was operated on a couple of hours after presentation. DISCUSSION Delayed splenic rupture remains a rare diagnosis with an open time window for presentation. While it is a rare entity, delayed splenic rupture increases the mortality rate in an otherwise non-mortal injury. CONCLUSION This case presents an important educational value in bringing forth such rare diagnoses in trauma patients and highlights the management transition from a non-operative approach to an operative one.
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Affiliation(s)
- Bayan Alqtishat
- Department of General Surgery, Ibn Sina Specialized Hospital, Jenin, Palestine.
| | - Ahmad Hodali
- Department of General Surgery, Ibn Sina Specialized Hospital, Jenin, Palestine
| | - Tawfiq Abukeshek
- Department of Radiology, Al Makassed Islamic Charitable Hospital, Jerusalem, Palestine; Department of Radiology, Ibn Sina Specialized Hospital, Jenin, Palestine
| | - Tawfeeq Al-Shobaki
- Department of General Surgery, Ibn Sina Specialized Hospital, Jenin, Palestine.
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Spittle A, Britcliffe A, Hamilton MJ. Splenic trauma in the Northern Territory; the impact of an interventional radiology service on splenic trauma management and outcomes. Heliyon 2023; 9:e16993. [PMID: 37484245 PMCID: PMC10361010 DOI: 10.1016/j.heliyon.2023.e16993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 05/04/2023] [Accepted: 06/02/2023] [Indexed: 07/25/2023] Open
Abstract
Background The spleen is the most commonly injured organ in abdominal trauma. Guidelines suggest non-operative management (NOM) is preferred over splenectomy for all haemodynamically stable patients, regardless of injury severity. The availability of splenic angioembolization has been shown to improve outcomes for high-grade splenic injuries by decreasing failure rates of NOM. Trauma incidence and fatality rates are higher in regional and remote areas, and rurality is associated with increased mortality from trauma. Additionally, rural hospitals have difficulty with staff retention and may offer less specialist services compared with urban centres. Methods A single-centre retrospective cohort study was conducted at the Royal Darwin Hospital, using the National Critical Care and Trauma Response Centre database. All patients with splenic injury admitted between January 2018 and December 2021 were selected, and divided into control and intervention cohorts, before and after January 1, 2020, correlating with interventional radiology availability. Demographic information included age, gender, mechanism of injury, AIS grade of splenic injury, injury severity score, and shock index. The primary outcome was management of splenic injury and failure rate of NOM. Secondary outcomes included mortality, ICU length of stay and hospital length of stay. Results Sixty-six patients met inclusion criteria, 32 controls and 34 interventions. Intervention and control groups were statistically similar for baseline demographics, and outcome measures of mortality and ICU length of stay. There was significant difference in the management of splenic injury, either OM or NOM, between intervention and control cohorts among high-grade splenic injury patients (AIS grade 4 and 5). In logistic regression analysis, the absence of interventional radiology was associated with increased OM (OR 12.8, SE 15.7, p = 0.04, 95%CI 1.15-142). Conclusion The absence of an interventional radiology service was associated with an increased risk of operative management, suggesting interventional radiology helps to prevent splenectomy, improving long term outcomes for splenic trauma patients in regional settings. The effects of availability of IR seen in international publications on decreased mortality and shorter length of stay were not replicated in this study.
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Affiliation(s)
- Ashleigh Spittle
- Royal Darwin Hospital, 105 Rocklands Drive, Tiwi, NT 0810, Australia
| | - Alex Britcliffe
- Royal Darwin Hospital, 105 Rocklands Drive, Tiwi, NT 0810, Australia
| | - Mark Joh Hamilton
- Royal Darwin Hospital, 105 Rocklands Drive, Tiwi, NT 0810, Australia
- National Critical Care and Trauma Response Centre, PO Box 41326, Casuarina, NT 0811, Australia
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18
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Chen H, Unberath M, Dreizin D. Toward automated interpretable AAST grading for blunt splenic injury. Emerg Radiol 2023; 30:41-50. [PMID: 36371579 DOI: 10.1007/s10140-022-02099-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/04/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND The American Association for the Surgery of Trauma (AAST) splenic organ injury scale (OIS) is the most frequently used CT-based grading system for blunt splenic trauma. However, reported inter-rater agreement is modest, and an algorithm that objectively automates grading based on transparent and verifiable criteria could serve as a high-trust diagnostic aid. PURPOSE To pilot the development of an automated interpretable multi-stage deep learning-based system to predict AAST grade from admission trauma CT. METHODS Our pipeline includes 4 parts: (1) automated splenic localization, (2) Faster R-CNN-based detection of pseudoaneurysms (PSA) and active bleeds (AB), (3) nnU-Net segmentation and quantification of splenic parenchymal disruption (SPD), and (4) a directed graph that infers AAST grades from detection and segmentation results. Training and validation is performed on a dataset of adult patients (age ≥ 18) with voxelwise labeling, consensus AAST grading, and hemorrhage-related outcome data (n = 174). RESULTS AAST classification agreement (weighted κ) between automated and consensus AAST grades was substantial (0.79). High-grade (IV and V) injuries were predicted with accuracy, positive predictive value, and negative predictive value of 92%, 95%, and 89%. The area under the curve for predicting hemorrhage control intervention was comparable between expert consensus and automated AAST grading (0.83 vs 0.88). The mean combined inference time for the pipeline was 96.9 s. CONCLUSIONS The results of our method were rapid and verifiable, with high agreement between automated and expert consensus grades. Diagnosis of high-grade lesions and prediction of hemorrhage control intervention produced accurate results in adult patients.
