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Lundy ME, Zhang B, Ditillo M. Management of the Geriatric Trauma Patient. Surg Clin North Am 2024; 104:423-436. [PMID: 38453311 DOI: 10.1016/j.suc.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
With a rapidly aging worldwide population, the care of geriatric trauma patients will be at the forefront of every career in Trauma and Acute Care Surgery. The unique intersection of advanced age, comorbidities, frailty, and physiologic changes presents a challenge in the care of elderly injured patients. It is well established that increasing age is associated with higher mortality and worse outcomes after injury, but it is also clear that there is room for improvement in the management of this special patient population.
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Affiliation(s)
- Megan Elizabeth Lundy
- University of Arizona Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, 1501 North Campbell Avenue, Tucson, AZ 85724, USA. https://twitter.com/MLundyMD
| | - Bo Zhang
- University of Arizona Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, 1501 North Campbell Avenue, Tucson, AZ 85724, USA. https://twitter.com/bo_zhang1
| | - Michael Ditillo
- University of Arizona Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, 1501 North Campbell Avenue, Tucson, AZ 85724, USA.
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Kim H, Song KJ, Hong KJ, Park JH, Kim TH, Lee SGW. Effects of Transport to Trauma Centers on Survival Outcomes Among Severe Trauma Patients in Korea: Nationwide Age-Stratified Analysis. J Korean Med Sci 2024; 39:e60. [PMID: 38374629 PMCID: PMC10876434 DOI: 10.3346/jkms.2024.39.e60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 12/14/2023] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Previous studies showed that the prognosis for severe trauma patients is better after transport to trauma centers compared to non-trauma centers. However, the benefit from transport to trauma centers may differ according to age group. The aim of this study was to compare the effects of transport to trauma centers on survival outcomes in different age groups among severe trauma patients in Korea. METHODS Cross-sectional study using Korean national emergency medical service (EMS) based severe trauma registry in 2018-2019 was conducted. EMS-treated trauma patients whose injury severity score was above or equal to 16, and who were not out-of-hospital cardiac arrest or death on arrival were included. Patients were classified into 3 groups: pediatrics (age < 19), working age (age 19-65), and elderly (age > 65). The primary outcome was in-hospital mortality. Multivariable logistic regression analysis was conducted to evaluate the effect of trauma center transport on outcome after adjusting of age, sex, comorbidity, mechanism of injury, Revised Trauma Score, and Injury Severity Score. All analysis was stratified according to the age group, and subgroup analysis for traumatic brain injury was also conducted. RESULTS Overall, total of 10,511 patients were included in the study, and the number of patients in each age group were 488 in pediatrics, 6,812 in working age, and 3,211 in elderly, respectively. The adjusted odds ratio (95% confidence interval [CI]) of trauma center transport on in-hospital mortality from were 0.76 (95% CI, 0.43-1.32) in pediatrics, 0.78 (95% CI, 0.68-0.90) in working age, 0.71(95% CI, 0.60-0.85) in elderly, respectively. In subgroup analysis of traumatic brain injury, the benefit from trauma center transport was observed only in elderly group. CONCLUSION We found out trauma centers showed better clinical outcomes for adult and elderly groups, excluding the pediatric group than non-trauma centers. Further research is warranted to evaluate and develop the response system for pediatric severe trauma patients in Korea.
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Affiliation(s)
- Hakrim Kim
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kyoung Jun Song
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Seoul Metropolitan Government-Seoul National University Hospital Boramae Medical Center, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea.
| | - Ki Jeong Hong
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Jeong Ho Park
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Tae Han Kim
- Department of Emergency Medicine, Seoul Metropolitan Government-Seoul National University Hospital Boramae Medical Center, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Stephen Gyung Won Lee
- Department of Emergency Medicine, Seoul Metropolitan Government-Seoul National University Hospital Boramae Medical Center, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
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Peña K, Borad A, Burjonrappa S. Pediatric Blunt Splenic Trauma: Disparities in Management and Outcomes. J Surg Res 2024; 294:137-143. [PMID: 37879164 DOI: 10.1016/j.jss.2023.09.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 09/07/2023] [Accepted: 09/09/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION While nonoperative management has become widely accepted, whether nonoperative management of blunt splenic trauma is standardized across pediatric trauma centers and different racial groups warrants further investigation. Using the National Trauma Database, the purpose of this study was to quantify the differences in the management of pediatric splenic trauma across different pediatric trauma centers, with respect to injury severity, race, ethnicity, and insurance. METHODS Patients under 20 y of age with blunt splenic trauma reported to the 2018 and 2019 National Trauma Data Bank were identified. Primary outcomes were splenectomy, embolization, transfusion, mortality, injury severity score (ISS), and length of hospital stay (LOS) and length of intensive care unit stay. Continuous data and categorical data were analyzed using ANOVA and Chi-squared test, respectively. Nearest 1:1 neighbor matching was performed between minority patients and White patients. P < 0.05 for all comparative analyses was considered statistically significant. RESULTS Of the total cohort (n = 1919), 70.3% identified as White, while 21.6% identified as Black or Hispanic. The mortality rate was 0.3%. Among different race categories, the frequency of spleen embolization (P = 0.99), splenectomy (P = 0.99), blood transfusion (P = 1), and mortality (P = 1), were not significantly different. After controlling for ISS and age with propensity score matching, the mean hospital LOS remained significantly higher in minority patients, with a mean of 5.44 d compared to 4.72 d (P = 0.05). Mean length of intensive care unit stay was not significantly different after propensity matching, with a mean of 1.79 d and 1.56 spent in the ICU for minority and White patients respectively (P = 0.17). While propensity score matching preserved statistical significance, the ISS for the minority group remained 1.12 times higher than the ISS of the Caucasian group. There was no statistically significant difference among races with respect to different payment methods and insurance status, although Black and Hispanic patients were proportionally underinsured. CONCLUSIONS While minority patients had a relatively higher number of operative interventions and longer hospital and ICU stays, after propensity score matching, mean ISS remained higher in the minority group. Our findings suggest that injury severity is likely to influence the difference in LOS between the two groups. Furthermore, our data highlight how nonoperative management is not standardized across pediatric trauma centers.
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Affiliation(s)
- Kayla Peña
- Rutgers, RWJMS, New Brunswick, New Jersey
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Adeyemi OJ, Meltzer-Bruhn A, Esper G, DiMaggio C, Grudzen C, Chodosh J, Konda S. Crosswalk between Charlson Comorbidity Index and the American Society of Anesthesiologists Physical Status Score for Geriatric Trauma Assessment. Healthcare (Basel) 2023; 11:1137. [PMID: 37107971 PMCID: PMC10137761 DOI: 10.3390/healthcare11081137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 04/03/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
The American Society of Anesthesiologists Physical Status (ASA-PS) grade better risk stratifies geriatric trauma patients, but it is only reported in patients scheduled for surgery. The Charlson Comorbidity Index (CCI), however, is available for all patients. This study aims to create a crosswalk from the CCI to ASA-PS. Geriatric trauma cases, aged 55 years and older with both ASA-PS and CCI values (N = 4223), were used for the analysis. We assessed the relationship between CCI and ASA-PS, adjusting for age, sex, marital status, and body mass index. We reported the predicted probabilities and the receiver operating characteristics. A CCI of zero was highly predictive of ASA-PS grade 1 or 2, and a CCI of 1 or higher was highly predictive of ASA-PS grade 3 or 4. Additionally, while a CCI of 3 predicted ASA-PS grade 4, a CCI of 4 and higher exhibited greater accuracy in predicting ASA-PS grade 4. We created a formula that may accurately situate a geriatric trauma patient in the appropriate ASA-PS grade after adjusting for age, sex, marital status, and body mass index. In conclusion, ASA-PS grades can be predicted from CCI, and this may aid in generating more predictive trauma models.
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Affiliation(s)
- Oluwaseun John Adeyemi
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Ariana Meltzer-Bruhn
- Department of Orthopedic Surgery, New York University Grossman School of Medicine, New York, NY 10016, USA; (A.M.-B.); (G.E.); (S.K.)
| | - Garrett Esper
- Department of Orthopedic Surgery, New York University Grossman School of Medicine, New York, NY 10016, USA; (A.M.-B.); (G.E.); (S.K.)
| | - Charles DiMaggio
- Department of Surgery, New York University Grossman School of Medicine, New York, NY 10016, USA;
- Department of Population Health, New York University Grossman School of Medicine, New York, NY 10016, USA;
| | - Corita Grudzen
- Department of Medicine, Memorial Sloan Kettering Cancer Center, West Harrison, NY 10604, USA;
| | - Joshua Chodosh
- Department of Population Health, New York University Grossman School of Medicine, New York, NY 10016, USA;
- Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Sanjit Konda
- Department of Orthopedic Surgery, New York University Grossman School of Medicine, New York, NY 10016, USA; (A.M.-B.); (G.E.); (S.K.)
