Nonoperative management of blunt splenic injury in associated abdominal trauma

Abstract

The aim of the study was to assess the results and evaluate the efficiency of nonoperative management (NOM) in polytrauma patients with blunt splenic injury (BSI). Material and methods: A prospective study on 30 patients, 2008-2009 with BSI; the m:f/ 19:11; mean age=39.97±20,35, RTS=7,66±0,5, ISS=6±8,95. The hemoperitoneum was first established by USG(100%). Its volume and extent of parenchimatous organ injury was subsequently quantified at CT(90%), the laparoscopy was performed in 6(20%) cases for assessing USG sensitivity and determined ascites in 2 cases of politrauma patients with splenic lesions established at CT, and exaggerate volume of free liquid. Results: Isolated BSI in 5(16,7%) patients, in 21(71%)-associated with thoracic trauma, in 9(30%)— with head trauma and in other 9(30%)-with musculoskeletal trauma. 7(23,3%) patients presented hemodynamic instability: 6 politrauma patients with BSI: Ilnd degreed and Bird degree-2 cases with unstable pelvic fractures, and one patient with isolated BSI; they were all hemodynamically stabilized, but the last resulted in failure of NOM in the first 4h. In 3 politrauma patients with cerebral contusion and GCS- 12p NOM succeeded, splenic lesions being of Ilnd (n=2) and Illrd (n=l) degree, despite of determining intraabdominal free liquid and hemodynamic instability in 2 cases. The severity of BSI was determined from Ilnd degree to IVth degree according to AAST, Ilnd degree16(53,3%), Illrd degree-13(43,3%), IVth degree-1(3,4%), simultaneously being diagnosed 3 cases of minor liver contusions (1st degree-2 patients, Ilnd degree-1 patient). The mean value of hemoperitoneum determined by CT for Illrd degree lesions was 766,67±208,17ml, while for Ilnd degree was 271,43±146,79ml (p<0,001). The volume of blood transfusions for patients with BSI associated with lesions of the musculoskeletal system was 933±208,79ml, but for Illrd degree BSI without pelvic fractures-282,3±82,5ml; Ilnd degree BSI did not require blood transfusions (p<0,01). Failure of NOM was reported in 3(19%) cases: in 2-isolated BSI of Illrd degree, 1 case associated with head trauma with hemoperitoneum mean value of 1400±200ml. Conclusions: NOM can be successful both in isolated and associated BSI of I—III degree. USG is the screening method for determining hemoperitoneum, but CT defines the degree and volume of hemoperitoneum, and it can serve as a relative prognostic criterion of failure. Lack of awareness is not a criterion to avoid NOM, laparoscopy in these conditions reflects the success of this option. Decreased haematocrit and the need for blood transfusions in patients with BSI and musculoskeletal trauma is not a failure index in case of stable and responsive to infusion therapy hemodynamics.