Nonoperative Management in Blunt Splenic Trauma: Can Shock Index Predict Failure?

INTRODUCTION: Predicting failure of nonoperative management (NOM) in splenic trauma remains elusive. Shock index (SI) is an indicator of physiologic burden in an injury but is not used as a prediction tool. The purpose of this study was to determine if elevated SI would be predictive of failure of NOM in patients with a blunt splenic injury. METHODS: Adult patients admitted to a level-1 trauma center from January 2011 to April 2017 for NOM of splenic injury were reviewed. Patients were excluded if they underwent a procedure (angiography or surgery) prior to admission. The primary outcome was requiring intervention after an initial trial of noninterventional management (NIM). An SI > 0.9 at admission was considered a high risk. Univariate and multivariate analyses were used to identify predicators of the failure of NOM. Findings were subsequently verified on a validation cohort of patients. RESULTS: Five hundred and eighty-five patients met inclusion criteria; 7.4% failed NIM. On an univariate analysis, findings of pseudoaneurysm or extra-arterial contrast on computed tomography did not differentiate successful NIM versus failure (8.1% versus 14.0%, P = 0.18). Age, the American Association for the Surgery of Trauma injury grade, and elevated SI were included in multivariate modeling. Grade of injury (OR 3.49, P = 0.001), age (OR 1.02, P = 0.009), and high SI (OR 3.49, P = 0.001) were each independently significant for NIM failure. The risk-adjusted odds of failure were significantly higher in patients with a high risk SI (OR 2.35, P < 0.001). Validation of these findings was confirmed for high SI on a subsequent 406 patients with a c-statistic of 0.71 (95% CI 0.62-0.80). CONCLUSIONS: Elevated SI is an independent risk factor for failure of NIM in those with splenic injury. SI along with age and computed tomography findings may aid in predicting the failure of NIM. Trauma providers should incorporate SI into decision-making tools for splenic injury management.

Discreet Values of Shock Index Pediatric Age-Adjusted (SIPA) to Predict Intervention in Children With Blunt Organ Injuries.

INTRODUCTION: Elevated shock index pediatric age-adjusted (SIPA) has been shown to be associated with the need for both blood transfusion and intervention in pediatric patients with blunt liver and spleen injuries (BLSI). SIPA has traditionally been used as a binary value, which can be classified as elevated or normal, and this study aimed to assess if discreet values above SIPA cutoffs are associated with an increased probability of blood transfusion and failure of nonoperative management (NOM) in bluntly injured children. MATERIALS AND METHODS: Children aged 1-18 y with any BLSI admitted to a Level-1 pediatric trauma center between 2009 and 2020 were analyzed. Blood transfusion was defined as any transfusion within 24 h of arrival, and failure of NOM was defined as any abdominal operation or angioembolization procedure for hemorrhage control. The probabilities of receiving a blood transfusion or failure of NOM were calculated at different increments of 0.1. RESULTS: There were 493 patients included in the analysis. The odds of requiring blood transfusion increased by 1.67 (95% CI 1.49, 1.90) for each 0.1 unit increase of SIPA (P < 0.001). A similar trend was seen initially for the probability of failure of nonoperative management, but beyond a threshold, increasing values were not associated with failure of NOM. On subanalysis excluding patients with a head injury, increased 0.1 increments were associated with increased odds for both interventions. CONCLUSIONS: Discreet values above age-related SIPA cutoffs are correlated with higher probabilities of blood transfusion in pediatric patients with BLSI and failure of NOM in those without head injury. The use of discreet values may provide clinicians with more granular information about which patients require increased resources upon presentation.

Assessing associated factors for failure of nonoperative management in pediatric blunt liver and spleen injuries: a secondary analysis of the SHIPPs study.

PURPOSE: The purpose of this study was to describe the characteristics of pediatric patients who underwent nonoperative management (NOM) for blunt splenic and hepatic injuries and to explore factors associated with NOM failure. METHODS: This was a secondary analysis of a multicenter cohort study of pediatric patients with blunt liver and spleen injuries in Japan. Participants included pediatric trauma patients aged 16 years or younger between 2008 and 2019 with NOM, which was defined as no surgery provided within 6 h of hospital arrival. NOM failure, defined as abdominal surgery performed after 6 h of hospital arrival, was the primary outcome. Descriptive statistics were provided and exploratory analysis to assess the associations with outcome using logistic regression. RESULTS: During the study period, 1339 met our eligibility criteria. The median age was 9 years, with a majority being male. The median Injury Severity Score (ISS) was 10. About 14.0% required transfusion within 24 h, and 22.3% underwent interventional radiology procedures. NOM failure occurred in 1.0% of patients and the in-hospital mortality was 0.7%. Factors associated with NOM failure included age, positive focused assessment with sonography for trauma (FAST), contrast extravasation on computed tomography (CT), severe liver injury, concomitant pancreas injury, concomitant gastrointestinal injury, concomitant mesenteric injury, and ISS. CONCLUSIONS: In our study, NOM failure were rare. Older age, positive FAST, contrast extravasation on CT, severe liver injury, concomitant pancreas injury, concomitant gastrointestinal injury, concomitant mesenteric injury, and higher ISS were suggested as possible risk factors for NOM failure.

