Non-Operative Management of Solid Organ Injuries Secondary to Blunt
Abdominal Trauma: JRRMMC Experience January – March 2015
Alain Neil Ancheta, MD
Introduction:
Early in the twentieth century, abdominal trauma was associated with high mortality and a low
threshold for laparotomy. A major change in the paradigm of the management of blunt abdominal
trauma was the introduction of non-operative management. High rate of operative complications
caused paradigm shift from operative to non-operative management in hemodynamically stable blunt
abdominal trauma patients. This coincided with the widespread availability of CT scans and the
introduction of angioembolisation as a common procedure for the management of solid organ injuries.
Repeated clinical examination supplemented with modern imaging and laboratory investigations play a
key role in reaching therapeutic decisions. Non-operative management can be safely practiced in a
Trauma Care Centre which has trauma surgeons, newer imaging modalities, high dependency unit
(HDU), ICU and other supporting services. In combination this shift has resulted in the reduction in the
morbidity associated with laparotomy.
Objectives:
-
To discuss the management of 5 cases of solid organ injury secondary to blunt abdominal injury
To discuss the demographics, history, and course in the wards of the cases
To discuss factors that terminate non-operative management
Methods:
This report will focus on the management of solid organ injuries in a tertiary hospital from January to
March 2015. Patients with blunt abdominal injury without solid organ injuries are excluded from this
report. There are a total of 5 patients admitted secondary to solid organ injury from blunt abdominal
trauma.
Results:
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Age
4
12
13
27
31
Sex
Female
Female
Male
Male
Male
Mechanism
Vehicular
Crash
Vehicular
Crash
Vehicular
Crash
Vehicular
Crash
Fall
Time from injury
until initiation of
Non-operative
management
1hr
1hr 30 mins
30mins
24hrs
9hrs
Initial vital signs
Normal
Normal
Normal
Normal
Normal
Initial abdominal
examination
Tender Right
Upper
quadrant and
epigastric area
Tender left
upper
quadrant
Tender left
upper
quadrant
Tender right
upper
quadrant
Tender left
upper and
left lower
quadrant
FAST
Hepatorenal
Hepatorenal
Hepatorenal
Hepatorenal
Hepatorenal
and
splenorenal
Liver injury
none
Grade II-III
none
Grade IV
none
Spleen injury
Grade II
none
Grade IV
(Intraop)
none
Grade II
Other injuries
Pneumothorax, Skull fracture, Diffuse
Right
Cerebral
Axonal Injury
Concussion
None
Radial Bone
Fracture
Factor(s)
terminating nonoperative
management
N/A
-Hypotension
N/A
N/A
-Increasing
heart rate
-Decreasing
blood
pressure
-Generalized
Peritonitis
-Decreasing
Hemoglobin
and
Hematocrit
count
Total time until
termination of nonoperative
management
N/A
N/A
6hrs
6 days
N/A
Total Transfusion
requirements
1 unit PRBC
None
3 units PRBC
10 units PRBC
None
13 units FWB
12 units PC
24 units FFP
OR done
None
None
Exploratory
Laparotomy,
Splenectomy
Damage
Control
Surgery
None
Feeding started
4th HD
3rd HD
5th POD
N/A
4th HD
Morbidity
None
None
Hospital
acquired
pneumonia
N/A
None
Outcome
Discharged
Discharged
Recuperrating Expired
Dischaged
Total Hospital Days
6 days
5 days
N/A
5 days
6 days
Discussion:
Jose R. Reyes Memorial Medical Center is a 300 bed capacity hospital that caters to the indigent
population of Metro Manila and all over Luzon. As the flagship hospital of DOH, it serves as one of the
referral centers for trauma in the region. Trauma facilities include a surgical emergency room, a
radiologic unit equipped with x-ray, ultrasound and Ct-scan, 4 emergency operating theaters and a 5 bed
capacity surgical ICU for some of the critically ill trauma patients. The hospital, however, is far from
perfect as monitoring equipment, advanced imaging and even man-power are still lacking. The hospital,
though, adopts up-to-date guidelines and it is particularly challenging to individualize treatment of
patients on available resources. The hospital still maintains as one of the best trauma centers in the
Philippines.
From January to March 2015, there are a total of 5 patients admitted due to solid organ injury
secondary to blunt abdominal trauma. Three males and two females, age ranges from 4yrs old to 31yrs
old with a mean age of 17yrs old. Modes of injuries are vehicular crashes (4/5) and fall (1/5).
Current clinical practice guideline for blunt abdominal injury in JRRMMC is a follows:
Stable Patient
Surgery
No
Yes
FAST
Positive
Negative
Observe; treat other
injuries
Normotensive
Hypotensive
CT scan with triple
contrast or DPL
Surgery
(+) CT scan for
hollow viscus organ,
(+) DPL (excluding
blood)
(-) DPL, (-)CT scan
for hollow viscus
organ injury
Surgery
Non-operative
management
Before going into the non-operative management, what are the risks and costs of directly operating on a
patient? Trauma literature describes a category of laparotomies that reveal no pathologic findings and
are termed ‘nontherapeutic’. Nontherapeutic laparotomy is also defined by some as a laparotomy for a
minor injury that, in retrospect, required no surgical treatment. Nontherapeutic laparotomies are
associated with significant morbidity and costs. The reported incidence of laparotomy or anesthesiarelated early complications varies between 8.6% and 25.6%. Both overall cost and hospital stay for
patients undergoing NTL are also significantly greater than for patients successfully managed
nonoperatively. In one study, the mean hospital charges for patients with abdominal gunshot wounds
successfully managed non-operatively were nearly $10,000 less than those for patients with
unnecessary operations. It is partly because of this experience that the trauma surgeon’s scope of
practice has shifted toward selective nonoperative management of an entire spectrum of injuries.
