Initial nonoperative management of splenic injury is standard in hemodynamically stable patients. Over the past decade, the success rates have climbed by adding angioembolization to the algorithm, according to several published series. However, the objective benefit and specific indications have not been worked out.
A paper published this month by the University of Florida, Jacksonville used the NTRACS registry to try to clarify these issues. They identified 1039 patients undergoing nonoperative management (NOM) over a nearly 10 year period. Patients who died shortly after arrival, those who went directly to OR for hemodynamic reasons, and children were excluded, leaving 539 patients. Only about 1/6 of the patients underwent embolization.
The overall failure rate was about 4%, a little higher in the non-angio patients, a little lower with angio. Incidentally, the angio group had significantly higher injury severity (26 vs 20). Analysis of the lower grade spleen injury group showed no improvement in success rate by adding angio. However, the high grade groups (grades IV-V) did benefit by adding this procedure. Similarly, success improved when performing angio in patients with contrast blush or evidence of slow, ongoing bleeding. If NOM did fail, it usually occurred on day 2.
Bottom line: Although we’ve been adding angio to non-operative management of spleen and liver injury for a decade, here’s the first paper that has been able to define the real indications for doing it. First, all unstable patients go to the OR (don’t even consider nonop management). In the remaining patients, if the CT shows a grade IV or V injury, or a contrast blush, angio is recommended. If neither of these is noted, but the hemoglobin continues to decline “too quickly” (surgeon judgement), then a trip to angio is also warranted. Applying these principles can increase your success rate to about 96%.
Lateral Canthotomy For Orbital Compartment Syndrome
I’ve previously written about the orbital compartment syndrome and described the symptoms in the awake patient. I’d like to share a video of the procedure and provide a tip for diagnosing it in unconscious patients.
Patients at risk will have obvious facial trauma. During your physical exam, look for proptosis. This is caused by swelling or hemorrhage behind the globe pushing it forward. It may manifest itself as uneven opening of the eyelids, with the affected side being “propped” open (get it?). But in trauma, there may be significant edema which keeps the lid closed.
The easiest way to observe proptosis is to stand above the patients head, looking toward their feet. Crouch down so you can look across the lids in a direction horizontal to the floor. You should easily be able to detect if one eye protrudes further that the other.
You can also do a poor man’s compartment pressure test by gently using your thumbs to compress both globes simultaneously. If there is substantial difference in resistance between the two sides, a compartment syndrome may be present. Important note! Do a thorough globe exam first! If there is any evidence of globe rupture (hyphema, irregular pupil, extra tissue in the anterior compartment), don’t press the eye or perform a canthotomy. CT scan of the facial bones can help confirm the diagnosis if a mass effect is seen in the orbit or if the optic nerve appears to be on stretch.
The orbital compartment syndrome is an emergency! Once diagnosed, immediately proceed to canthotomy. Otherwise, damage to the optic nerve and retina is likely, and the patient may become blind in the affected eye.
We see seat belt signs at our trauma center with some regularity. There are plenty of papers out there that detail the injuries that occur and the need for a low threshold for surgically exploring these patients. I have not been able to find specific management guidelines, and want to share some tidbits I have learned over the years. Yes, this is based on anecdotal experience, but it’s the best we have right now.
Tips for surgeons:
Common injuries involve the terminal ileum, proximal jejunum, and sigmoid colon. My observation is that location in the car is associated with the injury location, probably because of the location of the seat belt buckle. In the US, drivers buckle on the right, and I’ve seen more terminal ileum and buckethandle injuries in this group. Front seat passengers buckle on the left, and I tend to see proximal jejunum and sigmoid injuries more often in them.
Seat belt sign on physical exam requires abdominal CT for evaluation, regardless of age. The high incidence of significant injury mandates this test.
Seat belt sign plus any anomaly on CT requires evaluation in the OR. The only exception would be a patient with minimal fluid only in the pelvis with an unremarkable abdominal exam. But I would watch them like a hawk.
In patients who cannot be examined clinically (e.g. severe TBI), a rising WBC count or lactate beginning on day 2 after adequate resuscitation should prompt a trip to the OR. This is an indirect method for detecting injured bowel or mesentery.
Laparoscopy may be used in patients with equivocal findings. Excessive blood, bile tinged fluid, succus, or lots of fibrin deposits on the bowel should prompt conversion to laparotomy. Tip: place all ports distant to the seat belt mark. The soft tissues are frequently disrupted, and gas may leak into this pocket prohibiting good insufflation of the peritoneal cavity.
If in doubt, open the abdomen. It’s bad form to put in the scope, see something odd, and walk away. Remember, any abnormal finding after trauma is related to trauma until proven otherwise. It’s almost never pre-existing disease.
Over the past year, I’ve written about bleeding problems in trauma patients caused or exacerbated by the various anticoagulants now on the market. The field of available drugs keeps growing, and the number of ways to keep blood in liquid form is increasing.
Here’s a link to a set of guidelines for approaching and treating patients who are taking these medications and then develop problematic bleeding. There are few good studies that have actually analyzed the efficacy of these methods, but it’s what we have to work with now.
If you have any additional maneuvers that you think should be included, please comment or email. And feel free to implement some studies to find the real best practices.