Organ injury scaling 2018 update: Spleen, liver, and kidney

Kozar, Rosemary A.; Crandall, Marie; Shanmuganathan, K.; Zarzaur, Ben L.; Coburn, Mike; Cribari, Chris; Kaups, Krista L.; Schuster, Kevin M.; Tominaga, Gail T.

doi:10.1097/ta.0000000000002058

Cited by 357 publications

(238 citation statements)

References 25 publications

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“…Uncontrollable haemorrhage following complex hepatic injury is the leading cause of mortality in these patients 7. The American Association for the Surgery of Trauma published the Organ Injury Scaling 2018 update where liver injuries were graded from level 1 through to 6 8. Injury to the hepatic arteries automatically puts the patient at a grade 3 and when that bleeding enters the peritoneal cavity such as in the reported case it becomes a grade 4.…”

Section: Discussionmentioning

confidence: 97%

Traumatic bruising of the hepatoduodenal ligament can conceal a catastrophic injury to the hepatic artery

Gerrard

Lunevičius²,

Heavey

2019

BMJ Case Rep

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We present the case of a 22-year-old man transferred to the regional major trauma centre following a fall of ~15 m. He remained consistently haemodynamically stable for over 10 hours of observation until he deteriorated suddenly with major haemorrhagic shock requiring immediate trauma laparotomy. At laparotomy, 2 L of blood was drained from the abdomen but no source of active bleeding identified. 30 minutes after closure of the abdomen, 500 mL of fresh blood was noted in the drain so he was returned to the theatre where the bleeding source was found to be—after manual compression of a mildly bruised hepatoduodenal ligament—the proper hepatic artery (PHA). This case describes an unusual finding at relaparotomy and shows that even when there is no active bleeding from abdominal organs or classified vessels, it is possible to have isolated injury to PHA.

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Section: Discussionmentioning

confidence: 97%

Traumatic bruising of the hepatoduodenal ligament can conceal a catastrophic injury to the hepatic artery

Gerrard

Lunevičius²,

Heavey

2019

BMJ Case Rep

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“…Splenic and hepatic lesions were classified according to the 1994-AAST classification [ 13 , 14 ], the 2018-AAST classification [ 24 ], the CTSI for splenic injuries [ 21 ] and to a novel own adaptation for hepatic injuries of the previously published splenic CTSI (Table 2 ). Analogously, the hepatic CTSI scoring system describes four grades of injury, with grade IV being divided into two subgroups (IVa, IVb).…”

Section: Methodsmentioning

confidence: 99%

“…However, an adaption for liver injuries has so far not been provided. In 2018, the AAST published an update for their classification of spleen and liver injuries implementing imaging features of contrast media extravasation to improve its value for clinical patient management (Table 3 ) [ 24 ]. Both the CTSI and 2018-AAST classifications have so far not been independently validated.…”

Section: Introductionmentioning

confidence: 99%

Validation of the revised 2018 AAST-OIS classification and the CT severity index for prediction of operative management and survival in patients with blunt spleen and liver injuries

