Vol 39 # 2 June 2007 - Kma.org.kw

June 2007KUWAIT MEDICAL JOURNAL 145Fig. 1: Algorithmic approch to Blunt Splenic TraumaTable 1: ASST* splenic organ injury scaleCLASS ICLASS IICLASS IIICLASS IVCLASS VHematoma subcapsular < 10% surface area lacerationcapsular tear < 1 cm parenchymal depthHematoma subcapsular 10 - 50% surface areaIntraparenchymal < 5 cm diameterLaceration 1 - 3 cm parenchymal depth not involving aparenchymal vesselHematoma subcapsular > 50% surface area or expandingRuptured subcapsular or parenchymal hematomaIntraparenchymal hematoma > 5 cmLaceration > 3 cm parenchymal depth or involvingtrabecular vesselsLaceration of segmental or hilar vessels producing majordevascularization (> 25% of spleen)Laceration completely shattered spleenHilar laceration injury which devascularized spleen* American Society for the Surgery of Traumaimaging investigations, associated injuries, bloodtransfusion, complications, treatment and surgicalprocedures, morbidity, mortality and hospital stay.The patients were divided into two groups; theoperative management group included patientswho were hemodynamically unstable and requiredexploratory laparotomy. The surgical procedureswere either splenectomy, splenorrhaphy or partials p l e n e c t o m . y The NOM was applied inhemodynamically stable patients on presentationor who were hypotensive and stabilized withminimal intravenous fluids in emergency room.The patients with blunt splenic trauma weremanaged according to the algorithm shown in Fig.1. The diagnosis of intraperitoneal hemorrhage wasconfirmed by diagnostic peritoneal lavage (DPL) orpositive abdominal ultrasonogram (USG) for freeintraperitoneal fluids in hemodynamically unstablepatients. The imaging modalities employed forh e m o d y n a m i c a l l ystable patients were abdominalultrasonogram and CT scan of the abdomen. Thesplenic injuries were classified according to thesplenic injury scale of the American Society for theSurgery of Trauma (ASST) (Table 1). Patients withhigh class injuries were admitted to the IntensiveCare Unit (ICU) for close monitoring for the first 48hours with serial clinical examinations andhemoglobin checkup. Patients with isolated splenicminor injuries were observed in the surgical wardwith close monitoring. Patients were kept on bedrest for 5-7 days. The failure of NOM wasc o n s i d e red when the patient became hemodynamicallyunstable during observation or required more thantwo units of blood transfusion for splenic injury.They underwent exploratory laparo t o m y. Theoutcome of both groups was compared withemphasis on the patients’ age, class of injuries,numbers of blood transfusion, morbidity, mortalityand hospital stay. Statistical analysis was carriedout employing exact Fisher test, Chi-square test,and analysis of variance for comparative analysis ofthe data using IBM-compatible PC and SPSS 10.0for Windows (SPSS Inc., Chicago).RESULTSA total of 83 patients with splenic injuries due toblunt abdominal trauma were treated at the RiyadhMedical Complex over the five year period underreview. There were 72 men and 11 women. Themean age was 23.5 years (range 4-63 years). Themechanisms of injury were as follows: motorvehicle accident in 60 patients, fall from height in 13and sport injuries in 10 patients.Thirty five patients were hemodynamicallyunstable and underwent exploratory laparotomy(operative management group) due to ongoingbleeding from the injured spleen. The remaining 48patients were hemodynamically stable and wereselected for NOM.Thirty five patients underwent exploratoryl a p a rotomy due to ongoing intraperitonealhemorrhage. There were 30 male and 5 femalepatients. The mean age was 24 years (4 - 63 years).Seven patients were less than 13 years of age. Allpatients presented to emergency room withhypovolemic shock. DPL was performed in 30patients and was positive. The other five patientsunderwent USG which showed free intraperitonealfluid. The associated injuries were as follow:thoracic injuries in 18, extremities injuries in 11,head injuries in nine, spinal injuries in two, andpelvic injury in two patients. The associated intraabdominalinjuries were liver in seven,retroperitoneal hematoma in five, mesenteric tearin four, renal injuries in two, duodenum in one,diaphragm in one, and pancreas in one patient. Theclass of splenic injuries were low and moderate in