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Musetti S, Coccolini F, Tartaglia D, Cremonini C, Strambi S, Cicuttin E, Cobuccio L, Cengeli I, Zocco G, Chiarugi M. Non-operative management in blunt splenic trauma: A ten-years-experience at a Level 1 Trauma Center. EMERGENCY CARE JOURNAL 2022. [DOI: 10.4081/ecj.2022.10339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Trauma;
Spleen injuries are among the most frequent trauma-related injuries. The approach for diagnosis and management of Blunt Splenic Injury (BSI) has been considerably shifted towards Non- Operative Management (NOM) in the last few decades. NOM of blunt splenic injuries includes Splenic Angio-Embolization (SAE). Aim of this study was to analyze Pisa Level 1 trauma center (Italy) last 10-years-experience in the management of Blunt Splenic Trauma (BST), and more specifically to evaluate NOM rate and failure. Retrospective analysis of all patients admitted with blunt splenic trauma was done. They were divided into two groups according to the treatment: hemodynamically unstable patients treated operatively (OM group) and patients underwent a nonoperative management (NOM group). The CT scan performed in all NOM group patients. Univariate analysis was performed to identify differences between the two groups. Multivariate analysis adjusting for factors with a p value < 0.05 or with clinical relevance was used to identify possible risk factors for NOM failure. 193 consecutive patients with blunt splenic trauma were admitted. Emergency splenectomies were performed in 53 patients (OM group); 140 were managed non-operatively with or without SAE (NOM group). NOM rate in high grade injuries is 57%. Overall NOM failure rate is 9%, and success rate in high grade splenic injuries is 48%; multivariate analysis showed AAST score ≥3 as a risk factor for NOM failure. Non-operative management currently represents the gold standard management for hemodynamically stable patient with blunt splenic trauma even in high grade splenic injuries. AAST ≥3 spleen lesion is a failure risk factor but not a contraindication to for non-operative management.
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Adolescent blunt solid organ injury: Differences in management strategies and outcomes between pediatric and adult trauma centers. Am J Surg 2022; 224:13-17. [DOI: 10.1016/j.amjsurg.2022.02.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 12/20/2021] [Accepted: 02/17/2022] [Indexed: 12/29/2022]
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Kofinas AG, Stavrati KE, Symeonidis NG, Pavlidis ET, Psarras KK, Shulga IN, Marneri AG, Nikolaidou CC, Pavlidis TE. Non-Operative Management of Delayed Splenic Rupture 4 Months Following Blunt Abdominal Trauma. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e932577. [PMID: 34417433 PMCID: PMC8392706 DOI: 10.12659/ajcr.932577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Delayed splenic rupture is a rare complication of non-operative management of a primary splenic trauma which, without proper clinical vigilance, may result in life-threatening events. It usually occurs 4-8 days after injury and, in most cases, surgery is the treatment of choice. Since non-operative management of splenic trauma, which allows splenic salvage, has become increasingly popular, the same approach could also be applied in delayed splenic rupture. We herein present a case of delayed splenic rupture that occurred 4 months after the trauma and was successfully managed non-operatively. CASE REPORT A 32-year-old woman presented with diffuse abdominal pain, chest pain, and dyspnea 4 months after sustaining minor thoracoabdominal blunt trauma due to a car accident. That event was inadequately investigated and was not admitted for further monitoring. Computerized tomography revealed a rupture of a splenic hematoma in the context of the previous splenic trauma. She was closely monitored and remained hemodynamically stable. She was discharged and followed up, with no reported relapse of her clinical condition. CONCLUSIONS Delayed splenic rupture occurring 4 months after the primary splenic trauma is extremely rare. Due to its prolonged delay, delayed rupture of the spleen can easily be overlooked and not be included in the original differential diagnosis. Negligence of this event can result in dreaded complications with hemodynamic instability or even death. Furthermore, its higher mortality rate compared to primary splenic rupture highlights the importance of proper clinical vigilance. Non-operative management should be attempted in hemodynamically stable patients.
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Romeo L, Bagolini F, Ferro S, Chiozza M, Marino S, Resta G, Anania G. Laparoscopic surgery for splenic injuries in the era of non-operative management: current status and future perspectives. Surg Today 2020; 51:1075-1084. [PMID: 33196920 PMCID: PMC8215029 DOI: 10.1007/s00595-020-02177-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/12/2020] [Indexed: 11/28/2022]
Abstract
The spleen is one of the organs most commonly injured by blunt abdominal trauma. It plays an important role in immune response to infections, especially those sustained by encapsulated bacteria. Nonoperative management (NOM), comprising clinical and radiological observation with or without angioembolization, is the treatment of choice for traumatic splenic injury in patients who are hemodynamically stable. However, this strategy carries a risk of failure, especially for high-grade injuries. No clear predictors of failure have been identified, but minimally invasive surgery for splenic injury is gaining popularity. Laparoscopic surgery has been proposed as an alternative to open surgery for hemodynamically stable patients who require surgery, such as after failed NOM. We reviewed research articles on laparoscopic surgery for hemodynamically stable patients with splenic trauma to explore the current knowledge about this topic. After presenting an overview of the treatments for splenic trauma and the immunological function of the spleen, we try to identify the future indications for laparoscopic surgery in the era of NOM.
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Affiliation(s)
- Luigi Romeo
- Department of Morphology, Surgery and Experimental Medicine, Sant'Anna University Hospital, University of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy.
| | - Francesco Bagolini
- Department of Morphology, Surgery and Experimental Medicine, Sant'Anna University Hospital, University of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Silvia Ferro
- Department of Morphology, Surgery and Experimental Medicine, Sant'Anna University Hospital, University of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Matteo Chiozza
- Department of Morphology, Surgery and Experimental Medicine, Sant'Anna University Hospital, University of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Serafino Marino
- Department of Surgery, Surgery 1 Unit, Sant'Anna University Hospital, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Giuseppe Resta
- Department of Surgery, Surgery 1 Unit, Sant'Anna University Hospital, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Gabriele Anania
- Department of Morphology, Surgery and Experimental Medicine, Sant'Anna University Hospital, University of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy.,Department of Surgery, Surgery 1 Unit, Sant'Anna University Hospital, Via Aldo Moro 8, 44124, Ferrara, Italy
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Gakumazawa M, Toida C, Muguruma T, Shinohara M, Abe T, Takeuchi I. In-Hospital Mortality Risk of Transcatheter Arterial Embolization for Patients with Severe Blunt Trauma: A Nationwide Observational Study. J Clin Med 2020; 9:jcm9113485. [PMID: 33126724 PMCID: PMC7692569 DOI: 10.3390/jcm9113485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/26/2020] [Accepted: 10/26/2020] [Indexed: 12/05/2022] Open
Abstract
This study investigated the risk factors for in-hospital mortality of severe blunt trauma patients who underwent transcatheter arterial embolization (TAE). We analysed data from the Japan Trauma Data Bank from 2009 to 2018. Patients with severe blunt trauma and an Injury Severity Score (ISS) ≥ 16 who underwent TAE were enrolled. The primary analysis evaluated patient characteristics and outcomes, and variables with significant differences were included in the secondary multivariate logistic regression analysis. In total, 5800 patients (6.4%) with ISS ≥ 16 underwent TAE. There were significant differences in the proportion of male patients, transportation method, injury mechanism, injury region, Revised Trauma Score, survival probability values, and those who underwent urgent blood transfusion and additional urgent surgery. In multivariable regression analyses, higher age, urgent blood transfusion, and initial urgent surgery were significantly associated with higher in-hospital mortality risk [p < 0.001, odds ratio (OR), 95% confidence interval (CI): 1.01 (1.00–1.01); p < 0.001, 3.50 (2.55–4.79); and p = 0.001, 1.36 (1.13–1.63), respectively]. Inter-hospital transfer was significantly associated with lower in-hospital mortality risk (p < 0.001, OR = 0.56, 95% CI = 0.44–0.71). Treatment protocols for urgent intervention before and after TAE and a safe, rapid inter-hospital transport system are needed to improve mortality risks for severe blunt trauma patients.
