1. The use of a computed tomography (CT)-based splenic injury grading system was superior to clinical evaluation for determining the need for procedural intervention in hemodynamically-stable patients with blunt splenic injury.
2. The combination of the CT-based grading system and the abdominal Abbreviated Injury Severity Score provided the strongest predictive value for the need for intervention in blunt splenic injury.
Evidence Rating Level: 3 (Average)
Study Rundown: The management of hemodynamically-stable patients with blunt splenic injury ranges from conservative observation to splenectomy or splenic artery embolization (SAE). The choice of how to management different patients is guided by the use of clinical parameters in conjunction with imaging findings on multi-detector computed tomography (CT) scans and splenic arteriography. Despite this, there are currently no accepted criteria that define which patients should undergo surgical management versus medical management, and thus this decision is left to individual clinicians. The purpose of the present study was to evaluate the utility of a multi-detector computed tomography (CT) grading system in the determination of appropriate treatment for hemodynamically-stable patients with blunt splenic injury. CT images from patients suspected of a blunt splenic injury were retrospectively evaluated, triaged to observation or intervention based on the imaging results, and correlated with final clinical outcomes. The authors demonstrated that patients triaged to observation based on CT grading did not require further surgical treatment of their blunt splenic injury. Furthermore, the use of the CT grading system alone demonstrated significantly higher predictive power for the need for surgical intervention than traditional clinical parameters. The combination of both CT grading and the Abbreviated Injury Severity Score (AISS) demonstrated the strongest ability to predict accurate triage to non-surgical interventions. The primary limitation of this study was the retrospective, single-institution methodology. Future prospective trials are required to validate these results within patient cohorts in multiple centers to determine the utility in predicting the need for surgical intervention for these patients.
In-Depth [retrospective cohort]: This study retrospectively analyzed the CT images of 171 consecutive hemodynamically-stable trauma patients admitted with blunt splenic injury from January 2009 to July 2011. Each patient was triaged to either observation or operative management based on a CT-based splenic injury grading system. Final clinical outcome was confirmed by either splenic arteriograms, surgical pathology, or last known clinic follow-up. Overall, 50% (85/171) of patients underwent observation. Within the observation cohort, only 6 patients (3.5%) required splenectomy and 4 patients required SAE. The area under the receiver operating characteristic (ROC) curve of the CT-based splenic injury grading system for successful observation versus splenic intervention was 0.947 (CI95: 0.89-0.97), indicating a very strong correlation between CT-based triage and the need for procedural intervention. This was significantly higher than all other clinical parameters measured within this study, such as vital signs and laboratory data. Step-wise logistical regression analysis demonstrated that the combination of the CT-based splenic injury grading system and the abdominal AISS were the best combination for prediction of successful observation versus need for splenic intervention (AUC: 0.97; P=0.02). Among those that required intervention, CT-based triage was less accurate at predicting treatment modality (surgery versus SAE) than mean arterial pressure or abdominal AISS.
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Image: CC Liz West, Wikimedia Commons
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