M. Day1, D. Marsh1, J. Wu1, A. Maleson1, J. Vosswinkel1, E. Huang1, R. Jawa1 1Stony Brook University Medical Center,Stony Brook, NY, USA
Introduction:
Splenic injury is a common sequela of blunt trauma. With increasing emphasis on non-operative management (NOM) and splenic artery embolization (SAE) over splenic surgery as treatment, we sought to evaluate the management strategies at a suburban ASC level 1 trauma center.
Methods:
The trauma registry was reviewed for blunt trauma admissions (age ≥ 18 years) with splenic injury between 1/2009 and 9/2018. ED deaths, penetrating trauma, and burns were excluded. Chart review was also performed for SAE and splenic surgery patients.
Results:
There were 426 blunt splenic trauma patients meeting study criteria. Patients underwent splenic surgery (n=113: 108 splenectomy, 5 splenorrhaphy), SAE (n=45), or NOM (n=268) for their splenic injury. The most common mechanism of injury in all groups was motor vehicle collisions (46.9% splenic surgery, 48.9% SAE, and 47.4% NOM patients), followed by motorcycle crashes in the splenic surgery group and falls in the SAE and NOM groups. Median age was similar amongst groups (42 years splenic surgery, 50 years SAE, and 40 years NOM).
Splenic surgery patients, as compared to SAE and NOM patients, had the lowest median admission systolic blood pressure (SBP, 105.0 mmHg vs. 114.0 mmHg SAE vs. 124.5 mmHg NOM, p<0.001) and highest median Injury Severity Score (ISS, 34.0 vs. 22.0 SAE vs. 17.0 NOM, p<0.001). Additionally, surgery patients had the highest median spleen AIS score (4.0 [IQR 3-5] vs 3.0 [IQR 3-3] SAE vs. 2.0 [IQR 2-2] NOM, p<0.05).
For all blunt splenic trauma patients, median spleen AIS was 3 [IQR 2-4] in 2009 and 3 [IQR 2-3] in 2018. Temporal trends demonstrated a general increase in SAE rates from 3.0% in 2009 to 19.0% in 2018, while splenic surgery rates generally decreased from 39.4% in 2009 to 26.9% in 2018. NOM decreased from 57.6% in 2009 to 40.0% in 2018.
With regards to outcomes, surgery patients had significantly higher mortality rates than those with NOM or SAE (14.2% in surgery, 7.1% in NOM, 2.2% in SAE, p<0.05). However, the groups had similar discharge to home and discharge to rehabilitation rates. The 30-day readmission rate for splenic surgery patients was 8.8% and was similar to those who underwent NOM or SAE.
Conclusion:
Splenic surgery patients had the lowest admission SBP, highest spleen AIS, and highest Injury Severity Scores, yet they had comparable discharge to home and readmission rates to NOM and SAE patients. Mortality rates were expectedly higher than the other groups. Splenectomy was necessary in 3 cases after failed SAE. The steady increase in SAE with similar to slightly lower spleen AIS over time raises an interesting question: are we being too aggressive?