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Smith A, Onyiego A, Duchesne J, Tatum D, Harris C, Moreno-Ponte OI, Strumwasser A, Inaba K, O'Keeffe T, Black J, Quintana MT, Gupta S, Brocker J, Schreiber M, Pickett ML, Cripps MW, Guidry C. A Multi-Institutional Analysis of Damage Control Laparotomy in Elderly Trauma Patients: Do Geriatric Trauma Protocols Matter? Am Surg 2020; 86:1135-1143. [PMID: 32809869 DOI: 10.1177/0003134820943646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Trauma centers are receiving increasing numbers of older trauma patients. There is a lack of literature on the outcomes for elderly trauma patients who undergo damage control laparotomy (DCL). We hypothesized that trauma centers with geriatric protocols would have better outcomes in elderly patients after DCL. METHODS A retrospective chart review of consecutive adult trauma patients with DCL at 8 level 1 trauma centers was conducted from 2012 to 2018. Patients aged 40 or older were included. Age ≥ 55 years was defined as elderly. Demographics, injury information, clinical outcomes, including mortality, and complications were recorded. Univariate and multivariate analyses were performed. RESULTS A total of 379 patients with DCLs were identified with an average age of 54.8 ± 0.4 years with 39.3% (n = 149/379) of patients aged ≥ 55. Geriatric protocols or a consulting geriatric service was present at 37.5% (n = 3/8) of institutions. Age ≥ 55 was a significant risk factor for in-hospital mortality (OR 2, 95% CI 1.0-4.0, P = .04). Institutions without dedicated geriatric trauma protocols/services had higher overall in-hospital mortality on both univariate (57.9% vs 34.3%, P = .02) and multivariate analyses (OR 2.1, 95% CI 1.3-3.4, P < .001). CONCLUSIONS Surgical management of older trauma patients remains a challenge. Geriatric protocols or dedicated services were found to be associated with improved outcomes. Future efforts should focus on standardizing the availability of these resources at trauma centers.
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Affiliation(s)
- Alison Smith
- 57835783 Department of Surgery, Tulane School of Medicine, New Orleans, LA, USA
| | - Alexandra Onyiego
- 57835783 Department of Surgery, Tulane School of Medicine, New Orleans, LA, USA
| | - Juan Duchesne
- 57835783 Department of Surgery, Tulane School of Medicine, New Orleans, LA, USA
| | - Danielle Tatum
- Our Lady of the Lake Trauma Hospital, Baton Rouge, LA, USA
| | - Charles Harris
- 57835783 Department of Surgery, Tulane School of Medicine, New Orleans, LA, USA
| | | | | | - Kenji Inaba
- University of Southern California, Los Angeles, CA, USA
| | | | | | - Megan T Quintana
- 21668 Shock Trauma Center University of Maryland, Baltimore, MD, USA
| | - Shailvi Gupta
- 21668 Shock Trauma Center University of Maryland, Baltimore, MD, USA
| | - Jason Brocker
- 21668 Shock Trauma Center University of Maryland, Baltimore, MD, USA
| | | | | | | | - Chrissy Guidry
- 57835783 Department of Surgery, Tulane School of Medicine, New Orleans, LA, USA
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Bashir R, Grigorian A, Lekawa M, Joe V, Schubl SD, Chin TL, Kong A, Nahmias J. Octogenarians with blunt splenic injury: not all geriatrics are the same. Updates Surg 2020; 73:1533-1539. [PMID: 32306276 PMCID: PMC7223657 DOI: 10.1007/s13304-020-00765-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 04/11/2020] [Indexed: 11/29/2022]
Abstract
Geriatric trauma patients (GTP) (age ≥ 65 years) with blunt splenic injury (BSI) have up to a 6% failure rate of non-operative management (NOM). GTPs failing NOM have a similar mortality rate compared to GTPs managed successfully with NOM. However, it is unclear if this remains true in octogenarians (aged 80–89 years). We hypothesized that the failure rate for NOM in octogenarians would be similar to their younger geriatric cohort, patients aged 65–79 years; however risk of mortality in octogenarians who fail NOM would be higher than that of octogenarians managed successfully with NOM. The Trauma Quality Improvement Program (2010–2016) was queried for patients with BSI. Those undergoing splenectomy within 6 h were excluded to select for patients undergoing NOM. Patients aged 65–79 years (young GTPs) were compared to octogenarians. A multivariable logistic regression model was used to determine the risk for failed NOM and mortality. From 43,041 BSI patients undergoing NOM, 3660 (8.5%) were aged 65–79 years and 1236 (2.9%) were octogenarians. Both groups had a similar median Injury Severity Score (ISS) (p = 0.10) and failure rate of NOM (6.6% young GTPs vs. 6.8% octogenarians p = 0.82). From those failing NOM, octogenarians had similar units of blood products transfused (p > 0.05) and a higher mortality rate (40.5% vs. 18.2%, p < 0.001), compared to young GTPs. Independent risk factors for failing NOM in octogenarians included ≥ 1 unit of packed red blood cells (PRBC) (p = 0.039) within 24 h of admission. Octogenarians who failed NOM had a higher mortality rate compared to octogenarians managed successfully with NOM (40.5% vs 23.6% p = 0.001), which persisted in a multivariable logistic regression analysis (OR 2.25, CI 1.37–3.70, p < 0.001). Late failure of NOM ≥ 24 h (vs. early failure) was not associated with increased risk of mortality (p = 0.88), but ≥ 1 unit of PRBC transfused had higher risk (OR 1.88, CI 1.20–2.95, p = 0.006). Compared to young GTPs with BSI, octogenarians have a similar rate of failed NOM. Octogenarians with BSI who fail NOM have over a twofold higher risk of mortality compared to those managed successfully with NOM. PRBC transfusion increases risk for mortality. Therefore, clinicians should consider failure of NOM earlier in the octogenarian population to mitigate the risk of increased mortality.
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Affiliation(s)
- Rame Bashir
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA.
| | - Areg Grigorian
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Michael Lekawa
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Victor Joe
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Sebastian D Schubl
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Theresa L Chin
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Allen Kong
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Jeffry Nahmias
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
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Davies J, Wells D. Splenic artery embolisation in trauma: A five-year single-centre experience at a UK major trauma centre. TRAUMA-ENGLAND 2019. [DOI: 10.1177/1460408618781412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
IntroductionSince the introduction of major trauma centres and regional trauma networks in 2012, management of splenic injury has shifted, with non-operative management now favoured. For those requiring intervention, splenic artery embolisation is well established as a first-line treatment in all but the most severely injured. Follow-up is variable, with few guidelines, highlighting the paucity of data addressing the need for further imaging and antimicrobial prophylaxis. This review was undertaken to assess practice and outcomes at our centre in the context of the contemporary literature.MethodsThis retrospective study captured splenic embolisations over five years (January 2012–December 2016). CRIS interventional radiology codes were used to retrieve embolisation cases and Trauma Audit and Research Network and hospital event statistics data were used to identify all cases of traumatic splenic injury and to identify splenectomy and non-operative management patients. Outcomes were compared with available standards from different sources.ResultsOver the study period 176 splenic injuries were identified, of which 122 underwent non-operative management, 28 were laparotomy first, and 26 undergoing embolisation with an increased trend to an ‘embolisation-first’ approach over this time. In the embolisation group, the age range was 16–79 yr (mean 41), 18 were male and the median time to intervention was 2 h 9 min (range 1.1–171 h), with eight following failed non-operative management. The proportion of proximal versus selective embolisation versus both was 10:14:1 and the predominant mechanism was coiling. One patient was not embolised due to absence of contrast extravasation on initial angiogram and two proceeded to splenectomy due to failure of splenic artery embolisation. There were complications in six patients: five ongoing left upper quadrant pain, one infected haematoma requiring drainage, two chest infections with pleural effusions, one of which required drainage. There were two deaths from other injuries. Fifteen of the 25 patients who underwent splenic artery embolisation had follow-up imaging, seven did not and three were excluded due to splenectomy and/or death; five patients were vaccinated according to the hospital splenectomy protocol, and six received prophylactic antibiotics.ConclusionOur data show that non-operative management is the mainstay of treatment for the majority of splenic injury patients. Serious complications are not common but variation does exist in follow-up. The changing management trends are in line with national data. These findings will help to further implement and develop local protocols but more work is required to address splenic function after embolisation and the requirement for antimicrobial prophylaxis.
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Affiliation(s)
- James Davies
- Department of Interventional Radiology, Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | - David Wells
- Department of Interventional Radiology, Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke-on-Trent, UK
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Lauerman M, Brenner M, Simpson N, Shanmuganathan K, Stein D, Scalea T. Extra-parenchymal splenic abnormalities not vascular injury predict need for primary splenectomy. Eur J Trauma Emerg Surg 2019; 46:1063-1069. [PMID: 30721339 DOI: 10.1007/s00068-019-01085-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 01/30/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE Radiographic indications for primary splenectomy (PS) in blunt splenic injury (BSI) after radiographic diagnosis are unknown. Improved understanding of radiographic characteristics of patients requiring splenectomy will help to appropriately triage patients to PS or non-operative management (NOM). METHODS A retrospective, single-center review was performed of BSI diagnosed with computerized tomography (CT). Patients undergoing splenectomy prior to CT diagnosis were excluded. RESULTS BSI was identified in 195 patients. On logistic regression, only subcapsular hematoma presence (OR 7.521, p = 0.002) and left upper quadrant hemoperitoneum (OR 6.146, p = 0.03) were associated with need for PS, while splenic laceration length, number of pseudoaneurysms (PSA), and active contrast extravasation (NS for all) were not. CONCLUSIONS Need for PS is predicted by extra-parenchymal pathology in subcapsular hematoma and hemoperitoneum. Splenic vascular injuries through PSA and active contrast extravasation do not predict the need for PS and can be considered for NOM.
