Overall Splenectomy Rates Stable Despite Increasing Usage of Angiography in the Management of High-grade Blunt Splenic Injury. Dolejs SC, Savage SA, Hartwell JL, Zarzaur BL. Ann Surg. 2018 Jul;268(1):179-185.
Nonoperative management of blunt splenic injury is successful in the vast majority of patients. Angiography and embolization has further improved nonoperative management success rates in several series. However, the use of angiography in many centers is selective based on computed tomography findings such as vascular abnormality or IV contrast extravasation while other centers advocate for the nonselective use of angiography for all high grade (III-V or IV-V) injuries. Dojels et al. analyzed 7 years of NTDB data to better evaluate the relationship between splenectomy and the use of angiography after high-grade (III-V) splenic injuries.
53,689 patients with high-grade injuries were analyzed. Centers that utilized angiography were more often Level I centers and overall angiography utilization rates increased from 5.7% in 2008 to 14.1% in 2014. This increased angiography utilization did not correspond to a decrease in overall splenectomy rates in angiography centers (24.1% in 2008, 23.5% in 2014). Importantly, during this same study period, overall splenectomy rates decreased in non-angiography centers (27.0% in 2008, 20.7% in 2014). The rate of early splenectomy (<6 hours) was stable over time in angiography and non-angiography centers across all injury grades. While the rates of late splenectomy (>6 hours) decreased over the study period in both angiography and non-angiography centers, the decrease was greater in non-angiography centers (6.0% in 2008, 3.3% in 2014). This well-designed, carefully analyzed and executed study suggests that increased angiography utilization for high-grade blunt splenic injuries does not impact either overall or late splenectomy rates.
Prehospital spine immobilization/spinal motion restriction in penetrating trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma (EAST). Velopulos CG, Shihab HM, Lottenberg L, Feinman M, Raja A, Salomone J, Haut ER. J Trauma Acute Care Surg. 2018 May;84(5):736-744.
More practice-changing work from the EAST Practice Management Guideline group. Spine immobilization has been associated with pressure ulcers, missed penetrating injuries, and delay to life saving interventions yet has shown limited ability to stabilize the uncommon, penetrating, “incomplete” spine injuries requiring operative fixation.
Utilizing GRADE methodology, Velopulos et al. asked 2 PICO questions analyzed with respect to 3 primary outcome measures (mortality, neurologic deficit, potentially reversible neurologic deficit): In adult penetrating trauma patients, does spine immobilization versus no spine immobilization decrease mortality? In adult penetrating trauma patients, does spine immobilization versus no spine immobilization decrease the incidence of neurologic deficit or the incidence of potentially reversible deficit? 294 reports were identified and ultimately 24 studies were included in the qualitative analysis and 5 in the quantitative analysis. Importantly, no study included in the analysis showed a mortality or neurologic outcome benefit to spine immobilization—even in those with penetrating neck injuries.
Overall, patients without prehospital spine immobilization were 2.4x as likely to survive yet no more likely to sustain neurologic deficit or potentially reversible deficits than their counterparts who underwent spine immobilization. Based on these compelling findings, the authors made a strong recommendation against the routine use of spine immobilization in adult patients with penetrating trauma. These findings and recommendations have implications in both prehospital and ED settings. Although prehospital spinal immobilization after penetrating trauma will likely become less common over time, when penetrating trauma victims are transported with spinal immobilization, clinicians can quickly and safely remove cervical collars and longboards upon arrival.
Civilian Prehospital Tourniquet Use Is Associated with Improved Survival in Patients with Peripheral Vascular Injury. Teixeira PGR, Brown CVR, Emigh B, Long M, Foreman M, Eastridge B, Gale S, Truitt MS, Dissanaike S, Duane T, Holcomb J, Eastman A, Regner J; Texas Tourniquet Study Group. J Am Coll Surg. 2018 May;226(5):769-776.
Tourniquets have been proven effective and life-saving on battlefields. Although their use has been extrapolated to civilian settings, data proving benefit to injured civilians is scarce. In this retrospective, 11 center study from Teixeira et al., 1026 patients (17% had a pre-hospital tourniquet placed) with vascular injuries were studied over a 6-year period. Patients with prehospital tourniquet placement were compared to those without by baseline characteristics, injuries and primary (hospital mortality) and secondary (delayed amputation, VTE) study outcomes. After multiple variable logistic regression controlling for several clinical variables, no difference in delayed amputation was demonstrated in those managed with prehospital tourniquets. However, those who had a prehospital tourniquet placed were 5x as likely to survive as those transported to trauma centers without a tourniquet.
Interestingly, the use of prehospital tourniquets did not appear to decrease either the need for massive transfusion protocol activation or blood transfusion during the initial 24 hours following injury. Without a clear association with blood transfusion, the impact of prehospital tourniquets on survival is perhaps less apparent. While several other questions remain, this important manuscript has provided an essential foundation for further study and is another step towards the translation of battlefield point of injury lessons to civilian care.