Blunt splenic injury in adults: Multi-institutional Study of the Eastern Association for the Surgery of Trauma

BACKGROUND: 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 purpose of this multi-institutional study was to determine which factors predict successful observation of blunt splenic injury in adults. METHODS: A total of 1,488 adults (>15 years of age) with blunt splenic injury from 27 trauma centers in 1997 were studied through the Multi-institutional Trials Committee of the Eastern Association for the Surgery of Trauma. Statistical analysis was performed with analysis of variance and extended chi2 test. Data are expressed as mean +/- SD; a value of p < 0.05 was considered significant. RESULTS: A total of 38.5 % of patients went directly to the operating room (group I); 61.5% of patients were admitted with planned nonoperative management. Of the patients admitted with planned observation, 10.8% failed and required laparotomy; 82.1% of patients with an Injury Severity Score (ISS) < 15 and 46.6% of patients with ISS > 15 were successfully observed. Frequency of immediate operation correlated with American Association for the Surgery of Trauma (AAST) grades of splenic injury: I (23.9%), II (22.4%), III (38.1%), IV (73.7%), and V (94.9%) (p < 0.05). Of patients initially managed nonoperatively, the failure rate increased significantly by AAST grade of splenic injury: I (4.8%), II (9.5%), III (19.6%), IV (33.3%), and V (75.0%) (p < 0.05). A total of 60.9% of the patients failed nonoperative management within 24 hours of admission; 8% failed 9 days or later after injury. Laparotomy was ultimately performed in 19.9% of patients with small hemoperitoneum, 49.4% of patients with moderate hemoperitoneum, and 72.6% of patients with large hemoperitoneum. CONCLUSION: In this multicenter study, 38.5% of adults with blunt splenic injury went directly to laparotomy. Ultimately, 54.8% of patients were successfully managed nonoperatively; the failure rate of planned observation was 10.8%, with 60.9% of failures occurring in the first 24 hours. Successful nonoperative management was associated with higher blood pressure and hematocrit, and less severe injury based on ISS, Glasgow Coma Scale, grade of splenic injury, and quantity of hemoperitoneum.     

Nonoperative management of severe blunt splenic injury: are we getting better?

BACKGROUND: Most minor splenic injuries are readily treated nonoperatively but controversy exists regarding the role of nonoperative management for higher-grade injuries. The infrequency of these injuries has made evaluation of factors critical to their management difficult. METHODS: Through the National Trauma Data Bank, 3,085 adults sustaining severe (Abbreviated Injury Scale score > or = 4) blunt splenic injury from 1997 to 2003 were retrospectively reviewed. Patient management, demographic information, physiologic data, procedures performed, and outcomes were analyzed. RESULTS: Nonoperative management was attempted in 40.5% of patients but ultimately failed in 54.6% of those. Failure of nonoperative management was associated with increased age, low admission systolic blood pressure, higher injury severity score, and increased hospital and intensive care unit length of stay. Mortality associated with failure of nonoperative management (12.3%) and successful observation (13.8%) was similar. CONCLUSIONS: Nonoperative management of higher-grade splenic injuries is associated with a high rate of failure and prolonged hospital stay. Careful judgment must be exercised in applying nonoperative management to patients with severe splenic injuries.     

Operative intervention for pediatric liver injuries: avoiding delay in treatment.

To identify the physiological and anatomic factors that characterize the need for operative management of blunt pediatric liver injuries, the case records of 106 pediatric trauma victims with liver injuries over a 6-year period were reviewed. Sixty-nine patients were managed without operation (nonoperative) and 37 underwent operation, 7 with penetrating and 30 with blunt liver injuries. Of these 30 patients, 21 underwent laparotomy due to blunt liver injuries (operative); the remaining 9 patients required operation due to associated intraabdominal injuries. Nine (45%) of the 21 operative patients had major hepatic vein or retrohepatic vena caval injuries, 7 of whom died. Overall mortality was 9.4% (10/106). When nonoperative and operative groups were compared, those who underwent laparotomy due to blunt liver injuries: (1) had significantly lower Champion and Pediatric Trauma Scores due to multisystem injury; (2) had 25% or greater lobar disruption with pelvic blood collections on computed tomography scan; (3) underwent early transfusion within 2 hours of admission (18/21); and (4) were frequently found to have a major hepatic vein or retrohepatic vena caval injury at the time of operation. Only one patient successfully managed without operation received greater than 30 mL/kg of blood products within 24 hours of admission. As selective nonoperative management of pediatric liver injuries gains widespread acceptance, the identification of factors that predict the need for operative intervention will limit the potential risks of delay in treatment.     

