PAPER Management of the Most Severely Injured A Multicenter Study of the Research Consortium of New England Centers for Trauma (ReCONECT)

George C. Velmahos, MD, PhD; Nikos Zacharias, MD; Timothy A. Emhoff, MD; James M. Feeney, MD; James M. Hurst, MD; Bruce A. Crookes, MD; David T. Harrington, MD; Shea C. Gregg, MD; Sheldon Brotman, MD; Peter A. Burke, MD; Kimberly A. Davis, MD; Rajan Gupta, MD; Robert J. Winchell, MD; Steven Desjardins, MD; Reginald Alouidor, MD; Ronald I. Gross, MD; Michael S. Rosenblatt, MD; John T. Schulz, MD; Yuchiao Chang, PhD

Objective: To determine the rate and predictors of failure At the end, 64% of patients required surgery. Multivar- of nonoperative management (NOM) in grade IV and V iate analysis identified 2 independent predictors of f-NOM: blunt splenic (BSI). grade V BSI and the presence of a brain . The like- lihood of f-NOM was 32% if no predictor was present, Design: Retrospective case series. 56% if 1 was present, and 100% if both were present. The mortality of patients for whom NOM failed was almost Setting: Fourteen trauma centers in New England. 7-fold higher than those with successful NOM (4.7% vs 0.7%; P=.07). Patients: A total of 388 adult patients with a grade IV or V BSI who were admitted between January 1, 2001, Conclusions: Nearly two-thirds of patients with grade and August 31, 2008. IV or V BSI require surgery. A grade V BSI and brain in- jury predict failure of NOM. This data must be taken into Main Outcome Measures: Failure of NOM (f-NOM). account when generalizations are made about the over- all high success rates of NOM, which do not represent Results: A total of 164 patients (42%) were operated on severe BSI. immediately. Of the remaining 224 who were offered a trial of NOM, the treatment failed in 85 patients (38%). Arch Surg. 2010;145(5):456-460

HE MANAGEMENT PAT- of patients to evaluate research topics that terns of blunt splenic inju- are difficult to address by any single in- ries (BSI) have shifted from stitution. Our hypothesis for this study is routine to that most grade IV and V BSI require sur- nonoperative manage- gery and that certain risk factors increase mentT (NOM) over the last 3 decades.1,2 Al- though low-grade injuries are success- See Invited Critique fully managed without surgery, NOM of at end of article high-grade BSI is associated with fre- 3-8 quent failures. In one of the largest mul- the likelihood of receiving an operation. ticenter studies, the failure of NOM was The objective of the study is to determine 4.8% for grade I, 9.5% for grade II, 19.6% the rate and risk factors of failure of NOM for grade III, 33.3% for grade IV, and 75% in patients with BSI. for grade V BSI.9 Therefore, the effective- ness of NOM for grade IV and V injuries is under scrutiny. Most studies have a pro- METHODS hibitively low number of such injuries to draw valid conclusions. PATIENTS

CME available online at Adult patients with a grade IV or V BSI who were admitted from January 1, 2001, to August 31, www.jamaarchivescme.com 2008, in 14 New England trauma centers were and questions on page 415 included retrospectively. Grading was per- formed individually by each center based on The ReCONECT (Research Consor- computed tomographic (CT) findings and ac- Author Affiliations are listed at tium of New England Centers for Trauma) cording to the American Association for the Sur- the end of this article. initiative focuses on using high numbers gery of Trauma Organ Injury Scale (Table 1).10

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©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 Table 1. Grading of According to the American Association for the Surgery of Trauma Organ Injury Scale10

Gradea Description I Subcapsular hematoma, Ͻ10% of surface area; laceration, Ͻ1 cm parenchymal depth II Subcapsular hematoma, 10%-50% of surface area, Ͻ5 cm in diameter; laceration, 1-3 cm in depth III Subcapsular hematoma, Ͼ50% of surface area or expanding; laceration, Ͼ5-cm depth or expanding; intraparenchymal hematoma, Ͼ3 cm or expanding IV Laceration involving segmental or hilar vessels producing major devascularization V Completely shattered spleen; hilar injury that devascularizes the entire spleen

a Advance 1 grade for multiple injuries up to grade III.

