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Open Access

Quantity of hemoperitoneum is associated with need for intervention in patients with stable blunt splenic injury

Kristin Salottolo, Robert M Madayag, Michael O'Brien, James Yon, Allen Tanner, Andrew Topham, Mark Lieser, Matthew M Carrick, Charles W Mains, David Bar-Or
DOI: 10.1136/tsaco-2019-000406 Published 9 February 2020
Kristin Salottolo
1Trauma Research, Swedish Medical Center, Englewood, Colorado, USA
2St. Anthony Hospital, Lakewood, Colorado, USA
3Penrose-St. Francis Health Services, Colorado Springs, Colorado, USA
4Radiology, Wesley Medical Center Trauma Services, Wichita, Kansas, USA
5Trauma Services, Research Medical Center, Kansas City, Missouri, USA
6Medical Center of Plano, Plano, Texas, USA
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Robert M Madayag
2St. Anthony Hospital, Lakewood, Colorado, USA
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Michael O'Brien
3Penrose-St. Francis Health Services, Colorado Springs, Colorado, USA
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James Yon
1Trauma Research, Swedish Medical Center, Englewood, Colorado, USA
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Allen Tanner
3Penrose-St. Francis Health Services, Colorado Springs, Colorado, USA
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Andrew Topham
4Radiology, Wesley Medical Center Trauma Services, Wichita, Kansas, USA
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Mark Lieser
5Trauma Services, Research Medical Center, Kansas City, Missouri, USA
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Matthew M Carrick
6Medical Center of Plano, Plano, Texas, USA
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Charles W Mains
2St. Anthony Hospital, Lakewood, Colorado, USA
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David Bar-Or
1Trauma Research, Swedish Medical Center, Englewood, Colorado, USA
2St. Anthony Hospital, Lakewood, Colorado, USA
3Penrose-St. Francis Health Services, Colorado Springs, Colorado, USA
4Radiology, Wesley Medical Center Trauma Services, Wichita, Kansas, USA
5Trauma Services, Research Medical Center, Kansas City, Missouri, USA
6Medical Center of Plano, Plano, Texas, USA
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    Figure 1

    Presence of radiographic features by quantity of HP. BSI, blunt splenic injury; HP, hemoperitoneum.

  • Figure 2
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    Figure 2

    Rate (%) of observation by quantity of HP and AAST grade. AAST, American Association for the Surgery of Trauma; HP, hemoperitoneum.

Tables

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  • Table 1

    Demographics and clinical characteristics by quantity of HP

    CovariateNo HP
    (n=146)
    Minimal HP (n=92)Moderate HP (n=76)Large HP
    (n=46)
    P value
    General characteristics
     Age, years*38 (25–55)36 (25–54)35.5 (25–55)30.5 (24–52)0.51
     Age≥65 years11.0% (16)6.5% (6)13.2% (10)13.0% (6)0.48
     Female sex37.7% (55)25.0% (23)27.6% (21)37.0% (17)0.15
     Cause of injury0.24
     Vehicular cause78.1% (114)78.3% (72)69.7% (53)65.2% (30)
     Fall cause14.4% (21)13.0% (12)13.2% (10)21.7% (10)
     Other cause7.5% (11)8.7% (8)17.1% (13)13.0% (6)
    ISS*17 (10–24)21 (14–29)17 (10–26)17 (14–27)0.04
    ED GCS 3–813.0% (19)18.5% (17)11.8% (9)6.5% (3)0.25
    ED RR<12 or >2025.4% (33)22.7% (20)27.4% (20)25.6% (11)0.92
    ED HR>12010.4% (15)12.4% (11)9.2% (7)10.9% (5)0.93
    Blood type O30.8% (45)34.8% (32)50.0% (38)39.1% (18)0.04
    First Hb<10ˆ9.6% (14)5.4% (5)10.5% (8)21.7% (10)0.03
    Radiographic characteristics
     High AAST grade (IV/V)5.48% (8)16.30% (15)28.95% (22)50.00 (23)<0.001
     Non-surgical abdominal finding4.1% (6)6.5% (6)9.2% (7)6.5% (3)0.51
     Blush (any)8.4% (12)9.1% (8)24.3% (18)29.6% (13)<0.001
     Splenic vascular injury2.1% (3)2.4% (2)4.2% (3)13.6% (6)0.01
    Definitive management<0.001
     Observation89.0% (130)82.6% (76)56.6% (43)50% (23)
     SAE8.9% (13)17.4% (16)42.1% (32)47.8% (22)
     fNOM2.1% (3)0%1.3% (1)2.2% (1)
    Outcomes
     Mortality1.4% (2)4.4% (4)5.3% (4)2.2% (1)0.35
     ICU admission79.5% (116)87.0% (80)92.1% (70)87.0% (40)0.07
     # blood products*5 (2–12)5 (2–8)3 (2–5)4 (2–7)0.56
     Hospital LOS*6 (3–12)7 (4–14)6 (4–11)6 (3–8)0.33
     ICU LOS*2 (1–5)3 (2–6)3 (2–5)3 (2–4)0.10
    • Bold values denote significance <0.05.

    • *Results presented as median (IQR).

    • AAST, American Association for the Surgery of Trauma; fNOM, failing nonoperative management; GCS, Glasgow Coma Score; HP, hemoperitoneum; HR, heart rate; ICU, intensive care unit; ISS, injury severity score; SAE, splenic artery embolization.

