Injuries to the spleen are one of the most common injuries in abdominal trauma. The spleen is the most vascular organ in the body. Since bleeding in splenic injuries is mainly arterial, significant haemoperitoneum can occur. Unrecognized injury can be a cause of preventable traumatic death. This activity reviews the framework for the evaluation and initial management of patients with abdominal trauma with a suspected injury of the spleen and highlights the role of the interprofessional team in managing the patients presenting with it.
Describe the typical imaging findings to aid in the diagnosis of suspected splenic injury.
Explain the common physical exam findings associated with splenic injury in patients with abdominal trauma.
Review the conservative management of trauma patients with suspected spleen injuries.
Employ interprofessional team strategies for improving care coordination and communication to advance and improve outcomes for the trauma patients with suspected spleen injuries.
Injuries to the spleen are one of the most common injuries in abdominal trauma. Unrecognized injury can be a cause of preventable traumatic death. 
The spleen is the most vascular organ in the body. Since bleeding in splenic injuries is mainly arterial, significant hemoperitoneum can occur. Also, bleeding from injuries to the spleen is mainly intraperitoneal.
Because of the immunological functions of the spleen, there is a trend toward salvaging the spleen rather than removing it in traumatic cases. The development of CT scans has made conservative management of splenic injuries possible today.
The spleen is susceptible to injury if the trauma involves the lower left chest or the upper left abdomen. It is vulnerable to injury during trauma because of its juxtaposition in the left upper abdomen to the 9th, 10th, and 11th ribs
The following are three mechanisms of injury:
Penetrating trauma, for example, abdominal gunshot wounds occur in 7% to 9% of total penetrating trauma cases
Blunt trauma, for example, a direct blow to the left upper quadrant
Indirect trauma, for example, a tear in the splenic capsule during colonoscopy or traction on the splenocolic ligament
The most common cause is a motor vehicle accident, followed by direct trauma and fall.
The spleen is commonly injured in blunt abdominal trauma. Each year, an average of 25% (800 to 1200) admissions are for blunt trauma.
The spleen is a highly vascularized organ, and an injury to this organ can result in significant blood loss either from the parenchyma or the arteries and veins that supply the spleen. The spleen is an important lymphopoietic organ. The normal splenic function is necessary for the opsonization of encapsulated organisms.
The spleen serves the following functions:
Maturation of red cells
Extraction of abnormal cells via phagocytosis
Remove particulates such as opsonized bacteria, or antibody-coated cells from the blood
Contribute to humoral and cell-mediated immunity
In adults, normal splenic size is up to 250 gm and up to 13 cm long. It involutes with age and is usually not palpable in adults. The spleen, in adults, is less pliable than in children.
History and Physical
The mechanisms most commonly described are trauma to the left upper quadrant, left rib cage, or left flank. However, the absence of these types of injuries cannot exclude the possibility of splenic injury.
Inquire about previous operations, including splenectomy. Other questions that doctors should explore are liver or portal venous disease, the use of an anticoagulant agent, bleeding tendency, and the use of aspirin or nonsteroidal anti-inflammatory agents.
The typical presentation includes left upper quadrant pain, abdominal distension, and hypotension. Left shoulder pain may occur due to diaphragmatic irritation.
Evaluate the abdomen for external signs of trauma such as abrasions, lacerations, contusions, and seatbelt sign. The absence of these external findings does not exclude intra-abdominal injury. Up to 10% to 20% of patients with intra-abdominal injury may not have these findings upon examination. An initial examination on arrival may not show tenderness, rigidity, or distention. Therefore, it may not be sufficiently sensitive nor specific enough to identify a splenic injury.
The presentation of splenic injury depends upon associated internal hemorrhage. Patients may present with hypovolemic shock manifesting tachycardia and hypotension. Other findings include tenderness in the upper left quadrant, generalized peritonitis, or referred pain in the left shoulder (Kehr's sign). This is a rare finding, which should increase the suspicion of splenic injury. Some patients may have pleuritic left-sided chest pain. Physical examination may be limited by decreased mental status or distracting injuries. Upon initial evaluation, a splenic injury that is contained may have few symptoms.