All centers were verified by the American College of Surgeons RESULTS Committee on Trauma as level I (11 centers) or II (3 centers) trauma centers. Patients who received a resuscitative thora- cotomy in the emergency department were excluded, as none Of 388 patients with grade IV or V BSI admitted during eventually survived. the study period in the 14 ReCONECT hospitals, 164 (42%) were operated on immediately and 224 (58%) were DEFINITIONS offered NOM. The mean (SD) age of the population was 38(17) years (median, 36 years; range, 16-98 years) and Patients were categorized as receiving NOM or an immediate , 31(12) (median, 29; range, 8-66). operation (IO). Nonoperative management was defined by Sixty-nine percent were men, 19% had grade V injury, either a clear note in the medical record committing the 33.5% had other intra-abdominal organ injuries, 13% had patient to NOM or by the fact that no operation was per- a brain injury, and 20% had long bone or pelvic frac- formed within 3 hours of diagnosis of BSI. The 3-hour limit tures. The average hospital stay was 13(18) days (me- was arbitrary and based on a consensus among the centers dian, 7 days; range, 1-205 days). Thirty-three patients that it would be very unlikely to decide to perform an opera- (8.5%) died. tion for a high-grade splenic injury and delay it for more than 3 hours. However, it is plausible that there were patients who were offered NOM initially but for whom it NOM vs IO failed in fewer than 3 hours. These patients may have been recorded as having received IO. Failure of NOM was defined All examined variables except for age, sex, the presence of as the need for surgery after a trial of NOM. free blood, and contrast extravasation on CT were signifi- cantly different between patients who received NOM and DATA AND OUTCOMES IO (Table 2). As expected, patients who received IO had higher morbidity, mortality, and length of hospital stay. We collected data on demographics, mechanism of (motor vehicle–related crash, fall, or assault), severity of in- s-NOM vs f-NOM jury according to the Injury Severity Score, associated inju- ries, grade of splenic injury (IV or V), presence of free abdomi- Of 224 patients who were initially offered NOM, it failed nal blood on CT (around the spleen only or diffuse), type of in 85 (38%) within 2(3.5) days of admission (median, 1 management (NOM or IO), failure of NOM (f-NOM), morbid- day; range, 0-18 days) and required surgery. In 66% of ity, mortality, and length of hospital stay. The outcome mea- patients, the failure occurred within 24 hours; in 18%, sure was f-NOM. between 24 and 48 hours; and in 16%, after 48 hours up to 18 days after admission. The NOM failure rate was STATISTICAL ANALYSIS 34.5% among patients with grade IV and 60% among pa- tients with grade V injury. Compared with s-NOM, pa- Patients who received NOM and IO were compared. Addi- tients with f-NOM had higher rates of brain injury, grade tionally, patients with f-NOM were compared with patients who had successful NOM (s-NOM). Continuous variables V BSI, and contrast extravasation on CT (Table 3). They were dichotomized across clinically meaningful values. Age had higher morbidity, longer hospital stay, and a trend was dichotomized at 55 years; systolic blood pressure, 100 toward higher mortality. mm Hg; heart rate, 100 beats per minute; Injury Severity The multivariate analysis identified 2 independent pre- Score, 25; and hematocrit level, 30%. Continuous variables dictors of failure of NOM: a grade V BSI and the pres- (reported as mean [standard deviation] unless otherwise ence of brain injury (Table 4). The likelihood of f-NOM specified) were compared using the t test and categorical was 32% if none of the 2 predictors were present, 56% if variables (reported as absolute values and proportions) by 1 was present, and 100% if both were present. ␹2 the or Wilcoxon rank sum tests. Stepwise logistic regres- In an additional multivariate analysis, we considered sion was performed to identify independent predictors of a P value of .1 significant to allow inclusion of more vari- f-NOM. Odds ratios and 95% confidence intervals were cal- culated for each predictor. The predictive ability of different ables. This analysis identified 2 additional independent combinations of independent predictors of f-NOM was predictors of NOM failure: male sex and contrast ex- examined. P Յ .05 indicated statistical significance. The travasation on CT (Table 5). The likelihood of NOM study was approved by the institutional review boards of all failure was 22% if no predictor was present, 32% if 1 was participating hospitals. present, 40% if 2 were present, and 78% if 3 were present.