  • Table 2

    Demographics and clinical characteristics by definitive management

    CovariateObservation (n=272)Intervention* (n=88)P value
    General characteristics
     Age, years†34 (25–53)42.5 (26–57)0.03
     Age≥65 years9.2% (25)14.8% (13)0.14
     Female sex33.1% (90)29.6% (26)0.54
     Cause of injury0.64
     Vehicular cause72.3% (202)76.1% (67)
     Fall cause14.3% (39)15.9% (14)
     Other cause11.4% (31)8.0% (7)
    ISS†17 (10–24)22 (16–29)<0.001
    ED GCS 3–813.6% (37)12.5% (11)0.79
    ED RR<12 or>2022.3% (56)33.7% (28)0.04
    ED HR>12010.1% (27)12.6% (11)0.50
    Blood type O33.5% (91)47.7% (42)0.02
    First Hb<10ˆ10.3% (28)10.2% (9)0.99
    Radiographic characteristics
     High AAST grade (IV/V)10.29% (28)45.45% (40)<0.001
     Non-surgical abdominal finding5.2% (14)9.1% (8)0.18
     Blush10.3% (27)27.9% (24)<0.001
     HP52.2% (142)81.8% (72)<0.001
     Splenic vascular injury1.2% (3)13.3% (11)<0.001
    Outcomes
     Mortality2.94 (8)3.41 (3)0.82
     ICU admission80.5% (219)98.9% (87)<0.001
     # blood products†3.5 (2–10)3 (2–6)0.45
     Hospital LOS†5 (3–10)8.5 (5–14)<0.001
     ICU LOS†2 (1–5)4 (2–8)<0.001
    • Bold values denote <0.05.

    • *Intervention: SAE (n=83) or failed NOM (n=5).

    • †Median (IQR).

    • AAST, American Association for the Surgery of Trauma; GCS, Glasgow Coma Score; HP, hemoperitoneum; ICU, intensive care unit; ISS, injury severity score; NOM, nonoperative management; SAE, splenic artery embolization.

  • Table 3

    Logistic regression modeling the need for SAE or failing nonoperative management, vs. successful observation

    CovariateOR
    (95% CI)
    P value
    No HP1.0 (Ref)Ref
    Small HP1.21 (0.46 to 2.76)0.80
    Moderate HP3.51 (1.49 to 8.26)0.004
    Large HP2.89 (1.03 to 8.06)0.03
    Age (10-unit increase)1.25 (1.06 to 1.49)0.01
    Male sex vs. females1.55 (0.76 to 3.17)0.23
    ISS (10-unit increase)1.39 (0.96 to 2.00)0.08
    Blood type O vs. other1.60 (0.83 to 3.07)0.16
    Abnormal RR vs. RR 12–201.82 (0.90 to 3.71)0.10
    Blush vs. not1.39 (0.62 to 3.14)0.43
    Splenic vascular injury vs. not5.88 (1.12 to 30.99)0.04
    Initial hemoglobin <100.52 (0.16 to 1.75)0.29
    BSI grade (continuous)2.41 (1.68 to 3.47)<0.001
    • Variables marginally associated in the univariate analysis (p<0.15) were included in the final multivariate logistic regression model. Model fit: AUROC: 0.87; r2=0.47. Bold values denote p<0.05.

    • AUROC, area under the receiver operating characteristic curve; BSI, blunt splenic injury; HP, hemoperitoneum; ISS, injury severity score; RR, respiratory rate; SAE, splenic artery embolization.

  • Table 4

    Logistic regression modeling the need for SAE or failing nonoperative management, vs. successful observation: subset of patients with low grade I–III injury and absence of blush and splenic vascular injury (n=258)

    CovariateOR
    (95% CI)
    P value
    No HP1.0 (Ref)Ref
    Small HP0.68 (0.22 to 2.06)0.49
    Moderate HP5.55 (2.07 to 14.82)<0.001
    Large HP4.88 (1.23 to 19.40)0.03
    Age (10-unit increase)1.40 (1.12 to 1.74)0.003
    Male sex vs. females2.77 (1.03 to 7.40)0.04
    ISS (10-unit increase)1.60 (1.04 to 2.46)0.03
    Blood type O vs. other1.93 (0.85 to 4.36)0.12
    Abnormal RR vs. RR 12–201.28 (0.53 to 3.10)0.59
    Initial hemoglobin <100.47 (0.11 to 2.08)0.32
    • Variables marginally associated in the univariate analysis (p<0.15) were included in the final multivariate logistic regression model. Model fit: AUROC: 0.80; r2=0.28. Bold values denote p<0.05.

    • AUROC, area under the receiver operating characteristic curve; HP, hemoperitoneum; ISS, injury severity score; SAE, splenic artery embolization.

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Quantity of hemoperitoneum is associated with need for intervention in patients with stable blunt splenic injury
Kristin Salottolo, Robert M Madayag, Michael O'Brien, James Yon, Allen Tanner, Andrew Topham, Mark Lieser, Matthew M Carrick, Charles W Mains, David Bar-Or
Trauma Surg Acute Care Open Feb 2020, 5 (1) e000406; DOI: 10.1136/tsaco-2019-000406

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Quantity of hemoperitoneum is associated with need for intervention in patients with stable blunt splenic injury
Kristin Salottolo, Robert M Madayag, Michael O'Brien, James Yon, Allen Tanner, Andrew Topham, Mark Lieser, Matthew M Carrick, Charles W Mains, David Bar-Or
Trauma Surg Acute Care Open Feb 2020, 5 (1) e000406; DOI: 10.1136/tsaco-2019-000406
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Quantity of hemoperitoneum is associated with need for intervention in patients with stable blunt splenic injury
Kristin Salottolo, Robert M Madayag, Michael O'Brien, James Yon, Allen Tanner, Andrew Topham, Mark Lieser, Matthew M Carrick, Charles W Mains, David Bar-Or
Trauma Surgery & Acute Care Open Feb 2020, 5 (1) e000406; DOI: 10.1136/tsaco-2019-000406
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