Management Of Blunt Splenic Injury Research Articles

Variations in the management of adolescents with blunt splenic trauma in England and Wales: are we preserving enough?

Management of blunt splenic injury has changed drastically with non-operative management increasingly used in paediatric and adult patients. Studies from America and Australia demonstrate disparities in care of patients treated at paediatric and adult centres. This study assessed management of splenic injuries in UK adolescents. Data were acquired from the Trauma Audit and Research Network on isolated blunt splenic injuries reported 2006-2015. Adolescents were divided into age groups of 11-15 years and 16-20 years, and injuries classified as minor (grades 1/2) or major (3+). Primary outcomes were needed for splenectomy and blood transfusion. A total of 445 adolescents suffered isolated blunt splenic injuries. Road traffic collisions were the most common mechanism. There were no deaths as a result of isolated blunt splenic injuries, but 49 (11%) adolescents needed transfusions and 105 (23.6%) underwent splenectomies. There was no significant difference observed in the management of adolescents with minor trauma. In major trauma, 11-15-year-olds were more likely to have splenectomies when managed at local trauma units compared with major trauma centres (31% vs 4%, odds ratio 11.5; 95% confidence interval 3.82-34.38, p < 0.0001). Within major trauma centres, older adolescents were more likely to have splenectomies than younger adolescents (35.5% vs 3.8%, odds ratio 14; 95% confidence interval 4.55-43.26, p < 0.0001). There were no significant differences in haemodynamic status, transfusion requirement or embolisation rates. There appears to be a large variation in the management of isolated blunt splenic injuries in the UK. The reasons for this remain unclear however non-operative management is safe and should be first line management in the haemodynamically stable adolescent, even with major splenic injuries.

Predictors of splenectomy after failure of non-operative management: An analysis of the nation trauma database from 2013 to 2014

Introduction There is practice variability in non-operative management (NOM) of blunt splenic trauma. This is particularly true for management decisions following failure of NOM, i.e. splenectomy versus angioembolization (AE). The objective of this study was to identify predictors of splenectomy versus AE in patients who failed NOM. Methods We included adult patients from the National Trauma Data Bank for 2013–2014, who had a splenic injury and who were admitted to a Level I Trauma Center (L1TC). Patients undergoing splenectomy after 2 h of emergency department arrival were deemed to have failed NOM. Multivariate logistic regression modeling was used to identify independent predictors of intervention after failed NOM. Results There were 2284 patients admitted for splenic injury between 2013 and 2014 who failed NOM. A total of 1253 patients underwent AE and 1031 patients underwent splenectomy. Seven independent factors were identified that predicted failure of NOM: penetrating injury, community L1TC, hospital bed size, number of trauma surgeons on call, functional dependence, chronic steroid use, and cirrhosis. Conclusions Seven independent variables were identified that predicted failure of NOM. These results contribute to the body of data regarding management of blunt splenic injury. Knowing predictive factors could help personalize management of patients, minimize delay of care, efficient resource allocation, and inform future studies.

Routine follow-up imaging has limited advantage in the non-operative management of blunt splenic injury in adult patients