Is delayed laparotomy for blunt abdominal trauma a valid quality improvement measure in the era of nonoperative management of abdominal injuries?

BACKGROUND: Review of hemodynamically stable patients who undergo laparotomy for trauma greater than 4 hours after admission is an American College of Surgeons quality improvement filter. We reviewed our recent experience with patients who underwent laparotomy for trauma greater than 4 hours after admission to evaluate the reasons for delay, and to determine whether they were because of failure of nonoperative management or other causes. METHODS: The registry at our Level I trauma center was searched from January 1998 through December 2000 for patients who required a laparotomy for trauma greater than 4 hours after admission. Of 3,369 admitted blunt trauma patients, 90 (2.7%) underwent laparotomy for trauma, of which 26 (29%) were identified as delayed laparotomies greater than 4 hours after admission. RESULTS: The most common mechanism of injury was motor vehicle crash, the mean Injury Severity Score was 18, and 65% of the patients had significant distracting injuries. Five patients had laparotomy greater than 24 hours after admission. The average time to the operating room in the remaining patients was 8.6 hours. Clinical examination (61%) findings were the most common indication for operation. Gastrointestinal (GI) tract injury was the most common injury associated with delay in laparotomy (58%). CONCLUSION: GI tract injuries are the predominant injury leading to delayed laparotomy for blunt trauma (58%). Failed nonoperative management of solid organ injuries occurred less frequently (15%). Future efforts should concentrate on earlier identification of GI tract injury. Delayed laparotomy for blunt abdominal trauma is a valid quality improvement measure.     

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.     

Twenty Years of Splenic Preservation in Trauma: Lower Early Infection Rate Than in Splenectomy

BACKGROUND: Retrospective studies concerning the operative preservation and nonoperative management of splenic injuries in patients with splenic trauma have been published; however, few studies have analyzed prospectively the results and early complication rates of a defined management in splenic injury. METHODS: From 1986 to 2006, adult patients with blunt splenic injuries were evaluated prospectively with the intent of splenic preservation. Hemodynamically unstable patients underwent laparotomy. Stable patients were treated conservatively regardless of the grade of splenic injury determined by ultrasound and/or CT scan. RESULTS: During a 20-year period, 155 patients were prospectively evaluated. In 98 patients (63%), the spleen could be preserved by nonoperative (64 patients, 65%) or operative (34 patients, 35%) treatment and 57 patients (37%) needed splenectomy. There were no differences in age, sex, or trauma score between the groups, but a higher early infection rate in patients with splenectomy compared with patients with splenic preservation (p < 0.005) was observed, even if the patients were matched with respect to multiple trauma using the Injury Severity Score (p < 0.01). CONCLUSIONS: Splenic preservation in patients with blunt splenic injury by operative or nonoperative treatment leads to lower early infection rates in adults and, therefore, should be advocated.     

Admission angiography for blunt splenic injury: advantages and pitfalls.

BACKGROUND: To analyze the use of admission angiography as a nonoperative adjunct for management of blunt splenic injury. METHODS: Retrospective chart review of all blunt splenic injuries to a Level I trauma center from March 1997 through July 1999. RESULTS: One hundred twenty-six patients underwent angiography for splenic injury. Eighty-six patients (68%) had a negative angiogram and were treated expectantly. Of these, seven patients (8%) required laparotomy, with a splenic salvage rate of 92%. Embolization was performed on 40 patients (32%) for evidence of vascular injury. Of these, three patients (8%) required laparotomy, for a total salvage of 92%. Repeat angiography was performed for suspicion of bleeding in 12 patients (10%), with 50% requiring embolization. Outcome based on CT grade demonstrated an average grade of 2.9, with a salvage rate of greater than 70% for grade IV and V injuries. CONCLUSION: Vascular injury increases with splenic injury grade. Embolization improves nonoperative salvage rates to 92%, even with high-grade injuries. Ten percent of patients require additional therapy including "second-look" angiography. A significant portion of patients with negative screening angiograms (10%) required either embolization or laparotomy to control delayed hemorrhage.     

