Nonoperative management of solid abdominal organ injuries from blunt trauma: Impact of neurologic impairment

The role of nonoperative management of solid abdominal organ injury from bl unt trauma in neurologically impaired patients has been questioned. A state wide trauma registry was reviewed from January 1993 through December 1995 f or all adult (age >12 years) patients with blunt trauma and an abdominal so lid organ injury (kidney, liver, or spleen) of Abbreviated Injury Scale sco re greater than or equal to2. Patients with initial hypotension (systolic b lood pressure <90 mm Hg) were excluded. Patients were stratified by Glasgow Coma Score (GCS) into normal (GCS 15), mild to moderate (GCS 8-14), and se vere (GCS <less than or equal to>7) impairment groups. Management was eithe r operative or nonoperative; failure of nonoperative management was defined as requiring laparotomy for intraabdominal injury more than 24 hours after admission. In the 3-year period 2327 patients sustained solid viscus injur ies; 1561 of these patients were managed nonoperatively (66 per cent). The nonoperative approach was initiated less frequently in those patients with greater impairment in mental status: GCS 15, 71 per cent; GCS 8 to 14, 62 p er cent; and GCS less than or equal to7, 50 per cent. Mortality, hospital l ength of stay, and intensive care unit days were greater in operatively man aged GCS 15 and 8 to 14 groups but were not different on the basis of manag ement in the GCS less than or equal to7 group. Failure of nonoperative mana gement occurred in 94 patients (6%). There was no difference in the nonoper ative failure rate between patients with normal mental status and those wit h mild to moderate or severe head injuries. Nonoperative management of neur ologically impaired hemodynamically stable patients with blunt injuries of liver, spleen, or kidney is commonly practiced and is successful in more th an 90 per cent of cases. No differences were noted in the rates of delayed laparotomy or survival between normal, mild to moderately head-injured, and severely head-injured patients.