Blunt splenic injury

Delayed splenic rupture presenting 8 days following blunt abdominal trauma due to a motor vehicle accident

INTRODUCTION

Hemodynamic instability in previously stable trauma patients carries rather not a wide differential diagnosis. Delayed Splenic Rupture is certainly not on the top of the list.

CASE PRESENTATION

We present a patient with delayed splenic rupture eight days after a blunt abdominal trauma caused by a motor vehicle accident. The patient's initial full-body trauma protocol CT scan was negative for internal injuries and rib fractures. He was discharged after 48 h of uneventful observation. Returning eight days with grade III subcapsular splenic hematoma; with negative history of strenuous activities or a second trauma. A trial of non-operative management was opted for after stabilizing the patient. However, the patient's hemodynamic status deteriorated and he was operated on a couple of hours after presentation.

DISCUSSION

Delayed splenic rupture remains a rare diagnosis with an open time window for presentation. While it is a rare entity, delayed splenic rupture increases the mortality rate in an otherwise non-mortal injury.

CONCLUSION

This case presents an important educational value in bringing forth such rare diagnoses in trauma patients and highlights the management transition from a non-operative approach to an operative one.

Splenic rupture or infarction associated with Epstein-Barr virus infectious mononucleosis: a systematic literature review

BACKGROUND

Epstein-Barr virus (EBV), also known as human herpesvirus 4, is one of the most common pathogenic viruses in humans. EBV mononucleosis always involves the spleen and as such it predisposes to splenic rupture, often without a trauma, and splenic infarction. Nowadays the goal of management is to preserve the spleen, thereby eliminating the risk of post-splenectomy infections.

METHODS

To characterise these complications and their management, we performed a systematic review (PROSPERO CRD42022370268) following PRISMA guidelines in three databases: Excerpta Medica, the United States National Library of Medicine, and Web of Science. Articles listed in Google Scholar were also considered. Eligible articles were those describing splenic rupture or infarction in subjects with Epstein-Barr virus mononucleosis.

RESULTS

In the literature, we found 171 articles published since 1970, documenting 186 cases with splenic rupture and 29 with infarction. Both conditions predominantly occurred in males, 60% and 70% respectively. Splenic rupture was preceded by a trauma in 17 (9.1%) cases. Approximately 80% (n = 139) of cases occurred within three weeks of the onset of mononucleosis symptoms. A correlation was found between the World Society of Emergency Surgery splenic rupture score, which was retrospectively calculated, and surgical management: splenectomy in 84% (n = 44) of cases with a severe score and in 58% (n = 70) of cases with a moderate or minor score (p = 0.001). The mortality rate of splenic rupture was 4.8% (n = 9). In splenic infarction, an underlying haematological condition was observed in 21% (n = 6) of cases. The treatment of splenic infarction was always conservative without any fatal outcomes.

CONCLUSIONS

Similarly to traumatic splenic rupture, splenic preservation is increasingly common in the management of mononucleosis-associated cases as well. This complication is still occasionally fatal. Splenic infarction often occurs in subjects with a pre-existing haematological condition.

Delayed splenic rupture after a minor blunt trauma: A case report and literature review

Delayed Splenic Rupture (DSR) is a rare but well-known manifestation of Blunt Splenic Injury (BSI), which most commonly occurs following a car accident, a fall from a great height, or a direct blow to the left thorax or abdomen. If the history of trauma is remote or unknown, the diagnosis can be difficult or missed, and a high index of suspicion is not warranted. Regardless of the time and mechanism of the inciting event, DSR should be considered in the differential diagnosis of an acute surgical abdomen. We present a case of DSR in an 81-year-old woman caused by a remote minor blunt abdominal trauma four weeks prior to her admission to our emergency department for acute abdominal pain and hemorrhagic shock (ATLS CLASS III). Starting with this case report, we conducted a literature review on the subject in order to raise awareness, knowledge, and understanding of DSR among emergency clinicians.

Delayed splenic rupture following trivial trauma: A case report and review of literature

Introduction and importance

Delayed Splenic Rupture (DSR) is a rare but well-known presentation of Blunt Splenic Injury (BSI), most of which occur due to motor accidents, fall from height or direct blow to the left thorax or abdomen. Here we present a case of DSR five days after a trivial trauma.

Case presentation

A 37-year-old female presented with pain in the left-hypochondrium after an accidental bump against a furniture at home. Initially, it was a grade III splenic injury but upon arrival to our hospital from her hometown it had progressed to grade IV. Since the patient was hemodynamically stable, non-operative management (NOM) was chosen with close monitoring at the intensive care unit (ICU). However, the next morning, the patient deteriorated, showing signs of hemorrhagic shock, and a successful emergency splenectomy was done.

