Clinical parameters for the early detection of complications in patients with blunt hepatic and/or splenic injury undergoing non-operative management.

BACKGROUND: Complications arising during non-operative management (NOM) of blunt hepatic and/or splenic trauma, particularly in cases of severe injury, are associated with significant morbidity and mortality. Abdominal computed tomography (CT) is the gold standard for the initial detection of complications during NOM. Although many institutions advocate routine in-hospital follow-up scans to improve success rates, others recommend a more selective approach. The use of follow-up CT remains a subject of ongoing debate, with no validated guidelines available regarding the timing, effectiveness, or intervals of follow-up imaging. OBJECTIVE: We aimed to identify the clinical parameters for the early detection of complications in patients with blunt hepatic and/or splenic injury undergoing NOM. MATERIALS AND METHODS: This retrospective cohort study included patients with blunt hepatic and/or splenic trauma treated at Songklanagarind Hospital, a level 1 trauma center, from 2013 to 2022. We assessed all patients indicated for non-operative management and examined their clinical parameters and complications. RESULTS: Of 542 patients with blunt hepatic and/or splenic injuries, 315 (58%) were managed non-operatively. High-grade hepatic injuries were significantly associated with complications, as determined through a multivariate logistic regression analysis after adjusting for factors such as contrast blush findings, age, sex, and injury severity score (ISS) (adjusted OR = 7.69, 95% CI 1.59-37.13; p = 0.011). Among the patients with complications (n = 27), 17 (63%) successfully underwent non-operative management. Notably, eight patients presented with clinical symptoms prior to the diagnosis of complications, while only two patients had no clinical symptoms before the diagnosis. Tachycardia, abdominal pain, decreased hematocrit levels, and fever were significant indicators of complications (p < 0.05). CONCLUSION: Routine CT to detect complications may not be necessary in patients with asymptomatic low-grade blunt hepatic injuries. By contrast, in those with isolated blunt hepatic injuries that are managed non-operatively, high-grade injuries, the presence of a contrast blush on initial imaging, and the patient's age may warrant consideration for routine follow-up CT scans. Clinical symptoms and laboratory observations during NOM, such as tachycardia, abdominal pain, decreased hematocrit levels, and fever, are significantly associated with complications. These symptoms necessitate further management, regardless of the initial injury severity, in patients with blunt hepatic and/or splenic injuries undergoing NOM.

Acute portal vein thrombosis in an isolated, blunt, minor liver injury near the porta hepatis.

Portal vein thrombosis (PVT) secondary to blunt abdominal trauma associated with liver injury is extremely rare in healthy individuals as well as in minor liver injury, and it carries a high rate of morbidity and mortality. Moreover, acute asymptomatic PVT is difficult to diagnose. We present a young trauma patient with isolated minor liver injury associated with acute PVT. A 27-year-old man presented to the emergency department after a motor vehicle collision. His primary survey findings were unremarkable. His secondary survey showed a large contusion (7 cm × 7 cm) at the epigastrium with marked tenderness and localized guarding. The CT angiography of the whole abdomen revealed liver injury grade 3 in hepatic segments 2/3 and 4b (according to the American Association for the Surgery of Trauma classification) extending near the porta hepatis with patent hepatic and portal veins and without other solid organ injury. The follow-up CT of the whole abdomen on post-injury day 7 showed a 1.8-cm thrombus in the left portal vein with patent right portal and hepatic veins, and a decreased size of the hepatic lacerations. A liver function test was repeated on post-injury day 4, and it revealed improved transaminitis. The patient received intravenous anticoagulant therapy with low-molecular-weight heparin according to weight-based dosing for treatment. The CT of the whole abdomen performed 2 weeks after anticoagulant therapy showed small residual thrombosis in the left portal vein. The patient received intravenous anticoagulant therapy for a total 3 months. On the follow-up visits at 1 month, 2 months, 6 months, and 1 year after the injury, the patients did not have any detectable abnormal symptoms. PVT post-blunt minor liver injury is an extremely rare complication. If the thrombosis is left untreated, serious morbidity and mortality can ensue. However, its diagnosis in asymptomatic patients is still challenging. Periodic imaging is necessary for highly suspected PVT, especially in liver injury with lacerations close to the porta hepatis, even in cases of a minor injury.

Age as the Impact on Mortality Rate in Trauma Patients.

Background: Globally, the fastest-growing population is that of older adults. Geriatric trauma patients pose a unique challenge to trauma teams because the aging process reduces their physiologic reserve. To date, no agreed-upon definition exists for the geriatric trauma patients, and the appropriate age cut point to consider patients at increased risk of mortality is unclear. Objectives: To determine the age cut point at which age impacts the mortality rate in trauma patients in Thailand. Materials and Methods: This was a retrospective cohort and prognostic analysis study conducted in trauma patients ≥40 years. Patient data were retrieved from the trauma registry database and hospital information system in Songklanagarind Hospital. The estimated sample size of 1,509 patients was calculated based on the trauma registry data. The age with the maximum mortality rate was used as the cut point to define the elderly population. Hospital cost, intensive care unit (ICU) length of stay, gender, precomorbidity, mechanism of injury, injury severity score (ISS), and trauma and injury severity score were analyzed for any correlation with mortality, and whether or not they were associated with elderly trauma patients. Results: A total of 1,523 trauma patients ≥40 years were included in the study. The median age in both the survival and death groups was 61 years, with gender in both groups being similar (p value = 0.259). In the multivariate logistic regression analyses, the adjusted odds ratio (OR) showed that increasing age was significantly associated with mortality (OR = 1.05; 95% CI, 1.02-1.07; p value <0.001). In the age group of 70 to 79 years and >80 years, the odds of mortality were significantly increased (OR 3.29, 95% CI, 1.24-8.68; p value = 0.016 and OR 3.29, 95% CI, 1.27-12.24; p value = 0.018, respectively). Conclusion: Age is a significant risk factor for mortality in trauma patients. The mortality significantly increased at the age of 70 and higher.