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©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 Table 2. Comparison Between Patients Who Received Table 3. Comparison Between Patients Successfully Treated an Immediate Operation and Those Offered a Trial Nonoperatively and Patients for Whom Nonoperative of Nonoperative Management Management Failed

No. (%) No. (%)

IO NOM s-NOM f-NOM Characteristic (n=164) (n=224) P Value Characteristic (n=139) (n=85) P Value Age, mean (SD), y 38 (17) 39 (17) .68 Age, mean (SD), y 36 (16) 43 (18) .11 Male sex 114 (69.5) 155 (69) Ͼ.99 Age Ն55 y 20 (14) 20 (23.5) .11 Type of injury Male sex 91 (65.5) 64 (75) .14 Motor vehicle crash 131 (80) 144 (64) Type of injury .83 Fall 27 (16.5) 65 (29) Motor vehicle crash 87 (63) 57 (67) Assault 6 (3.5) 15 (7) Fall 42 (30) 23 (27) Injury Severity Score, 36 (13) 27 (11) Ͻ.001 Assault 10 (7) 5 (6) mean (SD) Injury Severity Score, mean (SD) 26 (10) 29 (12) .21 Systolic blood pressure 109 (27) 121 (26) .001 Injury Severity Score Ͼ25 64 (46) 47 (55) .40 on admission, Systolic blood pressure 122 (24) 119 (29) .19 mm Hg, mean (SD) on admission, Heart rate on admission, 101 (26) 93 (21) Ͻ.001 mm Hg, mean (SD) beats/min, Systolic blood pressure 21 (15) 18 (21) .26 mean (SD) on admission Hematocrit level 33 (7) 35 (11) .01 Յ100 mm Hg on admission, %, Heart rate on admission, 91 (21) 95 (21) .29 mean (SD) beats/min, Brain injury 28 (17) 22 (10) .05 mean (SD) Other abdominal organ injury 72 (44) 58 (26) Ͻ.001 Heart rate on admission 22 (16) 13 (15) .65 Major fracturea 42 (26) 36 (16) .02 Ͼ100 beats/min CT grade of splenic injury .002 Hematocrit on admission, 34 (10) 37 (12) .15 4 121 (74) 194 (87) mean (SD), % 5 43 (26) 30 (13) Hematocrit level 30 (21.5) 17 (20) .87 Contrast extravasation on CT 77 (47) 101 (45) .76 on admission Յ30% Free blood on CT .88 Brain injury 9 (6.5) 13 (15) .04 Perisplenic 125 (76) 168 (75) Other abdominal organ injury 37 (27) 21 (25) .76 Diffuse 39 (24) 56 (25) Major fracturea 22 (16) 14 (16.5) Ͼ.99 Morbidity 52 (32) 80 (36) Ͻ.001 CT grade of splenic injury .009 Mortality 28 (17) 5 (2) Ͻ.001 4 127 (91) 67 (79) Hospital stay, d, mean (SD) 14 (15) 12 (19) .01 5 12 (9) 18 (21) Contrast extravasation on CT 55 (40) 46 (54) .04 Abbreviations: CT, computed tomography; IO, immediate operation; Free blood on CT Ͼ.99 NOM, nonoperative management. Perisplenic 104 (75) 64 (75) a Includes pelvic, long bone, or spinal fractures. Diffuse 35 (25) 21 (25) Morbidity 28 (20) 52 (61) Ͻ.001 Mortality 1 (0.7) 4 (4.7) .07 There were no patients with all 4 predictors present to Hospital stay, d, mean (SD) 10 (19) 16 (20) Ͻ.001 estimate a likelihood of NOM. Abbreviations: CT, computed tomography; f-NOM, failed NOM; PATIENTS WHO RECEIVED SURGERY NOM, nonoperative management; s-NOM, successful NOM. a Includes pelvic, long bone, or spinal fractures. Overall, 64% of patients (249 of 388) received surgery, 60% with grade IV and 83.5% with grade V BSI. In all but 2 pa- BSI to date. The literature of NOM for BSI has increased tientswhohadsplenorrhaphy,asplenectomywasperformed. during the last 2 decades, and (possibly subject to pub- To examine if patients with f-NOM should have been lication bias) the message conveyed has become overly identified earlier as candidates for immediate surgery, we optimistic. As studies reported NOM success rates rang- compared patients with f-NOM and IO. If the 2 groups ing from 80% to 100%,1,11,12 the fact that only a few se- were similar, we could hypothesize that patients with verely injured were included was often over- f-NOM were erroneously offered NOM at the first place. looked. In most studies, high-grade injuries were operated However, the two populations had significant differ- on immediately and excluded from the analysis of NOM. ences in age, Injury Severity Score, blood pressure, heart This may have conveyed the false impression that all rate, and hematocrit on arrival, as well as presence of other grades of BSI respond favorably to NOM. abdominal and extra-abdominal injuries and grade of Whereas there is little doubt that NOM is highly suc- splenic injury (data not shown). cessful in grade I, II, and possibly III injuries, the data on higher grades is uncertain. The Eastern Association COMMENT for the Surgery of Trauma has described a large number of patients with BSI from 27 trauma centers including This multicenter initiative of 14 New England trauma cen- 194 patients with grade IV and 78 with grade V inju- ters included the largest population with grade IV and V ries.9 Although more than half of the patients were ulti-

