Diagnosis And Treatment Of Ruptured Spleen Due To Blunt Abdominal Trauma At 103 Military Hospital - Nguyen Van Tiep

Journal of military pharmaco-medicine n o 5-2019 192 DIAGNOSIS AND TREATMENT OF RUPTURED SPLEEN DUE TO BLUNT ABDOMINAL TRAUMA AT 103 MILITARY HOSPITAL Nguyen Van Tiep1; Dang Viet Dung1 SUMMARY Objectives: To study the clinical and subclinical characteristics and treatment outcomes of patients with ruptured spleen due to blunt abdominal trauma at 103 Military Hospital. Subjects and methods: A descriptive, retrospective and prospective study on 165 patients who were diagnosed with ruptured spleen due to blunt abdominal trauma from 2013 - 2018. Results: Patients had an average age of 31.97 ± 13.58. The percentage of male patients was 78.85%. Traffic accident was the most common cause which accounted for 66.7%. Clinical signs on admission: 10.9% of cases went in shock, 12.7% had multiple injuries, 70.9% intra-abdominal bleeding, 78.8% hemodynamic stability and 12.7% had hemodynamic instability bradycardica and hypotension were 8.5%, 23.6% had associated injuries, 1.2% had peritonitis and death within the first 24 hours or after emergency surgery occurred in 1.2% of cases. Abdominal ultrasound revealed 72.1% of the cases had abdominal fluid, 77.5% had splenic lesions . CT demonstrated rupture spleen level I, II, III, IV were 27.9%, 33.9%, 26.75%, 11.5%, respectively. 79.4% of the cases were treated conservatively: 44.8% of the cases underwent abdominal drainage via ultrasound, 34.5% were treated via pharmacology methods. For those who required surgical intervention, 3.1% was done laparoscopically, 15.8% via open surgery and 1.8% was performed conservative surgery. Operation was more often performed for patients with hemodynamic instability (p < 0.05). Average hospital stay was 8.6 ± 3.8 days. Conclusion: Diagnosis of ruptured spleen due to blunt abdominal trauma depended on intra-abdominal syndrome, abdominal ultrasound and CT. Patients with hemodynamic stability were often treated conservatively and operations were often given for patients with hemodynamic instability. * Keywords: Abdominal trauma; Ruptured spleen; Blunt abdominal trauma. INTRODUCTION Blunt abdominal trauma (BAT) is a common surgical emergency and ruptured spleen is the most common complication of trauma (40 - 50%). The most common cause was traffic accident (60 - 70%). Over these years, the incidence of splenic injury has been on the rise and becoming complicated. Many years ago, people assumed that splenectomy is the surgery to treat splenic injuried caused by trauma. In recent years, conservative treatment has been used widely for ruptured spleen. Nowadays, thanks for imaging tools such as ultrasound and CT, along with physical examination, we can diagnose the quality, level, and form of splenic lesions as well as estimated blood loss due to ruptured spleen. Therefore, we can choose a suitable management method. We carried out this research: To evaluate the treatment outcomes of patients with ruptured spleen at 103 Military Hospital from 2013 - 2018. 1. 103 Military Hospital Corresponding author: Nguyen Van Tiep (chiductam@gmail.com) Date received: 10/03/2019 Date accepted: 21/05/2019 Journal of military pharmaco-medicine n o 5-2019 193 SUBJECTS AND METHODS A retrospective study from January 2013 to May 2018 at 103 Military Hospital was performed on 165 patients who were diagnosed with splenic trauma due to blunt abdominal injury based on clinical features, ultrasound imaging, abdominal CT imaging and lesions determined in surgery. Data including clinical features, causes of injury, presence of traumatic shocks, intra-abdominal hemorrhage, peritonitis and other coordinated injuries were collected. Treatment of splenic trauma due to blunt abdominal injury by non-operative or operative treatments were also determined. The data are collected and processed on Excel software with statistical algorithms. RESULTS AND DISCUSSION 165 patients diagnosed with blunt splenic injury were eligible for the study. 1. Patients’ characteristics and causes of injury. Average age: 31.97 ± 13.58, the lowest was 6 years old, the highest was 67 years old, most of them were in the group of 20 - 40 years old, accounting for 58.8% of the sample population. Males: 130 patients (78.8%); females: 35 patients (21.2%), male/female ratio: 3.7/1. * Causes of injury: Traffic accidents: 110 patients (66.7%); household accidents: 31 patients (18.8%); working accidents: 12 patients (7.3%); assault: 12 patients (7.3%). Traffic accident was the most common cause of blunt splenic injury. 