Arizona Trauma and Acute Care Consortium

1
Arizona Trauma and Acute Care Consortium
NONOPERATIVE MANAGEMENT OF SOLID ORGAN INJURIES
SELECT UPDATES

• Chris Salvino, MD, MS, MS, MT, FACS
• Trauma Director
• John C Lincoln Hospital

2
AGENDASelect Topics
3
EVALUATION
Throughout this presentation non-operative
management (NOM) of blunt solid organ injuries is
based on stability and CT scan evaluation
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SPLEEN
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HISTORY

• 1900s
• 100 Mortality with NOM
• Splenectomy treatment of choice
• 1952
• Five cases of fatal infections in infants
  following splenectomy
• Start of NOM
• Modern impetus for attempting NOM was concern for
  infection

King H, Shumacker HB Splenic Studies.
Susceptibility to Infection After Splenectomy
Performed in Infancy. Ann Surg 136 239,1952
6
IMMUNOLOGY

• Function
• Filter
• Antigens, bacteria old RBCs
• Regulation
• Helper/suppressor T-cell ratios
• Produces host defense proteins
• Immunoglobulin M
• Antibodies produced by lymphocytes sequestered in
  the spleen that respond to antigens
• Tuftsin
• Tetra-peptide that stimulates phagocytes to
  destroy pathogens

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IMMUNOLOGY

• Partial rationale for NOM
• Overwhelming Post-Splenectomy Infection (OPSI)
  from encapsulated bacteria (S pneumoniae, N
  meningitidis, H influenzae)
• Rare
• Younger people with higher risk
• Risk greatest 1st year after splenectomy
• Risk of death based on population studies
• 0.03-0.02 adults
• 0.6--0.3 peds
• Vaccine
• Reduce OPSI
• Risk for early post-operative complications
• i.e., pneumonia, sub-phrenic abscess others
• Immunology plays part of a role in the decision
  to attempt NOM but definitely not the sole role

Willis BK, Deitch EA The Influence of Trauma
to the Spleen on Post-Operative Complications and
Mortality. J Trauma 261074,1986
8
GRADING SCALE Spleen
Grading scale proposed by AAST from Moore EE,
Cogbill TH, et al Organ Injury Scaling Spleen
Liver . J Trauma 381995
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DEDICATED STUDY 1
Early study (1989). Success of non-operative
management retrospective review from 6
institutions with 832 blunt splenic injuries.
14 (112) were treated with NOM. Indications for
NOM vs. OM stability?

• Findings
• Conclusions
• Some study limitations
• Success of NOM in stable Grade I-III
• 98 Children
• 83 Adults

Cogbill TH, Moore EE, et al Non-Operative
Management of Blunt Splenic Trauma A
Multi-Center Experience. J Trauma 291312, 1989
10
DEDICATED STUDY 2
Prospective study of 190 adult trauma patients
with splenic injuries. 102 stable patients
underwent 3-5 days of bed rest regardless of
grade

• Findings
• Of the 102 initially stable patients
• 2 Required subsequent laparotomy
• 15 Required blood transfusions
• 0 Mortality rate
• Of the 190 total patients
• Infection rate
• 31.9 In survivors with splenectomy
• 3.2 In survivors who had splenic repair
• 0.0 In NOM
• Transfusion rate
• 0.8 Average units for NOM
• 6.0 Average units for splenectomy patients
• Conclusions
• If stable, a very high NOM rate should be seen
• Splenectomy had a markedly higher infection and
  transfusion rate over NOM
• Splenectomy had a markedly higher infection rate
  over splenic repair patients

Pachter HL, Guth AA, et al Changing Patterns in
the Management of Splenic Trauma The impact of
Non-Operative Management. Ann Surge 227708, 1998
11
DEDICATED STUDY 3
35,767 Patients with splenic injuries identified
in the ACS National Trauma Data Bank 1994-03.
92.5 Blunt 85.6 underwent NOM

• Findings
• gt 18 years old 81.8 underwent successful NOM
  (blunt penetrating combined)
• lt 18 years old 91.8 underwent successful NOM
  (blunt penetrating combined)
• The usage of NOM increased 140 from 1994-2003
• AIS and successful NOM
• II 68.0
• III 63.2
• IV 59.9
• V 60.7
• The odds for sucessful NOM were somewhat lower
• Increased age
• Increased initial systolic BP in the ED
• Increased ISS
• Conclusions
• NOM increased significantly over the 10 years
• Success rate of NOM
• High in general
• Slight decrease with increasing grade as well as
  ISS, age and initial high ED SBP

