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| Journal of the New Zealand Medical Association,
10-September-2004, Vol 117 No 1201
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Impact of concomitant trauma in the management of blunt
splenic injuries
Albert Lo, Anne-Marie Matheson, Dave Adams
Major changes have occurred in the management of blunt
splenic injuries in the previous 50 years. The concept of universal splenectomy
for splenic injuries remained unchallenged until King and Shumacker described
(in 1951) life-threatening infections in paediatric patients after
splenectomy.1
The incidence of overwhelming post-splenectomy infection
(OPSI) following splenectomy in the trauma setting is reported to be 0.5%, and
can reach up to 20% in patients with haematological
disorders.2 The concept of conservative
management of splenic injuries has become increasingly accepted by trauma
surgeons, especially in the past two decades because of the development of
modern imaging techniques.
However, in the presence of a tender, distended abdomen and
other concomitant injuries, a rapid deterioration in a patient's haemodynamic
condition presents a major challenge for clinicians trying to pinpoint the
source of bleeding. These patients are often taken to theatre for exploratory
laparotomy after positive findings on ultrasound (FAST) scan or diagnostic
peritoneal lavage (DPL). Alternatively, if the patient's initial haemodynamic
status is stable enough to allow for abdominal computed tomography (CT) imaging
which shows splenic injuries, clinicians are faced with the dilemma of whether
to operate or to monitor these patients with multisystem injuries, whose
potential to withstand subsequent major haemorrhage may be compromised.
Conservative management remains the cornerstone of treating
haemodynamically stable blunt splenic injuries. This study is undertaken to
review our cumulative experience of non-operative management and to identify the
risk factors for operative management in patients with blunt splenic injuries.
Patients and MethodsFrom September 1997 to February
2003, retrospective analysis of medical records of patients with blunt splenic
injury treated in Middlemore Hospital, Auckland was carried out.
Data collected included patient demographics,
mechanisms of injury, vital signs, blood results on admission, imaging and other
diagnostic modalities, transfusion requirement, operative findings,
postoperative course, duration of hospital stay, and follow-up. Details of
immunisation such as Pneumovax®,
Haemophilus influenzae type B vaccine,
meningococcal vaccine, and further use of CT scans in re-assessment of the
progress of splenic injuries were also recorded.
For each patient, an injury severity
score3,4
(ISS) and grading of severity of splenic injury by CT scan (based on the
organ injury scale [OIS])5 were calculated. The
ISS is an anatomical scoring system that provides an overall score derived by
combining squared abbreviated injury scores3
from the three most severely injured body regions.
Patient management was categorised as:
Statistical analysis of the data was
performed with the Student's t test for
age, ISS, and chi-squared test for comparison of parameters between patient
groups.
ResultsEighty patients were identified. The
overall mean age at presentation was 34.2 years (range 2 to 84 years). There
were 52 males and 28 females patients (male:female ratio of 1.86:1). Seven of
the patients were ≤15 years old.
As illustrated in Figure 1, there were 35 patients (24 male,
11 female) in the operative management (OM) group; 43 patients (27 male, 16
female) in the non-operative management (NOM) group; and 2 patients (1 male, 1
female) who required splenectomy after failure of conservative treatment
(F/NOM).
The mean age of patients was 34.0 in the OM group and 34.3
in the NOM and F/NOM group. Stated ethnic origins were European: 54%; Maori:
23%; Pacific Island: 11%; and other ethnic groups (including Chinese and Indian)
in the remainder.
Mechanism of injuriesMotor vehicle accident (MVA) was the
most common (involving 57 patients) mechanism of injury, while 10 patients
sustained splenic injuries from sports activities; 8 from falls, and 5 from
various other mechanisms (eg, assault, crush injuries).
Figure 1. Distribution of patients
Among the patients involved in MVA, 38 patients were either
passengers or drivers in a vehicle, while the remaining patients were
pedestrians (n=9), motorcyclists (n=9), and a cyclist (n=1).
