Non-operative management of blunt splenic trauma: a 10-year experience

Hemodilution in pediatric trauma: Defining the expected hemoglobin changes in patients with liver and/or spleen injury: An ATOMAC+ secondary analysis

BACKGROUND

Many children with blunt liver and/or spleen injury (BLSI) never bleed intraperitoneally. Despite this, decreases in hemoglobin are common. This study examines initial and follow up measured hemoglobin values for children with BLSI with and without evidence of intra-abdominal bleeding.

METHODS

Children ≤18 years of age with BLSI between April 2013 and January 2016 were identified from the prospective ATOMAC+ cohort. Initial and follow up hemoglobin levels were analyzed for 4 groups with BLSI: (1) Non bleeding; (2) Bleeding, non transfused (3) Bleeding, transfused, and (4) Bleeding resulting in non operative management (NOM) failure.

RESULTS

Of 1007 patients enrolled, 767 were included in one or more of four study cohorts. Of 131 non bleeding patients, the mean decrease in hemoglobin was 0.83 g/dL (+/-1.35) after a median of 6.3 [5.1,7.0] hours, (p = 0.001). Follow-up hemoglobin levels in patients with and without successful NOM were not different. For patients with an initial hemoglobin >9.25 g/dL, the odds ratio (OR) for NOM failure was 14.2 times less, while the OR for transfusion was 11.4 times less (p = 0.001).

CONCLUSION

Decreases in hemoglobin are expected after trauma, even if not bleeding. A hemoglobin decrease of 2.15 g/dL [0.8 + 1.35] would still be within one standard deviation of a non bleeding patient. An initial low hemoglobin correlates with failure of NOM as well as transfusion, thereby providing useful information. By contrast, subsequent hemoglobin levels do not appear to guide the need for transfusion, nor correlate with failure of NOM. These results support initial hemoglobin measurement but suggest a lack of utility for routine rechecking of hemoglobin.

LEVEL OF EVIDENCE

Level II Prognostic Study.

The Utility of Serial Hemoglobin Monitoring in Non-Operative Management of Blunt Splenic Injury

BACKGROUND

The Eastern Association for the Surgery of Trauma (EAST) states there is not enough evidence to recommend a particular frequency of measuring Hgb values for non-operative management (NOM) of blunt splenic injury (BSI). This study was performed to compare the utility of serial Hgb (SHgb) to daily Hgb (DHgb) in this population.

METHODS

We conducted a retrospective chart review of patients with BSI between 2013 and 2019. Demographics, comorbidities, lab values, clinical decisions, and outcomes were gathered through a trauma database.

RESULTS

A total of 562 patients arrive in the trauma bay with BSI. In the NOM group, 297 were successful and 37 failed NOM. Of those that failed NOM, 8 (21.6%) changed to OM due to a drop in Hgb. 5 (62.5%) were hypotensive first, 2 (25%) were no longer receiving SHgb, and 1 (12.5%) had a repeat CT scan and was embolized. DHgb patients were not significantly different from SHgb patients in injury severity, length of stay, the largest drop in Hgb, and incidence of failing NOM. Patients taking aspirin were more likely to fall below 7 g/dl at 48 and 72 hours into admission.

CONCLUSIONS

These results suggest that that trending SHgb may not influence clinical decision-making in NOM of BSI. Besides taking aspirin, risk factors for who would benefit from SHgb were not identified. Patients who received DHgb had similar injuries and outcomes than patients who received SHgb. Prospective studies are needed to evaluate the clinical utility of SHgb compared to DHgb.

Anticoagulation is Associated with Increased Mortality in Splenic Injuries

INTRODUCTION

Anticoagulation (AC) is associated with worse outcomes after trauma in some but not all studies. To further investigate the effect of AC on outcomes in patients with splenic injury, we analyzed the Trauma Quality Programs Participant Use File (PUF) METHODS: The 2017 PUF was used to identify adult (18+ y) with all mechanisms and grades of splenic injury. Demographics, comorbidities, hospital course and outcomes were compared between AC and non-AC patients.

RESULTS

A total of 18,749 patients were included, 622 were on AC. The AC patients were older but had comparable gender composition to non-AC patients. Injury Severity Score (18.2 versus 22.5) and rates of serious (AIS ≥ 3) injury were all lower in the AC group (P = 0.001). AC patients received fewer units of RBC (5.7 versus 8.0 units, P < 0.001) and FFP (3.9 versus 5.4 units, P < 0.001) in the first 24 h but underwent angiography at similar rates (23.6 versus 24.5%, P = 0.8). Among those who underwent angiography, patients were more likely to undergo embolization if they were on AC (89.7 versus 73.9%, P = 0.04). Rates of splenic surgery were comparable (19.3 versus 21.5%, P = 0.2) between AC versus non-AC patients. Median LOS was longer in AC patients (6.3 versus 5.6 d, P = 0.002). AC patients had a higher mortality (13.3 versus 7.0%, P = 0.001). In a multivariable binary logistic regression, AC was an independent risk factor for mortality with OR 1.4 (95% CI: 1.1-1.9) CONCLUSIONS: Anticoagulation is associated with increased mortality in patients with splenic injury.

The effect of anticoagulation on outcomes after liver and spleen injuries: A research consortium of New England centers for trauma (ReCONECT) study

BACKGROUND

Liver and spleen injuries are the most commonly injured solid organs, the effects of anticoagulation on these injuries has not yet been well characterized.

STUDY DESIGN

Multicenter retrospective study.

