Ultrasonography in traumatic splenic rupture

Nonparasitic Splenic Cysts

Sixty-three patients with splenic cysts, multiple in 7 cases, were reviewed. Only 3 patients had a history of previous abdominal trauma. The cysts ranged in size from less than 1 cm to 15 cm. They were anechoic in 40 patients, hypoechoic in 16, isoechoic in 4, mixed in one, and in 2 cases the echogenicity could not be assessed due to thick marginal calcifications. The echogenic cysts were larger than the anechoic ones and frequently calcified, and the findings at surgery, fine-needle aspiration biopsy and follow-up suggested the echogenicity to be related to a fresh or previous episode of intracystic hemorrhage. Initially, surgical treatment was undertaken on 10 patients, electively in 9 cases and due to cyst rupture in one. At follow-up (n = 37), the size of the cyst had increased markedly over several years in only 2 patients, necessitating delayed surgery in one. Routine follow-up of asymptomatic splenic cysts was of no clinical value.

Ultrasound or CT in Splenic Diseases?

To compare the value of US and CT for the detection and analysis of splenic abnormalities, we reviewed the medical records and imaging findings of 93 patients with 93 proven textural lesions of the spleen, which were visualized by US and/or CT. US revealed the abnormality in 91 (97.8%) patients and CT in 74 (79.6%) patients. US was more sensitive than CT in the detection of malignant lesions, particularly splenic lymphoma, while US and CT were equally effective in benign lesions. In 2 patients, one with sarcoidosis and the other with an acute infarct, the lesion was visualized by CT but not by US. On CT, i.v. injection of contrast material improved both the sensitivity of the examination and the delineation of the abnormality. The echogenicity or the attenuation of the lesions did not usually allow differentiation between the various benign and malignant splenic lesions. US is recommended as the method of choice for splenic imaging.

Ultrasonography in patients without trauma in the emergency department: impact on discharge diagnosis

OBJECTIVE

The aim of this study was to examine to what extent findings on ultrasonography performed in the emergency department (ED) after hours confirm or alter the referral diagnosis in patients without trauma as reflected in the discharge diagnosis.

METHODS

In this prospective study, data from 136 ultrasonographic examinations performed in patients without trauma after hours in the ED during January and February 2002 were evaluated against the suspected preimaging diagnosis of the referring ED physician and the actual discharge diagnosis from the ED or after hospitalization. The rate of preimaging and postimaging concordance was statistically analyzed and compared by calculation of confidence intervals and by the McNemar test.

RESULTS

Normal ultrasonographic findings were documented in 54 patients (40%), and pathologic findings were documented in 82 (60%). Thirty-four (25%) of the 136 examinations were concordant with the initial referring physician's diagnosis. Of the 102 studies that were not concordant with the initial referral suspected diagnoses, that is, being either a study with normal findings or offering an alternative diagnosis, 81 (79.4%) were concordant with the discharge diagnosis.

CONCLUSIONS

After-hours ultrasonographic findings in patients without trauma seen in the ED seem to have a high impact on the discharge diagnosis and are concordant with it in more than 80% of cases.

Reevaluation of ultrasonography for solid-organ injury in blunt abdominal trauma

OBJECTIVE

To reevaluate the usefulness of ultrasonography for detecting and classifying solid-organ injuries from blunt abdominal trauma by comparing ultrasonography with computed tomography (CT) and laparotomy.

METHODS

Six hundred four patients with blunt abdominal trauma were examined by both B-mode ultrasonography and CT for a study period of 14 years. The ultrasonographic examiners were divided into 2 groups depending on their experience with ultrasonography. The ultrasonographic results were then compared with CT and surgical findings. This was a retrospective study.

RESULTS

In 198 patients, solid-organ injuries were identified on CT, laparotomy, or both. Sensitivity values in group A (experts) were 87.5% for hepatic injuries, 85.4% for splenic injuries, 77.6% for renal injuries, and 44.4% for pancreatic injuries. Sensitivity values in group B were 46.2% for hepatic injuries, 50.0% for splenic injuries, and 44.1% for renal injuries. The detection rates in group A were 80% to 100% for different types of hepatic injuries except superficial injuries (20%) and 70% to 100% for different types of splenic injuries. The detection rates for renal parenchymal and pancreatic duct injuries were 53.3% and 80%, respectively. The detection rates for injuries requiring intervention were 86.1% in group A and 66.7% in group B.

