Optimizing the management of blunt splenic injury in adults and children

Pediatric trauma patients with isolated grade III blunt splenic injuries may be safely managed without intensive care unit admission

BACKGROUND

Non-operative management is the standard of care for pediatric blunt splenic injury. The American Pediatric Surgical Association recommends intensive care unit monitoring only for grade IV/V blunt splenic injury; however, variation remains regarding this practice. We hypothesized that pediatric trauma patients with near-isolated grade III blunt splenic injuries admitted to a non-intensive care unit setting would have similar outcomes to those admitted to the intensive care unit.

METHODS

The 2017 to 2019 Trauma Quality Improvement Program database was queried for blunt pediatric trauma patients (≤16 years) with near-isolated grade III blunt splenic injuries. Patients with systolic blood pressure <90 mmHg or heart rate >90 were excluded. Pediatric trauma patients admitted to the intensive care unit were compared to non-intensive care unit admissions. The primary outcome was splenectomy. Bivariate analyses were performed.

RESULTS

Of 461 pediatric trauma patients with near-isolated grade III blunt splenic injuries, 186 (40.3%) were admitted to the intensive care unit. Intensive care unit patients were older than their non-intensive care unit counterparts (15 vs 14 years, P = .03). Intensive care unit and non-intensive care unit patients had a similar rate of splenectomy (0.5% vs 0.7%, P = .80) and time to surgery (19.7 vs 19.8 hours, P = .98). Patients admitted to the intensive care unit had a longer length of stay (4 vs 3 days, P < .001). There were no significant complications or deaths in either group.

CONCLUSION

This national analysis demonstrated that hemodynamically stable pediatric trauma patients with near-isolated grade III blunt splenic injuries admitted to the floor or intensive care unit had a similar rate of splenectomy without complications or deaths. This aligns with American Pediatric Surgical Association recommendations that pediatric trauma patients with grade III blunt splenic injuries be managed in non-intensive care unit settings. Widespread adoption is warranted and should lead to decreased healthcare expenditures.

Non-operative management of solid organ injuries in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee systematic review

PURPOSE

The American Pediatric Surgical Association (APSA) guidelines for the treatment of isolated solid organ injury (SOI) in children were published in 2000 and have been widely adopted. The aim of this systematic review by the APSA Outcomes and Evidence Based Practice Committee was to evaluate the published evidence regarding treatment of solid organ injuries in children.

METHODS

A comprehensive search strategy was crafted and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Four principal questions were examined based upon the previously published consensus APSA guidelines regarding length of stay (LOS), activity level, interventional radiologic procedures, and follow-up imaging. A literature search was performed including multiple databases from 1996 to 2016.

RESULTS

LOS for children with isolated solid organ injuries should be based upon clinical findings and may not be related to grade of injury. Total LOS may be less than recommended by the previously published APSA guidelines. Restricting activity to grade of injury plus two weeks is safe but shorter periods of activity restriction have not been adequately studied. Prophylactic embolization of SOI in stable patients with image-confirmed arterial extravasation is not indicated and should be reserved for patients with evidence of ongoing bleeding. Routine follow-up imaging for asymptomatic, uncomplicated, low-grade injured children with abdominal blunt trauma is not warranted. Limited data are available to support the need for follow-up imaging for high grade injuries.

CONCLUSION

Based upon review of the recent literature, we recommend an update to the current APSA guidelines that includes: hospital length of stay based on physiology, shorter activity restrictions may be safe, minimizing post-injury imaging for lower injury grades and embolization only in patients with evidence of ongoing hemorrhage.

TYPE OF STUDY

Systematic Review.

LEVELS OF EVIDENCE

Levels 2-4.

Comparison of outcomes before and after establishing a regional trauma center and following a protocol to treat blunt splenic injury in South Korea: A retrospective study

Background:

Nonoperative management for hemodynamically stable splenic injury has been accepted as appropriate treatment. Objectives: This study aimed to investigate the changes in management and clinical outcomes of splenic injury by introducing a protocol for splenic injury at a newly established regional trauma center.

Methods:

From January 2005 to December 2016, we reviewed the outcomes of all 257 patients who sustained blunt trauma to the spleen at the first regional trauma center in South Korea. This 11-year period was divided into two intervals, before 1 January 2014 (period I, n = 189 patients) and after 1 January 2014 (period II, n = 68 patients), when the trauma center was established and a formal management protocol was followed for patients with blunt traumatic splenic injuries.

Results:

The proportion of emergency operations performed for patients with more serious (grades 3–5) splenic injuries was lower in period II than in period I (29% vs 22%, respectively, p < 0.001) whereas the rate of angioembolization was higher (89% vs 39.0%, respectively, p < 0.001). The time to intervention, irrespective of whether emergency operation or angioembolization was performed, was shorter in period II than in period I (312.8 min vs 129 min, respectively, p = 0.001). A greater proportion of patients was managed non-operatively in period II (78% vs 71%), and the non-operative management success rate was higher in period II than it was in period I (100% vs 83%; p = 0.014). Similarly, the splenic salvage rate was higher in period II (78% vs 59%, p = 0.03).

