European Journal of Cardiovascular Medicine

Blunt splenic injury is a leading cause of hemorrhage, often resulting in shock and mortality. Splenic injury accounts for 31% to 50% of blunt abdominal trauma [1]. Historically patients with splenic injury were surgically managed, with removal of the injured spleen [2]; however, the inception of high-resolution diagnostic imaging and angiography has changed the paradigm in management of splenic injuries towards nonoperative management (NOM) due to the enhanced accuracy of determining the severity of injury as well as the ability to treat [2, 3]. NOM includes angiography and embolization (SAE), which consists of identifying the vascular injury and/or hemorrhage through angiography, followed by embolization to control bleeding. Though observational management is the standard for low grade splenic injuries (≤ 3), there is no preferred treatment for splenic injury grades > 3 and it frequently varies by trauma center level and location [4].

Current guidelines and recommendations by the Eastern Association for the Surgery of Trauma (EAST) 2016 [5] support the following: operative management (OM) is an absolute indication for patients with hemodynamic instability who do not respond to initial resuscitation. NOM with observation is reserved for stable grade I-III blunt splenic injury, a repeat CT should be considered in grade III patients with a contrast blush to determine need for NOM-SAE, and grade IV/V injury without hypotension or a large hemoperitoneum should also be considered for NOM-SAE. However, particularly for trauma centers in remote areas where time to treatment is crucial, SAE is frequently unavailable or can be a time-consuming specialized procedure, requiring an interventional radiologist that may not be emergently available. Thus, lower-level trauma centers with limited resources must expeditiously decide who can be immediately transferred to a higher level of care for SAE and who can be safely admitted for either surgery (exploratory laparotomy and splenectomy) or observation. Although there are a proliferation of studies examining the triage of splenic injuries [3, 6–15], there are a paucity of studies on management of patients with blunt splenic injuries in remote settings and of the few that exist, most report very small numbers and are not current [16, 17]. There continues to be great variability in the processes of care for splenic injury patients, with sparse data reported across Level III or IV trauma centers.

The study objective was to identify a common set of clinical characteristics, as well as to describe management for splenic injuries in patients admitted under general surgery in resource limited hospital in Central India.

This study was conducted as retrospective observational study done at our hospital from January 1, 2023, to December 31, 2024. Trauma patients ≥ 18 years who had a blunt splenic injury were included. A total of 50 patients were enrolled in the study. The sampling technique adopted was convenience sampling, allowing the inclusion of patients who met the inclusion criteria and were available during the study period.

Patients who were dead on arrival, died in the emergency department before diagnostic work-up, and whose findings on initial assessment were not documented were excluded.

According to the advanced trauma life support (ATLS) guidelines, hemodynamically unstable patients with a positive focused assessment with sonography (FAST) exam are admitted for emergent damage control laparotomy and potential splenectomy. Hemodynamically stable patients can be selected for nonoperative management, which includes observation and continuous monitoring of vitals, or transfer to a higher level of care for angiographic embolization.

The following covariates were collected on each patient from the trauma registry: sex, age (≥ 18), race, injury severity score (ISS, 1–15, ≥ 16), hospital length of stay (LOS), ICU LOS, mechanism of injury (bike, fall, motor vehicle crash (MVC), other), admission Glasgow Coma Scale (GCS, 3–8, 9–13, 14–15), abbreviated injury severity (AIS,) score (≤ 3 vs. > 3) in-hospital mortality, and the existing comorbid conditions in this patient population: chronic obstructive pulmonary disease (COPD), hypertension, and smoker.

The following covariates were collected from patient electronic medical records: initial and final splenic injury grade (uses the American Association for the Surgery of Trauma Spleen Injury Scale, which is currently the most widely used grading system for splenic trauma and is classified into grades I-V using CT findings; 2018 version used) [18], presence of contrast blush and size of blush (small, moderate, large) in radiology imaging, hemoperitoneum quantified from CT findings and size (small, moderate, large). Additional variables that were abstracted from the electronic medical record included prehospital vitals (systolic blood pressure, diastolic blood pressure, heart rate, respiration rate levels during the first 24 h (g/dL), hemodynamic instability (defined as < 90 mm Hg), total units of blood products received, initial intervention technique, and definitive intervention technique.

