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Trauma Conference October 22nd, 2007 Greg Feldman, MD, R3 Stanford Medical Center Department of Surgery

Case Presentation. 10/16/07, 5:00 PM56M unhelmeted bicyclist ?topples" onto left side. EtOH, LOC. Bikes home.10/16/07, midnightEMS takes patient to Kaiser with H/A, L flank pain. Hemodynamically stable. Hct 42. CT head: tentorial SDH. CT abd/pelvis: splenic lac, small L renal lac. Trans

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Trauma Conference October 22nd, 2007 Greg Feldman, MD, R3 Stanford Medical Center Department of Surgery

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    1. Trauma Conference October 22nd, 2007 Greg Feldman, MD, R3 Stanford Medical Center Department of Surgery

    2. Case Presentation 10/16/07, 5:00 PM 56M unhelmeted bicyclist topples onto left side. + EtOH, + LOC. Bikes home. 10/16/07, midnight EMS takes patient to Kaiser with H/A, L flank pain. Hemodynamically stable. Hct 42. CT head: tentorial SDH. CT abd/pelvis: splenic lac, small L renal lac. Transferred to Stanford. 10/17/07, 7:00 AM HR 82, BP 152/86. LUQ Abd TTP. Hct 37. Repeat imaging (8:30 AM) demonstrates no significant interval change in perisplenic fluid or SDH.

    3. CT Abdomen

    7. ICU course Patient admitted to ICU following splenic artery embolization at 5:00 PM On admission, Hct 35.3 (from 37). HR 70s, SBP 162/84. Patient cheerful, talkative, flirtatious. Abdomen soft, LUQ tenderness. At 9:00 PM, patient complained of sudden increased abdominal pain, first LUQ and then diffuse. Moaning in pain. HR 100s, SBP 120s/60s. Diffuse tap tenderness with rebound. Hct 32.7. FAST: fluid in RUQ, LUQ. Taken to OR emergently for ex-lap.

    9. The Spleen Greeks: spleen is linked with melancholy. China: spleen is seat of willpower. Talmud: spleen is the organ of laughter. Rabbi Johanan would drink wine until it could be smelt through his ears. Rabbi Na'hman would drink wine until his spleen would float in wine. - Babylonian Talmud, chp 18, p. 285 19th century England: spleen is linked with rage. To vent ones spleen. Medical school: spleen has something to do with the immune system.

    10. Splenic function Early fetal development: important role in hematopoietic function RBC culling: removes senescent and abnormal erythrocytes, and the microbes they contain (bartonella, malaria) Immune function: Suboptimal response to new antigens: subnormal IgM levels, suppressed immune response of peripheral B cells, T cells, and polys. Deficient complement function (both decreased production and effectiveness of opsonins) Asplenic adults are at significantly higher risk for overwhelming postspenectomy infection with bacteremia, pneumonia, or meningitis

    11. Splenic Trauma Most commonly injured organ in nonvehicular blunt trauma Injury to the spleen is the most common indication for laparotomy following blunt trauma Three dominant mechanisms: Deceleration forces result in splenic motion; capsular avulsion where spleen is tethered (splenophrenic, splenorenal, splenocolc, gastrosplenic ligaments) Direct transmission of energy via chest wall Puncture from adjacent rib fracture

    12. Splenic Injury Scale (AAST) Grade I: Hematoma: subcapsular, < 10% surface area Laceration: capsular, < 1-cm parenchymal depth Grade II: Hematoma: subcapsular, 10-50% surface area; intraparenchymal, <5 cm in diameter Laceration: 1-3 cm parenchymal depth Grade III: Hematoma: subcapsular, >50% surface area or expanding; ruptured subcapsular or parenchyma, intraparenchymal > 5 cm or expanding Laceration: >3 cm parenchymal depth or involving trabecular vessels Grade IV: Laceration: involving segmental or hilar vessels producing major devascularization (>25% of spleen) Grade V: Hilar vascular injury that devascularizes spleen

    13. Operative interventions Splenectomy Unstable patient Other intra-abdominal injuries requiring prompt attention Extensive splenic injury with continuous bleeding Bleeding associated with hilar injury Splenorrhaphy: used in 50% of splenic injuries in mid-80s, now less than 10% Superficial hemostatic agents (cautery, cellulose, thrombin) (grade I or II) Suture repair +/- pledgets (grade II or III) Absorbable mesh wrap (grade III or IV) Resectional debridement (grade III or IV)

    14. Non-Operative Management (NOM) Only for hemodynamically stable patients, in centers with adequate facilities for intensive monitoring and the ability to quickly mobilize an OR. Originated in pediatric surgery. Currently, 70-90% of children with splenic injury are successfully treated without operation 40-50% of adult patients with splenic injury are managed non-operatively in large-volume trauma centers Most grade I/II injuries are now managed nonoperatively (60-70% of non-op cases). Trend toward managing III/IV injuries non-operatively. Failure of non-op management: Between 3-48% in 8 published series. Predictors: pts older than 55, moderate to large hemoperitoneum, vascular blush on CT, higher grade of injury Mortality rate for successful non-op management 12%, compared with failed non-op management mortality of 9%.

    15. IR Embolization Performed on hemodynamically stable patients with CT demonstration of active bleeding Involves occlusion of splenic artery or branches by coiling or gelfoam Failure rate for non-op management following splenic artery embolization: 12-30% Has become increasingly accepted as an adjunct in nonoperative management of splenic injury Wide variety among institutions and individual surgeons as to specific indications for utilization; multiple retrospective studies have been well-matched, indicating that assignment is somewhat arbitrary.

    16. IR Embolization Early Selective Angioembolization Improves Success of Nonoperative Management of Blunt Splenic Injury. Wu et al. The American Surgeon. Sept 2007. From Division of Trauma in Changhua, Taiwan. Angiography for Blunt Splenic Trauma Does Not Improve the Success Rate of Nonoperative Management. Harbrecht et al. The Journal of Trauma. July 2007. From Departments of Surgery at Pitt and Louisville.

    17. Embolization: Pro Early Selective Angioembolization Improves Success of Nonoperative Management of Blunt Splenic Injury. Wu et al. The American Surgeon. Sept 2007. From Division of Trauma in Changhua, Taiwan. Retrospective review of 114 patients with blunt splenic injuries Used historical controls (61 patients were from before adoption of splenic embolization, 53 after). 10 patients were embolized; 2 failed non-op management. Non-operative management success rate went from 55.7% to 54.7%. Authors extracted only one group in which non-operative management success rate improved: patients with large hemoperitoneum who received embolization.

    18. Embolization: Con Angiography for Blunt Splenic Trauma Does Not Improve the Success Rate of Nonoperative Management. Harbrecht et al. The Journal of Trauma. July 2007. From Departments of Surgery at Pitt and Louisville. Retrospective review of 570 patients with blunt splenic injuries. 91% non-operative management (NOM) success rate. 46 patients underwent splenic angiography; 69% of these were embolized. No significant difference in NOM success rate between severity-matched patients receiving angiography or not Authors point out that, with increasing sensitivity of CT, more minor splenic injuries are being diagnosed. Studies that use historical controls are thus biased toward improved NOM rates after availability of IR.

    19. The best way to repair the spleen is in formaldehyde. - Dr. David Spain

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