The Journal of TRAUMA威 Injury, Infection, and Critical Care

Contribution of Age and Gender to Outcome of Blunt Splenic

Injury in Adults: Multicenter Study of the Eastern Association
for the Surgery of Trauma
Brian G. Harbrecht, MD, Andrew B. Peitzman, MD, Louis Rivera, MD, Brian Heil, MD, Martin Croce, MD,
John A. Morris, Jr., MD, Blaine L. Enderson, MD, Stanley Kurek, MD, Michael Pasquale, MD,
Eric R. Frykberg, MD, Joseph P. Minei, MD, J. Wayne Meredith, MDC, Joseph Young, MD,
G. Patrick Kealey, MD, Steven Ross, MD, Fred A. Luchette, MD, Mary McCarthy, MD, Frank Davis III, MD,
David Shatz, MD, Glenn Tinkoff, MD, Ernest F. J. Block, MD, John B. Cone, MD, Larry M. Jones, MD,
Thomas Chalifoux, BA, Michael B. Federle, MD, Keith D. Clancy, MD, Juan B. Ochoa, MD,
Samir M. Fakhry, MD, Ricard Townsend, MD, Richard M. Bell, MD, Leonard Weireter, MD,
Michael B. Shapiro, MD, Fred Rogers, MD, C. Michael Dunham, MD, and Clyde E. McAuley, MD

Background: The purpose of this
study was to examine the contribution of
age and gender to outcome after treat-
ment of blunt splenic injury in adults.
Methods: Through the Multi-Institu-
tional Trials Committee of the Eastern As-
sociation for the Surgery of Trauma
(EAST), 1488 adult patients from 27 trauma
centers who suffered blunt splenic injury in
1997 were examined retrospectively.
Results: Fifteen percent of patients
were 55 years of age or older. A similar
proportion of patients > 55 went directly
to the operating room compared with pa-
tients < 55 (41% vs. 38%) but the mor-
tality for patients > 55 was significantly
greater than patients < 55 (43% vs. 23%).
Patients > 55 failed nonoperative man-
agement (NOM) more frequently than pa-
tients < 55 (19% vs. 10%) and had in-
creased mortality for both successful
NOM (8% vs. 4%, p < 0.05) and failed
NOM (29% vs. 12%, p ⴝ 0.054). There
were no differences in immediate opera-
tive treatment, successful NOM, and
failed NOM between men and women.
However, women > 55 failed NOM more
frequently than women < 55 (20% vs.
7%) and this was associated with in-
creased mortality (36% vs. 5%) (both p <
0.05).
Conclusion: Patients > 55 had a
greater mortality for all forms of treat-
ment of their blunt splenic injury and
failed NOM more frequently than patients
< 55. Women > 55 had significantly
greater mortality and failure of NOM
than women < 55.
J Trauma. 2001;51:887–895.

N
onoperative management of the injured spleen has be-
come accepted in both adults and children. Over 90%
of children with blunt splenic injuries can be treated
without operation.1,2 Similar success rates are not seen in
adults but nonoperative management (NOM) of blunt splenic
injuries is now attempted in over 60% of adult patients.1– 4
The criteria utilized to select an adult patient for operative
management (OM) versus NOM continue to be refined.
Grade of splenic injury, quantity of hemoperitoneum, and
extent of associated injuries were associated with the rate of
Submitted for publication February 16, 2001.
Accepted for publication July 10, 2001.
Copyright © 2001 by Lippincott Williams & Wilkins, Inc.
From the University of Pittsburgh School of Medicine, (B.G.H.,
A.B.P., L.R., B.H., T.C., M.B.F., K.D.C., R.T.), Mercy Hospital (L.M.J.),
and Allegheny General Hospital Trauma Center (J.Y.), Pittsburgh, Lehigh
Valley Hospital (S.K., M.P.), Allentown, Brandywine Hospital (M.B.S.),
Coatesville, Pennsylvania, Vanderbilt University (J.A.M.), Nashville, Uni-
versity of Tennessee Memorial Hospital (B.L.E.), Knoxville, University of
Tennessee Medical Center (M.C.), Memphis, Tennessee, University of Flor-
ida Health Science Center (E.R.F.), Jacksonville, University of Miami (D.S.),
Miami, Orlando Regional Healthcare System (E.F.J.B.), Orlando, Florida,
Southwestern Medical Center (J.P.M.), Dallas, East Texas Medical Center
(C.E.M.), Tyler, Texas, Wake Forest University School of Medicine
(J.W.M.), Winston-Salem, North Carolina, University of Iowa Hospital
success or failure of NOM in a recent multi-institutional
study supported by the Multi-Institutional Trials Committee
of the Eastern Association for the Surgery of Trauma
(EAST).5 Whether age should be a factor in selecting OM or
NOM in adults with blunt splenic injuries continues to be
debated. High rates of failure of NOM have been documented
in older patients and some have considered age ⬎ 55 years to
be a contraindication to NOM.6 – 8 More recent studies have
(G.P.K.), Iowa City, Iowa, Cooper Hospital University Medical Center
(S.R.), Camden, New Jersey, University of Cincinnati Medical Center
(F.A.L.), Cincinnati, Miami Valley Hospital (M.M.), Dayton, St. Elizabeth
Health Center (C.M.D.), Youngstown, Ohio, Memorial Medical Center
(F.D.), Savannah, Georgia, Christiana Hospital (G.T.), Newark, Delaware,
University of Arkansas (J.B.C.), Little Rock, Arkansas, Chandler Medical
Center (J.B.O.), Lexington, Kentucky, Inova Fairfax Hospital (S.M.F.), Falls
Church, Eastern Virginia Medical School (L.W.), Norfolk, Virginia, Pal-
metto Richland Memorial Hospital (R.M.B.), Columbia, South Carolina, and
University of Vermont College of Medicine (F.R.), Burlington, Vermont.
Presented at the 14th Annual Meeting of the Eastern Association for the
Surgery of Trauma, January 10 –13, 2001, Tarpon Springs, Florida.
Address for reprints: Brian G. Harbrecht, MD, General/Trauma Sur-
gery, University of Pittsburgh Medical School, Presbyterian University Hos-
pital, Room A1010, 200 Lothrop Street, Pittsburgh, PA 15213-2582; email:
harbrechtbg@msx.upmc.edu.