While starting non-operative management, certain principles have to be applied. The trauma surgeon
should maintain high index of clinical suspicion; Always keep the mechanism of injury in mind; Patient
should be examinable, with clear mental status; Patient should be hemodynamically stable, with no
obvious operative indications; Be cautious when committing to nonoperative management in multiply
injured patients ; Adequate healthcare team resources must be available (ability to perform frequent
physical exams, re-imaging, repeat laboratory); Appropriate setting for nonoperative observation is
available (observation ward, intensive care unit, monitored emergency department bed); Operative
management should be available and instituted promptly if indicated by signs/symptoms.
Upon arrival at the emergency room, time from injury to start of consult and/or non-operative
management range; 30mins,1hr, 1hr 30mins, 9hrs, 24hrs. Patients were examined, initial vital signs
taken, appropriate ancillaries and imaging requested and other injuries identified. Most of the samples
are polytrauma patients involving Neurosurgical service 2/5 (Skull fracture with cerebral concussion,
diffuse axonal injury), Orthopedic service 1/5 (radial bone fracture) and Thoracic service 1/5
(pneumothorax). Only 1 patient had an isolated blunt abdominal injury. All patients were FAST positive
requiring further investigation with CT-scan (4 out of 5). Solid organ injuries involved are liver 2/5 and
spleen 3/5. Liver injuries range from grade 3 and grade 4-5 while splenic injuries are grade 2, grade 2
and grade 4. These represent the most commonly injured solid organs after blunt abdominal trauma.
Overall success rates of non-operative management of above solid organ injuries are 80% and 80-90%
respectively. However factors such as age, increasing transfusion requirements, high injury grade,
physiological deterioration, worsening abdominal examination, multiple intrabdomoninal injuries,
unexplained fever or leukocytocsis, hollow viscous signs on CT abdomen are predictors of failure of nonoperative management. Non-operative management of the pediatric splenic injuries are generally
excellent as they have a low incidence of delayed bleeding. This is attributable to the relative thickness
of the splenic capsule, perhaps conferring more structural integrity. The spleen in children is more likely
to fracture parallel to the splenic arterial blood supply rather than transverse to it. Published literatures
have shown that radiological grade of severity of injury is not a contraindication for non-operative
management. However, severe solid organ injury may dramatically affect the success rate of nonoperative management. Data above shows, 2 out of 5 patients failed non-operative management, both
of them having Grade 4 solid organ injuries. Studies show success rates drop to 67% for grade IV and
25% for grade V splenic injuries. In another study 14% of grade IV and 22.6% of grade V liver injuries fail
non-operative management. This was substantially higher than the 3-7.5% failure rate of more minor
liver injuries.
Patient 3 had no progression of the abdominal status but had increasing heart rate and decreasing blood
pressure. On a patient with decreased neurologic status and deteriorating vital signs, a decision was
made to terminate non-operative management on the 6th hour. In a review by S. P. Stawicki, patients for
whom clinical examination is not reliable, special investigations can be crucial in early and accurate
triage. Lack of reliable physical examination may constitute a relative contraindication to non-operative
management of traumatic injuries in patients who fall into this ‘indeterminate’ zone. It would be
prudent to pay attention in changes in vital signs and examination findings; as such a clear indication for
laparotomy (generalized peritonitis or hypotension) may be seen too late. Intra-op findings showed 1
liter hemoperitoneum and a grade 4 splenic injury. The patient subsequently underwent splenectomy.
The patient was fed on the 5th post-op day via naso-gastric tube and is still recuperating from his head
injury.
Patient 4 was successfully managed non-operatively until on the 6th day, the patient presented with
generalized tenderness and hypotension, a sign of delayed hemorrhage. Delayed hemorrhage after nonoperative management is a feared complication. A study suggested an overall incidence of 0-14%
without angioembolization. The patient underwent damage control surgery but eventually expired due
to multi-organ failure. In retrospect an alternative to surgical management in this setting would have
been angioembolization. In one study of hemodynamically unstable high grade solid organ injury
patients a survival rate of 86% after angioembolization and resucitative endovascular balloon occlusion
of the aorta was reported.
All of the lower grade solid organ injuries (3/3) were successfully managed non-operatively. Up to this
day, there are no clear guidelines enumerating the end-points of non-operative management. In our
setting, feeding was started when patient had no complaints of abdominal pain, vital signs were stable,
non-tender abdomen on palpation and when there is no proximate indication for immediate operation.
It would be safe to make tolerance of feeding as one of the end-points of safely discharging a patient
from ICU or the ward. As above all patients (3/3) who were managed non-operatively and tolerated
feeding were discharged successfully without complications. Overall, patients managed non-operatively
had lesser transfusion requirements, resumed feeding earlier, had no reported morbidities, and had
shorter hospital stay. However, caution must be used in interpreting these results as the patients who
failed non-operative management had more severe illnesses.
Conclusion:
Non-operative management of grades I-III liver and spleen injuries can be safely practiced in our setting.
However care must be taken in managing higher grades, with vigilant monitoring and more frequent
reassessments. It is better to bring the patient in the OR while normotensive if angioembolization is not
available.