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EVALUATION OF NON OPERATIVE MANAGMENT OF BLUNT SPLENIC TRAUMA.

EVALUATION OF NON OPERATIVE MANAGMENT OF BLUNT SPLENIC TRAUMA. Presented to you. by. Hossam abd ellatif mohamed M.B.B.Ch. Resident, Department of General Surgery Faculty of Medicine, Sohag University. Supervisors. Prof. Asem Elsani Mohamed Ali

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EVALUATION OF NON OPERATIVE MANAGMENT OF BLUNT SPLENIC TRAUMA.

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  1. EVALUATION OF NON OPERATIVE MANAGMENT OF BLUNT SPLENIC TRAUMA.

  2. Presented to you by Hossam abd ellatif mohamed M.B.B.Ch. Resident, Department of General Surgery Faculty of Medicine, Sohag University

  3. Supervisors • Prof. Asem Elsani Mohamed Ali • Professor of Surgery, Department of General surgery Faculty of Medicine, Sohag University • Dr. MohamedMahmoudAli • Assistant Professor of Surgery, Department of General surgery Faculty of Medicine, Sohag University • Dr. Tarek El sayed Ftohy • Assistant Professor of Maxillofacial surgery, Department of General surgery • Faculty of Medicine, Sohag University

  4. Trauma represents a global public health concern with an estimated 5 million deaths annually. Moreover, the incidence of blunt traumatic injuries particularly road traffic accidents and workplace-related injuries are rising throughout the world-wide. (Asim et al, 2014).

  5. The spleen is the most commonly injured organ following blunt abdominal trauma, and is affected in about one-third of patients with traumatic abdominal injuries, this injury is potentially fatal due to the risk of developing hemorrhagic shock, hypo perfusion and multiple organ dysfunction syndrome. (Rothrock et al, 2000).

  6. According to the American Association for the Surgery of Trauma-AAST splenic injury scale is the most widely used grading system for splenic trauma(Croce et al, 1991).grade I--V • Grade I • Sub capsular haematoma <10% of surface area • Capsular laceration <1 cm depth

  7. Grade II Sub capsular haematoma 10-50% of surface area Intraparenchymal haematoma <5 cm in diameter Laceration 1-3 cm in depth not involving trabecular vessels

  8. Grade III Sub capsular haematoma >50% of surface area or expanding Intraparenchymal haematoma >5 cm or expanding Laceration >3 cm in depth or involving trabecular vessels Ruptured subcapsular or parenchymal haematoma

  9. Grade IV Laceration involving segmental or hilar vessels with major devascularisation (>25% of spleen)

  10. Grade V Shattered spleen Hilar vascular injury with splenic devascularisation

  11. In the past splenectomy was the standard procedure for traumatic blunt splenic injury, when bleeding of the spleen occurred. This operative approach was based on the concept that spleen does not play essential functions for life and consists of a highly vascularized parenchyma that may cause uncontrollable bleeding, if not surgically removed, even in case of minor lesions. (Mile ski et al, 2007).

  12. The non-operative management, first routinely used in children with success rate of 75–93 %, has become the standard initial treatment for blunt splenic trauma in haemodynamically stable patients. In an effort to limit surgical risks and preserve an individual’s immunity against encapsulated organisms, trauma surgeons have shifted away from mandatory surgical exploration over the past 25 years. (Santucci et al, 2005).

  13. The standard criteria for NOM are: • Hemodynamic stability/ readily stabilizable (a systolic pressure >90 mmHg after adequate resuscitation (1 L of intravenous fluids within 1 hour). • Lack of rebound and guarding. • Blood transfusions ≤ 4 units. • No lack of consciousness. • Age < 55 years. • The only absolute indication for emergency laparotomy is hemodynamic instability. (Beuran et al, 2012).

  14. Conservative management generally includes: • Hospital admission for 2–5 days of bed rest. • Intravenous hydration. • Antibiotic therapy. • Monitoring of hemoglobin and vital signs. • Admission to the intensive care unit (ICU) is not mandatory. • Serial of physical examination and laboratory studies during conservative management recommended. • Providing blood transfusions for patients with a 20% decrease in hematocrit or clinical signs of continued blood loss. (Beuran et al, 2012).