Conclusion:

After establishing a regional trauma center and introducing a protocol for the management of blunt splenic injuries, the rates of non-operative management and splenic salvage improved significantly. The reasons for this may be multifactorial, being related to the early involvement of a trauma surgeon, expansion of angiographic facilities and resources, and the introduction and application of a protocol for managing blunt splenic injury.

Splenic trauma: WSES classification and guidelines for adult and pediatric patients

Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.

Management of blunt splenic injury in a UK major trauma centre and predicting the failure of non-operative management: a retrospective, cross-sectional study

PURPOSE

To review the management of patients >16 years with blunt splenic injury in a single, UK, major trauma centre and identify whether the following are associated with success or failure of non-operative management with selective use of arterial embolization (NOM ± AE): age, Injury Severity Score (ISS), head injury, haemodynamic instability, massive transfusion, radiological hard signs [contrast extravasation or pseudoaneurysm on the initial computed tomography (CT) scan], grade, and presence of intraparenchymal haematoma or splenic laceration.

METHODS

Retrospective, cross-sectional study undertaken between April 2012 and October 2015. Paediatric patients, penetrating splenic trauma, and iatrogenic injuries were excluded. Follow-up was for at least 30 days.

RESULTS

154 patients were included. Median age was 38 years, 77.3% were male, and median ISS was 22. 14/87 (16.1%) patients re-bled following NOM in a median of 2.3 days (IQR 0.8-3.6 days). 8/28 (28.6%) patients re-bled following AE in a median of 2.0 days (IQR 1.3-3.7 days). Grade III-V injuries are a significant predictor of the failure of NOM ± AE (OR 15.6, 95% CI 3.1-78.9, p = 0.001). No grade I injuries and only 3.3% grade II injuries re-bled following NOM ± AE. Age ≥55 years, ISS, radiological hard signs, and haemodynamic instability are not significant predictors of the failure of NOM ± AE, but an intraparenchymal or subcapsular haematoma increases the likelihood of failure 11-fold (OR 10.9, 95% CI 2.2-55.1, p = 0.004).

CONCLUSIONS

Higher grade injuries (III-V) and intraparenchymal or subcapsular haematomas are associated with a higher failure rate of NOM ± AE and should be managed more aggressively. Grade I and II injuries can be discharged after 24 h with appropriate advice.

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.

Outcomes of Nonoperative Management of Blunt Splenic Injury—Asian Experience

Management of blunt splenic injury (BSI) has evolved with a focus on nonoperative management (NOM) and spleen preservation. Factors predictive of failure of NOM are yet ill defined. We report our experience of outcomes of NOM of BSI and evaluate factors that predict failure. This is a retrospective study from a prospective trauma registry of a university-affiliated major trauma center over a 4 ½-year period. All the patients admitted with BSI from January 2004 to May 2009 were included in this study. Demographic, clinical, operative, and outcome data were studied. Forty-five patients (51.1%) with a mean age of 38 years (range, 16–77 years) were admitted for NOM. The majority of patients was male (88.9%). Mean Injury Severity Score (ISS) was 25.2 ± 12.7 and the majority of the patients (42.2%) had Grade II BSI. Three patients (6.7%) underwent splenic artery angioembolization. Three patients (6.7%) failed NOM and required splenectomy. The overall splenic salvage rate was 93.3%. The median hospital stay was 7 days (range, 2–66 days) and there was no mortality. Lower hemoglobin on admission (15.9 versus 10.1 g/dL, P = 0.006), hematocrit &lt;30.0% on admission (P = 0.04), higher ISS (39.3 versus 24.2, P = 0.04) and Grade V injury (P = 0.003) predicted failure of NOM. NOM for BSI is safe, feasible, and it increases splenic salvage. Splenic artery angioembolization is a useful adjunct. Low hemoglobin, hematocrit &lt;30%, high ISS, and grade V splenic injury predicts failure of NOM. Grade V splenic injury should be considered for routine angioembolization if NOM is contemplated.

Blunt splenic trauma: Assessment, management and outcomes

BACKGROUND

The approach for diagnosis and management of blunt splenic injury (BSI) has been considerably shifted towards non-operative management (NOM). We aimed to review the current practice for the evaluation, diagnosis and management of BSI.

METHODS

A traditional narrative literature review was carried out using PubMed, MEDLINE and Google scholar search engines. We used the keywords "Traumatic Splenic injury", "Blunt splenic trauma", "management" between December 1954 and November 2014.

RESULTS

Most of the current guidelines support the NOM or minimally approaches in hemodynamically stable patients. Improvement in the diagnostic modalities guide the surgeons to decide the timely management pathway Though, there is an increasing shift from operative management (OM) to NOM of BSI; NOM of high grade injury is associated with a greater rate of failure, prolonged hospital stay, risk of delayed hemorrhage and transfusion-associated infections. Some cases with high grade BSI could be successfully treated conservatively, if clinically feasible, while some patients with lower grade injury might end-up with delayed splenic rupture. Therefore, the selection of treatment modalities for BSI should be governed by patient clinical presentation, surgeon's experience in addition to radiographic findings.

CONCLUSION

About one-fourth of the blunt abdominal trauma accounted for BSI. A high index of clinical suspicion along with radiological diagnosis helps to identify and characterize splenic injuries with high accuracy and is useful for timely decision-making to choose between OM or NOM. Careful selection of NOM is associated with high success rate with a lower rate of morbidity and mortality.

