Prospective evaluation of criteria for the nonoperative management of blunt splenic trauma

Abstract

Meguid AA, Bair HA, Howells GA, et al (William Beaumont Hospital, Royal Oak, MI) There has been significant evolution in the management of blunt splenic trauma over the past 30 years. The trend toward nonoperative management of blunt splenic injury in adults has now been accepted as the standard of care in pediatric patients as well. However, recent reports have shown increased mortality rates and failure rates associated with nonoperative management of blunt splenic injury and have prompted questions regarding the appropriate criteria for nonoperative management. The authors of this study have prospectively applied criteria developed from 15 years of experience in the nonoperative management of blunt splenic injury. These criteria are hemodynamic stability on admission or after initial resuscitation with up to 2 L of crystalloid infusion, no physical findings or any associated injuries necessitating laparotomy, and a transfusion requirement attributable to the splenic injury of 2 units or less. The most recent results with application of these criteria to the treatment of blunt splenic trauma are presented. From 1994 through 2000, a total of 99 patients presented with splenic injury. Of these patients, 31 (31%) patients underwent splenectomy resulting from hemodynamic instability, leaving 68 patients for inclusion in this report. During the observation period, 8 (12%) of the 68 patients who initially met criteria for nonoperative management had hemodynamic instability develop and underwent splenectomy. All the nonoperative management failures occurred within 72 hours of admission. There was no mortality associated with splenic injury in the nonoperative management group or in the group that failed nonoperative management, and neither group had associated morbidities from the splenic injury. There were no significant differences between the nonoperative management group and the failed nonoperative management group in terms of demographics, clinical findings, or outcome measures. It would appear from these findings that established criteria for intervention and careful observation in an intensive care setting for a minimum of 72 hours will reduce the morbidity or mortality associated with blunt splenic trauma in adults.