Non-Operative Management of Adult Blunt Splenic Trauma: Choosing the Right Candidates
Abstract & Commentary
Source: Peitzman AB, et al. Blunt splenic injury in adults: Multi-institutional study of the Eastern Association for the Surgery of Trauma. J Trauma 2000;49:177-187.
The authors of this retrospective multicenter trial reviewed the management of 1488 adults (> 15 years of age) from 27 trauma centers over a one-year period with blunt splenic injury. The objective was to determine if a combination of hemodynamic parameters and findings on computed tomography (CT) could be used to predict successful, non-operative management. Patient age, injury severity score (ISS), mechanism of injury, GCS on admission, lowest systolic blood pressure and highest heart rate in the emergency department (ED), admission hematocrit and base deficit, and results of diagnostic studies (diagnostic peritoneal lavage, ultrasound, and CT) were reviewed. The initial management plan, indications for and time of laparotomy, associated injuries, and ultimate outcome (operative vs successful non-operative management) were reviewed.
The study population was divided into three groups: Group I (n = 575) went directly from the ED to the operating room (OR) (CT scan may have been obtained en route); group II (n = 816) was observed successfully; and group III (n = 97) failed non-operative management. Mechanism of injury was not significantly different between the three groups.
Thirty-eight percent of patients went directly to the OR for laparotomy (group I). This group presented with a significantly lower blood pressure, higher heart rate, lower GCS, higher ISS, and lower hematocrit and greater base deficit than patients who were observed successfully. Of the patients in this group who had a CT scan performed, there was a significant correlation (P < 0.05) between the decision to operate and the AAST grades of splenic injury: I (24%), II (22%), III (38%), IV (74%), and V (95%).
Sixty-two percent were admitted with planned non-operative management. Eleven percent of the patients in this group failed and required laparotomy. Of patients initially managed non-operatively, the failure rate increased significantly (P < 0.05) by AAST grade: I (5%), II (9%), III (20%), IV (33%), and V (75%). Sixty-one percent of failures occurred within 24 hours. Laparotomy ultimately was performed in 20% of patients with small hemoperitoneum, 50% of patients with moderate hemoperitoneum, and 73% of patients with large hemoperitoneum.
Comment by Michael A. Gibbs, MD, FACEP
Non-operative management of blunt splenic injury has become routine in children, with success rates of 75-90%. The indications for and risks of selection for observation of blunt splenic trauma in adults are less clear. While some authors base patient selection on CT scan findings (AAST injury grade and degree of hemoperitoneum), others have found these criteria to be less useful and rely instead on clinical markers.1,2
While this study is retrospective and has several important weaknesses, it suggests that the likelihood of successful non-operative management of adult blunt splenic injury may be predictable at the time of patient presentation, based on the patient’s hemodynamic status and findings on abdominal CT. There was no strict study protocol, and decision making may have been influenced by a combination of several factors, rather than one. It is virtually impossible to make this determination using retrospective methodology. A large prospective study (even if observational) would add credence to the authors’ conclusions.
References
1. Powell M, et al. Management of blunt splenic trauma: Significant differences between adults and children. Surgery 1997;122:654-660.
2. Alonso M. Practice management guidelines for the nonoperative management of blunt injury to the liver and spleen: EAST Practice Parameters Workgroup for Solid Organ Injury Management. In press.
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