Blunt splenic injuries: Have we watched long enough?
ABSTRACT Nonoperative management (NOM) of blunt splenic injuries (BSIs) has been used with increasing frequency in adult patients. There are currently no definitive guidelines established for how long BSI patients should be monitored for failure of NOM after injury.
This study was performed to ascertain the length of inpatient observation needed to capture most failures, and to identify factors associated with failure of NOM. We utilized the National Trauma Data Bank to determine time to failure after BSI.
During the 5-year study period, 23,532 patients were identified with BSI, of which 2,366 (10% overall) were taken directly to surgery (within 2 hours of arrival). Of 21,166 patients initially managed nonoperatively, 18,506 were successful (79% of all-comers). Patients with isolated BSI are currently monitored approximately 5 days as inpatients. Of patients failing NOM, 95% failed during the first 72 hours, and monitoring 2 additional days saw only 1.5% more failures. Factors influencing success of NOM included computed tomographic injury grade, severity of patient injury, and American College of Surgeons designation of trauma center. Importantly, patients who failed NOM did not seem to have detrimental outcomes when compared with patients with successful NOM. No statistically significant predictive variables could be identified that would help predict patients who would go on to fail NOM.
We conclude that at least 80% of BSI can be managed successfully with NOM, and that patients should be monitored as inpatients for failure after BSI for 3 to 5 days.
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ABSTRACT: The management of the severe blunt splenic injuries remains debated. The aim of this study is to evaluate the morbidity and mortality of splenic injury according to severity and management (surgery, embolization, non-operative management [NOM]). A prospective multicenter study was conducted including patients aged 16 years and older with diagnosed splenic injury. We evaluated severity according to the AAST classification, the presence of hemoperitoneum or a contrast blush on initial CT scan. The initial hemodynamic status, patients co-morbidities, the ISS (injury severity score), management and morbidity were also noted. Between May 2010 and May 2012, 91 patients were included. Thirty-seven patients (41%) had mild splenic injury (AAST I or II and a small hemoperitoneum) while 54 patients (59%) had severe splenic injury (AAST III or greater). The management included 18 splenectomies (20%), 15 embolizations (16%). Among 67 patients undergoing NOM without initial embolization, five (7%) developed secondary bleeding, five required surgery and nine underwent secondary embolization. No patient died and morbidity was 44% (n=40), 13% for mild injuries vs. 65% for severe injuries (P<0.01). For severe injuries, total morbidity was 58% after NOM, 73% after embolization and 70% after surgery. Specific morbidity related to the management was 10% after NOM vs. 47% after embolization (P=0.02). Specific morbidity after surgery was 15%. Embolization, because of its important specific morbidity, should not be performed as a prophylactic measure, but only in presence of clinical or laboratory signs of bleeding. Copyright © 2015 Elsevier Masson SAS. All rights reserved.Journal of Visceral Surgery 02/2015; DOI:10.1016/j.jviscsurg.2015.01.003 · 1.32 Impact Factor
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ABSTRACT: Splenic injuries constitute the most common injuries accompanying blunt abdominal traumas. Non-operative treatment is currently the standard for treating hemodynamically stable patients with blunt splenic injuries. The introduction of splenic angiography has increased the possibility of non-operative treatment for patients who, in the past, would have qualified for surgery. This cohort includes mainly patients with severe splenic injuries and with active bleeding. The results have indicated that applying splenic angioembolization reduces the frequency of non-operative treatment failure, especially in severe splenic injuries; however, it is still necessary to perform prospective, randomized clinical investigations.Videosurgery and Other Miniinvasive Techniques / Wideochirurgia i Inne Techniki Malo Inwazyjne 09/2014; 9(3):309-14. DOI:10.5114/wiitm.2014.44251 · 1.09 Impact Factor
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ABSTRACT: Background Abdominal injuries occur relatively infrequently during trauma, and they rarely require surgical intervention. In this era of non-operative management of abdominal injuries, surgeons are seldom exposed to these patients. Consequently, surgeons may misinterpret the mechanism of injury, underestimate symptoms and radiologic findings, and delay definite treatment. This situation may result in an increasing proportion of non-operative management failures. Here, we determined the incidence, diagnosis, and treatment of traumatic abdominal injuries at our hospital to provide a basis for identifying potential hazards in non-operative management of patients with these injuries in a low trauma volume hospital.Methods This retrospective study included prehospital and in-hospital assessments of 110 patients that received 147 abdominal injuries from an isolated abdominal trauma (n¿=¿70 patients) or during multiple trauma (n¿=¿40 patients). Patients were primarily treated at the University Hospital of Umeå from January 2000 to December 2009.ResultsThe median New Injury Severity Score was 9 (range: 1¿57) for 147 abdominal injuries. Among patients that received prehospital responses (n¿=¿56), 64% had a time on scene¿<¿15 min, and 75% arrived at the emergency room in¿<¿60 min from the alert. Most patients (94%) received computed tomography (CT), but only 38% of patients with multiple trauma were diagnosed with CT¿<¿60 min after emergency room arrival. Penetrating trauma caused injuries in seven patients. Solid organ injuries constituted 78% of abdominal injuries. Non-operative management succeeded in 82 patients. Surgery was performed for 28 patients, either immediately (n¿=¿17) as result of operative management or later (n¿=¿11), due to non-operative management failure; the latter mainly occurred with hollow viscus injuries. Patients with multiple abdominal injuries, whether associated with multiple trauma or an isolated abdominal trauma, had significantly more non-operative failures than patients with a single abdominal injury. One death occurred within 30 days.Conclusions Non-operative management of patients with abdominal injuries, except for hollow viscus injuries, was highly successful in our low trauma volume hospital, even though surgeons receive low exposure to these patients. However, a growing proportion of surgeons lack experience in decision-making and performing trauma laparotomies. Quality assurance programmes must be emphasized to ensure future competence and quality of trauma care at low trauma volume hospitals.Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 08/2014; 22(1):48. DOI:10.1186/s13049-014-0048-0 · 1.93 Impact Factor