Very Large Haematoma Following the Non-Operative Management of a Blunt Splenic Injury in a Patient with Pre-Existing Liver Cirrhosis

BackgroundWe sought to identify predictors of splenic artery embolization (SAE) over observation for hemodynamically stable patients with blunt splenic injury (BSI), by Organ Injury Scale (OIS) grade.MethodsThis was a multi-institutional retrospective study of all adults (≥18) with BSI who were initially managed non-operatively between 2014 and 2016. Multivariate logistic regression analysis was used to identify predictors of SAE by OIS grade. Covariates included radiographic characteristics (presence/quantity of hemoperitoneum, blush, vascular injury), demographics (age, sex, cause), Injury Severity Score, vital signs, and hemoglobin values. We also examined outcomes of death, length of stay (LOS), intensive care unit (ICU) admission, blood products, and failed non-operative management (NOM).ResultsAmong 422 patients with stable BSI, 93 (22%) had SAE and 329 (78%) were observed. The rate of SAE increased by grade (p<0.001). In grade I and II BSI, 7% had SAE; significant predictors of SAE were blush (OR: 5.9, p=0.02), moderate or large hemoperitoneum (OR: 3.0, p=0.01), and male sex (OR: 6.3, p=0.05). In grade III BSI, 26% had SAE; significant predictors included moderate or large hemoperitoneum (OR: 3.9, p=0.04), motor vehicle crash (OR: 6.1, p=0.005), and age (OR=1.4, 40% with each decade increase in age, p=0.02). The rate of SAE was 52% for grade IV and 85% for grade V BSI; there were no independent predictors of SAE in either grade. Clinical outcomes were comparable by NOM strategy and grade, except longer LOS with SAE in grades I–III (p<0.05) and longer ICU LOS with SAE in grades I–IV (p<0.05). Only 5 (1.2%) patients failed NOM (4 observation, 1 SAE).ConclusionThese results strongly support SAE consideration for patients with stable grade IV and V BSI even if there are no other high-risk clinical or radiographic findings. For grades I–III, the identified predictors may help refine consideration for SAE.Level of evidenceLevel III, retrospective epidemiological study.

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Is non-operative management of severe blunt splenic injury safer than embolization or surgery? Results from a French prospective multicenter study

Journal of Visceral Surgery ◽

10.1016/j.jviscsurg.2015.01.003 ◽

2015 ◽

Vol 152 (2) ◽

pp. 85-91 ◽

Cited By ~ 13

Author(s):

L. Chastang ◽

T. Bège ◽

M. Prudhomme ◽

A.C. Simonnet ◽

A. Herrero ◽

...

Keyword(s):

Multicenter Study ◽

Splenic Injury ◽

Operative Management ◽

Prospective Multicenter Study ◽

Blunt Splenic Injury ◽

Non Operative Management

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Recent Changes in the Management of Blunt Splenic Injury: Effect on Splenic Trauma Patients and Hospital Implications

Annals of The Royal College of Surgeons of England ◽

10.1308/003588408x242033 ◽

2008 ◽

Vol 90 (2) ◽

pp. 109-112 ◽

Cited By ~ 11

Author(s):

S Sinha ◽

SVV Raja ◽

MH Lewis

Keyword(s):

Blood Transfusion ◽

Hospital Stay ◽

Splenic Injury ◽

Transfusion Requirement ◽

Operative Management ◽

Splenic Trauma ◽

Trauma Patients ◽

Blunt Splenic Injury ◽

Non Operative Management

INTRODUCTION Management of blunt splenic injury has been controversial with an increasing trend towards splenic conservation. A retrospective study was performed to identify the effect of this changed policy on splenic trauma patients and its implications. PATIENTS AND METHODS Data regarding patient demography, mode of splenic injury, CT grading, blood transfusion requirement, operative findings hospital stay and follow-up were collected. Statistical analysis of the data was performed using non-parametric Mann–Whitney tests RESULTS Over an 8-year period, only 21 patients were admitted with blunt splenic injury. Ten patients were managed operatively and 11 non-operatively. Non-operative management failed in one patient due to continued bleeding. Using Buntain's CT grading, the majority of grades I and II splenic injuries were managed non-operatively and grades III and IV were managed operatively (P = 0.008). Blood transfusion requirement was significantly higher among the operative group (P = 0.004) but the non-operative group had a significantly longer hospital stay (P = 0.029). Among those managed non-operatively (median age, 24.5 years), a number of patients were followed up with CT scans with significant radiation exposure and unknown long-term consequences. CONCLUSIONS Non-operative management of blunt splenic trauma in adults can be performed with an acceptable outcome. Although CT is classed as the ‘gold standard’, initial imaging for detection and evaluation of blunt splenic injury, ultrasound can play a major role in follow-up imaging and potentially avoids major radiation exposure.

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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

Hong Kong Journal of Emergency Medicine ◽

10.1177/1024907918773202 ◽

2018 ◽

Vol 25 (6) ◽

pp. 343-349

Author(s):

Min A Lee ◽

Byungchul Yu ◽

Jungnam Lee ◽

Kang Kook Choi ◽

Jae Jeong Park ◽

...

Keyword(s):

South Korea ◽

Trauma Center ◽

Splenic Injury ◽

Emergency Operation ◽

Operative Management ◽

Blunt Splenic Injury ◽

Management Protocol ◽

Before And After ◽

Non Operative Management ◽

Splenic Salvage

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 < 0.001) whereas the rate of angioembolization was higher (89% vs 39.0%, respectively, p < 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.

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