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Affiliation(s)
- Margaret Lauerman
- Division of Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene St, Baltimore, MD, 21201, USA.
| | - Megan Brenner
- Department of Surgery, University of California Riverside School of Medicine, Moreno Valley, CA, 92555, USA
| | - Nana Simpson
- Division of Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene St, Baltimore, MD, 21201, USA
| | - Kathirkamanthan Shanmuganathan
- Division of Radiology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Deborah Stein
- Division of Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene St, Baltimore, MD, 21201, USA
| | - Thomas Scalea
- Division of Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene St, Baltimore, MD, 21201, USA
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Teuben MPJ, Spijkerman R, Blokhuis TJ, Pfeifer R, Teuber H, Pape HC, Leenen LPH. Safety of selective nonoperative management for blunt splenic trauma: the impact of concomitant injuries. Patient Saf Surg 2018; 12:32. [PMID: 30505349 PMCID: PMC6260576 DOI: 10.1186/s13037-018-0179-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 11/13/2018] [Indexed: 11/10/2022] Open
Abstract
Background Nonoperative management for blunt splenic injury is the preferred treatment. To improve the outcome of selective nonoperative therapy, the current challenge is to identify factors that predict failure. Little is known about the impact of concomitant injury on outcome. Our study has two goals. First, to determine whether concomitant injury affects the safety of selective nonoperative treatment. Secondly we aimed to identify factors that can predict failure. Methods From our prospective trauma registry we selected all nonoperatively treated adult patients with blunt splenic trauma admitted between 01.01.2000 and 12.21.2013. All concurrent injuries with an AIS ≥ 2 were scored. We grouped and compared patients sustaining solitary splenic injuries and patients with concomitant injuries. To identify specific factors that predict failure we used a multivariable regression analysis. Results A total of 79 patients were included. Failure of nonoperative therapy (n = 11) and complications only occurred in patients sustaining concomitant injury. Furthermore, ICU-stay as well as hospitalization time were significantly prolonged in the presence of associated injury (4 versus 13 days,p < 0.05). Mortality was not seen. Multivariable analysis revealed the presence of a femur fracture and higher age as predictors of failure. Conclusions Nonoperative management for hemodynamically normal patients with blunt splenic injury is feasible and safe, even in the presence of concurrent (non-hollow organ) injuries or a contrast blush on CT. However, associated injuries are related to prolonged intensive care unit- and hospital stay, complications, and failure of nonoperative management. Specifically, higher age and the presence of a femur fracture are predictors of failure.
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Affiliation(s)
- Michel Paul Johan Teuben
- 1Department of Trauma, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Roy Spijkerman
- 1Department of Trauma, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Taco Johan Blokhuis
- 2Department of Surgery, Maastricht University Medical Center, P. Debyelaan 24, 6229 HX Maastricht, The Netherlands
| | - Roman Pfeifer
- 3Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zürich, Switzerland
| | - Henrik Teuber
- 3Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zürich, Switzerland
| | - Hans-Christoph Pape
- 3Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zürich, Switzerland
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Fugazzola P, Morganti L, Coccolini F, Magnone S, Montori G, Ceresoli M, Tomasoni M, Piazzalunga D, Maccatrozzo S, Allievi N, Occhionorelli S, Ansaloni L. The need for red blood cell transfusions in the emergency department as a risk factor for failure of non-operative management of splenic trauma: a multicenter prospective study. Eur J Trauma Emerg Surg 2018; 46:407-412. [PMID: 30324241 DOI: 10.1007/s00068-018-1032-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 10/08/2018] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The majority of patients with splenic trauma undergo non-operative management (NOM); around 15% of these cases fail NOM and require surgery. The aim of the current study is to assess whether the hemodynamic status of the patient represents a risk factor for failure of NOM (fNOM) and if this may be considered a relevant factor in the decision-making process, especially in Centers where AE (angioembolization), intensive monitoring and 24-h-operating room are not available. Furthermore, the presence of additional risk factors for fNOM was investigated. MATERIALS AND METHODS This is a multicentre prospective observational study, including patients presenting with blunt splenic trauma older than 17 years, managed between 2014 and 2016 in two Italian trauma centres (ASST Papa Giovanni XXIII in Bergamo and Sant'Anna University Hospital in Ferrara-Italy). The risk factors for fNOM were analyzed with univariate and multivariate analyses. RESULTS In total, 124 patients were included in the study. In univariate analysis, the risk factors for fNOM were AAST grade > 3 (fNOM 37.5% vs 9.1%, p = 0.024), and the need of red blood cell (RBC) transfusion in the emergency department (ED) (fNOM 42.9% vs 8.9%, p = 0.011). Multivariate analysis showed that the only significant risk factor for fNOM was the need for RBC transfusion in the ED (p = 0.049). CONCLUSIONS The current study confirms the contraindication to NOM in case of hemodynamically instability in case of splenic trauma, as indicated by the most recent guidelines; attention should be paid to patients with transient hemodynamic stability, including patients who require transfusion of RBC in the ED. These patients could benefit from AE; in centers where AE, intensive monitoring and an 24-h-operating room are not available, this particular subgroup of patients should probably be treated with operative management.
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Affiliation(s)
- Paola Fugazzola
- General and Emergency Surgery Department, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy.
| | - Lucia Morganti
- General Surgery Department, Sant'Anna University Hospital, Ferrara, Italy
| | - Federico Coccolini
- General and Emergency Surgery Department, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy
| | - Stefano Magnone
- General and Emergency Surgery Department, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy
| | - Giulia Montori
- General and Emergency Surgery Department, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy
| | - Marco Ceresoli
- General and Emergency Surgery Department, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy
| | - Matteo Tomasoni
- General and Emergency Surgery Department, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy
| | - Dario Piazzalunga
- General and Emergency Surgery Department, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy
| | - Stefano Maccatrozzo
- General and Emergency Surgery Department, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy
| | - Niccolò Allievi
- General and Emergency Surgery Department, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy
| | | | - Luca Ansaloni
- General and Emergency Surgery Department, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy
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Is It safe? Nonoperative management of blunt splenic injuries in geriatric trauma patients. J Trauma Acute Care Surg 2018; 84:123-127. [PMID: 29077678 DOI: 10.1097/ta.0000000000001731] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Because of increased failure rates of nonoperative management (NOM) of blunt splenic injuries (BSI) in the geriatric population, dogma dictated that this management was unacceptable. Recently, there has been an increased use of this treatment strategy in the geriatric population. However, published data assessing the safety of NOM of BSI in this population is conflicting, and well-powered multicenter data are lacking. METHODS We performed a retrospective analysis of data from the National Trauma Data Bank (NTDB) from 2014 and identified young (age < 65) and geriatric (age ≥ 65) patients with a BSI. Patients who underwent splenectomy within 6 hours of admission were excluded from the analysis. Outcomes were failure of NOM and mortality. RESULTS We identified 18,917 total patients with a BSI, 2,240 (12%) geriatric patients and 16,677 (88%) young patients. Geriatric patients failed NOM more often than younger patients (6% vs. 4%, p < 0.0001). On logistic regression analysis, Injury Severity Score of 16 or higher was the only independent risk factor associated with failure of NOM in geriatric patients (odds ratio, 2.778; confidence interval, 1.769-4.363; p < 0.0001). There was no difference in mortality in geriatric patients who had successful vs. failed NOM (11% vs. 15%; p = 0.22). Independent risk factors for mortality in geriatric patients included admission hypotension, Injury Severity Score of 16 or higher, Glasgow Coma Scale score of 8 or less, and cardiac disease. However, failure of NOM was not independently associated with mortality (odds ratio, 1.429; confidence interval, 0.776-2.625; p = 0.25). CONCLUSION Compared with younger patients, geriatric patients had a higher but comparable rate of failed NOM of BSI, and failure rates are lower than previously reported. Failure of NOM in geriatric patients is not an independent risk factor for mortality. Based on our results, NOM of BSI in geriatric patients is safe. LEVEL OF EVIDENCE Therapeutic, level IV.