Serial CT for Nonoperatively Managed Splenic Injuries.

INTRODUCTION: The role of serial computed tomography (CT) in the nonoperative management of blunt splenic injuries (NOMSIs) remains unclear. The purpose of the study was to determine the utility of serial CT of Grade 2-5 NOMSI in the modern era. METHODS: Blunt splenic injuries were identified over a 3.5-year period, ending in 6/2020. Our institutional protocol for NOMSI mandates a repeat 24-hour CT for Grade 2-5 injuries. Patients age<18, Grade 1 injuries and patients that underwent intervention prior to repeat scan were excluded. Demographics, comorbidities, timing of events (admission, CTs, splenectomy, and angiography), injury details, procedural details, total transfusion requirements, complications, length of stay, mortality, and discharge disposition were recorded. Descriptive statistics were performed. RESULTS: 219 patients with Grade 2-5 NOMSI had both an initial and 24-hour CT after exclusions. 24-hour CT identified 14 patients with new PSA(s) and 11 (5%) went to angiography within 24 hours with 9 (4%) undergoing angioembolization and 4 (2%) had splenectomy. Two hundred and four (93%) had no intervention though eventually 12 went on to angiography and 6 went for splenectomy. The 24-hour CT rarely altered management in the absence of clinical indication or prior PSA on initial CT with 5 (2%) receiving a therapeutic embolization and 2 (1%) had a nontherapeutic angiogram. No deaths were attributable to splenic injury. CONCLUSIONS: Routine 24-hour CT for NOMSI did not impact management. Clinical status and change in exam may warrant repeat CT in select cases in the setting of a plausible alternate explanation. Prompt angioembolization or splenectomy is more appropriate in clear-cut cases of failed NOMSI.

[Mechanism of blunt spleen injury: a finite element analysis].

OBJECTIVE: To explore the biomechanical mechanism of blunt spleen injury based on finite element analysis. OBJECTIVE: A fist finite element model was used to simulate the impact at 4-8 m/s in the spleen area of THUMS4.0 human body model from the front of the left costal area, the left anterior axillary line and the rear scapular line. The strain distribution and damage of the spleen under different conditions were observed. The simulation results were compared with the clinical cases of spleen rupture to analyze the mechanism of spleen injury. OBJECTIVE: The damage location and strain distribution of the spleen could vary under different conditions. Due to the special anatomical location of the spleen, a blunt impact at the speed of 4-8 m/s on the front side did not easily cause spleen injury, and the strain was distributed mainly in the front of the spleen and the spleen hilum; a similar blunt impact on the left side was likely to cause spleen diaphragmatic surface injury, the splenic visceral surface could be injured by the compression of the medial tissue and organs and the traction of the splenic pedicle, and the strain was distributed in the spleen diaphragmatic and visceral surfaces; an impact on the back side was likely to cause injuries in the posterior portion and hilum of the spleen, and the strain was mainly concentrated in the injured area. OBJECTIVE: Blunt spleen injuries caused by punches on the abdomen are mostly caused by direct impact on the ribs, the compression by the surrounding tissues and organs and the traction by the spleen pedicle.

Long-term sustainability of Washington State's quality improvement initiative for the management of pediatric spleen injuries.

BACKGROUND: Initial results of Washington State's quality improvement initiative addressing the management of blunt traumatic pediatric spleen injuries were published in 2008. In this update, we evaluated whether these effects were sustained over time. METHODS: Data from the Washington Trauma Registry for years 1999-2001 (pre-intervention), 2003-2005 (post-intervention), and 2012-2014 (follow-up) were used in a retrospective cohort study. Children between ages 0 to 14 years who were hospitalized with a traumatic blunt spleen injury were included. Multivariable logistic regression was used to account for patient, injury, and hospital characteristics. RESULTS: Overall, splenectomies continued to be less common with 8.3% of pediatric patients receiving splenectomies in the follow-up period compared with 14.3% and 7.2% in the preintervention and post-intervention periods (p = 0.034). After adjustment, splenectomies remained less likely to be performed in both post-intervention (OR = 0.37; 95% CI = 0.16-0.90) and follow-up periods (OR = 0.29; 95% CI = 0.12-0.70) compared to pre-intervention. Children were much more likely to be cared for at pediatric trauma hospitals in the follow-up period (OR = 5.13; 95% CI = 2.79-9.43) after adjustment. CONCLUSIONS: Evaluation of this statewide quality improvement initiative showed that positive changes in management practices persist. This evidence suggests that statewide quality improvement initiatives can be sustainable with minimal ongoing effort. LEVEL OF EVIDENCE: Level III.

National trends in pediatric blunt spleen and liver injury management and potential benefits of an abbreviated bed rest protocol.