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©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 nificance, these variables should be taken into consid- Table 4. Independent Predictors of Failure eration in the treatment of patients with BSI. of Nonoperative Management This multicenter study is subject to limitations re- lated to its retrospective design and the lack of a com- Predictor OR (95% CI) P Value mon NOM policy in the participating institutions. Also, Spleen injury grade V 3.01 (1.36-6.67) .007 there was no central authority to grade the injuries, which Brain injury 2.82 (1.14-7.01) .03 was done separately in each institution. The reliance on CT grading to predict NOM failure has been debated by Abbreviations: CI, confidence interval; OR, odds ratio. some authors.14 A number of other factors that have been commonly reported as predictors of NOM failure includ- ing age greater than 55 years, spleen pathology, mul- Table 5. Independent Predictors of Failure of Nonoperative Management When Level of Significance Was PϽ.1 tiple abdominal injuries, number of blood transfusions, Instead of PϽ.05 time of in-house observation, and quantity of free blood, among many others, were not found to be statistically 3,5,11,15 Predictor OR (95% CI) P Value significant in our study. Splenic artery emboliza- tion was used in only a handful of cases and therefore Spleen injury grade V 2.84 (1.26-6.40) .01 Brain injury 2.50 (0.99-6.28) .05 not reported. Its liberal use has resulted in high rates of 16-18 Contrast extravasation on CT 1.71 (0.96-3.01) .07 NOM success in certain centers, whereas others have Male sex 1.74 (0.92-3.28) .09 not realized similar benefits.19 Data on ultrasonographic examinations and diagnostic peritoneal lavage were not Abbreviations: CT, computed tomography; CI, confidence interval; collected in our database. Such information has been in- OR, odds ratio. cluded in management algorithms offered by consensus groups.20 Although we could not examine causality be- mately treated nonoperatively, only 26.3% of patients with tween the failure of NOM and mortality, the nearly 7-fold grade IV and 5.1% with grade V injury were offered NOM. increase in mortality of patients with f-NOM (4.7%) com- One-third of the patients with grade IV and three- pared with s-NOM (0.7%) was alarming even if it did not fourths of the patients with grade V injuries had failure achieve statistical significance (P=.07). It is possible that, of NOM. Ultimately, only 16.9% of patients with grade on certain occasions, persistent attempts to save a se- IV and 1.3% with grade V injuries avoided a lapa- verely injured spleen may lead to loss of life. It, of course, rotomy. Other groups have also reported that a high grade needs to be noted that patients with f-NOM had a higher of BSI independently predicts NOM failure.3,13 rate of brain injury, which may be a reason for the higher In our study of only grade IV and V BSI, 38% of pa- mortality rate in this group. tients had failed NOM, and the failure rate in grade V in- In summary, this multicenter initiative confirms that juries was almost twice as high as in grade IV. Ulti- only a minority of grade IV and V BSI can be managed mately, only 40% of patients with grade IV and 26.5% of without surgery and that the rate of NOM failure is high. patients with grade V BSI were treated nonoperatively. Although this study was not designed to evaluate the type These rates of successful NOM, even if higher than the and timing of interventions, it is recommended that NOM rates reported by the Eastern Association’s study, are still is offered cautiously in these patients and only if close much lower than the overall NOM rates typically re- monitoring and rapid surgical response is available. ported for the general BSI population. We compared the f-NOM group individually with the Accepted for Publication: December 23, 2009. s-NOM and the IO groups and realized that statistically Author of Affiliations: Departments of Surgery, Massa- significant differences existed in all comparisons. Essen- chusetts General Hospital and Harvard Medical School, tially, patients with f-NOM comprise a distinct popula- Boston (Drs Velmahos and Zacharias); University of Mas- tion that lies between those who obviously need an IO sachusetts Memorial Hospital, Worchester (Dr Em- and those who are very likely to be treated nonopera- hoff); Hartford Hospital and University of Connecticut, tively with success. Although they may not show the early Hartford (Dr Feeney); Beth Israel Deaconess Medical Cen- signs of hemodynamic instability or ongoing bleeding that ter and Harvard Medical School, Boston, Massachusetts prompt immediate surgery, they are characterized by risk (Dr Hurst); Fletcher Allen Healthcare and University of factors that should alert the astute clinician to the high Vermont, Burlington (Dr Crookes); Rhode Island Hos- likelihood of failure of NOM. In our study, the multi- pital and Brown University, Providence, Rhode Island (Drs variate analysis identified 2 such independent predic- Harrington and Gregg); Berkshire Medical Center, Pitts- tors: a grade V BSI and the presence of a brain injury. field, Massachusetts (Dr Brotman); Boston Medical Cen- Because we realized that some variables closely ap- ter and Boston University, Boston, Massachusetts (Dr proached the arbitrary .05 level of statistical signifi- Burke); Yale-New Haven Hospital and Yale University, cance, we relaxed our P value to .1 to consider other po- New Haven, Connecticut (Dr Davis); Dartmouth- tential factors that predict NOM. Besides grade V BSI and Hitchcock Medical Center, Lebanon, New Hampshire (Drs brain injury, which remained statistically significant pre- Winchell and Gupta); Maine Medical Center, Portland dictors of NOM at P values of .01 and .05, respectively, (Drs Winchell and Desjardins); Baystate Medical Cen- this new analysis offered contrast extravasation (P=.07) ter, Springfield, Massachusetts (Drs Alouidor and Gross); and male sex (P=.09) as additional predictors. Even if Lahey Clinic, Burlington, Massachusetts (Dr Rosen- they do not meet the traditional criteria for statistical sig- blatt); Bridgeport Hospital, Bridgeport, Connecticut (Dr