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17
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Al-Tarrah K, Moiemen N, Lord JM. The influence of sex steroid hormones on the response to trauma and burn injury. BURNS & TRAUMA 2017; 5:29. [PMID: 28920065 PMCID: PMC5597997 DOI: 10.1186/s41038-017-0093-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 07/19/2017] [Indexed: 12/24/2022]
Abstract
Trauma and related sequelae result in disturbance of homeostatic mechanisms frequently leading to cellular dysfunction and ultimately organ and system failure. Regardless of the type and severity of injury, gender dimorphism in outcomes following trauma have been reported, with females having lower mortality than males, suggesting that sex steroid hormones (SSH) play an important role in the response of body systems to trauma. In addition, several clinical and experimental studies have demonstrated the effects of SSH on the clinical course and outcomes following injury. Animal studies have reported the ability of SSH to modulate immune, inflammatory, metabolic and organ responses following traumatic injury. This indicates that homeostatic mechanisms, via direct and indirect pathways, can be maintained by SSH at local and systemic levels and hence result in more favourable prognosis. Here, we discuss the role and mechanisms by which SSH modulates the response of the body to injury by maintaining various processes and organ functions. Such properties of sex hormones represent potential novel therapeutic strategies and further our understanding of current therapies used following injury such as oxandrolone in burn-injured patients.
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Affiliation(s)
- K Al-Tarrah
- Institute of Inflammation and Ageing, Birmingham University Medical School, B15 2TT, Birmingham, UK.,Scar Free Foundation Centre for Burns Research, University Hospital Birmingham Foundation Trust, B15 2WB, Birmingham, UK
| | - N Moiemen
- Scar Free Foundation Centre for Burns Research, University Hospital Birmingham Foundation Trust, B15 2WB, Birmingham, UK
| | - J M Lord
- Institute of Inflammation and Ageing, Birmingham University Medical School, B15 2TT, Birmingham, UK
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18
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Coccolini F, Montori G, Catena F, Kluger Y, Biffl W, Moore EE, Reva V, Bing C, Bala M, Fugazzola P, Bahouth H, Marzi I, Velmahos G, Ivatury R, Soreide K, Horer T, Ten Broek R, Pereira BM, Fraga GP, Inaba K, Kashuk J, Parry N, Masiakos PT, Mylonas KS, Kirkpatrick A, Abu-Zidan F, Gomes CA, Benatti SV, Naidoo N, Salvetti F, Maccatrozzo S, Agnoletti V, Gamberini E, Solaini L, Costanzo A, Celotti A, Tomasoni M, Khokha V, Arvieux C, Napolitano L, Handolin L, Pisano M, Magnone S, Spain DA, de Moya M, Davis KA, De Angelis N, Leppaniemi A, Ferrada P, Latifi R, Navarro DC, Otomo Y, Coimbra R, Maier RV, Moore F, Rizoli S, Sakakushev B, Galante JM, Chiara O, Cimbanassi S, Mefire AC, Weber D, Ceresoli M, Peitzman AB, Wehlie L, Sartelli M, Di Saverio S, Ansaloni L. Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg 2017; 12:40. [PMID: 28828034 PMCID: PMC5562999 DOI: 10.1186/s13017-017-0151-4] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 08/04/2017] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Giulia Montori
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Walter Biffl
- Acute Care Surgery, The Queen's Medical Center, Honolulu, HI USA
| | - Ernest E Moore
- Trauma Surgery, Denver Health Medical Center, Denver, CO USA
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Camilla Bing
- General and Emergency Surgery Department, Empoli Hospital, Empoli, Italy
| | - Miklosh Bala
- General and Emergency Surgery, Hadassah Medical Center, Jerusalem, Israel
| | - Paola Fugazzola
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Hany Bahouth
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ingo Marzi
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie Universitätsklinikum Goethe-Universität Frankfurt, Frankfurt, Germany
| | - George Velmahos
- Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA USA
| | - Rao Ivatury
- Virginia Commonwealth University, Richmond, VA USA
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital and Örebro University, Orebro, Sweden.,Department of Surgery, Örebro University Hospital and Örebro University, Obreo, Sweden
| | - Richard Ten Broek
- Department of Surgery, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands
| | - Bruno M Pereira
- Trauma/Acute Care Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Gustavo P Fraga
- Trauma/Acute Care Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Kenji Inaba
- Division of Trauma and Critical Care, LAC+USC Medical Center, Los Angeles, CA USA
| | - Joseph Kashuk
- Department of Surgery, Assia Medical Group, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Neil Parry
- General and Trauma Surgery Department, London Health Sciences Centre, Victoria Hospital, London, ON Canada
| | - Peter T Masiakos
- Pediatric Trauma Service, Massachusetts General Hospital, Boston, MA USA
| | | | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB Canada
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | | | - Noel Naidoo
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - Francesco Salvetti
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Stefano Maccatrozzo
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | | | | | - Leonardo Solaini
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Antonio Costanzo
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Andrea Celotti
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Matteo Tomasoni
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Vladimir Khokha
- General Surgery Department, Mozir City Hospital, Mozir, Belarus
| | - Catherine Arvieux
- Clin. Univ. de Chirurgie Digestive et de l'Urgence, CHUGA-CHU Grenoble Alpes UGA-Université Grenoble Alpes, Grenoble, France
| | - Lena Napolitano
- Trauma and Surgical Critical Care, University of Michigan Health System, East Medical Center Drive, Ann Arbor, MI USA
| | - Lauri Handolin
- Trauma Unit, Helsinki University Hospital, Helsinki, Finland
| | - Michele Pisano
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Stefano Magnone
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - David A Spain
- Department of Surgery, Stanford University, Stanford, CA USA
| | - Marc de Moya
- Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA USA
| | - Kimberly A Davis
- General Surgery, Trauma, and Surgical Critical Care, Yale-New Haven Hospital, New Haven, CT USA
| | | | - Ari Leppaniemi
- General Surgery Department, Mehilati Hospital, Helsinki, Finland
| | - Paula Ferrada
- Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA USA
| | - Rifat Latifi
- General Surgery Department, Westchester Medical Center, Westchester, NY USA
| | - David Costa Navarro
- Colorectal Surgery Unit, Trauma Care Committee, Alicante General University Hospital, Alicante, Spain
| | - Yashuiro Otomo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, USA
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA USA
| | | | - Sandro Rizoli
- Trauma and Acute Care Service, St Michael's Hospital, Toronto, ON Canada
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, University of California, Davis Medical Center, Davis, CA USA
| | | | | | - Alain Chichom Mefire
- Department of Surgery and Obstetric and Gynecology, University of Buea, Buea, Cameroon
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Marco Ceresoli
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Andrew B Peitzman
- Surgery Department, University of Pittsburgh, Pittsburgh, Pensylvania USA
| | - Liban Wehlie
- General Surgery Department, Ayaan Hospital, Mogadisho, Somalia
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Salomone Di Saverio
- General, Emergency and Trauma Surgery Department, Maggiore Hospital, Bologna, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
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Zarzaur BL, Rozycki GS. An update on nonoperative management of the spleen in adults. Trauma Surg Acute Care Open 2017; 2:e000075. [PMID: 29766085 PMCID: PMC5877897 DOI: 10.1136/tsaco-2017-000075] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 04/05/2017] [Accepted: 04/07/2017] [Indexed: 11/05/2022] Open
Abstract
Many patients with blunt splenic injury are considered for nonoperative management and, with proper selection, the success rate is high. This paper aims to provide an update on the treatments and dilemmas of nonoperative management of splenic injuries in adults and to offer suggestions that may improve both consensus and patient outcomes.
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Affiliation(s)
- Ben L Zarzaur
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Grace S Rozycki
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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20
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Rong JJ, Liu D, Liang M, Wang QH, Sun JY, Zhang QY, Peng CF, Xuan FQ, Zhao LJ, Tian XX, Han YL. The impacts of different embolization techniques on splenic artery embolization for blunt splenic injury: a systematic review and meta-analysis. Mil Med Res 2017; 4:17. [PMID: 28573044 PMCID: PMC5450228 DOI: 10.1186/s40779-017-0125-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 05/10/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Splenic artery embolization (SAE) has been an effective adjunct to the Non-operative management (NOM) for blunt splenic injury (BSI). However, the optimal embolization techniques are still inconclusive. To further understand the roles of different embolization locations and embolic materials in SAE, we conducted this system review and meta-analyses. METHODS Clinical studies related to SAE for adult patients were researched in electronic databases, included PubMed, Embase, ScienceDirect and Google Scholar Search (between October 1991 and March 2013), and relevant information was extracted. To eliminate the heterogeneity, a sensitivity analysis was conducted on two reduced study sets. Then, the pooled outcomes were compared and the quality assessments were performed using Newcastle-Ottawa Scale (NOS). The SAE success rate, incidences of life-threatening complications of different embolization techniques were compared by χ2 test in 1st study set. Associations between different embolization techniques and clinical outcomes were evaluated by fixed-effects model in 2nd study set. RESULTS Twenty-three studies were included in 1st study set. And then, 13 of them were excluded, because lack of the necessary details of SAE. The remaining 10 studies comprised 2nd study set, and quality assessments were performed using NOS. In 1st set, the primary success rate is 90.1% and the incidence of life-threatening complications is 20.4%, though the cases which required surgical intervention are very few (6.4%). For different embolization locations, there was no obvious association between primary success rate and embolization location in both 1st and 2nd study sets (P > 0.05). But in 2nd study set, it indicated that proximal embolization reduced severe complications and complications needed surgical management. As for the embolic materials, the success rate between coil and gelfoam is not significant. However, coil is associated with a lower risk of life-threatening complications, as well as less complications requiring surgical management. CONCLUSIONS Different embolization techniques affect the clinical outcomes of SAE. The proximal embolization is the best option due to the less life-threatening complications. For commonly embolic material, coil is superior to gelfoam for fewer severe complications and less further surgery management.