Management of splenic trauma: a single institution's 8-year experience

BACKGROUND

Management of splenic trauma has evolved, with current practice favoring selective angiographic embolization and non-operative treatment over immediate splenectomy. Defining the optimal selection criteria for the appropriate management strategy remains an important question.

METHODS

This retrospective registry review was conducted at a Level I trauma center. The patient population consisted of 20,561 patients in the State Trauma Registry from April 2004 to May 2012. Splenectomy, angiography, splenic embolization, nonoperative, and noninterventional (NI) observation were the management strategies under study. Morbidity and mortality were the outcome measures. Morbidity and mortality by management strategy.

RESULTS

During the 8-year study period, 926 (4.5%) patients sustained splenic injury. Observational management increased over time despite the similar distribution of splenic injury grade over the study period: grade I/II (50%), grade III (24.2%), and grade IV/V (25.8%). Mortality rates associated with each management strategy were the following: immediate splenectomy (IS; 25%), splenic embolization (SE; 3.9%), and angiography only or observation, that is, NI (6.5%) management. Injury severity score (ISS) was highest in IS (36.1 ± 1.3) compared with SE (29.1 ± 1.0, P = .001) and NI (21.6, P < .001). Splenectomy was required in 5 of the 129 (3.9%) patients managed with SE and 9 of the 677 (1.3%) patients managed by NI. Mortality was significantly lower among those managed by SE (odds ratio .12, 95% confidence interval: .05 to .32) or NI (odds ratio .21, 95% confidence interval: .12 to .35). This survival benefit was explained by the association of IS with systolic blood pressure <90, high ISS, low GCS at presentation, ISS, development of shock, need for transfusion, and multiorgan failure.

CONCLUSIONS

In this large 8-year single institution study, we observed an increase in nonoperative management by an increased application of angiography and embolization. An aggressive utilization of SE in patients with appropriate indications will result in low failure rates and improved mortality.

Blunt splenic injury

PURPOSE OF REVIEW

To review the current care of the patient with an injured spleen.

RECENT FINDINGS

The initial care of the patient with splenic injury is dictated by their hemodynamic presentation and the institution's resources. Although most high-grade injuries require splenectomy, up to 38% are successfully managed nonoperatively. Angioembolization has increased splenic salvage with a minimum of complications. In the absence of injuries that mandate longer hospital stays, patients with low-grade injuries are successfully discharged in 1-2 days and high-grade injuries in 3-4 days. Delayed splenic hemorrhage remains a feared complication, but fortunately the 180-day readmission rate for splenectomy is low with the majority of those returning within 8 days of injury.

SUMMARY

Nonoperative management (NOM) is the standard of care for the hemodynamically stable patient with an isolated blunt splenic injury. Splenic salvage can be safely increased, even in higher grade injuries, with the use of angioembolization. Patients managed nonoperatively are successfully discharged as early as 1-2 days for low-grade injuries and as early as 3-4 days for higher grade. Safe management of the patient with blunt splenic injury requires careful selection for NOM, meticulous monitoring and follow-up.

Consensus strategies for the nonoperative management of patients with blunt splenic injury: a Delphi study

BACKGROUND

Nonoperative management is the standard of care in hemodynamically stable patients with blunt splenic injury. However, a number of issues regarding the management of these patients are still unresolved. The aim of this study was to reach consensus among experts concerning optimal treatment and follow-up strategies.

METHODS

The Delphi method was used to reach consensus among 30 expert trauma surgeons and interventional radiologists from around the world. An online survey was used in the two study rounds. Consensus was defined as an agreement of 80% or greater.

RESULTS

Response rates of the first and second rounds were 90% and 80%, respectively. Consensus was reached for 43% of the (sub)questions. The American Association for the Surgery of Trauma organ injury scale for grading splenic injury is used by 93% of the experts. In hemodynamically stable patients, observation or splenic artery embolization (SAE) can be applied in the presence of a small or no hemoperitoneum combined with an intraparenchymal contrast extravasation or no contrast extravasation, regardless of the presence of an arteriovenous (AV) fistula/pseudoaneurysm. Hemodynamic instability is an indication for operative management, irrespective of computed tomographic characteristics and grade of splenic injury (≥82% of the experts). Operative management is also indicated in the presence of associated intra-abdominal injuries and/or the need for five or more packed red blood cell transfusions (22 of 27 experts, 82%). Recommended time span to start SAE in a stable patient with an intraparenchymal contrast extravasation is 60 minutes (19 of 24 experts). Patients should be admitted 1 to 3 days to a monitored setting (27 of 27 experts, 100%). Serial hemoglobin checks are performed by all experts, every 4 to 6 hours in the first 24 hours and once or twice a day after that (21 of 24 experts, 88%), in nonoperative management as well as after SAE. Routine postdischarge imaging is not indicated (21 of 24 experts, 88%).

CONCLUSION

Although treatment should always be adjusted to the specific patient, the results of this study may serve as general guidelines.

Meta-analysis of predictive factors and outcomes for failure of non-operative management of blunt splenic trauma

BACKGROUND

This study aimed to analyse predictive factors and outcomes of failure of non-operative management (NOM) following blunt splenic trauma.

