J Trauma Acute Care Surg Volume 77, Number 5
Letters to the Editor
Christopher Neuhaus, MD Department for Anaesthesiology University Hospital of Heidelberg Heidelberg, Germany
Stefan Braunecker, MD Department for Anaesthesiology and Intensive Care Medicine University Hospital Cologne Cologne, Germany
REFERENCES 1. Chesters A, Grieve PH, Hodgetts TJ. 26-year comparative review of United Kingdom helicopter emergency medical services crashes and serious incidents. J Trauma Acute Care Surg. 2014;76:1055Y1060. 2. Hinkelbein J, Schwalbe M, Genzwuerker HV. Comparison of Helicopter Emergency Medical Services (HEMS) accident rates in different international air rescue systems. Open Access Emerg Med. 2010;2:45Y49. 3. Hinkelbein J, Schwalbe M, Wetsch WA, et al. Helicopter type and accident severity in Helicopter Emergency Medical Services missions. Aviat Space Environ Med. 2011;82((12)):1148Y1152. 4. Hinkelbein J, Schwalbe M, Wetsch WA, et al. Application of the FIA score for German rescue helicopter accidents to predict fatalities in HEMS crashes. J Emerg Med. 2012;43(6):1014Y1019. 5. Hinkelbein J, Neuhaus C, Schwalbe M, et al. Significant lack of data in aviation accident analysis. Aviat Space Environ Med. 2010;81(1):77.
Delayed hemorrhagic complications in the nonoperative management of blunt splenic trauma To the Editor: have read the article by Leeper et al.1 with interest. I thought the study was well done and may have a significant clinical implication. I like the authors’ idea of repeating computed tomography (CT) within 48 hours to possibly help decrease the failure rate of nonoperative management, but I am not certain as a cost conscientious clinician that I like the idea of repeating CT on every grade injury for a mere 6% yield (29 of 453). I have the following comments and questions for the authors: 1. Can the authors provide us the denominator for the different splenic grade (Fig. 3 in their article) that had positive findings on a repeated CT? It would make more sense (economic sense anyway) to screen and repeat CT for those with high-grade injury first (IV and V). Some authors2
I
800
went further and advocated even more aggressive approach and performed angiography on everyone with high-grade injuries, but even that seemed so excessive. I realize the authors had commented that delayed arterial extravasation and splenic pseudoaneurysm (SPA) could still occur even in the low-grade injuries (I and II, 6 patients in their study), which leads me to my next question. 2. Can the authors elaborate in details on those six Grade I and II splenic injuries that had delayed arterial extravasation and SPA? Were these underappreciated injuries, or were these correctly graded? What did the authors actually see on the angiography? Was there anything unique about them, maybe an outlier that may be of interest that one can use to identify these individuals? Could this be the limitation of the CT scan used? They mentioned in their study that these six patients represented 20% of Grade I and II, which implied that their study only had 30 patients with Grade I and II splenic injuries. Was that correct? 3. As quoted in the article, Dr. Leeper and the group modeled the repeated CT algorithm after the Memphis group.3 In that original study, the rationale for repeating CT was to detect a missed or delayed SPA, which occurred at the rate of 5%. However, that was based on an earlier CT model (in that study by Weinberg et al., the CT used was Siemens Somatom Plus 4, which was a 4-slice CT). What CT scan did Dr. Leeper and the group use in their present study? Was the CT scan used different between the two eras? Do Dr. Leeper and the group think that with the more advanced CT (our institution uses a 64-slice CT), the incidence of missed or delayed SPA will diminish? Again, Dr. Leeper and the group had shown the decrease in the failure of nonoperative management from 12% to less than 1% after establishing the described management algorithm of routine repeated CT, which is quite remarkable, although half of that effect probably benefited from the advance in CT image quality that led to early aggressive angiography and intervention. I look forward to hear the authors’ reply and thank the group for their study endeavor. *The author declares no conflict of interest.