Nonoperative management of blunt splenic injury in adults 55 years and older: a twenty-year experience

The nonoperative management of splenic injury secondary to blunt trauma in older patients remains controversial. We have reviewed our experience from January 1978 to December 1997 with selective nonoperative management of blunt splenic injury in adults 55 years and older. Criteria for nonoperative management included hemodynamic stability with any transient hypotension corrected using less than 2,000 cm3 crystalloid infusion, a negative abdominal physical examination ruling out associated injuries, and a blood transfusion requirement of no more than 2 units attributable to the splenic injury. During the study period, 18 patients over age 55 with radiographic confirmation of a splenic injury met the above criteria for nonoperative management. Their mean age was 72 years (range 56-86), and 13 of the 18 were female (72%). The mean Injury Severity Score was 15 (range 4-29), with the mechanism of injury equally divided between automobile crashes (9) and falls (9). During a similar time period, 15 patients 55 years or older with splenic injury composed an operative group; these patients did not differ with respect to age (mean 68 years), sex (60% female), or mechanism of injury. CT scans of 8 patients managed nonoperatively were available and graded using the American Association for the Surgery of Trauma classification, with a mean score of 2.3 (range 2-3). Eight of the 18 nonsurgical patients received blood transfusions. None of the 18 patients who met the criteria for nonoperative management "failed" the protocol, and none were taken to the operating room for abdominal exploration. Two patients (11%) died of associated thoracic injuries after lengthy hospital stays, one at 10 days and one at 24 days. We conclude from our data that nonoperative management of blunt splenic injury in patients age 55 years and older is indicated provided they are hemodynamically stable, do not require significant blood transfusion, and have no other associated abdominal injuries.     

Overuse of splenic scoring and computed tomographic scans.

BACKGROUND: As the most commonly injured abdominal organ in blunt trauma, the management of splenic injury has undergone evolution. The risk of blood transfusions administered in an attempt to save the spleen has lowered the threshold for operation and also expanded the limits for nonoperative management. An in-depth analysis was carried out of risk factors on patients requiring immediate surgery and those who fail non-operative management based on organ injury scaling grading by computed tomographic (CT) scan and operation. The application of nonoperative management in the elderly population and the use of follow-up CT scanning and sonography in the outpatient setting was also examined. METHODS: Between January of 1991 and June of 1996, 226 consecutive blunt splenic trauma, injured patients at a Level I trauma center were evaluated. All subsequent CT scans and sonograms in the inpatient and outpatient setting were analyzed. The Student's t test, Pearson chi2 analysis with Yates correction, and analysis of variance were used to compare between and among groups. RESULTS: There were 153 men (67.7%), an average age of 34.8 years, an average Injury Severity Score of 24.4, and 28 deaths (12%). There was a significant difference with respect to Injury Severity Score, Glasgow Coma Scale score, Revised Trauma Score, units of packed red blood cells transfused, length of stay, intensive care unit length of stay, mean splenic injury grade, and cost between patients observed initially and those operated on initially. There was no significant difference in age between the two groups. Of 170 patients, 37 patients (22%) who had an initial CT scan underwent immediate exploratory laparotomy. The remaining 133 patients (78%) had nonoperative management; however, 15 patients (11%) failed the period of observation. Five in this group had a laparotomy secondary to other causes and another six were operated on within 24 hours of their injury for their splenic injury. Thus, only four of the nonoperative management patients (3%) actually failed nonoperative splenic management after 24 hours of injury. There were 100 second CT scans obtained. Three of these patients, who had developed hemodynamic instability, required operation for a bleeding spleen. The subsequent CT scan was confirmatory in these three patients who resided in the intensive care unit. All other CT scans and sonograms for clinically unremarkable patients failed to yield any alteration in care based on the scans. CONCLUSION: Blunt splenic injured patients can be safely observed; however, there are certain risk factors in those requiring immediate surgery and those failing nonoperative management. The CT scan underestimates injury, possibly related to a progression of bleeding found at the time of operation. No outpatient studies altered the course of management. Age also did not influence outcome. Thus, in the dedicated trauma center, nonoperative management of blunt splenic injury patients does not lead to undue morbidity or mortality. Once discharged, follow-up radiographs in asymptomatic patients are not necessary.     