CONCLUSIONS

The sensitivity of ultrasonography with the use of CT and surgical findings as reference standards decreased compared with our prior study. However, ultrasonography was found to enable experienced examiners to detect and classify parenchymal injuries efficiently, despite disadvantages in detecting superficial and vascular injuries. Ultrasonography should be used to explore not only free fluid but also solid-organ injuries.

Sonographic patterns of intraperitoneal hemorrhage associated with blunt splenic injury

OBJECTIVE

To determine the correlation between sonographic detection of free fluid in the left upper quadrant and blunt splenic injury.

METHODS

A retrospective review was conducted of all consecutive emergency blunt trauma sonograms obtained at a level I trauma center from January 1995 to January 2001. Data were collected on demographics, free fluid location, and patient outcome. Injuries were determined from computed tomography, diagnostic peritoneal lavage, laparotomy, or a combination thereof.

RESULTS

A total of 4320 blunt trauma sonograms were obtained, and 596 patients (14%) had intra-abdominal injuries. The mean age was 33.7 +/- 19.1 years (range, 1-95 years), with 294 (49%) male and 302 (51%) female. There was no statistical difference between age, sex, or mechanism for all subgroups. There were 409 true-positive, 187 false-negative, 88 false-positive, and 3636 true-negative findings. Sensitivity of sonography for detecting all intra-abdominal injuries was 68%, and specificity was 97.6%; sensitivity for detecting isolated splenic injuries was 73.8%. Locations of free fluid in patients with nonsplenic injuries were compared with those in patients with splenic injuries. Isolated left upper quadrant free fluid was significantly associated with splenic injury (odds ratio = 3.0; P = .002), followed by diffuse free fluid (odds ratio = 2.1; P = .005). A subanalysis of isolated splenic injuries also revealed a significant association with left upper quadrant free fluid (odds ratio = 3.1; P = .007) and diffuse free fluid (odds ratio = 2.7; P = .0007).

CONCLUSIONS

Free fluid in the left upper quadrant is significantly associated with splenic injury. This finding should triage patients more rapidly to computed tomography, angiography, embolization, and laparotomy.

Conservative management of splenic trauma: history and current trends

Evolution of the present-day policy of conservative management of ruptured spleen has been hailed as one of the most notable advances in pediatric surgery. Until 1971, routine splenectomy used to be the sacrosanct treatment for splenic trauma. It was universally believed that non-operative management carried a high mortality of 90 to 100%. Sporadic reports of successful conservative treatment appeared in the early twentieth century, but regrettably, these were ignored. Likewise, experimental studies pointing to the danger of post-splenectomy sepsis were also disregarded. Dominant surgical opinion continued to practice removal of the injured spleen. In 1968, Upadhyaya and Simpson, based on a well-designed clinical analysis of 52 children made a convincing plea for conservative management. In 1971, Upadhyaya et al. presented results of a corroborative experimental study, which provided the conclusive evidence that isolated splenic tears are well tolerated and heal spontaneously by first intention. Seeing the surge of publications that followed this presentation, it becomes apparent that this study constituted the real turning point that changed the world opinion in favour of salvage of the ruptured spleen. By 1979, numerous authors had reported the safety of non-operative management in hundreds of children all over the world. Currently, the policy of routine splenectomy has been universally abandoned; and the reported salvage rate of ruptured spleen is more than 90%. This paper traces the historical perspectives in the management of injured spleen from the times of Aristotle to the present day.

The focused abdominal sonography for trauma scan: pearls and pitfalls

OBJECTIVE

To review the state-of-the-art use of sonography in evaluating the patient with trauma.

METHODS

We reviewed our experience in performing more than 5000 sonographic examinations in the patient with trauma. The recent experience of other publications advocating newer applications of sonography in the patient with trauma are discussed and presented in a pictorial fashion.

RESULTS

The main focus of sonography in the patient with trauma has been in performance of the focused abdominal sonography for trauma scan. The focused abdominal sonography for trauma scan is usually performed in the patient with blunt abdominal trauma and is used to check for free fluid in the abdomen or pelvis. There are certain pitfalls that need to be avoided and certain limitations of the focused abdominal sonography for trauma scan that need to be recognized. These pitfalls and limitations are reviewed. More recently, sonography has been used to detect certain solid-organ injuries that have a variety of appearances. Thus, sonography may be used to localize the specific site of injury in these patients. More recently, sonography has been used to evaluate thoracic abnormalities in patients with trauma, including pleural effusions, pneumothoraces, and pericardial effusions.

CONCLUSIONS

The use of sonography in evaluating the patient with trauma has rapidly expanded in the past decade. Those using sonography in this group of patients should be aware of its many uses but also its potential pitfalls and limitations.