METHODS

A systematic review of the literature was performed for studies comparing failed NOM (fNOM) to successful NOM (sNOM) in adults (≥ 16 years). The main endpoints were fNOM and associated mortality. Between-study heterogeneity was assessed. Meta-analysis of high quality studies, identified using the Newcastle-Ottawa Scale, was performed using fixed or random models.

RESULTS

Four prospective and 21 retrospective studies were included. From 24,615 unselected patients, 3025 experienced fNOM (12%, range 4-52%). Meta-analysis of the high quality studies revealed that mortality was significantly higher with fNOM in unselected age groups (odds ratio 1.93, 95% confidence interval 1.04-3.57, p = 0.04, I(2) = 0%), in those <55 years old (OR 3.42, 95% CI 1.73-6.77, p = 0.02, I(2) = 0%) and in those ≥ 55 years old (OR 2.65, 95% CI 1.20-5.82, p = 0.02, I(2) = 0%). There was a significant improvement in sNOM following introduction of angioembolisation protocols (OR 0.26, 95% CI 0.13-0.53, p<0.002, I(2) = 51%), although these five studies were non-randomised. American Association for the Surgery of Trauma injury grades 4-5, the presence of moderate or large haemoperitoneum, increasing injury severity score and increasing age were all significantly associated with increased risk of fNOM. fNOM led to significantly longer intensive care unit and overall lengths of stay.

CONCLUSIONS

fNOM leads to increased resource use and increased mortality. Methods of preventing fNOM, such as angioembolisation, warrant further assessment. Patients with increasing age, AAST scores and moderate or large haemoperitoneums may benefit from closer monitoring.

Nonoperative management of adult blunt splenic injury with and without splenic artery embolotherapy: a meta-analysis

BACKGROUND

Observation and splenic artery embolotherapy (SAE) are nonoperative management (NOM) modalities for adult blunt splenic injury; however, they are quite different, inconsistently applied, and controversial. This meta-analysis compares the known outcomes data for observational management versus SAE by splenic injury grade cohort.

METHODS

Thirty-three blunt splenic injury outcomes articles, published between 1994 and 2009, comprising 24 unique data sets are identified. Of these, nine gave outcomes data by splenic injury grade for observational management and SAE separately. Failure rates were collected and analyzed using random effects estimates.

RESULTS

Overall, 68.4% of the 10,157 patients were managed nonoperatively. The overall failure rate estimate of NOM is 8.3% with a 95% confidence interval (CI) of 6.7% to 10.2%. The observational management failure rate estimate without SAE increases from 4.7% to 83.1% in splenic injury grade 1 to 5 patients. The overall failure rate estimate of SAE is 15.7% (95% CI, 10.4-23.2) and did not vary significantly from splenic injury grades 1 to 5 (p=0.413). The failure rate of observational management without SAE is statistically higher than the failure rare estimate of SAE in splenic injury grade 4 and 5 injuries: 43.7% (95% CI, 25.5-63.8) versus 17.3% (95% CI, 7.8-34.1), p=0.035 and 83.1% (95% CI, 45.2-96.7) versus 25.0% (95% CI, 8.7-53.8), p=0.016, respectively.

CONCLUSIONS

This meta-analysis synthesizes NOM outcomes data by modality and splenic injury grade. The failure rate of observational management increases with splenic injury grade, whereas the failure rate of SAE does not change significantly. SAE is associated with significantly higher splenic salvage rates in splenic injury grade 4 and 5 injuries.

Does Splenic Embolization and Grade of Splenic Injury Impact Nonoperative Management in Patients Sustaining Blunt Splenic Trauma?

Nonoperative management (NOM) for blunt splenic trauma (BST) is an established practice. The impact of splenic embolization (SE) in the algorithm for NOM has not been well studied. This study evaluates the role of SE and spleen injury grade on failure of NOM. Retrospective cohort of trauma registry over a 7-year period (2000-2006) for patients who suffered BST was studied. Data including demographics, splenic injury grade, and SE were recorded. Characteristics were compared between the successful and failed NOM groups. Kaplan-Meier, life table, and Cox-proportional hazard regression analyses were performed. Of the 499 patients who suffered BST, 407 (81.6%) patients had successful NOM and 92 (18.4%) patients failed NOM (including splenectomies performed within 1 hour of admission). Failed NOM group had a higher splenic injury grade compared with the successful NOM group ( P < 0.0001). Seventy-five per cent underwent a splenectomy within 7.7 hours of admission. Nearly all grade I and II splenic injuries that failed NOM occurred by 24 hours. Grade 3 and 4 injuries that failed NOM occurred by 150 hours. SE was protective against splenectomy (Hazard Ratio (HR) 0.18, 95% confidence interval: 0.06-0.55, P = 0.004), whereas splenic injury grades III or higher was associated with increased risk of splenectomy (grade III: HR 5.26, P = 0.003; grade IV: HR 6.84, P = 0.002; grade V: HR 9.81, P = 0.002) compared with those with splenic injury grade I. Splenic embolization is a protective measure to reduce the failure of NOM. Spleen injury grade III and higher was significantly associated with NOM failure and would require a 5-day inpatient observation.