BackgroundTo date, limited evidence exists regarding follow-up imaging during the non-operative management (NOM) of blunt splenic injury (BSI), especially concerning ultrasound as first-line imaging modality. The aim of this study was to investigate the incidence and time to failure of NOM as well as to evaluate the relevance of follow-up imaging. MethodsAll adult patients with BSI admitted to our level I trauma center, including two associated hospitals, between 01/01/2010 and 31/12/2017 were retrospectively analyzed. Demographic data, comorbidities, injury pattern, trauma mechanism, Injury Severity Score, splenic injury grade and free intra-abdominal fluid were reviewed. Additional analysis of indication, frequency, modality, results and consequences of follow-up imaging was performed. Risk factors for failure of NOM were evaluated using fisher's exact test. ResultsA total of 122 patients with a mean age of 43.8 ± 20.7 years (16–84 years) met inclusion criteria. Twenty patients (16.4%) underwent immediate intervention. One-hundred-and-two patients (83.6%) were treated by NOM. Failure of NOM occurred in 4 patients (3.9%). Failure was significantly associated with active bleeding (3 of 4 [75%] failures vs. 8 of 98 [8.2%] non-failures, OR 33.75, 95% CI 3.1, 363.2, p = 0.004), and liver cirrhosis (2 of 4 [50%] failures vs. 0 of 98 [0%] non-failures, OR 197, 95% CI 7.4, 5265.1, p = 0.001). Eighty patients (78.4%) in the NOM-Group received follow-up imaging by ultrasound (US, n = 51) or computed tomography (CT, n = 29). In 57 cases, routine imaging examinations were conducted (43 US and 14 CT scans) without prior clinical deterioration. Fifty-fife (96.4%) of these imaging results revealed no new significant findings. Every failure of NOM was detected following clinical deterioration in the first 48 h. ConclusionTo our knowledge this study includes the largest single centric patient cohort undergoing ultrasound as first-line follow-up imaging modality in the NOM setting of BSI in adult patients. The results indicate that a routine follow-up imaging, regardless of the modality, has limited therapeutic advantage. Indication for radiological follow-up should be based on clinical findings. If indicated, a CT scan should be used as preferred imaging modality.

The adherence of adult trauma centers to American Pediatric Surgical Association guidelines on management of blunt splenic injuries

BackgroundNonoperative management (NOM) is commonly utilized in hemodynamically stable children with blunt splenic injuries (BSI). Guidelines published by the American Pediatric Surgical Association over the past 15 years support this approach. We sought to determine the rates and outcomes of NOM in pediatric BSI and compare trends between pediatric (PTC), mixed (MTC) and adult trauma centers (ATC). MethodsThis was a retrospective database analysis of the NTDB data from 2011 to 2015 including pediatric patients with BSI, as described by ICD-9-CM Codes 865.00–865.09. Patients with head injuries with AIS > 2, multiple intraabdominal injuries, and transfers-out were excluded. According to ACS and/or state designation, trauma facilities were defined as PTC (level I/II pediatric only), MTC (level I/II adult and pediatric) and ATC (level I/II adult only). OM group was defined as presence of procedure codes reflecting exploratory laparotomy/laparoscopy and/or any splenic procedures. NOM group consisted of patients who were observed, transfused or had transarterial embolization (TAE). Variables analyzed were age, ISS, spleen AIS, amount and type of blood products transfused, and intensive care unit (ICU) and hospital (H) length of stay (LOS). Results5323 children met the inclusion criteria. 11.4% received care at PTC (NOM, 97%), 40.7% at MTC (NOM, 89.9%) and 47.8% at ATC (NOM, 83.8%) (P < 0.001). In NOM group, PTC patients had the highest spleen AIS (3.46 ± 0.95, P < 0.001). TAE was predominantly used at MTC and ATC (P = 0.001). MTC and ATC were more likely to transfuse than PTC (P = 0.002). MTC and ATC OM rates were lower in children aged ≤12 than in children aged >12 (P < 0.001). Splenectomy rate was 1.5% at PTC, 8.4% at MTC, and 14.4% at ATC (P < 0.001). In OM group, PTC patients had a higher ISS (P = 0.018) and spleen AIS (P = 0.048) than both MTC and ATC. The proportion of patients treated by NOM at ATC increased during the 5-year period studied (P = 0.015). Treatment at MTC or ATC increased the risk for OM by 3.89 and 5.36 times respectively (P < 0.001). ConclusionsPTCs still outperform ATCs in NOM success rates despite higher ISS and splenic injury grades. From 2011 to 2015, ATC OM rates dropped from 17% to 12.4% suggesting increased adoption of the APSA guidelines. Further educational initiatives may help augment this trend. Level of evidenceII Type of studyRetrospective.