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©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 Schulz); and the Department of Clinical Epidemiology, 3. Velmahos GC, Chan LS, Kamel E, et al. Nonoperative management of splenic in- Massachusetts General Hospital, Boston (Dr Chang). Dr juries: have we gone too far? Arch Surg. 2000;135(6):674-681. 4. Peitzman AB, Harbrecht BG, Rivera L, Heil B; Eastern Association for the Sur- Zacharias is now with Johns Hopkins University, Balti- gery of Trauma Multiinstitutional Trials Workgroup. Failure of observation of blunt more, Maryland. splenic injury in adults: variability in practice and adverse consequences. JAm Correspondence: George C. Velmahos, MD, PhD, De- Coll Surg. 2005;201(2):179-187. partment of Surgery, Massachusetts General Hospital, 165 5. Galvan DA, Peitzman AB. Failure of nonoperative management of abdominal solid organ injuries. Curr Opin Crit Care. 2006;12(6):590-594. Cambridge St, Ste 810, Boston, MA 02030 (gvelmahos 6. Schroeppel TJ, Croce MA. Diagnosis and management of blunt abdominal solid @partners.org). organ injury. Curr Opin Crit Care. 2007;13(4):399-404. Financial Disclosure: None reported. 7. Hunt JP, Lentz CW, Cairns BA, et al. Management and outcome of splenic in- Author Contributions: Study concept and design: Vel- jury: the results of a five-year statewide population based study. Am Surg. 1996; mahos, Zacharias, Feeney, Brotman, and Gross. Acqui- 62(11):911-917. 8. Clancy TV, Ramshaw DG, Maxwell JG, et al. Management outcome in splenic sition of data: Velmahos, Zacharias, Emhoff, Hurst, injury: a statewide review. Ann Surg. 1997;226(1):17-24. Crookes, Harrington, Brotman, Burke, Davis, Gupta, 9. Peitzman AB, Heil B, Rivera L, et al. Blunt splenic injury in adults: multi- Winchell, Desjardins, Alouidor, Gross, Rosenblatt, and institutional study of the Eastern association for the surgery of trauma. J Trauma. Schulz. Analysis and interpretation of data: Velmahos, 2000;49(2):177-189. 10. Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Zacharias, Feeney, Harrington, Gregg, Brotman, Davis, Organ injury scaling: spleen and liver. J Trauma. 1995;38(3):323-324. Winchell, Desjardins, Gross, and Chang. Drafting of the 11. Smith J, Armen C, Cook CH, Martin LC. Blunt splenic injuries: have we watched manuscript: Velmahos and Gregg. Critical revision of the long enough? J Trauma. 2008;64(3):656-665. manuscript for important intellectual content: Velmahos, 12. Richardson JD. Changes in the management of injuries to the liver and spleen. Zacharias, Emhoff, Feeney, Hurst, Crookes, Harring- J Am Coll Surg. 2005;200(5):648-669. 13. Velmahos GC, Toutouzas KG, Radin R, Chan L, Demetriades D. Nonoperative treat- ton, Brotman, Burke, Davis, Gupta, Winchell, Desjar- ment of blunt injury to solid abdominal organs: a prospective study. Arch Surg. dins, Alouidor, Gross, Rosenblatt, Schulz, and Chang. 