Outcomes in splenic injury at a high volume tertiary care centre

INTRODUCTION

Traumatic injuries are the major cause of mortality in the under 40 year old population and abdominal trauma is the third common trauma with a high rate of morbidity and mortality.^1-3 Rapid diagnosis and treatment can decrease the rate of abdominal trauma related mortality, up to 50%.⁴ Immediate referral of the victim to a trauma center and timely diagnosis and treatment play a key role in improvement of patient outcome. When a patient with suspected blunt abdominal trauma is presented to emergency department, the physicians look to determine the presence of intra-abdominal injuries and predict patient outcome.⁵ The spleen is one of the most commonly injured organs in blunt abdominal trauma.⁶ The spleen is particularly vulnerable to injury by virtue of its position and its fragile capsule. Advanced trauma life support (ATLS) has been recognized globally as the best modality in assessing polytrauma patients. This system provides a systematic approach of managing the patients. It begins with assessment of life threatening conditions first (primary survey), followed by serial sequential valuations to exclude other injuries (secondary survey) and finally a more comprehensive evaluation to identify any pre-existing conditions present (tertiary survey).⁷

During the initial assessment of the polytrauma patient, time is always of the essence. Hence, early identification of life threatening conditions and prompt initiation of definitive care are crucially important. A focused abdominal sonography in trauma (FAST) is the earliest radiological modality utilized to exclude, presence of a cardiac tamponade as well as the presence of haemoperitoneum in a traumatized patient.⁸ Other radiological evaluations may be employed such as Computer aided tomography scans (CT scans) or X-rays, once the patient has been stabilized. The problem of missed injuries has been noted for a long time. This has been alluded to: clinical and radiological misdiagnoses, the lack of equipment and the lack of experience. Commonly missed clinically significant injuries include: diaphragmatic, splenic, liver, duodenal, pancreatic, renal and colonic injuries. At this point if the patient is found to have splenic laceration it is graded according to the AAST splenic injury scale. This study conducted in the department of General Surgery at Dayanand Medical College and Hospital, reviewed the management and outcome of patients with diagnosis of splenic trauma diagnosed on CT scan or ultrasound abdomen.

The hemodynamically stable trauma patient with splenic injury identified on CT scan may be initially observed or undergo angiographic embolization as an adjunct to observational management. However, observational management requires adequate resources, and if unavailable, initial surgical management should be considered depending on the patient’s medical comorbidities.

Grade-V injuries with hemodynamic instability warrant an early surgical intervention. Indications for surgical exploration in the hemodynamically stable trauma patient with splenic injury who is being nonoperatively managed (i.e., observation with or without splenic embolization) include:

• • Signs of other intra-abdominal injury (e.g., free air, peritonitis) necessitating exploration.
• • Failure of nonoperative management.

METHODS

This prospective study was conducted over a period of 2 years, from January 2017 to December 2018, at Dayanand Medical College and Hospital, Ludhiana to include all patients presenting to the emergency department with splenic injury diagnosed on FAST/CECT abdomen. 60 cases were studied over this time-period after obtaining consent for inclusion to the study. After a detailed history and clinical examination, routine investigations including hemogram, RFT, amylase, lipase, chest X ray, FAST, ultrasound and CECT abdomen as indicated was done. After a thorough a work-up, American Association for Surgery in Trauma (AAST) grading scale was used to formulate a treatment plan. Patients were either managed conservatively or by surgical intervention. The results were recorded in a predesigned proforma and the statistics were analyzed to determine the outcome of splenic injury patients at DMCH, Ludhiana.

• • Time of surgery (if performed) after the trauma was noted along with the post op complications.
• • Stay of the patient in ICU or ward noted in days.

Outcome of the patient noted after 4 weeks of the trauma episode. Most of the operated patients had uneventful recovery. Diagnosis of the pathology was confirmed by histopathology reports.

Patients were asked to present themselves for follow up during at regular intervals. Relevant data was collected in specifically designed case sheets.

Statistical analysis was done by using descriptive and inferential statistics using Chi-square test and software used in the analysis were SPSS 17.0 version and graph pad prism 5.0 version and p<0.05 was considered as level of significance.

RESULTS

In this study, author used AAST splenic injury grading scale to define the grade of injury. Following is the distribution of various grades on injury in 60 patients that were a part of the study.