Nonoperative management of splenic injury in closely monitored patients with reduced consciousness is safe and feasible

BackgroundTreatment of blunt splenic injury has changed over the past decades. Nonoperative management (NOM) is the treatment of choice. Adequate patient selection is a prerequisite for successful NOM. Impaired mental status is considered as a relative contra indication for NOM. However, the impact of altered consciousness in well-equipped trauma institutes is unclear. We hypothesized that impaired mental status does not affect outcome in patients with splenic trauma.MethodsOur prospectively composed trauma database was used and adult patients with blunt splenic injury were included during a 14-year time period. Treatment guidelines remained unaltered over time. Patients were grouped based on the presence (Group GCS: < 14) or absence (Group GCS: 14–15) of impaired mental status. Outcome was compared.ResultsA total of 161 patients were included, of whom 82 were selected for NOM. 36% of patients had a GCS-score < 14 (N = 20). The median GCS-score in patients with reduced consciousness was 9 (range 6–12). Groups were comparable except for significantly higher injury severity scores in the impaired mental status group (19 vs. 17, p = 0.007). Length of stay (28 vs. 9 days, p < 0.001) and ICU-stay (8 vs. 0 days, p = 0.005) were longer in patients with decreased GCS-scores. Failure of NOM, total splenectomy rates, complications and mortality did not differ between both study groups.ConclusionThis study shows that NOM for blunt splenic trauma is a viable treatment modality in well-equipped institutions, regardless of the patients mental status. However, the presence of neurologic impairment is associated with prolonged ICU-stay and hospitalization. We recommend, in institutions with adequate monitoring facilities, to attempt nonoperative management for blunt splenic injury, in all hemodynamically stable patients without hollow organ injuries, also in the case of reduced consciousness.

Application of non-operative management protocol in pediatric blunt splenic injuries with other associated injuries

Background: Non-operative management (NOM) has become the standard of care for isolated blunt splenic injuries with satisfactory success rates. However, literature is scarce about the non-operative management of blunt splenic injuries (BSI) with other associated injuries (OAI). The main aim of this study is to assess the applicability of protocol-based NOM in BSI with OAI.Methods: Protocol based resuscitative algorithm was followed for the management of patients with BSI and OAI. NOM was taken up in those patients who were hemodynamically stable and was not attempted in patients who remained hemodynamically unstable or developed hemodynamic instability even after the resuscitative efforts. The data was collected and analyzed.Results: Forty patients with the mean age of 7.05±3.9 years were studied. Fall from height formed the commonest mode of injury. The mean AAST grade was 2.55. The most common association was a left lung contusion (20%). Fifteen patients presented with shock among which two failed the protocol-based resuscitative efforts and were hence explored. One of the patients had lung contusion and the other dorsal vertebral fractures (3rd and 4th). Another patient with mesenteric tear and delayed hemorrhage was operated. Two other patients underwent surgical interventions for bowel perforation and fracture of right femur respectively. Spleen was preserved in both of these patients. Though, the NOM was successful in overall 87.5% patients, spleen specific success rate was 92.5%.Conclusions: Application of protocol-based NOM in patients with BSI with OAI is highly successful if instituted in properly selected patients especially those with low grades of injury and also in those with delayed presentation.

Outcomes Following Blunt Traumatic Splenic Injury Treated with Conservative or Operative Management

Laparotomy, embolization, and observation are described for blunt splenic injury management. This study evaluated outcomes of blunt splenic injury management based on baseline factors, splenic injury severity, and associated injuries. A nine-year retrospective review was conducted of adult patients with blunt splenic injury. Collected data included demographics, injury characteristics, treatment modality, complications, and outcomes (mechanical ventilation, days on mechanical ventilation, intensive care unit [ICU] admission and length of stay, hospital length of stay, and in-hospital mortality). Categorical and continuous variables were analyzed using χ2 analysis and one-way analysis of variance for normally distributed variables and a non-parametric test of medians for variables that did not meet the assumption of normality, respectively. Splenic injury grade was similar between operative and embolization groups, but severe hemoperitoneum was more common in the operative group. Complications and mortality were highest in the operative group (50.7% and 26.3%, respectively) and lowest in the embolization group (5.3% and 2.6%, respectively). Operative patients required more advanced interventions (ICU admission, mechanical ventilation). There were no differences between those treated with proximal versus distal embolization. Observation carried a failure rate of 11.2%, with no failures of embolization. Embolization patients had the lowest rates of complications and mortality, with comparable splenic injury grades to those treated operatively. Further prospective research is warranted to identify patients that may benefit from early embolization and avoidance of major abdominal surgery.