Narong Kulvatunyou, MD Division of Acute Care Surgery Department of Surgery University of Arizona Tucson, AZ
REFERENCES 1. Leeper WR, Leeper TJ, Ouellette D, et al. Delayed hemorrhagic complications in the nonoperative management of blunt splenic trauma: early screening leads to a decrease in failure rate. J Trauma Acute Care Surg. 2014;76:1349Y1353. 2. Bhullar IS, Frykberg ER, Tepas JJ, et al. At first blush: absence of computed tomography contrast extravasation in grade IV or V adult blunt splenic trauma should not preclude angioembolization. J Trauma Acute Care Surg. 2013;74:105Y112. 3. Weinberg JA, Magnotti LJ, Croce MA, et al. The utility of serial computed tomography imaging of blunt splenic injury: still worth a second look? J Trauma. 2007;62:1143Y1148.
Re: Delayed hemorrhagic complications in the nonoperative management of blunt splenic trauma In Reply: he authors thank Dr. Kulvatunyou for his interest in the article and his thoughtful comments. Each of his questions raised important points, and these have been addressed in the following sections:
T
1. Re: Clarification of the ‘‘denominator’’ for delayed computed tomographic (CT) findings Our current management protocol for splenic injury includes mandatory repeat CT imaging at 48 hours and splenic artery embolization whenever high-risk vascular lesions, splenic pseudoanuerysm (PSA), or arterial extravasation are identified. During the era of our current protocol, a total of 475 patients were treated initially with nonoperative management. Breakdown of these 475 patients by grade of injury and identification of high-risk vascular lesions on CT scan are given in the table online (Supplemental Digital Content [SDC] 1, http://links.lww.com/TA/A485). The development of delayed high-risk vascular lesions not seen on initial CT occurred in 21% of Grade 4 injuries (15 of 70), 8% of Grade 3 injuries (8 of 97), 4.5% of Grade 2 injuries (4 of 87), and 1% of Grade 1 injuries (2 of 189). If an argument is to be made concerning omission of mandatory repeat CT, Grade 1 injuries seem a logical place to start. Regarding the question raised by Dr. Kulvatunyou about the statement in the article that ‘‘20% of all delayed findings occurred in Grade I and II injuries,’’ this is true in that 6 * 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Letters to the Editor
Christopher Neuhaus, MD Department for Anaesthesiology University Hospital of Heidelberg Heidelberg, Germany
Stefan Braunecker, MD Department for Anaesthesiology and Intensive Care Medicine University Hospital Cologne Cologne, Germany
REFERENCES 1. Chesters A, Grieve PH, Hodgetts TJ. 26-year comparative review of United Kingdom helicopter emergency medical services crashes and serious incidents. J Trauma Acute Care Surg. 2014;76:1055Y1060. 2. Hinkelbein J, Schwalbe M, Genzwuerker HV. Comparison of Helicopter Emergency Medical Services (HEMS) accident rates in different international air rescue systems. Open Access Emerg Med. 2010;2:45Y49. 3. Hinkelbein J, Schwalbe M, Wetsch WA, et al. Helicopter type and accident severity in Helicopter Emergency Medical Services missions. Aviat Space Environ Med. 2011;82((12)):1148Y1152. 4. Hinkelbein J, Schwalbe M, Wetsch WA, et al. Application of the FIA score for German rescue helicopter accidents to predict fatalities in HEMS crashes. J Emerg Med. 2012;43(6):1014Y1019. 5. Hinkelbein J, Neuhaus C, Schwalbe M, et al. Significant lack of data in aviation accident analysis. Aviat Space Environ Med. 2010;81(1):77.