2003;138(8):844-851. Statistical analysis: Chang. Administrative, technical, and 14. Cohn SM, Arango JI, Myers JG, et al. Computed tomographic grading systems material support: Velmahos, Zacharias, Hurst, Gregg, poorly predict the need for intervention after spleen and liver injuries. Am Surg. 2009;75(2):133-139. Brotman, Burke, and Gross. Study supervision: Velma- 15. Crawford RS, Tabbara M, Sheridan R, Spaniolas KG, Velmahos GC. Early dis- hos, Zacharias, Emhoff, Brotman, Alouidor, and Gross. charge after nonoperative management for splenic injuries: increased patient risk Previous Presentations: This study was presented at the caused by late failure? Surgery. 2007;142(3):337-342. 90th Annual Meeting of the New England Surgical So- 16. Sclafani SJA, Shaftan GW, Scalea TM, et al. Nonoperative salvage of computed ciety; September 11, 2009; Newport, Rhode Island; and tomography-diagnosed splenic injuries: utilization of angiography for and embolization for hemostasis. J Trauma. 1995;39(5):818-827. is published after peer review and revision. 17. Dent D, Alsabrook G, Erickson BA, et al. Blunt splenic injuries: high nonoper- ative management rate can be achieved with selective embolization. Surgery. 2004; 136:891-899. 18. Davis KA, Fabian TC, Croce MA, Gavin TJ. Improved success in nonoperative REFERENCES management of blunt splenic injuries: embolization of splenic artery pseudoaneurysms. J Trauma. 1998;44(6):1008-1015. 1. Pachter HL, Guth AA, Hofstetter SR, Spencer FC. Changing patterns in the man- 19. Harbrecht BG, Ko SH, Watson GA, Forsythe RM, Rosengart MR, Peitzman AB. agement of splenic trauma: the impact of nonoperative management. Ann Surg. Angiography for blunt splenic trauma does not improve the success of nonop- 1998;227(5):708-719. erative management. J Trauma. 2007;63(1):44-49. 2. Konstantakos AK, Barnoski AL, Plaisier BR, Yowler CJ, Fallon WF Jr, Malangoni 20. Moore FA, Davis JW, Moore EE Jr, Cocanour CS, West MA, McIntyre RC Jr. MA. Optimizing the management of blunt splenic injury in adults and children. Western Trauma Association (WTA) critical decisions in trauma: management Surgery. 1999;126(4):805-813. of adult blunt splenic trauma. J Trauma. 2008;65(5):1007-1011.

INVITED CRITIQUE Preservation of the Most Severely Injured Spleen: Is There Anything New?

he NOM failure rate in this study was 34.5% for increased length of stay, morbidity, and trend toward in- patients with grade IV and 60% for grade V in- creased mortality. T jury, comparing favorably with the failure rate Recent literature2,3 has suggested that vascular inju- of 33.3% for grade IV and 75% for grade V reported in ries of the spleen (eg, active splenic bleeding, pseudo- the Eastern Association for the Surgery of Trauma (EAST) aneurysm formation, posttraumatic arteriovenous fis- multi-institutional study1 in 2000. tula seen on contrast enhanced CT) are associated with In this study grade V splenic injury and brain injury increased likelihood of failed NOM, and that CT-based were independent predictors of failure of NOM, and con- grading algorithms that incorporate vascular injuries are trast extravasation and brain injury were associated with more discriminating in identifying high-grade splenic in-

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