Selective nonoperative management of blunt splenic trauma in adults

The use of selective nonoperative management of blunt splenic trauma in adults is based on the undeniable benefits of this approach in children. Proper patient selection requires hemodynamic stability, lack of generalized peritoneal irritation, and minimal blood transfusion needs. Computed tomography is now used to make the diagnosis, but the decision for laparotomy is based on clinical grounds. Forty-one (87%) of 47 patients selected for nonoperative management were treated successfully without laparotomy, while the remaining 6 patients underwent delayed operations for persistent splenic bleeding. Blood transfusion requirements were significantly less in the observed group than in the operative group for patients with isolated trauma and for patients with polytrauma. There were no known missed intra-abdominal injuries and no deaths with the nonoperative approach. Analysis of our results has confirmed that nonoperative management is a safe and effective alternative to immediate laparotomy in properly selected patients and it can result in splenic salvage without the need for an operation.     

The management of blunt splenic trauma

Seventy cases of blunt splenic trauma were retrospectively reviewed for the period 1979-1984. There were 57 adults and 13 children. Motor vehicle accidents were implicated in 62%. Forty-five splenectomies and eight splenorrhaphies were performed. The patients fell into two groups. Group A, numbering 48 patients, were those operated upon within 24 hours of injury. The mortality rate was 16%, and no deaths were attributable to splenic injury. Indications for surgery were hemodynamic instability in 46% and positive peritoneal lavage in 40%. Group B included 22 patients, 17 of whom were managed nonoperatively with no deaths. Five patients eventually went to laparotomy. Fifty per cent of all patients had associated intra-abdominal injury but only 17% needed repair; 31% of patients were initially managed conservatively with a 77% success rate and no mortality. It is concluded that conservative management is safe in stable patients with blunt splenic trauma.     

Conservative management in blunt splenic trauma

We reviewed for analysis the charts of two groups of adults patients with blunt splenic injuries issued from two University Hospital Centers; the group 1 (G1) of 22 patients and the group 2 (G2) of 20 patients. The results of actually therapeutic procedures concerning blunt splenic injuries and subsequently the effectiveness of non operative treatment were evaluated. Splenectomy was performed in G1 for 11 patients, instead of 19 patients in G2 (p = 0.0003), whereas, the non surgical treatment was done in 9 patients and 1 patient, respectively (p = 0.02). The mean Splenic Injury Score (SIS) was 2,95 in G1 and 3.47 in G2 (p = 0.03). The spleen was preserved in G1 for 8 patients, instead 1 patient in G2 (p = 0.04). In G1, the non operative treatment was successfully accomplished in 66% of patients. It was obtained with lack of mortality, with a lower overall morbidity and a lower length of hospital stay than in splenectomized patients, but the latter group accounted higher values of Injury Severity Scores (p < 0.05). If proper selection criteria for non operative management are used, more than a third of patients with blunt splenic injury can be treated by splenic preservation at least as safely as splenectomized patients.     

Nonoperative management of blunt splenic trauma in adults

Forty-five adult patients with traumatic splenic injuries were treated during a 6-year period between 1980-1986 at Hadassah Hospital. The diagnosis was confirmed by splenic scintigraphy with 99mTc Tin-colloid. Fifteen patients (33%) who were stable on admission or after initial resuscitation were treated non-operatively and selected for this study. Treatment consisted of careful hemodynamic monitoring, strict bed rest, nasogastric suction, and i.v. fluids. In no case was emergency laparotomy necessary for deterioration of clinical condition or late complications. Splenic scans were repeated in 11 of the patients to assess resolution. In six of the patients, minimal residual defects were detected with no further complications. It is concluded that nonoperative treatment of splenic injuries in carefully selected patients is both safe and effective.     