Delayed hemorrhagic complications in the nonoperative management of blunt splenic trauma To the Editor: have read the article by Leeper et al.1 with interest. I thought the study was well done and may have a significant clinical implication. I like the authors’ idea of repeating computed tomography (CT) within 48 hours to possibly help decrease the failure rate of nonoperative management, but I am not certain as a cost conscientious clinician that I like the idea of repeating CT on every grade injury for a mere 6% yield (29 of 453). I have the following comments and questions for the authors: 1. Can the authors provide us the denominator for the different splenic grade (Fig. 3 in their article) that had positive findings on a repeated CT? It would make more sense (economic sense anyway) to screen and repeat CT for those with high-grade injury first (IV and V). Some authors2
I
800
went further and advocated even more aggressive approach and performed angiography on everyone with high-grade injuries, but even that seemed so excessive. I realize the authors had commented that delayed arterial extravasation and splenic pseudoaneurysm (SPA) could still occur even in the low-grade injuries (I and II, 6 patients in their study), which leads me to my next question. 2. Can the authors elaborate in details on those six Grade I and II splenic injuries that had delayed arterial extravasation and SPA? Were these underappreciated injuries, or were these correctly graded? What did the authors actually see on the angiography? Was there anything unique about them, maybe an outlier that may be of interest that one can use to identify these individuals? Could this be the limitation of the CT scan used? They mentioned in their study that these six patients represented 20% of Grade I and II, which implied that their study only had 30 patients with Grade I and II splenic injuries. Was that correct? 3. As quoted in the article, Dr. Leeper and the group modeled the repeated CT algorithm after the Memphis group.3 In that original study, the rationale for repeating CT was to detect a missed or delayed SPA, which occurred at the rate of 5%. However, that was based on an earlier CT model (in that study by Weinberg et al., the CT used was Siemens Somatom Plus 4, which was a 4-slice CT). What CT scan did Dr. Leeper and the group use in their present study? Was the CT scan used different between the two eras? Do Dr. Leeper and the group think that with the more advanced CT (our institution uses a 64-slice CT), the incidence of missed or delayed SPA will diminish? Again, Dr. Leeper and the group had shown the decrease in the failure of nonoperative management from 12% to less than 1% after establishing the described management algorithm of routine repeated CT, which is quite remarkable, although half of that effect probably benefited from the advance in CT image quality that led to early aggressive angiography and intervention. I look forward to hear the authors’ reply and thank the group for their study endeavor. *The author declares no conflict of interest.
Narong Kulvatunyou, MD Division of Acute Care Surgery Department of Surgery University of Arizona Tucson, AZ
REFERENCES 1. Leeper WR, Leeper TJ, Ouellette D, et al. Delayed hemorrhagic complications in the nonoperative management of blunt splenic trauma: early screening leads to a decrease in failure rate. J Trauma Acute Care Surg. 2014;76:1349Y1353. 2. Bhullar IS, Frykberg ER, Tepas JJ, et al. At first blush: absence of computed tomography contrast extravasation in grade IV or V adult blunt splenic trauma should not preclude angioembolization. J Trauma Acute Care Surg. 2013;74:105Y112. 3. Weinberg JA, Magnotti LJ, Croce MA, et al. The utility of serial computed tomography imaging of blunt splenic injury: still worth a second look? J Trauma. 2007;62:1143Y1148.
Re: Delayed hemorrhagic complications in the nonoperative management of blunt splenic trauma In Reply: he authors thank Dr. Kulvatunyou for his interest in the article and his thoughtful comments. Each of his questions raised important points, and these have been addressed in the following sections:
T
1. Re: Clarification of the ‘‘denominator’’ for delayed computed tomographic (CT) findings Our current management protocol for splenic injury includes mandatory repeat CT imaging at 48 hours and splenic artery embolization whenever high-risk vascular lesions, splenic pseudoanuerysm (PSA), or arterial extravasation are identified. During the era of our current protocol, a total of 475 patients were treated initially with nonoperative management. Breakdown of these 475 patients by grade of injury and identification of high-risk vascular lesions on CT scan are given in the table online (Supplemental Digital Content [SDC] 1, http://links.lww.com/TA/A485). The development of delayed high-risk vascular lesions not seen on initial CT occurred in 21% of Grade 4 injuries (15 of 70), 8% of Grade 3 injuries (8 of 97), 4.5% of Grade 2 injuries (4 of 87), and 1% of Grade 1 injuries (2 of 189). If an argument is to be made concerning omission of mandatory repeat CT, Grade 1 injuries seem a logical place to start. Regarding the question raised by Dr. Kulvatunyou about the statement in the article that ‘‘20% of all delayed findings occurred in Grade I and II injuries,’’ this is true in that 6 * 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