RESULT

During the 4-year study period, 1254 patients, 64 (5%) on anticoagulation (AC), were admitted with liver and/or splenic injury. 58% of patients had a splenic injury, 53% had a liver injury and 11% had both. Patients on AC were older than non-AC patients (mean age 60.9 vs. 38.6 years, p < 0.001). The most common AC drug was warfarin (70%) with atrial fibrillation (47%) the most common indication for AC. There was no significant difference in AAST injury grade between AC and non-AC patients (median grade 2), but AC patients required a blood product transfusion more commonly (58 vs 40%, p = 0.007) particularly FFP (4 vs 19%, p < 0.01). Among those transfused, non-AC patients required slightly more PRBC (5.7 vs 3.8 units, p = 0.018) but similar amount of FFP (3.2 vs 3.1 units, p = 0.92). The two groups had no significant difference in the rates of initial non-operative management (50% (AC) vs 56% (non-AC), p = 0.3)) or failure of non-operative management (7 vs 4%, p = 0.16). AC patients were more likely to be managed initially with angiography (36 vs 20%, p = 0.001) while non-AC patients with surgery (24% vs 13%, p = 0.04). There was no significant difference in LOS and mortality.

CONCLUSION

The use of anticoagulation did not result in a difference in outcomes among patients with spleen and/or liver injuries.

Nonoperative management of splenic injury in closely monitored patients with reduced consciousness is safe and feasible

BACKGROUND

Treatment of blunt splenic injury has changed over the past decades. Nonoperative management (NOM) is the treatment of choice. Adequate patient selection is a prerequisite for successful NOM. Impaired mental status is considered as a relative contra indication for NOM. However, the impact of altered consciousness in well-equipped trauma institutes is unclear. We hypothesized that impaired mental status does not affect outcome in patients with splenic trauma.

METHODS

Our prospectively composed trauma database was used and adult patients with blunt splenic injury were included during a 14-year time period. Treatment guidelines remained unaltered over time. Patients were grouped based on the presence (Group GCS: < 14) or absence (Group GCS: 14-15) of impaired mental status. Outcome was compared.

RESULTS

A total of 161 patients were included, of whom 82 were selected for NOM. 36% of patients had a GCS-score < 14 (N = 20). The median GCS-score in patients with reduced consciousness was 9 (range 6-12). Groups were comparable except for significantly higher injury severity scores in the impaired mental status group (19 vs. 17, p = 0.007). Length of stay (28 vs. 9 days, p < 0.001) and ICU-stay (8 vs. 0 days, p = 0.005) were longer in patients with decreased GCS-scores. Failure of NOM, total splenectomy rates, complications and mortality did not differ between both study groups.

CONCLUSION

This study shows that NOM for blunt splenic trauma is a viable treatment modality in well-equipped institutions, regardless of the patients mental status. However, the presence of neurologic impairment is associated with prolonged ICU-stay and hospitalization. We recommend, in institutions with adequate monitoring facilities, to attempt nonoperative management for blunt splenic injury, in all hemodynamically stable patients without hollow organ injuries, also in the case of reduced consciousness.

Blunt Splenic Trauma

The treatment of blunt splenic injury has evolved over time from splenectomy in all patients to nonoperative management in stable patients with operation reserved for failures of NOM. While rates of OPSI remain low in trauma patients, splenic salvage in stable patients should be attempted. However, clinical evidence of ongoing blood loss or instability should be addressed with prompt splenectomy. Careful patient selection is of paramount importance in nonoperative management of blunt splenic injury.

Blunt splenic injury and severe brain injury: a decision analysis and implications for care

BACKGROUND

The initial nonoperative management (NOM) of blunt splenic injuries in hemodynamically stable patients is common. In soldiers who experience blunt splenic injuries with concomitant severe brain injury while on deployment, however, NOM may put the injured soldier at risk for secondary brain injury from prolonged hypotension.

METHODS

We conducted a decision analysis using a Markov process to evaluate 2 strategies for managing hemodynamically stable patients with blunt splenic injuries and severe brain injury--immediate splenectomy and NOM--in the setting of a field hospital with surgical capability but no angiography capabilities. We considered the base case of a 40-year-old man with a life expectancy of 78 years who experienced blunt trauma resulting in a severe traumatic brain injury and an isolated splenic injury with an estimated failure rate of NOM of 19.6%. The primary outcome measured was life expectancy. We assumed that failure of NOM would occur in the setting of a prolonged casualty evacuation, where surgical capability was not present.

RESULTS

Immediate splenectomy was the slightly more effective strategy, resulting in a very modest increase in overall survival compared with NOM. Immediate splenectomy yielded a survival benefit of only 0.4 years over NOM.

CONCLUSION

In terms of overall survival, we would not recommend splenectomy unless the estimated failure rate of NOM exceeded 20%, which corresponds to an American Association for the Surgery of Trauma grade III splenic injury. For military patients for whom angiography may not be available at the field hospital and who require prolonged evacuation, immediate splenectomy should be considered for grade III-V injuries in the presence of severe brain injury.

Controversies in the management of splenic trauma

BACKGROUND

The technologic innovations of the last three decades, coupled with a deeper understanding of the immunologic role of the spleen, have significantly shifted the management of splenic injuries towards non-operative approaches. However, there continuous to be a wide range of practice patterns related to the non-operative management of splenic injuries, from which the authors infer a gap between the best available evidence and its translation into practice. We sought to explore ongoing areas of controversy in the non-operative management of splenic trauma with the aim of further elucidating why these controversies continue to exist.

METHODS

We explored areas of ongoing controversy in the management of splenic injury though a series of iterative surveys. We invited 70 experts in trauma care from ten countries around the world to participate. Areas of controversy explored included: indications and frequency for in-hospital and follow-up imaging, definitions of failure of non-operative management, indications for angioembolisation and non-operative management in special populations (i.e. elderly, concomitant traumatic brain injury, penetrating trauma).