2. Clinical features in blunt abdominal injury. * The conditions of patients on admission (n = 165): One patient died from multiple trauma and hypovolemic shock due to damage of multiple organs: abdominal hemorrhage, pleural effusion, pneumothorax, complicated pelvic trauma. The other was dead after emergency operation due to splenic rupture, left pleural effusion, pelvic injury, left kidney rupture, diaphragm rupture. The patients underwent splenectomy, nephrotomy, left pleural cavity drainage, suture the tear in the diaphragm and died after 6 hours. - Shock: 18 patients (10.9%) suffered from shock, all of them had severe abdominal hemorrhage, 12/18 patients had resultant multiple trauma shock. The causes of shock in blunt abdominal injury patients mostly are loss of blood and multiple trauma. - Coordinated damage: 39 patients (23.6%) had coordinated damage, there were patients who were injured 5 regions of the body: brain, chest, abdomen, limbs, facial damage. The rate of coordinated damage was alarmingly high in Nguyen Chanh Tin’s study (2003), which was 47.6%. - Multiple trauma: 21 patients (12.7%) had multiple trauma, severe damage in 2 different regions of the body, affecting some crucial functions of the body. - Severe abdominal hemorrhage: Frequently seen in blunt splenic injury, 70.9% of the patients had abdominal hemorrhage syndrome. This rate was also high in the study by Nguyen Van Long (2005) (83.5%), Peitzman A.B (83.2%) [4, 8]. Journal of military pharmaco-medicine n o 5-2019 194 - Acute peritonitis: There were 2 cases of jejuni damage and splenic injury. They were early diagnosed by ultrasound-guided abdominocentesis. * The period of time from accidents on admission: ≤ 6 hours: 78 patients (47.3%); 6 - 12 hours: 35 patients (21.2%); 12 - 24 hours: 34 patients (20.6%); > 24 hours: 18 patients (10.9%). Most patients were admitted to hospital in less than 24 hours, which accounted for 89.1%. * Patients’ hemodynamic conditions on admission (heart rate and blood pressure): - Hemodynamically stable (heart rate ≤ 100 beat/minute, systolic blood pressure ≥ 100 mmHg): 130/165 patients (78.8%). - Hemodynamically unstable (100 mmHg < heart rate ≤ 140 beat/minute and 80 mmHg < systolic beat/minute ≤ 100 mmHg): 21/165 patients (12.7%). - Rapid but weak pulse, low blood pressure (heart rate > 140 beat/minute and systolic blood pressure < 80 mmHg): 14/165 patients (8.5%). 3. Subclinical features. Table 1: Ultrasonography and ultrasound-guided abdominocentesis (n = 165). Ultrasonography and ultrasound-guided abdominocentesis Number of patients % Ultrasonography Fluid 117 72.1 No fluid 59 35.8 Envidence of splenic injury 128 77.5 Ultrasound-guided abdominocentesis Blood 85 51.5 Blood with digestive fluid 2 1.2 Ultrasonography is a method of valuable diagnosis and prognosis in treating splenic rupture due to BAT. Detection of splenic lesions on ultrasound was 77.5%. Ultrasound- guided abdominocentesis is also a valuable method. There were 85/165 patients who were sucked for diagnosis. Table 2: The relationship between CT imaging and hemodyamics of patients on admisson. CT Hemodynamics Grade I Grade II Grade III Grade IV Total Stable hemodynamics 46 52 30 2 130 Unstable hemodynamics 0 4 9 8 21 Rapid but weak pulse, low blood pressure 0 0 5 9 14 Total 46 (27.9%) 56 (33.9) 44 (26.7%) 19 (11.5%) 165 CT is valuable tool for diagnosis and evaluation of injury with splenic rupture due to BAT. In the study of the grade of splenic splitting grade I, II, III and IV, the rate was Journal of military pharmaco-medicine n o 5-2019 195 27.9%; 33.9%; 26.7%; 11.5%, respectively. The majority of patients with splenic rupture of I, II had stable hemodynamics meanwhile unstable hemodynamics was found in splenic rupture of grade III, IV. 4. Treatment. Table 3: Treatments Number of patients % Non-operative management Observation only 57 34.5 Ultrasound-guided peritoneal lavage 74 44.8 Operative management Non splenectomy operation 3 1.8 Splenectomy Laparotomy 5 3.1 Open surgery 15 9.1 Operation after lavage failure 11 6.7 Total 165 100 Non-operative management without splenectomy accounted for a small number of patients (3/34 patients). Splenectomy is still the main surgical method for patient with ruptured spleen due to injury, assisted laparoscopy still accounted for a low rate. 5 patients in another study underwent surgery after non-operative management unsuccessfully following a few days of treatment. Non-operative management is indicated for the majority of patients (79.4%). 