Nonoperative management of blunt splenic injury: a 5-year experience

OBJECTIVES: The purpose of this study was to examine the success rate of nonoperative management of blunt splenic injury in an institution using splenic embolization. METHODS: We conducted a retrospective review of all patients admitted to a Level I trauma center with blunt splenic injury. Data review included patient demographics, computed tomographic (CT) scan results, management technique, and patient outcomes. RESULTS: A total of 648 patients with blunt splenic injury were admitted, 280 of whom underwent immediate surgical management. Three hundred sixty-eight underwent planned nonoperative management, and 70 patients were treated with observation, serial abdominal examination, and follow-up abdominal CT scanning. All were hemodynamically stable, with a 100% salvage rate. One hundred sixty-six patients had a negative angiogram, with a nonoperative salvage rate of 94%, and 132 patients underwent embolization, with a nonoperative salvage rate of 90%. Overall salvage rates decreased with increasing injury grade; however, over 80% of grade 4 and 5 injuries were successfully managed nonoperatively. The salvage rate was similar for main coil embolization versus selective or combined embolization techniques. Admission abdominal CT scan correlated with splenic salvage rates. Significant hemoperitoneum, extravasation, and pseudoaneurysm had acceptable salvage rates, whereas arteriovenous fistula had a high failure rate, even after embolization. CONCLUSION: Splenic embolization is a valuable adjunct to splenic salvage in our experience, allowing for the increased use of nonoperative management and higher salvage rates for American Association for the Surgery of Trauma splenic injury grades when compared with prior studies. Main coil embolization has a similar salvage rate when compared with other angiographic techniques. An arteriovenous fistula as a CT finding was predictive of a 40% nonoperative failure rate.     

Improved outcome of adult blunt splenic injury: a cohort analysis

BACKGROUND: The purpose of this study was to review our 15-year experience in the treatment of blunt splenic injury in adults. Our hypothesis was that the implementation of a change in practice, with stress on splenic preservation and splenic artery embolization for the management of splenic injury, would result in improved splenic salvage rates without negatively affecting mortality rates. METHODS: A retrospective cohort analysis was performed on all consecutive adults with blunt splenic injury who were admitted to a Level One Trauma Center. The cohorts were defined by 2 separate 7.5-year periods (1991-1998 and 1998-2005). RESULTS: Six hundred twenty-five patients with blunt splenic trauma were identified; 403 patients who were treated from 1998 to 2005 were compared with 222 patients whose cases had been reviewed previously (1991 to 1998). The present cohort differed in age (35 vs 40 years; P < .001) and injury severity score (27 vs 21; P < .0001). Nonoperative treatment was implemented in 136 patients (61%) in the initial cohort and 344 patients (85%) in the present cohort. The frequency of splenic artery embolization increased from 2.7% to 22.6% (P < .001). The success of nonoperative management increased from 77% to 96% (P < .001); the splenic salvage rate for all patients improved from 57% to 88% (P < .0001). Hospital mortality rates decreased from 12% to 6% (P < .001), and the mean hospital length of stay decreased from 15 to 9 days (P < .001). CONCLUSION: These results demonstrate that the success of nonoperative management and the splenic preservation for blunt injury has improved over time. This improvement correlated with a greater use of splenic artery embolization.     

Protocol-driven nonoperative management in patients with blunt splenic trauma and minimal associated injury decreases length of stay

BACKGROUND: The purpose of this study was to analyze the impact of more selective use of admission angiography combined with protocolized nonoperative management for blunt splenic injury. METHODS: This was a retrospective chart review of all patients with splenic injuries and Injury Severity Score < 20 managed by protocol and comparison with a prior matched group managed with admission angiography. RESULTS: Forty-three patients were managed under the protocol, with 22 patients treated with admission angiography and the remainder undergoing observation only. Nonoperative salvage was 100% in this group, with a length of stay of 3.3 days. The matched, nonprotocol group had a nonoperative salvage rate of 95%, with a length of stay of 6.8 days. CONCLUSION: Protocol-driven management of splenic injury using admission angiography selectively for higher grade splenic injuries led to a decreased length of stay, higher therapeutic yield, and decreased use of hospital resources without any increase in the failure rate of nonoperative management in a selected group of patients with isolated splenic injuries.     

Management outcomes in splenic injury: a statewide trauma center review.

