Western Trauma Association (WTA) critical decisions in trauma: management of adult blunt splenic trauma

Determinants of adverse management outcomes of blunt abdominal trauma patients operated at a referral hospital in southern Ethiopia: a retrospective record review

BACKGROUND

Abdominal trauma is one of the common reasons for emergency visits yet there is paucity of data about the subject in the horn of Africa. This study was aimed at determining the determinants of adverse management outcomes of blunt abdominal trauma among operated patients at Wolaita Sodo University Teaching and Referral Hospital, Ethiopia.

METHODS

This was a three-year retrospective review conducted among 128 patient records selected using purposive sampling in which all records for the patients operated for a diagnosis of blunt abdominal trauma during the study period were included. A pretested checklist was used to extract the data relating to adverse outcomes and characteristics of the patients. A descriptive analysis followed by logistic regression was done.

RESULTS

Of the 128 patients, adverse management outcomes related to blunt abdominal trauma occurred in 52%. Patients residing in rural areas (adjusted odds ratio 3.23, 95% confidence interval: 1.13-9.24) and those with tachycardia, (adjusted odds ratio = 3.25, 95% confidence interval: 1.19-8.83) or tachypnea (adjusted odds ratio 3.25, 95% confidence interval: 1.19-8.83) were more likely to have adverse management outcomes.

CONCLUSION

Adverse management outcomes are relatively high and associated with rural residence and deranged vital signs (tachycardia and tachypnea). Close monitoring targeting patients from rural residence and those presenting with tachycardia and tachypnea is recommended.

Role of Serial Phlebotomy in the Management of Blunt Solid Organ Injury in Adults

BACKGROUND

The management of blunt spleen and liver trauma has become increasingly nonoperative. There is no consensus on timing or duration of serial hemoglobin and hematocrit monitoring in this patient population.

OBJECTIVE

This study examined the clinical utility of serial hemoglobin and hematocrit monitoring. We hypothesized that most interventions occur early in the hospital course, based on hemodynamic instability or physical examination findings rather than serial monitoring.

METHODS

We conducted a retrospective cohort study of adult trauma patients with blunt spleen or liver injury from November 2014 through June 2019 at our Level II trauma center. Interventions were classified as no intervention, surgical intervention, angioembolization, or packed red blood cell transfusion. Demographics, length of stay, total blood draws, laboratory values, and clinical triggers preceding intervention were reviewed.

RESULTS

A total of 143 patients were studied, of whom 73 (51%) received no intervention, 47 (33%) received an intervention within 4 hr of presentation, and 23 (16%) had interventions beyond 4 hr. Of these 23 patients, 13 received an intervention based on phlebotomy results alone. Most of these patients (n = 12, 92%) received blood transfusion without further intervention. Only one patient underwent operative intervention based on serial hemoglobin results on hospital day 2.

CONCLUSION

The majority of patients with these injury patterns either require no intervention or declare themselves promptly after arrival. Serial phlebotomy after initial triage and intervention may add little value in the management of blunt solid organ injury.

Atraumatic splenic rupture and infection-related glomerulonephritis in a patient with infected aortic aneurysm: A case report

Introduction

Atraumatic splenic rupture is very rare and the case is often difficult to determine. We report a case of atraumatic splenic rupture in a patient with an infected aortic aneurysm.

Case presentation

A 40-year-old man under evaluation and treatment for renal dysfunction presented with the sudden onset of epigastric pain. The patient had a previous history of aortic arch replacement for Stanford type B aortic dissection. Contrast-enhanced computed tomography revealed intraabdominal hemorrhaging around the spleen and intrasplenic extravasation of contrast medium, and atraumatic splenic rupture was diagnosed. The patient slipped into hemorrhagic shock, and emergency splenectomy was scheduled. The histopathological diagnosis was splenic rupture with splenic infarction. The patient became febrile on postoperative day 10. Repeat contrast-enhanced computed tomography revealed enlargement of a cystic aortic aneurysm that was present prior to splenectomy. Infected aortic aneurysm was suspected, which was confirmed following thoracic endovascular aortic repair performed on postoperative day 12.

Discussion

We consider that splenic rupture occurred following infected of the kidney and spleen by an infected aortic aneurysm.

Conclusion

Infection should be considered as a cause in patients with atraumatic splenic rupture.

•

Atraumatic splenic rupture was related to infection in only 27.3% of cases.

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Atraumatic splenic rupture in patients with infected aortic aneurysm is not well-documented.

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Infection-related splenic rupture should be considered in patients with acute abdominal pain.

Laparoscopic splenectomy as a definitive management option for high-grade traumatic splenic injury when non operative management is not feasible or failed: a 5-year experience from a level one trauma center with minimally invasive surgery expertise

Technique, indications and outcomes of laparoscopic splenectomy in stable trauma patients have not been well described yet. All hemodynamically non-compromised abdominal trauma patients who underwent splenectomy from 1/2013 to 12/2017 at our Level 1 trauma center were included. Demographic and clinical data were collected and analysed with per-protocol and an intention-to-treat comparison between open vs laparoscopic groups. 49 splenectomies were performed (16 laparoscopic, 33 open). Among the laparoscopic group, 81% were successfully completed laparoscopically. Laparoscopy was associated with a higher incidence of concomitant surgical procedures (p 0.016), longer operative times, but a significantly faster return of bowel function and oral diet without reoperations. No significant differences were demonstrated in morbidity, mortality, length of stay, or long-term complications, although laparoscopic had lower surgical site infection (0 vs 21%).The isolated splenic injury sub-analysis included 25 splenectomies,76% (19) open and 24% (6) laparoscopic and confirmed reduction in post-operative morbidity (40 vs 57%), blood transfusion (0 vs 48%), ICU admission (20 vs 57%) and overall LOS (7 vs 9 days) in the laparoscopic group. Laparoscopic splenectomy is a safe and effective technique for hemodynamically stable patients with splenic trauma and may represent an advantageous alternative to open splenectomy in terms of post-operative recovery and morbidity.

