Blunt Splenic Trauma: Increased complexity or progress?

Current Management of Splenic Trauma

No financial disclosures

Historical Milestones 2nd-12th Cent.

Seat of emotions; source of laughter, mirth, anger, malice or bad temper, latent malevolence, melancholy, depression, black bile cleanse the blood

1549

First splenectomy for disease

1590

Partial splenectomy for trauma

1678

Total splenectomy for trauma

Historical Milestones, cont’d 1892

Splenectomy for blunt trauma

1900

Nonoperative Tx associated with mortality of 90-100% Prevalence of “delayed rupture” (15-30%)

1895-1930

Splenorrhaphy, partial splenectomy

“Injuries of the spleen demand excision of the gland. No evil effects follow its removal, while the danger of hemorrhage is effectually stopped.” Kocher, 1911

Historical Milestones, cont’d 1952

Increased infection in children after splenectomy

1969

Overwhelming Post Splenectomy Infection (OPSI)

1971

Nonoperative management of spleen (pediatric patients)

1990’s

Nonop management in adults

Epidemiologic Facts Related to Infections after Splenectomy Pneumococcal pneumonia is a common community acquired pneumonia

Post splenectomy cases often poorly documented Other risk factors for pneumonia/infection are often present Not all infections after splenectomy are OPSI

Therefore …… What is the risk of OPSI after splenectomy?

Best guess is < 1% in adults after trauma (0.020.2%) More frequently rapidly fatal in adults (less meningitis) Impact of immunization after splenectomy

Diagnostic Modalities Influence Treatment of Blunt Splenic Injuries Physical Exam (premodern era) Physical Exam (modern era) DPL Computed tomography ?Ultrasound/CT?

No specific treatment Splenectomy Splenorrhaphy Nonoperative management ?????

100

Percent

80

60 Dx using CT Dx using US Dx using surgery

40

Total PTSF Patients,#

0 1986 24000

1988

1990

1992

1994

1996

1998

2000

2002 6

Total PTSF patients Patients with splenic injuries

22000

5

20000

18000 4 16000

14000 1986

1988

1990

1992

1994

1996

Year

1998

2000

3 2002

Patients with Splenic Injuries,%

20

Magnitude of Splenic Injury is changing over time 1000

Number of Patients

900 800 700 600 500

All Injuries 865.04 865.03 865.02 865.01

400 300 200 100 0 1986

1988

1990

1992

1994

Year

1996

1998

2000

2002

Splenic Injury Severity Trends from the National Trauma Data Bank 5000

4000

AIS 2 3000

AIS 3

# Cases

AIS 4 & 5

2000

Total 1000

03 20

02 20

01 20

00 20

99 19

98 19

19

97

0

Mortality with Moderately Severe Splenic Injuries 40 35

Mortality, %

30 All Injuries 865.03 865.02

25 20 15 10 5 0 1986

1988

1990

1992

1994

Year

1996

1998

2000

2002

Mechanism of Injury is changing over time

Fall

Percent

Other

20

60

10

50

0 40 1986 1988 1990 1992 1994 1996 1998 2000 2002

Year MCC, Assaults, Peds struck were unchanged

MVC, Percent

MVC

Nonoperative treatment is the most common form of management for blunt splenic injuries More frequent use of CT for diagnosis/triage More low magnitude splenic injuries Low velocity accidents Decreased overall number/severity of associated injuries

Nonoperative Management Delay in Tx

Missed Injuries

Operative Management Risk of operation

OPSI

Operative vs Nonoperative Tx Is this splenic injury actively bleeding? (likely to bleed)?

Splenic Injury with extravasation of contrast

Minor Blunt Splenic Injury

Moderately Severe Blunt Splenic Injury

Grade of Splenic Injury I

II

Hematoma

subcapsular, 5cm

Laceration

>3 cm, + trabecular vessels

IV

Laceration

segmental or hilar vessel with major devascularization

V

Laceration

shattered spleen, avulsion

III

Grade of Splenic Injury correlates with success of NOM

EAST, J Trauma 2000

Quantity of Hemoperitoneum correlates with success of NOM

EAST, J Trauma 2000

Magnitude of injury correlates with success of nonoperative management *p