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Affiliation(s)
- Haomin Chen
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
| | - Mathias Unberath
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
| | - David Dreizin
- Emergency and Trauma Imaging, Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.
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19
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Gopireddy DR, Kee-Sampson JW, Vulasala SSR, Stein R, Kumar S, Virarkar M. Imaging of penetrating vascular trauma of the body and extremities secondary to ballistic and stab wounds. J Clin Imaging Sci 2023; 13:1. [PMID: 36751564 PMCID: PMC9899476 DOI: 10.25259/jcis_99_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/20/2022] [Indexed: 01/04/2023] Open
Abstract
In the United States, gunshot wounds (GSWs) have become a critical public health concern with substantial annual morbidity, disability, and mortality. Vascular injuries associated with GSW may pose a clinical challenge to the physicians in the emergency department. Patients demonstrating hard signs require immediate intervention, whereas patients with soft signs can undergo further diagnostic testing for better injury delineation. Although digital subtraction angiography is the gold standard modality to assess vascular injuries, non-invasive techniques such as Doppler ultrasound, computed tomography angiography, and magnetic resonance angiography have evolved as appropriate alternatives. This article discusses penetrating bodily vascular injuries, specifically ballistic and stab wounds, and the corresponding radiological presentations.
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Affiliation(s)
- Dheeraj Reddy Gopireddy
- Department of Radiology, UF College of Medicine-Jacksonville, Jacksonville, Florida, United States
| | - Joanna W. Kee-Sampson
- Department of Radiology, UF College of Medicine-Jacksonville, Jacksonville, Florida, United States
| | - Sai Swarupa Reddy Vulasala
- Department of Internal Medicine, East Carolina University Health Medical Center, Greenville, North Carolina, United States.,Corresponding author: Sai Swarupa Reddy Vulasala, Department of Internal Medicine, East Carolina University Health Medical Center, Greenville, United States.
| | - Rachel Stein
- Department of Radiology, UF College of Medicine-Jacksonville, Jacksonville, Florida, United States
| | - Sindhu Kumar
- Department of Radiology, UF College of Medicine-Jacksonville, Jacksonville, Florida, United States
| | - Mayur Virarkar
- Department of Radiology, UF College of Medicine-Jacksonville, Jacksonville, Florida, United States
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20
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Dreizin D, Champ K, Dattwyler M, Bodanapally U, Smith EB, Li G, Singh R, Wang Z, Liang Y. Blunt splenic injury in adults: Association between volumetric quantitative CT parameters and intervention. J Trauma Acute Care Surg 2023; 94:125-132. [PMID: 35546417 PMCID: PMC9652480 DOI: 10.1097/ta.0000000000003684] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND. Several ordinal grading systems are employed in deciding whether to perform angioembolization or splenectomy following blunt splenic injury. The 2018 AAST Organ Injury Scale (OIS) incorporates vascular lesions but not hemoperitoneum, which is considered in the Thompson classifier. Granular and verifiable quantitative measurements of these features may have a future role in facilitating objective decision-making. PURPOSE. To compare performance of CT volumetry-based quantitative modeling to the 1994 and 2018 AAST OIS and Thompson classifier for the following endpoints: decision to perform splenectomy (SPY), and the composite of SPY or angioembolization (AE) MATERIALS AND METHODS. Adult BSI patients (age ≥ 18 years) scanned with dual-phase CT prior to intervention at a single level I trauma center from 2017-2019 were included in this retrospective study (n=174). Scoring using 2018 AAST, 1994 AAST, and Thompson systems was performed retrospectively by two radiologists and arbitrated by a third. Endpoints included 1. SPY and 2. The composite of SPY or AE. Logistic regression models were developed from segmented active bleed, contained vascular lesion, splenic parenchymal disruption, and hemoperitoneum volumes. AUCs for ordinal systems and volumetric models were compared. RESULTS. Forty-seven BSI patients (27%) underwent SPY, and 87 patients (50%) underwent SPY or AE. Quantitative model AUCs (0.85- SPY, 0.82-composite) were not significantly different from 2018 AAST AUCs (0.81, 0.88, p=0.66, 0.14) for both endpoints, and were significantly improved over Thompson scoring (0.76, p=0.02; 0.77, p=0.04). CONCLUSION: Quantitative CT volumetry can be used to model intervention for BSI with accuracy comparable to 2018 AAST scoring and significantly higher than Thompson scoring. Study Type: Prognostic Level of Evidence: IV CT volumetry of blunt splenic injury-related features predicts splenectomy and angioembolization in adults and identifies clinically important target features for computer vision and automation research.