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Affiliation(s)
- Jing-Jing Rong
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Dan Liu
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Ming Liang
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Qing-Hua Wang
- Department of Cardiology, Xinqiao Hospital of Third Military Medical University, Chongqing, 400038 China
| | - Jing-Yang Sun
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Quan-Yu Zhang
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Cheng-Fei Peng
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Feng-Qi Xuan
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Li-Jun Zhao
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Xiao-Xiang Tian
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Ya-Ling Han
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
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Abstract
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.
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Affiliation(s)
- R M Forsythe
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
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Summers JI, Ziembicki JA, Corcos AC, Peitzman AB, Billiar TR, Sperry JL. Characterization of sex dimorphism following severe thermal injury. J Burn Care Res 2015; 35:484-90. [PMID: 24823341 DOI: 10.1097/bcr.0000000000000018] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Sex-based outcome differences have been previously studied after thermal injury, with a higher risk of mortality being demonstrated in women. This is opposite to what has been found after traumatic injury. Little is known about the mechanisms and time course of these sex outcome differences after burn injury. A secondary analysis was performed using data from a prospective observational study designed to characterize the genetic and inflammatory response after significant thermal injury (2003-2010). Clinical outcomes were compared across sex (female vs male), and the independent risks associated with sex were determined using logistic regression analysis after controlling for important confounders. Stratified analysis across age and burn severity was performed, whereas Cox hazard survival curves were constructed to determine the time course of any sex differences found. During the time period of the study, 548 patients met inclusion criteria for the cohort study. Men and women were found to be similar in age, TBSA%, inhalation injury, and Acute Physiology and Chronic Health score. Regression analysis revealed that female sex was independently associated with over a 2-fold higher mortality after controlling for important confounders (odds ratio, 2.2; P = .049; 95% confidence interval, 1.01-4.8). The higher independent mortality risk for women was exaggerated and remained significant only in pediatric patients and demonstrated a dose-response relationship with increasing burn size (%TBSA). Survival analysis demonstrated early separation of female and male curves, and a greater independent risk of multiple organ failure was demonstrated in the pediatric cohort. The current results suggest that sex-based outcome differences may be different after thermal injury compared with traumatic injury and that the sex dimorphism may be exaggerated in patients with higher burn size and in those in the pediatric age group, with female sex being associated with poor outcome. These sex-based mortality differences occur early and may be a result of a higher risk of organ failure and early differences in the inflammatory response after burn injury. Further investigation is required to thoroughly characterize the mechanisms responsible for these divergent outcomes.
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Affiliation(s)
- Jessica I Summers
- From the Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, Pennsylvania
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Alabbasi T, Nathens AB, Tien H. Blunt splenic injury and severe brain injury: a decision analysis and implications for care. Can J Surg 2015; 58:S108-17. [PMID: 26100770 DOI: 10.1503/cjs.015814] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
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.
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Affiliation(s)
- Thamer Alabbasi
- The Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Avery B Nathens
- The Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Homer Tien
- The Canadian Forces Health Services, the 1 Canadian Field Hospital, Petawawa, Ont., the Trauma Services and the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont
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Sadro CT, Sandstrom CK, Verma N, Gunn ML. Geriatric Trauma: A Radiologist’s Guide to Imaging Trauma Patients Aged 65 Years and Older. Radiographics 2015; 35:1263-85. [DOI: 10.1148/rg.2015140130] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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25
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Untaroiu CD, Lu YC, Siripurapu SK, Kemper AR. Modeling the biomechanical and injury response of human liver parenchyma under tensile loading. J Mech Behav Biomed Mater 2015; 41:280-91. [DOI: 10.1016/j.jmbbm.2014.07.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 07/02/2014] [Accepted: 07/04/2014] [Indexed: 12/12/2022]
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Fernandes TM, Dorigatti AE, Pereira BMT, Cruvinel Neto J, Zago TM, Fraga GP. Nonoperative management of splenic injury grade IV is safe using rigid protocol. Rev Col Bras Cir 2014; 40:323-9. [PMID: 24173484 DOI: 10.1590/s0100-69912013000400012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 10/18/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To demonstrate the protocol and experience of our service in the nonoperative management (NOM) of grade IV blunt splenic injuries. METHODS This is a retrospective study based on trauma registry of a university hospital between 1990-2010. Charts of all patients with splenic injury were reviewed and patients with grade IV lesions treated nonoperatively were included in the study. RESULTS ninety-four patients with grade IV blunt splenic injury were admitted during this period. Twenty-six (27.6%) met the inclusion criteria for NOM. The average systolic blood pressure on admission was 113.07 ± 22.22 mmHg, RTS 7.66 ± 0.49 and ISS 18.34 ± 3.90. Ten patients (38.5%) required blood transfusion, with a mean of 1.92 ± 1.77 packed red cells per patient. Associated abdominal injuries were present in two patients (7.7%). NOM failed in two patients (7.7%), operated on due to worsening of abdominal pain and hypovolemic shock. No patient developed complications related to the spleen and there were no deaths in this series. Average length of hospital stay was 7.12 ± 1.98 days. CONCLUSION Nonoperative treatment of grade IV splenic injuries in blunt abdominal trauma is safe when a rigid protocol is followed.
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Delayed splenic rupture: dating the sub-capsular hemorrhage as a useful task to evaluate causal relationships with trauma. Forensic Sci Int 2013; 234:64-71. [PMID: 24378304 DOI: 10.1016/j.forsciint.2013.10.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Revised: 10/13/2013] [Accepted: 10/28/2013] [Indexed: 11/21/2022]
Abstract
The aim of the paper was to perform a chronological assessment of the phenomenon of delayed rupture of the spleen, to assess the phenomenological order about the sub-capsular hematoma transformation to determine the causal relationship with trauma as hypothetical cause of death. 80 cases of blunt trauma with splenic capsular hematoma and subsequent rupture of the spleen were evaluated: 38 had an acute rupture of the spleen, 42 presented a break in days or weeks after the traumatic injury. Time between the traumatic event and delayed rupture of the spleen is within a range of time from one day to more than one month. Data recorded included age, sex, type of trauma, injury severity score, grade of splenic injury, associated intra-abdominal injuries, pathologic specimen evaluation. Immunohistochemical investigation of perisplenic hematoma or laceration was performed utilizing polyclonal antibodies anti-fibrinogen, CD61 and CD68, and showed structural chronological differences of sub-capsular hematoma. Expression of modification and organization of erythrocytes, fibrinogen, platelets and macrophages provides an informative picture of the progression of reparative phenomena associated with sub-capsular hematoma and subsequent delayed splenic rupture. Sub-capsular splenic hematoma dating, which we divided into 4 phases, is representing a task in both clinical practice and forensic pathology.