Blunt abdominal trauma in children: evaluation with emergency US

PURPOSE

To assess the accuracy of emergency abdominal ultrasonography (US) in the detection of both hemoperitoneum and parenchymal organ injury in children.

MATERIALS AND METHODS

Imaging findings were recorded prospectively in 744 consecutive children who underwent emergency US from January 1995 to October 1998; free fluid and parenchymal abnormalities of specific organs were also noted. Patients with intraabdominal injuries were identified retrospectively. Computed tomographic (CT) findings, intraoperative findings, and clinical outcome were compared with the initial US findings. Sensitivity, specificity, and positive and negative predictive values were calculated for patients who underwent CT, laparotomy, or both after US.

RESULTS

Seventy-five (10%) of 744 patients had intraabdominal injuries, and US depicted free fluid in 42 of them. US had 56% sensitivity, 97% specificity, 82% positive predictive value, and 91% negative predictive value for detection of hemoperitoneum alone. US helped identify parenchymal abnormalities that corresponded to actual organ injury without accompanying free fluid in nine patients (12%). Inclusion of identification of parenchymal organ injury at US increased the sensitivity of US to 68%, with an accuracy of 92%.

CONCLUSION

US for blunt abdominal trauma in children is highly accurate and specific, but moderately sensitive, for detection of intraabdominal injury.

Sonographic assessment of blunt abdominal trauma: a 4-year prospective study

PURPOSE

Emergency abdominal sonography has become a common modality worldwide in the evaluation of injuries caused by blunt trauma. The sensitivity of sonography in the detection of hemoperitoneum varies, and little is known about the accuracy of sonography in the detection of injuries to specific organs. The purpose of this study was to determine the overall accuracy of sonography in the detection of hemoperitoneum and solid-organ injury caused by blunt trauma.

METHODS

From January 1995 to October 1998, 3,264 patients underwent emergency sonography at our institution to evaluate for free fluid and parenchymal abnormalities of specific organs caused by blunt trauma. All patients with intra-abdominal injuries (IAIs) were identified, and their sonographic findings were compared with their CT and operative findings, as well as their clinical outcomes.

RESULTS

Three hundred ninety-six (12%) of the 3,264 patients had IAIs. Sonography detected free fluid presumed to represent hemoperitoneum in 288 patients (9%). The sonographic detection of free fluid alone had a 60% sensitivity, 98% specificity, 82% positive predictive value, and 95% negative predictive value for diagnosing IAI. The accuracy was 94%. Seventy patients (2%) had parenchymal abnormalities identified with sonography that corresponded to actual organ injuries. The sensitivity of the sonographic detection of free fluid and/or parenchymal abnormalities in diagnosing IAI was 67%.

CONCLUSIONS

Emergency sonography to evaluate patients for injury caused by blunt trauma is highly accurate and specific. The sonographic detection of free fluid is only moderately sensitive for diagnosing IAI, but the combination of free fluid and/or a parenchymal abnormality is more sensitive.

Color Doppler detection of acoustic streaming in a hematoma model

Accurate differentiation between stagnant blood and soft tissue or clotted and unclotted blood has potential value in managing trauma patients with internal hemorrhage. Determination by regular ultrasound (US) imaging is sometimes difficult because the sonographic appearance of blood, clots and soft tissue may be similar. A hematoma model was developed to investigate the use of acoustic streaming for hematoma diagnosis in an in vivo environment. The results showed that a derated spatial peak temporal average (SPTA) intensity of 30 W/cm(2) was needed to generate color-Doppler-detectable streaming in stirred blood. The streaming velocity increased in proportion to the derated intensity. Streaming was also detected in stagnant blood, but at higher intensities. In clots, streaming was not detected even at high intensities. The streaming detection may be a valuable tool for improving the distinction between liquid blood and clots or soft tissue in hematoma diagnosis.

Ultrasound detection of blunt splenic injury

The purpose of this study was to determine the sensitivity of emergency ultrasound (US) for the detection of blunt splenic injury (BSI), and to describe sonographic parenchymal patterns. Over 3 years, 2138 emergency US were performed, and 162 patients had BSI. CT was performed for 76 patients, and there were 86 laparotomies. Seventy patients (43%) had concomitant intraabdominal injuries. Ultrasound detected free fluid in 109 patients (67%), and parenchymal injury in 31 patients (19%). There were 48 false negative US (30%). Sonographic patterns included a diffuse heterogeneous appearance, hyperechoic and hypoechoic perisplenic crescents, and discrete hypoechoic or hyperechoic areas within the spleen. Overall sensitivity of US for detection of BSI was 69%, but was 86% for grade III or higher injuries. Ultrasound is most sensitive for the detection of grade III or higher BSI based on the presence of haemoperitoneum. Ultrasound may also identify BSI on the basis of parenchymal abnormality, with a diffuse heterogeneous pattern most commonly encountered. Sonographic evaluation for both free fluid and parenchymal injury improves sensitivity of US.