OBJECTIVE: Clinical pathways now highlight both observation and operation as acceptable initial therapeutic options for the management of patients with splenic injury. The purpose of this study was to evaluate treatment trends for splenic injury in all North Carolina trauma centers over a 6-year period. METHODS: Splenic injuries in adults over a 6-year period (January 1988-December 1993) were identified in the North Carolina Trauma Registry using ICD-9-CM codes. Patients were divided into four groups by method of management: 1) no spleen operation, 2) splenectomy, 3) definitive splenorrhaphy, and 4) splenorrhaphy failure followed by splenectomy. The authors examined age, mechanism of injury, admitting blood pressure, and severity of injury by trauma score and injury severity score. SUMMARY BACKGROUND DATA: Comparisons were made between adult (17-64 years of age) and geriatric (older than 65 years of age) patients and between patients with blunt and penetrating injury. Resource utilization (length of stay, hospital charges) and outcome (mortality) were compared. RESULTS: One thousand two hundred fifty-five patients were identified with splenic injury. Rate of splenic preservation increased over time and was achieved in more than 50% of patients through nonoperative management (40%) and splenorrhaphy (12%). Splenorrhaphy was not used commonly in either blunt or penetrating injury. Overall mortality was 13%. Geriatric patients had a higher mortality and resource utilization regardless of their mechanism of injury or method of management.CONCLUSIONS: Nonoperative management represents the prevailing method of splenic preservation in both the adult and geriatric population in North Carolina trauma center hospitals. Satisfactory outcomes and economic advantages accompany nonoperative management in this adult population.     

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.     

Contrast extravasation predicts the need for operative intervention in children with blunt splenic trauma

BACKGROUND: Although the presence of a contrast blush (CB) on computed tomographic (CT) scan is associated with an increased failure rate of nonoperative management in adults with blunt splenic injury, little information is available for the pediatric population, where nonoperative management is the standard of care. Our aim was to determine whether the finding of CB on CT scan could predict failure of nonoperative therapy in children with blunt splenic injury. METHODS: A retrospective analysis of 343 patients admitted with blunt splenic injury to our Level I pediatric trauma center over a 7-year period was performed. All CT scans were reviewed by a radiologist who was blinded to the patient outcome. We excluded 127 patients who either underwent immediate laparotomy without a CT scan or whose CT scans were unavailable at the time of this review. We divided the patients into two groups on the basis of the presence or absence of CB on the updated reading of the CT scan. Demographic variables analyzed included age, sex, mechanism of injury, Injury Severity Score, Glasgow Coma Scale score, initial hemoglobin and hematocrit, and emergency department pulse rate and systolic blood pressure. Outcome measures compared include length of stay, length of intensive care unit stay, the need for splenic intervention, and mortality. Continuous variables were compared using Student's t test for normally distributed data and the Mann-Whitney test for skewed data. Categorical data were compared using chi2 analysis or Fisher's exact test. Statistical significance was assigned to values of p < 0.05. RESULTS: Among the study population (N = 216), 27 patients (12.5%) had CB on CT scan. Patients with CB had significantly lower hematocrit (p = 0.0004) and required operative intervention more frequently than those without CB (22% vs. 4%;p = 0.0008). Among patients with CB, mean pulse rate at presentation was higher in those that required splenic intervention (SI) (129 +/- 20.1) compared with those who underwent successful nonoperative therapy (100.4 +/- 23.1; p = 0.01). Only grade V injuries correlated with the need for laparotomy. CONCLUSION: Children with blunt splenic injury who have CB on CT scan are more likely to require SI than those without CB. However, because the majority of patients with CB did not require SI, in the absence of hemodynamic instability, this finding may be insufficient to determine the need for SI. CB is a specific marker of active bleeding that may predict the need for early splenic intervention in a specific subset of patients at presentation.     

Nonoperative management of blunt splenic trauma in the adult: a community hospital's experience

Nonoperative management of blunt splenic injury has been infrequently selected for adults. Nonoperative management was initially utilized in seven adult patients (23%) with blunt splenic injury during a 6-year period. Two patients eventually failed nonoperative management and required surgical intervention. No morbidity or mortality has been recorded in the remaining five patients (16%) successfully followed after 32.6 months. No added morbidity was sustained by the two patients who failed nonoperative management during the delay of surgical intervention. Hospitalization was briefer in the nonoperative group. Our experience indicates that blunt splenic injury can be successfully nonoperatively managed in an adult population seen at a community hospital.     