34.5% of patients were treated with isolated non-operative management, 44.8% of patients were treated by non-operative management with abdominal drainage following the guidance of ultrasound. Table 4: The relationship between treatment and patients’ hemodynamics at admission. Hemodynamics Treatment Stable hemodynamics Unstable hemodynamics Rapid but weak pulse, low blood pressure Total Non-operative management 125 5 1 131 Operative management 5 16 13 34 Total 130 (27.9%) 21 (33.9) 14 (26.7%) 165 Bảng 5: The relationship between treatment and CT imaging. CT Treatment Grade I Grade II Grade III Grade IV Total Non-operative management 46 52 31 2 131 Operative management 0 4 13 17 34 Total 46 (27.9%) 56 (33.9) 44 (26.7%) 19 (11.5%) 165 Journal of military pharmaco-medicine n o 5-2019 196 Average time of hospitalization: 8.6 ± 3.8 days. Hemodynamics are the most important factors affecting the medical therapy: Non-operative management or sugery. The former was administered for patients with stable hemodynamics, the latter was indicated for patients with unstable hemodynamic (p < 0.05). Surgical therapy: 34 patients (20.6%) had surgery in which 29 patients had unstable hemodynamics. There were just 5 patients with stable hemodynamics who were treated by abdominal drainage under the guidance of ultrasound. However, the splenic lesions in surgical patient was at grade III and grade IV (30/34 patients). Splenic lesion at grade I and II are often treated by non-operative management, splenic lesion grade III or even grade IV is treated by the same way if patients have stable hemodynamics. In the study, 31 patients with spleen rupture grade III and 2 patients with splenic ruptured grade IV splitting were successfully treated. According to Roland A. Hernandez’s research (2010) [7], the rate of non- operative management of splenic trauma was 65%. The average hospitalization time of the patient with splenic injury treated by non-operative management was 8.2 ± 3.1 days (2 - 16 days) and 10.8 ± 5.7 days (5 - 32 days) for the patients treated by surgery. CONCLUSION Ruptured spleen caused by BAT is a surgical emergency. The common cause was traffic accident (66.7%). Diagnosis of ruptured spleen was mainly based on some symptoms and signs, including: abdominal bleeding syndrome (70.9%), abdominal ultrasound detecting abdominal fluid (72.1%), splenic lesions (77.5%). CT-scan demonstrating splenic rupture grade I, II, III, IV were 27.9%; 33.9%; 26.7%; 11.5%, respectively. Treatment of rupture spleen was mainly based on the patient's hemodynamics. Non-operative management is indicated for patients with stable hemodynamics and surgery is indicated for patients with unstable hemodynamics (p < 0.05). REFERENCES 1. Trần Văn Đảng. Nghiên cứu chỉ định và kết quả bảo tồn chấn thương lách do chấn thương bụng kín tại Bệnh viện Đa khoa tỉnh Bình Dương. Luận án Tiến sỹ Y học. Học viện Quân y. 2010. 2. Đỗ Sơn Hà, Đặng Việt Dũng, Đỗ Sơn Hải. Nhận xét kết quả điều trị bảo tồn không mổ vỡ lách do chấn thương bụng kín tại Bệnh viện Quân y 103. Tạp chí Y - Dược học Quân sự. 2014, số 3. 3. Trần Bình Giang, Nguyễn Xuân Thùy, Tôn Thất Bách. Nghiên cứu kỹ thuật mổ bảo tồn trong điều trị vỡ lách do chấn thương. Ngoại khoa. 2003, 3, tr.31-37. 4. Nguyễn Văn Long. Vài nhận xét trong bảo tồn lách không mổ ở người trưởng thành. Y học TP. HCM. 2005, tập 9, phụ bản số 1, tr.72-78. 5. Nguyễn Đức Tiến. Điều trị bảo tồn không mổ vỡ lách do chấn thương bụng kín tại Bệnh viện Hữu Nghị Việt Đức. Tạp chí Y học Việt Nam. 2011, tháng 9, số 1. 6. Trần Chánh Tín và CS. Chẩn đoán chấn thương bụng kín. Y học TP. HCM. 2003, tập 7, phụ bản số 1, tr.122-126. 7. Hernandez R.A et al. Abdominal trauma: Operative or nonoperative management. Emergency Surgery. Blackwell Publishing Ltd. 2010, pp.185-191. 8. Peitzman A.B et al. Blunt splenic injury in adults: Multi-institutional study of the Eastern Association for the Surgery of Trauma. J Trauma. 2000, 49 (2), pp.177-187; discussion 187-9.