Hurtuk M, Reed R, et al Trauma Surgeons Practice
What They Preach The NTDB Story on Solid Organ
Injury Management. J Trauma 61243-255, 2006
12
DEDICATED STUDY 4
92 Children (average age 8.4 yrs) were evaluated.
53 Underwent NOM 6 G I, 21G II, 24 G III, 2 G
IV. All patients had serial HCT until stable. CT
scan follow-up at day 5-7

• Findings
• 100 Successful NOM
• All CT scans showed healing
• LOS 7 days
• HCT stabilized PID 2 in non-transfused
  patients
• Transfused patients
• G II mixed with multiple injuries data not
  meaningful
• G III 12.5 required (9.7 ml/kg) in first 2
  days only
• Conclusions in children
• No benefit to ICU
• HCT checks after 2 days not normally helpful
• Most could have been discharged POD 3
• CT scan follow-up was not useful

Lynch JM, Ford H, et al Is Early Discharge
Following Isolated Splenic Injury in the
Hemodynamically Stable Child Possible? J
Pediatric Surg. 281403, 1993
13
DEDICATED STUDY 5
108 Patients with splenic injuries 73 (68) NOM.
Routine (not clinically indicated) follow-up CT
scans were performed on many (not all) of the
patients. 2 G I, 29 G II, 27 G III, 15 G IV, 0 G
V

• Findings
• Children 88 successful NOM
• Adults 92 successful NOM
• 2 of Routine CT scans actually changed
  management
• 16 Scans performed lt 10 days
• 1 Changed management pseudoaneurysm G IV with
  subsequent angiographic embolization
• 33 Scans performed gt 10 days
• No changes
• Conclusions
• Routine CT scan follow-up is not necessary in
  most patients undergoing NOM
• A subset of patients may benefit from routine CT
  scans such as higher grades (IV) or initial CT
  scan blush

Bradley TC, Gogbill TH, et al Non-Operative
Management of Splenic Injury Are Follow-up CT
Scans of Any Value? J Trauma 43748, 1997
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DEDICATED STUDY 6
Retrospective review of Washington State Trauma
Registry. 1633 Patients with splenic injury
underwent planned NOM. Grades not reported.
Which presenting sings/symptoms can predict
failure of NOM?

• Findings
• 15 Failed NOM
• Increased risk of failure of NOM
• gt 55 years
• gt 25 ISS
• Level III/IV gt Level I/II
• No change in risk of failure of NOM
• GCS
• Associated injuries
• Presenting hemodynamics
• Conclusions
• Age gt 55, ISS gt 25 and admission to a Level
  III/IV were associated with a significant risk of
  failure
• GCS, associated injuries and initial
  hemodynamics were not associated with failure
• Limited study from a data bank

lt 5 of the total patients had a SBP lt 90
therefore, is this conclusion valid?
McIntyre LK, Schiff M, et al Failure of
Non-Operative Management of Splenic Injuries
Arch Surg140563, 2005
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DEDICATED STUDY 7
Retrospective review of 3085 adults with blunt
splenic injuries with a AIS gt 4 obtained from the
NTDB. NOM attempted in 1248 (40.5). This study
looked at higher grade injuries

• Findings
• NOM unsuccessful in 682 (54.6)
• Failure associated with
• Age gt 55
• Low (unstable?) admission BP
• Higher LOS
• 16.9 vs. 8.6
• Higher LOS ICU
• 10.1 vs. 3.9
• Mortality of NOM failure (12.3) similar to
  successful NOM (13.8)
• Conclusions regarding higher grade splenic
  injuries
• NOM is associated with a high rate of failure and
  longer LOS
• No difference in mortality between success and
  failure of NOM

Watson GA, Rosengart MR, et al Non-Operative
Management of Severe Blunt Splenic Injury Are We
Getting Better? J Trauma 611113-1119, 2006
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DEDICATED STUDY 8
Retrospective EAST study from 27 institutions of
1488 adults with splenic injuries of these, 97
patients failed NOM. 78 of these were available
and form the basis of the review. Upon admission
44 stable, 31 transient responders, 25 unstable

• Findings
• Failure of NOM
• Increased LOS
• Mortality of those failing NOM (note ISS similar
  from one group to the next)
• Overall 12.8
• Stable 3
• Responders 8
• Unstable 37
• 60 (6) of the deaths caused by delayed treatment
  of splenic or other abdominal injuries all from
  the Responder (1) and Unstable (5) categories
• Conclusion
• Majority of deaths were from delayed treatment of
  splenic or intra-abdominal injuries
• Highest death rate of patients failing NOM is
  with patients presenting with instability
• Unstable patients should not undergo an attempt
  at NOM
• Transient responders and NOM?

