Abstract
ObjectivesNon-operative management (NOM) is increasingly utilised in blunt abdominal trauma. The 1994 American Association of Surgery of Trauma grading (1994-AAST) is applied for clinical decision-making in many institutions. Recently, classifications incorporating contrast extravasation such as the CT severity index (CTSI) and 2018 update of the liver and spleen AAST were proposed to predict outcome and guide treatment, but validation is pending.MethodsCT images of patients admitted 2000–2016 with blunt splenic and hepatic injury were systematically re-evaluated for 1994/2018-AAST and CTSI grading. Diagnostic accuracy, diagnostic odds ratio (DOR), and positive and negative predictive values were calculated for prediction of in-hospital mortality. Correlation with treatment strategy was assessed by Cramer V statistics.ResultsSeven hundred and three patients were analysed, 271 with splenic, 352 with hepatic and 80 with hepatosplenic injury. Primary NOM was applied in 83% of patients; mortality was 4.8%. Comparing prediction of mortality in mild and severe splenic injuries, the CTSI (3.1% vs. 10.3%; diagnostic accuracy = 75.4%; DOR = 3.66; p = 0.006) and 1994-AAST (3.3% vs. 10.5%; diagnostic accuracy = 77.9%; DOR = 3.45; p = 0.010) were more accurate compared with the 2018-AAST (3.4% vs. 8%; diagnostic accuracy = 68.2%; DOR = 2.50; p = 0.059). In hepatic injuries, the CTSI was superior to both AAST classifications in terms of diagnostic accuracy (88.7% vs. 77.1% and 77.3%, respectively). CTSI and 2018-AAST correlated better with the need for surgery in severe vs. mild hepatic (Cramer V = 0.464 and 0.498) and splenic injuries (Cramer V = 0.273 and 0.293) compared with 1994-AAST (Cramer V = 0.389 and 0.255; all p < 0.001).ConclusionsThe 2018-AAST and CTSI are superior to the 1994-AAST in correlation with operative treatment in splenic and hepatic trauma. The CTSI outperforms the 2018-AAST in mortality prediction.Key Points• Non-operative management of blunt abdominal trauma is increasingly applied and correct patient stratification is crucial.• CT-based scoring systems are used to assess injury severity and guide clinical decision-making, whereby the 1994 version of the American Association of Surgery of Trauma Organ Injury Scale (AAST-OIS) is currently most commonly utilised.• Including contrast media extravasation in CT-based grading improves management and outcome prediction. While the 2018-AAST classification and the CT-severity-index (CTSI) better correlate with need for surgery compared to the 1994-AAST, the CTSI is superior in outcome-prediction to the 2018-AAST.
Highlights
Advances in imaging techniques have led to the development of multiple radiological classification systems for blunt splenic and hepatic injuries [1, 2]
With more than 85% of cases classified as polytraumatic, 83% treated primarily with Non-operative management (NOM) and an overall mortality < 5%, this cohort represents a solid basis for radiological evaluation within a state-of-the-art environment
Re-evaluation of CT images confirmed that the splenic CT severity index (CTSI) incorporating contrast media extravasation, as previously proposed [21], is comparable with the 1994-Association for Surgery of Trauma (AAST) classification in terms of accuracy to predict mortality but is correlating better with the need for primary or secondary OM
Summary
Advances in imaging techniques have led to the development of multiple radiological classification systems for blunt splenic and hepatic injuries [1, 2] These are used as primary screening tools in early decision-making (operative [OM] vs nonoperative [NOM] management) [3]. The refinement of CT scanning is partially responsible for the increasing tendency towards NOM in hemodynamically stable patients [4,5,6,7,8] Despite their widespread use, only few of these classifications have been adequately validated [9] and several studies have proven CT findings inaccurate to determine management and outcome [1, 10,11,12]. In determining the treatment strategy, the AAST-OIS should always be supplemented by hemodynamic status and associated injuries
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