Nonoperative Management Of Blunt Trauma

There is no question that many injuries previously thought to require surgery may now be managed nonoperatively. The evolution of this technique has been greatly advanced by the evolution of CT. CT makes the diagnosis of solid visceral injury and often can rule out other injuries requiring surgery. Solid visceral injuries can be graded as to severity.

Unfortunately, CT grading may not agree with intraoperative observation.16 In addition, CT grading does not always predict the success of nonoperative therapy.17 This may be true for several reasons. CT provides a good description of the status of the internal parenchyma but does not provide three-dimensional injury anatomy. Operative grading, on the other hand, provides an excellent three-dimensional view of the organ but may underestimate internal damage. In addition, a traditional CT cannot provide information as to the integrity of the parenchymal vasculature. It is a single snapshot in time that cannot diagnose ongoing blood loss.

Organ-specific properties may affect the success or failure rate of nonoperative management. As patients age, the capsule of the spleen and liver weakens. Parenchymal changes may occur as well. Thus nonoperative management of even very severe injuries is the norm in children. Failure rates are much higher in adults. In addition, as patients age, the consequences of rebleeding become more substantial. Thus many tramatologists are less willing to attempt nonoperative management in elderly patients.

Over the last several years, several technologic advances have increased the sophistication of nonoperative management. The increased resolution of helical CT often identifies vascular injuries such as pseudoaneurysms or AV fistulas. Helical CT also can identify contrast material extravasation, indicating active bleeding. The role of angiography and nonoperative hemostasis has expanded greatly in nonoperative management of solid visceral injuries. Angiography has the ability to diagnose intraparenchymal vascular injury and evaluate the possibility of ongoing blood loss. Patients without vascular injury usually can be managed nonoperatively. In patients in whom vascular injury is diagnosed, percutaneous transcatheter embolization with either stainless steel coils or Gelfoam pledgets can arrest hemorrhage with a high degree of reliability.

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