Pedestrians were the most severely injured group, with
moderate-to-severe head injuries being noted in 78% of this group (Table 1). A
higher proportion of pedestrians required operative management, although this
did not reach statistical significance.
Table 1. Mechanism of injury in motor vehicle accident
(MVA) patients
GCS=Glasgow coma score;
ISS=injury severity score; *p<0.05
Utility of CT scans on initial assessment of splenic injuriesAll patients (100%) in the NOM group
had a CT scan to determine the extent of splenic injuries; while only 48.6% of
patients in the OM group had a CT scan. The remaining patients in the OM group
were haemodynamically unstable after initial fluid resuscitation. One patient
(an 8-year-old male pedestrian hit by a car) was transferred to the operating
theatre on clinical grounds alone, while the other subjects had positive
findings either on diagnostic peritoneal lavage (34.3%) or focused abdominal
sonography for trauma (FAST) exams (14.3%).
Half of those patients with positive diagnostic peritoneal
lavage (DPL) were found to have other associated intra-abdominal injuries (eg,
liver laceration, mesenteric tear, greater omentum tear).
The distribution of the severity of splenic injury (as
determined by CT scan) for the operative management group and conservative
treatment group is demonstrated in Figure 2. There is a trend towards increased
severity of splenic injuries in the operative management group. For those
patients who had successful conservative management of their grade 4 and 5
splenic injuries, associated injuries were limited to thoracic injuries such as
rib fractures and haemopneumothorax.
Figure 2. Distribution of severity of splenic injuries by CT gradingOM=operative management; NOM=non-operative
management.
Non-operative management (NOM)Forty-five patients (56%) were
initially treated non-operatively, 43 (54%) of these had successful NOM. This is
a 96% success rate of non-operative management. Thirteen patients (29% in the
NOM group) were initially admitted to the intensive care unit (ICU) for
observation, incurring an average length of stay of 2 days (range 1–11
days). There were no deaths in the NOM group.
Four patients (9%) required epidural anaesthesia for pain
relief. Red blood cell (RBC) transfusion was given to three NOM patients
(average: 3 units). Repeat CT scans (during both inpatient stay and outpatient
follow-up) to examine the extent and progress of splenic injuries were performed
on five patients (11% in the NOM group).
Operative management (OM)A total of 28 patients (35%
splenectomy rate) had splenectomy (26 of the 35 patients in the OM group and 2
patients in the F/NOM group). The remaining 9 patients in the OM group did not
have splenic injuries, which were severe enough to warrant splenectomy. A
variety of splenic conservation techniques were performed in these patients
including Surgicel® wrap, suturing, and partial excision.
Five out of 9 patients (in OM group) who did not have
splenectomy were found to have other intra-abdominal injuries such as small
bowel mesenteric tear, liver lacerations, and ruptured bladder which required
simultaneous surgical interventions. The mean operative time was 81 minutes.
Twenty-five patients (71.4% in the OM group) required
intra-operative blood transfusion, with an average of 6.8 units transfused.
Twenty-one patients (60% in the OM group) were admitted into ICU postoperatively
for an average of 3 days.
Mortality ratesThere were no deaths in the NOM
group including those two patients with failure of NOM. However, there were 3
intra-operative deaths and seven postoperative deaths. Two patients succumbed to
uncontrolled intra-abdominal haemorrhage intra-operatively, and the remaining
death was due to the severity of combined intra-abdominal and thoracic injuries
(haemopneumothorax and haemopericardium).
Causes of postoperative deaths included extensive brain
injury sustained during trauma (three patients), coagulopathy (three patients)
and multi-organ failure (one patient). This gives a mortality rate of 28.6% in
the OM group (12.5% overall mortality rate).
