Management of Blunt Solid Organ Injuries

QUESTIONS TO BE ANSWERED

as per Indian Society for Trauma and Acute Care (ISTAC) Consensus Guidelines March 2021 

1. Initial assessment of a patient with blunt abdominal trauma in ED. 

2. Management of patients with blunt liver and splenic injuries 

i. Non-operative management 

ii. Operative management 

iii. Role of interventional radiology 

iv. In special scenarios (e.g. head injury, pregnancy etc.) 

v. Complications and sequelae 

3. Critical care issues in the management of patients with solid organ injury 

4. Discharge protocols for patients with solid organ injury 

5. Follow-up protocols for patients with solid organ injury 

6. Management of patients with pancreatic injuries

1: Initial Assessment of a Patient with Blunt Abdominal Trauma

1. What should be the initial management strategy in a hemodynamically unstable patient with suspected blunt abdominal trauma (BAT)?

2. What should be the volume of the initial fluid bolus in a patient with BAT?

3. What is the role of antifibrinolytic in patients with BAT?

4. What is the role of massive haemorrhage protocols (MHPs) in trauma management?

5. What should be the blood transfusion ratio during the initial resuscitation of a trauma patient?

6. What is the role of vasopressors in haemorrhagic shock?

7. What is the role of focused assessment with sonography for trauma (FAST) in the initial assessment of BAT?

2: Non-operative management (NOM) of Blunt Liver and Splenic Injury (BLSI)

1. How frequently should serial clinical examination (SCE) be performed in NOM?

2. What should be the frequency of laboratory parameters to be measured during NOM?

3. What is the role of repeat imaging during the hospital stay in NOM?

4. For how long a patient should be monitored in the hospital for NOM?

5. Is there any role of prophylactic antibiotics in NOM for BLSI?

6. What is the role of prophylactic intraperitoneal drain placement for haemoperitoneum in BLSI?

3: Operative Management of Blunt Liver Injury (BLI)

1. What are the criteria for the decision of operative management of BLI?

2. What should be the intraoperative surgical approach to BLI?

4: Operative Management of Blunt Splenic Injury (BSI)

1. What are the criteria for Operative Management (OM) of BSI?

2. Should splenic salvage be attempted during OM of patients with BSI?

3. Is there any role of splenic tissue replantation after splenectomy?

4. How should a splenic injury be managed when found incidentally during laparotomy?

Best Practice Statement The injured spleen should be mobilized to determine the full extent of the injury before deciding for further management.

5: Angioembolization in Blunt Liver Injury (BLI)

1. What is the role of AE in patients with BLI'?

2. Should prophylactic AE be considered in a haemodynamically stable patient with a high-grade (grade IV-V) BLI?

3. Should AE be considered routinely in BLI after operative intervention?

4. Should AE be done in BLI with concomitant injuries??

5. Which type of AE protocol (permanent or temporary) should be used?

6. Does AE increase the rate of biliary complications?

7. Does complication rate vary with the type of material used (gel foam or coil) and selectivity (selective/ non-selective) of AE?

Recommendation: No recommendation can be made regarding the choice of material used in terms of complications. 

Best Practice Statement: Super selective AE should be considered as it is associated with less complications.

 

6: Angioembolization (AE) in Blunt Splenic Injury (BSI)

1. What is the role of SAE in patients with a BSI?

2. Which is the preferred technique of SAE with respect to selectivity and material used?

3. How safe is SAE in the BSI with respect to post embolization complication?

Statement 

Level 4: The frequency of significant complications after SAE is minimal and more likely to occur with distal embolization

4. What are the effects of SAE on immune function?

5. What is the alternative to SAE in case it is not available?

7: Critical Care Issues in Blunt Liver and Splenic Injury (BLSI)

1. What are the ventilatory targets for patients with BLSI?

2. What should be the target haemoglobin (Hb) level in patients with BLSI?

3. Does the measurement of serum lactate or base deficit have any importance in BLSI patients?

Recommendation 

Grade B: We recommend routine measurement of serum lactate levels or base deficit in patients with BLSI.

4. How to monitor the coagulation profile in patients with BLSI?

Recommendation 

Grade B: Early and repeated coagulation profile either by traditional method or viscoelastic method (VEM) in haemodynamically unstable patients with solid organ injury, is recommended.

5. What should be the target systolic blood pressure and mean blood pressure in haemodynamically unstable patients with BLSI?

