Splenic Trauma
A. All trauma patients are evaluated using ATLS protocols including AMPLE history,
primary and secondary surveys. This algorithm applies to the isolated splenic injury.
Associated injuries can alter the treatment algorithm.
B. Non-operative management is now the standard treatment for blunt splenic injuries. This requires that the patient is hemodynamically normal after 2L crystalloid challenge (rapid responder per ATLS). In adults, the survival benefit of avoiding overwhelming post-splenectomy sepsis (OPSS) by splenic salvage is negated by the risk of blood borne pathogens associated with transfusion of the first unit of packed red blood cells. Therefore, adults with bleeding from isolated splenic injury should undergo operative therapy rather than transfusion. In children, the survival benefit of splenic salvage is maintained until the child is transfused 50% of blood volume (40 cc/kg) in 24 hours due to increased risk of OPSS.
C. For now, penetrating splenic injury is managed operatively. Splenic salvage should be attempted.
D. Patients who are hemodynamically abnormal after 2L crystalloid challenge (transient responder, non-responder per ATLS) require operative management. Usually, a splenectomy, rather than splenic salvage, is necessary in this setting. It is important to rule out other causes of hemodynamic abnormalities including neurotrauma, pelvic and thoracic hemorrhage. The focused abdominal sonogram for trauma (FAST) or diagnostic peritoneal lavage (DPL) can be used to confirm the abdomen as source of hemodynamic abnormalities.
E. Splenic injury should be suspected in patients with the following: abdominal
tenderness, left lower thoracic trauma, macroscopic hematuria, positive FAST, mechanism (fall >12ft., rapid deceleration (>35 mph), etc.), or change in mental status suggesting hemorrhagic shock.
F. AAST splenic injury scale (1994 revision)
I Hematoma Subcapsular, nonexpanding, <10% surface area
Laceration Capsular tear, nonbleeding, <1 cm in parenchymal depth
II Hematoma Subcapsular, nonexpanding, 10-50% surface area;
Intraparenchymal, nonexpanding, < 5cm. in diameter
Laceration Capsular tear, active bleeding, 1-3 cm. depth which does
not involve a trabecular vessel.
III Hematoma Subcapsular, >50% surface area or expanding; ruptured
subcapsular hematoma with active bleeding;
intraparenchymal hematoma > 5 cm. or expanding
Laceration > 3 cm. depth or involving trabecular vessels
IV Hematoma Ruptured intraparenchymal hematoma with active bleeding
Laceration Laceration involving segmental or hilar vessels producing
major devascularization. (>25% of spleen)
V Laceration Completely shattered spleen
Vascular Hilar vascular injury which devascularizes the spleen
G. After splenectomy, patients over the age of 2 should be vaccinated against H. influenza, S.pneumonia, and meningococcus. At present, there is no clear data on the best time to give the immunizations. Pneumococcal vaccination should be repeated every 6-10 years. Children should be placed on daily penicillin prophylaxis
until at least age 5. Many pediatric surgeons would continue prophylaxis until age
18. The use of splenic autotransplantation for prevention of OPSS has been proposed.
H. Patients without active extravasation of contrast or evidence of pseudoaneurysm on
abdominal CT scan can be managed non-operatively with success rates >90%.
I. Several studies have demonstrated that active extravasation of contrast or evidence of
Pseudoaneurysm on CT scan are predictive for failure of non-operative management.
J. Patients with splenic injuries are admitted and carefully monitored. There have been
several clinical pathways proposed which monitor Grade I and II injuries out of the ICU. Most surgeons admit Grade III-V injuries to an ICU, follow serial Hct’s , and repeat a CT scan in 24-48 hours. However, the need for follow-up CT scan is debatable.
K. Several studies have demonstrated that embolization of splenic pseudoaneurysms can
decrease non-operative management failures to as low as 6%.
L. If a patient becomes hypotensive or tachycardic, has a decreasing hematocrit, or
increasing abdominal pain after isolated splenic injury, they have failed non-operative management. They can be taken to the OR for splenectomy, splenic salvage, or identification of missed associated injuries. There is a higher rate of failure of non-operative management associated with blunt splenic injuries compared to blunt hepatic injuries. This is due to the arterial nature of splenic injuries.
M. The appropriate long-term management of isolated splenic injuries is unknown at this
time. Most trauma surgeons will obtain a follow-up scan in 4-6 weeks after injury. Our practice is to allow resumption of full activity when there is evidence of complete or near complete healing of the splenic injury on CT scan. However, the appropriate time for resumption of work and contact sports remains debatable.
Bibliography
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http://www.east.org/tpg/livsplenn.pdf