Majority of the patients (70%) sustained Grade II and Grade III injuries. In this study, splenectomy was required in all patients of Grade-5 injury. 2 patients with Grade-2 underwent exploratory laparotomy due to associated injuries. 86.7% of cases were managed conservatively. It was seen that average hospital stay for splenic trauma patient was 11.8 days with a mean 5 days ICU stay and 6.8 days stay in the ward.

Author noted that blood products were required in 50% of patients with splenic injury. 22 patients out 60 (42.3%) who required blood products were conservatively managed and all patients (13.3%) who underwent surgical intervention required blood products.

50 out of 60 patients (83.3%) were discharged in stable condition and 8 patients took discharge against medical advice. Mortality rate in this study was 3.3% (2 out of 60 patients).

DISCUSSION

Road traffic accident forms the single most important cause for splenic injury abdomen in this study. This assumes all the more significance because people involved in RTA are in their most active and productive phase of life. By the year 2020 road traffic accidents will be the second most important cause of death in developing nations. Prevention is better than cure. A 10% increase in speed translates into 40% rise in case fatality risk for the occupants of motor vehicle. Use of seat belts reduces the risk of death or serious injury for front seat occupants by 45%. Helmets reduce the risk of fatal head injury by about one-third and reduce the risk of facial injury by two thirds. Among persons who ride two wheelers. Avoiding alcohol before driving is an important preventive step. In the management of poly trauma patients, the steps in the ATLS philosophy should be followed.

• • Primary survey with simultaneous resuscitation of the patient.
• • Secondary survey to proceed and identify all other injuries.
• • Tertiary survey and definitive care of the injuries.

The steps in the primary survey are:

• • Airway with stabilization of cervical spine.
• • Breathing and oxygen supplementation.
• • Circulation and hemorrhage control.
• • Disability evaluation.
• • Exposure and complete examination.

In this study of 60 patients, who were admitted in triage ward, met with deceleration type motor vehicle accident, a driver with a driver’s side impact type motor vehicle accident or any patient with a direct blow to the left lower ribs or left upper quadrant of the abdomen.

There is no substitute to a thorough history and clinical examination to arrive to an early diagnosis. This can be augmented with the use of imaging investigations like FAST and CECT Abdomen to correctly grade the severity of injury. Using AAST injury scale can help in deciding the type of management that is required, along with better outcomes of patients.

Clinical examination has been found to be the corner stone for primary assessment of blunt abdominal trauma patients.⁹ In this study, author found abdominal distension and tenderness to be the most common positive findings in about 75% cases which was consistent with the existent literature.¹⁰

In this study the most common grades of splenic injury were Grade II and III (According to AAST grading system on CECT abdomen) comprising 70% of the patients. Savage and colleagues found that 80% of patients with lower-grade (AAST grades I-II) injuries showed complete healing of the spleen by post-injury day 50.¹¹ Among 13.3% (8 out of 60) of the patients were managed surgically. Majority of these (75%) were Grade-V injury, reinstating the fact that Grade-5 injury can have better outcome with an early surgical intervention. 2 out 60 cases underwent surgical exploration due to associated injuries to the mesentery, colon etc.

Roberto Cirocchi et al, in their study stated Non-Operative Management as the treatment of choice for grade I, II and III blunt splenic injuries. Splenectomy was the chosen technique in patients who met exclusion criteria for NOM, as well as for patients with grade IV and V injury.¹²

Among 86.7% cases in this study were managed conservatively, establishing the use of AAST Grade to define the management protocol. 83.3 % patients were discharged in stable condition and the mortality rate was only 3.3% as compared Pitcher et al, who reported an overall mortality rate of 10% about three decades.¹³ It is evident that with the advent of better imaging technology like FAST and CECT abdomen coupled with an efficient AAST injury scale, a surgeon can provide better outcomes to splenic injury patients.

CONCLUSION

Author conclude that early diagnosis and grading is paramount in determining the morbidity and mortality due to splenic injury. CECT abdomen is the most sensitive imaging modality in diagnosing splenic trauma. Surgical management is needed mostly in Grade V injuries while Grade I, II, III, IV injuries can be managed conservatively with close monitoring.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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