Trust the FAST: Confirmation that the FAST examination is highly specific for intra-abdominal hemorrhage in over 1,200 patients with pelvic fractures

BACKGROUND

Use of the focused assessment with sonography for trauma (FAST) examination in patients with pelvic fractures has been reported as unreliable. We hypothesized that FAST is a reliable method for detecting clinically significant intra-abdominal hemorrhage in patients with pelvic fractures.

METHODS

All patients with pelvic fractures over a 10-year period were reviewed at a Level I trauma center. The predictive ability of FAST was assessed by calculating the sensitivity, specificity, positive predictive value and negative predictive value against the criterion standard of either computed tomography (CT) or laparotomy findings. The FAST examination was considered "false negative" if findings at laparotomy indicated traumatic intra-abdominal hemorrhage. Likewise, the FAST examination was considered "false positive" if either CT or findings at laparotomy indicated no intra-abdominal hemorrhage. Hemodynamic instability scores were calculated for all patients.

RESULTS

There were 1,456 patients with pelvic fractures and an initial FAST reviewed; 1,219 (83.7%) underwent FAST and either CT or operative exploration. Median age was 43 years (interquartile range, 26-56 years) and mean Injury Severity Score was 18.5 ± 12.3. The sensitivity and specificity for FAST in this group of patients with pelvic fracture was 85.4% and 98.1%, respectively. The positive predictive value and negative predictive value were 78.4% and 98.8%, respectively. Of 21 patients with a false-positive FAST, 15 (71.4%) were confirmed with a negative CT scan, and 6 (28.6%) underwent laparotomy without findings of intra-abdominal hemorrhage. Of 13 patients with a false-negative FAST, all were identified with positive findings at the time of laparotomy. The specificity of the FAST examination remained high regardless of hemodynamic instability score grade.

CONCLUSION

The false positive rate of FAST examination for intra-abdominal hemorrhage is 1.1%. These data suggest that a positive FAST in this clinical scenario should be considered to represent intra-abdominal fluid. This series contradicts prior reports that FAST is unreliable in patients with pelvic fracture.

LEVEL OF EVIDENCE

Diagnostic, level III.

Negative Focused Abdominal Sonography for Trauma examination predicts successful nonoperative management in pediatric solid organ injury: A prospective Arizona-Texas-Oklahoma-Memphis-Arkansas + Consortium study

BACKGROUND

Focused Abdominal Sonography for Trauma (FAST) examination has long been proven useful in the management of adult trauma patients, however, its utility in pediatric trauma patients is not as proven. Our goal was to evaluate the utility of a FAST examination in predicting the success or failure of nonoperative management (NOM) of blunt liver and/or spleen (BLSI) in the pediatric trauma population.

METHODS

A retrospective analysis of a prospective observational study of patients younger than 18 years presenting with BLSI to one of ten Level I pediatric trauma centers between April 2013 and January 2016. 1,008 patients were enrolled and 292 had a FAST examination recorded. We analyzed failure of NOM of BLSI in the pediatric trauma population. We then compared FAST examination alone or in combination with the pediatric age adjusted shock index (SIPA) as it relates to success of NOM of BLSI.

RESULTS

Focused Abdominal Sonography for Trauma examination had a negative predictive value (NPV) of 97% and positive predictive value (PPV) of 13%. The odds ratio of failing with a positive FAST examination was 4.9 and with a negative FAST was 0.20. When combined with SIPA, a positive FAST examination and SIPA had a PPV of 17%, and an odds ratio for failure of 4.9. The combination of negative FAST and SIPA had an NPV of 96%, and the odds ratio for failure was 0.20.

CONCLUSION

Negative FAST is predictive of successful NOM of BLSI. The addition of a positive or negative SIPA score did not affect the PPV or NPV significantly. Focused Abdominal Sonography for Trauma examination may be useful clinically in determining which patients are not at risk for failure of NOM of BLSI and do not require monitoring in an intensive care setting.

LEVEL OF EVIDENCE

Prognostic study, level IV; therapeutic/care management, level IV.

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

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.

Safety and efficacy of transcatheter embolization with Glubran®2 cyanoacrylate glue for acute arterial bleeding: a single-center experience with 104 patients

PURPOSE

To assess the efficacy and the safety of Glubran^®2 n-butyl cyanoacrylate metacryloxysulfolane (NBCA-MS) transcatheter arterial embolization (TAE) for acute arterial bleeding from varied anatomic sites and to evaluate the predictive factors associated with clinical success and 30-day mortality.

METHODS

A retrospective review of consecutive patients who underwent emergent NBCA-MS Glubran^®2 TAE between July 2014 and August 2016 was conducted. Variables including age, sex, underlying malignancy, cardiovascular comorbidities, coagulation data, systolic blood pressure, and number of red blood cells units (RBC) transfused before TAE were collected. Clinical success, 30-day mortality, and complication rates were evaluated. Prognostic factors were evaluated by uni- and multivariate logistic regression analyses for clinical success, and by uni- and bivariate analyses after adjustment by bleeding sites for 30-day mortality.

