Indermeet S. Bhullar

Selective Nonoperative Management of Blunt Splenic Injury: An Eastern Association for the Surgery of Trauma Practice Management Guideline

BACKGROUND During the last century, the management of blunt force trauma to the spleen has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. These issues were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the Practice Management Guidelines for Non-operative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the current EAST guideline. METHODS The National Library of Medicine and the National Institute of Health MEDLINE database was searched using Pub Med (www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords splenic injury and blunt abdominal trauma. RESULTS One hundred seventy-six articles were reviewed, of which 125 were used to create the current practice management guideline for the selective nonoperative management of blunt splenic injury. CONCLUSION There has been a plethora of literature regarding nonoperative management of blunt splenic injuries published since the original EAST practice management guideline was written. Nonoperative management of blunt splenic injuries is now the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury, patient age, or the presence of associated injuries. Its use is associated with a low overall morbidity and mortality when applied to an appropriate patient population. Nonoperative management of blunt splenic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and has an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt splenic injuries. Repeat imaging should be guided by a patient’s clinical status. Adjunctive therapies like angiography with embolization are increasingly important adjuncts to nonoperative management of splenic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt splenic injuries remain without conclusive answers in the literature.

Nonoperative management of blunt hepatic injury: An Eastern Association for the Surgery of Trauma practice management guideline

Background During the last century, the management of blunt force trauma to the liver has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. These issues were first addressed by the Eastern Association for the Surgery of Trauma in the Practice Management Guidelines for Nonoperative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the previous Eastern Association for the Surgery of Trauma guideline. Methods The National Library of Medicine and the National Institutes of Health MEDLINE database were searched using PubMed (www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords liver injury and blunt abdominal trauma. Results One hundred seventy-six articles were reviewed, of which 94 were used to create the current practice management guideline for the selective nonoperative management of blunt hepatic injury. Conclusion Most original hepatic guidelines remained valid and were incorporated into the greatly expanded current guidelines as appropriate. Nonoperative management of blunt hepatic injuries currently is the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury or patient age. Nonoperative management of blunt hepatic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt hepatic injuries. Repeated imaging should be guided by a patient’s clinical status. Adjunctive therapies like angiography, percutaneous drainage, endoscopy/endoscopic retrograde cholangiopancreatography and laparoscopy remain important adjuncts to nonoperative management of hepatic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt hepatic injuries remain without conclusive answers in the literature.

Selective angiographic embolization of blunt splenic traumatic injuries in adults decreases failure rate of nonoperative management.

BACKGROUND: To determine whether angioembolization (AE) in hemodynamically stable adult patients with blunt splenic trauma (BST) at high risk for failure of nonoperative management (NOM) (contrast blush [CB] on computed tomography, high-grade IV–V injuries, or decreasing hemoglobin) results in lower failure rates than reported. METHODS: The records of patients with BST from July 2000 to December 2010 at a Level I trauma center were retrospectively reviewed using National Trauma Registry of the American College of Surgeons. Failure of NOM (FNOM) occurred if splenic surgery was required after attempted NOM. Logistic regression analysis was used to identify factors associated with FNOM. RESULTS: A total of 1,039 patients with BST were found. Pediatric patients (age <17 years), those who died in the emergency department, and those requiring immediate surgery for hemodynamic instability were excluded. Of the 539 (64% of all BST) hemodynamically stable patients who underwent NOM, 104 (19%) underwent AE and 435 (81%) were observed without AE (NO-AE). FNOM for the various groups were as follows: overall NOM (4%), NO-AE (4%), and AE (4%). There was no significant difference in FNOM for NO-AE versus AE for grades I to III: grade I (1% vs. 0%, p = 1), grade II (2% vs. 0%, p = 0.318), and grade III (5% vs. 0%, p = 0.562); however, a significant decrease in FNOM was noted with the addition of AE for grades IV to V: grade IV (23% vs. 3%, p = 0.04) and grade V (63% vs. 9%, p = 0.03). Statistically significant independent risk factors for FNOM were grade IV to V injuries and CB. CONCLUSION: Application of strictly defined selection criteria for NOM and AE in patients with BST resulted in one of the lowest overall FNOM rates (4%). Hemodynamically stable BST patients are candidates for NOM with selective AE for high-risk patients with grade IV to V injuries, CB on initial computed tomography, and/or decreasing hemoglobin levels. LEVEL OF EVIDENCE: III, therapeutic study.

At first blush: absence of computed tomography contrast extravasation in Grade IV or V adult blunt splenic trauma should not preclude angioembolization.