One should evaluate splenic injury if lower left rib (below the sixth rib) fractures are identified. In adults, up to 20% of patients with lower left rib fractures may have an associated splenic injury. However, in children, the plasticity of the chest wall can result in a severe underlying injury to the spleen in the absence of any rib fracture. One should suspect a pelvic fracture if the mechanism involves a high-energy blunt trauma. Also, one should consider bowel injuries in patients presenting with blunt splenic trauma, which occurs in less than 5% of patients initially thought to have an isolated organ injury.
Several adjuncts can be used to identify a splenic injury.
Focused Assessment with Sonography for Trauma (FAST)
The focused assessment with sonography for trauma (FAST) examination can rapidly identify free intraperitoneal fluid in patients with blunt abdominal trauma. The FAST examination is particularly useful in the evaluation of hemodynamically unstable patients.
This examination consists of four acoustic windows (pericardiac, perihepatic, perisplenic, pelvic). FAST is considered positive if the fluid is identified as an anechoic band or a (black) rim around the spleen. Ultrasound is a sensitive modality to identify hemoperitoneum. However, it is important to remember that an intraperitoneal hemorrhage is not always present, especially when the splenic capsule remains intact. Up to 25% of splenic injuries do not exhibit intraperitoneal hemorrhage. Hemodynamic instability in the presence of free fluid on FAST examination requires rapid surgical evaluation and immediate laparotomy.
Certain injuries, such as intraperitoneal injuries involving bowel and mesentery and retroperitoneal organ injuries, may not be identified by the FAST exam due to the presence of hemoperitoneum.
Computed Tomography (CT)
The CT scan is the diagnostic modality of choice for detecting solid organ injuries. CT scans may show disruption in the normal splenic parenchyma, surrounding hematoma, and free intra-abdominal blood. CT scan is also useful in identifying solid organ vascular injuries. A contrast-enhanced CT scan should be obtained to determine the density difference between the splenic parenchyma and hematoma. This will also identify associated injuries. It is important to obtain good imaging as the suboptimal scan may result in a missed diagnosis of subtle splenic injuries.
Treatment / Management
The initial management of the trauma patient with splenic injury should follow the ABCs (airway, breathing, and circulation) of trauma resuscitation. The assessment of circulation during the primary survey includes early evaluation of the possibility of hemorrhage in patients with blunt trauma. It is important to assess whether the patient is in early shock and provide prompt resuscitation. Beware that there is a possibility of concomitant hollow viscus injury in patients with solid organ injury.
Spleen Organ Injury Scale
Splenic injury is classified based on CT findings according to the American Association for the Surgery of Trauma (AAST) Organ Injury Scale. It is a useful scale that categorizes splenic injuries, but it does not predict the need for surgical intervention.
Hematoma, subcapsular, less than 10% surface area
Laceration, capsular tear, less than 1 cm parenchymal depth
Hematoma, subcapsular, 10% to 50% surface area
Intraparenchymal, less than 5 cm in diameter
Laceration, capsular tear, 1 cm to 3 cm parenchyma depth that does not involve a trabecular vessel
Hematoma, subcapsular, more than 50% surface area expanding; ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma 5 cm or greater and expanding
Laceration greater than 3 cm parenchymal depth or involving trabecular vessels
Laceration, laceration involving segmental or hilar vessels producing major devascularization ( more than 25% of the spleen)
Laceration, completely shattered spleen
Vascular; a hilar vascular injury that devascularizes the spleen
This CT grading may not always correlate with the grading of the injury as identified with surgical exploration. This may be due to technical issues and variability of the CT scan interpretation.
Hemorrhaging from a splenic injury can be ongoing at the time of presentation or may have stopped. Injuries in which bleeding has ceased can be managed without splenectomy, although patients may develop delayed hemorrhaging. Delayed splenic rupture may occur up to 10 days following an injury. The rate of late bleeding may occur up to 10.6% of the time, but it varies with the grade rating of the splenic injury. Therefore, a careful selection of patients should be performed, and make sure that one closely monitors these patients, and a serial abdominal examination should be performed.