RESULTS

104 patients underwent technically successful embolization with bleeding located in muscles (n = 34, 32.7%), digestive tract (n = 28, 26.9%), and viscera (n = 42, 40.4%). Clinical success rate was 76% (n = 79) and 30-day mortality rate was 21.2% (n = 22). Clinical failure was significantly associated with mortality (p < 0.0001). A number of RBC units transfused greater than or equal to 3 were associated with poorer clinical success (p = 0.025) and higher mortality (p = 0.03). Complications (n = 4, 3.8%) requiring surgery occurred only at puncture site. No ischemic complications requiring further invasive treatment occurred. Mean TAE treatment time was 4.55 min.

CONCLUSIONS

NBCA-MS Glubran^®2 TAE is a fast, effective, and safe treatment for acute arterial bleeding whatever the bleeding site.

Use of interventional radiology as initial hemorrhage control to improve outcomes for potentially lethal multiple blunt injuries

INTRODUCTION

Recently, trauma management has been markedly improved with interventional radiology (IVR) and damage-control strategies. However, the indications for its use in hemodynamically unstable patients with severe trauma remains unclear. In some cases, IVR may be more effective than surgery for damage-control hemostasis; however, performing IVR in life-threatening trauma settings is challenging. To address this, we practiced and evaluated a trauma-management system with emergency physicians who trained for both severe trauma management, and techniques of surgery and IVR.

MATERIALS AND METHODS

Among the 1822 patients with severe trauma admitted between October 2014 and December 2016, 201 underwent emergency surgery or IVR. Among these, 16 patients whose systolic blood pressure was ≤90 mmHg, without improvement following primary resuscitation, and whose first intervention was IVR, were analyzed. We retrospectively evaluated the admission characteristics, IVR-related characteristics, and prognoses, and compared several parameters before and after IVR.

RESULTS

This study included 10 men and 6 women (median age: 46 years). IVR was performed for 10 pelvic fractures; five liver-, one splenic-, and one renal injury; and one transection each of the external carotid-, vertebral-, axillosubclavian-, intercostal-, and lumbar arteries. The mean times from the patient arrival, and diagnosis to the start of IVR were 56.3 ± 26.6 and 15.1 ± 3.8 min, respectively. The mean time spent in the angiography suite was 50 min. The systolic blood pressure, pulse rate, base excess/deficit, serum-lactate levels, and D-dimer values were significantly improved after IVR. Although two patients needed additional treatment for morbidities following IVR intervention, all achieved complete recovery. The mortality rate was 25.0%, and no preventable deaths were noted. Eight patients showed unexpected survival.

CONCLUSIONS

In some cases, IVR may be the best first measure for resuscitative hemostasis in potentially lethal multiple injuries, given efficient diagnoses/actions and the ability to deal with complications.

[Abdominal injuries in polytraumatized adults : Systematic review]

Abdominal injuries are potentially life-threatening and occur in 20-25% of all polytraumatized patients. Blunt trauma is the main mechanism. The liver and spleen are most commonly injured and much less often the intestines. The clinical evaluation proves equivocal in many cases; therefore, the gold standard is computed tomography (CT), which has been increasingly used even in hemodynamically weakly stable or sometimes even unstable patients because it promptly provides precise diagnostic findings, which present the basis for successful therapy. Hemodynamically unstable patients always need an exploratory laparotomy (EL). An EL should also be carried out with a positive focused assessment with sonography for trauma (FAST) or CT for severe parenchymal lesions, hollow organ lesions, intraperitoneal bladder lesions, peritonitis and organ evisceration, impalement injuries and lesions of the abdominal fascia. Hemodynamically stable patients without signs of peritonitis and a lack of such findings can often be treated conservatively irrespective of the extent of an injury. Angiography (and if needed embolization) can additionally be diagnostically and therapeutically utilized.

Is It safe? Nonoperative management of blunt splenic injuries in geriatric trauma patients

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.

A comparison of the management of blunt splenic injury in children and young people-A New South Wales, population-based, retrospective study

The importance and safety of non-operative management (NOM) of Blunt Splenic Injury (BSI) has been established in children and adults over recent decades. However, studies have shown higher operation rates in adults. There is international evidence that when children are managed in adult centres, operation rates are higher while adolescents in paediatric centres, are operated on in line with paediatric guidelines. This difference between children and young adults, and the factors responsible, have not been examined in New South Wales (NSW).

OBJECTIVE

To use NSW hospital and mortality data to compare the characteristics of BSI in patients aged 0-16 to those aged 17-25, and determine factors related to operative management (OM) and splenic salvage in each group.

METHODS

Patients age 0-25 between July 2000 and December 2011, with a diagnosis of BSI, were identified in the NSW Admitted Patient Data Collection, and linked to deaths data from Registry of Births Deaths and Marriages and Bureau of Statistics. Operation rate was compared between the two groups. Univariable analysis was used to determine factors associated with OM. Multivariable logistic regression with stepwise elimination was then performed to determine likelihood of OM according to age group, adjusting for potential confounders.

RESULTS

1986 cases were identified, with 422 (21.2%) managed operatively - 101/907 children (11.1%) and321/1079 (29.7%)young adults(p<0.001). Of these, 59 (58%) children underwent splenectomy compared with 233 (73%) young adults (p<0.001). OM increased significantly after the age of 12 (p=0.03), and the percentage almost tripled in the teenage years, coinciding with a higher proportion admitted to adult centres. OM doubled again in young adults(p<0.001), all of whom were managed away from paediatric centres. On multivariable analysis, factors significantly associated with operation included age over 16 (OR 2.82, 95%CI 2.10-3.81), splenic injury severity, associated thoracic, liver, pancreatic and hollow viscus injury, and blood transfusion.

CONCLUSION

While Paediatric Surgeons have wholeheartedly adopted non-operative management, away from paediatric centres, it is possible children and young people in NSW are undergoing operation unnecessarily. Further evaluation of the surgeon attitudes and institutional factors involved in the management of injured children and young people within the broad NSW trauma system is required.