RESULTS

A 49% response rate was obtained. Even though a wide range of practice patterns were identified, no controversies were identified in areas that do not involve the adoption of new technologies. In areas where practice pattern variation was observed, the strong influence of the local environment was constantly identified as an impediment to changes in practice.

CONCLUSIONS

We have identified that barriers present within local practice environments are the major driving forces behind controversies in the non-operative management of splenic injuries.

Post traumatic splenic function depending on severity of injury and management

Because splenectomy has been linked to overwhelming infection years ago, management of splenic traumatisms has become progressively conservative. To assess the immunological function of the spleen in patients with splenic traumatism of different intensity, 43 patients with splenic injury (grades I through V) undergoing either nonoperative management, splenectomy, splenectomy with autotransplantation, or splenic embolization were analyzed for lymphocyte subpopulations and antibody responses to Streptococcus pneumoniae and Haemophilus influenzae vaccinations. Patients treated with splenectomy exhibited a significant decrease in CD4+ T lymphocytes and in Immunoglobulin (Ig) M(high)IgD(low) B cells (related to T-cell independent responses). Median fluorescence intensity of CD54+ in B cells also was reduced. The percent of IgM(high)IgD(low) B cells-a marker of marginal zone function-was inversely correlated with the number of pitted-red blood cells-a marker of red pulp function loss. IgM anti-S pneumoniae identified those patients with a defective rapid response to polysaccharide antigens. These results reinforce the importance of conservative options in the treatment of splenic traumatism for even a severely damaged organ. Despite the significant differences among the groups reported, it remains difficult to predict the IgM response to S pneumoniae vaccine of the individual patients. Better markers to assess splenic function and vaccination response after severe splenic traumatism-even in patients with nonoperative management-might improve risk assessment for overwhelming postsplenectomy infection.

Doppler ultrasound for the assessment of conservatively treated blunt splenic injuries: a prospective study

INTRODUCTION

The type and need for follow-up of non-operatively managed blunt splenic injuries remain controversial. The use of Doppler ultrasound to identify post-traumatic splenic pseudoaneurysms, considered to be the main cause of "delayed" splenic rupture, has not been well described.

PATIENTS AND METHODS

A 5-year prospective study was performed from 2004 to 2008. All patients with blunt splenic injury diagnosed with computerized tomography, who were treated non-operatively, were included in the study. Doppler ultrasound examination was performed 24-48 h post-injury. Consecutive Doppler ultrasound examinations were done on 7, 14 and 21 days post-injury for patients diagnosed with a splenic pseudoaneurysm. Demographic and clinical data were collected. Ambulatory follow-up continued for 4 weeks after hospital discharge.

RESULTS

A total of 38 patients were enrolled in the study. Grading of splenic injury demonstrated 19 (50%) patients with Grade I, 16 (42%) with Grade II and 3 (8%) with Grade III injuries. Two patients (5%) had pseudoaneurysms. All pseudoaneurysms underwent complete resolution within 2 weeks after diagnosis. No patients received blood products, or had angio-embolization or surgery during the study period. All patients were found to be asymptomatic and stable at the 4-week follow-up.

CONCLUSIONS

Doppler ultrasound can be an effective and a safe noninvasive modality for evaluation and follow-up of patients with blunt splenic injury. The utility and cost-effectiveness of routine surveillance requires further study.

Abdominal trauma: from operative to nonoperative management

The nonoperative care of intraabdominal trauma in the polytraumatised patient greatly depends on imaging techniques. The haemodynamically unstable patient should undergo expedient sonography to rule out abdominal haemorrhage. The use of computer tomography (CT) in this difficult patient group is also currently evaluated, however it takes specific amendments to the protocol and institution. In the hemodynamically stable patient however, computer tomography is the modality of choice to evaluate the injured abdomen. Nonoperative treatment can be successful in up to 80% of selected cases. Adjuncts to nonoperative care include embolisation of the spleen and liver in cases of arterial bleeding, and endoscopic retrograde cholangio pancreaticography (ERCP) and stenting for injuries to the biliary tree.

Blunt splenic injuries: have we watched long enough?

BACKGROUND

Nonoperative management (NOM) of blunt splenic injuries (BSIs) has been used with increasing frequency in adult patients. There are currently no definitive guidelines established for how long BSI patients should be monitored for failure of NOM after injury.

METHODS

This study was performed to ascertain the length of inpatient observation needed to capture most failures, and to identify factors associated with failure of NOM. We utilized the National Trauma Data Bank to determine time to failure after BSI.

RESULTS

During the 5-year study period, 23,532 patients were identified with BSI, of which 2,366 (10% overall) were taken directly to surgery (within 2 hours of arrival). Of 21,166 patients initially managed nonoperatively, 18,506 were successful (79% of all-comers). Patients with isolated BSI are currently monitored approximately 5 days as inpatients. Of patients failing NOM, 95% failed during the first 72 hours, and monitoring 2 additional days saw only 1.5% more failures. Factors influencing success of NOM included computed tomographic injury grade, severity of patient injury, and American College of Surgeons designation of trauma center. Importantly, patients who failed NOM did not seem to have detrimental outcomes when compared with patients with successful NOM. No statistically significant predictive variables could be identified that would help predict patients who would go on to fail NOM.

CONCLUSIONS

We conclude that at least 80% of BSI can be managed successfully with NOM, and that patients should be monitored as inpatients for failure after BSI for 3 to 5 days.

