SOLID AND HOLLOW ORGANS
| NONOPERATIVE MANAGEMENT OF SOLID ORGAN INJURY —Michael D. McGonigal, MD, Assistant Professor
of Surgery, University of Minnesota Medical School, and Director of Trauma Services, Regions Hospital, St.
Paul
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| Shift in management: >20 yr ago, liver or spleen injuries managed operatively; have moved away from operative
management with advent of newer diagnostic techniques, eg, computed tomography (CT); starting in 1960s, diagnostic
peritoneal lavage (DPL) mainstay of abdominal diagnosis in trauma; DPL has fallen out of favor for diagnosing
significant intra-abdominal injuries in patients not in shock; even patients with minor liver or spleen injuries
likely to have positive DPL, leading to many unnecessary surgeries; CT gives more information (may show unknown
injuries and/or show extent of known injuries); as of 10 yr ago, nonoperative management of hemodynamically
stable patients has become the norm; currently experiencing high success rate and relatively low complication
rate with spleen injuries (not so low with liver injuries); disadvantages include need for more resources and more
thinking than rushing patient to operating room (OR)
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| Requirements: 1) readily available CT, including operator and clinician who can read results; 2) facilities to monitor
patients appropriately (eg, intensive care unit [ICU]); 3) round-the-clock OR, and OR staff for patients who fail
nonoperative management (can occur abruptly); 4) rapidly available surgeon comfortable with nonoperative management
and with performing emergent surgeries
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| Criteria: originally looked at CT grade of liver or spleen injury; used to look at degree of hemoperitoneum; age (<55
yr) and associated injuries no longer used
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| Splenic injury grading from American Association for the Surgery of Trauma (AAST): similar to liver injury grading
system; grades based on depth of laceration and size of subcapsular hematomas; remember “1 and 3, 10 and 50,” ie,
grade I for laceration <1 cm deep, grade III if >3 cm deep, grade II if in-between; grade I if subcapsular hematomas
<10% of surface area of organ, grade III if >50%, grade II if in-between; grade IV for active bleeding into spleen;
grade V if organ shattered; contusions ignored (no clinical significance); liver avulsed from all vascular structures
grade VI injury (considered nonsurvivable)
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| CT grading: no longer used; cannot predict anatomic grade of injury because of spleen’s irregular shape; often understates
injury
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| Current criteria: patient must maintain hemodynamic stability; abdominal findings limited to upper quadrant in
question (can have focal tenderness but not generalized tenderness or peritonitis); patient must be available for serial
abdominal examinations (ie, not undergoing surgery for other injuries, eg, orthopedic); criteria for failure—
ongoing blood loss; softening of vital signs; evidence of other intra-abdominal pathology, eg, peritonitis
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| Follow-up evaluation: routine follow-up studies not performed
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| Success rate: overall success rate 84% 7 yr ago (100% for grade I and II injuries, 64% for grade III, no salvage for
grade IV or V); current nonoperative salvage rate >90% as result of introduction of protocols, using angiography
more aggressively, clinicians’ increased comfort level, use of clinical practice guidelines, and information from adjunctive
studies
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| Clinical practice guidelines: streamline care; teach consistent treatment; decrease length of stay; save money
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| Angiography: adjunctive study has made tremendous difference; trend toward becoming more selective; improves
salvage rate, length of stay, and late failures; implementing angioembolization of spleen—study compiled experience
of 4 trauma centers (140 patients); looked at grades IV and V injuries; found that age and amount of hemoperitoneum
not predictive of failure; presence of “blush” (area of active arterial bleeding on CT) predicts
failure of nonoperative management unless spleen embolized; can embolize main splenic artery (≈10% failed,
≈20% had infarction) or specific area of bleeding (failure rate about same [≈13%], infarction rate higher); if both
types of embolization used, failure rate higher and two thirds of patients had infarction); complication rate low
but significant
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 | Protocol-driven care: no angiography for grade I; for grade II, angiography used at attending physician’s discretion
(usually not used); angiography required for grade III but if no blush present, patient can wait until morning;
grades IV and V require immediate angiography; highly selective embolization allowed; main splenic artery embolization
done if >3 areas bleeding or if hilar branches injured; treat grades III through V in ICU; test hemoglobin
levels every 6 hr until level same on 2 sequential tests; salvage rate >90%; length of stay drops from 7 days to
3.5 days
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| Speaker’s nonoperative management protocol: patients must be hemodynamically stable and have no peritonitis;
grade I or II injuries go to surgery ward and have ward protocol implemented; grades III through V go to surgical
ICU, and ICU side of protocol activated (angiography recommended); if vascular blush present, patient must go to
angiography; retrospective study showed average length of stay 3 days (dropped by 1 day in low-grade group,
stayed about same in high-grade group), hospital cost decreased by almost $1000/patient, $1500/patient for low-
