Selective nonoperative management of liver and spleen injuries in neurologically impaired adult patients.

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.