Trauma surgeons practice what they preach: The NTDB story on solid organ injury management

BACKGROUND

Recent studies advocate a nonoperative approach for hepatic and splenic trauma. The purpose of this study was to determine whether the literature has impacted surgical practice and, if so, whether or not the overall mortality of these injuries had changed.

METHODS

The American College of Surgeons' National Trauma Data Bank (NTDB 4.0) was analyzed using trauma admission dates ranging from 1994 to 2003. All hepatic and splenic injuries were identified by ICD-9 codes. As renal trauma management has not changed during the study period, renal injuries were included as a control. Nonoperative management (NOM) rates and overall mortality were determined for each organ. Proportions were compared using chi analysis with significance set at p < 0.05.

RESULTS

There were 87,237 solid abdominal organ injuries reported and included: 35,767 splenic, 35,510 hepatic, 15,960 renal injuries. There was a significant (p < 0.00000000005) increase in percentage of NOM for hepatic and splenic trauma whereas renal NOM remained stable for the study period. Despite an increase in NOM for splenic and hepatic injuries, mortality has remained unchanged.

CONCLUSIONS

This study demonstrates that the management of hepatic and splenic injuries has significantly changed in the past 10 years with no appreciable effect on mortality. NOM has become the standard of care for the management of hepatic and splenic trauma. The NTDB can be used to monitor changes in trauma care in response to new knowledge regarding improved outcomes.

Nonoperative management of traumatic splenic injuries: is there a role for proximal splenic artery embolization?

OBJECTIVE

The objective of our study was to evaluate our experience with transcatheter proximal (i.e., main) splenic artery embolization (TPSAE) in the nonsurgical management of patients with grade III-V splenic injuries, according to the American Association for the Surgery of Trauma (AAST) guidelines, and patients with splenic injuries associated with CT evidence of active contrast extravasation or blush (or cases meeting both criteria).

MATERIALS AND METHODS

The records of patients with traumatic splenic injuries admitted during a 52-month period were retrospectively reviewed for patient age and sex, mechanism of injury, injury severity score (ISS), RBC transfusion requirements, AAST splenic injury CT grade, presence of active contrast extravasation or blush on CT examination, and amount of hemoperitoneum on CT examination. Demographics, CT findings, transfusion requirements, and outcome were compared using the Student's t test or chi-square test in patients undergoing standard nonoperative management and nonoperative management TPSAE-that is, TPSAE followed by nonoperative management.

RESULTS

Of the 79 identified patients with splenic trauma, 67 were managed nonoperatively. Thirty-seven patients (28 men, nine women; mean age, 40 years; mean ISS, 28.8) underwent nonoperative management TPSAE and 30 patients (27 men, three women; mean age, 37 years; mean ISS, 25.1) underwent nonoperative management. Age, sex, and ISS were not significantly different between the two groups. TPSAE was always technically feasible. Splenic injuries were significantly more severe in the nonoperative management TPSAE group than in the nonoperative management group with respect to the mean splenic injury AAST CT grade (3.7 vs 2, respectively; p < 0.0001), active contrast extravasation or blush (38% [14/37] vs 3% [1/30], respectively; p = 0.0005), and hemoperitoneum grade (1.6 vs 0.8, respectively; p = 0.0006). Secondary splenectomy rate was lower in the nonoperative management TPSAE group (2.7% [1/37] vs 10% [3/30]). No procedure-related complications were encountered during early and delayed clinical follow-up.

CONCLUSION

TPSAE is a feasible and safe adjunct to observation in the nonoperative management of severe traumatic splenic injuries. The secondary splenectomy rate using nonoperative management TPSAE (2.7%) is among the lowest reported despite a selection of severe injuries.

Failure of Observation of Blunt Splenic Injury in Adults: Variability in Practice and Adverse Consequences

BACKGROUND

The Eastern Association for the Surgery of Trauma Multiinstitutional Workgroup reported a failure rate for nonoperative management of blunt splenic injury in adults of 10.8%. Sixty percent of the failures occurred within 24 hours of admission. The purpose of this multiinstitutional study by the Eastern Association for the Surgery of Trauma was to determine common variables in failure of nonoperative management of blunt splenic injury in adults.

STUDY DESIGN

Medical records were reviewed in a blinded fashion on 78 patients in whom nonoperative management failed. Statistical analysis was performed with ANOVA, extended chi-square, and Fisher's exact test; statistical significance was p<0.05.

RESULTS

The 78 patients were categorized based on hemodynamic status. Forty-four percent were stable; 31% had transient hypotension or tachycardia that resolved with fluid infusion (responders); and 25% were unstable. Two-thirds of the unstable patients required laparotomy within 12 hours of admission; all had laparotomy within 72 hours. Mortality was significantly different when comparing the unstable to the stable and responder groups: stable (3%), responders (8%), and unstable (37%), despite similar age and only modest differences in Injury Severity Score. Eight CT scans were misinterpreted initially. Of 26 Focused Abdominal Sonography for Trauma (FAST) studies, 11 (42.3%) were false negative. Abnormal abdominal findings were noted in 67.7% of patients on admission. Ten patients died (12.8%). Sixty percent of the deaths were caused largely by delayed treatment of splenic or other abdominal injuries; one patient died in the responder group and five unstable patients died.

CONCLUSIONS

Thirty percent to 40% of the patients who had unsuccessful nonoperative management in this study were selected inappropriately, with hemodynamic instability or initial misinterpretation of diagnostic studies. As a consequence, the majority of the deaths were from delayed treatment of intraabdominal injuries. This article suggests that written protocols, better adherence to sound clinical judgment, and experienced and timely interpretation of radiologic studies would reduce the incidence of failure of nonoperative management of blunt splenic injury in adults.

