Changing patterns in diagnostic strategies and the treatment of blunt injury to solid abdominal organs

Background: In recent years there has been increasing interest shown in the nonoperative management (NOM) of blunt traumatic injury. The growing use of NOM for blunt abdominal organ injury has been made possible because of the progress made in the quality and availability of the multidetector computed tomography (MDCT) scan and the development of minimally invasive intervention options such as angioembolization. Aim: The purpose of this review is to describe the changes that have been made over the past decades in the management of blunt trauma to the liver, spleen and kidney. Results: The management of blunt abdominal injury has changed considerably. Focused assessment with sonography for trauma (FAST) examination has replaced diagnostic peritoneal lavage as diagnostic modality in the primary survey. MDCT scanning with intravenous contrast is now the gold standard diagnostic modality in hemodynamically stable patients with intra-abdominal fluid detected with FAST. One of the current discussions in the l erature is whether a whole body MDCT survey should be implemented in the primary survey. Conclusions The progress in imaging techniques has contributed to NOM being currently the treatment of choice for hemodynamically stable patients. Angioembolization can be used as an adjunct to NOM and has increased the succe

Splenic injury diagnosis & splenic salvage after trauma

Non-operative management (NOM) has replaced surgery as the treatment of choice for hemodynamically stable patients with splenic injury after trauma. The growing use of NOM for blunt abdominal organ injury has been made possible by the progress in the quality and availability of the multidetector CT scan and the development of minimally invasive intervention options such as splenic artery embolization (SAE). This thesis contributed to the further refinement of patient selection for the (non-)operative treatment of blunt splenic injury after trauma. The challenge is to use the least invasive techniques to control life threatening haemorrhage as quickly as possible (‘Time is life’) in order to reduce the number of unnecessary splenectomies. This maximises patient benefit while maintaining high standards of safety. The most important findings of this thesis are: • If 24/7 interventional radiology facilities are available, SAE is not associated with time loss compared to splenic surgery, even in patients who are HD unstable upon presentation. • After correction for confounders with the propensity score technique, there was a small, but consistent advantage of SAE over observation alone with regard to successful treatment in patients with blunt splenic injury after trauma. • From a prospective study we concluded that splenic function of embolised patients is intact and routine vaccination appears not to be indicated. • Lastly, one of the studies showed that variation in treatment and outcome of splenic injury exists in the Netherlands. The development of a national guideline is advised to minimalize splenectomy after trauma

Missing patients in a regional trauma registry: incidence and predictors

Trauma systems have data registries in order to describe and evaluate (the quality of) trauma care. If results between centres and countries (benchmarking) are to be compared, data has to be accurate, reliable and complete. All trauma registries deal with incompleteness. A contributor to incompleteness of the data is failure to include patients that fulfil the criteria; the so-called missing patients. The aim of this study is to assess the number of missing patients in our regional trauma registry and to identify predictors for being missing from the trauma registry. A random sample was taken. Four calendar weeks from 2012 were selected and medical files of all consecutive presentations to the emergency department or trauma room during those weeks were studied. Patients who were already correctly included in the trauma registry were assigned to the 'included' group and patients who should have been but were not to the 'missing' group. Multivariable logistic regression analysis was performed to identify predictors for being missed from the trauma registry. Of a total of 338 patients, 50 (15%) were identified as missing. Characteristics of the missing patients did not differ substantially from the included patients. Transfer to another hospital after initial assessment and presentation in a Level 3 hospital compared to a Level 1 hospital were independent predictors for being missed from the trauma registry, with an adjusted odds ratio of 5.86 (95% CI: 2.08-16.52) and 6.64 (95% CI: 1.86-23.78), respectively. Overall, 15% of the patients who met the inclusion criteria of the trauma registry were not included in the registry. Special attention should be paid to patients who are transferred to other hospitals in the network after initial assessment and to registration in Level 3 hospital

Prognostic factors for failure of nonoperative management in adults with blunt splenic injury: A systematic review

BACKGROUND: Contradictory findings are reported in the literature concerning prognostic factors for failure of nonoperative management (NOM) in the treatment of adults with blunt splenic injury. The objective of this systematic review was to identify prognostic factors for failure of NOM, with or without angiography and embolization. METHODS: MEDLINE, Embase, and the Cochrane Library databases were searched. Prospective or retrospective cohort studies addressing failure of nonoperative treatment, with and/or without angiography and embolization, of blunt abdominal injuries were included. Methodological quality of the studies was assessed. RESULTS: A total of 335 titles and abstracts were screened, of which 31 fulfilled the inclusion criteria. No randomized controlled trials were found. Ten articles were qualified as high-quality articles and used for data extraction (best-evidence synthesis). A total of 25 prognostic factors were investigated, of which 14 were statistically significant in one or more studies. Strong evidence exists that age of 40 years or above, Injury Severity Score (ISS) of 25 or greater, and splenic injury grade of 3 or greater are prognostic factors for failure of NOM. Moderate evidence was found for a splenic Abbreviated Injury Scale score of 3 or greater, trauma and ISS of less than 0.80, the presence of an intraparenchymal contrast blush, as well as transfusion of 1 unit of packed red blood cells or more. Limited evidence was found for large hemoperitoneum, lower Revised Trauma Score, lower Glasgow Coma Scale score, lower systolic blood pressure, male sex, the presence of traumatic brain injury, and splenic embolization as protective factor for failure of NOM. CONCLUSION: Awareness for failure ofNOMis required in patients aged 40 years or older, in patients with an ISS of 25 or higher or those with splenic injury grade 3 or higher. The prognostic factors for failure that we identified should be confirmed in future prospective cohort studies or meta-analyses using individual patient data. (J Trauma Acute Care Surg. 2013;74: 546-557. Copyright (C) 2013 by Lippincott Williams & Wilkins