Statistical Analysis

All data collected were coded and entered into a secure database. Analysis was performed using SPSS (Statistical Package for Social Sciences) software. Descriptive statistics were applied to calculate mean, median, standard deviation, and frequency distribution. Inferential analysis included:

• Chi-square and Fisher exact test: For categorical variables.
• P-values < 0.05 were considered statistically significant.

A total of 50 patients were studied with a mean age of 28 years of which 34 were males and 16 were females. Among the causes of injury, bike accident was 42% in. majority followed by motor vehicle accident (30%) and fall (22%). 30% were smokers and 10% had hypertension followed by 6% having diabetes found from records.

Table 1 showing socio-clinical profile of the patients undergoing surgery.

Table 2 showing types of management done

Table 3: Clinical characteristics of splenic injury by type of management

The AIS >3 was found 56% in the head or neck area and 44% in the chest area. (table 1) 90% patients underwent splenectomy as compared to 10% who were managed by non-operative methods. (NOM) (table 2)

Among the clinical characteristics, almost all patients i.e. 97.7% who had haemodynamic instability were operated. All patients i.e. 100% patients with hemoperitoneum and FAST positive results were operated while only 1 such case was managed non-operatively.

Median stay in hospital was 5 days in cases of operated patients and 3 days in cases of those managed by non-operative methods

There has been a shift in recent years towards using SAE for patients suffering from splenic injuries to preserve function, as it has been shown to be safe and effective, as well as require less resources and time spent in the hospital. Lower-level trauma centers, however, frequently do not have SAE capabilities and must make clinical decisions prudently on triage strategies. Though multiple studies discuss splenic injury management, very few take place in a remote setting. This study described in detail, the predictors for transfer, management, and outcomes of patients with a blunt splenic injury who were managed surgically in a resource limited setting.

Though there is considerable literature discussing management strategies of splenic injuries, to our knowledge, this is one of the first studies to specifically describe the patient population with a blunt splenic injury who were injured in a remote area. Harwell et al. describe rural trauma patients who underwent damage control laparotomy (damage control laparotomy) prior to or following transfer, and showed that although damage control laparotomy is not a new procedure in urban trauma centers, it is still a relatively uncommon procedure in remote settings [19]. Similar to our study, they outlined clinical parameters of each group (damage control laparotomy at a rural facility, stable with damage control laparotomy after transfer, unstable with damage control laparotomy after transfer) and determined which patients can safely be transferred, and who should be admitted. In Harwell et al., unstable patients who were transferred and had immediate laparotomy in this study had more than double the ISS of the other groups, equating to multiple concomitant injuries including basilar skull fractures, liver lacerations, distal aortic lacerations, pneumothoraxes, and splenic injuries. We also found that concomitant injuries, including femoral artery dissections, pneumothoraxes, multiple rib fractures, hemothoraces, as well as findings on CT such as hemoperitoneum and contrast blush, determined need for transfer.

Interestingly, although overall there were more males than females, Female patients tended to be slightly older and have a moderately higher average ISS than males and were more commonly involved in MVCs, while males were involved predominantly in snowboarding accidents. Additionally, more females had SAE and less had operative management, while males had a higher proportion with observations and operative management, which are reflective of differences in splenic salvage upon admission to the higher level of care and admission splenic injury severity.

Limitations to the study include the fact that it cannot be generalized to other trauma centers with different patient populations, as it was a new hospital in a resource limited setting, however, this is one of the few studies to describe clinical characteristics of patients with splenic injury in a remote environment. A second limitation included the small sample size after stratification by splenic injury grade was performed.

This study shows that a resource limited trauma center is mainly operating on hemodynamically unstable patients with splenic injury grade ≥ 3 and concomitant injuries, and nearly all of these patients were successfully managed.

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