title: Blunt assault is associated with failure of nonoperative management of the spleen independent of organ injury grade and despite lower overall injury severity.
abstract: OBJECTIVE
  Nonoperative management (NOM) of blunt splenic injuries has become standard of care for its high success rate. We observe that many blunt assault (BA) patients fail NOM despite lower overall injury severity. We performed this study to determine whether BA is independently associated with failed initial NOM (FiNOM) of splenic injuries.
  
  
  METHODS
  Using the Trauma Registry at our level I center, we reviewed data of all patients with blunt splenic injuries, who did not undergo immediate operative management of the spleen, admitted from January 1, 1992 to December 31, 2007. Initial NOM was defined as any patient who did not undergo immediate (< or =12 hours after admission) operative intervention for the spleen or did not undergo operation for the spleen at any time during the admission. FiNOM was defined as any patient who underwent operative management of the spleen greater than 12 hours after admission. Logistic regression was performed to determine whether BA was independently associated with FiNOM.
  
  
  RESULTS
  FiNOM occurred in 57 of the 419 (13.6%) patients initially managed nonoperatively. FiNOM decreased significantly in non-BA patients from 15.8% (1992-1999) to 6.2% (2005-2007) (p = 0.05) over time. This was not true for BA patients (33.3% vs. 30%) (p = 0.78). FiNOM for BA patients was 36.1% (13 of 36) versus 11.5% (44 of 383) for all other mechanisms combined. FiNOM was increased across all Organ Injury Scale scores for the spleen in BA patients. BA was independently associated with FiNOM.
  
  
  CONCLUSIONS
  BA is associated with FiNOM independent of severity of splenic injury. Despite an increasingly successful policy of NOM in all blunt splenic injuries, this does not apply for BA. BA should be an important factor considered when initial NOM is contemplated for blunt splenic injury because of the high failure rates compared with all other mechanisms.
authors.affiliation: Department of Surgery, Division of Trauma/Surgical Critical Care, LAC + USC Medical Center, Los Angeles, California 91024, USA. plurad@usc.edu
authors.forename: David S
authors.initials: DS
authors.lastname: Plurad
authors.forename: Donald J
authors.initials: DJ
authors.lastname: Green
authors.forename: Kenji
authors.initials: K
authors.lastname: Inaba
authors.forename: Rodd
authors.initials: R
authors.lastname: Benfield
authors.forename: Lydia
authors.initials: L
authors.lastname: Lam
authors.forename: Brad
authors.initials: B
authors.lastname: Putty
authors.forename: Demetrios
authors.initials: D
authors.lastname: Demetriades
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D009104:Multiple Trauma / Q000401:mortality / Q000628:therapy; D012042:Registries; D012189:Retrospective Studies; D013156:Splenectomy; D013161:Splenic Rupture / Q000401:mortality / Q000628:therapy*; D015996:Survival Rate; D017211:Treatment Failure; D014949:Wounds, Nonpenetrating / Q000401:mortality / Q000628:therapy*; D055815:Young Adult