Literature review of the role of ultrasound, computed tomography, and transcatheter arterial embolization for the treatment of traumatic splenic injuries

Introduction

The spleen is the second most frequently injured organ following blunt abdominal trauma. Trends in management have changed over the years. Traditionally, laparotomy and splenectomy was the standard management. Presently, nonoperative management (NOM) of splenic injury is the most common management strategy in hemodynamically stable patients. Splenic injuries can be managed via simple observation (OBS) or with angiography and embolization (AE). Angio-embolization has shown to be a valuable alternative to observational management and has increased the success rate of nonoperative management in many series.

Diagnostics

Improved imaging techniques and advances in interventional radiology have led to a better selection of patients who are amenable to nonoperative management. Despite this, there is still a lot of debate about which patients are prone to NOM.

Angiography and Embolization

The optimal patient selection is still a matter of debate and the role of CT and angio-embolization has not yet fully evolved. We discuss the role of sonography and CT features, such as contrast extravasation, pseudoaneurysms, arteriovenous fistulas, or hemoperitoneum, to determine the optimal patient selection for angiography and embolization. We also review the efficiency, technical considerations (proximal or selective embolization), logistics, and complication rates of AE for blunt traumatic splenic injuries.

[Prognostic factors related to non surgical treatment failure of splenic injuries in the abdominal blunt trauma]

OBJECTIVE

Identify prognostic factors related to treatment failure of blunt splenic injuries managed by non surgical treatment (NST).

METHODS

Fifty six adult patients submitted to NST were prospectively studied. The injuries were diagnosed by computed axial tomography scan and classified according to AAST (American Association for Surgery of Trauma) criteria. Patients were divided in success and failure groups. NST failure was defined as the need for laparotomy for any reason.

RESULTS

NST failures (19.6%) were due to: abdominal pain (45.4%), hemodinamic instability (36.4%), splenic haematoma associated to a fall in hematocrit (9.1%) and splenic abscess (9.1%). There were no failures in grade I and II of the splenic injuries; failure rate was 17.5% in grade III and IV injuries grouped, and 80% in grade V injuries (p = 0,0008). In the success group, 31.3% patients received red cell transfusions, versus 63.6% patients in the failure group (p = 0,05). Failure rate in patients with ISS = 8 was zero; 15.9% in patients with ISS 9 to 25; and 50% in patients with ISS = 26 (p = 0,05). There were no deaths or missed bowel injuries.

CONCLUSION

ISS and splenic injury grade were related to failure of NST.

Management Differences for Pediatric Solid Organ Injuries in a Rural State

Pediatric liver and spleen injuries are frequently treated in specialized hospitals. Not all injured children, however, are treated in referral centers. We evaluated the management of pediatric liver and spleen injuries in a rural state without a state trauma system to determine if differences existed between trauma centers and nontrauma centers. A state database was queried for patients ≤15-years-old who suffered liver and spleen injuries from 2003 to 2005. Iatrogenic injuries were excluded. There were 115 pediatric liver and 183 pediatric spleen injuries. Fifty per cent of liver and 63 per cent of spleen injuries in nontrauma centers were isolated solid organ injuries compared with 18 per cent and 36 per cent, respectively, in trauma centers. The mortality rate for both liver and spleen injuries was similar in trauma and nontrauma centers. Hospital charges were higher in trauma centers but this was due to patients with associated injuries. The nonoperative management rate was similar for liver injuries. Pediatric patients with splenic injuries had a lower rate of nonoperative management in nontrauma centers (75% to 90%, nontrauma vs trauma). In Kentucky, pediatric solid organ injuries are usually managed nonoperatively in both trauma and nontrauma centers, but trauma centers cared for fewer isolated solid organ injuries.

Transcatheter embolization for delayed hemorrhage caused by blunt splenic trauma

Although the exact benefit of adjunctive splenic artery embolization (SAE) in the nonoperative management (NOM) of patients with blunt splenic trauma has been debated, the role of transcatheter embolization in delayed splenic hemorrhage is rarely addressed. The purpose of this study was to evaluate the effectiveness of SAE in the management of patients who presented at least 3 days after initial splenic trauma with delayed hemorrhage. During a 24-month period 4 patients (all male; ages 19-49 years) presented with acute onset of pain 5-70 days after blunt trauma to the left upper quadrant. Two had known splenic injuries that had been managed nonoperatively. All had computed axial tomography evidence of active splenic hemorrhage or false aneurysm on representation. All underwent successful SAE. Follow-up ranged from 28 to 370 days. These cases and a review of the literature indicate that SAE is safe and effective for NOM failure caused by delayed manifestations of splenic arterial injury.

Proximal splenic angioembolization does not improve outcomes in treating blunt splenic injuries compared with splenectomy: a cohort analysis

BACKGROUND

Although splenic angioembolization (SAE) has been introduced and adopted in many trauma centers, the appropriate selection for and utility of SAE in trauma patients remains under debate. This study examined the outcomes of proximal SAE as part of a management algorithm for adult traumatic splenic injury compared with splenectomy.

METHODS

A retrospective cohort analysis was performed on all hemodynamically stable (HDS) blunt trauma patients with isolated splenic injury and computed tomographic (CT) evidence of active contrast extravasation that presented to a level 1 Trauma Center over a period of 5 years. The cohorts were defined by two separate 30 month periods and included 78 patients seen before (group I) and 76 patients seen after (group II) the introduction of an institutional SAE protocol. Demographics, splenic injury grade, and outcomes of the two groups were compared using Student's t test, or chi2 test. Analysis was by intention-to-treat.