Nonoperative management of blunt splenic trauma in adults

The management of isolated blunt splenic trauma in adults is controversial. The authors present a series of 17 patients with blunt splenic trauma who were selected for nonoperative management. Only one patient eventually required surgery, for a ruptured spleen. Complications included pneumonia (two cases) and pleural effusion, atelectasis and ileus (one case each). There were no deaths. Five patients required transfusion, for a total of 17 units of blood. The mean length of hospital stay was 9.4 days. Comparison with a group of 17 patients treated operatively during the same period showed that those treated nonoperatively had fewer complications, required less blood and had a similar length of hospital stay. The authors conclude that nonoperative management of selected patients with isolated blunt splenic trauma is safe, if the patient's condition is closely monitored.     

Current management of blunt splenic trauma in children

BACKGROUND: Non-operative management of the great majority of blunt splenic injuries in children has become routine. Debate continues on the need for intensive care unit (ICU) admission, follow-up imaging and the duration of physical activity restrictions following injury. The purpose of this study was to review the recent experience of an Australian Paediatric Trauma Centre with splenic trauma to define current practice. METHODS: A retrospective chart review of patients with splenic trauma admitted to the Children's Hospital at Westmead between November 1995 and December 2003. RESULTS: A total of 39 patients with blunt splenic trauma were identified: 20 (51%) were multiply injured. Thirty-three (85%) children were managed non-operatively. The most common initial imaging method was computed tomography (n = 28, 72%). Fourteen patients (36%) were admitted to the ICU with a mean length of stay (LOS) of 4.1 days (range 1-13 days). The overall mean LOS was 10.8 days (range 1-43 days). Nineteen patients (50%) had imaging studies performed after diagnosis but before discharge. Further post-discharge imaging was carried out in 21 cases (54%). There were no deaths, but 10 patients developed complications. The mean documented activity restriction was 7.4 weeks (range 1-16 weeks). CONCLUSION: The majority of children who had suffered blunt splenic trauma were safely managed non-operatively outside an ICU. In stable patients, there appeared to be no benefits associated with repeated imaging following the diagnosis of splenic trauma. Physical activity restriction in excess of 3-4 weeks did not appear to be warranted.     

Selective operative management of major blunt renal trauma

BACKGROUND: We reviewed the management and outcomes of patients at our Level I trauma center suffering major blunt renal trauma diagnosed and staged by CT scan. METHODS: We retrospectively reviewed the cases of 26 patients with blunt trauma at our institution who were initially hemodynamically stable and diagnosed with grade 4 or 5 renal injuries by CT scan. Patients were broken down into two groups based on whether they were managed conservatively or surgically. Patient characteristics and morbidity were analyzed. RESULTS: There were 14 patients managed conservatively and 12 patients managed surgically. There was no statistically significant difference in morbidity between the two groups. The only statistically significant predictor of failure of conservative management was a coexisting solid organ intra-abdominal injury. CONCLUSIONS: Conservative management of major blunt renal trauma is appropriate in hemodynamically stable patients.     

Nonoperative management of blunt splenic trauma: a multicenter experience

The experience of six referral trauma centers with 832 blunt splenic injuries was reviewed to determine the indications, methods, and outcome of nonoperative management. During this 5-year period, 112 splenic injuries were intentionally managed by observation. There were 40 (36%) patients less than 16 years old and 72 adults. The diagnosis was established by computed tomography in 89 (79%) patients, nuclear scan in 23 (21%), ultrasound in four (4%), and arteriography in two (2%). There were 28 Class I, 51 Class II, 31 Class III, two Class IV, and no Class V splenic injuries. Nonoperative management was unsuccessful in one (2%) child and 12 (17%) adults (p less than 0.05). Failure was due to ongoing hemorrhage in 12 patients and delayed recognition of pancreatic injury in one patient. Of the 12 patients ultimately requiring laparotomy for control of hemorrhage, seven (58%) were successfully treated with splenic salvage techniques. Overall mortality was 3%; none of the four deaths was due to splenic or associated abdominal injury. This contemporary multicenter experience suggests that patients with Class I, II, or III splenic injuries after blunt trauma are candidates for nonoperative management if there is: 1) no hemodynamic instability after initial fluid resuscitation; 2) no serious associated abdominal organ injury; and 3) no extra-abdominal condition which precludes assessment of the abdomen. Strict adherence to these principles yielded initial nonoperative success in 98% of children and 83% of adults. Application of standard splenic salvage techniques to treat the patients with persistent hemorrhage resulted in ultimate splenic preservation in 100% of children and 93% of adults.     