Peitzman AB, Harbrecht GB, et al EAST
Multi-Institutional Trials Working Group Failure
of Observation of Blunt Splenic Injury in Adults
Variability in Practice and Adverse Consequences.
J Am Coll Surg 201179-187, 2005
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DEDICATED STUDY 9
Retrospective WEST study from 4 institutions of
140 patients (96 blunt) with splenic injuries
who had () CT findings and subsequent
Angiography Embolization (AE) followed by NOM.
It is unclear how many patients with () CT had
active bleeding vs. aneurysm vs. hemoperitoneum
w/o active bleeding. Results compared to EAST

• Findings
• Success of NOM
• Hemoperitoneum did not affect success
• Presence of A-V fistula had a high failure rate
  (40) despite A E
• Salvage rates similar between main and selective
  artery
• 4.3 (6) developed abscesses
• Conclusion
• A E can increase salvage especially at the
  higher grades

Haan JM, Knudson M, et al WEST
Multi-Institutional Trials Committee Splenic
Embolization Revisited a Multi-Center Review. J
Trauma 56542-547, 2004
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SELECT COMPLICATIONSAbscess

• Mechanism
• Proximity injuries (i.e., stomach)
• Contamination of splenic hematoma from systemic
  infections
• Gram (-) enteric bacteria most common
• Treatment
• Antibiotics
• Mechanical
• Percutaneous drainage
• Splenectomy

Sarr MG, Zuidema GD, Splenic Abscess-
Presentation, Diagnosis Treatment. Surgery
198292480-485
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CONTROVERSIESAngiography Embolization (AE)

• No controversy
• A E has a role in certain splenic injuries
• Controversy
• Indications
• All patients with a blush?
• Patients without a blush of a higher grade?
• Other
• Method of embolization
• Main artery
• Reduce perfusion pressure while maintaining
  splenic blood flow via short gastric
  vessels/collaterals to prevent infarcts
• Distal (segmental) artery
• Attacks vascular injury more directly, but
  associated with a higher infarct rate?
• Complications of T E
• Delayed bleeding
• Abscess and false abscess
• Difficulty getting angio team in at some
  hospitals
• Other

Forsythe RM, Harbrecht BG, et al Blunt Splenic
Trauma. Scan J Surg
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LIVER
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HISTORY

• In 1908 Pringle implied that the structural
  integrity of the liver was incapable of achieving
  spontaneous hemostasis
• The technical breakthroughs in CT imaging were
  principally responsible for the reversal of the
  long standing above belief now that the liver
  could be imaged and imaged repeatedly
• 1983, Karp et al (pediatric surgeons) were the
  first to demonstrate that the liver is capable of
  spontaneous hemostasis and healing
• 1990, Knudson et al reported on 52 patients with
  liver injuries treated successfully with NOM

Pringle JH Notes on the Arrest of Hepatic
Hemorrhage Due to Trauma Ann Surg 48541, 1908
Karp M, Cooney DR, et al The Non-Operative
Management of Pediatric Hepatic Trauma J
Pediatric Surg. 18512, 1983
Knudson MM, Lim RC, et al Non-Operative
Management of Blunt Liver Injuries in Adults The
Need for Continued Surveillance. J Trauma
301494, 1990
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GRADING SCALELiver
Grading scale proposed by AAST from Moore EE,
Cogbill TH, et al Organ Injury Scaling Spleen
and Liver. J Trauma 38323-4, 1995
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DEDICATED STUDY 1
Retrospective 13 institution study of 404
patients in stable blunt liver injuries. 19 G I,
31 G II, 36 G III, 10 G IV, 4 G V

• Findings
• 98.5 Success of NOM
• 0.4 (2) Mortality attributed to hepatic injury
• 5 (21) Complication rate
• 14 Bleeding the most common
• 3 OR of these, 2 had underlying hemostatic
  disorders
• 4 Embolizations
• 6 Transfusions
• 1 Observed
• 2 Bilomas (percutaneous drainage)
• 3 Abscesses (percutaneous drainage)
• 0 Hemobilia
• LOS overall and for those with complications was
  13.1 and 26.9 respectively
• Conclusions
• High rate of successful NOM in patients with
  blunt liver injuries
• Mortality attributed to liver injury is very low
• Unlike splenic injuries, rate of successful NOM
  is less dependent on grade
• Complications result in a much higher LOS

Pachter HL, Knudson MM, et al Status of
Non-Operative Management of blunt Hepatic
Injuries in 1995 A Multi-Center Experience with
404Patients. J Trauma 14031, 1996
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DEDICATED STUDY 2
35,510 Patients with hepatic injuries identified
in the ACS National Trauma Data Bank 1994-03.
78 Blunt 95.1 underwent NOM