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Trauma center variation in splenic artery embolization and spleen salvage: a multicenter analysis. J Trauma Acute Care Surg 2013; 75:69-74; discussion 74-5. [PMID: 23778441 DOI: 10.1097/ta.0b013e3182988b3b] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study aimed to evaluate if variation in management of blunt splenic injury (BSI) among Level I trauma centers is associated with different outcomes related to the use of splenic artery embolization (SAE). METHODS All adult patients admitted for BSI from 2008 to 2010 at 4 Level I trauma centers were reviewed. Use of SAE was determined, and outcomes of spleen salvage and nonoperative management (NOM) failure were evaluated. A priori, a 10% SAE rate was used to group centers into high- or low-use groups. RESULTS There were 1,275 BSI patients. There were intercenter differences in age, injury severity, and grade of spleen injury (Spleen Injury Scale [SIS]). Mortality was similar by center; however, BSI treatment varied significantly by center. Overall, SAE use was highest at center A compared with B, C, and D (19%, 11%, 1%, and 4%, respectively; p < 0.01). High SAE use centers had significantly higher spleen salvage rates and fewer NOM failures. Differences in the use of SAE (25% vs. 2%, p < 0.01) and salvage rate (67% vs. 56%, p = 0.03) were most dramatic between high- and low-use SAE centers for Grade 3 and 4 injured spleens. In patients who received initial NOM, multivariate logistic regression analysis showed that SAE was an independent predictor of spleen salvage (odds ratio, 5; 95% confidence interval, 1.8-13.5; p < 0.01) as were lower age, lower SIS, and Injury Severity Score (ISS). Patients treated at high SAE use centers were more likely to leave the hospital with their spleen in situ (odds ratio, 3; 95% confidence interval, 1.7-6.3; p < 0.01). CONCLUSION Significant practice variation exists in the use of SAE in treating BSI at Level I trauma centers. Centers with higher rates of SAE use have higher spleen salvage and less NOM failure. SAE was shown to be an independent predictor of spleen salvage. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Bhullar IS, Frykberg ER, Tepas JJ, Siragusa D, Loper T, Kerwin AJ. At first blush. J Trauma Acute Care Surg 2013; 74:105-11; discussion 111-2. [DOI: 10.1097/ta.0b013e3182788cd2] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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31
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Large animal-related injury requiring hospital admission: injury pattern disparities. Injury 2012; 43:1898-902. [PMID: 21561618 DOI: 10.1016/j.injury.2011.03.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 03/21/2011] [Accepted: 03/21/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND Due to the infrequent occurrence of large animal-related injury (LARI) in many areas, their significance as a public health problem could be overlooked. The purpose of this study was to examine the demographics and injury disparities associated with LARI. METHODS The Healthcare Cost and Utilization Project Nationwide Inpatient Survey from 2001 was used to construct a cohort of patients admitted after LARI. Patients were stratified by age, gender, race, and median household income of patient's zip code. Where available total hospital charges were converted to cost using the hospital's cost-to-charge ratio. To determine variables associated with injury type, univariable and multivariable logistic regression analysis were used. RESULTS 2424 LARI admissions were identified within the database. The largest proportion of admitted patients were female (53.8%), Caucasian (64.6%), and from areas with median income >$45,000 (41.8%). Average hospital cost was $5062. Overall, the most common injuries were rib fractures (15.2%), vertebral fractures (11.6%) and haemo-pneumothorax (9%). Multivariable logistic regression analysis revealed that age disparities with older patients receiving more rib fractures, haemo-pneumothorax, vertebral fractures, and pelvic fractures. Skull fractures and head injuries are disproportionately seen in younger patients. Gender disparities were also present, with females more likely to have vertebral fractures but less likely to have rib fractures and heart and lung injuries. CONCLUSIONS Disparities based on age and gender are associated with hospital admission for LARI in the United States. These admissions have a significant impact on the healthcare system with nationwide cost estimates of nearly $60 million. These findings represent potential areas for targeted prevention efforts.
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Bhangu A, Nepogodiev D, Lal N, Bowley DM. Meta-analysis of predictive factors and outcomes for failure of non-operative management of blunt splenic trauma. Injury 2012; 43:1337-46. [PMID: 21999935 DOI: 10.1016/j.injury.2011.09.010] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Accepted: 09/13/2011] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Aneel Bhangu
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Birmingham, UK.
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Kawasaki T, Chaudry IH. The effects of estrogen on various organs: therapeutic approach for sepsis, trauma, and reperfusion injury. Part 1: central nervous system, lung, and heart. J Anesth 2012; 26:883-91. [DOI: 10.1007/s00540-012-1425-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 05/24/2012] [Indexed: 10/28/2022]
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Bhullar IS, Frykberg ER, Siragusa D, Chesire D, Paul J, Tepas JJ, Kerwin AJ. Age Does Not Affect Outcomes of Nonoperative Management of Blunt Splenic Trauma. J Am Coll Surg 2012; 214:958-64. [DOI: 10.1016/j.jamcollsurg.2012.03.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 03/09/2012] [Accepted: 03/09/2012] [Indexed: 11/29/2022]
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Skattum J, Naess PA, Gaarder C. Non-operative management and immune function after splenic injury. Br J Surg 2012; 99 Suppl 1:59-65. [PMID: 22441857 DOI: 10.1002/bjs.7764] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND There is still considerable controversy about the importance and method of preserving splenic function after trauma. Recognition of the immune function of the spleen and the risk of overwhelming postsplenectomy infection led to the development of spleen-preserving surgery and non-operative management. More recently angiographic embolization has been used to try to reduce failure of conservative management and preserve splenic function. METHODS A literature review was performed of the changing treatment of splenic injury over the last century, focusing on whether and how to maintain splenic immune function. RESULTS Non-operative management continues to be reported as a successful approach in haemodynamically stable patients without other indications for laparotomy, achieving high success rates in both children and adults. Except for haemodynamic instability, reported predictors of failure of conservative treatment should not be seen as absolute contraindications to this approach. Angiographic embolization is generally reported to increase success rates of non-operative management, currently approaching 95 per cent. However, the optimal use of angioembolization is still debated. Splenic immunocompetence after angioembolization remains questionable, although existing studies seem to indicate preserved splenic function. CONCLUSION Non-operative management has become the treatment of choice to preserve splenic immune function. Current knowledge suggests that immunization is unnecessary after angiographic embolization for splenic injury. Identifying a diagnostic test of splenic function will be important for future studies. Most importantly, in efforts to preserve splenic function, care must be taken not to jeopardize patients at risk of bleeding who require early surgery and splenectomy.
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Affiliation(s)
- J Skattum
- Department of Traumatology, Division of Emergency and Critical Care, Oslo University Hospital, N-0407 Oslo, Norway
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Time dependent influence of host factors on outcome after trauma. Eur J Epidemiol 2012; 27:233-41. [PMID: 22278437 DOI: 10.1007/s10654-012-9651-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 01/12/2012] [Indexed: 02/07/2023]
Abstract
The impact of host factors, such as gender and co-morbidity, on mortality after trauma has been debated. Quantification of risk factors is dependent on methodological considerations including follow-up time, definitions and adjustment of potential confounders. Optimal follow-up time of trauma patients remains to be elucidated. We investigated the impact of gender and co-morbidity on short and long term mortality in a cohort including 4,051 patients from a level 1 trauma centre. Data from the trauma cohort were linked to validated national registries. 30 and 360-day survival were analysed with logistic and Cox regression, respectively. Long term survival was also estimated as standardized mortality ratio, which implies a comparison with a matched general population. The influence of host factors on outcome after trauma differed over time. Male gender was an independent risk factor for mortality at 1 year but not at 30-days post-injury, even after adjustment for clinically relevant confounders. This gender difference was also apparent when comparing mortality rates with the general population. Moreover, the effect of gender seems to be restricted to elderly patients. The presence of co-morbidity became a significant risk factor beyond 30 days after trauma, suggesting that this patient group may benefit from a more thorough follow up after hospital discharge. A persistent excess mortality compared to the general population was still seen 1 year after the trauma. Our findings indicate that the effect of trauma is not limited to the early post-injury period but adversely affects the long term outcome.
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Biomechanical response of human spleen in tensile loading. J Biomech 2012; 45:348-55. [DOI: 10.1016/j.jbiomech.2011.10.022] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 09/09/2011] [Accepted: 10/07/2011] [Indexed: 11/19/2022]
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Changing patterns in diagnostic strategies and the treatment of blunt injury to solid abdominal organs. Int J Emerg Med 2011; 4:47. [PMID: 21794108 PMCID: PMC3170179 DOI: 10.1186/1865-1380-4-47] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Accepted: 07/27/2011] [Indexed: 11/29/2022] Open
Abstract
Background In recent years there has been increasing interest shown in the nonoperative management (NOM) of blunt traumatic injury. The growing use of NOM for blunt abdominal organ injury has been made possible because of the progress made in the quality and availability of the multidetector computed tomography (MDCT) scan and the development of minimally invasive intervention options such as angioembolization. Aim The purpose of this review is to describe the changes that have been made over the past decades in the management of blunt trauma to the liver, spleen and kidney. Results The management of blunt abdominal injury has changed considerably. Focused assessment with sonography for trauma (FAST) examination has replaced diagnostic peritoneal lavage as diagnostic modality in the primary survey. MDCT scanning with intravenous contrast is now the gold standard diagnostic modality in hemodynamically stable patients with intra-abdominal fluid detected with FAST. One of the current discussions in the literature is whether a whole body MDCT survey should be implemented in the primary survey.
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Wu SC, Fu CY, Chen RJ, Chen YF, Wang YC, Chung PK, Yu SF, Tung CC, Lee KH. Higher incidence of major complications after splenic embolization for blunt splenic injuries in elderly patients. Am J Emerg Med 2011; 29:135-40. [DOI: 10.1016/j.ajem.2009.07.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Revised: 07/24/2009] [Accepted: 07/28/2009] [Indexed: 01/26/2023] Open
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Peitzman AB, Richardson JD. Surgical treatment of injuries to the solid abdominal organs: a 50-year perspective from the Journal of Trauma. ACTA ACUST UNITED AC 2011; 69:1011-21. [PMID: 21068605 DOI: 10.1097/ta.0b013e3181f9c216] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Andrew B Peitzman
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Doppler ultrasound for the assessment of conservatively treated blunt splenic injuries: a prospective study. Eur J Trauma Emerg Surg 2010; 37:197-202. [PMID: 26814956 DOI: 10.1007/s00068-010-0044-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2010] [Accepted: 08/13/2010] [Indexed: 10/19/2022]
Abstract
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.
