During the study period, data of a total of 16047 patients were included. Out of these, 1134 (7 %) patients suffered from an abdominal injury. There were 267 (23.5 %) patients with
splenic injury in this cohort. Out of these 267 patients, 70 (26%) required splenectomy. In 20 cases, data regarding splenectomy or any other surgery was missing. So, these cases were excluded from the statistical analysis (Fig. 1). The mean age of the population was 27.9 years with males constituting a vast majority (86%). The commonest mechanism for splenic trauma was road traffic injuries (60%). 256 (95%) patients suffered from blunt abdominal trauma. The patient demographics, epidemiological data and vital parameters on admission are given in Table 1.
Table 1
Distribution of demographic, physiological and Process variables of the cohort
Variables
|
N = 267
|
Missing Data
|
Age
|
27.94 (± 14)
|
-
|
Sex
Male
Female
|
230 (86.1%)
37 (13.9%)
|
-
|
Type of Injury
Blunt
Penetrating
|
256 (95.9%)
11 (4.1%)
|
-
|
Mechanism of Injury
Road Traffic Accident
Fall
Railway Accident
Assault
Other
|
161 (60.3%)
66 (24.7%)
15 (5.6%)
20 (7.5%)
5 (1.9%)
|
-
|
Transfer from Other Hospital
|
143 (53.6%)
|
-
|
Mode of Transport
Ambulance
Police
Private Car
Taxi
|
139 (52.1%)
40 (15%)
52 (19.5%)
36 (13.4%)
|
-
|
Vitals on Arrival
SBP (mmHg)
HR (Beats Per Minute)
RR (Per Minute)
Spo2 (%)
GCS
Severe (< 8)
Moderate (9–12)
Mild (13–15)
|
110 (99–124)
96 (80.5-110.75)
18 (16–20)
100 (99–100)
33 (12.3%)
10 (3.8%)
207 (77.5%)
|
-
4 (1.4%)
3 (1.1%)
18 (6.7%)
28 (10.4%)
17 (6.4%)
|
Injury Severity Score (ISS)
|
17 (9–25)
|
56 (20.9%)
|
Time from Injury to Admission, minutes
|
210 (70–673)
|
9 (3.3%)
|
Continuous Values Are Listed as Median (Interquartile Range) And Categorical Variables as Count (Percentage). Age Is Listed as Mean (± Standard Deviation)
SBP Indicates Systolic Blood Pressure; HR, Heart Rate; RR, Respiratory Rate; GCS, Glasgow Coma Scale; SPO2, Oxygen Saturation.
|
The liver was the most common organ concomitantly injured followed by the intestines. Injury to thorax was noted in 119 (44.5%) cases. Out of these, rib fractures were noted in 81 cases and fractures of the thoracolumbar vertebrae or pelvis were noted in 58 (21.7%) of the patients (Fig. 2).
Out of the 267 patients, 251 (94 %) underwent focused assessment with sonography in trauma (FAST) examination; a positive result was seen in 43% of the tests. X-rays were performed for 257 (96%) patients. A CECT scan was ordered for 237 (88.8 %) cases. Out of the 30 patients not undergoing a CECT scan, x-rays were available for 26 patients. Thoracic, vertebral, or spinal fractures were diagnosed using x-rays in these patients. In the remaining 4 patients, thoracic injury in the form of hemothorax was diagnosed on extended FAST examination in one patient.
In this cohort of splenic injuries (n = 267), 12 patients underwent an emergency surgery within 1 hour of arrival and 102 more patients required operative management within 24 hours of admission. The indications of surgery were diverse, and splenectomy was performed in 70 (26%) cases. 132 (49%) patients required PCV transfusions within 24 hours of admission. Mortality was noted in 3 (8%) of grade 1 and 6 (12%) of grade 2 injuries. In contrast, mortality was noted in 9 (28%) grade 5 splenic injuries. There were overall 41 (15%) deaths in the study cohort (Table 2).
Table 2 Distribution of Investigations, Surgery and Outcomes of Splenic Trauma Patients
Investigation and Surgery
|
n = 267
|
MISSING
|
|
Hemoglobin
|
10.7 (9.07–12.83)
|
-
|
|
Hematocrit
|
29.4 (0-37.1)
|
-
|
|
X-Ray
|
257 (96%)
|
10 (3.7%)
|
|
FAST
Positive
|
251 (94%)
110 (43.8%)
|
16 (5.9%)
|
|
CT scan
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
|
237 (88.8%)
34 (12.7%)
61 (22.8%)
60 (22.4%)
47 (17.6%)
35 (13.1%)
|
30 (11.2%)
|
|
Surgery
within 1 hour
from 1 to 24 hours
|
12 (4.4%)
102 (38.2%)
|
-
|
|
Type of surgery
EEL (unspecified)
EEL + Splenectomy
EEL + Other organ repair
Others
|
20 (7.4%)
70 (26.2%)
16 (5.9%)
8 (2.9%)
|
-
|
|
PCV transfused
within 1 hour
from 1 to 24 hours
|
52 (19.4%)
80 (29.9%)
|
-
|
|
Length of hospital stay, days
|
7 (4–14)
|
1 (0.3%)
|
Mortality
|
41 (15.3%)
|
-
|
|
Continuous values are listed as median (interquartile range) and categorical variables as count (percentage).