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

Recent reports have shown an increased mortality associated with the nonoperative management of blunt splenic injury. We have prospectively applied criteria developed from our previous 15-year experience for the nonoperative management (NOM) of blunt splenic injury. These criteria consist of 1) hemodynamic stability on admission or after initial resuscitation with up to two liters of crystalloid infusion, 2) no physical findings or any associated injuries necessitating laparotomy, and 3) a transfusion requirement attributable to the splenic injury of 2 units or less. From 1994 through 2000 a total of 99 patients presented with blunt splenic injury. Thirty-one patients (31%) underwent splenectomy secondary to hemodynamic instability. During the observation period eight of the 68 patients (12%) who initially met criteria for NOM developed hemodynamic instability and underwent splenectomy. All NOM failures occurred within 72 hours of admission. There was no mortality associated with splenic injury in the NOM (Group I) or in the group failing NOM (Group II), and no associated morbidities from the splenic injury were seen in either group. No significant differences were seen between Groups I and II in terms of age, gender, mechanism of injury, Injury Severity Score, admitting systolic blood pressure, admitting hemoglobin, transfusion requirements, intensive care unit length of stay, or total hospital length of stay (all P > 0.200). We conclude that established criteria for intervention and careful observation in an intensive care setting for at least 72 hours will minimize morbidity or mortality associated with blunt splenic injury in adults.     

Complications arising from splenic embolization after blunt splenic trauma

Background

Nonoperative management (NOM) of splenic trauma is now the standard in stable trauma patients. Splenic artery embolization (SAE) is an increasingly used adjunct to NOM. We examined complications arising from SAE.

Methods

Patients admitted to a level I trauma center with splenic trauma over a 26-month period were identified. Management method, operative or nonoperative, was noted. SAE patients were analyzed in detail.

Results

There were 284 splenic trauma admissions. Ninety-three patients underwent operative management, and 191 received NOM. Fifteen patients (7.8%) underwent SAE. Embolization was proximal in 10, distal in 1, and combined in 4 patients. No NOM failures occurred. Major complications (27%) included splenic bleeding, splenic infarction, splenic abscess, and contrast-induced renal insufficiency. Minor complications of fever, pleural effusions, and coil migration occurred in 53% of patients. No relationship between SAE location and the presence of complications was noted.

Conclusions

SAE is an effective and safe procedure. Both major and minor complications can arise after SAE.     

Non-operative management of blunt splenic trauma: a 10-year experience.

There is growing awareness that the majority of traumatic splenic injuries should be managed non-operatively. This review of all traumatic spleen injuries at a large community teaching hospital over a 10-year period (1978-1988) confirms that principle. The study generated selection criteria and principles of non-operative management. Of a total of 91 patients, 23 were initially treated non-operatively. The average age was 27 years and all but two were adults. Splenic injury was confirmed by computed tomography scan in 20 patients (87 per cent) and by liver/spleen scan in three patients (13 per cent). Of the 23 patients, 21 (91 per cent) were successfully treated non-operatively. Of these, 14 had intraparenchymal or subcapsular haematomas and seven had splenic lacerations with haemoperitoneum. Two patients (9 per cent) initially treated non-operatively required splenectomy. Haemodynamically stable adult patients with blunt splenic injuries can be managed non-operatively if monitored in a setting where immediate operative intervention is available. Operative intervention is indicated not only in haemodynamically unstable patients, but also in patients who require more than four units of blood during a 48-h period.     

The significance of pseudoaneurysms in the nonoperative management of pediatric blunt splenic trauma

Purpose

Nonoperative management is the standard of care for hemodynamically stable pediatric and adult blunt splenic injuries. In adults, most centers follow a well-defined protocol involving repeated imaging at 24 to 48 hours, with embolization of splenic pseudoaneurysms (SAPs). In children, the significance of radiologically detected SAP has yet to be clarified.