Volume 51 • Number 5 887

 The Journal of TRAUMA威 Injury, Infection, and Critical Care

suggested that age should not be a consideration for NOM since

over 80% of adults older than 55 years of age with splenic
injuries can be successfully treated nonoperatively.3,9,10 These
latter studies include relatively small numbers of patients, how-
ever, which may limit their ability to detect outcome differences
or to identify factors associated with failure of NOM in older
patients.
Similarly, the influence of gender on outcome after in-
jury has undergone renewed examination. Recent clinical
studies suggest that male gender predisposes to increased
infectious morbidity after injury and these findings are sup-
ported in animal models of shock and injury.11–13 Since the
data collected in the EAST multicenter study represents the
largest contemporary population of patients with blunt
splenic injuries, it represents a unique opportunity to examine
the relationship between age and gender on outcome in in-
jured adults. We sought to determine whether a) advanced
age affected outcome and success of NOM in adult patients
Fig. 1. Mortality per decade of life. Eligible patients were stratified
with blunt splenic injuries and b) if gender affected outcome
by decade and total mortality calculated. Numbers over each col-
after splenic injury.
umn represent the percentage of female patients in each decade.

MATERIALS AND METHODS The proportion of patients ⬍ 55 and patients ⱖ 55 taken

Details on trauma center participation and data collection directly to the operating room from the ED for treatment of
have been previously published.5 Briefly, 27 trauma centers their blunt splenic injuries was similar (38% vs. 41%). This
(26 Level I and 1 Level II) retrospectively collected data on left 62% of patients ⬍ 55 and 59% of patients ⱖ 55 who were
patients with blunt splenic injuries for 1997. In addition to treated with planned NOM. The failure rate for NOM in
demographic, physiologic, and treatment data, operative find- patients ⱖ 55 was significantly greater than that of patients ⬍
ings and computed tomographic (CT) records were included. 55 (19% vs. 10%) (Fig. 2). Similar to the previous analysis,5
Splenic injuries were graded according to the AAST Organ failure of NOM was associated with an increased mortality
Injury Scale (1994 version) and hemoperitoneum was quan- rate in both patients ⬍ 55 and ⱖ 55 (12% and 29%, respec-
tified either from the operative or CT reports.5,14,15 Patients tively) compared with those successfully managed nonopera-
who went directly from the emergency department (ED) to
the operating room (OR) were classified as OM. Patients
admitted to the intensive care unit (ICU) or ward were clas-
sified as planned NOM regardless of the duration of stay at
that location.
Data are presented as the mean ⫾ SEM (SEM). Data
were analyzed using StatView (Abacus Concepts, Inc.,
Berkeley, CA) software. Categorical variables were com-
pared using the ␹2 test while numerical variables were ana-
lyzed using analysis of variance and the Student-Newman-
Keuls post hoc test. A p value less than 0.05 was considered
statistically significant.

RESULTS
Of the 1488 patients who had data submitted, age was
recorded in 1485. We first examined overall mortality rates in
each decade of life for eligible patients (Fig. 1). Mortality in
patients with blunt splenic injuries increased in patients 55
years old and older. Since age ⱖ 55 corresponded to increas- Fig. 2. Success of NOM. Patients taken directly to the OR were
ing mortality in this population and since it was the age cut excluded and percentage of patients with successful or failed NOM
off for many previously published studies,3,7–10,16 we strati- was calculated for patients ⬍ 55 (open columns) and patients ⱖ 55
fied patients based on this criterion. There were 1261 (85%) (filled columns). Mortality rate for each group is included above the
patients younger than 55 (⬍ 55) and 224 patients (15%) who column. #p ⬍ 0.05 vs. age ⬍ 55; *p ⬍ 0.05 vs. successful NOM; @p
were 55 years old or older (ⱖ 55). ⫽ 0.054 vs. age ⬍ 55.