BACKGROUND To clarify the role, indications, and outcomes for angioembolization (AE) of nonoperatively managed (NOM) splenic trauma, the implications of absent contrast blush (CB) on computed tomography of high-grade (IV–V) blunt splenic trauma (BST) in adults were analyzed. METHODS All BST patients presenting at a single institution from July 2000 to December 2011 were retrospectively reviewed. Grade of injury (American Association for the Surgery of Trauma scale), CB on initial computed tomography, numbers of NOM and undergoing AE, and failures of NOM were analyzed. Statistical analysis was performed using &khgr;2. RESULTS Of the 1,056 total BST patients, 556 (64%) were hemodynamically stable and eligible for NOM; 95 NOM patients (17%) had CB. AE was performed in 88 of these, with angiographic extravasation found in 86 (97.7%), and 3 of these 88 (3.4%) failed NOM. The remaining 7 CBs were observed without AE, of which 5 (71.4%) failed NOM (p = 0.0004). Of all 556 NOM patients, 51 (9.5%) had high-grade injuries without CB; 20 of these (39%) underwent AE, 17 (85.0%) underwent angiographic extravasation, and there were no NOM failures in this group. The other 31 high-grade injuries without CB or AE had 8 failures of NOM (26%) (p = 0.03). CONCLUSION The strong correlation of CB with active bleeding on angiogram mandates AE for CB in all BST undergoing NOM. However, the absence of CB in high-grade (IV–V) BST does not reliably exclude active bleeding. This may be the reason for the high reported failure rates of NOM in high-grade (IV–V) BST because AE is not typically performed in the absence of CB. These data suggest that all hemodynamically stable high-grade (IV–V) BST in adults should undergo AE regardless of CB to optimize the success and safety of NOM. LEVEL OF EVIDENCE Therapeutic study, level III.

More harm than good: antiseizure prophylaxis after traumatic brain injury does not decrease seizure rates but may inhibit functional recovery.

BACKGROUND The purposes of this study were to examine the current Brain Trauma Foundation recommendation for antiseizure prophylaxis with phenytoin during the first 7 days after traumatic brain injury (TBI) in preventing seizures and to determine if this medication affects functional recovery at discharge. METHODS The records of adult (age ≥ 18 years) patients with blunt severe TBI who remained in the hospital at least 7 days after injury were retrospectively reviewed from January 2008 to January 2010. Clinical seizure rates during the first 7 days after injury and functional outcome at discharge were compared for the two groups based on antiseizure prophylaxis, no prophylaxis (NP) versus phenytoin prophylaxis (PP). Statistical analysis was performed using &khgr;2. RESULTS A total of 93 adult patients who met the previously mentioned criteria were identified (43 [46%] NP group vs. 50 [54%] PP group). The two groups were well matched. Contrary to expectation, more seizures occurred in the PP group as compared with the NP group; however, this did not reach significance (PP vs. NP, 2 [4%] vs. 1 [2.3%], p = 1). There was no significant difference in the two groups (PP vs. NP) as far as disposition are concerned, mortality caused by head injury (4 [8%] vs. 3 [7%], p = 1), discharge home (16 [32%] vs. 17 [40%], p = 0.7), and discharge to rehabilitation (30 [60%] vs. 23 [53%], p = 0.9). However, with PP, there was a significantly longer hospital stay (PP vs. NP, 36 vs. 25 days, p = 0.04) and significantly worse functional outcome at discharge based on Glasgow Outcome Scale (GOS) score (PP vs. NP, 2.9 vs. 3.4, p < 0.01) and modified Rankin Scale score (2.3 ± 1.7 vs. 3.1 ± 1.5, p = 0.02). CONCLUSION PP may not decrease early posttraumatic seizure and may suppress functional outcome after blunt TBI. These results need to be verified with randomized studies before recommending changes in clinical practice and do not apply to penetrating trauma. LEVEL OF EVIDENCE Therapeutic study, level IV; epidemiologic study, level III.

A prehospital shock index for trauma correlates with measures of hospital resource use and mortality

BACKGROUND The assessment and treatment of trauma patients begins in the prehospital environment. Studies have validated the shock index as a correlate for mortality and the identification of shock in trauma patients. We investigated the use of the first shock index obtained in the prehospital environment and the first shock index obtained upon arrival in the trauma center as correlates for other outcomes to evaluate its usefulness as a triage tool. METHODS This is a retrospective review of data from a level I trauma center. Prehospital and trauma center shock indices for 16,269 patients were evaluated as correlates for duration of hospital stay, duration of stay in the intensive care unit, the number of ventilator days, blood product use, and destination of transfer from the trauma center. RESULTS Pearson correlation coefficients revealed that the relationship of prehospital and trauma center shock indices were correlates for duration of hospital stay, duration of stay in the intensive care unit, the number of ventilator days, and blood product use. A chi-square analysis found that shock indices ≥0.9 indicate a higher likelihood of disposition to the intensive care unit, operating room, or death. CONCLUSION A prehospital shock index for trauma correlates with measures of hospital resource use and mortality. A prospective study is needed to determine the use of this measure as a triage tool.