Comparison of US utilization and technical costs before and after establishment of 24-hour in-house coverage for US examinations

PURPOSE

To compare data regarding the cost and number of ultrasonographic (US) examinations performed for 6 months, before and after institution of 24-hour in-house sonographer coverage.

MATERIALS AND METHODS

Data for a 6-month period during which US services were provided by a sonographer on call from 11 PM to 7 AM were compared with data for a 6-month period during which a sonographer was in house during this shift.

RESULTS

With 11 PM to 7 AM on-call coverage, the sonographers performed 147 examinations in a 6-month period, an average of 0.81 examination per shift. After institution of in-house coverage for this shift, 792 US examinations were performed in 6 months, an average of 4.3 examinations per shift. The cost for 11 PM to 7 AM in-house sonographer coverage for 6 months was approximately $16,000 more than that for on-call coverage. This cost would be offset by revenues from one additional examination per night. The cost per examination for the 11 PM to 7 AM shift decreased from $124.70 to $43.33.

CONCLUSION

At the authors' institution, 24-hour in-house sonographer coverage resulted in additional cost, which was offset by revenues from additional examinations. There was nearly a fivefold increase in the number of US examinations performed per shift. These examinations were performed more expediently, enabling more rapid patient triage.

Sonographic detection of blunt hepatic trauma: hemoperitoneum and parenchymal patterns of injury

OBJECTIVES

To determine the sensitivity and utility of emergency sonography for the detection of blunt hepatic injury (BHI) in patients with abdominal trauma and to describe parenchymal sonographic patterns of BHI.

METHODS

This report was a prospective clinical study in which the findings of all patients who had emergency sonograms were recorded on a data sheet by the initial sonographer and interpreting physicians. All patients with hepatic injuries during this period were identified and physical examination, laboratory, computed tomographic and intraoperative findings were compared with the prospective data sheets.

RESULTS

From January of 1995 to December of 1998, 2,622 emergency sonograms were performed, and in this group, a total of 146 patients had BHI. Emergency sonograms allowed detection of free fluid in 98 patients (67%), and parenchymal injury with no free fluid in seven patients (5%). There were 41 false negatives (28%). The most common pattern identified on a sonogram was a discrete area of increased echogenicity followed by a diffuse hyperechoic pattern. Seventy-six patients (52%) had concomitant intra-abdominal injuries, including spleen (n = 46), bowel (n = 30), and kidney (n = 19). There were 102 exploratory laparotomies performed. Abdominal tenderness or distention was present in 127 patients (87%), and 108 patients had right rib fractures (74%). Based on detection of free fluid, parenchymal injury, or both, the overall sensitivity of sonography for the detection of BHI was 72 % but was 98 % for grade III or higher injuries.

CONCLUSION

Emergency sonography is sensitive for the detection of grade III or higher liver injuries resulting from blunt abdominal trauma. Sonography may also reveal BHI on the basis of parenchymal abnormality, with a discrete hyperechoic area the most commonly encountered pattern.

Bowel and mesenteric injury: evaluation with emergency abdominal US

PURPOSE

To assess emergency ultrasonography (US) for detection of bowel and mesenteric injury from blunt trauma.

MATERIALS AND METHODS

For 3 years, prospective data on all patients undergoing emergency US were recorded. Patients with bowel and mesenteric injury were identified, and physical examination, laboratory, computed tomographic (CT), and intraoperative findings were compared with prospective data.

RESULTS

From January 1995 to January 1998, emergency US was performed in 1,686 patients; 71 patients had bowel and mesenteric injury. Forty-one examinations were true-positive (i.e., with free fluid), and 30 were false-negative. Twenty-five of the 41 patients with true-positive US results had concomitant injuries that may have accounted for the free fluid, including liver, spleen, pancreas, gallbladder, kidney, and/or bladder injuries. The remaining 16 patients had isolated bowel and mesenteric injury. Bowel and mesenteric damage was identified intraoperatively in 70 patients. Twenty-nine of 30 patients with false-negative US examinations had abdominal tenderness. Sixteen patients with false-negative US results had bowel and mesenteric injury that was detected 12 or more hours after initial scanning.