888 November 2001

 Age and Gender, and Outcome of Splenic Injury in Adults

Table 1 Variables Stratified by Age and Management

Age ⬍ 55 Age ⱖ 55
Direct to OR Successful NOM Failed NOM Direct to OR Successful NOM Failed NOM

N 477 699 73 90 108 24

ISS 31.8 ⫾ 0.6 20.2 ⫾ 0.41 28.2 ⫾ 1.51,2 32.3 ⫾ 1.3 22.0 ⫾ 1.11 26.4 ⫾ 2.61
Highest ED heart rate (bpm) 123 ⫾ 1 108 ⫾ 11 113 ⫾ 31 107 ⫾ 2# 102 ⫾ 2# 102 ⫾ 4
Lowest ED BP (mm Hg) 90 ⫾ 1 112 ⫾ 11 105 ⫾ 31,2 88 ⫾ 3 115 ⫾ 31 104 ⫾ 51
ED Hemocrit (%) 32.8 ⫾ 0.3 37.6 ⫾ 0.21 36.1 ⫾ 0.71,2 29.8 ⫾ 0.8# 36.3 ⫾ 0.61,# 33.2 ⫾ 1.21,2,#
ED Base deficit (mEq/L) 9.0 ⫾ 0.4 4.9 ⫾ 0.21 5.5 ⫾ 0.71 7.6 ⫾ 0.8 3.5 ⫾ 0.51,# 3.5 ⫾ 0.71
24-h PRBC (units) 8.3 ⫾ 0.5 1.2 ⫾ 0.11 4.0 ⫾ 0.81,2 9.4 ⫾ 0.9 1.9 ⫾ 0.31,# 5.3 ⫾ 1.81,2
ICU LOS (days) 7.9 ⫾ 0.6 3.9 ⫾ 0.31 6.8 ⫾ 1.12 10.2 ⫾ 1.3 6.0 ⫾ 0.7# 18.3 ⫾ 6.11,2,#
Hospital LOS (days) 14.8 ⫾ 0.9 9.9 ⫾ 0.61 13.4 ⫾ 1.62 15.8 ⫾ 1.9 11.2 ⫾ 1.1 25.8 ⫾ 7.61,2,#
1
p ⬍ 0.05 vs. direct to OR; 2
p ⬍ 0.05 vs. successful NOM; #
p ⬍ 0.05 vs. age ⬍ 55.

tively (⬍55, 4%; ⱖ 55, 8%). In addition, the mortality rate was greater for patients ⱖ 55 with large hemoperitoneum
for patients ⱖ 55 was greater than patients ⬍ 55 for those compared with patients ⬍ 55; however, this was not true for
patients treated with immediate operation (⬍ 55, 23%; ⱖ 55, patients with small and moderate hemoperitoneum (Table 2).
43%; p ⬍ 0.05), successful NOM (⬍ 55, 8%; ⱖ 55, 4%; p ⬍ When patient management was stratified according to the
0.05), and those who failed NOM (⬍ 55, 12%; ⱖ 55, 29%; quantity of hemoperitoneum, patients ⱖ 55 with small
p ⫽ 0.054). amounts of hemoperitoneum were taken directly to the OR
Patients taken directly to the OR for treatment of their more frequently than patients ⬍ 55. The amount of hemo-
blunt splenic injury in both age groups had a lower ED BP, peritoneum in patients ⬍ 55 and ⱖ 55 successfully or un-
higher Injury Severity Score (ISS), lower ED hematocrit, successfully treated nonoperatively was similar (Table 2).
worse ED base deficit, and greater 24 hour packed red blood When the grade of splenic injury was examined, the
cell (PRBC) transfusion requirement (Table 1). Patients severity of splenic injury was similar between patients ⬍ 55
treated successfully nonoperatively, in both age groups, had a and ⱖ 55; (⬍ 55: I, 24%; II, 28%; III, 22%; IV, 19%; V, 8%;
higher ED BP, lower ISS, higher ED hematocrit, lower ED ⱖ 55: I, 29%; II, 30%; III, 22%; IV, 14%; V, 5%). However,
base deficit, and lower 24 hour PRBC transfusion require- the mortality rate for patients ⱖ 55 was significantly greater
ment while patients who failed NOM had values between than that of patients ⬍ 55 for grades II–IV (Fig. 4). When
these two groups (Table 1). When compared with patients ⬍ stratified by grade of injury, there were no differences be-
55, patients ⱖ 55 had a relatively lower ED heart rate and tween patients ⬍ 55 and ⱖ 55 in ISS, ED base deficit, or
hematocrit although most other parameters were similar. units of blood transfused in the first 24 hours (data not
However, the length of stay (LOS) was markedly different shown). Patients ⱖ 55 with grade V injuries had a signifi-
between these groups (Table 1). The ICU and hospital LOS in
patients ⬍ 55 was the lowest in patients treated with success-
ful NOM and the highest for those taken directly to the OR.
Patients ⬍ 55 who failed NOM had a LOS that was the same
as those taken directly to the OR at the outset. In patients ⱖ
55, the ICU and hospital LOS were also lowest in those
successfully treated nonoperatively. In patients ⱖ 55, how-
ever, the LOS for those patients who failed NOM was not
only greater than those treated with NOM successfully but it
was greater than those taken directly to the OR from the ED
(Table 1).
There were 1020 patients in whom the magnitude of
hemoperitoneum could be quantified. There were no differ-
ences between patients ⬍ 55 and ⱖ 55 in the proportion of
patients with small (32% and 40%), moderate (25% and
22%), and large (43% and 39%) hemoperitoneum. However,
the mortality rate for patients ⱖ 55 for each level of hemo-
peritoneum was significantly greater than that of patients ⬍ Fig. 3. Mortality rates per quantity magnitude of hemoperitoneum.
55 (Fig. 3). When specific patient characteristics were exam- The quantity of hemoperitoneum was estimated as described in the
ined between groups stratified for the quantity of hemoperi- Materials and Methods section for patients ⬍ 55 and (open col-
toneum, patients ⱖ 55 had a lower ED hematocrit and a lower umns) and patients ⱖ 55 (filled columns). #p ⬍ 0.05 vs. age ⬍ 55;
ED heart rate (Table 2). The ED BP was lower and the LOS *p ⬍ 0.05 vs. small/moderate hemoperitoneum.

