Splenic injuries at Bugando Medical Centre in northwestern Tanzania: a tertiary hospital experience

A Clinical Review and Experience of Splenic Trauma in North India: A Retrospective Observational Study

INTRODUCTION

The spleen is one of the frequently injured solid organs in abdominal blunt trauma. The standard of care is nonoperative nowadays depending on the hemodynamic stability (World Society of Emergency Surgery (WSES) grade I-III) of the patient due to advancements in treating modalities. Operative interventions are required in hemodynamically unstable patients or failure of nonoperative management. The study was planned to find the clinical spectrum of abdominal blunt trauma, specifically those having splenic trauma, and their subsequent management in an institution.

METHODS

This is a retrospective observational study. All included patients with blunt abdominal injuries were treated in a level 1 trauma center between July 2021 and December 2022. Data regarding demographic profile, blood transfusion, pre- and postoperative findings, and management including the period of hospital stay, morbidity, and mortality were collected and analyzed.

RESULTS

One hundred sixty-four patients were analyzed, of which 142 were males and 22 were females. The commonest mechanism of injury was motor vehicle collision, followed by falls. Grade III splenic injury was the most common injury, while the predominantly associated injury was rib fracture. The patients were managed preferably through nonoperative management, followed by angioembolization and operative management. The commonest postoperative complication was pneumonia.

CONCLUSIONS

Nonoperative management of splenic trauma has evolved as the standard of care replacing operative management in order to sustain its immune function, thereby preventing overwhelming post-splenectomy infection.

The role of clinical and sonographic assessments in pre-operative evaluation of patients with splenic injuries in a resource-limited economy

Background

Splenic trauma has been recognized as the most common cause of preventable deaths amongst trauma patients. Due to paucity of modern diagnostic imaging facilities in our setting, determination of the error rates and role of the simple, available diagnostic approaches are worthwhile and relevant to the practice of general surgery.

Objectives

The aim was to determine the role and diagnostic accuracy of clinical and sonographic assessments of splenic injuries.

Methods

This was a prospective study of the value of pre-operative clinical and sonographic assessments of patients with splenic injuries in our setting.

Results

A total of 111 patients with abdominal trauma were evaluated. Of these, splenic injuries were confirmed in 75 patients intra-operatively, mainly from blunt trauma. Of the 97 cases diagnosed by clinical method, 66(68.0%) were confirmed by intraoperative findings. Similarly, of 86 sonographic diagnoses of splenic injuries, 61 (70.9%) truly had splenic trauma. Sensitivity for sonographic and clinical assessments was 84.7% and 78.9% respectively. False positive and negative rates for clinical (27.3% versus 44.1%) and ultrasonographic (29.1% versus 40.0%) assessments were high.

Conclusions

Majority of splenic injuries were due to blunt abdominal trauma. The two diagnostic methods showed high sensitivity, but performed poorly for other validity tests.

Splenic injuries in native Africans: Presentation, limitations of management, and treatment outcomes in a civilian trauma service in Southeast Nigeria

Background

Splenic trauma has emerged as a major global health burden, especially in developing nations with limited diagnostic and therapeutic facilities. The current trend toward nonoperative management (NOM) and adoption of splenic salvage whenever feasible calls for local evaluation of our current practice. The aim of this study was to document the epidemiology and outcomes of management of splenic injuries in our setting.

Patients and Methods

This was a multicenter, prospective study of epidemiology and outcomes of patients with splenic injuries recruited over 10 years in southeast Nigeria.

Results

Approximately 66% of all patients with abdominal injuries sustained splenic trauma. A total of 313 patients with splenic trauma were recruited; 226 (72.2%) were managed operatively (OM) and 87 (27.8%) conservatively (NOM). Majority (75.7%) had blunt abdominal trauma (BAT), while 24.3% sustained penetrating injuries. Sonographic grading showed that 46 (14.7%), 58 (18.5%), 79 (25.2%), 106 (33.9%), and 24 (7.7%) patients had grades I, II, III, IV, and V injuries, respectively. Isolated splenic injuries occurred in 172 (55%) patients, and the rest (141, 45%) had associated intra-abdominal injuries. Two-thirds (67.1%) were aged 16-45 years. In the OM group, 178 (78.7%) had total splenectomy, while 48 (21.3%) had splenic salvage. There was a statistically significant difference (P = 0.022) in the rate of postoperative complications between the splenectomy and splenorrhaphy groups. The overall mortality rate was 4.5%. Major predictors of morbidity and mortality were high-grade splenic injuries, total splenectomy, multiple injuries, advanced age, and comorbidities.

Conclusion

Splenic injuries complicate approximately two-thirds of all abdominal injuries in our environment and majority of these injuries were due to BAT. In this study, majority had OM and splenic salvage rate was relatively low.

