Blunt aortic injury with concomitant intra-abdominal solid organ injury: treatment priorities revisited.
BACKGROUND
Patients with blunt aortic injury (BAI) often have concomitant liver or spleen (L/S) injuries. With increasing use of cardiopulmonary bypass with heparinization in repair of BAI, many advocate operative management of the L/S injury before aortic repair to eliminate risk of hemorrhage. We evaluated the safety of nonoperative management (NOM) of blunt L/S injuries in patients undergoing acute BAI repair with bypass.


METHODS
All patients admitted over a 6-year period with BAI were identified from the registry of our Level I trauma center. Patients with isolated L/S injuries without BAI admitted over the same period served as controls. Groups were compared with regard to demographics, injury characteristics, hospital course, and mortality.


RESULTS
Eighty-four patients were diagnosed with BAI from 1994 to 2000; 28 (33%) also had blunt abdominal trauma. Three patients with severe brain injury did not undergo BAI repair, and five required laparotomy before BAI repair for other intra-abdominal injuries (two for hemodynamic instability with splenic injury, and three for concomitant bowel injury). Therefore, 20 of 28 (71.4%) BAI patients with grade I or II L/S injury (Aorta L/S group) underwent planned NOM. All BAIs were repaired using partial bypass with full heparinization. These 20 patients are compared with 894 patients with grade I or II L/S injuries with no BAI (L/S group) over the same time period. There was no difference in the nonoperative failure rate of the Aorta L/S group versus the L/S group (0% vs. 1.7%). Both groups had similar complication rates. The Aorta L/S group was also compared with 56 BAIs without solid organ injury (Aorta group). Although the Aorta L/S group was more severely injured than the Aorta group (Injury Severity Score of 35.3 vs. 26.8, < 0.0001), transfusion rates (5.7 U of packed red blood cells vs. 8.0 U of packed red blood cells, p = NS), hospital days (17.9 vs. 19.1, p = NS) and mortality (10% vs. 9%, p = NS) were similar.


CONCLUSIONS
NOM of patients with grade I or II L/S injury who undergo systemic anticoagulation with heparin for repair of BAI is safe and associated with transfusion rates similar to BAI alone. Patients with low-grade liver or spleen injuries do not require laparotomy before BAI repair using partial bypass.
D000007:Abdominal Injuries / Q000150:complications / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D000328:Adult; D001013:Aorta, Thoracic / Q000000981:diagnostic imaging / Q000293:injuries*; D003422:Critical Care / Q000379:methods; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D008099:Liver / Q000293:injuries; D008297:Male; D008499:Medical Records; D009104:Multiple Trauma / Q000150:complications / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications; D011859:Radiography; D012189:Retrospective Studies; D013154:Spleen / Q000293:injuries; D013714:Tennessee / Q000453:epidemiology; D014193:Trauma Centers / Q000706:statistics & numerical data*; D014949:Wounds, Nonpenetrating / Q000150:complications / Q000401:mortality / Q000473:pathology / Q000628:therapy*