Failure of non-operative management (NOM)There were two patients in the F/NOM
group. The first patient had re-bleeding from her splenic lacerations 5 days
after admission to the general surgical ward. On admission, her GCS was 15, ISS:
13, and haemoglobin: 123 g/L. She had a grade II splenic injury on CT. However,
on day 5, she became hypotensive (despite fluid resuscitation) and was found to
have a reduced haemoglobin (93 g/L). She was taken to the operating theatre for
emergency splenectomy.
The second patient was a 35-year-old female who was
anticoagulated with warfarin for Factor V Leiden and previous deep vein
thromboses (DVTs) (INR=2.2 on admission). She sustained right radius and left
humerus fractures in a motor vehicle accident. She was haemodynamically stable
with a haemoglobin level of 143 g/L. CT abdomen on admission did not reveal any
splenic injury or other evidence of intra-abdominal bleeding.
Eight days post-injury she became hypotensive with signs of
abdominal peritonism and her haemoglobin level dropped to 82 g/L. During
emergency laparotomy, it was found that there was a small splenic capsular tear
with 2 litres of free blood in the peritoneal cavity. Splenectomy was carried
out.
Both patients had an uneventful recovery period. Due to the
small number of patients, meaningful analysis of predictors for failure of
conservative treatment was not possible. Neither of the patients in the F/NOM
group had a repeat CT abdomen prior to emergency splenectomy.
Operative versus non-operative managementTable 2 highlights the differences
between those patients who were initially planned for conservative treatment
(NOM and F/NOM) and those who had emergency surgery (OM). Thirty-five patients
were taken to the operating theatre for emergency laparotomy. The mean ISS of
this OM group was 30, significantly higher (p<0.05) than conservative
treatment groups, 13.
Table 2. Comparison of patient groups
OM=operative management;
NOM=non-operative management; F/NOM=failure of NOM, requiring splenectomy;
GCS=Glasgow coma score; ISS=injury severity score; BP=blood pressure;
ED=emergency department; *p<0.05.
Put another way, the proportion of patients with severe
injuries (as defined by
ISS ≥16) was 89% in the OM
group compared with 34% in the NOM and F/NOM group. The respective differences
between these groups with regards to systolic hypotension (BP <100 mmHg):
(37% vs 2%), severity of head injury (GCS
≤13): (40% vs 9%) and requirement of
blood transfusion in ED: (40% vs 9%), were also statistically significant
(p<0.05).
VaccinationsAll the patients who had
splenectomy received pneumococcal vaccine. In addition, all except three of
these patients were immunised against
Haemophilus influenzae type b and
meningococcal infections. Twelve patients in the NOM group received pneumococcal
vaccine, the majority of whom had high grade (III-V) splenic injuries on their
CT scans.
DiscussionAlgorithms delineating the initial
management of splenic injury recommend either observation or operation as
acceptable initial therapeutic options in patients who are appropriately
selected.6
A variety of operative techniques for salvaging injured
spleens have been described, and splenorrhaphy is an accepted alternative to
splenectomy when clinically and
technically feasible.7 Splenectomy is
increasingly reserved for the conditions of haemodynamic instability or anatomic
injury beyond repair. In this study series, both patients in the F/NOM group had
splenectomy because of haemodynamic instability. Their splenic injuries did not
preclude repair (grade II injury and capsular tear respectively), but rather
their unstable haemodynamic conditions mandated the procedure.
We attempted non-operative management in 56% of patients,
and achieved 96% success rate (54% overall rate of NOM). Two large series
corroborate these results. Hunt et al,8 in a
state-wide analysis of 2258 patients, found that conservative management rate
increased from 33.9% to 46.3% over a 5-year period, with a success rate of 94%.