Clinical discussion

Over the last two decades, there has been an increasing inclination of surgeons towards NOM, even for high grade injury. NOM failure has been found to be associated with advancing age, high Injury Severity Score (ISS) or splenic injury. Some factors that improve the success of NOM are admission to ICU/floor, frequent monitoring of hemoglobin/hematocrit, vital signs, abdominal examination, and limiting heavy physical activity.

Conclusion

Clinicians should not limit the possibility of occurrence of DSR to only major traumatic events. It is imperative that a detailed history of major or trivial trauma in the preceding weeks be elicited for any patients presenting with abdominal pain.

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Delayed Splenic Rupture is a rare but well reported presentation following blunt splenic injury.

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Delayed Splenic Rupture can even occur following trivial trauma.

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Clinicians must consider the entire clinical scenario to decide between operative or non-operative management.

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A detailed history of major or minor trauma must be elicited for any patients with abdominal pain.

Strategies in liver Trauma

The management of pediatric liver trauma has evolved significantly over the last few decades. While surgical intervention was frequently and mostly unsuccessfully practiced during the first half of the last century, the 1960s were witness to the birth and gradual acceptance of non-operative management of these injuries. In 2000, the American Pediatric Surgical Association (APSA) Trauma Committee disseminated evidenced-based guidelines to help guide the non-operative management of pediatric blunt solid organ injury. The guidelines significantly contributed to conformity in the management of these patients. Since then, a number of well-designed studies have questioned the strict categorization of these injuries and have led to a renewed reliance on clinical signs of the patient's hemodynamic status. In 2019, APSA introduced an updated set of guidelines emphasizing the use of physiologic status rather than radiologic grade as a driver of clinical decision making for these injuries. This review will focus on liver injuries, in particular blunt injury, as this mechanism is by far the most commonly seen in children. Procedures required when non-operative management fails will be detailed, including surgery, angioembolization, and less commonly employed interventions. Finally, the updated inpatient and post-discharge aspects of care will be reviewed, including hemoglobin monitoring, bedrest, length of hospital stay, and activity restriction.

The role of splenic angioembolization as an adjunct to nonoperative management of blunt splenic injuries: A systematic review and meta-analysis

BACKGROUND

Nonoperative management (NOM) of hemodynamically normal patients with blunt splenic injury (BSI) is the standard of care. Guidelines recommend additional splenic angioembolization (SAE) in patients with American Association for the Surgery of Trauma (AAST) Grade IV and Grade V BSI, but the role of SAE in Grade III injuries is unclear and controversial. The aim of this systematic review was to compare the safety and effectiveness of SAE as an adjunct to NOM versus NOM alone in adults with BSI.

METHODS

A systematic literature search (Medline, Embase, and CINAHL) was performed to identify original studies that compared outcomes in adult BSI patients treated with SAE or NOM alone. Primary outcome was failure of NOM. Secondary outcomes included morbidity, mortality, hospital length of stay, and transfusion requirements. Bayesian meta-analyses were used to calculate an absolute (risk difference) and relative (risk ratio [RR]) measure of treatment effect for each outcome.

RESULTS

Twenty-three studies (6,684 patients) were included. For Grades I to V combined, there was no difference in NOM failure rate (SAE, 8.6% vs NOM, 7.7%; RR, 1.09 [0.80-1.51]; p = 0.28), mortality (SAE, 4.8% vs NOM, 5.8%; RR, 0.82 [0.45-1.31]; p = 0.81), hospital length of stay (11.3 vs 9.5 days; p = 0.06), or blood transfusion requirements (1.8 vs 1.7 units; p = 0.47) between patients treated with SAE and those treated with NOM alone. However, morbidity was significantly higher in patients treated with SAE (SAE, 38.1% vs NOM, 18.6%; RR, 1.83 [1.20-2.66]; p < 0.01). When stratified by grade of splenic injury, SAE significantly reduced the failure rate of NOM in patients with Grade IV and Grade V splenic injuries but had minimal effect in those with Grade I to Grade III injuries.