2019 Canadian Surgery Forum Abstracts.

# 01. The future of general surgery training: a Canadian resident nationwide Delphi consensus statement {#article-title-2} Various pedagogical models have been introduced in an attempt to improve and restructure surgical training, but significant obstacles remain. Before implementing national

The Impact of Race and Socioeconomic Status on Treatment and Outcomes of Blunt Splenic Injury

BackgroundRacial, ethnic, and socioeconomic disparities have been shown to exist in trauma patients. Management of blunt splenic injuries (BSIs) can include splenectomy, embolization, or nonoperative management. This study assesses the effect of race and insurance status on outcomes in patients after blunt splenic trauma. MethodsThe National Trauma Data Bank was used to study patients aged 15-89 y with BSIs from 2013 to 2015. Patients with abbreviated injury scores greater than two in nonabdominal areas, excluding extremities, were eliminated, as were patients with other concomitant abdominal injuries requiring repair. Variables of interest were compared across groups using chi-square tests, and those with significant associations were used in multivariate regression models for each outcome. ResultsWe analyzed 13,537 BSI patients. Uninsured patients had increased odds of mortality, more splenic operations, and were less likely to have nonoperative management (P < 0.001). Uninsured patients were also twice as likely to be discharged home and three times as likely to leave against medical advice (P < 0.001). African Americans and Hispanics had higher mortality (odds ratio [OR] 2.03, CI 1.34-3.08; OR 1.58, CI 1.03-2.44, respectively). African Americans had more splenic operations (OR 1.33, CI 1.08-1.64) and were 60% less likely to receive angioembolization (CI 0.41-0.84). Hispanics had fewer splenic operations (OR 0.79, CI 0.63-0.98). ConclusionsNoteworthy differences exist in the management of splenic trauma patients based on race/ethnicity and socioeconomic status, despite controlling for demographics and injury characteristics. Insurance status and race likely affect surgical treatment plans and mortality, particularly for uninsured, black, and Hispanic patients, but further research is needed to identify the root cause of these disparities.

Non-operative management of blunt splenic injury: is it really so extensively feasible? a critical appraisal of a single-center experience.

IntroductionThe spleen is one of the most commonly injured organ following blunt abdominal trauma. Splenic injuries may occur in isolation or in association with other intra-and extra-abdominal injury. Nonoperative management of blunt injury to the spleen has become routine in children. In adult most minor splenic injuries are readily treated nonoperatively but controversy exists regarding the role of nonoperative management for higher grade injuries above all in multi-trauma patients. The aim of this study is the assessment of splenic trauma treatment, with particular attention to conservative treatment, its limits, its efficiency, and its safety in multi-trauma patient or in a severe trauma patient.MethodsThe present research focused on a retrospective review of patients with splenic injury. The research was performed by analyzing data of the trauma registry of St. Andrea University Hospital in Rome. The St. Andrea University Hospital trauma registry includes 1859. The variables taken into account were spleen injury and general injuries, age, sex, cause and dynamic of trauma, hemoglobin, hematocrit, white blood cells count, INR, number and time blood transfusion, hemodynamic stability, type of treatment provided, hospitalization period, morbidity and mortality. Assessment of splenic injuries was evaluated according to Abbreviated Injury Scale (AIS).ResultsThe analysis among the general population of spleen trauma patients identified 68 patients with a splenic injury representing the 41.2% of all abdomen injury. The Average age was of 37.01 ± 17.18 years. The Average ISS value was of 22.88 ± 12.85; mediana of 24.50 (range 4-66). The average Spleen AIS value was of 3.13 ± 0.88; mediana 3.00 (range 2-5). The overall mortality ratio was of 19.1% (13 patients). The average ISS value in patients who died was of 41.92 ± 12.48, whereas in patients who survided was of 23.33 ± 10.15. The difference was considered to be statistically significant (p <0.001). The relashionship between the ISS and AIS values in patients who died was considered directly proportional but not statistically significant (Pearson test AIS/ISS = 0.132, p = n.s.). The initial management was a conservative treatment in 27 patients (39.7%) of them 4 patients (15%) failed, in the other 41 cases urgent splenectomies were performed. The average spleen AIS in all the patients who underwent splenectomy was 3.61 ± 0.63 whereas in the patients who were not treated surgically was 2.42 ± 0.69. The difference was deemed statistically significant (p <0.001).ConclusionSplenic injury, as reported in our statistic as well as in literature, is the most common injury in closed abdominal trauma. Nonoperative management of blunt injury to the spleen in adults has been applied with increasing frequency. However, the criteria for nonoperative management are controversial. The preference of a conservative treatment must be based on the hemodynamic stability indices as well as on the spleen lesion severity and on the general trauma severity. The conservative treatment represent a feasible and safe therapeutic alternative even in case of severe lesions in politrauma patients, but the choice of the treatment form requires an assessment for each singular case.

