Splenic Injury

Aka: Splenic Injury, Injury of Spleen, Ruptured Spleen, Splenic Rupture, Splenic Laceration, Laceration of Spleen

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II. Epidemiology

  1. Rare Sports Injury
  2. Most frequent cause of Blunt Abdominal Trauma related death in sports

III. Causes

  1. Spontaneous Splenic Rupture
    1. Seen in Infectious Mononucleosis (EBV) with Splenomegaly
    2. Spontaneous rupture accounts for 50% of Infectious Mononucleosis related Splenic Rupture cases
    3. Asgari (1997) Yale J Biol Med 70(2): 175-82 [PubMed]
  2. Direct blow or projectile to the left upper quadrant
  3. More commonly associated sports
    1. Football
    2. Rugby
    3. Soccer
    4. Lacrosse
    5. Dowhill Skiing or snow boarding
    6. Surfing
    7. Mountain Biking

IV. Symptoms

  1. Left Upper Quadrant Abdominal Pain
  2. Sharp progressing to Dull Epigastric Abdominal Pain
  3. Radiation to left Shoulder (Kehr Sign) or right Shoulder
  4. Nausea
  5. Vomiting

V. Signs

  1. Hemodynamic instability if Hemorrhagic Shock
  2. Left upper quadrant tenderness
  3. Abdominal guarding and Rebound Tenderness
  4. Hemoperitoneum findings (delayed presentation)
    1. Periumbilical Ecchymosis (Cullen Sign)
    2. Flank Eccymosis (Turner Sign)

VI. Imaging

  1. Fast Scan
  2. CT Abdomen and Pelvis with IV Contrast

VII. Precautions

  1. Splenic capsule may contain intial Hemorrhage
    1. Contributes to delayed diagnosis

VIII. Grading: AAST CT Grade for Splenic Injury

  1. Precautions
    1. May not accurately correlate with surgical findings
    2. Does not consistently predict the need for surgical intervention
  2. Grade 1
    1. Subcapsular Hematoma <10% surface area OR
    2. Splenic Laceration <1 cm depth into parenchyma
  3. Grade 2
    1. Subcapsular Hematoma 10-50% surface area OR
    2. Splenic Laceration 1-3 cm depth into parenchyma (not involving trabecular vessels)
  4. Grade 3
    1. Subcapsular Hematoma >50% surface area or expanding OR
    2. Ruptured subcapsular or parenchymal Hematoma OR
    3. Intraparenchymal Hematoma >5 cm or expanding OR
    4. Splenic Laceration >3 cm depth into parenchyma OR
    5. Trabecular vessel involvement
  5. Grade 4
    1. Splenic Laceration involving segmental or hilar vessels with >25% splenic devascularization
  6. Grade 5
    1. Shattered Spleen OR
    2. Hilar vessel injury with complete splenic devascularization
  7. References
    1. Tinkoff (2008) J Am Coll Surg 207:646 [PubMed]

IX. Management: Surgery

  1. Indications: Emergent Surgery (to identify and control intraperioneal Hemorrhage)
    1. Hemodynamically unstable Trauma patient AND
    2. Positive FAST Scan or DPL
  2. Indications: Other findings despite hemodynamic stability
    1. High grade Splenic Injury (Grade 4 and especially Grade 5)
    2. Age over 55 years old
    3. Other serious comorbid injuries or illness and unlikely to tolerate Hypotension
    4. Generalized peritonitis
    5. Evidence for other intraabdominal injuries
    6. Refusal of Blood Products in the presence of severe Anemia (e.g. Jehovah Witness)
    7. Unreliable patient for serial abdominal examinations (e.g. Altered Level of Consciousness)
  3. Indications: Other findings that may be amenable to splenic embolization as an alternative instead of surgery
    1. Large volume hemoperitoneum
    2. Active radiocontrast extravasation

X. Management: Splenic Embolization

  1. Contraindications
    1. Hemodyanmic instability
    2. Surgical indications as above
  2. Indications
    1. Abdominal CT with contrast extravasation or blush
    2. Intraparenchymal pseudoaneurysm
    3. Large volume hemoperitoneum
  3. Protocol
    1. Intervention Radiology cannulates and embolizes via the Celiac Artery
      1. Access via brachial or femoral artery to the abdominal aorta
    2. Continue with nonoperative observation as below

XI. Management: Nonoperative

  1. Contraindications
    1. Close medical and nursing monitoring not available
    2. Urgent or emergent surgical or embolization not available
    3. Hemodynamic instability
    4. Surgical interventions above
  2. Protocol
    1. Admit to Intensive Care unit (or other highly monitored hospital setting)
    2. Serial Hemoglobin every 6 hours for the first 24 hours
    3. Nothing by mouth for the first 24 hours
      1. May then eat when emergent surgery is unlikely
      2. Must first demonstrate stable Vital Signs and serial Hemoglobins
    4. Consider repeat Abdominal CT imaging
      1. Hemoglobin decrease (via trend or significant drop)
      2. Increased Abdominal Pain or left Shoulder Pain
      3. Fever
      4. Unreliable abdominal examination (e.g. Altered Level of Consciousness)
      5. Consider at 24-48 hours if high grade Splenic Injury (Grade 3 or higher)
    5. Indications for surgical intervention
      1. Continued Hemoglobin decrease or need for repeated Blood Transfusion
      2. Hemodynamic instability (e.g. Hypotension, persistent Sinus Tachycardia)
      3. Repeat imaging indicates further intervention
  3. Safety
    1. Initial non-operative management in stable patients with Grade 4-5 Splenic Lacerations appears safe
      1. Scarborough (2016) J Am Coll Surg 223(2): 249-58 +PMID: 27112125 [PubMed]

XII. Management: Follow-up

  1. See Asplenia
  2. Return to Play (Sports)
    1. Activity restriction for 3 months after injury
    2. Light Aerobic Activity allowed during recovery period
  3. Spleen expected to heal over 2 to 2.5 months
  4. Repeat imaging indications (not routinely performed)
    1. Recurrent left upper quadrant pain
    2. Referred Shoulder Pain
    3. Early satiety

XIII. References

  1. Dreis (2020) Crit Dec Emerg Med 34(7):3-21
  2. Maung in Frankel (2014) Management of Splenic Injury in the Adult Trauma Patient, UpToDate, Wolters Kluwer
  3. Hildebrand (2014) BMJ 348:g1864 [PubMed]
  4. Stein (2006) J Intensive Care Med 21:296-304 [PubMed]

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