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Renzulli P, Gross T, Schnüriger B, Schoepfer AM, Inderbitzin D, Exadaktylos AK, Hoppe H, Candinas D. Management of blunt injuries to the spleen. Br J Surg 2010; 97:1696-703. [DOI: 10.1002/bjs.7203] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Non-operative management (NOM) of blunt splenic injuries is nowadays considered the standard treatment. The present study identified selection criteria for primary operative management (OM) and planned NOM.
Methods
All adult patients with blunt splenic injuries treated at Berne University Hospital, Switzerland, between 2000 and 2008 were reviewed.
Results
There were 206 patients (146 men) with a mean(s.d.) age of 38·2(19·1) years and an Injury Severity Score of 30·9(11·6). The American Association for the Surgery of Trauma classification of the splenic injury was grade 1 in 43 patients (20·9 per cent), grade 2 in 52 (25·2 per cent), grade 3 in 60 (29·1 per cent), grade 4 in 42 (20·4 per cent) and grade 5 in nine (4·4 per cent). Forty-seven patients (22·8 per cent) required immediate surgery. Transfusion of at least 5 units of red cells (odds ratio (OR) 13·72, 95 per cent confidence interval 5·08 to 37·01), Glasgow Coma Scale score below 11 (OR 9·88, 1·77 to 55·16) and age 55 years or more (OR 3·29, 1·07 to 10·08) were associated with primary OM. The rate of primary OM decreased from 33·3 to 11·9 per cent after the introduction of transcatheter arterial embolization in 2005. Overall, 159 patients (77·2 per cent) qualified for NOM, which was successful in 143 (89·9 per cent). The splenic salvage rate was 69·4 per cent. In multivariable analysis age at least 40 years was the only factor independently related to failure of NOM (OR 13·58, 2·76 to 66·71).
Conclusion
NOM of blunt splenic injuries has a low failure rate. Advanced age is independently associated with an increased failure rate.
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Affiliation(s)
- P Renzulli
- Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital, and University of Berne, Switzerland
| | - T Gross
- Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital, and University of Berne, Switzerland
| | - B Schnüriger
- Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital, and University of Berne, Switzerland
- Department of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, California, USA
| | - A M Schoepfer
- Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital, and University of Berne, Switzerland
- Farncombe Family Institute of Digestive Health Research, McMaster University, Hamilton, Ontario, Canada
| | - D Inderbitzin
- Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital, and University of Berne, Switzerland
| | - A K Exadaktylos
- Department of Emergency Medicine, Inselspital, Berne University Hospital, and University of Berne, Switzerland
| | - H Hoppe
- Department of Diagnostic Radiology, Inselspital, Berne University Hospital, and University of Berne, Switzerland
| | - D Candinas
- Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital, and University of Berne, Switzerland
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Talmor D, Legedza ATR, Nirula R. Injury thresholds after motor vehicle crash--important factors for patient triage and vehicle design. ACCIDENT; ANALYSIS AND PREVENTION 2010; 42:672-675. [PMID: 20159093 DOI: 10.1016/j.aap.2009.10.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2009] [Revised: 09/17/2009] [Accepted: 10/16/2009] [Indexed: 05/28/2023]
Abstract
INTRODUCTION The Committee on Trauma recommends that older motor vehicle crash (MVC) victims or victims of crashes with significant vehicle intrusion of more than 12 in. be transferred to a trauma center since those older than 55 have an increased risk of death after injury. Yet, the precise injury thresholds as they relate to age, gender and velocity remain ill-defined. To maintain a low rate of under triage, reliable methods to identify patients at moderate injury risk are needed. We therefore characterized the likelihood of moderate to severe injury in MVC victims to determine the influence of age, gender and velocity. METHODS An analysis of drivers from the National Automotive Sampling System (1993-2001) was performed. Weighted logistic regression models were developed to predict the probability of head, leg, and torso injuries as a function of vehicle speed, age, and gender while controlling for confounders. A 10% probability of injury threshold was set and differences in velocity, gender and age were identified in terms of reaching this probability of injury threshold. RESULTS The analysis yielded 56,459 drivers which is equivalent to a population of 28,877,696 drivers nationwide. Restraint use, steering away prior to impact, breaking maneuver, gender, delta velocity, driver height and age were independent predictors of injury. Women had a higher velocity injury threshold than men for the 10% probability of injury cut-off to the torso or head which disappeared with increasing age. Conversely, men had a higher velocity injury threshold than women for the 10% probability of injury cut-off to the extremity which persisted even in older victims. CONCLUSIONS Our data indicate that age and gender must be considered in addition to crash velocity when making triage decisions. Furthermore, Federal Motor Vehicle Safety Standards may need to be modified to address the increased risk of injury among older adults at lower velocities given the increasing number of elderly drivers in the US.
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Affiliation(s)
- Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
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Combined Splenectomy and Nephrectomy for Trauma: Morbidity, Mortality, and Outcomes Over 30 Years. ACTA ACUST UNITED AC 2010; 68:519-21. [DOI: 10.1097/ta.0b013e3181cda28d] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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In Search of Benchmarking for Mortality Following Multiple Trauma: A Swiss Trauma Center Experience. World J Surg 2009; 33:2477-89. [DOI: 10.1007/s00268-009-0193-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Haider AH, Crompton JG, Oyetunji T, Stevens KA, Efron DT, Kieninger AN, Chang DC, Cornwell EE, Haut ER. Females have fewer complications and lower mortality following trauma than similarly injured males: a risk adjusted analysis of adults in the National Trauma Data Bank. Surgery 2009; 146:308-15. [PMID: 19628090 DOI: 10.1016/j.surg.2009.05.006] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2009] [Accepted: 05/08/2009] [Indexed: 11/17/2022]
Abstract
BACKGROUND Studies of sexual dimorphism in trauma outcomes suggest that women have a survival advantage compared to equivalently injured men. It is unknown if this gender disparity is mediated by potentially life-threatening complications. OBJECTIVE To determine (1) if there is a sex-based differences in the odds of developing inpatient complications after trauma, and (2) if are these complications associated with death among trauma patients. METHODS Review of adult trauma patients admitted to hospitals in the National Trauma Data Bank that report complications. Patient and injury severity covariates were adjusted using multiple logistic regression and the independent effect of sex on developing complications and associated mortality was determined. RESULTS A total of 681,730 adult patients met the inclusion criteria of hospital admission > or =3 days. Women demonstrated a 21% lower adjusted risk of death compared to males (OR 0.79, 95% CI 0.76-0.83). Females had decreased adjusted odds of developing life-threatening complications including pneumonia, acute respiratory distress syndrome, acute renal failure and pulmonary embolism. However, when compared to males with life-threatening complications, females with complications were found to be at greater risk of dying. CONCLUSION This study demonstrates that women are less likely than men to develop inpatient complications, suggesting that the survival advantage among women after traumatic injury may involve a reduced susceptibility to developing life-threatening complications.
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Affiliation(s)
- Adil H Haider
- Trauma Outcomes Research Group-Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Abstract
In the acute-care setting, it is widely accepted that elderly patients have increased morbidity and mortality compared with young healthy patients. The reasons for this, however, are largely unknown. Although animal modeling has helped improve treatment strategies for young patients, there are a scarce number of studies attempting to understand the mechanisms of systemic insults such as trauma, burn, and sepsis in aged individuals. This review aims to highlight the relevance of using animals to study the pathogenesis of these insults in the aged and, despite the deficiency of information, to summarize what is currently known in this field.
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Observation For Nonoperative Management of the Spleen: How Long is Long Enough? ACTA ACUST UNITED AC 2008; 65:1354-8. [DOI: 10.1097/ta.0b013e31818e8fde] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
The spleen remains a vulnerable organ to blunt or penetrating abdominal trauma and recognition of its important immunological role has meant that alternatives to mandatory splenectomy for splenic injury are now available. This article examines the alternatives to splenectomy and then discusses the post-splenectomy management of patients.
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Zmora O, Kori Y, Samuels D, Kessler A, Schulman CI, Klausner JM, Soffer D. Proximal Splenic Artery Embolization In Blunt Splenic Trauma. Eur J Trauma Emerg Surg 2008; 35:108. [DOI: 10.1007/s00068-008-8030-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2008] [Accepted: 07/01/2008] [Indexed: 10/21/2022]
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