A large, single institution study by Pachter et
al9 of 190 consecutive patients reported 65%
initial rate of NOM and 98% success rate. In an Australasia setting, the
reported initial rate of NOM ranged from 46% to
75%.10–12
Patients with blunt splenic injuries often have a variety of
concomitant injuries (eg, head injuries, orthopaedic injuries, or other
intra-abdominal injuries). There is no specific rigid treatment protocol for
treating splenic injuries in our institution. Management is individualised for
each patient and based on multiple variables. For persistent haemodynamic
instability (or unresolved concerns about other concomitant injuries), operative
management is the preferred treatment option. The mean ISS of OM group in our
study series was 30, compared to 13 in the conservative treatment group.
Within the limitations of a retrospective study, ISS
≥16, hypotension, GCS
≤13, and requirement for blood
transfusion were found to be significantly associated with operative management.
Furthermore, a study of 226 patients by Shapiro et al over a 5.5-year period
also identified ISS, GCS score, revised trauma score (RTS), and amount of RBC
transfused as risk factors for patients sustaining blunt splenic injuries
requiring immediate surgery.13
These observations may lead to the suggestion that the
responsible trauma surgeons have a selection bias for treating multi-system
trauma patients operatively in a bid to decrease the proportion of patients
likely to fail non-operative management without compromising the overall rate of
successful non-operative management. Indeed, this problem of selecting
appropriate treatment option for multi-system trauma patients will continue to
exist in the absence of concrete, reliable predictors for failure of
non-operative management. Age >55, degree of haemoperitoneum, ISS >15, and
American Association for the Surgery of Trauma (AAST) injury scale of grade
>III on CT scans are suggested by some authors to be contraindications for
non-operative management of blunt splenic
injuries.14,15 However, none of these
predictors have proven to be completely reliable.
In this study, 9 patients (out of 35) in the operative group
did not have splenic injuries which were severe enough to warrant
splenectomy—but 5 of these were found to have other intra-abdominal
injuries and were treated accordingly. One may argue that the remaining 4
patients (11.4% in OM group) should be given a trial of conservative therapy.
However, their haemodynamic instability after initial fluid resuscitation, in
whom concomitant intra-abdominal injuries cannot be definitely ruled out,
mandated exploratory laparotomy.
The use of CT imaging has become an integral tool for the
management of splenic injuries in patients who are haemodynamically stable.
Several grading systems for the severity of splenic injuries are
available.10,11,16,17 We used the OIS (organ
injury score) because of its compatibility with the calculation of the ISS.
Sugrue et al12 suggested that CT changes are
predictive of outcome for non-operative treatment and that patients with more
severe splenic injuries on CT grading should undergo early surgical intervention
regardless of the cardiovascular status of the patient. On the other hand,
Pachter et al9 reported their algorithmic
approach to stable patients which includes a period of nonoperative management
for all stable patients, regardless of the grade of injury.
Shapiro et al13 concluded
that CT imaging underestimate the severity of injury, especially in the subset
of patients who failed non-operative management because of progression of injury
and continued bleeding. In the present series, there were 6 patients in the
non-operative group with grade 4 and 5 splenic injuries on CT scans with
successful conservative treatment.
Although CT imaging is a useful tool, the reported accuracy
in determining the severity of splenic injury is
variable.18 Therefore, we believe
decision-making should not be dictated solely by the CT findings.
ConclusionBoth non-operative (NOM) and
operative management (OM) have a role in the current treatment of blunt splenic
injuries. The results of this study suggest that non-operative management of
appropriately selected patients can be achieved with acceptable outcome. In the
presence of concomitant trauma, patients with blunt splenic injuries are more
likely to require operative management if they have ISS
≥16, hypotension, GCS
≤13, and requirement for blood
transfusion.
Author information:
Albert Lo, House Surgeon; Anne-Marie Matheson, Trauma Co-ordinator; Dave Adams,
General and Vascular Surgeon, Department of General Surgery, Middlemore
Hospital, Otahuhu, Auckland
Correspondence: Mr
Dave Adams, Department of General Surgery, Middlemore Hospital, Otahuhu,
Auckland. Fax: (09) 623 6451; email: DaveA@middlemore.co.nz
References:
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