title: Blunt splenic injury and severe brain injury: a decision analysis and implications for care.
abstract: BACKGROUND
  The initial nonoperative management (NOM) of blunt splenic injuries in hemodynamically stable patients is common. In soldiers who experience blunt splenic injuries with concomitant severe brain injury while on deployment, however, NOM may put the injured soldier at risk for secondary brain injury from prolonged hypotension.
  
  
  METHODS
  We conducted a decision analysis using a Markov process to evaluate 2 strategies for managing hemodynamically stable patients with blunt splenic injuries and severe brain injury--immediate splenectomy and NOM--in the setting of a field hospital with surgical capability but no angiography capabilities. We considered the base case of a 40-year-old man with a life expectancy of 78 years who experienced blunt trauma resulting in a severe traumatic brain injury and an isolated splenic injury with an estimated failure rate of NOM of 19.6%. The primary outcome measured was life expectancy. We assumed that failure of NOM would occur in the setting of a prolonged casualty evacuation, where surgical capability was not present.
  
  
  RESULTS
  Immediate splenectomy was the slightly more effective strategy, resulting in a very modest increase in overall survival compared with NOM. Immediate splenectomy yielded a survival benefit of only 0.4 years over NOM.
  
  
  CONCLUSIONS
  In terms of overall survival, we would not recommend splenectomy unless the estimated failure rate of NOM exceeded 20%, which corresponds to an American Association for the Surgery of Trauma grade III splenic injury. For military patients for whom angiography may not be available at the field hospital and who require prolonged evacuation, immediate splenectomy should be considered for grade III-V injuries in the presence of severe brain injury.
authors.affiliation: The Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont.
authors.forename: Thamer
authors.initials: T
authors.lastname: Alabbasi
authors.affiliation: The Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont.
authors.forename: Avery B
authors.initials: AB
authors.lastname: Nathens
authors.affiliation: The Canadian Forces Health Services, the 1 Canadian Field Hospital, Petawawa, Ont., the Trauma Services and the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont.
authors.forename: Homer
authors.initials: H
authors.lastname: Tien
mesh_terms: D000328:Adult; D001930:Brain Injuries / Q000401:mortality / Q000628:therapy*; D002170:Canada; D003661:Decision Support Techniques; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008390:Markov Chains; D008889:Military Personnel; D009104:Multiple Trauma / Q000401:mortality / Q000628:therapy*; D012189:Retrospective Studies; D013154:Spleen / Q000293:injuries*; D013156:Splenectomy; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000401:mortality / Q000628:therapy*