Methods

A systematic review of the medical literature was conducted to analyze the outcomes of documented posttraumatic SAP in the pediatric population.

Results

Sixteen articles, including 1 prospective study, 4 retrospective reviews, and 11 case reports were reviewed. Forty-five SAPs were reported. Ninety-six percent of children were reported as stable. Yet, 82% underwent splenectomy, splenorrhaphy, or embolization. The fear of delayed complications owing to SAP was often cited as the reason for intervention in otherwise stable children. Only one child with a documented pseudoaneurysm experienced a delayed splenic rupture while under observation. No deaths were reported.

Conclusions

There is no evidence to support or dispute the routine use of follow-up imaging and embolization of posttraumatic SAP in the pediatric population. At present, the decision to treat SAP in stable children is at the discretion of the treating physician. A prospective study is needed to clarify this issue.     

Selective peritoneal lavage in the management of comatose blunt trauma patients

Comatose blunt trauma patients undergo diagnostic peritoneal lavage to aid in the management of severe injuries. In deference to routine performance of lavage, patients felt to be a risk for abdominal injury were prospectively studied by using selective criteria for lavage. One hundred consecutive comatose blunt trauma patients were studied; five underwent urgent celiotomy for refractory hypotension. Five criteria for lavage were: history of postinjury hypotension, abdominal physical findings suggestive of underlying abdominal injuries, evidence of fracture of the bones of the trunk and/or femur, blunt trauma of unknown etiology, and operative general anesthesia required for nonabdominal injuries. Fifty-five patients satisfied at least one of the above criteria and underwent peritoneal lavage. Forty patients not satisfying the criteria were observed without peritoneal lavage, as it was felt they had a decreased probability of serious abdominal injury. One of these patients had a minor liver laceration found at the time of autopsy following his death from severe head injury. None of the other patients had evidence of intra-abdominal injury by autopsy or subsequent clinical course. Utilizing the selective criteria, none of the 100 consecutive blunt trauma patients had major delay in abdominal diagnosis or missed significant abdominal pathology defined by operation, clinical course, or autopsy. Routine peritoneal lavage in all comatose blunt trauma patients may subject the patient to unnecessary risk, waste valuable time, increase the cost of care, and alter subsequent diagnostic procedures. Based on this small study, it appears that comatose blunt trauma victims not fulfilling the criteria may be effectively evaluated without the use of peritoneal lavage.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison between level 1 and level 2 trauma centers for the management of splenic blunt trauma

IntroductionThe management of blunt splenic trauma has evolved in the last years, from mainly operative approach to the non-operative management (NOM). The aim of this study is to investigate whether trauma center (TC) designation (level 1 and level 2) affects blunt splenic trauma management.MethodsA retrospective analysis of blunt trauma patients with splenic injury admitted to 2 Italian TCs, Niguarda (level 1) and San Carlo Borromeo (level 2), was performed, receiving either NOM or emergency surgical treatment, from January 1, 2015 to December 31, 2020. Univariate comparison was performed between the two centers, and multivariate analysis was carried out to find predictive factors associated with NOM and splenectomy.Results181 patients were included in the study, 134 from level 1 and 47 from level 2 TCs. The splenectomy/emergency laparotomy ratio was inferior at level 1 TC for high-grade splenic injuries (30.8% for level 1 and 100% for level 2), whose patients presented higher incidence of other injuries. Splenic NOM failure was registered in only one case (3.3%). At multivariate analysis, systolic pressure, spleen organ injury scale (OIS) and injury severity score (ISS) resulted significant predictive factors for NOM, and only spleen OIS was predictive factor for splenectomy (Odds Ratio 0.14, 0.04–0.49 CI 95%, P < .01).ConclusionBoth level 1 and 2 trauma centers demonstrated application of NOM with a high rate of success with some management difference in the treatment and outcome of patients with splenic injuries between the two types of TCs.