• Key findings
• Age and successful NOM
• gt 18 years old 91.9 (blunt penetrating
  combined)
• lt 18 years old 96.5 (blunt penetrating
  combined)
• AIS and successful NOM
• II 90.5
• III 76.6
• IV 69.3
• V 62.3
• The usage of NOM increased 17 from 1994-2003
• Mortality was relatively constant
• The chance of sucess of NOM was lower
• Increased age
• Increased initial systolic BP in the ED
• Increased Revised Trauma Score
• Increased for level II trauma centers

Hurtuk M, Reed R, et al Trauma Surgeons Practice
What They Preach The NTDB Story on Solid Organ
Injury Management. J Trauma 61243-255, 2006
25
DEDICATED STUDY 3
Single institution retrospective study of 243
hepatic injuries, 95 of these were stable and
treated with NOM. 29 G I, 30 G II, 33 G III, 3 G
IV, 0 G V. 51 (54) had more than one CT scan

• Findings
• 0 NOM failure
• 0 Direct mortality
• 3 Patients (2 G III 1 G IV) with () clinical
  findings (pain elevated bilirubin) prompted CT
  scans leading to percutaneous bile drainage
• 48 Patients had at least routine 1 F/U CT scan
  with no intervention performed
• Conclusions
• No patients failed NOM
• Positive clinical findings did lead to helpful CT
  scans and altered treatment
• Findings on routine repeat CT scan did not alter
  the decision to discharge clinically or change
  the management plan in stable patients with Grade
  I-III injuries
• Study was weak beyond these global conclusions

Population too small for statistical evaluation
Ciraulo DL, Nikkanen HE, et al Clinical Analysis
of the Utility of Repeat CT Scan Before Discharge
in Blunt Hepatic Trauma. J Trauma 41821, 1996
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DEDICATED STUDY 4
11 Patients with grade IV/V hepatic injuries and
a mean ISS of 36 underwent angiography 7 were
found to have arterial bleeding and underwent
embolization. Study entrance criteria included
only those patients who were unstable upon
presentation then stabilized only with
continuous aggressive resuscitation

• Findings
• Aggressive resuscitation was successfully
  withdrawn after embolization in all patients
• Mean
• 12 PRBCs
• 9.1 ICU LOS
• 23.9 LOS
• 2 Complications
• 1 Biloma (percutaneous drainage)
• 1 Large devitalized tissue in a Grade V injury
  -gt debridement ((-) for infection). Subsequent
  MSOF-gt death
• 14.3 Mortality
• Conclusions
• Pushed the limits of conservative management
• Study was directed to a subset of hepatic
  injuries initially unstable G IV/V
• Embolization negated the need for surgical
  intervention in patients that normally would have
  gone to surgery.
• Literature review of patients undergoing surgery
  for hepatic injuries had similar LOS, blood
  transfusion and mortality rates (4-76)

Ciraulo DL, Luk S, et al Selective Hepatic
Arterial Embolization of Grade IV and V Blunt
Hepatic Injuries An Extension of Resuscitation
in the Non-Operative Management of Traumatic
Hepatic Injuries. J Trauma 45353, 1998
27
DEDICATED STUDY 5
Single institution review of 126 blunt liver
injuries 74.6(94) underwent NOM w/o A E
(Group 1) , 4.8 (6) underwent NOM with A E for
bleeding seen on CT (Group 2) (stable?). 90 of
Group 1 were G I-III. Group 2 consisted of 3 G
III, 3 G IV

• Findings of Group 2
• Success?
• 66 Successful resolution of bleeding
• 33 (2) Unsuccessful embolization
• 1 Bad head injury and instability
• 1 Inability to cannulate atherosclerotic celiac
  trunk -OR no liver bleeding massive
  retropertioneal bleed
• Mortality
• 33 Overall
• 0 Hepatic related
• 3 OR
• 1 Delayed nephrectomy
• 1 Retroperitoneal bleed not hepatic
• 1 Bile leak
• Success of stopping bleeding from embolization
  100
• Conclusions
• A E can be used successfully in Grade III and
  IV liver injuries with bleeding seen on CT
• Other meaningful data cannot be extracted

Wahl Wl, Ahrns KS, et al The Need for Early
Angiographic Embolization in Blunt Liver
Injuries. J Trauma 521097-1101, 2002
28
DEDICATED STUDY 6
Single institution retrospective study of 106
patients with blunt injury of those, 64 (60)
were stable and evaluated with CT. Angiography
was performed on 26 with suspected vascular
injuries on CT