Safety of selective nonoperative management for blunt splenic trauma: the impact of concomitant injuries

BackgroundNonoperative management for blunt splenic injury is the preferred treatment. To improve the outcome of selective nonoperative therapy, the current challenge is to identify factors that predict failure. Little is known about the impact of concomitant injury on outcome. Our study has two goals. First, to determine whether concomitant injury affects the safety of selective nonoperative treatment. Secondly we aimed to identify factors that can predict failure.MethodsFrom our prospective trauma registry we selected all nonoperatively treated adult patients with blunt splenic trauma admitted between 01.01.2000 and 12.21.2013. All concurrent injuries with an AIS ≥ 2 were scored. We grouped and compared patients sustaining solitary splenic injuries and patients with concomitant injuries. To identify specific factors that predict failure we used a multivariable regression analysis.ResultsA total of 79 patients were included. Failure of nonoperative therapy (n = 11) and complications only occurred in patients sustaining concomitant injury. Furthermore, ICU-stay as well as hospitalization time were significantly prolonged in the presence of associated injury (4 versus 13 days,p < 0.05). Mortality was not seen. Multivariable analysis revealed the presence of a femur fracture and higher age as predictors of failure.ConclusionsNonoperative management for hemodynamically normal patients with blunt splenic injury is feasible and safe, even in the presence of concurrent (non-hollow organ) injuries or a contrast blush on CT. However, associated injuries are related to prolonged intensive care unit- and hospital stay, complications, and failure of nonoperative management. Specifically, higher age and the presence of a femur fracture are predictors of failure.

Pediatric trauma center verification improves quality of care and reduces resource utilization in blunt splenic injury

PurposeWe sought to evaluate value impact of transition from an adult trauma center treating children (ATC) to a verified pediatric trauma center (PTC) in children with blunt splenic injury (BSI). MethodsChildren with BSI from FY 2005 to FY 2017 were extracted from the hospital trauma registry. February 2009 distinguished “ATC” treated children from “PTC” treated children. Cohorts were subcategorized into “isolated injury” and “multisystem injury”. Quality and financial characteristics were statistically compared. Analysis of covariance was used to evaluate changes in quality and financial trends over the transition period. A multiple linear regression was performed to identify variables independently predictive of hospital and professional charges. Results126 children with BSI were identified (ATC, n = 56; PTC, n = 70). Splenic procedure rates and hospital charges decreased. Quality and cost metrics for isolated BSI remained unchanged while multisystem BSI children experienced improvements. PTC designation, ISS, splenic procedure, isolated BSI, average hospital LOS, and mortality were all independently predictive of hospital and professional charges. ConclusionsPTC verification improves the value of BSI management, but the associated decrease in operative rate is only partially responsible. Multisystem injury children experience the greatest value benefit from PTC verification. Type of studyTreatment and cost-effectiveness study. Level of evidenceLevel III.