Selective Angiographic Embolization of Blunt Hepatic Trauma Reduces Failure Rate of Nonoperative Therapy and Incidence of Post-Traumatic Complications

Background

Conflict still remains as to the benefit of angioembolization (AE) for non-operative therapy (NOT) of blunt hepatic trauma (BHT). The aim of this study was to determine whether AE could result in lower failure rates in hemodynamically stable BHT patients with high failure risk factors for NOT, and to systematically evaluate the effectiveness of AE for NOT of BHT.

Material/Methods

Medical records of all BHT patients from January 1, 1998 to December 31, 2015 at a large trauma center were collected and analyzed. Failure of NOT (FNOT) occurred if hepatic surgery was performed after attempted NOT. Logistic regression analysis was used to identify factors associated with FNOT. Hepatobiliary complications related to hepatic trauma during follow-up were reviewed.

Results

No significant difference in FNOT for the no angiographic embolization (NO-AE) group versus angiographic embolization (AE) group was found in hepatic trauma of grades I, II, and V. However, decrease in FNOT was significant with AE performed for hepatic trauma of grades III to IV. Risk factors for FNOT included grade III to IV injuries and contrast blush on CT. Follow-up data of six months also showed that the incidence of hepatobiliary complications in the NO-AE group was higher than the AE group.

Conclusions

Hemodynamically stable BHT patients with grade III to IV injuries, contrast blush on initial CT, and/or decreasing hemoglobin levels can be candidates for selective AE during NOT course.

Recent trends in 30-day mortality in patients with blunt splenic injury: A nationwide trauma database study in Japan

BACKGROUND

Splenic injury frequently occurs after blunt abdominal trauma; however, limited epidemiological data regarding mortality are available. We aimed to investigate mortality rate trends after blunt splenic injury in Japan.

METHODS

We retrospectively identified 1,721 adults with blunt splenic injury (American Association for the Surgery of Trauma splenic injury scale grades III-V) from the 2004-2014 Japan Trauma Data Bank. We grouped the records of these patients into 3 time phases: phase I (2004-2008), phase II (2009-2012), and phase III (2013-2014). Over the 3 phases, we analysed 30-day mortality rates and investigated their association with the prevalence of certain initial interventions (Mantel-Haenszel trend test). We further performed multiple imputation and multivariable analyses for comparing the characteristics and outcomes of patients who underwent TAE or splenectomy/splenorrhaphy, adjusting for known potential confounders and for within-hospital clustering using generalised estimating equation.

RESULTS

Over time, there was a significant decrease in 30-day mortality after splenic injury (p < 0.01). Logistic regression analysis revealed that mortality significantly decreased over time (from phase I to phase II, odds ratio: 0.39, 95% confidence interval: 0.22-0.67; from phase I to phase III, odds ratio: 0.34, 95% confidence interval: 0.19-0.62) for the overall cohort. While the 30-day mortality for splenectomy/splenorrhaphy diminished significantly over time (p = 0.01), there were no significant differences regarding mortality for non-operative management, with or without transcatheter arterial embolisation (p = 0.43, p = 0.29, respectively).

CONCLUSIONS

In Japan, in-hospital 30-day mortality rates decreased significantly after splenic injury between 2004 and 2014, even after adjustment for within-hospital clustering and other factors independently associated with mortality. Over time, mortality rates decreased significantly after splenectomy/splenorrhaphy, but not after non-operative management. This information is useful for clinicians when making decisions about treatments for patients with blunt splenic injury.

Multicenter retrospective study of noncompressible torso hemorrhage: Anatomic locations of bleeding and comparison of endovascular versus open approach

BACKGROUND

Rational development of technology for rapid control of noncompressible torso hemorrhage (NCTH) requires detailed understanding of what is bleeding. Our objectives were to describe the anatomic location of truncal bleeding in patients presenting with NCTH and compare endovascular (ENDO) management versus open (OPEN) management.

METHODS

This is a retrospective study of adult trauma patients with NCTH admitted to four urban Level I trauma centers in the Houston and San Antonio metropolitan areas in 2008 to 2012. Inclusion criteria include named axial torso vessel disruption, Abbreviated Injury Scale chest or abdomen score of 3 or higher with shock (base excess, <-4) or truncal operation in 90 minutes or less, or pelvic fracture with ring disruption. Exclusion criteria include isolated hip fractures, falls from standing, or prehospital cardiopulmonary resuscitation. After dichotomizing into OPEN, ENDO, and resuscitative thoracotomy (RT) groups based on the initial approach to control NCTH, a mixed-effects Poisson regression with robust error variance (controlling for age, mechanism, Injury Severity Score, shock, hypotension, and severe head injury as fixed effects and site as a random effect) was used to test the hypothesis that ENDO was associated with reduced in-hospital mortality in NCTH patients.

RESULTS

Five hundred forty-three patients with NCTH underwent ENDO (n = 166, 31%), OPEN (n = 309, 57%), or RT (n = 68, 12%). Anatomic bleeding locations were 25% chest, 41% abdomen, and 31% pelvis. ENDO was used to treat relatively few types of vascular injuries, whereas OPEN and RT injuries were more diverse. ENDO patients had more blunt trauma (95% vs. 34% vs. 32%); severe injuries (median Injury Severity Score, 34 vs. 27 vs. 21), and increased time to intervention (median, 298 vs. 92 vs. 51 minutes) compared with OPEN and RT. Mortality was 15% versus 20% versus 79%. ENDO was associated with decreased mortality compared to OPEN (relative risk, 0.58; 95% confidence interval, 0.46-0.73).

CONCLUSION

Although ENDO may reduce mortality in NCTH patients, significant group differences limit the generalizability of this finding.

