Western Trauma Association (WTA) Critical Decisions in Trauma: Management of Adult Blunt Splenic Trauma

Weill Cornell Medical College, New York, New York, University of California, San Francisco, USA.
The Journal of trauma (Impact Factor: 2.96). 12/2008; 65(5):1007-11. DOI: 10.1097/TA.0b013e31818a93bf
Source: PubMed
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Available from: James W Davis
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    • "A recent report from the National Trauma Data Bank, for example, indicated that the incidence of splenectomy at a number of institutions varies from 18% to as much as 40%, and that this percentage is highly dependent on the definition that is applied to NOM [4]. This is important because it has been shown that variation in management can influence splenic salvage [5] [6]. Banerjee et al. [6] compared trauma centers with high rates (defined as >10%) of SAE with centres with low rates (<10%) and found that patients treated at high SAE volume centers were less likely to undergo splenectomy, both after observation and SAE. "
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    ABSTRACT: 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.
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    • "Further study by Federle et al. noted a 19% incidence of contrast blush in their patient population of which only 7% were successful in NOM [2]. Therefore, angiography for patients manifesting a blush associated with their splenic injury has been recommended [11]. However, these data do not answer the question of whether all patients with evidence of contrast extravasation from splenic injury mandate intervention. "
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    ABSTRACT: 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. During a 10-year period, we reviewed all patients transferred with blunt splenic injuries and contrast extravasation on initial postinjury CT scan. 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. 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.
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