RESULTS

Six hundred eighty-two patients with blunt splenic injury were identified; 154 patients (29%) were HDS with CT evidence of active contrast extravasation. Group I (n = 78) was treated with splenectomy and group II (n = 76) was treated with proximal SAE. There was no difference in age (33 +/- 14 vs. 37 +/- 17 years), Injury Severity Score (31 +/- 13 vs. 29 +/- 11), or mortality (18% vs. 15%) between the two groups. However, the incidence of Adult Respiratory Distress Syndrome (ARDS) was 4-fold higher in those patients that underwent proximal SAE compared with those that underwent splenectomy (22% vs. 5%, p = 0.002). Twenty two patients failed nonoperative management (NOM) after SAE. This failure appeared to be directly related to the grade of splenic organ injury (grade I and II: 0%; grade III: 24%; grade IV: 53%; and grade V: 100%).

CONCLUSION

Introduction of proximal SAE in NOM of HDS splenic trauma patients with active extravasation did not alter mortality rates at a Level 1 Trauma Center. Increased incidence of ARDS and association of failure of NOM with higher splenic organ injury score identify areas for cautionary application of proximal SAE in the more severely injured trauma patient population. Better patient selection guidelines for proximal SAE are needed. Without these guidelines, outcomes from SAE will still lack transparency.

Angioembolization reduces operative intervention for blunt splenic injury

BACKGROUND

Nonoperative management for blunt splenic injury (BSI) has become gold standard, but the role of angiographic embolization (AE) is still controversial for bleeding. We postulated that splenic AE for BSI would have superior outcomes compared with operation and increase our splenic salvage rate.

METHODS

This was a retrospective study of all adult trauma patients admitted to our Level I center from 2000 through 2006. Multivariate analysis adjusting for age, Injury Severity Score, and Glasgow Coma Scale score was performed. Only patients who had a computed tomographic (CT) scan before surgery (CT + OR) were compared with those who had CT scans then AE.

RESULTS

Eighty-seven of 317 patients required initial intervention for their BSI, for a no intervention rate (no OR or AE) of 73% and a nonoperative rate of 89%. The groups had similar Injury Severity Score, mortality, and lengths of stay. The AE group was older (p < 0.01), had higher spleen Abbreviated Injury Score (p = 0.02), and required significantly fewer packed RBC transfusions, p < 0.01. The overall hospitalization costs were not different, but the number of intraabdominal complications was higher for the CT + OR group (36% vs. 6%, p < 0.01). Pneumonia, thromboembolic events, and pleural effusions were equivalent. There were no deaths from splenic hemorrhage.

CONCLUSION

Despite recent concerns that AE may be overutilized for BSI, this study showed a lower incidence of abdominal complications and blood utilization in the AE group despite an older age and higher splenic Abbreviated Injury Score. Use of AE decreased operative intervention by 16%.

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.

Nonoperative management of severe blunt splenic injury: are we getting better?

BACKGROUND

Most minor splenic injuries are readily treated nonoperatively but controversy exists regarding the role of nonoperative management for higher-grade injuries. The infrequency of these injuries has made evaluation of factors critical to their management difficult.

METHODS

Through the National Trauma Data Bank, 3,085 adults sustaining severe (Abbreviated Injury Scale score > or = 4) blunt splenic injury from 1997 to 2003 were retrospectively reviewed. Patient management, demographic information, physiologic data, procedures performed, and outcomes were analyzed.

RESULTS

Nonoperative management was attempted in 40.5% of patients but ultimately failed in 54.6% of those. Failure of nonoperative management was associated with increased age, low admission systolic blood pressure, higher injury severity score, and increased hospital and intensive care unit length of stay. Mortality associated with failure of nonoperative management (12.3%) and successful observation (13.8%) was similar.

CONCLUSIONS

Nonoperative management of higher-grade splenic injuries is associated with a high rate of failure and prolonged hospital stay. Careful judgment must be exercised in applying nonoperative management to patients with severe splenic injuries.

Improved outcome of adult blunt splenic injury: a cohort analysis

BACKGROUND

The purpose of this study was to review our 15-year experience in the treatment of blunt splenic injury in adults. Our hypothesis was that the implementation of a change in practice, with stress on splenic preservation and splenic artery embolization for the management of splenic injury, would result in improved splenic salvage rates without negatively affecting mortality rates.

METHODS

A retrospective cohort analysis was performed on all consecutive adults with blunt splenic injury who were admitted to a Level One Trauma Center. The cohorts were defined by 2 separate 7.5-year periods (1991-1998 and 1998-2005).

RESULTS

Six hundred twenty-five patients with blunt splenic trauma were identified; 403 patients who were treated from 1998 to 2005 were compared with 222 patients whose cases had been reviewed previously (1991 to 1998). The present cohort differed in age (35 vs 40 years; P < .001) and injury severity score (27 vs 21; P < .0001). Nonoperative treatment was implemented in 136 patients (61%) in the initial cohort and 344 patients (85%) in the present cohort. The frequency of splenic artery embolization increased from 2.7% to 22.6% (P < .001). The success of nonoperative management increased from 77% to 96% (P < .001); the splenic salvage rate for all patients improved from 57% to 88% (P < .0001). Hospital mortality rates decreased from 12% to 6% (P < .001), and the mean hospital length of stay decreased from 15 to 9 days (P < .001).