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 The Journal of TRAUMA威 Injury, Infection, and Critical Care

Table 2 Variables Stratified by Age and Magnitude of Hemoperitoneum

Age ⬍ 55 Age ⱖ 55
Small Moderate Large Small Moderate Large

N 276 221 375 59 32 57

ISS 22.9 ⫾ 0.8 24.7 ⫾ 0.9 28.7 ⫾ 0.71,2 25.0 ⫾ 1.5 30.1 ⫾ 2.2# 29.8 ⫾ 1.7
Highest ED heart rate (bpm) 111 ⫾ 1 113 ⫾ 2 117 ⫾ 11 102 ⫾ 3# 101 ⫾ 4# 106 ⫾ 3#
Lowest ED BP (mm Hg) 110 ⫾ 2 102 ⫾ 21 97 ⫾ 11 111 ⫾ 5 102 ⫾ 4 87 ⫾ 41,2,#
ED Hemocrit (%) 37.6 ⫾ .4 35.3 ⫾ .41 33.9 ⫾ .41,2 34.5 ⫾ .8# 30.9 ⫾ 1.31,# 31.6 ⫾ .81,#
ED Base deficit (mEq/L) 5.9 ⫾ .4 6.1 ⫾ 0.4 7.6 ⫾ 0.41,2 5.1 ⫾ 0.8 3.8 ⫾ 0.8# 7.7 ⫾ 1.42
24-h PRBC (units) 1.7 ⫾ 0.3 3.2 ⫾ 0.41 6.0 ⫾ 0.51,2 3.2 ⫾ 0.6# 4.7 ⫾ 0.9 7.8 ⫾ 1.11,2
ICU LOS (days) 4.9 ⫾ 0.6 6.7 ⫾ 0.8 6.0 ⫾ 0.6 7.7 ⫾ 1.0 8.4 ⫾ 1.6 11.1 ⫾ 2.8#
Hospital LOS (days) 11.9 ⫾ 1.3 14.0 ⫾ 1.3 11.3 ⫾ 0.6 12.0 ⫾ 1.3 14.8 ⫾ 2.5 17.2 ⫾ 3.6#
Direct to OR (%) 10 22 67 22# 23 55#
Successful NOM (%) 51 26 23 64 14 22
Failed NOM (%) 21 36 44 30 40 30
1
p ⬍ 0.05 vs. small; 2
p ⬍ 0.05 vs. moderate; #
p ⬍ 0.05 vs. age ⬍ 55.

cantly lower ED BP than patients ⬍ 55 (71 ⫾ 12 mm Hg vs.
92 ⫾ 3 mm Hg, respectively) with the BP similar for all other
grades. Patients ⱖ 55 also had a longer LOS compared with
patients ⬍ 55 for grade II (ICU— 8.4 ⫾ 1.3 days vs. 5.6 ⫾
0.5 days, p ⬍ 0.05) and grade III (ICU—16.7 ⫾ 4.5 days vs.
Fig. 4. Mortality rates by grade of splenic injury. Grade of splenic
injury was estimated using the AAST grading system (1994 version).
Open columns represent patients ⬍ 55 and filled columns represent
patients ⱖ 55. #p ⬍ 0.05 vs. age ⬍ 55. @p ⫽ 0.05 vs. age ⬍ 55.
6.7 ⫾ 0.9 days, p ⬍ 0.05) (hospital—24.3 ⫾ 5.8 days vs. 13.2
⫾ 1.4 days, p ⬍ 0.05) with the LOS between other grades of
injury being similar.
When the management of the splenic injury was exam-
ined, the proportion of patients taken directly to the OR
increased as the grade of injury increased while the propor-
tion of patients successfully treated nonoperatively was in-
versely proportional to grade both for patients ⬍ 55 and for
patients ⱖ 55 (Table 3). In addition, the total percentage of
patients successfully treated nonoperatively was less in pa-
tients ⱖ 55 for all grades of splenic injury except grade I
(Table 3). It was notable that in this multicenter study no
patient ⱖ 55 with a grade IV injury had successful NOM
while no patient ⱖ 55 with a grade V splenic injury had an
attempt at NOM.
We next examined whether management and outcome
differed according to gender. There were no differences be-
tween men and women in the frequency of patients taken
directly to the OR (38% vs. 40%), successfully treated non-
operatively (55% vs. 54%), or unsuccessfully treated nonop-
eratively (7% vs. 6%). Overall, 89% of men admitted with
planned NOM were successfully treated nonoperatively while
90% of women who had planned NOM succeeded (p ⫽ NS).
In addition, the mortality rate was similar for men and women
for those taken directly to the OR (25% vs. 28%), those
successfully treated nonoperatively (4% vs. 4%), or those