  15. The non-operative management was considered unsuccessful if, during observation, the following conditions occurred: hemodynamic instability, progressive fall in hemoglobin level, diffuse peritonitis or detection of missed abdominal injuries requiring surgery. It was considered successful when the patient discharged with the spleen in situ. (Brillantino et al, 2016).

  16. In this study, we conducted a prospective trial to evaluate non-operative management after blunt splenic injuries in patients managed in Sohag University Hospital over a period of one year,A total of 71 patients were admitted to the emergency.Patient age ranged from 2 to 85 years with a mean of 18.2 years at time of presentation in emergency, 20(28.2%) of them were females, and 51 (71.8%) were males. , 53 patients (74.6%) were hemodynamically stable while 18 patients (25.4%) were unstable.

  17. A total of 39 patients (54.9%) fell from height, where 32 (45.1%) cases had motor vehicle accident. Splenic injury grade was assessed using the AAST scale, 2 (2.8%) patients had grade I injuries, 7 (9.9%) patients with grade II, 29 (40.8%) patients were grade III, 25(35.4%) patients with grade IV, and 8 (11.2%) patient had grade V injury. Conservative management was successful in 56 (78.9%) cases while 15(21.1%) patients needed operative intervention. The main indication of surgery was hemodynamic instability in addition to penetrating injuries or peritonitis.

  18. Successful non-operative management of splenic injuries. According to AAST grade injuries (Croce et al, 1991). Grades Successful NOM I 100% II >95% III 80% IV 65–70% V <10% (Croce et al, 1991). In our study, from our 71 cases we had the following results, Grades Successful NOM I 100% II 100% III 100% IV 65–70% V 0%

  19. Factors had significant relation with conservative management: • Haemodynamical status of patients, (p-value .000). • grade of splenic trauma, (p-value .000). • Abdominal examination ( laxity of abdomen and absence of dullness ,shifting dullness ) (p-value .000). • Level of Total leucocytic count and Haemoglobin,correlate (p-value .001), (p-value .02). • On the other side, some factors had no significant effect on conservation (age ,gender, occupation ,mode of trauma(FFH,MCA),time of trauma(recent ,old) ,address and splenic trauma alone or combined with(liver,kidney,lung).

  20. Following hospital discharge, Activity restriction. Routine clinical follow-up are recommended. Follow up imaging has provided valuable information about healing patterns. Within 6 weeks of injury, CT examinations have demonstrated apparent complete healing in half of all splenic injuries (of any grade). Complete healing of all grades is seen 3 months after injury. (Farquharson et al, 2014).

  21. NOM of BST, is the treatment of choice for the American Association for the Surgery of Trauma grades I, II, III while grade IV and V can also be treated conservatively with hemodynamicaly stable patient with strict monitoring.

  22. References • Asim R, Mohammad D. "Blunt traumatic injury in the Arab Middle Eastern populations". J emerg, trauma shock. 2014; 7.2: 88.‏ • Brillantino A. "Non operative management of blunt splenic trauma: a prospective evaluation of a standardized treatment protocol".  Ear J Trauma Emerg Surg2016; 42.5: 593-98.‏ • Caroche G, Roberto L. "Is non-operative management safe and effective for all splenic blunt trauma? A systematic review".  Critical Care 2013; 17.5: 185. • Croce H, Martin A. "AAST organ injury scale: correlation of CT-graded liver injuries and operative findings". J Trauma Acute Care Surg 1990; 31.6: 806-12.‏ • Gabelmann A, Görich J, Merkle M. "Endovascular treatment of visceral artery aneurysms". J Endovas Therapy 2002; 9.1: 38-47.‏ • Liddell H, George H, Scott R, et al. "A Greek-English lexicon/compiled by Henry George Liddell and Robert Scott". 1940.‏ • Mileski M, William J. "Injuries to the Liver and Spleen". Trauma  2007; 15.4: 433.‏ • Richard A, Mark B. "The literature increasingly supports expectant (conservative) management of renal trauma—a systematic review". J Trauma Acute Care Surg 2005; 59.2: 491-501.‏ • Steven G, Steven M, Morgan R. "Abdominal trauma in infants and children: prompt identification and early management of serious and life-threatening injuries. Part I: injury patterns and initial assessment". Ped emerg care  2000; 16.2: 106-15.‏

  23. Thank you

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