Age Does Not Affect Outcomes of Nonoperative Management of Blunt Splenic Trauma

BACKGROUND The purpose of this study was to examine the effect of age on the outcomes of nonoperative management (NOM) of blunt splenic trauma (BST). STUDY DESIGN The records of patients with BST, from July 2000 to December 2010 at a level I trauma center, were retrospectively reviewed using NTRACS (National Trauma Registry of the American College of Surgeons). Patients were divided into 2 age groups: 17 to 55 years and greater than 55 years. Stepwise logistic regression analysis was used to identify risk factors associated with failure of nonoperative management (FNOM). RESULTS There were 539 hemodynamically stable patients with BST who underwent NOM. Of these, 459 were age 55 or less, and 80 were greater than 55. Overall, there was no significant difference in FNOM rate for patients age 55 or less vs greater than 55 (4% vs 5%, p = 0.73). This also held true when FNOM was analyzed by each grade: I (1% vs 3%, p = 0.38), II (2% vs 0%, p = 1.0), III (4% vs 0%, p = 1.0), IV (8% vs 20%, p = 0.33), and V (21% vs 50%, p = 0.47). The addition of angioembolization (AE) to high grade IV to V injuries significantly lowered the FNOM rate: age 55 or less (6% AE vs 28% NO-AE, p = 0.02); with a trend toward significance for age greater than 55 (0% AE vs 60% NO-AE, p = 0.2). Age was not a statistically significant independent risk factor for FNOM (p = 0.37). CONCLUSIONS Age does not affect outcomes of NOM of BST. High grade (IV to V) injuries are not a contraindication to NOM for patients older than 55. As experience with AE grows in patients with high grade injury and age greater than 55, it may prove to be a valuable adjunct to NOM in this group of patients.

An analysis of shock index as a correlate for outcomes in trauma by age group.

BACKGROUND Shock index as the ratio of heart rate to systolic blood pressure is a simple triage tool that correlates well with various outcomes in trauma patients. Concern has been raised regarding the accuracy of shock index in older patients. We sought to investigate the effects of age on the accuracy of shock index. METHODS This is a retrospective review of data from a level I trauma center. Shock index was calculated for 16,269 patients, and they were stratified into age groups by decade. The correlation between prehospital shock index for each of the age groups and for several outcome variables were evaluated by Pearson correlation coefficients. Logistic regression was used to evaluate an increase in shock index during transit and its relationship with mortality. RESULTS All correlation values for patients between 16 and 60 years of age were positive (P < .05). In patients who are older than 80 years, none of the correlations with the outcome variables were statistically significant. In patients older than 60 years, an increased shock index during transit correlated with an increase in mortality rates. CONCLUSION As expected, prehospital shock index alone has diminishing accuracy for patients older than 60 years of age and should be interpreted cautiously by trauma triage personnel. Shock index alone in patients younger than 60, and its increase during transit in patients older than 60, can be used as a valuable tool for the prehospital triage of trauma patients when determining the need for transport to a trauma center, preparation of resources, or activation of the trauma team.

To nearly come full circle: Nonoperative management of high-grade IV–V blunt splenic trauma is safe using a protocol with routine angioembolization

Introduction Nonoperative management (NOM) of hemodynamically stable high-grade (IV–V) blunt splenic trauma remains controversial given the high failure rates (19%) that persist despite angioembolization (AE) protocols. The NOM protocol was modified in 2011 to include mandatory AE of all grade (IV–V) injuries without contrast blush (CB) along with selective AE of grade (I–V) with CB. The purpose of this study was to determine if this new AE (NAE) protocol significantly lowered the failure rates for grade (IV–V) injuries allowing for safe observation without surgery and if the exclusion of grade III injuries allowed for the prevention of unnecessary angiograms without affecting the overall failure rates. Methods The records of patients with blunt splenic trauma from January 2000 to October 2014 at a Level I trauma center were retrospectively reviewed. Patients were divided into two groups and failure of NOM (FNOM) rates compared: NAE protocol (2011–2014) with mandatory AE for all grade (IV–V) injuries without CB and selective AE for grade (I–V) with CB versus old AE (OAE) protocol (2000–2010) with selective AE for grade (I–V) with CB. Results Seven hundred twelve patients underwent NOM with 522 (73%) in the OAE group and 190 (27%) in the NAE group. Evolving from the OAE to the NAE strategy resulted in a significantly lower FNOM rate for the overall group (grade I–V) (OAE vs. NAE, 4% to 1%, p = 0.04) and the grade (IV–V) group (OAE vs. NAE, 19% vs. 3%, p = 0.01). Angiograms were avoided in 113 grade (I–III) injuries with no CB; these patients had NOM with observation alone and none failed. Conclusions A protocol using mandatory AE of all high-grade (IV–V) injuries without CB and selective AE of grade (I–V) with CB may provide for optimum salvage with safe NOM of the high-grade injuries (IV–V) and limited unnecessary angiograms. LEVEL OF EVIDENCE Therapeutic study, level IV.