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Affiliation(s)
- David Dreizin
- From the Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine (D.D., M.D., U.B., E.B.S., G.L., Z.W., K.C., R.S.); and Department of Epidemiology and Public Health (Y.L.), University of Maryland School of Medicine, Baltimore, Maryland
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21
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Beloy V, Dull M. Blunt chest wall trauma: Rib fractures and associated injuries. JAAPA 2022; 35:25-31. [PMID: 36219110 DOI: 10.1097/01.jaa.0000885136.91189.83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
ABSTRACT Blunt injuries to the chest wall, specifically those related to rib fractures, need to be promptly identified and effectively managed to reduce patient morbidity and mortality. Furthermore, judicious use of multimodal pain management and early identification of patients who will benefit from the surgical stabilization of rib fractures are paramount to optimal outcomes.
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Affiliation(s)
- Victoria Beloy
- Victoria Beloy practices in general and trauma surgery at Intermountain Healthcare Good Samaritan Hospital in Lafayette, Colo. Matthew Dull is an acute care and trauma general surgeon at Spectrum Health Butterworth Hospital in Grand Rapids, Mich. The authors have disclosed no potential conflicts of interest, financial or otherwise
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22
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Borio G, Semeraro G, Manzo E, Maffi PAM, Etteri M. Delayed splenic rupture after a minor blunt trauma: A case report and literature review. EMERGENCY CARE JOURNAL 2022. [DOI: 10.4081/ecj.2022.10822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Delayed Splenic Rupture (DSR) is a rare but well-known manifestation of Blunt Splenic Injury (BSI), which most commonly occurs following a car accident, a fall from a great height, or a direct blow to the left thorax or abdomen. If the history of trauma is remote or unknown, the diagnosis can be difficult or missed, and a high index of suspicion is not warranted. Regardless of the time and mechanism of the inciting event, DSR should be considered in the differential diagnosis of an acute surgical abdomen. We present a case of DSR in an 81-year-old woman caused by a remote minor blunt abdominal trauma four weeks prior to her admission to our emergency department for acute abdominal pain and hemorrhagic shock (ATLS CLASS III). Starting with this case report, we conducted a literature review on the subject in order to raise awareness, knowledge, and understanding of DSR among emergency clinicians.
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23
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Carlin M, Elkbuli A, Maka P, McKenney M, Boneva D. A rare case of delayed splenic rupture following initial negative CT scan imaging: A case report and review of the literature. Int J Surg Case Rep 2022; 98:107517. [PMID: 36030762 PMCID: PMC9434024 DOI: 10.1016/j.ijscr.2022.107517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/11/2022] [Accepted: 08/11/2022] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Delayed splenic rupture is an often unpredictable event with high mortality. In this report, we discuss the successful management of delayed splenic rupture, presenting days after index injury, with no commonly associated injuries or blunt abdominal trauma. CASE PRESENTATION A 50 year old male, not on anticoagulants, presented with blunt trauma after driving his motorcycle into a tree. The patient sustained right 3-5 rib fractures, displaced right midclavicular fracture, 25 % right pneumothorax, T5-9 posterior spinous process fractures, left 2nd-5th metatarsal fractures, and scattered abrasions to the left foot, knee and hand. Focused abdominal sonography for trauma (FAST) and admission abdominal multi-detector CT were negative for any intra-abdominal injuries. On hospital day 5, the patient acutely decompensated. FAST was grossly positive and emergent laparotomy revealed a splenic rupture. After a splenectomy, he recovered. DISCUSSION The spleen is the most commonly injured organ in blunt abdominal trauma. Although acute injury often presents with imaging findings or sequelae of hemorrhagic shock, complications of splenic trauma have the potential to result in delayed catastrophe. Bedside ultrasonography is a useful tool to assess acute decompensation in trauma patients along with CT imaging. Prompt identification and hemorrhage control are crucial to survival after trauma. CONCLUSION Repeat CT scans are also important for the identification of delayed splenic rupture and timely intervention. Delayed hemorrhage after blunt trauma should never be ruled out regardless of the injury complexity or length of hospital admission.