grade injuries (more of these)
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| Summary: nonoperative management remains standard of care in treating significant injuries to liver and spleen;
good success rate; angiography mainstay of management in higher-grade injuries (grades III, IV, and V); use of
practice guidelines well documented to decrease hospital stay, save hospital costs, and provide at least same quality
of outcome as before guidelines implemented
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| ECTOPIC PREGNANCY —Lisa K. Everson, MD, Assistant Clinical Professor of Obstetrics, Gynecology and Reproductive
Sciences, University of California, San Francisco, School of Medicine
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| Introduction: must assume ruptured ectopic pregnancy in any woman with positive pregnancy test who is hemodynamically
unstable; abnormal bleeding and abdominal pain typical presentation; in 1920s, one third of 1% of all
pregnancies ectopic, 2% in late 1990s (probably related to increased incidence of pelvic inflammatory disease
[PID]); 90% decrease in mortality rate over last 20 yr (probably due to availability of highly sensitive urine pregnancy
tests and high-resolution transvaginal ultrasonography); leading cause of death in first trimester of pregnancy
(9%-13% of all pregnancy deaths); most deaths occur in places with poor access to medical care
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| Case 1: patient presents in sixth week of gestation; looks well; good vital signs; soft nontender abdomen, no masses;
small amount of blood in vagina; uterus small and nontender; right adnexa normal, left side slightly tender but unremarkable;
pregnancy test positive; hematocrit normal, quantitative β-human chorionic gonadotropin (HCG) 1000
mIU/mL
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| Urine pregnancy test: highly sensitive and accurate; excellent way to screen for ectopic pregnancy; if negative, look
for other cause of symptoms; better screen than serum HCG
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| Quantitative HCG level: not useful by itself; helpful in interpreting results of ultrasonography; changes over time informative;
discriminatory zone—level of HCG above which intrauterine pregnancy expected on transvaginal ultrasonography
(varies with institution, but usually 1500-2000 mIU/mL); if HCG >2000 mIU/mL and intrauterine
pregnancy not seen, nonviable intrauterine pregnancy, spontaneous abortion, or ectopic pregnancy present; if HCG
below discriminatory zone, transvaginal ultrasonography still helpful; HCG not proportional to size of mass or predictive
of likelihood of rupture
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| Case 1 continued: patient has small empty uterus; HCG 1000 mIU/mL; 2-cm cyst found on left ovary (suspected to
be normal corpus luteum cyst); no other adnexal masses; has small amount of free fluid in cul-de-sac
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| Important points: CT bad way to evaluate uterus, ovaries, and tubes; rely on ultrasonography for evaluation of pelvis;
accuracy of ultrasonography operator-dependent; absent adnexal mass does not mean no pregnancy; can be fairly confident
no ectopic pregnancy present if intrauterine pregnancy visible; presence of some fluid in cul-de-sac normal finding
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| Case 1 continued: any type of pregnancy possible with HCG below discriminatory zone; consider what patient wants
and what patient able and willing to do; this patient can be followed at home because she wants to be pregnant, is
reliable, and lives with partner; HCG should double over next 48 hr; patient sent home with ectopic precautions, ie,
return to hospital if experiencing acute pain or light-headedness; patient returns in 48 hr; inadequate rise in HCG,
indicating abnormal pregnancy; ultrasonography shows 2-cm extraovarian mass with no cardiac activity (suggestive
of ectopic pregnancy)
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| Management options: laparoscopic salpingostomy or medical treatment with methotrexate
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| Indications and contraindications for methotrexate therapy: ruptured tube absolute contraindication (go to OR);
contraindications relative, based on clinical picture; patients with lower HCG level more likely to have success with
single course of methotrexate; smaller mass size increases likelihood of success (mass <3.5 cm in diameter); more
likely to be unsuccessful if cardiac activity present; patient must be reliable since process long and requires follow-
up
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| Management: first confirm patient has normal laboratory tests; give intramuscular (IM) methotrexate 50 mg/m2 ; check
HCG on day 4 (expect it to go up); check again on day 7 (should have at least 15% drop between days 4 and 7);
check HCG weekly thereafter, looking for 15% drop every week; repeat dose or go to surgery if drop does not occur
(≈20% need retreatment); 35 days ±1.5 wk mean time to resolution of HCG (spotting and bleeding not uncommon);
abdominal pain common after methotrexate treatment; remain vigilant because rupture can occur any time
during treatment
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| Case 1 concluded: patient returns 4 days later with moderate abdominal pain; normal vital signs, tender abdomen with
no rebound or peritoneal signs; hematocrit stable; HCG 1300 mIU/mL; ultrasonography unchanged; pelvic examination
contraindicated because it might precipitate rupture
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| Discussion: 50% of patients receiving methotrexate have some pain, 35% have significant pain, usually occurring
within first 2 to 10 days of treatment; perform abdominal examination to evaluate for acute abdomen; check vital
