COMPUTED TOMOGRAPHIC GRADING IS USEFUL IN THE SELECTION OF PATIENTS FOR NONOPERATIVE MANAGEMENT OF BLUNT INJURY TO THE SPLEEN

Although nonoperative management of blunt splenic injury (NMBSI) has a n established role in the overall management of adult patients with bl unt splenic injury, the criteria by which patients are selected contin ue to be debated. The purpose of this study is to establish the effect iveness of a defined set of criteria that includes CT grading for the selection of patients for NMBSI by examining the outcomes of patients managed in this manner 1 year before with those 1 year after the imple mentation of this specific set of selection criteria. All patients hos pitalized at St. Joseph Mercy Hospital over the time period April 1994 through July 1996 with blunt splenic injury were included. Patients w ho died in the Emergency Department were excluded. Patients admitted f rom April 1994 through April 1995 composed Group I, those treated befo re the specific selection criteria, whereas those admitted from July 1 995 through July 1996 composed Group II, those treated after the imple mentation of selection criteria. The two groups were compared with res pect to demographic parameters, Injury Severity Score, mechanism of in jury and length of stay. Outcomes were compared between these two grou ps. Those patients successfully managed without operation were further compared with those for whom NMBSI was unsuccessful. A total of 57 pa tients met the criteria for study entry, 28 from Group I and 29 from G roup II. There were no significant differences between these two group s with respect to age, sex, mechanism of injury, Injury Severity Score , or length of stay. Nine of 27 in Group I required immediate operatio n; 19 were initially managed nonoperatively. Four of 19 required delay ed laparotomy for bleeding, and all required splenectomy. Between pati ents successfully managed nonoperatively and those requiring delayed o peration, the only significant difference was CT grade (1.47 vs 3.5; P = 0.0001). In Group II, after the implementation of selection criteri a that included CT grade, no patient required delayed operation. Eleve n underwent immediate operation, whereas 18 were successfully managed nonoperatively. We conclude that, in the hemodynamically stable patien t without clinical indication for laparotomy, CT grading of the spleni c injury is a reliable criterion by which patients may be selected for nonoperative management.