CONCLUSION

Splenic angioembolization should be strongly considered as an adjunct to NOM in patients with AAST Grade IV and Grade V BSI but should not be routinely recommended in patients with AAST Grade I to Grade III injuries.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

Epidemiology and management of splenic injury: An analysis of a Chinese military registry

In China, there have been few meta-analyses of the epidemiology and management of splenic injury. Due to the success of Chinese military hospitals in the domestic treatment of splenic injury, the present study conducted a systematic review of such cases, identifying a high occurrence rate of splenic trauma, as well as a number of strategies of managing splenic injury in China. Data were collected from sixteen Chinese military hospitals between July 2000 and March 2009, and retrospectively reviewed. It was observed that between July 2000 and March 2009 a total of 7,807 patients (84.32% male and 15.68% female) with splenic injury were admitted to hospital. The mean duration of hospital stay was 17.9±18.6 days and the gender distribution of splenic injury over the successive years did not differ significantly (P>0.05, c=0.034). However, there was a significant difference in the gender distribution of splenic injury patients in different months (P<0.05, c=0.063). In addition, admission numbers for splenic injury were highest in September, October and November. It was also found that splenic injury may occur at all ages, though patients of working age (20-50 years), which comprises 85.59% of patients, the highest proportion of all recorded cases. Associations between mortality rate and each management strategy were as follows: Operative management, 0.11% and non-operative management, 0.15%. Furthermore, multivariate analysis demonstrated that transfusion, New Injury Severity Score and management strategies were all correlated with mortality rate. Thus, despite a lack of data for inpatients from civilian hospitals, the present study has, in part, identified the epidemiology and management strategies of splenic injury in China. These findings may supplement those from previous analyses of splenic injury in other countries and regions.

Predictors of Active Extravasation and Complications after Conventional Angiography for Acute Intraabdominal Bleeding

Conventional angiography is used to evaluate and treat possible sources of intraabdominal bleeding, though it may cause complications such as contrast-induced nephropathy (CIN). The study’s purpose was to identify factors predicting active extravasation and complications during angiography for acute intraabdominal bleeding. All conventional angiograms for acute bleeding (January 2013–June 2015) were reviewed retrospectively, including 75 angiograms for intraabdominal bleeding in 70 patients. Demographics, comorbidities, vital signs, complications within one month, and change in hematocrit (ΔHct) and fluids and blood products administered over the 24 h prior to angiography were recorded. Of 75 exams, 20 (27%) demonstrated extravasation. ΔHct was the only independent predictor of extravasation (p = 0.017), with larger ΔHct (−17%) in patients with versus those without extravasation (–1%) (p = 0.01). CIN was the most common complication, occurring in 10 of 66 angiograms (15%). Glomerular filtration rate (GFR) was the only independent predictor (p = 0.03); 67% of patients with GFR < 30, 29% of patients with GFR 30–60, and 8% of patients with GFR > 60 developed CIN. For patients with intraabdominal bleeding, greater ΔHct decrease over 24 h before angiography predicts active extravasation. Pre-existing renal impairment predicts CIN. Patients with large hematocrit declines should be triaged for rapid angiography, though benefits can be weighed with the risk of renal impairment.

Nonoperative Management of Blunt Solid Organ Injury in Pediatric Surgery

In the last decade, higher rates of nonoperative management of liver, spleen, and kidney injuries have been achieved. An algorithmic approach may improve success on a national level. Factors for success include management strategy based on physiologic status of the child, early attempt at resuscitation using blood products, and appropriate use of adjuncts. Shorter hospitalizations are appropriate for children who have not bled significantly, and discharge instructions facilitate the safety of early discharge. Although routine imaging is not required for liver or spleen injury, symptoms should prompt reevaluation. Reimaging of renal injuries remains in common use.

Management of children with solid organ injuries after blunt torso trauma

BACKGROUND

Management of children with intra-abdominal solid organ injuries has evolved markedly. We describe the current management of children with intra-abdominal solid organ injuries after blunt trauma in a large multicenter network.

METHODS

We performed a planned secondary analysis of a prospective, multicenter observational study of children (<18 years) with blunt torso trauma. We included children with spleen, liver, or kidney injuries identified by computed tomography, laparotomy/laparoscopy, or autopsy. Outcomes included disposition and interventions (blood transfusion for intra-abdominal hemorrhage, angiography, laparotomy/laparoscopy). We performed subanalyses of children with isolated injuries.