Recommendation

 Grade B: Target systolic blood pressure of 90–100 mm Hg and mean arterial blood pressure of 50–60 mmHg is recommended in an adult BLSI patient without comorbidities.

6. What should be the type and amount of IV fluids administered in trauma patients?

7. What should be the target body temperature in a trauma patient?

Recommendation 

Grade B: We recommend the maintenance of normothermia (36°C-37°C) in trauma patients.

8. What should be the ideal mode and timing of thromboprophylaxis in patients with BLSI?

9. What is the role of abdominal girth charting in patients with BLSI?

Recommendation 

Grade D: Abdominal girth charting may be considered along with other vital parameters in patients with BLSI.

8: Management of Blunt Liver and Splenic Injury (BLSI) in Special Scenarios

1. How trauma management is different in pregnancy?

 

Assessment and management of the pregnant trauma patient. Based on the content in Katz, 2012. ACLS advanced cardiac life support, CT computed tomography, EDT emergency department thoracotomy, FHT fetal heart tones, GA gestational age, GCS Glasgow coma score, HR heart rate, ISS injury severity score, NICU neonatal intensive care unit, ROSC return of spontaneous circulation

> Pseudocholinesterase levels Decreased in pregnancy —consider lower dose of succinylcholine during rapid sequence induction

2. What are the concerns regarding radiation exposure in a pregnant trauma patient?

3. What should be the management approach to BLSI with concomitant traumatic brain injury (TBI)?

4. What should be the management approach to a patient with BLSI with pre-existing coagulation disorder?

9: Complications and Sequelae of Blunt Liver Injury (BLI)

1. Does the management plan impact the complication rate in patients with BLI?

Statement 

Level 2a: Blunt liver injuries have a higher complication rate with operative management.

2. Does the grade of injury impact the complication rate in patients with BLI?

Statement 

Level 2a: Complication rate increases with higher grades of liver injury.

3. What should be the management strategy in the failure of NOM?

4. What should be the appropriate management strategy for biliary complications following BLI?

5. What should be the most appropriate management for hepatic or perihepatic abscess?

6. What is the appropriate management of Haemobilia?

7. What should be the most appropriate management for post-traumatic Bilhemia?

10: Complications and Sequelae of Blunt Splenic Injury (BSI)

1. What should be the management approach to the failure of NOM in BSI?

2. What is the choice of management for Delayed Splenic Haemorrhage (DSH)?

Various reasons may be attributed to DSH such as expansion and rupture of a small subcapsular hematoma, sub-optimal initial imaging (poor timing of phase, contrast volume <100ml or rate <4ml/s, imaging artefact, poor study acquisition), delayed appearance and rupture of pseudoaneurysms, and direct action of fracture rib edge on the splenic capsule and parenchyma

3.1 What are the rationale and ideal time of vaccination after splenectomy in trauma? 

3.2 Is antibiotic prophylaxis for Opportunistic Post Splenectomy Infection (OPSI) routinely indicated after splenectomy?

4. What are the preventive measures for postoperative thromboembolic (TE) complications after BSI?

11: Discharge and Follow-up Protocols for Patients with Blunt Liver and Splenic Injury (BLSI)

1. What should be the frequency of follow up after successful NOM in BLSI?

Best practice statement: We recommend that patients with BLSI managed non-operatively should be followed at seven days after discharge.

2. What is the role of reimaging at follow-up in patients with BLSI managed non-operatively?

3. What is the time to return to regular activity in a patient with BLSI managed non-operatively?

12: Management of Pancreatic Injury

1. What is the role of serum amylase and lipase levels in the diagnosis of pancreatic injury?

2. What is the role of contrast-enhanced ultrasonography (CEUS) in the diagnosis of pancreatic injuries?

3. What is the role of CECT scan in the diagnosis of pancreatic injury

4. What are the indications of magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) in the management of pancreatic injury

5. What is the management of choice for the patients with grade I and II pancreatic injuries detected on a CECT or found incidentally intraoperatively?

6. How should grade III pancreatic injuries be managed?

7. Should the spleen be preserved while performing a distal pancreatectomy (DP)?

8. What is the optimum surgical technique of pancreatic stump closure after DP?

9. What is the management approach to grade IV and V pancreatic injuries?

10. What are the common complications following pancreatic injury? What should be the optimal treatment modality for the management of complications of pancreatic injury?