Table 3 Management by Age and Splenic Injury Grade

Age ⬍ 55 Age ⱖ 55
Grade Direct to OR Successful NOM1 Failed NOM1 Direct to OR Successful NOM1,# Failed NOM1
n % n % n % n % n % n %

I 48 22.4 158 73.8 8 3.7 5 11.6 36 83.7 2 4.7

II 54 21.6 181 72.4 15 6.0 13 29.5 24 54.5 7 15.9
III 74 36.5 106 52.2 23 11.3 19 59.4 9 28.1 4 12.5
IV 127 74.7 32 18.8 11 6.5 15 71.4 0 0 6 28.6
V 64 94.1 1 1.5 3 4.4 8 100 0 0 0 0
1
p ⬍ 0.05 vs. direct to OR; #
p ⬍ 0.05 vs. age ⬎ 55.

890 November 2001

 Age and Gender, and Outcome of Splenic Injury in Adults

Table 4 Variables Stratified by Gender and Management

Male Female
Direct to OR Successful NOM Failed NOM Direct to OR Successful NOM Failed NOM

N 350 505 64 226 308 33

Age (years) 33.2 ⫾ 0.9 33.0 ⫾ 0.7 37.2 ⫾ 2.31 39.9 ⫾ 1.4 35.8 ⫾ 1.0# 50.0 ⫾ 3.91,2,#
ISS 31.7 ⫾ 0.7 20.5 ⫾ 0.51 28.0 ⫾ 1.61,2 32.0 ⫾ 0.9 20.1 ⫾ 0.61 24.9 ⫾ 2.11,2
Highest ED heart rate (bpm) 122 ⫾ 1 107 ⫾ 11 109 ⫾ 21 117 ⫾ 2 108 ⫾ 1 113 ⫾ 5
Lowest ED BP (mm Hg) 90 ⫾ 2 114 ⫾ 11 104 ⫾ 31,2 89 ⫾ 2 110 ⫾ 11,# 105 ⫾ 41
ED Hemocrit (%) 34.2 ⫾ 0.4 39.0 ⫾ 0.31 37.0 ⫾ 0.71,2 29.3 ⫾ 0.5# 35.1 ⫾ 0.31,# 32.1 ⫾ 1.11,2,#
ED Base deficit (mEq/L) 9.0 ⫾ 0.4 4.5 ⫾ 0.21 5.4 ⫾ 0.71 8.4 ⫾ 0.5 5.0 ⫾ 0.41 4.0 ⫾ 0.71
24-h PRBC (units) 8.5 ⫾ 0.5 1.1 ⫾ 0.11 5.0 ⫾ 1.01,2 8.4 ⫾ 0.8 1.5 ⫾ 0.21 3.0 ⫾ 0.91
ICU LOS (days) 8.6 ⫾ 0.8 4.2 ⫾ 0.41 8.0 ⫾ 1.22 7.8 ⫾ 0.7 4.1 ⫾ 0.31 13.1 ⫾ 4.61,2
Hospital LOS (days) 15.8 ⫾ 1.2 9.7 ⫾ 0.71 15.1 ⫾ 1.92 13.7 ⫾ 1.0 10.6 ⫾ 1.0 19.9 ⫾ 5.71,2
1
p ⬍ 0.05 vs. direct to OR; 2
p ⬍ 0.05 vs. successful NOM; #
p ⬍ 0.05 vs. male.