signs to check for bleeding; ultrasonography can help gauge how much blood in peritoneal cavity; rupture usually occurs
within first 2 wk of treatment but has been reported as far out as 42 days; if patient in pain and no evidence of
rupture, can send home with pain medication; if unsure, admit for serial examinations and serial hematocrits
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| Follow-up: patient stable, so sent home with precautions and pain medication; returned on day 7 with improved
pain and HCG of 900 mIU/mL (appropriate response to methotrexate); have patient return every week and check
for 15% drop in HCG; if patient had HCG of 1200 mIU/mL on day 7, would have given another dose of methotrexate
or offered surgery
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| Rationale for methotrexate: many patients do not want surgery; surgical morbidity and cost avoided; fertility rate
same as after surgery
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| Case 2: 30-yr-old woman; gravida II para I; calculates herself to be 8 wk pregnant; acute onset of severe right lower
quadrant pain; afebrile; tachycardic; blood pressure normal; abdomen soft, very tender; no blood in vagina; cervix
closed; uterus globular and slightly tender; left adnexa mildly tender, right exquisitely tender; white blood cell
count 12,000/mm3 (not abnormal in pregnancy); hematocrit normal; HCG 22,000 mIU/mL; ultrasonography shows
viable intrauterine pregnancy, small amount of cul-de-sac fluid and 7-cm right adnexal cyst; blood flow documented
to right adnexa
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| Differential diagnosis of positive pregnancy test and severe pain: appendicitis, stone or some other gastrointestinal
process; ectopic pregnancy; heterotopic pregnancy (low possibility); pelvic inflammatory disease (PID; rare in
pregnancy); ovarian torsion; ruptured ovarian cyst (should be irregular with fluid around it; self-limited; provide
pain relief; pain worsening over time and falling hematocrit indicates ongoing bleeding; laparoscopic cystectomy
indicated); ovarian torsion—more common on right and in pregnancy; ultrasonography helpful to show size of
ovary but not diagnostic (normal-sized ovary does not twist); diagnosis clinical; blood flow to ovary does not rule
out torsion; must treat promptly
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| Summary: always consider ectopic pregnancy with positive urine pregnancy test; torsion is clinical diagnosis (do
not be fooled by evidence of Doppler blood flow to adnexa; surgical emergency)
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Educational Objectives
| The goal of this program is to educate the listener about nonoperative management of solid organ injury and ectopic
pregnancy. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Review the history of the management of solid organ injury.
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| 2. List the requirements for managing solid organ injury nonoperatively.
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| 3. Describe the grading system for splenic injury published by the American Association for the Surgery of
Trauma.
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| 4. Discuss the current nonoperative management of solid organ injury.
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| 5. Illustrate the evaluation and management of ectopic pregnancy using a case presentation.
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Discussed on This Program
Methotrexate (amethopterin; MTX) [Methotrexate LPF, Rheumatrex Dose Pack, Trexall]
Programs of Related Interest
Counselman FL, Everson L: Pregnancy problems. Audio-Digest Emergency Medicine 20:03(Feb 7), 2003; Fylstra
DL, Lebovic D: Early pregnancy risk. Audio-Digest Obstetrics/Gynecology 51:14(Jul 21), 2004; Schlachta CM et al:
Special topics in general surgery. Audio-Digest General Surgery 51:11(Jun 7), 2004; Trunkey DD, Knudson MM:
Traumatic injuries. Audio-Digest General Surgery 51:13(Jul 7), 2004.
To Order, Contact Subscriber Service (1-800-423-2308)
Suggested Reading
Dupuy DE et al: Current concepts in splenic trauma. J Intensiv Care Med 10:76, 1995; Keller MS: Blunt injury to
solid abdominal organs. Semin Pediatr Surg 13:106, 2004; Paddock HN et al: Management of blunt pediatric hepatic
and splenic injury: similar process, different outcome. Am Surg 70:1068, 2004; Parks RW et al: Management of liver
trauma. Br J Surg 86:1121, 1999; Pranikoff T et al: Resolution of splenic injury after nonoperative management. J Pediatr
Surg 29:1366, 1994; Robinson WP 3rd et al: Blood transfusion is an independent predictor of increased mortality
in nonoperatively managed blunt hepatic and splenic injuries. J Trauma 58:437, 2005; Sharma OP et al:
Assessment of nonoperative management of blunt spleen and liver trauma. Am Surg 71:379, 2005; Sharma OP et al:
Role of repeat computerized tomography in nonoperative management of solid organ trauma. Am Surg 71:244, 2005;
Sugrue M et al: Management of splenic trauma: a new CT-guided splenic injury grading system. Aust N Z J Surg
61:349, 1991; Yoon W et al: CT in blunt liver trauma. Radiographics 25:87, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the faculty reported nothing to disclose.
Dr. McGonigal was recorded November 17, 2004, in Minneapolis, at Emergency Medicine and Trauma Update,
sponsored by Regions Hospital Surgery and Emergency Medicine Departments, Hennepin County Medical Center
Surgery and Emergency Medicine Departments and HealthPartners Institute for Medical Education, Center for Continuing
Professional Development; Dr. Everson, on October 26, 2004, in San Francisco, at Topics in Emergency Medicine,
sponsored by the University of California, San Francisco, School of Medicine. The Audio-Digest Foundation
thanks the speakers and the sponsors for their cooperation in the production of this program.
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