Spleen
Splenic Injury
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Splenic Injury
, Injury of Spleen, Ruptured Spleen, Splenic Rupture
See Also
Abdominal Trauma
Pediatric Blunt Abdominal Trauma Decision Rule
Primary Trauma Evaluation
Secondary Trauma Evaluation
FAST Exam
Liver Laceration
Epidemiology
Rare
Sports Injury
Most frequent cause of
Blunt Abdominal Trauma
related death in sports
Causes
Direct blow or projectile to the left upper quadrant
More commonly associated sports
Foot
ball
Rugby
Soccer
Lacrosse
Dowhill
Skiing
or snow boarding
Surfing
Mountain Biking
Symptoms
Left Upper Quadrant Abdominal Pain
Sharp progressing to Dull
Epigastric Abdominal Pain
Radiation to left
Shoulder
(Kehr Sign) or right
Shoulder
Nausea
Vomiting
Signs
Hemodynamic instability if
Hemorrhagic Shock
Left upper quadrant tenderness
Abdominal guarding and
Rebound Tenderness
Hemoperitoneum findings (delayed presentation)
Periumbilical
Ecchymosis
(
Cullen Sign
)
Flank Eccymosis (Turner Sign)
Imaging
Fast Scan
CT Abdomen and Pelvis
with IV Contrast
Precautions
Splenic capsule may contain intial
Hemorrhage
Contributes to delayed diagnosis
Grading
AAST CT Grade for Splenic Injury
Precautions
May not accurately correlate with surgical findings
Does not consistently predict the need for surgical intervention
Grade 1
Subcapsular hematoma <10% surface area OR
Splenic
Laceration
<1 cm depth into parenchyma
Grade 2
Subcapsular hematoma 10-50% surface area OR
Splenic
Laceration
1-3 cm depth into parenchyma (not involving trabecular vessels)
Grade 3
Subcapsular hematoma >50% surface area or expanding OR
Ruptured subcapsular or parenchymal hematoma OR
Intraparenchymal hematoma >5 cm or expanding OR
Splenic
Laceration
>3 cm depth into parenchyma OR
Trabecular vessel involvement
Grade 4
Splenic
Laceration
involving segmental or hilar vessels with >25% splenic devascularization
Grade 5
Shattered
Spleen
OR
Hilar vessel injury with complete splenic devascularization
References
Tinkoff (2008) J Am Coll Surg 207:646 [PubMed]
Management
Surgery
Indications: Emergent Surgery (to identify and control intraperioneal
Hemorrhage
)
Hemodynamically unstable
Trauma
patient AND
Positive FAST Scan or DPL
Indications: Other findings despite hemodynamic stability
High grade Splenic Injury (Grade 4 and especially Grade 5)
Age over 55 years old
Other serious comorbid injuries or illness and unlikely to tolerate
Hypotension
Gene
ralized peritonitis
Evidence for other intraabdominal injuries
Refusal of
Blood Product
s in the presence of severe
Anemia
(e.g. Jehovah Witness)
Unreliable patient for serial abdominal examinations (e.g.
Altered Level of Consciousness
)
Indications: Other findings that may be amenable to splenic embolization as an alternative instead of surgery
Large volume hemoperitoneum
Active radiocontrast extravasation
Management
Splenic Embolization
Contraindications
Hemodyanmic instability
Surgical indications as above
Indications
Abdominal CT
with contrast extravasation or blush
Intraparenchymal pseudoaneurysm
Large volume hemoperitoneum
Protocol
Intervention Radiology
cannulates and embolizes via the
Celiac Artery
Access via brachial or femoral artery to the abdominal aorta
Continue with nonoperative observation as below
Management
Nonoperative
Contraindications
Close medical and nursing monitoring not available
Urgent or emergent surgical or embolization not available
Hemodynamic instability
Surgical interventions above
Protocol
Admit to
Intensive Care
unit (or other highly monitored hospital setting)
Serial
Hemoglobin
every 6 hours for the first 24 hours
Nothing by mouth for the first 24 hours
May then eat when emergent surgery is unlikely
Must first demonstrate stable
Vital Sign
s and serial
Hemoglobin
s
Consider repeat
Abdominal CT
imaging
Hemoglobin
decrease (via trend or significant drop)
Increased
Abdominal Pain
or left
Shoulder Pain
Fever
Unreliable abdominal examination (e.g.
Altered Level of Consciousness
)
Consider at 24-48 hours if high grade Splenic Injury (Grade 3 or higher)
Indications for surgical intervention
Continued
Hemoglobin
decrease or need for repeated
Blood Transfusion
Hemodynamic instability (e.g.
Hypotension
, persistent
Sinus Tachycardia
)
Repeat imaging indicates further intervention
Safety
Initial non-operative management in stable patients with Grade 4-5 splenic
Laceration
s appears safe
Scarborough (2016) J Am Coll Surg 223(2): 249-58 +PMID: 27112125 [PubMed]
Management
Follow-up
See
Asplenia
Return to Play (Sports)
Activity restriction for 3 months after injury
Light Aerobic Activity
allowed during recovery period
Spleen
expected to heal over 2 to 2.5 months
Repeat imaging indications (not routinely performed)
Recurrent left upper quadrant pain
Referred
Shoulder Pain
Early satiety
References
Dreis (2020) Crit Dec Emerg Med 34(7):3-21
Maung in Frankel (2014) Management of Splenic Injury in the Adult
Trauma
Patient, UpToDate, Wolters Kluwer
Hildebrand (2014) BMJ 348:g1864 [PubMed]
Stein (2006) J Intensive Care Med 21:296-304 [PubMed]
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