Assessment of Nonoperative Management of Blunt Spleen and Liver Trauma

An 8-year analysis of nonoperative management (NOM) of spleen and liver trauma was done in a level 1 trauma center. Spleen and liver trauma was diagnosed in 279 patients: 93 children (<18), 137 younger adults (18–54), and 49 older adults (≥ 55). Nineteen patients who failed resuscitations died within 0–60 minutes of arrival and were excluded from treatment analysis. Operative management (OM) was done in 39 (15%) and NOM in 221 (85%) patients with failure (NOMF) in 11 (5%). NOM and NOMF was 82 per cent and 5.6 per cent in spleen, 74 per cent and 14.3 per cent in combined spleen/liver, and 96 per cent and 1.5 per cent in liver trauma ( P value <0.001). NOM was done in 99 per cent of children, 81 per cent of younger adults, and 68 per cent of older adults with 0 per cent, 8 per cent, and 10 per cent NOMF. Higher grades of splenic trauma and CT fluid had higher OM rate. NOM success rates were 93.8 per cent in grade 3 and 90.3 per cent in higher grades of spleen trauma. There was no NOMF in higher grades of liver trauma. CT fluid grade had no impact on NOMF. Female patients had higher mean injury severity score, age, and mortality compared to cohorts. NOM should be attempted in hemodynamically stable patients. Age over 55, higher grades of injury, and large hemoperitoneum were not predictors of failure of NOM.

Role of Repeat Computerized Tomography in Nonoperative Management of Solid Organ Trauma

Nonoperative management (NOM) of blunt spleen and liver trauma is currently well accepted. CT imaging is helpful in selecting treatment options and to evaluate resolution of solid organ trauma. This 8-year study was undertaken to assess the role of repeat CT scans in NOM by analyzing indications of surgery in NOM failures. NOM was undertaken in 221 patients with spleen/liver trauma. After initial CT scans, 82 (37%) scans were repeated in 65 patients. There was failure of NOM (NOMF) in 11 patients. Follow-up imaging was done prior to delayed surgery in 4 (36%) patients, 4.9 per cent of repeat scans. Two of these patients had hemodynamic instability and, in the other two, there were clinical signs of peritonitis. The remaining seven patients had delayed surgery due to hemodynamic instability. There is a limited role of repeat CT scans in NOM of spleen and liver trauma. Repeat CT should be done more liberally in patients with suspected intestinal and mesenteric trauma, unexplained blood loss, complex hepato-biliary trauma, and in patients with neurological or pharmacological paralysis.

Hospital Factors Associated with Splenectomy for Splenic Injury: A National Perspective

BACKGROUND

The management of patients with splenic injury has shifted from routine splenectomy to attempts at splenic salvage. Using the Healthcare Cost and Utilization Project's National Inpatient Sample (HCUP-NIS), we assessed the patterns of care for splenic trauma. We hypothesized that the processes of care in urban and rural hospitals would differ.

METHODS

Generalized estimating equations were used to identify predictor variables associated with laparotomy and splenectomy from a national, population-based sample of inpatients (HCUP-NIS). Fourteen thousand nine hundred one patients with an International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis code of 865 were selected from the 1998 to 2000 HCUP-NIS data. Exclusion criteria included age greater than 80 years. Analyses were compared using all patients and excluding patients who died during the first 2 hospital days.

RESULTS

Eight thousand five hundred fifty-three patients were treated in urban teaching hospitals. Forty percent underwent a laparotomy and 28% underwent a splenectomy at that time. Another 4,461 patients were cared for in urban nonteaching hospitals. Of these, 46% had a laparotomy and 35% underwent a splenectomy. The remaining 1,887 patients were seen in rural hospitals. Forty-six percent had a laparotomy and 36% had a splenectomy. Patients in urban teaching hospitals had lower risk-adjusted odds of splenectomy in multivariate models controlling for confounders including overall injury severity. Overall splenic salvage increased from 1998 to 2000, primarily because of increased salvage rates among urban teaching hospitals.

CONCLUSION

The management of patients with splenic injury differs among urban teaching, urban nonteaching, and rural hospitals. Surgeons at urban teaching hospitals appear more willing to attempt splenic salvage by means of nonoperative management.

Is delayed laparotomy for blunt abdominal trauma a valid quality improvement measure in the era of nonoperative management of abdominal injuries?

BACKGROUND

Review of hemodynamically stable patients who undergo laparotomy for trauma greater than 4 hours after admission is an American College of Surgeons quality improvement filter. We reviewed our recent experience with patients who underwent laparotomy for trauma greater than 4 hours after admission to evaluate the reasons for delay, and to determine whether they were because of failure of nonoperative management or other causes.

METHODS

The registry at our Level I trauma center was searched from January 1998 through December 2000 for patients who required a laparotomy for trauma greater than 4 hours after admission. Of 3,369 admitted blunt trauma patients, 90 (2.7%) underwent laparotomy for trauma, of which 26 (29%) were identified as delayed laparotomies greater than 4 hours after admission.

RESULTS

The most common mechanism of injury was motor vehicle crash, the mean Injury Severity Score was 18, and 65% of the patients had significant distracting injuries. Five patients had laparotomy greater than 24 hours after admission. The average time to the operating room in the remaining patients was 8.6 hours. Clinical examination (61%) findings were the most common indication for operation. Gastrointestinal (GI) tract injury was the most common injury associated with delay in laparotomy (58%).

CONCLUSION

GI tract injuries are the predominant injury leading to delayed laparotomy for blunt trauma (58%). Failed nonoperative management of solid organ injuries occurred less frequently (15%). Future efforts should concentrate on earlier identification of GI tract injury. Delayed laparotomy for blunt abdominal trauma is a valid quality improvement measure.

