An autopsy study of splenic injuries seen in patients with blunt abdominal trauma at Parirenyatwa Group of Hospitals in Harare: Prevalence of missed splenic injuries

Abstract

The spleen is one of the most commonly injured organs following blunt abdominal trauma1. Significant evolution has occurred in the management of splenic injuries, with a paradigm shift, from splenectomy to non-operative management.2 In low resource centres, absent management protocols and the lack of expertise and equipment, have resulted in a significant number of splenic injuries being missed.3 1.2 OBJECTIVES (i) To determine the frequency of missed splenic injuries related to blunt abdominal trauma at the Parirenyatwa Group of Hospitals at autopsy. (ii) To evaluate the initial diagnostic modalities being utilised in screening for splenic injuries. (iii) To identify other injuries associated with missed splenic injuries at autopsy. 1.3 STUDY DESIGN Retrospective Descriptive autopsy study 12 | P a g e 1.4 MATERIALS AND METHODS Records of autopsies done over the period January 2008-December 2011were analysed in conjunction with those from casualty at the Parirenyatwa Group of Hospitals. All autopsies performed for blunt trauma were included in the study. Analysis was done using Stata version 10.0. 1.5 RESULTS A total of 2171 autopsies were conducted for blunt trauma during the period January 2008 and December 2011. Of these, 136 cases were identified as having a missed splenic injury, giving a prevalence of 6% (p=0.001). Data for analysis was available in 87 cases. The remaining cases (n=49) were excluded from the study. Median age was 33 years (Q1=27, Q3=40). Male: female ratio was 4.2:1.Road traffic accidents accounted for 86% of all injuries. In 83% of cases, the initial attending clinician was the casualty officer. None of the initial attending clinicians had Advanced Trauma Life Support(ATLS® )training. Sixty per cent of cases presented with a GCS of 3-8. Head injuries were the most common association in 46% of cases. None of the cases had an ultrasound scan done. At autopsy, the median volume of haemoperitoneum was 1000ml; (Q1=713 Q3=1069). The commonest cause of death was hypovolemic shock in 60% of cases. Combined splenic and liver injuries accounted for 40% and isolated splenic injuries accounted for 33% of these cases. 13 | P a g e 1.6 CONCLUSION The study confirms that a significant number of splenic injuries were missed by the attending clinician. A low Glasgow Coma Scale and the presence of serious injuries were the commonest associations. The lack of training in ATLS®, absence of protocols of managing trauma patients and inadequate diagnostic equipment and expertise were the other contributory factors associated with the missed splenic injuries. Early detection and appropriate management of these cases could significantly reduce the mortality of these polytrauma patients.