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Affiliation(s)
- Margo Carlin
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA; Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
| | - Piueti Maka
- John A. Burns School of Medicine, Honolulu, HI, USA
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA; University of South Florida, Tampa, FL, USA
| | - Dessy Boneva
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA; University of South Florida, Tampa, FL, USA.
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24
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Predictive factors of non-operative management failure in 494 blunt liver injuries: a multicenter retrospective study. Updates Surg 2022; 74:1901-1913. [DOI: 10.1007/s13304-022-01367-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 08/21/2022] [Indexed: 10/15/2022]
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25
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Liver Trauma: Management in the Emergency Setting and Medico-Legal Implications. Diagnostics (Basel) 2022; 12:diagnostics12061456. [PMID: 35741266 PMCID: PMC9221646 DOI: 10.3390/diagnostics12061456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/09/2022] [Accepted: 06/11/2022] [Indexed: 11/17/2022] Open
Abstract
Traumatic abdominal injuries are life-threatening emergencies frequently seen in the Emergency Department (ED). The most common is liver trauma, which accounts for approximately 5% of all ED admissions for trauma. The management of blunt liver trauma has evolved significantly over the past few decades and, according to the injury’s severity, it may require massive resuscitation, radiological procedures, endoscopy, or surgery. Patients admitted to the ED with blunt abdominal trauma require a multidisciplinary evaluation, including emergency physicians, surgeons, radiologists, and anesthetists, who must promptly identify the extent of the injury to prevent serious complications. In case of a patient’s death, the execution of a forensic examination carried out with a multidisciplinary approach (radiological, macroscopic, and histological) is essential to understand the cause of death and to correlate the extent of the injuries to the possibility of survival to be able to manage any medico-legal disputes. This manuscript aims to collect the most up-to-date evidence regarding the management of hepatic trauma in the emergency room and to explore radiological findings and medico-legal implications.
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26
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Doklestić K, Lončar Z, Coccolini F, Gregorić P, Mićić D, Bukumiric Z, Djurkovic P, Sengul D, Sengul I. “Zooming” in strategies and outcomes for trauma cases with Injury Severity Score (ISS) ≥16: promise or passé? REVISTA DA ASSOCIAÇÃO MÉDICA BRASILEIRA 2022; 68:847-852. [PMID: 35584438 PMCID: PMC9575904 DOI: 10.1590/1806-9282.20220216] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE: Rescuing severe trauma cases is extremely demanding. The present study
purposed to analyze the efficiency of trauma management at Emergency Centre,
University Clinical Centre of Serbia, Belgrade, included outcome within 28
days. METHODS: This retrospective study involved 131 intensive care unit trauma cases with
total Injury Severity Score ≥16, in terms of administrating the two
strategies: (i) definitive surgical repair and (ii) damage control
laparotomy. RESULTS: The damage control laparotomy cases revealed statistically higher Injury
Severity Score and APACHE II scores, significant brain dysfunction, and
hemorrhagic shock on arrival (p<0.001). In addition, the damage control
laparotomy had a higher rate of respiratory complications, multiple organ
deficiency syndrome, and surgical wound complications (p=0.017, <0.001,
and 0.004, respectively), with more days on mechanical ventilation
(p=0.003). Overall mortality was 29.8%. Although higher early mortality
within ≤24 h in the damage control laparotomy (p=0.021) had been observed,
no difference between groups (p=0.172) after the 4th day of hospitalization
was detected. CONCLUSIONS: Trauma patients have a high mortality rate in the 1st hours after the
incident. Compelling evidence linking host and pathogen factors, such as
mitochondrial apoptosis pathways, appears to correlate with loss of organ
dysfunction, both cytopathologically and histopathologically. Adequate
selection of patients necessitating damage control laparotomy, allowed by
the World Society of Emergency Surgery, abdominopelvic trauma
classifications, and improvements in resuscitation, may improve the results
of severe trauma treatment.