CONCLUSION

Free fluid in the abdomen is not detected in the majority of patients with isolated bowel and mesenteric injury. For clinical suspicion of bowel and mesenteric injury, observation, serial physical abdominal examination, and CT may be helpful in diagnosing this condition.

The emerging role of bedside ultrasonography in trauma care

Ultrasonography has emerged as a primary imaging modality in the evaluation of the trauma victim. Both emergency physicians and surgeons have been proven capable of performing this rapid, noninvasive evaluation of the chest and abdomen. This article describes the trauma ultrasound examination and illustrates how bedside ultrasonography can be incorporated into routine trauma care.

Computed tomography grade of splenic injury is predictive of the time required for radiographic healing

It is largely unknown when a child who has suffered a splenic laceration can return to full unrestricted activity. The purpose of this prospective study is to establish whether the grade of splenic injury is predictive of the length of time required for radiographic healing, and to determine whether there are any adverse long-term sequelae after resumption of unlimited activity. Sixty-nine patients underwent successful nonoperative management (NOM) of computed tomography (CT)-documented splenic injury over a 4-year period. Fifty-eight patients completed follow-up. Mean age was 9.8 years (range, 1 to 17) and mean injury severity score (ISS) was 14.4 (range, 4 to 38). Mechanisms of injury were motor vehicle accident (n = 11), motor vehicle pedestrian (n = 5), falls (n = 13), bike crashes (n = 12), sports (n = 8), all-terrain vehicle (n = 4), and horse (n = 5). The CT-documented injury was identified by discharge ultrasound scan (US) in all cases. There were no long-term complications. Mean time to US healing in grade I (n = 9), II (n = 26), III (n = 19), IV (n = 4) injuries was 3.1, 8.2, 12.1, and 20.7 weeks, respectively. P values were significant (P < .01) in all cases when compared with the next lower injury grade. The time to radiographic healing is directly proportional to the severity of the splenic injury. There was excellent correlation between the initial CT scan and identification of the injury on the discharge US. No long-term complications leg, delayed splenic rupture, splenic pseudocyst) were seen in this study. Pediatric patients who have suffered splenic injury can safely return to full unrestricted activity when the US documents healing.

Use of abdominal ultrasonography to assess pediatric splenic trauma. Potential pitfalls in the diagnosis

OBJECTIVE

The purpose of this study was to evaluate the accuracy of abdominal ultrasonography (US) for screening and grading pediatric splenic injury.

SUMMARY BACKGROUND DATA

The use of abdominal US has increased rapidly as a method of evaluating organ damage after blunt abdominal trauma. Despite US's increasing use, little is known about its accuracy in children with splenic injury.

METHODS

Children (N = 32) suffering blunt abdominal trauma who were diagnosed with splenic injury by computerized tomography (CT) scan prospectively were enlisted in this study. Degree of splenic injury was evaluated by both CT and US. The ultrasounds were evaluated by an initial reading as well as by a radiologist who was blinded as to the results of the CT.

RESULTS

Twelve (38%) of the 32 splenic injuries found on CT were missed completely on the initial reading of the US. When the ultrasounds were graded in a blinded fashion, 10 (31%) of the splenic lacerations were missed and 17 (53%) were downgraded. Seven (22%) of the 32 splenic fractures were not associated with any free intraperitoneal fluid on the CT scan.

CONCLUSIONS

This study has shown that US has a low level of sensitivity (62% to 78%) in detecting splenic injury and downgrades the degree of injury in the majority of cases. Reliance on free intraperitoneal fluid may be inaccurate because not all patients with splenic injury have free intra-abdominal fluid. Based on these findings, US may be of limited use in the initial assessment, management, and follow-up of pediatric splenic trauma.

A review of non-operative treatment of splenic trauma

From January 1984 to June 1992, a period of 8.5 years, 60 patients with splenic trauma were treated in Lacor Hospital. the spleen trauma was managed conservatively in 47 (78%) of the patients. Of these, 36 of the patients (60%) were not operated upon. Eleven (18%) were operated upon but nine (15%) patients had exploratory laparotomy only without spleen manipulation and in two (3%) splenic repair was performed. Thirteen (22%) patients had splenectomy. In the non-operative group, recurrent or rebleeding was detected in one patient (2%) and delayed bleeding occurred in five patients (8%). Overall mortality rate was five (8%); two (3%) occurring in splenic salvage and three (5%) in splenectomized patients. It is concluded that with availability of facilities and personnel, in selected cases of blunt splenic trauma, splenic conservation is safe but requires close monitoring.