• Findings
• 92 were Grade III
• 13 (50) had positive findings on angiogram
• Extra-vascular leakage of contrast
• Pseudoaneurysm
• A-V fistula
• 12 Had successful embolization
• 1 A-V fistula was extensive -gtOR
• Complications associated with A E
• 1 Developed a delayed A-P fistula
• Conclusions
• A E can be highly successful stopping bleeding
• Not all () CT findings (50) lead to actual
  findings of bleeding on angiogram
• Higher grades are more likely to have initial
  bleeding

Sugimoto K , Horiike S, et al The Role of
Angiography in the Assessment of Blunt Liver
Injury. Injury, 25283-287, 1994
29
DEDICATED STUDY 7
Retrospective review of 202 pediatric patients
with blunt hepatic injury at a single pediatric
level I trauma center, 185 were stable and
underwent NOM. 65 G I, 62 G II, 53 G III, 4 G
IV, 0 G V, 0 G VI

• Findings
• 90.8 (168) were managed successfully w/o
  complications
• Mortality
• 5.4 Overall
• 0 Attributed to the hepatic injury
• Complications
• 3.8 (7)
• Grade III-IV
• All right lobe
• All with symptoms
• 1 Hepatic A-V fistula (embolization)
• 5 Bilomas (2 OR, 1 drainage, 2 drainage and
  stent)
• 1 Necrotic gallbladder (OR)
• Conclusions
• NOM very successful in pediatric patients
• Complications
• Rate low
• Grade III or higher
• Most non-operative

Giss SR, Dobrilovic N, et al Complications of
Non-Operative Management of Pediatric Blunt
Hepatic Injury Diagnosis, Management, and
Outcomes. J Trauma 61334-339, 2006
30
DEDICATED STUDY 8
Single institution retrospective review of 80 G
IV-V hepatic injuries 36 underwent NOM and 44
underwent OM. All 36 NOM had a CT. Indications
for NOM vs. OM?

• Findings
• Mortality
• 66 OM
• 8.3 NOM
• Conclusions
• Data analysis was limited
• 50 Of severe hepatic injuries overall will
• require surgery
• Mortality is high with OM
• Mortality was much lower in those undergoing NOM
  however, this may be a function of other factors
  not just liver grade
• Bleeding is common in those undergoing NOM of G
  IV-V and subsequently A E was useful and
  sucessful
• This does not extrapolate to a recommendation
  that all NOM G IV-V have A E automatically

Duane TM, Como JJ, et al Re-Evaluating the
Management and Outcomes of Severe Blunt Liver
Injury. J Trauma 57494-500, 2004
31
DEDICATED STUDY 9
Single institution retrospective review of 135
patients with blunt hepatic trauma who were
treated with NOM 24 (32) of which developed
complications that required additional
interventional treatment. Of the 135 18 G I, 22
G II, 43 G III, 35 G IV, 17 G V. Of the 32 0 G
I-II, 2 G III, 18 G IV, 12 G V

• Findings
• 58 of G IV-V developed complications requiring
  intervention
• 94 of those (32) developing complications were G
  IV-V
• Interventional treatment
• 12 A E 2 unsuccessful -gt OR
• 10 CT drainage of abscesses 2 unsuccessful -gt OR
• 8 ERCP and stenting 1 unsuccessful -gt OR
• 2 Laparoscopy
• 15 Unsuccessful non-operative intervention
• 0 Mortality
• Conclusions
• Complications with severe hepatic trauma managed
  with NOM are common gt 50 in G IV-V
• The majority of complications can be managed with
  non-operative intervention

Carrillo ED, Spain DA, et al Interventional
Techniques Are Useful Adjuncts in Non-Operative
Management of Hepatic Injuries. J Trauma
46619-624, 1999
32
INFLAMMATORY HOST RESPONSE SYNDROME

• Occurs PID 2-5
• Generalized inflammatory response similar to
  sepsis
• Fever, WBC, tachycardia, tenderness, ileus
• Normal Hgb
• Mechanism?
• Liver ischemia
• Inflammatory mediators
• Bile and/or blood
• Infection 7-13
• Treatment
• Infected drain and ABX
• Non-infected
• Watch
• Drain? Reduction in inflammatory response
  duration?
• Laparoscopically
• Open

Carrillo EH, Wohltmann Chris, et al Current
Problems in Surgery. 9-60, 2001
33
HEMOBILIA

• 0.2-3 Of blunt liver injuries
• Etiology
• Communication between arterial and biliary system
• Presentation
• RUQ pain, jaundice, GI hemorrhage
• Diagnosis
• Angiography
• Treatment
• Selective embolization
• OR for failures

Carrillo EH, Richardson JD The Current
Management of Hepatic Trauma. Advances in Surgery
3539-59, 2001
34
DELAYED HEMORRHAGE