PURPOSE: Recent reports suggest that an abbreviated bed rest protocol (ABRP) may safely reduce length of stay (LOS) and resource utilization in pediatric blunt spleen and liver injury (BSLI) patients. This study evaluates national temporal trends in BLSI management and estimates national reduction in LOS using an ABRP. METHODS: Pediatric patients (<18 years old) sustaining BLSI were identified in the Kids' Inpatient Database from 2000 to 2009. Yearly rates of injury and operative intervention were examined and stratified by type of injury. APSA guidelines and the reported ABRP were applied based on abbreviated injury score (AIS) and compared with actual LOS. RESULTS: 22,153 patients were identified. Over the study period, operative rates for spleen and liver injuries and overall mortality significantly declined: LOS=3.1 days (±1.6) and 2.7 days (±1.9) for spleen and liver, respectively. If APSA guidelines were followed, the rates were LOS=3.7 days (±1.1) and 3.4 days (±0.7), respectively. Application of the ABRP would result in LOS=1.3 days (±0.5) for all BSLI patients. An ABRP could potentially save 1.7 hospital days/patient or 36,964 patient hospital days nationally. CONCLUSION: Our study confirms a significant national decrease in operative intervention and overall mortality in patients with BSLI. Additionally, it appears that a shorter observation period than the APSA guidelines is being utilized. The implementation of ABRP holds potential in further reducing LOS and resource utilization.

Concomitant hollow viscus injuries in patients with blunt hepatic and splenic injuries: an analysis of a National Trauma Registry database.

INTRODUCTION: Non-operative management has become the standard approach for treating stable patients sustaining blunt hepatic or splenic injuries in the absence of other indications for laparotomy. The liberal use of computed tomography (CT) has reduced the rate of unnecessary immediate laparotomies; however, due to its limited sensitivity in the diagnosis of hollow viscus injuries (HVI), this may be at the expense of a rise in the incidence of missed HVI. The aim of this study was to assess the incidence of concomitant HVI in blunt trauma patients diagnosed with hepatic and/or splenic injuries, and to evaluate whether a correlation exists between this incidence and the severity of hepatic or splenic injuries. METHODS: A retrospective cohort study involving blunt trauma patients with splenic and/or liver injuries, between the years 1998 and 2012 registered in the Israel National Trauma Registry. The association between the presence and severity of splenic and/or liver injuries and the incidence of HVI was examined. RESULTS: Of the 57,130 trauma victims identified as suffering from blunt torso injuries, 2335 (4%) sustained hepatic injuries without splenic injuries (H group), 3127 (5.4%) had splenic injuries without hepatic injuries (S group), and 564 (1%) suffered from both hepatic and splenic injuries (H+S group). Overall, 957 patients sustained 1063 HVI. The incidence of HVI among blunt torso trauma victims who sustained neither splenic nor hepatic injuries was 1.5% which is significantly lower than in the S (3.1%), H (3.1%), and H+S (6.7%) groups. In the S group, there was a clear correlation between the severity of the splenic injury and the incidence of HVI. This correlation was not found in the H group. CONCLUSIONS: The presence of blunt splenic and/or hepatic injuries predicts a higher incidence of HVI, especially if combined. While in blunt splenic injury patients there is a clear correlation between the incidence of HVI and the severity of splenic injury, such a correlation does not exist in patients with blunt hepatic injury.

Follow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children.

OBJECTIVE: Current APSA recommendations for blunt spleen/liver injury (BSLI) entail bedrest equal to grade of injury plus one. We reported our experience 3 years ago with a prospectively implemented abbreviated protocol, one concern of which was that more numbers would be needed to support the safety of such a protocol. We are now reporting the final experience with this protocol as we move forward with further investigation. METHODS: Following IRB approval, data were collected prospectively in all patients with BSLI up to 8 weeks after discharge. There were no exclusion criteria, and patient accrual was consecutive. Bedrest was restricted to one night for Grade I & II injuries and two nights for Grade ≥ III. RESULTS: Between 11/2006 and 10/2012, 249 patients were admitted with BSLI. Mean age and weight were 10.3±4.8 years and 40.1±19.8 kg, respectively. Injuries included isolated spleen in 130 (52%), liver only in 107 (43%), and both in 12 (5%). One splenectomy was required for a grade V injury. Transfusions were used in 40 patients (16%), with 28 (11%) due to the injured solid organ. Bedrest for solid organ injury was applicable to 199 patients (80%), for which the mean grade of injury was 2.7±1.0 and mean bedrest was 1.6±0.6 days, resulting in 2.5±1.9 days of hospitalization. The need for bedrest was the limiting factor for length of stay in 155 patients (62%), for which mean grade of injury was 2.5±1.0 and mean bedrest was 1.6±0.6 days, resulting in 1.7±0.8 days of hospitalization. There were 4 deaths, 3 from brain injury and 1 from grade V liver injury. There were no patients readmitted for complications of solid organ injury. CONCLUSIONS: These data further validate that an abbreviated protocol of one night of bedrest for grade I and II injuries and two nights for grade ≥ III can be safely employed, resulting in dramatic decreases in hospitalization compared to the current APSA recommendations.