Angioembolization has become a common procedure that can increase the likelihood of success for nonoperative management for splenic trauma. It does have its own set of complications to be aware of, however.
The most obvious complication is mechanical injury to the femoral artery. This occurs in 1 to 3% of patients. It is more common in the very young (small caliber artery) and the elderly (arteries of stone). Rarely, the substance or device that is used for the embolization may migrate or end up on the wrong spot, infarcting something important.
A common issue that occurs is infarction of portions of the spleen. This is actually the desired effect, as it stops the bleeding. Most of the time, we are unaware of the changes that take place in the spleen post-procedure. But every once in a while we get a repeat CT scan days or weeks down the road and see some very interesting things.
The most common finding is a splenic infarct alone. This is an area of the spleen, sometimes wedge shaped, that does not take up contrast. This is normal. In some cases, gas bubbles are seen within the spleen parenchyma, usually within the infarcted area. In others, large areas of gas are present, and an air-fluid level may also be seen. This is definitely not normal.
Note the infarcted area at the arrow, with a tiny gas bubble visible.
Tiny bubbles are normal after this procedure, and can be ignored if the patient does not appear ill and does not have any systemic evidence of inflammation or sepsis. On the other hand, big bubbles or air-fluid levels probably indicate a developing splenic abscess, and the patient will usually appear ill and have a high WBC count. Unfortunately, the only treatment for this is splenectomy. Insertion of drainage catheters does not work and the patient will only become sicker if it is attempted.
Interventional radiology (IR) can be a very helpful adjunct to the evaluation and management of trauma patients. I’m going to talk specifically about using it for blunt trauma today because the use in penetrating trauma can be a little more nuanced.
For blunt trauma, IR is used primarily to stop bleeding. In a smaller subset of patients, this tool is used to evaluate pulse deficits. There are two basic principles that apply in either case, and I’ve wrapped them up into a single concept: the 30:60 rule for interventional radiology.
Of course, the second law of trauma still applies: hypotensive patients cannot leave the ED to go anywhere but the OR. Once you make sure you are not violating that one, you can start the process of going to IR.
The two portions of the rule are times: the time for the IR team to arrive to start the evaluation, and the maximum time allowed for them to succeed, hence the 30:60 numbers.
The maximum acceptable time for the patient to wait until the IR team is ready for them is typically 30 minutes. US trauma center verification requires a reasonable arrival time frame, and the vast majority of hospitals have a 30 minute expectation if the team is not already in place. This response time needs to be monitored by the trauma performance improvement program (PI) and addressed if it ever exceeds the limit.
The second number is the maximum time the radiologist is given to be successful. Like other physicians, radiologists like to do a good job and finish the work they start. If they find a particularly tortuous splenic artery to navigate, they will persist at trying to get through it in order to do a selective embolization and kill the smallest piece of spleen possible. Unfortunately, this takes time and radiation (lots). And a bleeding patient is running out of time.
The good thing is that there are surgical alternatives to most of the tasks the radiologist is working on. True, some are much more difficult surgically, like managing a shattered liver or dealing with a bleeding pelvis. In those cases, I may let the interventionalist work a little longer while I keep up with blood transfusions and monitor patient status.
- Expect a 30 minute response time from the IR team
- Let the radiologist know they have about 60 minutes to succeed. If it looks like they can’t make that, have them go to plan B (e.g. main splenic artery embolization instead of selective)
- Make sure an experienced trauma physician is watching the patient for decompensation and is managing fluids and blood products (no pressors!)
- If the patient decompensates at any point, they are done in IR and must proceed to OR
The March issue of TraumaMedEd is ready to go! This issue is devoted to protocols.
Included are protocols for:
- Anticoagulation reversal
- TBI screening
- Chest tube management
- Solid organ injury management
- And more!
Be sure to have a good QR code reader for easy retrieval. Otherwise, warm up your fingers so you can enter URLs to download the protocols.
Subscribers will get the issue delivered Saturday. It will be available to everybody on the Tuesday blog post.
Check out back issues, and subscribe now! Get it first by clicking here!
Everywhere you turn in the trauma and EMS world, you run into the concept of the “golden hour.” Basically, it refers to the idea that it’s important to get an injured patient to definitive care promptly, or mortality begins to rise. It has been used to justify a lot of what we do in trauma care and trauma systems. But where did this come from? And is it true?
The BTLS course attributes the term to R Adams Cowley from the ShockTrauma Center in Baltimore. Unfortunately, no references are given. A biography of Cowley entitled Shock-Trauma names him the author of the term, basing it on dog research. No references were given.
A review of Cowley’s research reveals a few tidbits. A case series of patients implies that speed is good, but does not analyze time to definitive care. It does reference older work by other authors, but once again, no relationship between timing and outcome is evaluated.
A textbook edited by Cowley contains a reference to an article about “Cowley’s golden hour.” This article contains a statement that “patients are assumed to be dying and much of the golden hour has passed.” It goes on to state that the first 60 minutes after injury determines the patient’s mortality. It, in turn, refers to another of his earlier articles. This one states that “the first hour after injury will largely determine a critically injured person’s chance for survival.” No data or reference is given.
Bottom line: The concept of the “golden hour” has taken on a life of its own. Yes, it’s a good idea. And yes, there is some actual data to support it, although the quality is somewhat lacking. But this does point out the need to question everything, even some of our most deeply held beliefs. They are not always what they seem to be.
Reference: The Golden Hour: scientific fact or medical urban legend? Acad Emerg Med 8(7):758-760, 2001.
Sadly, Rick Frykberg passed away yesterday morning at the age of 63. He was the Chief of the Division of General Surgery at the University of Florida and Shands Hospital in Jacksonville, Florida. Rick was a Professor of Surgery and was a great educator and clinician. He did his internship at NYU Medical Center in New York, and completed his residency at the Medical University of South Carolina. From there he became a staff surgeon at the US Naval Hospital in Jacksonville. He then joined the faculty at the University Medical Center and stayed there for the rest of his career.
Rick was very active in the trauma community and was a member of AAST and EAST. He joined both organizations in 1988 (!), and was elected to the board of directors of EAST in 1996. From there he moved up and was elected president of the EAST in 2001. Rick generated a robust body of research, with much of it focused on the area he became known for, vascular injury. He also had interested in disaster medicine and breast surgery.
Rick will be missed by his family, colleagues, and trainees.