Conservative Versus Operative Management of Blunt Splenic Injuries

Background: The spleen is the most frequently injured organ in blunt abdominal trauma, mainly because of its highly vascularized parenchyma and its anatomic location. In the past the management of blunt splenic injuries was splenectomy, but high rate of operative complications caused paradigm shift from operative to non-operative management (NOM) in hemodynamically stable blunt abdominal trauma patients. Now, nonoperative management of hemodynamically stable patients with blunt splenic injuries is the standard of care and has been proven to be safe and successful in the acute setting. The advent of newer imaging techniques with high resolution CT scanners has enabled the clinicians to exactly diagnose the extent of intra-abdominal organ injury. Objective: This work aim to compare between operative and conservative management of splenic trauma. Methodology: Total numbers of patients in this study were 20 patients classified in two groups, the first group contained12 patients and the other group contained 8 patients. The First group was managed conservative and the second was managed operative with splenectomy and splenoraphy. The first group of patients consisted of 9 males (75%) and 3 female (25%). The second group of patients consisted of 6 males (75%) and 2 females (25%). Results: In this study, bunt splenic injury was found to be more common in males because of their risky and hard work. RTA and Falling from a height were found to be the most common causes of blunt abdominal injuries. According to CT, grade one and two of splenic injury are more common than other grades of splenic injury. As regard complication the operative management has more complication as postoperative wound infection and postoperative chest infection. So, NOM of splenic injury is the management of choice in haemodynamically stable patients. Conclusion: The nonoperative management is considered the ideal management for blunt splenic injuries due to less complication, less blood transfusion, less hospital stay and less mortality than operative management.

Operative versus conservative management of splenic trauma in pediatric patients

Objective The aim of this study was to compare between operative and conservative management of splenic trauma in pediatric patients. Background In the past the management of blunt splenic injuries was carried out using splenectomy. However, the high rate of operative complications caused a paradigm shift from operative to nonoperative management in hemodynamically stable blunt abdominal trauma patients. Patients and methods This prospective study included a total of 40 patients. The patients were managed conservatively or operatively. Nonoperative management criteria included hemodynamic stability and absence of other injuries requiring laparotomy. Unstable patients were operated using splenectomy. Results Road traffic accident was the most common mechanism of trauma in this study (55%) in the patients who were managed conservatively and (60%) in the patients who were managed operatively (χ2 = 1.507; P = 1.000). Computed tomography was performed for stable patients only; grade I and grade II splenic injury comprised 70% of cases. The incidence of complications was 5% in the patients who were managed conservatively and 10% in the patients who were managed operatively (χ2 = 0.360; P = 1.000). The incidence of blood transfusion was less in the patients who were managed conservatively (25%) than in the patients who were managed operatively (100%) (χ2 = 24.000; P < 0.001). There was no mortality in the patients who were managed conservatively, whereas in the patients who were managed operatively the incidence of mortality was 5% (χ2 = 1.026; P = 1.000). All these tests were used as tests of significance at P less than 0.05. Conclusion The nonoperative management is considered the ideal management for blunt splenic injuries in pediatric patients because of fewer complications, lower blood transfusion rate, shorter hospital stay, and less mortality compared with operative management.

Blunt splenic injury in children: haemodynamic status key to guiding management, a 5-year review of practice in a UK major trauma centre