EEL-Emergency exploratory laparotomy; FAST Focused assessment with sonography in trauma; CT computed tomography; PCV-packed cell volume; USG- Ultrasonography
|
26 (82%) of the grade 5 and 31 (67%) of grade 4 splenic injuries required operative management. All the cases of Grade 1 splenic injuries were conservatively managed (Figure 3).
Fractures of the thoracolumbar vertebrae or the pelvis, along with a splenic injury, were significantly associated with reduced odds of splenectomy. No similar association was present between rib fracture and other thoracic injuries and splenectomy. Injury severity score (ISS) was significantly higher in the patients undergoing splenectomy (Table 3).
Table 3
Unadjusted Analysis (n = 247)
|
No Splenectomy (N = 177)
|
Splenectomy (N = 70)
|
P Value
|
Odds Ratio (95% CI)
|
Age (years)
|
29
|
25
|
0.046
|
0.97 (0.95-1.0)
|
Males (%)
|
147 (81 %)
|
66 (94 %)
|
0.021
|
3.36 (1.12–9.94)
|
Blunt trauma (%)
|
169 (95 %)
|
70 (100%)
|
0.071
|
-
|
Intubated within one hour of arrival (%)
|
28 (16 %)
|
23 (32 %)
|
0.003
|
2.6 (1.37–4.94)
|
Transfusion within 24 hours of arrival (%)
|
54 (30 %)
|
39 (54 %)
|
< 0.001
|
2.86 (1.62–5.06)
|
Grade 1 (%)
|
32 (18 %)
|
0
|
-
|
-
|
Grade 2 (%)
|
54 (30 %)
|
3 (4 %)
|
-
|
-
|
Grade 3 (%)
|
48 (27 %)
|
10 (14 %)
|
0.032
|
0.44(0.21–0.94)
|
Grade 4 (%)
|
15 (8 %)
|
31 (45 %)
|
0.000
|
8.58 (4.22–17.43)
|
Grade 5 (%)
|
6 (3 %)
|
26 (37 %)
|
0.000
|
16.84 (6.52–43.43)
|
Missing grade (%)
|
22 (12%)
|
0
|
-
|
-
|
Thoracic injury (%)
|
84 (47 %)
|
29 (41 %)
|
0.391
|
0.78 (0.44–1.37)
|
Vertebral or pelvis fracture (%)
|
45 (25 %)
|
9 (13 %)
|
0.031
|
0.43 (0.19–0.94)
|
Vitals on arrival
SBP (mmHg)
HR (bpm)
RR (/minute)
SpO2 (%)
|
112
96
18
97
|
102
100
18
93
|
0.008
0.096
0.546
0.024
|
0.98 (0.97–0.99)
1.01 (0.99–1.02)
0.97(0.90–1.05)
0.97(0.94–0.99)
|
Injury severity score (ISS)
|
16
|
20
|
0.005
|
1.04 (1.01–1.08)
|
Time from injury to admission (minutes)
|
948
|
1239
|
0.565
|
-
|
Lab investigations
Hemoglobin (mg/dL)
Hematocrit
|
10.9
21
|
10.0
25
|
0.056
0. 147
|
0.90 (0.82-1.00)
1.01 (0.99–1.03)
|
Continuous variables are listed as mean and categorical variables as count (percentage).
SBP systolic blood pressure; HR heart rate; RR respiratory rate; mmHg millimeters of mercury; BPM beats per minute; SPO2 oxygen saturation.
|
Majority of patients in the splenectomy group had lower systolic blood pressure and oxygen saturation at arrival. More patients in the splenectomy group required transfusion within 24 hours of admission (p value < 0.001). A higher grade of splenic injury (grade 4 and grade 5) was associated with splenectomy (p value < 0.001). Male sex (p value 0.021) and requirement of intubation and mechanical ventilation within 1 hour of arrival (p value 0.003) were other significant predictors of splenectomy on unadjusted analysis.
On adjusted analysis, grade 4 and grade 5 splenic injuries were significantly associated with splenectomy (p value < 0.05). No other variables were statistically significant (Table 4).
Table 4
Adjusted analysis (n = 247), with Splenectomy as the Outcome
|
Odds Ratio (95% CI)
|
P Value
|
Transfusion within 24 hours of arrival
|
1.56 (0.64–3.79)
|
0.325
|
Intubated within one hour
|
1.75 (0.49–6.2)
|
0.384
|
Grade 3
|
8 (1.86–35.33)
|
0.005
|
Grade 4
|
91 (20.73-401.22)
|
0.000
|
Grade 5
|
170 (33.12-876.49)
|
0.000
|
Thoracic injury
|
0.85 (0.35–2.03)
|
0.720
|
Vertebral or pelvis fracture
|
1.15 (0.39–3.43)
|
0.791
|
Vitals on arrival
Systolic Blood Pressure
SpO2
|
0.99 (0.97–1.01)
0.96 (0.91–1.01)
|
0.409
0.118
|