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Friday
Mar232012

Blunt Abdominal Trauma Part 1 - The Grading of Splenic Injuries

from trauma.org

The spleen is the most commonly injured solid organ in abdominal trauma. Below, is the traditional grading system as described by Moore et al, from the Journal of Trauma 1995 - Organ Injury Scaling: Spleen & Liver (Published almost exactly 17 years ago this month!). 

In the haemodynamically unstable patient (noting associated injuries), with a splenic injury, the decision is simple, - embolization or laparotomy & splenctomy. But what about the rest? Can the traditional grading system accurately predict where non-operative management is likely to be successful?

Typically, grade 1-3 injuries are managed non-operatively, whilst grade 4 and above are managed operatively.

The problem with this grading system, is that it doesn't take into acount the appearance of contrast extravasation on CT, which leads to a higher rate of failed non-operative management. It also tends to underestimate the extent of injury. 

In a study published online in the European Journal of Trauma and Emergency Surgery, the authors conducted a retrospective study to compare the accuracy of traditional CT grading with pathological findings :

Background  

Computed tomography (CT) is the standard for grading blunt splenic injuries, but the true accuracy, especially for grade IV or V injuries as compared to pathological findings, is unknown.

Study design  

A retrospective study from 2005 to 2011 was undertaken.

Results  

There were 214 adults admitted with blunt splenic injury and 170 (79%) were managed nonoperatively. The remaining 44 patients (21%) required surgical intervention. There was a significant difference in the Injury Severity Score (ISS) between those who did and those who did not require splenectomy: median 31 (interquartile [IQ] range 11–51) versus 22 (IQ range 9–35, p = 0.0002). Ten patients presented in shock, had a positive ultrasound, and went to surgery. The remaining 34 had CT scans prior to surgery. Twenty-five (73%) had injury grades IV or V. The CT scan correctly graded the injury in 14 (41%) and was incorrect in 20 (59%). The assigned grade by the CT scan underestimated the true injury grade by one grade in six cases (30%), by two or more grades in nine (45%), and the CT images were obscured by blood and deemed “ungradeable” in five (25%). The CT scan was more accurate for grades I and II (100%) than for grades III–V (25–43%). The reasons for inaccuracy were either inability to visualize that the laceration involved the hilar vessels or excessive perisplenic blood which obscured the injury and/or the hilum.

Conclusions  

CT for splenic injury is accurate for grades I and II, but underestimates the true extent of injury for grades III–V. The reasons for the lack of correlation are the inability to determine hilar involvement and excessive perisplenic blood obscuring the injury. Patients with these image characteristics by CT scan should undergo splenectomy earlier if there are any signs of hemodynamic instability.

The grading system below was put forward by Marmery et al in Baltimore in 2007, published in the AJR, which includes vascular injury in the grading. They found that this system performs better than the original AAST grading system (see above) in predicting which patients with blunt splenic trauma need arteriography or splenic intervention. 
As with any grading system or predictive tool, it is of limited value without clinical correlation.
                                                                       

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    Response: グッチ 財布
    salvatore ferragamo

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