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Affiliation(s)
- Krstina Doklestić
- University of Belgrade, Serbia; University Clinical Centre of Serbia, Serbia
| | - Zlatibor Lončar
- University of Belgrade, Serbia; University Clinical Centre of Serbia, Serbia
| | | | - Pavle Gregorić
- University of Belgrade, Serbia; University Clinical Centre of Serbia, Serbia
| | - Dusan Mićić
- University of Belgrade, Serbia; University Clinical Centre of Serbia, Serbia
| | - Zoran Bukumiric
- University of Belgrade, Serbia; University of Belgrade, Serbia
| | | | | | - Ilker Sengul
- Giresun University, Turkey; Giresun University, Turkey
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27
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Melamed MT, Gigliotti JL. Atraumatic spontaneous splenic rupture in a female COVID-19 patient. J Osteopath Med 2022; 122:481-485. [PMID: 35510650 DOI: 10.1515/jom-2021-0291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 04/12/2022] [Indexed: 01/08/2023]
Abstract
Coronavirus disease (COVID-19), an infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has severely ravaged the world since the end of 2019. Although most cases range from mild to severe with primarily respiratory symptoms, there have been some unusual clinical presentations, one of which is described in this case report. A 30 year-old woman with no significant medical history presented to the emergency department (ED) in October 2020 with sudden onset of severe left upper and lower abdominal pain. Her initial triaged blood pressure was 70 mmHg systolic, associated with mild tachycardia. Her beta human chorionic gonadotropin (beta-hCG) was negative, and her initial hemoglobin was 9.3 g/dL. A bedside ultrasound (US) was immediately performed, which showed moderate free fluid in the pelvis as well as in the right and left upper quadrants of the abdomen. She was stabilized with a fluid bolus and later underwent a CT scan of the abdomen and pelvis, which showed an apparent grade III splenic laceration without active extravasation. The patient underwent a successful embolization procedure by interventional radiology (IR) and was discharged from the hospital 2 days later. The initial medical workup included a positive polymerase chain reaction (PCR) COVID-19 test but included no other findings that could serve as a cause for her spleen to spontaneously rupture. The purpose of this case report is to illustrate and make other clinicians aware of unusual potential complications and clinical presentations of COVID-19. The condition of spontaneous splenic rupture (SSR) is an uncommon but an emergent differential diagnosis in an otherwise healthy person with potential drastic outcomes. A careful approach in the management and care of these patients is warranted. This is one of a handful of case reports on SSR secondary to COVID-19 to the best of our knowledge.
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Affiliation(s)
- Michele T Melamed
- Department of Emergency Medicine, Northside Hospital Gwinnett, Lawrenceville, GA, USA
| | - Jake L Gigliotti
- Medical College of Georgia, Augusta University, Augusta, GA, USA
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28
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Slater SJ, Lukies M, Kavnoudias H, Zia A, Lee R, Bosco JJ, Joseph T, Clements W. Immune function and the role of vaccination after splenic artery embolization for blunt splenic injury. Injury 2022; 53:112-115. [PMID: 34565618 DOI: 10.1016/j.injury.2021.09.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 09/08/2021] [Accepted: 09/12/2021] [Indexed: 02/02/2023]
Abstract
The spleen is the most commonly injured solid organ following blunt abdominal trauma. Over recent decades, splenic artery embolization (SAE) has become the mainstay treatment for haemodynamically stable patients with high-grade blunt splenic trauma, with splenectomy the mainstay of treatment for unstable patients. Splenic function is complex but the spleen has an important role in immune function, particularly in protection against encapsulated bacteria. Established evidence suggests that following splenectomy immune function is impaired resulting in increased susceptibility to overwhelming post-splenectomy infection, however, immune function may be preserved following SAE. This review will discuss the current state of the literature on immune function following different treatments of blunt splenic injury, and the controversies surrounding what constitutes a quantitative test of splenic immune function.
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Affiliation(s)
- Samuel J Slater
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Matthew Lukies
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Helen Kavnoudias
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, Monash University Central Clinical School, Australia
| | - Adil Zia
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Robin Lee
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Julian J Bosco
- Department of Respiratory medicine, Allergy, asthma and Clinical Immunology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Tim Joseph
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, Monash University Central Clinical School, Australia; National Trauma Research Institute, Monash University Central Clinical School, Melbourne, Australia.