et al. 2020

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Objectives Non-operative management (NOM) is increasingly utilised in blunt abdominal trauma. The 1994 American Association of Surgery of Trauma grading (1994-AAST) is applied for clinical decision-making in many institutions. Recently, classifications incorporating contrast extravasation such as the CT severity index (CTSI) and 2018 update of the liver and spleen AAST were proposed to predict outcome and guide treatment, but validation is pending. Methods CT images of patients admitted 2000–2016 with blunt splenic and hepatic injury were systematically re-evaluated for 1994/2018-AAST and CTSI grading. Diagnostic accuracy, diagnostic odds ratio (DOR), and positive and negative predictive values were calculated for prediction of in-hospital mortality. Correlation with treatment strategy was assessed by Cramer V statistics. Results Seven hundred and three patients were analysed, 271 with splenic, 352 with hepatic and 80 with hepatosplenic injury. Primary NOM was applied in 83% of patients; mortality was 4.8%. Comparing prediction of mortality in mild and severe splenic injuries, the CTSI (3.1% vs. 10.3%; diagnostic accuracy = 75.4%; DOR = 3.66; p = 0.006) and 1994-AAST (3.3% vs. 10.5%; diagnostic accuracy = 77.9%; DOR = 3.45; p = 0.010) were more accurate compared with the 2018-AAST (3.4% vs. 8%; diagnostic accuracy = 68.2%; DOR = 2.50; p = 0.059). In hepatic injuries, the CTSI was superior to both AAST classifications in terms of diagnostic accuracy (88.7% vs. 77.1% and 77.3%, respectively). CTSI and 2018-AAST correlated better with the need for surgery in severe vs. mild hepatic (Cramer V = 0.464 and 0.498) and splenic injuries (Cramer V = 0.273 and 0.293) compared with 1994-AAST (Cramer V = 0.389 and 0.255; all p < 0.001). Conclusions The 2018-AAST and CTSI are superior to the 1994-AAST in correlation with operative treatment in splenic and hepatic trauma. The CTSI outperforms the 2018-AAST in mortality prediction. Key Points • Non-operative management of blunt abdominal trauma is increasingly applied and correct patient stratification is crucial. • CT-based scoring systems are used to assess injury severity and guide clinical decision-making, whereby the 1994 version of the American Association of Surgery of Trauma Organ Injury Scale (AAST-OIS) is currently most commonly utilised. • Including contrast media extravasation in CT-based grading improves management and outcome prediction. While the 2018-AAST classification and the CT-severity-index (CTSI) better correlate with need for surgery compared to the 1994-AAST, the CTSI is superior in outcome-prediction to the 2018-AAST.

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“…The following radiographic findings were abstracted from the electronic medical record: hemoperitoneum and quantity (small, moderate, large); AAST grade (the 1994 scale was in use during the study period11); presence of contrast blush; presence of splenic vascular injury (defined as a pseudoaneurysm or arteriovenous fistula12); presence of a nonsurgical abdominal injury.…”

Section: Methodsmentioning

confidence: 99%

Quantity of hemoperitoneum is associated with need for intervention in patients with stable blunt splenic injury

Salottolo¹,

Madayag

O’Brien

et al. 2020

Trauma Surg Acute Care Open

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Background In patients with hemodynamically stable blunt splenic injury (BSI), there is no consensus on whether quantity of hemoperitoneum (HP) is a predictor for intervention with splenic artery embolization (SAE) or failing nonoperative management (fNOM). We sought to analyze whether the quantity of HP was associated with need for intervention. Methods This retrospective cohort study included adult trauma patients with hemodynamically stable BSI admitted to six trauma centers between 2014 and 2016. Quantity of HP was defined as small (perisplenic blood or blood in Morrison's pouch), moderate (blood in one or both pericolic gutters), or large (additional finding of free blood in the pelvis). Multivariate logistic regression was performed to identify predictors of intervention with SAE or fNOM versus successful observation. Results There were 360 patients: hemoperitoneum was noted in 214 (59%) patients, of which the quantity was small in 92 (43%), moderate in 76 (35.5%), and large in 46 (21.5%). Definitive management was as follows: 272 (76%) were observed and 88 (24%) had intervention (83 SAE, 5 fNOM). The rate of intervention was univariately associated with quantity of HP, even after stratification by American Association for the Surgery of Trauma (AAST) grade. After adjustment, larger quantities of HP significantly increased odds of intervention (p=0.01). Compared with no HP, the odds of intervention were significantly increased for moderate HP (OR=3.51 (1.49 to 8.26)) and large HP (OR=2.89 (1.03 to 8.06)), with similar odds for small HP (OR=1.21 (0.46 to 2.76)). Other independent predictors of intervention were higher AAST grade, older age, and presence of splenic vascular injury. Conclusion Greater quantity of HP was associated with increased odds of intervention, with no difference in risk for moderate versus large HP. These findings suggest quantity of HP should be incorporated in the management algorithm of BSI as a consideration for angiography and/or embolization to maximize splenic preservation and reduce the risk of splenic rupture. Level of evidence III, retrospective epidemiological study.

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Organ injury scaling 2018 update: Spleen, liver, and kidney

Cited by 357 publications

References 25 publications

Traumatic bruising of the hepatoduodenal ligament can conceal a catastrophic injury to the hepatic artery

Traumatic bruising of the hepatoduodenal ligament can conceal a catastrophic injury to the hepatic artery

Validation of the revised 2018 AAST-OIS classification and the CT severity index for prediction of operative management and survival in patients with blunt spleen and liver injuries

Quantity of hemoperitoneum is associated with need for intervention in patients with stable blunt splenic injury

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