• 0-3.5 Of blunt liver injuries
• More frequent at higher grades
• Blood transfusion requirements
• 20 Of the patients
• Most requiring lt 4 units

Carrillo EH, Richardson JD The Current
Management of Hepatic Trauma. Advances in Surgery
3539-59, 2001
35
NOM BENEFITS
Overview summary from 5 articles regarding
additional benefits of NOM vs. OM

• Less
• Transfusions
• Abdominal complications
• LOS
• ICU LOS

Stein DM, Scalea TMl Non-Operative Management of
Spleen and Liver Injuries. J of Intensive Care
Med 21296-294, 2006
36
CONTROVERSYRoutine Follow-Up CT Scan

• Is there a role in stable patients with no
  clinical symptom to have routine CT scans in
  follow-up to blunt liver injury with NOM?
• Adults vs. peds
• If not for all grades, then certain grades?
• Discharge from the ICU?
• Discharge in general?
• Activity?

Stein DM, Scalea TMl Non-Operative Management of
Spleen and Liver Injuries. J of Intensive Care
Med 21296-294, 2006
37
RESUMPTION OF ACTIVITES
Overview review

• Trauma patients typically show complete
  resolution of injury
• 9-12 weeks in one pediatric study
• 4-12 weeks in other studies
• In an experimental model wound breaking strength
  of an injury is normal at 3-6 weeks
• This topic is still unclear

Carrillo EH, Wohltmann Chris, et al Current
Problems in Surgery. 9-60, 2001
38
KIDNEY
39
IMAGING

• CT scan gt IVP
• Fast
• Allows evaluation of other organ injuries
• Identifies contusions
• Depth and extent of injuries
• Size of surrounding hematoma
• Other
• IVP
• Some usage in the OR
• Angiography
• Acute
• Arterial bleeding/embolization
• Chronic
• Renal hypertension

40
GRADING SCALEKidney
Grading scale proposed by AAST from Moore EE,
Cogbill TH, et al Organ Injury Scaling Spleen,
Liver Kidney. J Trauma 291989
41
HISTORY

• Conservative management of blunt renal has
  evolved over the past 30-40 years as
  investigators have realized that the nephrectomy
  rate is higher for renal exploration than NOM
• 1987 Bergen et al reported on renal trauma
• 12.6 Overall nephrectomy rate
• 35 Nephrectomy rate in those explored

Bergen CT, Chan TN, et al IVP Results in
Association with Renal Pathology and Therapy in
Trauma Patients. J Trauma 27515, 1987
42
DEDICATED STUDY 1
Single institution retrospective review of 2
series of patients with diagnosed/suspected renal
injuries (series I 1964-73, series II 1977-81).
Series II much more reliant on imaging to dictate
surgical intervention and OR management. Series
I 185 pts, series II 190 pts

• Findings
• Conclusions
• Early study 1960s lt-gt early 80s
• High NOM success rate
• Imaging helped reduce the incidence of
  nephrectomy

McAninch JW, Carroll PR Renal Trauma Kidney
Preservation Through Improved Vascular Control A
refined Approach. J Trauma 22285, 1982
43
DEDICATED STUDY 2
Single institution retrospective review of 1007
blunt trauma patients with hematuria most who
underwent radiographic evaluation. Shock SBP lt
90 in field/ED
408 did not get imaged so excluded from this
chart

• Conclusions
• Definition of microscopic hematuria?
• Did not evaluate other groups for example,
  macrohematuria
• No imaging required if no shock AND only
  microhematuria or dip positive
• Imaging of those in shock AND with
  micro/marcohematuria should be done

Mee SL, et al Radiographic Assessment of Renal
Trauma A 10-Year Prospective Study of Patient
Selection. J Urol 1411095-1098, 1989
44
DEDICATED STUDY 3
Single institution retrospective review of 329
children with blunt trauma. 97 Had a CT upon
admission indications? 22 (21) had a renal
injury. Of these, 6 had isolated renal injuries
this study specifically looks at these 6

• Findings
• All had a painful tender flank with bruises,
  micro/macro-hematuria
• Grade and management
• 2 G III NOM
• 3 G IV OM
• 1 G V OM
• Conclusions
• Small study with limitations
• Is flank pain/bruising and micro/marco-hematuria
  always associated with significant renal
  injuries?
• This subset of patients all had positive clinical
  findings and G III-IV injuries
• Operative rate appears high 66

Rathaus V, Pomeranz A, et a Isolated Severe
Renal Injuries After Minimal Blunt Trauma to the
Upper Abdomen and Flank CT Findings Emergency
Radiology 10190-192, 2004
45
DEDICATED STUDY 4
Single institution retrospective review of CT
findings in 47 children with blunt renal trauma.
18 G I, 9 G II, 7 GIII, 7 G IV, 6 G V. This study
looked at the subset with GIV-V