Admission angiography for blunt splenic injury: advantages and pitfalls

BACKGROUND

To analyze the use of admission angiography as a nonoperative adjunct for management of blunt splenic injury.

METHODS

Retrospective chart review of all blunt splenic injuries to a Level I trauma center from March 1997 through July 1999.

RESULTS

One hundred twenty-six patients underwent angiography for splenic injury. Eighty-six patients (68%) had a negative angiogram and were treated expectantly. Of these, seven patients (8%) required laparotomy, with a splenic salvage rate of 92%. Embolization was performed on 40 patients (32%) for evidence of vascular injury. Of these, three patients (8%) required laparotomy, for a total salvage of 92%. Repeat angiography was performed for suspicion of bleeding in 12 patients (10%), with 50% requiring embolization. Outcome based on CT grade demonstrated an average grade of 2.9, with a salvage rate of greater than 70% for grade IV and V injuries.

CONCLUSION

Vascular injury increases with splenic injury grade. Embolization improves nonoperative salvage rates to 92%, even with high-grade injuries. Ten percent of patients require additional therapy including "second-look" angiography. A significant portion of patients with negative screening angiograms (10%) required either embolization or laparotomy to control delayed hemorrhage.

Nonoperative Management of Solid Abdominal Organ Injuries from Blunt Trauma: Impact of Neurologic Impairment

The role of nonoperative management of solid abdominal organ injury from blunt trauma in neurologically impaired patients has been questioned. A statewide trauma registry was reviewed from January 1993 through December 1995 for all adult (age >12 years) patients with blunt trauma and an abdominal solid organ injury (kidney, liver, or spleen) of Abbreviated Injury Scale score ≥2. Patients with initial hypotension (systolic blood pressure <90 mm Hg) were excluded. Patients were stratified by Glasgow Coma Score (GCS) into normal (GCS 15), mild to moderate (GCS 8–14), and severe (GCS ≤7) impairment groups. Management was either operative or nonoperative; failure of nonoperative management was defined as requiring laparotomy for intraabdominal injury more than 24 hours after admission. In the 3-year period 2327 patients sustained solid viscus injuries; 1561 of these patients were managed nonoperatively (66 per cent). The nonoperative approach was initiated less frequently in those patients with greater impairment in mental status: GCS 15, 71 per cent; GCS 8 to 14, 62 per cent; and GCS ≤7, 50 per cent. Mortality, hospital length of stay, and intensive care unit days were greater in operatively managed GCS 15 and 8 to 14 groups but were not different on the basis of management in the GCS ≤7 group. Failure of nonoperative management occurred in 94 patients (6%). There was no difference in the non-operative failure rate between patients with normal mental status and those with mild to moderate or severe head injuries. Nonoperative management of neurologically impaired hemody-namically stable patients with blunt injuries of liver, spleen, or kidney is commonly practiced and is successful in more than 90 per cent of cases. No differences were noted in the rates of delayed laparotomy or survival between normal, mild to moderately head-injured, and severely head-injured patients.

Blunt splenic injury in adults: Multi-institutional Study of the Eastern Association for the Surgery of Trauma

BACKGROUND

Nonoperative management of blunt injury to the spleen in adults has been applied with increasing frequency. However, the criteria for nonoperative management are controversial. The purpose of this multi-institutional study was to determine which factors predict successful observation of blunt splenic injury in adults.

METHODS

A total of 1,488 adults (>15 years of age) with blunt splenic injury from 27 trauma centers in 1997 were studied through the Multi-institutional Trials Committee of the Eastern Association for the Surgery of Trauma. Statistical analysis was performed with analysis of variance and extended chi2 test. Data are expressed as mean +/- SD; a value of p < 0.05 was considered significant.

RESULTS

A total of 38.5 % of patients went directly to the operating room (group I); 61.5% of patients were admitted with planned nonoperative management. Of the patients admitted with planned observation, 10.8% failed and required laparotomy; 82.1% of patients with an Injury Severity Score (ISS) < 15 and 46.6% of patients with ISS > 15 were successfully observed. Frequency of immediate operation correlated with American Association for the Surgery of Trauma (AAST) grades of splenic injury: I (23.9%), II (22.4%), III (38.1%), IV (73.7%), and V (94.9%) (p < 0.05). Of patients initially managed nonoperatively, the failure rate increased significantly by AAST grade of splenic injury: I (4.8%), II (9.5%), III (19.6%), IV (33.3%), and V (75.0%) (p < 0.05). A total of 60.9% of the patients failed nonoperative management within 24 hours of admission; 8% failed 9 days or later after injury. Laparotomy was ultimately performed in 19.9% of patients with small hemoperitoneum, 49.4% of patients with moderate hemoperitoneum, and 72.6% of patients with large hemoperitoneum.

CONCLUSION

In this multicenter study, 38.5% of adults with blunt splenic injury went directly to laparotomy. Ultimately, 54.8% of patients were successfully managed nonoperatively; the failure rate of planned observation was 10.8%, with 60.9% of failures occurring in the first 24 hours. Successful nonoperative management was associated with higher blood pressure and hematocrit, and less severe injury based on ISS, Glasgow Coma Scale, grade of splenic injury, and quantity of hemoperitoneum.