Routine urinalysis in patients with a blunt abdominal trauma mechanism is not valuable to detect urogenital injury

To investigate whether the routine performance of urinalysis in patients with a blunt trauma mechanism is still valuable. Consecutive patients aged ≥16 years, admitted to a Dutch Level 1 trauma centre between January 2008 and August 2011, were included in this retrospective cohort study. Results of urinalysis (erythrocytes per µL) were divided into no, microscopic or macroscopic haematuria. Patients were divided into four groups based on whether a urinalysis was performed or not, with or without imaging for urogenital injury. Main outcome measures were the presence of urogenital injury and whether the findings on urine specimen and/or imaging led to clinical consequences. A total of 1815 patients were included. The prevalence of intra-abdominal and urogenital injuries was 13% and 8%, respectively. In 1363 patients (75%), urinalysis was performed and 1031 patients (57%) underwent imaging for urogenital injury as well. The presence of macroscopic haematuria (n=16) led to clinical consequences in 73% of the patients (11 out of 15), regardless of the findings on imaging. Microscopic haematuria on urinalysis in combination with no findings on imaging led to clinical consequences in 8 out of 212 patients (4%). Microscopic haematuria on urinalysis in patients who did not have imaging for urogenital injury did not lead to clinical consequences (0 out of 54 patients; 0%). All the 8 patients who underwent an intervention had positive findings on imaging. The results do not support the routine performance of urinalysis in patients admitted with a blunt trauma mechanism. Although urinalysis could be valuable in specific patient populations, we should consider omitting this investigation as a routine part of the assessment of trauma patient

Consensus strategies for the nonoperative management of patients with blunt splenic injury: A Delphi study

BACKGROUND: Nonoperative management is the standard of care in hemodynamically stable patients with blunt splenic injury. However, a number of issues regarding the management of these patients are still unresolved. The aim of this study was to reach consensus among experts concerning optimal treatment and follow-up strategies. METHODS: The Delphi method was used to reach consensus among 30 expert trauma surgeons and interventional radiologists from around the world. An online survey was used in the two study rounds. Consensus was defined as an agreement of 80% or greater. RESULTS: Response rates of the first and second rounds were 90% and 80%, respectively. Consensus was reached for 43% of the (sub) questions. The American Association for the Surgery of Trauma organ injury scale for grading splenic injury is used by 93% of the experts. In hemodynamically stable patients, observation or splenic artery embolization (SAE) can be applied in the presence of a small or no hemoperitoneum combined with an intraparenchymal contrast extravasation or no contrast extravasation, regardless of the presence of an arteriovenous (AV) fistula/pseudoaneurysm. Hemodynamic instability is an indication for operative management, irrespective of computed tomographic characteristics and grade of splenic injury (>= 82% of the experts). Operative management is also indicated in the presence of associated intra-abdominal injuries and/or the need for five or more packed red blood cell transfusions (22 of 27 experts, 82%). Recommended time span to start SAE in a stable patient with an intraparenchymal contrast extravasation is 60 minutes (19 of 24 experts). Patients should be admitted 1 to 3 days to a monitored setting (27 of 27 experts, 100%). Serial hemoglobin checks are performed by all experts, every 4 to 6 hours in the first 24 hours and once or twice a day after that (21 of 24 experts, 88%), in nonoperative management as well as after SAE. Routine postdischarge imaging is not indicated (21 of 24 experts, 88%). CONCLUSION: Although treatment should always be adjusted to the specific patient, the results of this study may serve as general guidelines. (Copyright (C) 2013 by Lippincott Williams & Wilkins

Variation in treatment of blunt splenic injury in Dutch academic trauma centers

Background: The incidence of splenectomy after trauma is institutionally dependent and varies from 18% to as much as 40%. This is important because variation in management influences splenic salvage. The aim of this study was to investigate whether differences exist between Dutch level 1 trauma centers with respect to the treatment of these injuries, and if variation in treatment was related to splenic salvage, spleen-related reinterventions, and mortality. Methods: Consecutive adult patients who were admitted between January 2009 and December 2012 to five academic level 1 trauma centers were identified. Multinomial logistic regression was used to measure the influence of hospital on treatment strategy, controlling for hemodynamic instability on admission, high grade (American Association for the Surgery of Trauma 3-5) splenic injury, and injury severity score. Binary logistic regression was used to quantify differences among hospitals in splenic salvage rate. Results: A total of 253 patients were included: 149 (59%) were observed, 57 (23%) were treated with splenic artery embolization and 47 (19%) were operated. The observation rate was comparable in all hospitals. Splenic artery embolization and surgery rates varied from 9%-32% and 8%-28%, respectively. After adjustment, the odds of operative management were significantly higher in one hospital compared with the reference hospital (adjusted odds ratio 4.98 [1.02-24.44]). The odds of splenic salvage were significantly lower in another hospital compared with the reference hospital (adjusted odds ratio 0.20 [0.03-1.32]). Conclusions: Although observation rates were comparable among the academic trauma centers, embolization and surgery rates varied. A nearly 5-fold increase in the odds of operative management was observed in one hospital, and another hospital had significantly lower odds of splenic salvage. The development of a national guideline is recommended to minimalize splenectomy after trauma. (C) 2015 Elsevier Inc. All rights reserved