Delayed hemorrhagic complications in the nonoperative management of blunt splenic trauma: early screening leads to a decrease in failure rate.
BACKGROUND
Delayed splenic rupture is the Achilles' heel of nonoperative management (NOM) for blunt splenic injury (BSI). Early computed tomographic (CT) scanning for features suggesting high risk of nonoperative failure, splenic pseudoaneurysms (SPAs), and arterial extravasation (AE), in concert with the appropriate use of splenic arterial embolization (SAE) is a viable method to reduce rates of failure of NOM. We report our 12-ear experience with a protocol for mandatory repeat CT evaluation at 48 hours and selective SAE.


METHODS
A retrospective cohort analysis was performed on all consecutive adult trauma patients with BSI between 1995 and 2012. We evaluated an early/control (1995-1999) and a present/intervention (2000-2012) cohort in which SAE became available and 48-hour CT scans were implemented.


RESULTS
The study included 773 patients (157 early vs. 616 present) with BSI. The proportion of patients managed nonoperatively (53% vs. 77%, p < 0.01) and overall splenic salvage rate (46% vs. 77%, p < 0.01) were improved in the present cohort. Among patients selected for NOM, there was a significant improvement in the failure rate of NOM (12% vs. 0.6%, p < 0.01) as well as in the length of hospital stay (8 days vs. 6 days, p < 0.01). Delayed development of SPA and/or AE was detected in 6% of BSI in the present cohort and was distributed among all grades of injury.


CONCLUSIONS
The delayed development of SPA and AE is not an entirely rare event following BSI. Reevaluation with CT at 48 hours following admission and the use of SAE significantly decrease the failure rate of NOM.


METHODS
Therapeutic study, level III.
From the Trauma Program (W.R.L., T.C.-S., N.P., D.G.), London Health Sciences Center; Department of Radiology (S.K.), Division of Emergency Medicine (D.O.), Division of Critical Care (N.P.), and Department of Surgery (W.R.L., B.M., N.P., D.G.), Schulich School of Medicine and Dentistry (T.J.L., T.S., B.M.) University of Western Ontario, London, Ontario, Canada.
W Robert
WR
Leeper
Terrence J
TJ
Leeper
David
D
Ouellette
Bradley
B
Moffat
Thiru
T
Sivakumaran
Tanya
T
Charyk-Stewart
Stewart
S
Kribs
Neil G
NG
Parry
Daryl K
DK
Gray
D000007:Abdominal Injuries / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D000328:Adult; D004621:Embolization, Therapeutic / Q000009:adverse effects* / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006470:Hemorrhage / Q000175:diagnosis / Q000209:etiology* / Q000517:prevention & control; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D011379:Prognosis; D012189:Retrospective Studies; D013154:Spleen / Q000293:injuries*; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D017211:Treatment Failure; D014949:Wounds, Nonpenetrating / Q000150:complications / Q000175:diagnosis / Q000628:therapy*