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Thu May 8 22:44:52 BST 2008

That's a pity, Matthew.
Our radiologists have had great success with angioembolization. we use it for those with ongoing gradual blood loss or those who have responded to resus, but with a sizeable contrast extravasation. (I don't mean a tiny spot).
Yes, splenorraphy is an option, but then you have all the complications associated with the incision, which is fun for us surgeons, yes, but nice to avoid if possible.
You are right, though, it depends on a cooperative and available interventional radiologist, and it that sense we are very lucky.
Julie Miller
Royal Melbourne Hospital.

----- Original Message ----
From: Matthew Reeds <mgreeds at reeds.uk.com>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Thursday, May 8, 2008 11:53:28 PM
Subject: Blunt Splenic Injuries

Sal,

My comment was referring to the grossly unstable patients who have the high
grade splenic injuries (IV-V). In the low grade injuries who can be managed
conservatively and who might have an ongoing "ooze" then this is where
angiography with embolisation can be an effective tool. There is no doubt
that it is better to preserve the spleen if possible (I would not for a
minute suggest that splenectomise should be performed on all injuries!)
However, I have witnessed a number of occasions where individuals have
attempted to preserve spleens (unsuccessfully) rather than removing the
spleens and putting the patient's life in danger. [They considered it a
failure to perform a splenectomy - despite the substantial morbidity they
caused (blood products and ITU stay etc.) and the threat to the patient's
life!]

I know a number of excellent interventional radiologists who are highly
skilled (in our centre they have subspecialised - vascular, GI,
cardiothoracic & oncology interventional radiology.) Due to their heavy
elective workload, they have little scope (if any) to perform angios &
embolisation on emergency patients. If they can assist, the time it takes to
organise it (usually at least 1 hour) can seriously impact upon the
patient's morbidity and mortality. On a large number of occasions, they have
either not been able to stop the bleeding or they have "prophylatically"
embolised ("just in case") which has subsequently resulted in ischaemic
injuries and operations to remedy this (with further insult to the patient.)
This is another form of VOMIT. No doubt in your experienced hands, the
outcome would be better. I am not saying don't angio - but serious
consideration must be made to all potential options available - hence my
comment. There are also operative spleen preserving techniques (such as
splenorrhaphy or mesh wraps) which is another subject in itself.

Matthew

-----Original Message-----
From: sjasmd at aol.com [mailto:sjasmd at aol.com] 
Sent: 08 May 2008 07:30
To: trauma-list at trauma.org
Subject: Re: Blunt Splenic Injuries

matthew

what are you questioning about angio. Do you think that splenectomy is
preferable to splenic salvage? Do you have difficulties with angio or are
your interventionalists not particularly useful, interested, adept at trauma
care?

sal

-----Original Message-----

From: Matthew Reeds <mgreeds at reeds.uk.com>

To: 'Trauma &amp; Critical Care mailing list' <trauma-list at trauma.org>

Sent: Wed, 7 May 2008 2:29 pm

Subject: Blunt Splenic Injuries

If the patient is "stable" (translated to mean that the patient is not

having their "spleen preserved in a bucket") then, at least in our hospital,

they would be observed on the HDU for the first 24-48 hours. Like what used

to happen with Tim previously, grade is not a factor as to where they go as

there is not a "normal" dedicated trauma ward. If the patient shows no

clinical change after this time (they will have check Hb with HCT 12 hourly

- not 4 hourly like Tim's previous unit) and other vital signs remain

unchanged, then they get transferred to a general ward. I would not get

obsessed with specific observational readings such as BP & HR etc. - as it

is the patient's clinical condition that counts (treat the patient not the

numbers etc.) It is a change in the patient's vital signs that would warrant

reassessment of conservative management and not absolute values. After 2-4

days, if the patient remains well, they would be discharged home. Like Tim,

there is no further imaging or follow-up.

I agree with Ron that if transferring the patient to ITU is being

considered, then the patient is not "stable" and cannot be managed

conservatively (as the old saying goes - stable = a place for horses with

mess on the floor!!) In that case, I question the role for preserving the

spleen with angio rather than in a bucket. I also agree with Ron in that the

patient should not be transferred straight from the ED to ITU.

Matthew

-----Original Message-----

From: Ian Seppelt [mailto:seppeli at wahs.nsw.gov.au] 

Sent: 07 May 2008 07:50

To: trauma-list at trauma.org

Subject: Blunt splenic injuries

Quick and dirty survey:

Where do you nurse haemodynamically stable patients with an isolated

spleen injury being managed conservatively, and no other injuries? ICU?

General ward? Higher acuity ward?

What acuity of nursing? What monitors? 

Does the exact CT grade of injury matter, or merely the fact that the

patient is stable and the trauma surgeon is comfortable to watch?

Many thanks,

Ian

correspondence to: seppelt at med.usyd.edu.au

Ian Seppelt FANZCA FJFICM

Senior Staff Specialist

Dept of Intensive Care Medicine

The Nepean Hospital, PO Box 63 Penrith NSW 2751

Director of Clinical Research, Sydney West AHS

Clinical Lecturer, University of Sydney

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