• Findings
• Other injuries
• 50 abdominal
• 33 Head
• 13 G IV-V
• 4 Nephrectomy (indications? 2 from outside
  facilities before transfer)
• 9 Non-nephrectomy
• 2 Renal repair
• 1 Return of kidneys to abdomen from thorax
• 6 Observation
• Neither the nephrectomy or non-nephrectomy group
  required hemodialysis, had significant HTN or
  elevated Creatine at the time of D/C
• 66 Non-nephrectomy 100 nephrectomy groups
  were available for f/u (mean 120 months) and were
  normotensive
• Conclusions
• Indications for the 4 nephrectomies?
• Conservative management, when performed in these
  high grade lesions, was successful without long
  term sequele and should be attempted in all
  stable severe pediatric patients with renal
  injuries
• No patient developed significant reno-vascular
  HTN

Barsness KA, Bensard DD, et al Reno-Vascular
Injury An Argument for Renal Preservation. J
Trauma 57 310-315, 2004
46
DEDICATED STUDY 5
Single institution retrospective review of 178
initially stable adults with blunt renal trauma.
26 With G IV-V form the basis of this review

• Findings
• All patients had micro or macroscopic hematuria
• 14 NOM
• 1 required a stent otherwise uneventful
• 12 OM Patients developed
• 9 Instability -gt nephrectomy other organ injury
  repair in some?
• 3 Acute abdomen -gt renal repair other organ
  injury repair
• Morbidity same between NOM and OM
• 50 available for f/u average 7.5 months none
  with renal insufficiency or HTN
• Conclusions
• This subset of patients all had
  micro/macro-hematuria
• Stable G IV-V have a high rate of successful NOM
• Unstable G IV-V undergoing OM have a high
  nephrectomy rate (75)

Bozeman C, Carver B, et al Selective Operative
Management of Major Blunt Renal Trauma. J Trauma
57305-309, 2004
47
DEDICATED STUDY 6
Retrospective review of the NTDB of 742,774
patients 6890 blunt trauma patients with renal
injuries. NOM and OM combined

• Findings
• Overall
• 4.1 Nephrectomy
• 0.5 Dialysis
• 10.2 Death
• Grade of injuries
• Nephrectomy, dialysis and death increased with
  grade
• Nephrectomy rate highest correlation for grade
• 0.1 Grade II
• 10 Grade V
• Conclusions
• Grading predicts nephrectomy, dialysis and death
• Nephrectomy correlation strongest

Kuan JK, Wright JL, et al AAST Organ Injury
Scale for Kidney Injuries Predicts Nephrectomy,
Dialysis, and Death in Patients with Blunt Injury
and Nephrectomy for Penetrating Injuries. J
trauma 60351-356, 2006
48
RENOVASCULAR HTN NOM

• Etiology
• Renal artery stenosis or occlusion
• Internal thrombosis or flap
• External compression
• Restrictive fibrous capsule around kidney (Page
  kidney)
• Compress parenchyma and restrict blood flow
• Incidence low
• 3.2 Monstrey et al, 1989
• 0.0 Barsness et al, 2004 (peds)
• Low Montgomery et al, 1998

49
DEDICATED STUDY 7
Single institution retrospective review over 20
years to identify those with arterial
hypertension as a direct result of renal injury.
7 patients found who developed new onset of HTN
after discharge that was renal in origin. Study
was not designed to look at frequency.

• Findings
• Time from injury to diagnosis of HTN 2-32 weeks
• No history of HTN before accident or during
  hospital
• Initial w/u at time of accident
• 1 No workup
• 3 Negative CT
• 3 Negative IVP
• All 7 underwent renal angiography and 6 had
  renal-vein renin sampling
• 100 abnormal renin analysis
• Conclusions
• Development of renal HTN is not immediate
• Angiography renin analysis important
• Treatment based on response to RX and angio
  findings
• This study only guesses at renal HTN as low
  by the authors

Montgomery RC, Richardson JD, et al
Post-Traumatic Reno-Vascular Hypertension After
Occult Renal Injury. J Trauma 45106-110, 1998
50
VASCULAR INJURIES
Bux S, Tarry WF, et al Contemporary Management
of Renal Trauma. W Virg Medical J. 88152-155,
2002
51
URINARY LEAK

• Diagnosis
• CT
• Treatment
• NOM with stent
• OM
• Most injuries at the renal pelvis
• Infection?
• Worsening leak on subsequent CT scans