LEVEL OF EVIDENCE

Therapeutic, level V.

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

An update on nonoperative management of the spleen in adults

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.

MAIN CONTROVERSIES IN THE NONOPERATIVE MANAGEMENT OF BLUNT SPLENIC INJURIES

Introduction :

The nonoperative management of traumatic spleen injuries is the modality of choice in patients with blunt abdominal trauma and hemodynamic stability. However, there are still questions about the treatment indication in some groups of patients, as well as its follow-up.

Aim:

Update knowledge about the spleen injury.

Method :

Was performed review of the literature on the nonoperative management of blunt injuries of the spleen in databases: Cochrane Library, Medline and SciELO. Were evaluated articles in English and Portuguese, between 1955 and 2014, using the headings "splenic injury, nonoperative management and blunt abdominal trauma".

Results :

Were selected 35 articles. Most of them were recommendation grade B and C.

Conclusion :

The spleen traumatic injuries are frequent and its nonoperative management is a worldwide trend. The available literature does not explain all aspects on treatment. The authors developed a systematization of care based on the best available scientific evidence to better treat this condition.

Thrombocytosis in splenic trauma: In-hospital course and association with venous thromboembolism

INTRODUCTION

Thrombocytosis is common following elective splenectomy and major trauma. However, little is known about the in-hospital course of platelet count (PC) and incidence of thrombocytosis after splenic trauma. Extreme thrombocytosis (PC>1000×10⁹) is associated with increased risk of venous thromboembolism (VTE) in primary thrombocytosis leading to the use of acetylsalicylic acid (ASA) for risk reduction, but the need for this agent in splenic trauma is undefined.

METHODS

Retrospective cohort study of all patients with splenic trauma between April 1, 2010 and March 31, 2014. The in-hospital course of PC was assessed based on splenic injury management type. The association of management type with thrombocytosis was evaluated using a multivariable logistic regression model adjusting for potential confounders. The association of thrombocytosis, extreme thrombocytosis, and ASA use for the outcome of VTE was explored.

RESULTS

156 patients were eligible, PC initially increased in all patients with the highest peak after total splenectomy. The incidence of thrombocytosis was 41.0% (64/156). Thrombocytosis was more likely following splenectomy compared with spleen preserving strategies independent of length of stay, injury grade, ISS, age and transfusion (OR 7.58, 95% CI: 2.26-25.45). Splenectomy was associated with extreme thrombocytosis (OR 10.39, 95% CI: 3.59-30.07).

CONCLUSIONS

Thrombocytosis in splenic trauma is more likely after splenectomy than with spleen preserving strategies. Splenectomy is associated with extreme thrombocytosis. There was insufficient data in our study to determine the use of ASA as primary prevention of VTE after splenic trauma.

Definition of hemodynamic stability in blunt trauma patients: a systematic review and assessment amongst Dutch trauma team members

INTRODUCTION

Trauma is a great contributor to mortality worldwide. One of the challenges in trauma care is early identification and management of bleeding. The circulatory status of blunt trauma patients in the emergency room is evaluated using hemodynamic (HD) parameters. However, there is no consensus on which parameters to use. In this study, we evaluate the used terms and definitions in the literature for HD stability and compare those to the opinion of Dutch trauma team members.

METHOD

A systematic review was performed to collect the definitions used for HD stability. Studies describing the assessment and/or treatment of blunt trauma patients in the emergency room were included. In addition, an online survey was conducted amongst Dutch trauma team members.

RESULTS

Out of a total of 222, 67 articles were found to be eligible for inclusion. HD stability was defined in 70% of these articles. The most used parameters were systolic blood pressure and heart rate. Besides the variety of parameters, a broad range of corresponding cut-off points is noted. Despite some common ground, high inter- and intra-variability is seen for the physicians that are part of the Dutch trauma teams.

CONCLUSION

All authors acknowledge HD stability as the most important factor in the assessment and management of blunt trauma patients. There is, however, no consensus in the literature as well as none-to-fair consensus amongst Dutch trauma team members in the definition of HD stability. A trauma team ready to co-operate with consensus-based opinions together with a valid scoring system is in our opinion the best method to assess and treat seriously injured trauma patients.

The splenic injury outcomes trial: An American Association for the Surgery of Trauma multi-institutional study

BACKGROUND

Delayed splenic hemorrhage after nonoperative management (NOM) of blunt splenic injury (BSI) is a feared complication, particularly in the outpatient setting. Significant resources, including angiography (ANGIO), are used in an effort to prevent delayed splenectomy (DS). No prospective, long-term data exist to determine the actual risk of splenectomy. The purposes of this trial were to ascertain the 180-day risk of splenectomy after 24 hours of NOM of BSI and to determine factors related to splenectomy.

METHODS

Eleven Level I trauma centers participated in this prospective observational study. Adult patients achieving 24 hours of NOM of their BSI were eligible. Patients were followed up for 180 days. Demographic, physiologic, radiographic, injury-related information, and spleen-related interventions were recorded. Bivariate and multivariable analyses were used to determine factors associated with DS.

RESULTS

A total of 383 patients were enrolled. Twelve patients (3.1%) underwent in-hospital splenectomy between 24 hours and 9 days after injury. Of 366 discharged with a spleen, 1 (0.27%) required readmission for DS on postinjury Day 12. No Grade I injuries experienced DS. The splenectomy rate after 24 hours of NOM was 1.5 per 1,000 patient-days. Only extravasation from the spleen at time of admission (ADMIT-BLUSH) was associated with splenectomy (odds ratio, 3.6; 95% confidence interval, 1.4-12.4). Of patients with ADMIT-BLUSH (n = 49), 17 (34.7%) did not have ANGIO with embolization (EMBO), and 2 of those (11.8%) underwent splenectomy; 32 (65.3%) underwent ANGIO with EMBO, and 2 of those (6.3%, p = 0.6020 compared with no ANGIO with EMBO) required splenectomy.