Nonsurgical Management of Solid Abdominal Organ Injury in Patients over 55 Years of Age

Age greater than 55 is often stated to be a contraindication to nonoperative management of intraperitoneal solid organ injury, based upon failures in early experiences of nonoperative therapy. Refinements in the criteria for nonoperative management of hepatic and splenic injuries have yielded improved success rates compared with those in initial reports, raising questions as to the validity of an age-related contraindication. A retrospective chart review of patients more than 55 years of age sustaining blunt hepatic and/or splenic injury at two urban Level I trauma centers was performed. Patients were stratified into three groups in which selection criteria could not consistently be determined: those managed nonoperatively, those managed operatively, and those who died within 24 hours. The purpose of this review is to identify whether age is a determinant for nonoperative management of abdominal solid organ injury. Eighty-eight patients were identified (mean age, 68.7 ± 9.8), 17 of whom died in the emergency department or after operative intervention. Of the remaining 71 patients, 37 were originally managed nonoperatively (mean age 69.9 ± 9.1, mean Injury Severity Score 19.9), 24 sustained hepatic injuries (grades I–IV), 12 sustained splenic injuries (grades I–III), and one patient sustained both organ injuries. Three patients with multisystem trauma died from complications unrelated to their solid organ injury (one brain death, one septic death, and one respiratory arrest). A single patient, with a grade I liver injury, required delayed exploration (for a persistent, unexplained metabolic acidosis) and underwent a nontherapeutic celiotomy. All but one of the 37 patients were successfully treated nonoperatively, for a 97 per cent success rate. We conclude that hemodynamically stable patients more than 55 years of age sustaining intra-abdominal injury can be observed safely. Age alone should no longer be considered an exclusion criterion for nonoperative management of intraabdominal solid organ injury.

Blunt trauma to the spleen

BACKGROUND

The management of splenic injury resulting from blunt trauma in adults is controversial, with an increasing trend towards non-operative management and conservation of the spleen. A retrospective review was performed on adult patients treated in a single institution for splenic injury resulting from blunt trauma in an attempt to identify factors important in selecting an appropriate management option and predicting the success of that option.

METHODS

Associated injuries (standardized using Injury Severity Scores), clinical signs at presentation, computed tomographic grading of splenic injury, and transfusion requirements were documented. Statistical analysis was performed using non-parametric Mann-Whitney, Chi-squared, Kolmogorov-Smirnov and multivariate logistic regression tests.

RESULTS

Eighty-five patients were identified. Non-operative management was used on 39 patients, splenic conservation on 14 patients, and splenectomy on 32 patients. The mean Injury Severity Score was significantly lower in the non-operative group. Computed tomographic grading of the splenic injury was not found to correlate well with intraoperative findings. Transfusion requirements were lower in the non-operative group. Non-operative management failed in four patients; two had continued splenic bleeding, and two required surgery for other intra-abdominal injuries. Overall mortality was 7%. There was one death in the splenic conservation group, unrelated to the splenic injury, and two patients required a second laparotomy and splenectomy for persistent splenic bleeding. There were five deaths in the splenectomy group, only one of which was related to the splenic surgery.

CONCLUSION

Management of blunt splenic injury remains controversial. The decision to pursue non-operative management rather than splenic conservation or splenectomy depends on the individual merits of each case. There is an increasing trend towards splenic conservation, particularly in younger, stable patients with single organ injury.

Overuse of splenic scoring and computed tomographic scans

BACKGROUND

As the most commonly injured abdominal organ in blunt trauma, the management of splenic injury has undergone evolution. The risk of blood transfusions administered in an attempt to save the spleen has lowered the threshold for operation and also expanded the limits for nonoperative management. An in-depth analysis was carried out of risk factors on patients requiring immediate surgery and those who fail non-operative management based on organ injury scaling grading by computed tomographic (CT) scan and operation. The application of nonoperative management in the elderly population and the use of follow-up CT scanning and sonography in the outpatient setting was also examined.

METHODS

Between January of 1991 and June of 1996, 226 consecutive blunt splenic trauma, injured patients at a Level I trauma center were evaluated. All subsequent CT scans and sonograms in the inpatient and outpatient setting were analyzed. The Student's t test, Pearson chi2 analysis with Yates correction, and analysis of variance were used to compare between and among groups.

RESULTS

There were 153 men (67.7%), an average age of 34.8 years, an average Injury Severity Score of 24.4, and 28 deaths (12%). There was a significant difference with respect to Injury Severity Score, Glasgow Coma Scale score, Revised Trauma Score, units of packed red blood cells transfused, length of stay, intensive care unit length of stay, mean splenic injury grade, and cost between patients observed initially and those operated on initially. There was no significant difference in age between the two groups. Of 170 patients, 37 patients (22%) who had an initial CT scan underwent immediate exploratory laparotomy. The remaining 133 patients (78%) had nonoperative management; however, 15 patients (11%) failed the period of observation. Five in this group had a laparotomy secondary to other causes and another six were operated on within 24 hours of their injury for their splenic injury. Thus, only four of the nonoperative management patients (3%) actually failed nonoperative splenic management after 24 hours of injury. There were 100 second CT scans obtained. Three of these patients, who had developed hemodynamic instability, required operation for a bleeding spleen. The subsequent CT scan was confirmatory in these three patients who resided in the intensive care unit. All other CT scans and sonograms for clinically unremarkable patients failed to yield any alteration in care based on the scans.

CONCLUSION

Blunt splenic injured patients can be safely observed; however, there are certain risk factors in those requiring immediate surgery and those failing nonoperative management. The CT scan underestimates injury, possibly related to a progression of bleeding found at the time of operation. No outpatient studies altered the course of management. Age also did not influence outcome. Thus, in the dedicated trauma center, nonoperative management of blunt splenic injury patients does not lead to undue morbidity or mortality. Once discharged, follow-up radiographs in asymptomatic patients are not necessary.

