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22
Thoracoabdominal Trauma
Lawrence J. Keating • Ashley Adamovich
ABDOMINAL TRAUMA
BACKGROUND
During the past three decades, management of traumatic abdominal organ
injury has evolved from a predominantly surgical approach to a strategy of
nonoperative therapy in most cases. There is now broad consensus that most
patients with injuries to solid abdominal viscera who are hemodynamically
stable are candidates for nonoperative management (NOM), although debate
persists about the specifics including when to use angiography and which
patients should proceed directly to surgery. The change in philosophy has
been in large part a result of rapid advances in imaging capabilities,
specifically computed tomography (CT), and the increasing capability of
interventional radiology to treat vascular injuries using minimally invasive
endovascular techniques. During the 1980s, diagnostic peritoneal lavage
(DPL) was obviated by the development and availability of CT. With
concurrent expansion in the capabilities of interventional radiology, the risks
of surgery began to outweigh the risks of conservative management, defined
as observation with or without angiography and embolization, in many cases.
The Organ Injury Scale (OIS)—created by a committee of the American
Association for the Surgery of Trauma (AAST) in 1987 and since updated
and validated for the liver, kidney, and spleen using National Trauma Data
Bank (NTDB)—is the most commonly used grading system for evaluation of
abdominal trauma (Table 22.1
).1 The current scale was revised in 1994 for
the spleen and liver, partly to reflect the increasing reliance on CT for
diagnosis and grading. It provides a common nomenclature for studies and
outcomes research that is used almost exclusively in the trauma literature,
although it is imperfect, particularly when used to assign prognostic value,
which is not its fundamental objective.
1,2
It is designed primarily to allow
comparison of equivalent injuries managed differently.3 In a study designed
to evaluate and compare injury grading scales, Barquist et al.4 found
significant interreader variability among radiologists in higher grade injuries
as well as a tendency to underestimate injury grades based on CT compared
to operative findings. Contrast extravasation indicating continuing
hemorrhage and vascular injuries such as pseudoaneurysm or arteriovenous
fistula are prognostic factors and may be indications for nonoperative
interventions such as angioembolization but are not specifically described in
the scale. Modifications addressing these concerns including a new CT
grading system for splenic injuries and substratification of the renal OIS
grade IV into IVa (high risk) and IVb (low risk) have been proposed but not
yet widely adopted.
5,6
The OIS enables accurate outcomes comparisons among institutions
with differing protocols, but urgent decisions in the trauma setting are
typically made based on clinical status combined with imaging findings.
Current surgical guidelines support emergency surgery for hemodynamically
unstable patients (hypotension and tachycardia unresponsive to ongoing fluid
and packed red blood cell resuscitation) and a trial of NOM for stable patients
in settings where monitored beds and surgical teams are readily available.
6–10
The new standard of conservative management has been supported and
improved by the increasing availability and effectiveness of angiography with
embolization. By 2005, up to 85% of traumatic injuries involving liver,
spleen, and kidney were managed nonsurgically.10 Shafi et al.11 studied
operative intervention and mortality rates at 152 level I and level II trauma
centers and demonstrated that hospitals with higher risk-adjusted mortality
rates tend to also have the highest rates of surgical intervention for abdominal
trauma. Various conclusions can be drawn from this, but the lowest mortality
rates will occur when we have the best understanding of which patients need
operative versus conservative management. Because randomized trials are
impractical in this setting, collective experience in the form of retrospective
studies is our principal guide.
SPLEEN
The spleen may be the most commonly injured organ in blunt abdominal
trauma.12 Aristotle considered the spleen an unnecessary organ and this was
the prevailing view until recently.13 From the first splenectomy for trauma by
Nicholaus Matthias in 1678 until the 1970s, removal of the injured spleen
was accepted, if not standard, practice. The notion that without splenectomy
most patients with splenic injury would bleed to death because the spleen
cannot heal nor be easily repaired was rarely questioned.13 Interest in splenic
preservation increased after the description in 1952 by King and
Schumacker14 of overwhelming postsplenectomy infection (OPSI) in infants.
Upadhyaya and Simpson performed the first case-control study of operative
versus nonoperative management for pediatric splenic injury and
demonstrated the safety of the latter approach in 1968.13 Children were found
to recover from these injuries surprisingly well, and by the late 1980s, the
conservative management of pediatric splenic trauma was universally
accepted, a change largely predating the radiologic advances that were crucial
to the broad adoption of this strategy in adults.
14,15
New understanding about the spleen’s role in immunocompetence
encouraged early efforts at salvage in adult trauma patients. OPSI, although
rare, with a lifetime risk of less than 0.05%, carries a mortality rate of
50%.
12,16
Less severe infectious complications are more common, including
abscess, wound infection, and pneumonia, all of which are increased after
splenectomy, compared to splenic preservation after trauma.17 The reasons
for this remain incompletely understood. The spleen represents one-quarter to