CONCLUSION

These results demonstrate that the success of nonoperative management and the splenic preservation for blunt injury has improved over time. This improvement correlated with a greater use of splenic artery embolization.

Evaluation of a 15-year experience with splenic injuries in a state trauma system

BACKGROUND

The management of splenic injuries has evolved with a greater emphasis on nonoperative management. Although several institutions have demonstrated that nonoperative management of splenic injuries can be performed with an increasing degree of success, the impact of this treatment shift on outcome for all patients with splenic injuries remains unknown. We hypothesized that outcomes for patients with splenic injuries have improved as the paradigm for splenic injury treatment has shifted.

METHODS

Consecutive patients from 1987 to 2001 with splenic injuries who were entered into a state trauma registry were reviewed. Demographic variables, injury characteristics, and outcome data were collected.

RESULTS

The number of patients who were diagnosed with splenic injuries increased from 1987 through 2001, despite a stable number of institutions submitting data to the registry. The number of minor injuries and severe splenic injuries remained stable, and the number of moderately severe injuries significantly increased over time. Overall mortality rate improved but primarily reflected the decreased mortality rates of moderately severe injuries; the mortality rate for severe splenic injuries was unchanged.

CONCLUSION

Trauma centers are seeing increasing numbers of splenic injuries that are less severe in magnitude, although the number of the most severe splenic injuries is stable. The increased proportion of patients with less severe splenic injuries who are being admitted to trauma centers is a significant factor in the increased use and success rate of nonoperative management.

Pediatric blunt abdominal trauma

Blunt pediatric trauma is a major threat to the health and well-being of children. Nationwide, many practitioners care for children who face this issue. Some key principles related to the evaluation and management of these children are elucidated in this article.

The role of diagnostic algorithms in the management of blunt splenic injury

BACKGROUND

Diagnostic algorithms for patients with blunt abdominal trauma have been in use since 1995. This study investigated the role of diagnostic algorithms in the management of adult patients with blunt splenic injury at our institution.

METHODS

A retrospective review of hospital records was performed to enroll patients with blunt injury of the spleen. Demographic data and information about injury severity, diagnostic methods, management and final outcomes were evaluated. Patients were separated into an early and late group according to the year that diagnostic algorithms were used (1990-1994 or 1995-1999).

RESULTS

One hundred and twenty-one patients were enrolled. Initially, 71 patients had an operation (OP group), whereas 50 received non-operative management (NOM group). Patients in the OP versus NOM group had lower blood pressure and greater transfusion volumes in the emergency room, higher grade splenic injury, and a greater rate of intra-abdominal-related injury. NOM failed in 7 patients (14%). Early- versus late-group patients were less likely to have NOM and high grade splenic injury; however, the rate of NOM failure was not different between the early and late groups.

CONCLUSION

Diagnostic algorithms using sonograms for screening provide an initial means of selecting patients for NOM. Patients with higher grades of splenic injury can then be managed non-operatively.

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.

A new method to approach exact hemoperitoneum volume in a splenic trauma model using ultrasonography

In the trauma setting, the Focused Assessment for the Sonographic examination of the Trauma patient (FAST) accurately detects hemoperitoneum. Currently, only an approximate evaluation of the volume of free intraperitoneal fluid (FIPF) can be done by imaging modalities such as ultrasound (US). The aim of this study was to correlate the thickness of FIPF measured by US in different sites of the peritoneal cavity with the total volume of an experimental post-traumatic hemoperitoneum. An intra-abdominal collection with ongoing bleeding was simulated in eight cadavers with no previous abdominal surgery. Between 200 and 2000 ml of saline solution was instilled into the left hypochondrium of eight non-embalmed cadavers. During the instillation, FIPF thickness was measured every 200 ml by US in six different declivous sites of the peritoneal cavity. The volume of FIPF instilled could be mathematically correlated with fluid thickness in all the sites through the linear equation Y=aX+b, where Y is the volume of FIPF in milliliters, a is 33 (variability coefficient), X is the FIPF thickness in millimeters and b is 470 ml (minimum volume detectable by US). The best correlation between thickness and volume was obtained in the hepatorenal pouch (Morrison pouch). Evaluation of the impact of intraperitoneal hemorrhage on the hemodynamic state of spleen trauma patients is of paramount importance for the surgeon, who has to decide whether to perform a laparotomy for hemostasis or not, specially when intra- and extra-abdominal injuries conjointly exist. After clinical validation, this new method to calculate the exact volume of FIPF could be used in current clinical practice of abdominal trauma to assist in the decision-making regarding non-operative treatment of spleen trauma.

Pediatric splenic injuries with a contrast blush: successful nonoperative management without angiography and embolization

BACKGROUND

The presence of a contrast blush on computed tomography (CT) in adult splenic trauma is a risk factor for failure of nonoperative management. Arterial embolization is believed to reduce this failure rate. The significance of a blush in pediatric trauma is unknown. The authors evaluated the outcome of children with blunt splenic trauma and contrast extravasation.