CONCLUSION

Splenectomy after 24 hours of NOM is rare. After the initial 24 hours, no additional interventions are warranted for patients with Grade I injuries. For Grades II to V, close observation as an inpatient or outpatient is indicated for 10 days to 14 days. ADMIT-BLUSH is a strong predictor of DS and should lead to close observation or earlier surgical intervention.

LEVEL OF EVIDENCE

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

[Study on the improvement of trauma patient care: TRAUMACAT project]

Multiple injuries are a major source of morbidity and mortality in young people. The aim of this study was to evaluate the effect of a collaborative strategy to improve the implementation of six clinical indicators, recognized internationally, for the treatment of trauma patient. Prospective, multicentre, pre-and post-intervention study, in ten referral hospitals, offering polytrauma care in Catalonia. 378 patients were recruited for the pre-intervention study and 501 for the post-intervention study. All patients had a history of high-energy trauma requiring admission to critical or semi-critical care unit.

INTERVENTION

collaborative strategy aimed at participating professionals, involving the creation of a panel of experts, appointment of monitors to encourage improvements at each centre, training, distribution of information, material and meetings, to exchange impressions.

MAIN OUTCOME MEASURES

frequency and characteristics of trauma and percentage of compliance with clinical indicators. Study of 879 trauma patients. The injury mechanism was overall blunt trauma, in both pre and post intervention phases. The medium ISS (injury severity score) was 21 ± 12,8 and the medium TRISS (trauma and injury severity score) was 26,4 ± 11,4. We didn't find differences between both study phases, in relation to the severity of injury. The mortality rate was 11.5%. We observed significant improvement in the performance of chest X-rays (45% vs. 62%) and pelvis X-rays (27% vs. 62%) in the trauma box and in the fixation of the pelvis in patients with a fracture at this site (24% vs. 49%). The use of diagnostic radiology in hemodynamically unstable patients remained low (33%). The collaborative strategy was effective in improving certain indicators of clinical management.

Variation in treatment of blunt splenic injury in Dutch academic trauma centers

BACKGROUND

The incidence of splenectomy after trauma is institutionally dependent and varies from 18% to as much as 40%. This is important because variation in management influences splenic salvage. The aim of this study was to investigate whether differences exist between Dutch level 1 trauma centers with respect to the treatment of these injuries, and if variation in treatment was related to splenic salvage, spleen-related reinterventions, and mortality.

METHODS

Consecutive adult patients who were admitted between January 2009 and December 2012 to five academic level 1 trauma centers were identified. Multinomial logistic regression was used to measure the influence of hospital on treatment strategy, controlling for hemodynamic instability on admission, high grade (American Association for the Surgery of Trauma 3-5) splenic injury, and injury severity score. Binary logistic regression was used to quantify differences among hospitals in splenic salvage rate.

RESULTS

A total of 253 patients were included: 149 (59%) were observed, 57 (23%) were treated with splenic artery embolization and 47 (19%) were operated. The observation rate was comparable in all hospitals. Splenic artery embolization and surgery rates varied from 9%-32% and 8%-28%, respectively. After adjustment, the odds of operative management were significantly higher in one hospital compared with the reference hospital (adjusted odds ratio 4.98 [1.02-24.44]). The odds of splenic salvage were significantly lower in another hospital compared with the reference hospital (adjusted odds ratio 0.20 [0.03-1.32]).

CONCLUSIONS

Although observation rates were comparable among the academic trauma centers, embolization and surgery rates varied. A nearly 5-fold increase in the odds of operative management was observed in one hospital, and another hospital had significantly lower odds of splenic salvage. The development of a national guideline is recommended to minimalize splenectomy after trauma.

Abdominal injuries in a major Scandinavian trauma center - performance assessment over an 8 year period

INTRODUCTION

Damage control surgery and damage control resuscitation have reduced mortality in patients with severe abdominal injuries. The shift towards non-operative management in haemodynamically stable patients suffering blunt abdominal trauma has further contributed to the improved results. However, in many countries, low volume of trauma cases and limited exposure to trauma laparotomies constitute a threat to trauma competence. The aim of this study was to evaluate the institutional patient volume and performance for patients with abdominal injuries over an eight-year period.

METHODS

Data from 955 consecutive trauma patients admitted in Oslo University Hospital Ulleval with abdominal injuries during the eight-year period 2002-2009 were retrospectively explored. A separate analysis was performed on all trauma patients undergoing laparotomy during the same period, whether abdominal injuries were identified or not. Variable life-adjusted display (VLAD) was used in order to describe risk-adjusted survival trends throughout the period and the patients admitted before (Period 1) and after (Period 2) the institution of a formal Trauma Service (2005) were compared.

RESULTS

There was a steady increase in admitted patients with abdominal injuries, while the number of patients undergoing laparotomy was constant exposing the surgical trauma team leaders to an average of 8 trauma laparotomies per year. No increase in missed injuries or failures of non-operative management was detected. Unadjusted mortality rates decreased from period 1 to period 2 for all patients with abdominal injuries as well as for the patients undergoing laparotomy. However, this apparent decrease was not confirmed as significant in TRISS-based analysis of risk-adjusted mortality. VLAD demonstrated a steady performance throughout the study period.

CONCLUSION

Even in a high volume trauma center the exposure to abdominal injuries and trauma laparotomies is limited. Due to increasing NOM, an increasing number of patients with abdominal injuries was not accompanied by an increase in number of laparotomies. However, we have demonstrated a stable performance throughout the study period as visualized by VLAD without an increase in missed injuries or failures of NOM.

