Selective nonoperative management of liver and spleen injuries in neurologically impaired adult patients
L. P. Archer, F. B. Rogers and S. R. Shackford
Department of Surgery, National Naval Medical Center, Bethesda, Maryland, USA.
BACKGROUND: Nonoperative management of blunt liver and spleen injuries in
hemodynamically stable, neurologically intact patients has become an
accepted treatment in recent years. OBJECTIVE: To determine the morbidity
and mortality in neurologically impaired adult patients who had sustained
blunt liver or spleen injuries and who had been managed nonoperatively in a
monitored setting, owing to the preponderance of blunt trauma and
associated head injuries in Vermont. DESIGN: Case-control study. SETTING:
Regional level I trauma center in northern Vermont. PATIENTS: One hundred
eighty-seven consecutive patients with documented blunt splenic or hepatic
trauma who were admitted to a regional rural trauma referral center in
Vermont during an 8-year period, beginning in January 1987, were studied.
Hemodynamically stable patients underwent diagnostic imaging studies and
were classified by mental status as either normal or altered. Patients who
required operative intervention were excluded. MAIN OUTCOME MEASURES:
Morbidity and mortality rates for each group were recorded and compared to
determine if statistically significant differences between the two groups
existed. RESULTS: The groups were similar in age, systolic blood pressure,
and hematocrit at admission. The group of patients with an altered mental
status were more severely injured and had a longer hospital stay. Intensive
care unit stays were not significantly different. Transfusion requirements
for both groups were minimal; however, the group of patients with an
altered mental status received more blood transfusions compared with the
group of patients with a normal mental status. There was no significant
difference in morbidity and mortality between the two groups. There were no
failures of nonoperative management, no complications, and no missed
visceral injuries in the group of patients with an altered mental status.
Patients older than 50 years had higher morbidity and mortality.
CONCLUSIONS: Nonoperative management in patients with an altered mental
status can be done safely in a monitored setting. This challenges the
current criteria of excluding neurologically impaired patients with liver
or spleen trauma from nonoperative management.
