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To nearly come full circle: Nonoperative management of high-grade IV–V blunt splenic trauma is safe using a protocol with routine angioembolization

Bhullar, Indermeet S. MD; Tepas, Joseph J. III MD; Siragusa, Daniel MD; Loper, Todd MD; Kerwin, Andrew MD; Frykberg, Eric R. MD[LATIN CROSS]

Journal of Trauma and Acute Care Surgery: April 2017 - Volume 82 - Issue 4 - p 657–664
doi: 10.1097/TA.0000000000001366
AAST Plenary Papers

Introduction: Nonoperative management (NOM) of hemodynamically stable high-grade (IV–V) blunt splenic trauma remains controversial given the high failure rates (19%) that persist despite angioembolization (AE) protocols. The NOM protocol was modified in 2011 to include mandatory AE of all grade (IV–V) injuries without contrast blush (CB) along with selective AE of grade (I–V) with CB. The purpose of this study was to determine if this new AE (NAE) protocol significantly lowered the failure rates for grade (IV–V) injuries allowing for safe observation without surgery and if the exclusion of grade III injuries allowed for the prevention of unnecessary angiograms without affecting the overall failure rates.

Methods: The records of patients with blunt splenic trauma from January 2000 to October 2014 at a Level I trauma center were retrospectively reviewed. Patients were divided into two groups and failure of NOM (FNOM) rates compared: NAE protocol (2011–2014) with mandatory AE for all grade (IV–V) injuries without CB and selective AE for grade (I–V) with CB versus old AE (OAE) protocol (2000–2010) with selective AE for grade (I–V) with CB.

Results: Seven hundred twelve patients underwent NOM with 522 (73%) in the OAE group and 190 (27%) in the NAE group. Evolving from the OAE to the NAE strategy resulted in a significantly lower FNOM rate for the overall group (grade I–V) (OAE vs. NAE, 4% to 1%, p = 0.04) and the grade (IV–V) group (OAE vs. NAE, 19% vs. 3%, p = 0.01). Angiograms were avoided in 113 grade (I–III) injuries with no CB; these patients had NOM with observation alone and none failed.

Conclusions: A protocol using mandatory AE of all high-grade (IV–V) injuries without CB and selective AE of grade (I–V) with CB may provide for optimum salvage with safe NOM of the high-grade injuries (IV–V) and limited unnecessary angiograms.

LEVEL OF EVIDENCE: Therapeutic study, level IV.

From the Orlando Regional Medical Center (I.S.B.), Orlando, Florida; Division of Pediatric Surgery (J.T.P.), University of Florida College of Medicine-Jacksonville, Jacksonville, Florida; Division of Vascular and Interventional Radiology (D.S.), University of Florida College of Medicine, Jacksonville, Florida; Division of Vascular and Interventional Radiology (T.L.), University of Florida College of Medicine, Jacksonville, Florida; University of Florida College of Medicine (A.K.), Jacksonville, Florida; and University of Florida College of Medicine (E.R.F.), Jacksonville, Florida.

Submitted: September 4, 2015, Revised: October 24, 2016, Accepted: October 24, 2016, Published online: January 18, 2017.

[LATIN CROSS]Deceased 25 March 2013. This study was presented at the 74th annual meeting of the American Association for the Surgery of Trauma held in Las Vegas, Nevada, September 9–12, 2015.

Address for reprints: Indermeet S. Bhullar, MD, FACS, Acute Care Surgery Fellowship Orlando Regional Medical Center, 2nd Floor, Suite 201, 86W Underwood St, Orlando, FL 32806; email: Indermeet.bhullar@orlandohealth.com.

© 2017 Lippincott Williams & Wilkins, Inc.