who failed nonoperative treatment (16% vs. 18%). For both
men and women, the mortality rate associated with failure of
NOM was significantly higher than those successfully treated
nonoperatively.
When examined according to management of their
splenic injury, women tended to be older than men and had a
lower hematocrit but the ISS, heart rate, base deficit, and
transfusion requirements were similar for men and women
(Table 4). For each form of management, there were no
differences between men and women in either ICU or hos-
pital LOS. However, the pattern of LOS within gender groups
was different. The LOS for men was lowest in the group
successfully treated nonoperatively while the LOS for men
who failed NOM was similar to that of men taken directly to
the OR from the ED. For women, successful NOM was also
associated with the lowest LOS (Table 4). However, the LOS
for women who failed NOM was significantly greater than
that of women with successful NOM as well as greater than
that of women taken directly to the OR at the outset (Table 4).
The distribution of grade of splenic injury was compa-
rable between men and women (I, 24% vs. 26%; II, 30% vs.
25%; III, 22% vs. 23%; IV, 17% vs. 20%; V, 8% vs. 6%; men
vs. women, respectively) and the mortality rate for each
respective grade of splenic injury was similar between men
and women (I, 8% vs. 12%; II, 9% vs. 10%; III, 12% vs. 10%;
IV, 17% vs. 15%; V, 13% vs. 17%; men vs. women, respec-
tively). There were no differences between men and women
in ISS, highest ED heart rate, ED base deficit, or 24 hour
transfusion requirements although all these parameters tended
to become worse for both men and women as the grade of
splenic injury increased (data not shown). Female patients
tended to be older than male patients in each grade of splenic
injury but this was statistically significant only for grade II
(33.1 ⫾ 1.1 years vs. 38.8 ⫾ 2.1 years; men vs. women,
respectively) and grade III (31.1 ⫾ 1.3 years vs. 39.2 ⫾ 2.2
years; men vs. women, respectively). Female patients had
statistically similar lowest ED BP compared with male pa-
tients except for those with grade V injuries (97 ⫾ 3 mm Hg
vs. 73 ⫾ 5 mm Hg; men vs. women, respectively). Not
surprisingly, female patients had significantly lower ED he-
matocrits for each grade of splenic injury compared with
male patients but the ICU and hospital LOS for each grade of
injury were similar (data not shown). The management of
blunt splenic injury between men and women was similar for
each grade of splenic injury except grade III where more
women were taken directly to the OR than men (31% vs.
19%) while fewer women had successful (66% vs. 71%) or
failed (3% vs. 10%) NOM.
When men and women were examined for management
differences for each magnitude of hemoperitoneum, the pro-
portion of women taken directly to the OR or treated with
NOM was similar to men for all degrees of hemoperitoneum
and the mortality rates were similar (data not shown). For
each magnitude of hemoperitoneum, women were older than
men and had lower hematocrits, consistent with the findings
discussed above, but all other parameters were similar (data
not shown).
The proportion of patients that were female increased in
the older decades of life (Fig. 1). When we stratified both
male and female patients according to age ⬍ 55 or ⱖ 55, the
proportion of patients in each group taken directly to the OR
was similar (men ⬍ 55, 38%, n ⫽ 314; men ⱖ 55, 38%, n ⫽
36; women ⬍ 55, 39%, n ⫽ 170; women ⱖ 55, 44%, n ⫽ 56).
For patients taken directly to the OR, men ⱖ 55 had a greater
mortality than men ⬍ 55 (39% vs. 24%, p ⬍ 0.05) and
women ⱖ 55 had a greater mortality than women ⬍ 55 (46%
vs. 22%, p ⬍ 0.05) but the differences between men and
women were not statistically significant. For patients admit-
ted with planned NOM, women ⱖ 55 failed NOM more
frequently than women ⬍ 55 (Fig. 5). Men ⱖ 55 failed NOM
more frequently than men ⬍ 55 but this difference did not
reach statistical significance (p ⫽ 0.16). While the mortality
rate for men ⱖ 55 compared with men ⬍ 55 for those
successfully managed nonoperatively or who failed NOM
was similar, the mortality rate for women ⱖ 55 successfully
treated nonoperatively was significantly greater than women
⬍ 55 successfully treated nonoperatively (Fig. 5). The mor-
tality rate for women ⱖ 55 who failed NOM was also sig-
nificantly greater than that of women ⬍ 55 who failed NOM
and was greater than women who were successfully treated