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29
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Absence of Stress Hyperglycemia Indicates the Most Severe Form of Blunt Liver Trauma. Diagnostics (Basel) 2021; 11:diagnostics11091667. [PMID: 34574008 PMCID: PMC8470453 DOI: 10.3390/diagnostics11091667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/24/2021] [Accepted: 09/08/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Stress hyperglycemia is common in trauma patients. Increasing injury severity and hemorrhage trigger hepatic gluconeogenesis, glycogenolysis, peripheral and hepatic insulin resistance. Consequently, we expect glucose levels to rise with injury severity in liver, kidney and spleen injuries. In contrast, we hypothesized that in the most severe form of blunt liver injury, stress hyperglycemia may be absent despite critical injury and hemorrhage. Methods: All patients with documented liver, kidney or spleen injuries, treated at a university hospital between 2000 and 2020 were charted. Demographic, laboratory, radiological, surgical and other data were analyzed. Results: A total of 772 patients were included. In liver (n = 456), spleen (n = 375) and kidney (n = 152) trauma, an increase in injury severity past moderate to severe (according to the American Association for the Surgery of Trauma, AAST III-IV) was associated with a concomitant rise in blood glucose levels independent of the affected organ. While stress-induced hyperglycemia was even more pronounced in the most severe forms (AAST V) of spleen (median 10.7 mmol/L, p < 0.0001) and kidney injuries (median 10.6 mmol/L, p = 0.004), it was absent in AAST V liver injuries, where median blood glucose level even fell (5.6 mmol/L, p < 0.0001). Conclusions: Absence of stress hyperglycemia on hospital admission could be a sign of most severe liver injury (AAST V). Blood glucose should be considered an additional diagnostic criterion for grading liver injury.
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30
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Wong YC, Wang LJ, Wu CH, Chen HW, Yuan KC, Hsu YP, Lin BC, Kang SC. Differences of liver CT perfusion of blunt trauma treated with therapeutic embolization and observation management. Sci Rep 2020; 10:19612. [PMID: 33184342 PMCID: PMC7661500 DOI: 10.1038/s41598-020-76618-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 10/23/2020] [Indexed: 11/09/2022] Open
Abstract
Massive hepatic necrosis after therapeutic embolization has been reported. We employed a 320-detector CT scanner to compare liver perfusion differences between blunt liver trauma patients treated with embolization and observation. This prospective study with informed consent was approved by institution review board. From January 2013 to December 2016, we enrolled 16 major liver trauma patients (6 women, 10 men; mean age 34.9 ± 12.8 years) who fulfilled inclusion criteria. Liver CT perfusion parameters were calculated by a two-input maximum slope model. Of 16 patients, 9 received embolization and 7 received observation. Among 9 patients of embolization group, their arterial perfusion (78.1 ± 69.3 versus 163.1 ± 134.3 mL/min/100 mL, p = 0.011) and portal venous perfusion (74.4 ± 53.0 versus 160.9 ± 140.8 mL/min/100 mL, p = 0.008) were significantly lower at traumatic parenchyma than at non-traumatic parenchyma. Among 7 patients of observation group, only portal venous perfusion was significantly lower at traumatic parenchyma than non-traumatic parenchyma (132.1 ± 127.1 vs. 231.1 ± 174.4 mL/min/100 mL, p = 0.018). The perfusion index between groups did not differ. None had massive hepatic necrosis. They were not different in age, injury severity score and injury grades. Therefore, reduction of both arterial and portal venous perfusion can occur when therapeutic embolization was performed in preexisting major liver trauma, but hepatic perfusion index may not be compromised.
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Affiliation(s)
- Yon-Cheong Wong
- Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5 Fu-Hsin Street, Gueishan, Taoyuan, 333, Taiwan.
| | - Li-Jen Wang
- Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5 Fu-Hsin Street, Gueishan, Taoyuan, 333, Taiwan
| | - Cheng-Hsien Wu
- Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5 Fu-Hsin Street, Gueishan, Taoyuan, 333, Taiwan
| | - Huan-Wu Chen
- Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5 Fu-Hsin Street, Gueishan, Taoyuan, 333, Taiwan
| | - Kuo-Ching Yuan
- Division of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Pao Hsu
- Division of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Being-Chuan Lin
- Division of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Ching Kang
- Division of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
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