METHODS

The trauma registry was queried for all pediatric patients with blunt splenic injuries. Admission CT was reviewed for injury grade and presence of an arterial blush by a radiologist blinded to patient outcome. Hospital and office charts were reviewed for success of nonoperative management, late splenic rupture, and other complications.

RESULTS

One hundred seven children with blunt splenic trauma were identified over a 6-year period. Mean injury grade was 2.9. Six patients required emergency splenectomy. An additional 7 patients met hemodynamic criteria for surgical intervention (3 splenectomies, 4 splenorrhaphies). Admission CT was available in 63 patients. An arterial blush was identified in 5 (9.7%). Four remained stable and were treated conservatively. One underwent splenectomy for hemodynamic instability. There were no cases of delayed splenic rupture, failed nonoperative treatment, or long-term complications.

CONCLUSIONS

Contrast blush in children with blunt splenic trauma is rare, and its presence alone does not appear to predict delayed rupture or failure of nonoperative treatment. Based on this limited series, splenic artery embolization does not have a place in the management of splenic injuries in children.

Blunt injury to mesentery and small bowel:

Helical CT now allows rapid acquisition of sections through the abdomen and pelvis with optimal vascular opacification and minimal motion artifact. Oral contrast may aid in the identification of subtle bowel and mesenteric injuries and does not have any significant deleterious effects. CT findings of extraluminal enteric contrast, active hemorrhage, or free intraperitoneal-retroperitoneal air allow accurate diagnosis of SBMI in the setting of blunt abdominal trauma. Mesenteric hematoma in association with bowel wall thickening or the presence of significant amounts of free fluid without solid organ injury is highly suspicious for SBMI requiring laparotomy. CT alone or in concert with DPL and physical examination is a valuable tool in the timely diagnosis and treatment of bowel and mesenteric injury caused by blunt trauma.

Autologous thrombin: a new embolization treatment for traumatic intrasplenic pseudoaneurysm

PURPOSE

To report the use of autologous thrombin for transcatheter embolization of a traumatic parenchymal splenic pseudoaneurysm.

CASE REPORT

A 15-year-old boy presented with a splenic parenchymal laceration after blunt abdominal trauma. The patient was managed conservatively but developed an intrasplenic pseudoaneurysm (grade III AAST scale) with subcapsular contrast extravasation after 3 weeks. Autologous thrombin was isolated from the patient's blood and subsequently delivered to the lesion by transcatheter superselective injection into the aneurysm neck. The patient was asymptomatic after the procedure. Nine months' follow-up demonstrated a normal spleen with completely homogenous parenchyma.

CONCLUSIONS

Autologous thrombin injection to induce thrombosis of intrasplenic pseudoaneurysm represents a new treatment option for traumatic abdominal organ injuries. Intrasac thrombosis can be safely induced to successfully restore the splenic parenchymal integrity without introduction of foreign material and associated risks of adverse reactions or infection that might accompany the use of commercial thrombin preparations.

Contribution of age and gender to outcome of blunt splenic injury in adults: multicenter study of the eastern association for the surgery of trauma

BACKGROUND

The purpose of this study was to examine the contribution of age and gender to outcome after treatment of blunt splenic injury in adults.

METHODS

Through the Multi-Institutional Trials Committee of the Eastern Association for the Surgery of Trauma (EAST), 1488 adult patients from 27 trauma centers who suffered blunt splenic injury in 1997 were examined retrospectively.

RESULTS

Fifteen percent of patients were 55 years of age or older. A similar proportion of patients > or = 55 went directly to the operating room compared with patients < 55 (41% vs. 38%) but the mortality for patients > or = 55 was significantly greater than patients < 55 (43% vs. 23%). Patients > or = 55 failed nonoperative management (NOM) more frequently than patients < 55 (19% vs. 10%) and had increased mortality for both successful NOM (8% vs. 4%, p < 0.05) and failed NOM (29% vs. 12%, p = 0.054). There were no differences in immediate operative treatment, successful NOM, and failed NOM between men and women. However, women > or = 55 failed NOM more frequently than women < 55 (20% vs. 7%) and this was associated with increased mortality (36% vs. 5%) (both p < 0.05).

CONCLUSION

Patients > or = 55 had a greater mortality for all forms of treatment of their blunt splenic injury and failed NOM more frequently than patients < 55. Women > or = 55 had significantly greater mortality and failure of NOM than women < 55.

CT of blunt trauma bowel and mesenteric injury: typical findings and pitfalls in diagnosis

Detection of bowel and mesenteric injury can be challenging in patients after blunt abdominal trauma. Early diagnosis and treatment are critical to decrease patient morbidity and mortality. Computed tomography (CT) has become the primary modality for the imaging of these patients. Signs of bowel perforation such as free air and contrast material are virtually pathognomonic. Bowel-wall thickening, free fluid, and mesenteric infiltration may be seen with this type of injury and partial thickness injuries. The authors present and discuss the range of CT findings seen with bowel and mesenteric injuries. Examples of observation and interpretation errors are also provided to highlight pitfalls encountered in the evaluation of abdominopelvic CT scans in patients after blunt trauma.

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.