To review the management of children and adolescents (0-18years), with blunt splenic injury treated at a single UK major trauma centre over a 5-year period, focusing upon efficacy of non-operative management and the use of haemodynamic stability as a guide to planning treatment strategy, rather than radiological injury grading. To produce a treatment pathway for management of blunt splenic injury in children. Retrospective, cross-sectional study of all paediatric patients admitted with radiologically proven blunt splenic injury between January 2011 and March 2016. Penetrating injuries were excluded. Follow up was for at least 30days. 30 Patients were included, mean age was 14.5 (SD 3.6), median injury severity score was 16 (IQR 10-31). 6 Patients (20%) had a splenectomy, whilst 22 patients (73%) were successfully treated non-operatively with 100% efficacy at index admission. 5/8 (63%) patients with radiological grade V injuries were managed non-operatively, injury grade was not associated with surgical intervention (p = 1.57). Haemodynamic instability was initially treated with fluid resuscitation leading to successful non-operative management in 5/11 (45%) patients. However, haemodynamic instability is a significant predictor of requirement for surgical intervention (p = 0.03), admission to critical care (p = 0.017), presence of additional injuries (p = 0.015) and increased length of stay (p = 0.038). No such relationships were found to be associated with increased radiological injury grade. Non-operative management should be first-line treatment in the haemodynamically stable child with a blunt splenic injury and may be carried out with a high degree of efficacy. It may also be successfully implemented in those initially showing signs of haemodynamic instability that respond to fluid resuscitation. Radiological injury grade does not predict definitive management, level of care, or length of stay; however, haemodynamic stability may be utilised to produce a treatment algorithm and is key to guiding management.

A rare mechanism of delayed splenic rupture following the nonoperative management of blunt splenic injury in a child

BackgroundNonoperative management (NOM) has been established as the standard treatment for isolated blunt organ injury in hemodynamically stable pediatric patients. Although delayed splenic rupture or bleeding is a rare complication in NOM, it is an issue that many pediatric surgeons are greatly concerned about. We herein report a rare pediatric case concerning the mechanisms involved in delayed splenic rupture after NOM.Case presentationA 9-year-old boy with severe abdominal pain was transferred to our hospital. Twenty-one hours before the admission, he had been kicked in the region of his left lateral abdomen. Contrast-enhanced abdominal computed tomography revealed a severe intra-parenchymal hematoma and multiple lacerations of the spleen with a large amount of hemoperitoneum without active bleeding. His condition was diagnosed as a grade III injury on the AAST splenic injury scale. After fluid resuscitation, his vital signs became stable. The patient was treated with NOM in our intensive care unit. However, suddenly after defecation (72 h after the injury), he started complaining of severe abdominal pain and left shoulder pain. His blood pressure dropped to 70/35 mmHg, and he started to lose consciousness. Abdominal ultrasonography (US) revealed increased ascites. Fluid resuscitation and blood transfusion were performed. His symptoms and abdominal US findings suggested that splenic re-bleeding had caused delayed splenic rupture to occur. Emergency splenectomy was performed. The resected spleen was enlarged with a large parenchymal hematoma. The posterior-lateral side of the splenic capsule was ruptured.ConclusionsThe mechanism of delayed splenic rupture in our case was considered to be the result of a tear in the subcapsular hematoma caused by stretching the splenocolic ligament related to a bowel movement during defecation. Although delayed splenic rupture or bleeding is unpredictable, it is very important to understand the mechanisms and to educate the family of the children with splenic injuries of the warning signs of delayed rupture or bleeding.

Comparison of outcomes before and after establishing a regional trauma center and following a protocol to treat blunt splenic injury in South Korea: A retrospective study

Background: Nonoperative management for hemodynamically stable splenic injury has been accepted as appropriate treatment. Objectives: This study aimed to investigate the changes in management and clinical outcomes of splenic injury by introducing a protocol for splenic injury at a newly established regional trauma center. Methods: From January 2005 to December 2016, we reviewed the outcomes of all 257 patients who sustained blunt trauma to the spleen at the first regional trauma center in South Korea. This 11-year period was divided into two intervals, before 1 January 2014 (period I, n = 189 patients) and after 1 January 2014 (period II, n = 68 patients), when the trauma center was established and a formal management protocol was followed for patients with blunt traumatic splenic injuries. Results: The proportion of emergency operations performed for patients with more serious (grades 3–5) splenic injuries was lower in period II than in period I (29% vs 22%, respectively, p &lt; 0.001) whereas the rate of angioembolization was higher (89% vs 39.0%, respectively, p &lt; 0.001). The time to intervention, irrespective of whether emergency operation or angioembolization was performed, was shorter in period II than in period I (312.8 min vs 129 min, respectively, p = 0.001). A greater proportion of patients was managed non-operatively in period II (78% vs 71%), and the non-operative management success rate was higher in period II than it was in period I (100% vs 83%; p = 0.014). Similarly, the splenic salvage rate was higher in period II (78% vs 59%, p = 0.03). Conclusion: After establishing a regional trauma center and introducing a protocol for the management of blunt splenic injuries, the rates of non-operative management and splenic salvage improved significantly. The reasons for this may be multifactorial, being related to the early involvement of a trauma surgeon, expansion of angiographic facilities and resources, and the introduction and application of a protocol for managing blunt splenic injury.

