To nearly come full circle: Nonoperative management of high-grade IV-V blunt splenic trauma is safe utilizing a protocol with routine angioembolization.

Introduction: Nonoperative management (NOM) of hemodynamically stable high grade (IV-V) blunt splenic trauma (BST) remains controversial given the high failure rates (19%) that persist despite angioembolization (AE) protocols. The NOM protocol was modified in 2011 to include mandatory AE of all grade (IV-V) injuries without CB along with selective AE of grade (I-V) with CB. The purpose of this study was to determine if this new AE protocol significantly lowered the failure rates for grade (IV-V) injuries allowing for safe observation without surgery and if the exclusion of grade III injuries allowed for the prevention of unnecessary angiograms without affecting the overall failure rates. Methods: The records of patients with BST from January 2000 to October 2014 at a Level I trauma center were retrospectively reviewed. Patients were divided into two groups and failure of nonoperative management (FNOM) rates compared: New AE (NAE) protocol (2011-2014) with mandatory AE for all grade (IV-V) injuries without CB and selective AE for grade (I-V) with CB vs. Old AE (OAE) protocol (2000-2010) with selective AE for grade (I-V) with CB. Results: 712 patients underwent NOM with 522 (73%) in the OAE group and 190 (27%) in the NAE group. Evolving from the OAE to the NAE strategy resulted in a significantly lower FNOM rate for the overall group (grade I-V) (OAE vs. NAE, 4% to 1%, p=0.04) and the grade (IV-V) group (OAE vs. NAE, 19% vs. 3%, p=0.01). Angiograms were avoided in 113 grade (I-III) injuries with no CB; these patients had NOM with observation alone and none failed. Conclusions: A protocol utilizing mandatory AE of all high grade (IV-V) injuries without CB and selective AE of grade (I-V) with CB may provide for optimum salvage with safe NOM of the high grade injuries (IV-V) and limited unnecessary angiograms. p (C) 2017 Lippincott Williams & Wilkins, Inc.

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