10 year experience of splenic injury: an increasing place for conservative management after blunt trauma

It has been suggested that over 30 per cent of splenic injuries are suitable for conservative management by non-operative treatment and splenorrhaphy; splenic conservation avoids the risk of overwhelming post-splenectomy infection. In this study, injuries of the spleen have been retrospectively analysed for a 10 year period. In the first 5 years the spleen was conserved in only 6/45 (15 per cent) of patients with blunt injury (three non-operative, three splenorrhaphy). In the second 5 years of the study, the spleen was conserved in significantly more patients with blunt trauma, 25 of 61 (41 per cent). This change has been a result of increased non-operative management which has been successful in the majority of cases (20/22). This has been associated with the increased use of abdominal ultrasound. The rate of splenorrhaphy has not changed significantly, five patients compared with three in the previous 5 years. Non-operative management may be increasingly appropriate as less severe splenic injuries are being detected with an increased use of ultrasound. Splenic injury is not a mandatory indication for laparotomy; non-operative management of splenic injuries should be considered in selected patients who are haemodynamically stable and can be closely monitored.

Management of blunt splenic trauma: significant differences between adults and children

BACKGROUND

Although highly successful in children, nonoperative management of blunt splenic injury in adults is less defined. The purpose of this study was to determine whether mechanism of injury, grade of splenic injury, associated injuries, and pattern of injury differ between adults and children (younger than 15 years of age).

METHODS

Four hundred eleven patients (293 adults and 118 pediatric patients) with blunt splenic injury were admitted to an affiliated adult/pediatric trauma program from 1989 to 1994. Computed tomography (CT) scans were interpreted in a blinded fashion. Mechanism of injury was significantly different for adults versus children (p < 0.05): motor vehicle crash (66.9% versus 23.7%), motorcycle (8.8% versus 0.8%), sports (2.4% versus 16.9%), falls (8.8% versus 25.4%), pedestrian/automobile (4.4% versus 11.0%), bicycle (1.4% versus 9.3%), and other (7.3% versus 12.7%).

RESULTS

Higher injury severity scores, lower Glasgow Coma Scales, and higher mortality indicated that the adults were more severely injured than the children. Fifty-nine percent of the adults and 7% of the children required immediate laparotomy for splenic injury. Both CT grade and quantity of blood on CT predicted the need for exploration in adults but not in children. An injury severity score above 15 and high-energy mechanisms correlated with the need for operative intervention.

CONCLUSIONS

Rather than children simply being physically different, they are injured differently than adults, hence the high rate of nonoperative management.

Nonoperative management of the ruptured spleen: a revalidation of criteria

BACKGROUND

Our goal was to revalidate this institution's original criteria for safe nonoperative management of splenic injury.

METHODS

This was a prospective series between October 1991 and December 1995 entering all patients with splenic injury to a modified algorithm. Patients were taken to the operating room if hemodynamically unstable (systolic blood pressure less than 90 mm Hg; pulse greater than 110 beats per minute) after 2 liters of fluid resuscitation, positive abdominal examination findings, American Association for the Surgery of Trauma Organ Injury Scale Grade IV or V injuries by computed tomographic scan (unless younger than 15 years old), or associated severe head injuries (unless younger than 15 years old), or age greater than 55. The remainder of the patients were closely observed.

RESULTS

One hundred seventy-three patients were entered-six were excluded by death before operating room salvage, and one was excluded because of operation for a ruptured thoracic aorta. Therefore 166 patients were reviewed. Seventy splenectomies and 18 splenorrhaphies were performed, and 78 patients were treated nonoperatively (58% splenic salvage). Two failures occurred in the nonoperative group: a 16-year-old with a grade IV hilar injury was operated on on the eighth day after injury because of a continually falling hematocrit, and a 25-year-old with unresolved tachycardia was operated on at 6 hours (97% success rate). The patients in the operative group had a greater severity of injury as determined by mean Injury Severity Score of 32, 18 deaths, a mean transfusion requirement of 14 units of blood compared with mean injury severity score of 21, two deaths from brain injury, and no transfusions given in 58 of the 78 nonoperative cases.

CONCLUSIONS

Prospectively applied, these guidelines allow the safe nonoperative management of patients with blunt splenic injury.

Associated head injury should not prevent nonoperative management of spleen or liver injury in children

The appropriate management of children with liver or spleen injuries and associated head injury after blunt trauma remains controversial. To evaluate the success rates for nonoperative management and the impact this approach has on both abdominal and head injury outcome, children recorded in the National Pediatric Trauma Registry were reviewed. From January 1, 1994 to April 1, 1995, 107 children (aged < 19) were identified with liver, spleen, and associated head injury from blunt trauma. Forty-five (42%) children had combined head and spleen injury, 51 (48%) had head and liver injury, and 11 (10%) had head, liver, and spleen injury. Only 18 (17%) required laparotomy (head and spleen injury, 9 (8%); head and liver injury, 5 (5%); and head, liver, and spleen injury, 4 (4%)). Overall, there were no differences in Glasgow Coma Scale scores for children requiring laparotomy compared with those managed conservatively (13 vs. 14, p > 0.05). For all groups, the mean Injury Severity Score was significantly higher for children requiring laparotomy (19 vs. 31, p < 0.05). However, when comparison of the groups was stratified for type of injury and severity, the transfusion requirements, mortality, and abdominal and neurologic morbidity were all improved in children managed nonoperatively. Contrary to previous guidelines in the literature for selection of patients for nonoperative management of blunt solid organ abdominal injury, the association of altered mental status from head injury with liver and spleen injuries should not impact the decision for observational management.