Bux S, Tarry WF, et al Contemporary Management
of Renal Trauma. W Virg Medical J. 88152-155,
2002
52
CONCLUSIONS
53
CONCLUSIONSGeneral

• All stable patients with blunt spleen, liver /or
  kidney injuries diagnosed on CT scan should be
  considered for NOM
• NOM should not be used in unstable patients with
  blunt spleen, liver /or kidney injuries
• Rate of successful NOM is less dependent on grade
  with liver and kidney as opposed to splenic
  injuries
• Usage rate of NOM has increased over the past 10
  years
• 140 Spleen
• 17 Liver
• 0 Kidney
• Most studies on this topic are retrospective
  many small sample sizes

54
FUTURE QUESTIONSGeneral

• Indications for follow-up imaging
• Routine?
• Grade?
• Organ injured?
• Specific injuries?
• Type of imaging for follow-up
• CT vs. U/S?
• Angiography embolization
• Blush only?
• Higher grades?
• Spleen specific main or segmental arteries
• Hospitalization issues
• Bedrest?
• ICU vs. floor
• Resumption of activity
• Mild -gt contact sports

55
CONCLUSIONSSpleen

• Predictors of success of NOM
• Very high in children
• High in adults
• Medium in those gt 55
• Lower with higher grades
• G I-III success rate 83 and 98 with adults and
  peds respectively
• Lower with higher ISS
• Higher grades of injury (III-V) and NOM
• Higher failure rate
• Same mortality as successful NOM
• Very low OPSI is not a modern deterrent to
  splenectomy
• Post operative infection may be much higher in
  those undergoing splenectomy as opposed to repair
  or NOM
• 31 vs. 0 in one study

56
CONCLUSIONSSpleen

• Pediatric patients with NOM
• No benefit to ICU for most
• Earlier discharge possible (PID 3)
• Routine CT scan follow-up is not necessary in
  most patients
• May be helpful in subsets such as those with
  blush on initial CT and/or higher grades of
  injury
• Higher rate of failure of NOM with level III/IV
  centers
• A E has a higher rate of successful NOM than no
  A E for grade III-V (WEST vs. EAST study)
• Indications were a bit unclear (active and
  non-active bleeding mixed)
• Presence of a A-V fistula was associated with 40
  failure rate of embolization
• Gram (-) enteric most common bacteria in
  abscesses

57
CONCLUSIONS Liver

• Mortality directly attributed to liver injuries
  is very low
• Complications from NOM
• Much longer LOS
• 50 overall with G IV-V
• Predictors of success of NOM
• Very high in adults and children
• Lower
• Higher grades but not as signifcant of a drop
  as splenic injuries
• Higher Revised Trauma Scores
• Follow-up CT scans
• Useful with () clinical findings
• Not useful with (-) clinical findings
• Embolization
• Improved the success of NOM with G IV-V some G
  III
• Almost always stopped bleeding
• Consider using with G IV-V with or without signs
  of bleeding?

58
CONCLUSIONS Liver

• Inflammatory Host Response Syndrome
• Occurs PID 2-5
• Infection rate 7-13
• Usually self limiting
• Hemobilia
• Associated with () clinical findings
• Embolization usually successful
• Delayed hemorrhage
• lt 5 of all liver injuries
• 20 will require a transfusion
• NOM additional benefits
• Less
• Transfusions
• Abdominal complications
• LOS

59
CONCLUSIONS Kidney

• High sucessful NOM rate including G III-V
• Hematuria
• No shock only microscopic hematuria
• 0 Significant injuries
• Shock micro/macro hematuria
• 22 Significant injuries
• Pediatric patients with flank pain/bruising
  micro/marcohematuria
• Frequently have GIII-V injuries?

60
CONCLUSIONS Kidney

• Nephrectomy, dialysis and death correlate with
  increasing grade
• Nephrectomy having the highest correlation
• NOM and OM and nephrectomy rate
• NOM 10
• OM 75?
• Renovascular HTN
• Develops over weeks not days
• Angiography and renin sampling important in
  dictating management

61
CONCLUSIONS Kidney

• Vascular injuries
• Main artery
• Thrombosis/bleeding -gt OM
• Segmental artery
• Thrombosis -gt NOM
• Bleeding -gt NOM or embolization
• Urinary leak
• Most controlled with stent
• Exceptions
• Injury to pelvis
• Infection
• Worsening leak

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63
DIFFERENCE BETWEEN SPLEEN AND LIVER

• Liver may rely less on grading than spleen
• Delayed bleeding from the liver is rare

64
LARGE HEMOPERITONEUM

• Require intervention
• Embolization
• Repair extra-hepatic bile ducts
• Drain hemoperitoneum

39
65
CONCLUSIONS Kidney