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 The Journal of TRAUMA威 Injury, Infection, and Critical Care
Fig. 5. Success of NOM is stratified by age and gender. Patients
taken directly to the OR were excluded and the percentage with
successful vs. failed NOM was calculated. Open columns represent
men ⬍ 55 while black columns represent men ⱖ 55. Lined columns
represent women ⬍ 55 while gray columns represent women ⱖ 55.
Mortality rates are included above each column. #p ⬍ 0.05 vs. age
⬍ 55 (same gender); *p ⬍ 0.05 vs. successful NOM (same age and
gender).
nonoperatively (Fig. 5). These differences between groups
were also reflected in the LOS since both ICU and hospital
LOS for women ⱖ 55 were significantly greater than that of
women ⬍ 55 (p ⬍ 0.05) while other groups were similar
(men ⬍ 55: ICU 5.9 ⫾ 0.4 days and hospital 12.3 ⫾ 0.7 days;
men ⱖ 55: ICU 8.3 ⫾ 1.0 days and hospital 13.4 ⫾ 1.3 days;
women ⬍ 55: ICU 5.0 ⫾ 0.4 days and hospital 11.3 ⫾ 0.7
days; women ⱖ 55: ICU 9.7 ⫾ 1.3 days and hospital 15.7 ⫾
2.0 days).
DISCUSSION
The factors that influence morbidity and mortality and
the criteria that predict successful or unsuccessful NOM of
the bluntly injured spleen in adults continue to be defined.
While the presence of injuries that mandate operative repair
(hollow viscus injuries, intraperitoneal bladder rupture) and
the hemodynamic status of the patient are the dominant fac-
tors in deciding early management, the role of other charac-
teristics such as patient age, associated injuries, magnitude of
splenic injury, quantity of hemoperitoneum seen on CT, and
need for blood transfusions have been more difficult to de-
fine. The lack of a uniform consensus regarding the role of
many of these factors, and the limitations of the collected
series of relatively small single institution reports, prompted
the Multi-Institutional Trials Committee of the EAST to or-
ganize a multicenter study.5 The initial report with over 1400
patients from 27 trauma centers showed that the magnitude of
splenic injury and quantity of hemoperitoneum correlated
with overall mortality and success of NOM.5
892
The relative importance of age and gender on success of
treatment and outcome from blunt splenic injury has not yet
been defined. It seems clear that children fail NOM less
frequently than adults but this may be related more to the fact
that they are injured less severely and with less force than any
specific spleen-related factor due to age per se.1,2 While early
reports documented high failure rates for NOM in adults
older than 55 years of age, more recent reports have shown
success rates for NOM in older patients that are comparable
to that of younger patients.3–9 These latter studies have ques-
tioned whether age should be a consideration at all in the
treatment decision for splenic injury.3,9 Our data confirm
what other smaller studies have demonstrated, that is, that the
majority of patients older than 55 can be treated nonopera-
tively. The 80% success rate for NOM in these studies ap-
pears remarkably uniform.1–3,9 The large patient population
in the current undertaking, however, permits us to extend
these observations to show that the failure rate of NOM was
significantly greater in patients ⱖ 55. The mortality rate for
these older patients is greater than that of younger patients
regardless of the final management. Interestingly, failure of
NOM was associated with a mortality rate 21⁄2 times that of
patients ⬍ 55. The increased mortality for patients ⱖ 55 was
present across all grades of splenic injury (except grade I) and
all magnitudes of hemoperitoneum, factors important to suc-
cess in the previous study.5
One of the most striking differences between patients ⬍
55 and ⱖ 55 was present in LOS. For all patients, ICU and
hospital LOS were lowest for those treated successfully non-
operatively. For patients ⬍ 55, failure of NOM was associ-
ated with an increase in ICU and hospital LOS but the LOS
was similar to that of patients ⬍ 55 taken directly to the OR
from the ED. In patients ⱖ 55, failure of NOM was associ-
ated with a LOS that was greater than that of patients taken
directly to the OR from the ED. The data collected in this
analysis do not allow us to determine if this increased LOS in
patients ⱖ 55 who fail NOM is due to consequences of
ongoing hypoperfusion, increased frequency of complica-
tions, or some other factor(s). These data suggest, however,
that failure of NOM in patients ⱖ 55 is associated with
increases in mortality and LOS that have not been previously
appreciated.
Previous studies examining NOM in older patients have
had low numbers of patients that have precluded evaluating
the types of injuries treated.2,9 In this study, we had 132
patients ⱖ 55 treated nonoperatively. With an 80% success
rate, the absolute number of patients who failed NOM is still
relatively low (n ⫽ 24) but an examination of the types of
injuries treated in this group yields some interesting obser-
vations. It shows that the failure rate of NOM in patients ⱖ
55 with grade I injuries is similar to that of patients ⬍ 55
(5.4% vs. 4.8%, respectively). In patients ⬍ 55, the failure
rate for NOM for grade II injuries is still low (7.7%) and
increases for grades III–V (grade III, 18.5%; grade IV,
25.6%; grade V, 75%). For patients ⱖ 55, however, the
November 2001