Nonoperative management of blunt splenic injuries: factors influencing success in age >55 years

Historically poor success rates of nonoperative management of splenic injuries in elderly patients have led to recommendations for operative intervention in patients more than 55 years of age. Recent studies are in opposition to earlier recommendations revealing equal success rates of nonoperative management of splenic injuries in all age groups. A retrospective chart review was performed to assess factors related to the successful management of splenic injuries in patients over 55 years of age at a Level I trauma center. Thirty-seven patients over 55 presented with blunt splenic injuries during the 5-year study period. Thirteen patients were taken immediately to the operating room on the basis of clinical findings and/or abdomen/pelvis CT results. Nonoperative management was attempted in 24 patients on the basis of CT findings. Nonoperative management was successful in 15 patients (62.5%) and failed in eight patients (33.3%). Patients who failed nonoperative management had significantly higher American Association for the Surgery of Trauma splenic injury grade and associated pelvic free fluid. There were no deaths related to complications from failed nonoperative management. We conclude that nonoperative management of blunt splenic injuries in patients over 55 may be attempted. Patients with higher-grade injuries and pelvic free fluid are at greater risk for failure. Patients with these two findings must be monitored closely. The physicians caring for elderly patients with high-grade splenic injuries and free fluid in the pelvis must use clinical judgment regarding the need and timing of operative management.     

Management of high-grade splenic injury in children

Using the National Trauma Databank, we identified 413 children (age < or = 14 years) who sustained high-grade blunt splenic injury (Abbreviated Injury Scale scores > or = 4) from 2001 to 2005. Overall mortality was 13.5 per cent. Early operation within 6 hours of injury (EOM) was performed in 128 patients (31%). Patients not undergoing EOM (n = 285) were assumed to have been treated with initial nonoperative management (NOM). NOM was successful in 84 per cent of patients. Operative intervention was necessary in 42 per cent of cases with 74 per cent of these undergoing early operation (EOM). Total splenectomy was the most common procedure (83%). EOM and failure of NOM were both associated with lower systolic blood pressure and lower Glasgow Coma Scale score at admission, higher Injury Severity Score, longer hospital stay, and higher mortality. Need for surgery was independent of patient age and gender. Failure of NOM was associated with increased mortality compared with successful NOM, but had similar mortality and length of hospital or intensive care unit stay compared with EOM. We conclude that operative treatment is necessary in nearly half of pediatric patients with high-grade splenic injury. With careful selection, nonoperative management is usually successful but must include close monitoring, because 16 per cent required delayed operation.     

Contribution of age and gender to outcome of blunt splenic injury in adults: multicenter study of the eastern association for the surgery of trauma.

BACKGROUND: The purpose of this study was to examine the contribution of age and gender to outcome after treatment of blunt splenic injury in adults. METHODS: Through the Multi-Institutional Trials Committee of the Eastern Association for the Surgery of Trauma (EAST), 1488 adult patients from 27 trauma centers who suffered blunt splenic injury in 1997 were examined retrospectively. RESULTS: Fifteen percent of patients were 55 years of age or older. A similar proportion of patients > or = 55 went directly to the operating room compared with patients < 55 (41% vs. 38%) but the mortality for patients > or = 55 was significantly greater than patients < 55 (43% vs. 23%). Patients > or = 55 failed nonoperative management (NOM) more frequently than patients < 55 (19% vs. 10%) and had increased mortality for both successful NOM (8% vs. 4%, p < 0.05) and failed NOM (29% vs. 12%, p = 0.054). There were no differences in immediate operative treatment, successful NOM, and failed NOM between men and women. However, women > or = 55 failed NOM more frequently than women < 55 (20% vs. 7%) and this was associated with increased mortality (36% vs. 5%) (both p < 0.05). CONCLUSION: Patients > or = 55 had a greater mortality for all forms of treatment of their blunt splenic injury and failed NOM more frequently than patients < 55. Women > or = 55 had significantly greater mortality and failure of NOM than women < 55.     

Management of blunt splenic injury in patients with concurrent infectious mononucleosis

Selective nonoperative management is appropriate for most blunt splenic injuries in adults and children, but the efficacy of this approach is unknown when injury occurs in patients with concurrent infectious mononucleosis. We have reviewed our experience during the past 23 years with the selective nonoperative management of blunt splenic injury in these patients. Medical record review identified nine patients with blunt splenic injury and infectious mononucleosis from 1978 to 2001, representing 3.3 per cent of our total trauma population with blunt splenic injury treated during that interval. Two patients underwent immediate splenectomy because of hemodynamic instability. Seven patients were admitted with the intent to treat nonoperatively. Five patients were successfully managed nonoperatively. Two patients failed nonoperative management and underwent splenectomy, one because of hemodynamic instability and one because of an infected splenic hematoma. Concurrent infectious mononucleosis does not preclude the successful nonoperative management of blunt splenic injury. This small subset of patients may be managed nonoperatively using the same criteria as for patients whose splenic injuries are not complicated by infectious mononucleosis.