Computed tomographic grading is useful in the selection of patients for nonoperative management of blunt injury to the spleen

Although nonoperative management of blunt splenic injury (NMBSI) has an established role in the overall management of adult patients with blunt splenic injury, the criteria by which patients are selected continue to be debated. The purpose of this study is to establish the effectiveness of a defined set of criteria that includes CT grading for the selection of patients for NMBSI by examining the outcomes of patients managed in this manner 1 year before with those 1 year after the implementation of this specific set of selection criteria. All patients hospitalized at St. Joseph Mercy Hospital over the time period April 1994 through July 1996 with blunt splenic injury were included. Patients who died in the Emergency Department were excluded. Patients admitted from April 1994 through April 1995 composed Group I, those treated before the specific selection criteria, whereas those admitted from July 1995 through July 1996 composed Group II, those treated after the implementation of selection criteria. The two groups were compared with respect to demographic parameters, Injury Severity Score, mechanism of injury and length of stay. Outcomes were compared between these two groups. Those patients successfully managed without operation were further compared with those for whom NMBSI was unsuccessful. A total of 57 patients met the criteria for study entry, 28 from Group I and 29 from Group II. There were no significant differences between these two groups with respect to age, sex, mechanism of injury, Injury Severity Score, or length of stay. Nine of 27 in Group I required immediate operation; 19 were initially managed nonoperatively. Four of 19 required delayed laparotomy for bleeding, and all required splenectomy. Between patients successfully managed nonoperatively and those requiring delayed operation, the only significant difference was CT grade (1.47 vs 3.5; P = 0.0001). In Group II, after the implementation of selection criteria that included CT grade, no patient required delayed operation. Eleven underwent immediate operation, whereas 18 were successfully managed nonoperatively. We conclude that, in the hemodynamically stable patient without clinical indication for laparotomy, CT grading of the splenic injury is a reliable criterion by which patients may be selected for nonoperative management.