failure rate for NOM for grade II injuries increases to 22.6%
and 30.8% for grade III. While the relative numbers of pa-
tients in each group are too small to permit statistical com-
parison, it is interesting to note that all grade IV injuries in
patients ⱖ 55 that had an attempt at NOM failed while no
grade V injuries had an attempt at NOM.
The analysis also revealed that the highest ED heart rate
for patients ⱖ 55 was significantly lower than that of patients
ⱕ 55 (Table 1) despite similar ED blood pressure. In addi-
tion, patients ⱖ 55 had a lower ED hematocrit than patients
ⱕ 55. While these differences may reflect a relative anemia
of older age or a lower threshold for operative therapy in
patients ⱖ 55 with blunt splenic injury, they may also be
indicative of the diminished cardiovascular reserve and de-
creased physiologic response to hemorrhage present in el-
derly patients.17
The potential impact of gender on outcome after injury
or disease has come under renewed interest in both the clin-
ical arena as well as the animal laboratory. Male patients had
higher mortality rates and rates of infectious complications
after injury but other investigators have shown no gender
differences or greater mortality in female patients admitted
for sepsis.11–13,18 –21 Differences in outcome in animal mod-
els of shock and injury have been attributed to the differences
in sex steroids and their effects on cardiovascular and im-
mune function.22–26 In this multicenter study, there were no
differences in management, mortality rate, or success/failure
of NOM between men and women. Injury grade was similar
between men and women. As noted earlier, however, these
differences may be attributed, in part, to the increased per-
centage of female patients in the older decades of life (Fig. 1).
Female patients who failed NOM had an ICU and hospital
LOS that was significantly greater than those with successful
NOM and greater than female patients taken directly to the
OR from the ED. For male patients who failed NOM, their
LOS was no worse than men taken directly to the OR from
the ED.
Management differences were apparent when men and
women were stratified by age (Fig. 4). While the proportion
of patients taken directly to the OR was relatively constant,
women ⱖ 55 failed NOM more frequently than women ⬍ 55
(19.7% vs. 7.0%, p ⬍ 0.05). This difference is likely due to
the combination of several trends. First, women ⬍ 55 failed
NOM less frequently than men ⬍ 55 (7.0% vs. 10.7%).
Furthermore, women ⱖ 55 tended to fail NOM more fre-
quently than men ⱖ 55 (19.7% vs. 16.7%). Neither of these
trends reached statistical significance. A similar pattern was
also seen when mortality rates were examined. The mortality
rate for men ⱖ 55 who were successfully treated nonopera-
tively or who failed NOM was similar to that of men ⬍ 55
(successful NOM, 6.0% vs. 4.2%; failed NOM, 20.0% vs.
14.8%; ⱖ 55 vs. ⬍ 55 respectively). Women ⱖ 55, however,
had a significantly higher mortality rate for both successful
(8.8% vs. 2.4%) and failed (35.7% vs. 5.3%) NOM compared
with women ⬍ 55. In terms of mortality rates, success of
Volume 51 • Number 5
Age and Gender, and Outcome of Splenic Injury in Adults
treatment plan, and LOS, women ⱖ 55 resembled men ⬍ 55
and men ⱖ 55 more than they did women ⬍ 55. Whether this
finding represents a clinical manifestation of the differences
seen in animal models from differences in sex steroid levels
remains to be proven. These data are consistent, however,
with the hypothesis that menopause-induced changes in an-
drogens and estrogens are important in normal physiologic
function and the response to injury.
While the large size of the population available for study
is a significant advantage of this analysis, this study does
have limitations. Even given the large patient sample, the
total number of patients who failed NOM (n ⫽ 97) is rela-
tively low. It is therefore difficult to identify all possible
factors that might contribute to failure of NOM. This multi-
center effort has shown that quantity of hemoperitoneum and
grade of splenic injury correlate well with failure of NOM,5
and now we can add increased age as being associated with
failure of NOM. A point not previously appreciated in other
reports is that there were no grade IV injuries in patients ⱖ 55
that were successfully treated nonoperatively and no patient
ⱖ 55 with a grade V injury had an attempt at NOM. While we
cannot definitively rule out the possibility of a grade IV or V
injury being successfully treated nonoperatively in patients ⱖ
55, our data suggest that the likelihood of this is quite low. As
in our original analysis,5 the data collected do not permit a
distinction to be drawn between patients who went to the OR
for treatment of their splenic injuries alone versus treatment
of other intraabdominal injuries (liver lacerations, mesenteric
tears, etc.) who were also found to have splenic injuries.
Therefore, we cannot conclusively exclude potential effects
of other intraabdominal injuries. This limitation is tempered
by the fact that it does represent the broad population of
patients with blunt splenic injuries and, since isolated splenic
injuries occur less frequently in adults than children,2 reflects
well the total population of injuries seen in these 27 trauma
centers.
Our data demonstrate for the first time that failure of
NOM in patients ⱖ 55 was associated with increased mor-
tality and morbidity. The retrospective nature of this study
precludes us from being able to define the specific reasons for
these increases. Whether a failure of NOM contributed to the
increased morbidity and mortality in these patients will likely
continue to be debated. Bee et al. have recently published
their experience with blunt splenic injury and have included
50 patients ⱖ 55.16 An analysis of their published data re-
veals a greater mortality rate in patients ⱖ 55 who failed
NOM compared with patients ⱖ 55 who were successfully
observed although the numbers are likely too small for sta-
tistical comparison.16 Nevertheless, their trend supports the
findings in the current report. One could criticize the use of
LOS as an index of morbidity in this report since other factors
may play a role in determining ICU and hospital LOS, espe-
cially in older patients. The data collected for this analysis do
not account for the frequency of complications, return to
preinjury functional status, or discharge destination that may
893
 The Journal of TRAUMA威 Injury, Infection, and Critical Care
also reflect morbidity. There may be differences in these
parameters between patient groups that contribute to or are
independent of LOS differences. More detailed data collec-
tion would be required to clarify this point.
Finally, what constitutes an age indicative of elderly is
subject to debate. Many investigators have used 55– 60 years
and this age corresponds to an age when overall mortality
increases and when risk of organ failure increases.7–9,27–29
We did not control for the presence of preexisting medical
conditions in this study. While several derangements of nor-
mal physiologic function occur with aging that may alter the
response to injury,17,18,29 use of age to reflect this may not be
the most precise method. Patients ⬍ 55 may have increased
morbidity and mortality if their physiologic reserve is less-
ened by the presence of multiple preexisting medical prob-
lems. Similarly, patients ⱖ 55 may have risks more closely
resembling younger patients if their incidence of age-related
problems are minimal. A more precise analysis of age and
gender would require significantly more patients and more
detailed data to be definitive.
In conclusion, our data demonstrate that the mortality
rate in patients ⱖ 55 with blunt splenic injuries is greater than
that of younger patients. Although 80% of patients who have
attempted NOM of their splenic injuries are successfully
treated this way, patients ⱖ 55 fail NOM more frequently and
this failure is associated with increased mortality and length
of stay. There were few differences between men and women
overall in the management of blunt splenic injuries. When
stratified by age, women ⱖ 55 had a higher rate of failure of
NOM that was associated with a higher mortality rate and
greater length of stay. Data from women ⱖ 55 was more
similar in many respects to that of men of all ages than it was
to women ⬍ 55. These data demonstrate that changes asso-
ciated with age are associated with significant outcome dif-
ferences in the treatment of blunt splenic injuries in adults.
While confirming that most patients ⱖ 55 with blunt splenic
injuries can be treated nonoperatively, they demonstrate that
failure of NOM is this patient population is associated with
increased morbidity and mortality. They suggest that careful
selection of patients ⱖ 55 must be made if the success rate of
NOM is to be acceptable and to minimize morbidity and
mortality from failed attempts.
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