RESULTS

A total of 12,044 children were enrolled; 605 (5.0%) had intra-abdominal solid organ injuries. The mean (SD) age was 10.7 (5.1) years, and injured organs included spleen 299 (49.4%), liver 282 (46.6%), and kidney 147 (24.3%). Intraperitoneal fluid was identified on computed tomography in 461 (76%; 95% confidence interval [CI], 73-80%), and isolated solid organ injuries were present in 418 (69%; 95% CI, 65-73%). Treatment included therapeutic laparotomy in 17 (4.1%), angiographic embolization in 6 (1.4%), and blood transfusion in 46 (11%) patients. Laparotomy rates for isolated injury were 11 (5.4%) of 205 (95% CI, 2.7-9.4%) at non-freestanding children's hospitals and 6 (2.8%) of 213 (95% CI, 1.0-6.0%) at freestanding children's hospitals (difference, 2.6%; 95% CI, -7.1% to 12.2%). Dispositions of the 212 children with isolated Grade I or II organ injuries were home in 6 (3%), emergency department observation in 9 (4%), ward in 114 (54%), intensive care unit in 73 (34%), operating suite in 7 (3%), and transferred in 3 (1%) patients. Intensive care unit admission for isolated Grade I or II injuries varied by center from 9% to 73%.

CONCLUSION

Most children with solid organ injuries are managed with observation. Blood transfusion, while uncommon, is the most frequent therapeutic intervention; angiographic embolization and laparotomy are uncommon. Emergency department disposition of children with isolated Grade I to II solid organ injuries is highly variable and often differs from published guidelines.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Radiographic assessment of splenic injury without contrast: is contrast truly needed?

INTRODUCTION

Computed tomography (CT) has become an essential tool in the assessment of the stable trauma patient. Intravenous (i.v.) contrast is commonly relied upon to provide superior image quality, particularly for solid-organ injury. However, a substantial proportion of injured patients have contraindications to i.v. contrast. Little information exists concerning the repercussions of CT imaging without i.v. contrast, specifically for splenic injury.

METHODS

We performed a retrospective analysis using data from our trauma registry and chart review as part of a quality improvement project at our institution. All patients with splenic injury, during a 3-year period (2008-2010), where a CT of the abdomen without i.v. contrast (DRY) early during their admission were selected. All splenic injuries had to have been verified with abdominal CT imaging with i.v. contrast (CONTRAST) or via intraoperative findings. DRY images were independently read by a single, blinded, radiologist and assessed for parenchymal injury or "suspicious" splenic injury findings and compared with CONTRAST imaging results or intraoperative findings.

RESULTS

During the time period of the study, 319 patients had documented splenic injury with 44 (14%) patients undergoing DRY imaging, which was also verified by CONTRAST imaging or operative findings. Splenic parenchymal injury was only visualized in 38% of patients DRY patients. "Suspicious" splenic injury radiographic findings were common. When these less-specific findings for splenic injury were incorporated in the radiographic assessment, DRY imaging had more than 93% sensitivity for detecting splenic injury.

CONCLUSION

DRY imaging is increasingly being performed after injury and has a low sensitivity in detecting splenic parenchymal injury. However, less-specific radiographic findings suspicious for splenic injury in combination provide high sensitivity for the detection of splenic injury. These results suggest CONTRAST imaging is preferred to detect splenic injury; however, in those patients who have contraindications to i.v. contrast, DRY imagining may be able to select those who require close monitoring or intervention.

National variation in outcomes and costs for splenic injury and the impact of trauma systems: a population-based cohort study

OBJECTIVE

To measure national variation in splenectomy rates, mortality, and costs for hospitalized patients with splenic injury and the impact of state trauma systems on these outcomes.

METHODS

Using the HCUP State Inpatient Database for 2001, 2004, and 2007, all patients hospitalized with splenic injury were identified from 19 participating states. Multivariate regression was performed to compare splenectomy rates, inpatient mortality, and costs between states. Inclusiveness of statewide trauma systems was categorized based on the proportion of hospitals designated as a trauma center.

RESULTS

Of 33,131 patients, 26.2% underwent splenectomy, 6.1% died, and median hospital costs were $14,317. After adjusting for patient, injury, and hospital characteristics, there was a 1.7-fold variation (RR 1.67; 95% CI, 1.39-2.01) among the 19 states in rates of splenectomy. Adjusted inpatient mortality varied more than 2-fold between the highest and lowest states (RR 2.43; 95% CI, 1.76-3.37). Adjusted hospital costs varied over 60% between the highest and lowest states (cost ratio 1.61; 95% CI, 1.41-1.83). States with the most inclusive trauma systems had significantly lower splenectomy rate (RR 0.79; 95% CI, 0.68-0.92) and lower mortality (RR 0.71; 95% CI, 0.58-0.87), but similar hospital costs (CR 1.05; 95% CI, 0.95-1.16) compared to states with exclusive or no trauma systems.

CONCLUSIONS

Significant geographic variation in the management, outcome, and costs for splenic injury exists in the United States, and may reflect differences in quality of care. Inclusive trauma systems seem to improve outcomes without increasing hospital costs.