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

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. 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. 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). 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. Therapeutic, level IV.

The management of blunt splenic injury in adults: The trauma centre experience in Dubai

Introduction: The spleen is the most frequently injured solid organ during blunt abdominal trauma. The treatment strategy for managing splenic insults came under review as doctors were increasingly concerned about post-splenectomy sepsis. Nonoperative management (NOM) of blunt splenic injuries (BSIs) became the standard of care for most of the cases where patients are haemodynamically stable, irrespective of injury grade. Methodology: This is a retrospective study where all adult patients with blunt abdominal injuries treated at level-1 trauma centre in Dubai, between January 2011 and October 2013, were reviewed. Data regarding demographics, pre-operative management, intraoperative findings, blood transfusions requirements and length of hospital stay were collected from patients' files. SPSS (version 20, IBM) was used for data analysis. Results: During the study, 153 patients were enrolled. Nearly 82% of patients with splenic injury were between 13 and 44 years of age. Only 12 patients had an isolated splenic injury. Of 153 patients, 106 were managed conservatively; only 6/106 failed the conservative treatment and got operated. Of 6 patients, 2 were operated due to bowel perforation and the rest 4 patients underwent splenectomy due to hemodynamic instability and drop in haemoglobin. Among the living group, 25/30 patients with Grade I injury and 45/50 patients with Grade II injury were managed conservatively. Conclusion: NOM of BSI was successful in 62.1% in our study which is consistent with other studies. Careful selection of patient and resource availability should be taken into consideration while adopting NOM approach.

Assessment of blunt splenic trauma: Which imaging scoring system is superior?

Background:Spleen is the most common viscera that may be hurt in blunt abdominal trauma. Operative or nonoperative management of splenic injury is a dilemma. The American Association for the Surgery of Trauma (AAST) is the most common grading system which has been used for the management of blunt splenic injuries. The new recommended grading system assesses other aspects of splenic injury such as contrast extravasation, pseudoaneurysm, arteriovenous fistula, and severity of hemoperitoneum, as well. The aim of this study is to compare and prioritize the cutoff of AAST grading system with the new recommended one.Materials and Methods:This is a cross-sectional study on patients with splenic injury caused by abdominal blunt trauma referred to Isfahan University of Medical Sciences affiliated Hospitals, Iran, in 2013–2016. All patients underwent abdominopelvic computed tomography scanning with intravenous (IV) contrast. All images were reported by a single expert radiologist, and splenic injury grading was reported based on AAST and the new recommended system. Then, all patients were followed to see if they needed surgical or nonsurgical management.Results:Based on the findings of this study conducted on 68 patients, cutoff point of Grade 2, in AAST system, had 90.3% (95% confidence interval [CI]: 0.73–0.97) specificity, 51.4% (95% CI: 0.34–0.67) sensitivity, 86.4% (95% CI: 0.64–0.95) positive predictive value (PPV), and 60.9% (95% CI: 0.45–0.74) negative predictive value (NPV) for prediction of surgical management requirement, while it was 90.3% (95% CI: 0.73–0.97) specificity, 45.9% (95% CI: 0.29–0.63) sensitivity, 85% (95% CI: 0.61–0.96) PPV, and 58.3% (95% CI: 0.43–0.72) NPV for the new system (P = 0.816).Conclusion:In contrast to the previous studies, the new splenic injury grading method was not superior to AAST. Further studies with larger populations are recommended.