Blunt splenic injury

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Blunt hollow viscus and mesenteric injury: still underrecognized

BACKGROUND

Despite the availability of more accurate imaging modalities, specifically multidetector computed tomography (MDCT), the diagnosis of non-ischemic (NI-) and ischemic (I-) blunt hollow viscus and mesenteric injury (BHVMI) remains challenging. We hypothesized that BHVMI can be still missed with newer generations of MDCT and that patients with I-BHVMI have a poorer outcome than those with NI-BHVMI.

METHODS

We performed an eight-year retrospective review at a level 1 trauma center. Ischemic-BHVMI was defined as devascularization confirmed at laparotomy. Non-ischemic-BHVMI included perforation, laceration, and hematoma without devascularization. The sensitivity of each generation of MDCT for BHVMI was calculated. Potential predictors and outcomes of I-BHVMI were compared to the NI-BHVMI group.

RESULTS

Of 7,875 blunt trauma patients, 67 patients (0.8 %) were included in the BHVMI group; 13 patients did not have any CT findings suggestive of BHVMI (sensitivity 81 %), and 11 of them underwent surgical intervention without delay (<5 h). Newer generations of MDCT were not associated with higher sensitivity. Patients with I-BHVMI had a significantly higher rate of delayed laparotomy ≥ 12 h (23 % versus 2 %; p = 0.01) and a significantly longer length of hospital stay (median 14 versus 9 days; p = 0.02) than those with NI-BHVMI.

CONCLUSIONS

Even using an advanced imaging technique, the diagnosis of I-BHVMI can be delayed, with significant negative impact on patient outcome.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Is non-operative management feasible for splenic injury due to colonoscopy?

Colonoscopy is a widely used diagnostic and therapeutic procedure. While it is a relatively safe procedure, there is a risk of some complications. Splenic injury after colonoscopy is a very rare but a life-threatening complication; around 105 cases have been reported in the literature so far. Owing to the rarity of this complication, no management standards were defined. In the literature, most of the patients were managed with operative intervention and less frequently with observation. We report a case of splenic injury and massive hemoperitoneum due to colonoscopy treated non-operatively.

Endovascular treatment of active splenic bleeding after colonoscopy: a systematic review of the literature

PURPOSE

Colonoscopy is reported to be a safe procedure that is routinely performed for the diagnosis and treatment of colorectal diseases. Splenic rupture is considered to be a rare complication with high mortality and morbidity that requires immediate diagnosis and management. Nonoperative management (NOM), surgical treatment (ST), and, more recently, proximal splenic artery embolization (PSAE) have been proposed as treatment options. The goal of this study was to assess whether PSAE is safe even in high-grade ruptures.

METHODS

We report two rare cases of post colonoscopy splenic rupture. A systematic review of the literature from 2002 to 2010 (first reported case of PSAE) was performed and the three types of treatment compared.

RESULTS

All patients reviewed (77 of 77) presented with intraperitoneal hemorrhage due to isolated splenic trauma. Splenic rupture was high-grade in most patients when grading was possible. Six of 77 patients (7.8 %) were treated with PSAE, including the 2 cases reported herein. Fifty-seven patients (74 %) underwent ST. NOM was attempted first in 25 patients with a high failure rate (11 of 25 [44 %]) and requiring a salvage procedure, such as PSAE or ST. Previous surgery (31 of 59 patients), adhesions (10 of 13), diagnostic colonoscopies (49 of 71), previous biopsies or polypectomies (31 of 57) and female sex (56 of 77) were identified as risk factors. In contrast, splenomegaly (0 of 77 patients), medications that increase the risk of bleeding (13 of 30) and difficult colonoscopies (16 of 51) were not identified as risk factors. PSAE was safe and effective even in elderly patients with comorbidities and those taking medications that increase the risk of bleeding, and the length of the hospital stay was similar to that after ST.

CONCLUSION

We propose a treatment algorithm based on clinical and radiological criteria. Because of the high failure rate after NOM, PSAE should be the treatment of choice to manage grade I through IV splenic ruptures after colonoscopy in hemodynamically stabilized patients.

Delayed presentation of perisplenic abscess following arterial embolization

INTRODUCTION

Splenic abscess formation is a rare but significant complication that may occur after non-operative management (NOM) of a blunt splenic injury (BSI). we describe an unusual case of perisplenic abscess formation nearly 4 months after splenic artery angioembolization for a grade III splenic laceration.

PRESENTATION OF CASE

A 52-year-old male was transferred to the Emergency Department (ED) of our institution after falling off his bicycle. He was hemodynamically stable but complained of left upper quadrant pain. Computed tomography (CT) was notable for a Grade III splenic laceration. The patient underwent a successful splenic artery embolization on hospital day 1. He had an uneventful post-embolization course and was discharged 3 days later, afebrile, with a stable hematocrit. Four months after his initial presentation, the patient presented to the ED with fever, malaise, and left upper quadrant abdominal pain. A CT scan revealed a multiloculated perisplenic abscess. He underwent a splenectomy and drainage of peri-splenic abscess, received a course of antibiotics, and had an uneventful recovery.

DISCUSSION

NOM including splenic angioembolization (SAE) is the standard of care for blunt splenic trauma in hemodynamically stable patients. Known complications from SAE include bleeding, missed injuries to the diaphragm and pancreas, and splenic abscess. This report documents a delayed perisplenic abscess following NOM of blunt splenic trauma, a rare but potential complication of SAE.

CONCLUSION

Formation of a perisplenic abscess may occur several months after NOM of a blunt splenic injury. Prompt surgical management and antibiotic therapy are critical to avoid life-threatening complications.