Thefeasibility, appropriateness, and applicability of trauma scoring systems in low and middle-income countries: a systematic review

Background

About 5.8 million people die each year as a result of injuries, and nearly 90% of these deaths occur in low and middle-income countries (LMIC). Trauma scoring is a cornerstone of trauma quality improvement (QI) efforts, and is key to organizing and evaluating trauma services. The objective of this review was to assess the appropriateness, feasibility, and QI applicability of traditional trauma scoring systems in LMIC settings.

Materials and methods

This systematic review searched PubMed, Scopus, CINAHL, and trauma-focused journals for articles describing the use of a standardized trauma scoring system to characterize holistic health status. Studies conducted in high-income countries (HIC) or describing scores for isolated anatomic locations were excluded. Data reporting a score’s capacity to discriminate mortality, feasibility of implementation, or use for QI were extracted and synthesized.

Results

Of the 896 articles screened, 336 were included. Over half of studies (56%) reported Glasgow Coma Scale, followed by Injury Severity Score (ISS; 51%), Abbreviated Injury Scale (AIS; 24%), Revised Trauma Score (RTS; 19%), Trauma and Injury Severity Score (TRISS; 14%), and Kampala Trauma Score (7%). While ISS was overwhelmingly predictive of mortality, 12 articles reported limited feasibility of ISS and/or AIS. RTS consistently underestimated injury severity. Over a third of articles (37%) reporting TRISS assessmentsobserved mortality that was greater than that predicted by TRISS. Several articles cited limited human resources as the key challenge to feasibility.

Conclusions

The findings of this review reveal that implementing systems designed for HICs may not be relevant to the burden and resources available in LMICs. Adaptations or alternative scoring systems may be more effective.

PROSPERO registration number

CRD42017064600.

Laparotomy for Abdominal Injury Indication & Outcome of patients at a Teaching Hospital in Addis Ababa, Ethiopia

Background

Abdominal injury is among the major causes of trauma admissions. The aim was to determine etiology, commonly injured organs, indication and outcome of patients with abdominal injuries requiring laparotomy.

Methods

A retrospective study of all adult patients who underwent laparotomy for abdominal injury at St. Paul's Hospital Millennium Medical College was conducted from January 2014 to December 2016. The factors associated with outcome were identified with bivariate and multivariate logistic regressions.

Results

Laparotomy for abdominal injury was performed for 145 patients. Of these, 129 (89%) case records were retrieved. The male to female ratio was 6.2:1. The mean age was 29 years, and most of them were unemployed. Penetrating trauma was the commonest injury, stab (46, 35.7%) and Road Traffic Accidents (RTA) (27, 20.9%) being the leading causes. Extra-abdominal injuries were seen in 33.3% (46) of the cases. Hollow organs were commonly injured than solid organs. Small intestine (35, 43.8%) and Spleen (17, 34.7%) were the leading injured organs in penetrating and blunt respectively. The main procedure performed was repair of hollow and solid organ laceration/perforation (70,54.3%). The negative laparotomy rate was 4.6% (6). Complications were seen in 23(17.8%) patients, the commonest being irreversible shock (7,30.4%). The mortality rate was 8.5 % (11), and it was significantly associated with blunt abdominal injury (AOR=7.25; 95% CI 1.09–48.37; p=0.041) and systolic blood pressure<90mmHg (AOR=8.66; 95% CI 1.1–68.41; p=0.041).

Conclusion

Stab and RTA were the commonest indications of laparotomy. The mortality was significantly associated with blunt abdominal injury and hypotension (SBP<90mmHg).

Critical care issues in solid organ injury: Review and experience in a tertiary trauma center

Background and Aim:

Solid organ (spleen and liver) injuries are dreaded by both surgeons and anesthesiologists because of associated high morbidity and mortality. The purpose of this review is to describe our experience of critical care concerns in solid organ injury, which otherwise has been poorly addressed in the literature.

Materials and Methods:

Retrospective cohort of solid organ injury (spleen and liver) patients was done from January 2010 to December 2011 in tertiary level trauma Center.

Results:

Out of 624 abdominal trauma patients, a total of 212 patients (70%) were admitted in intensive care unit (ICU). Their ages ranged from 6 to 74 years (median 24 years). Nearly 89% patients in liver trauma and 84% patients in splenic trauma were male. Mechanism of injury was blunt abdominal trauma in 96% patients and the most common associated injury was chest trauma. Average injury severity score, sequential organ failure assessment, lactate on admission was 16.84, 4.34 and 3.42 mmol/L and that of dying patient were 29.70, 7.73 and 5.09 mmol/L, respectively. Overall mortality of ICU admitted solid organ injury was 15.55%. Major issues of concern in splenic injury were hemorrhagic shock, overwhelming post-splenectomy infection and post-splenectomy vaccination. Issues raised in liver injury are damage control surgery, deadly triad, thromboelastography guided transfusion protocols and hemostatic agents. Conclusions: A protocol-based and multidisciplinary approach in high dependency unit can significantly reduce morbidity and mortality in patients with solid organ injury.