Combat management of splenic injury: Trends during a decade of conflict

Background: As a performance improvement measure to optimize patient outcome, theater-wide clinical practice guidelines (CPGs) have been developed to standardize the management of many injury patterns seen during combat operations. Battle-related splenic injury presents differently from civilian practice, and a combat-related CPG was developed. The epidemiology and validation of the spleen injury CPG were analyzed. Methods: The Joint Theater Trauma Registry was queried for splenic injury from 2001 to 2010. Theater of operation (Afghanistan and Iraq), injury year, mechanism, patients' baseline characteristics, and severity were recorded. Patient charts were reviewed for management decisions and outcomes. Results: The 10-year experience identified 393 patients who sustained splenic injury (rate of 16.1 per 1000 injuries). Most victims were men (97.5%), blunt, and severely injured (70.7%; mean Injury Severity Score, 32.5, respectively), with a mean age of 25.4 years. The prominent mechanism was explosion (62.2%), followed by vehicle crash (25.9%). The most prevalent injury was grade II (56.2%), followed by III (21.1%), IV (11.7%), and V (9.7%). More than half of patients underwent splenectomy (52.7%), most of which occurred in theater (95.1%). All nonoperative failures were treated within 4 days of injury at the role IV facility in Landstuhl. Patients who underwent splenectomy received more blood products, crystalloid, and demonstrated a longer length of stay than those treated nonoperatively. High-grade injuries treated nonoperatively were successfully managed. The overall cohort mortality was 9%, and no death was directly related to delayed diagnosis or treatment. Conclusion: Splenic injury has been successfully managed during combat operations through the use of a well-established CPG. The overall mortality remains low, with few delayed nonoperative failures. Refinements in this validated CPG may now address controversies in higher grade injuries. Level of Evidence: Prognostic/epidemiologic study, level III.