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.

Emergency strategies and trends in the management of liver trauma

The liver is the most frequently injured organ during abdominal trauma. The management of hepatic trauma has undergone a paradigm shift over the past several decades, with mandatory operation giving way to nonoperative treatment. Better understanding of the mechanisms and grade of liver injury aids in the initial assessment and establishment of a management strategy. Hemodynamically unstable patients should undergo focused abdominal sonography for trauma, whereas stable patients may undergo computed tomography, the standard examination protocol. The grade of liver injury alone does not accurately predict the need for operation, and nonoperative management is rapidly becoming popular for high-grade injuries. Hemodynamic instability with positive focused abdominal sonography for trauma and peritonitis is an indicator of the need for emergent operative intervention. The damage control concept is appropriate for the treatment of major liver injuries and is associated with significant survival advantages compared with traditional prolonged surgical techniques. Although surgical intervention for hepatic trauma is not as common now as it was in the past, current trauma surgeons should be familiar with the emergency surgical skills necessary to manage complex hepatic injuries, such as packing, Pringle maneuver, selective vessel ligation, resectional debridement, and parenchymal sutures. The present review presents emergency strategies and trends in the management of liver trauma.

Evolution-based algorithm for the management of penetrating abdominal stab injury

PURPOSE

As an increasing amount of penetrating abdominal stab injuries has been observed in the last few decades, it is important to evaluate the adequacy of the medical systems and surgical education and training to handle this type of injury. The aim of this study was to analyze the outcome of patients with penetrating abdominal stab injuries admitted to the Emergency Unit and to evaluate the effects of using a new treatment algorithm.

METHODS

From January 2009 to April 2009, a standardized education and training system for the surgical team was implemented in order to improve the emergency medical care system. From April 2009 to April 2011, 106 patients with the diagnosis of a penetrating abdominal stab injury were prospectively included in the study.

RESULTS

The cohort included 98 males and the mean age was 29.40 ± 10.9 years. Eighty-two percent of the patients were managed conservatively, whereas 18 % underwent surgery. Based on the surgical outcomes of the patients, the rate of negative, non-therapeutic, and therapeutic laparotomies was 5, 11, and 84 %, respectively. No statistically significant difference between patients who did and did not receive surgery was observed with regards to blood pressure, temperature, hematocrit, hemoglobin, and C-reactive protein (CRP) values. However, a statistically significant difference was observed in the pulse rate, leukocyte, and neutrophil counts. The mortality and morbidity rates were 0.94 and 3.77 %, respectively.

CONCLUSIONS

Selective non-operative management, which has been standardized in trauma centers, may be carefully utilized in order to treat penetrating abdominal stab wounds with caution in well-equipped medical centers with well-trained staff.

Blunt trauma induced splenic blushes are not created equal

BACKGROUND

Currently, evidence of contrast extravasation on computed tomography (CT) scan is regarded as an indication for intervention in splenic injuries. In our experience, patients transferred from other institutions for angioembolization have often resolved the blush upon repeat imaging at our hospital. We hypothesized that not all splenic blushes require intervention.

METHODS

During a 10-year period, we reviewed all patients transferred with blunt splenic injuries and contrast extravasation on initial postinjury CT scan.

RESULTS

During the study period, 241 patients were referred for splenic injuries, of whom 16 had a contrast blush on initial CT imaging (88% men, mean age 35 ± 5, mean ISS 26 ± 3). Eight (50%) patients were managed without angioembolization or operation. Comparing patients with and without intervention, there was a significant difference in admission heart rate (106 ± 9 vs 83 ± 6) and decline in hematocrit following transfer (5.3 ± 2.0 vs 1.0 ± 0.3), but not in injury grade (3.9 ± 0.2 vs 3.5 ± 0.3), systolic blood pressure (125 ± 10 vs 115 ± 6), or age (38.5 ± 8.2 vs 30.9 ± 4.7). Of the 8 observed patients, 3 underwent repeat imaging immediately upon arrival with resolution of the blush. In the intervention group, 4 patients had ongoing extravasation on repeat imaging, 2 patients underwent empiric embolization, and 2 patients underwent splenectomy for physiologic indications.

CONCLUSIONS

For blunt splenic trauma, evidence of contrast extravasation on initial CT imaging is not an absolute indication for intervention. A period of observation with repeat imaging could avoid costly, invasive interventions and their associated sequelae.

Controversies in the management of splenic trauma

BACKGROUND

The technologic innovations of the last three decades, coupled with a deeper understanding of the immunologic role of the spleen, have significantly shifted the management of splenic injuries towards non-operative approaches. However, there continuous to be a wide range of practice patterns related to the non-operative management of splenic injuries, from which the authors infer a gap between the best available evidence and its translation into practice. We sought to explore ongoing areas of controversy in the non-operative management of splenic trauma with the aim of further elucidating why these controversies continue to exist.

METHODS

We explored areas of ongoing controversy in the management of splenic injury though a series of iterative surveys. We invited 70 experts in trauma care from ten countries around the world to participate. Areas of controversy explored included: indications and frequency for in-hospital and follow-up imaging, definitions of failure of non-operative management, indications for angioembolisation and non-operative management in special populations (i.e. elderly, concomitant traumatic brain injury, penetrating trauma).

RESULTS

A 49% response rate was obtained. Even though a wide range of practice patterns were identified, no controversies were identified in areas that do not involve the adoption of new technologies. In areas where practice pattern variation was observed, the strong influence of the local environment was constantly identified as an impediment to changes in practice.

CONCLUSIONS

We have identified that barriers present within local practice environments are the major driving forces behind controversies in the non-operative management of splenic injuries.