Non-operative Management of Splenic Trauma
Treatment of splenic injury is aimed to maximize salvage therapy. In children, the use of non-operative management of hemodynamically stable patients has become the standard of care. Up to 80% of blunt splenic injuries can be managed non-operatively. It has been increasingly used in adults, and age has not influenced the outcome of non-operative management of blunt splenic trauma.
However, it should be considered only in a hemodynamically stable patient without signs of peritonitis. It is important that only patients who are stable and have no evidence of ongoing blood loss should be selected for non-operative management.
Non-operative management has been attempted in high-grade injuries as long as the patient remains hemodynamically stable without evidence of active bleeding. These patients should be hospitalized in a center where a pediatric surgeon is available for close observation and a series of multiple examinations. In this situation, the option of surgical intervention must be available at all times.
Patients who require transfusions involving more than two units of blood, or show signs of ongoing bleeding, should be considered for operative management or embolization.
Operative intervention and splenectomy remain life-saving events for many patients. The decision for surgical intervention depends on the clinical or hemodynamic status and the results of imaging studies. These include:
Hemodynamic instability, which the majority of trauma surgeons consider an indication for emergent splenectomy in blunt trauma to the spleen
Associated intra-abdominal injuries that require surgical exploration (bowel injuries)
Splenic embolization requires specialized imaging facilities and a vascular interventionist. The following are guidelines for embolization in spleen trauma patients:
Grade 3 or higher splenic injury
Contrast blush on CT scan
Evidence of ongoing bleeding
Prophylactic angioembolization in patients with splenic trauma, active arterial blush on CT, and stable hemodynamics are not indicated.
The complication rate is up to 35%. The following are common complications:
Splenic infarction is devascularization of more than 25% of the spleen, which may occur in up to 20% of patients after embolization
In general, the physiologic stability of the patient is the major predictor of successful nonoperative management. Also, a CT-based grading system has shown successful observation in patients with blunt splenic injury. Overall, patients with low-grade splenic injury managed conservatively have good outcomes. But those who undergo spleen removal are always at risk for infection.
Delayed splenic rupture; Although rare, it can occur up to 10 days after injury. This is perhaps associated with subtle low-grade injury to the spleen, which may not have been identified on imaging studies.
Readmission for bleeding
Splenic artery pseudoaneurysm
Post-splenectomy infection: the risk is high in the first five years of life but can occur at any time.
Postoperative and Rehabilitation Care
Post-splenectomy patients should receive vaccinations for encapsulated bacteria before discharge from the hospital.
Prophylactic antibiotics are also recommended.
Trauma team activation or early surgical service involvement is important.
Pearls and Other Issues
Patients who undergo splenectomy are at a higher risk of infection and overwhelming sepsis. Therefore, post-splenectomy vaccines should be administered to ensure their protection from encapsulated bacteria, which include Streptococcus pneumoniae, Neisseria meningitidis, and Hemophilus influenzae.
Children receive penicillin V (250 mg/day) for at least two years, and life-long antibiotic therapy is recommended for high-risk patients.
Beware that patients with splenic injuries may worsen during the hours or days following initial trauma and should be carefully monitored.
Caution: Since the contrast agent diffuses relatively slowly through the pulp of the spleen and may appear as a defect in enhancement, these may be misinterpreted as splenic injury.
Enhancing Healthcare Team Outcomes
The management of splenic trauma must be with an interprofessional team that includes physicians, nurses, radiologists, intensivists, and laboratory personnel. One must always be aware of the physiological and immunological derangements that may occur with splenic trauma. While most patients are now managed conservatively with observation, close monitoring is vital. ICU nurses play a vital role in the monitoring of splenic injury. The abdomen must be examined carefully, and a serial CBC must follow. Any signs of hemodynamic stability should be reported to the surgeon.
Besides regular physical exams, the patient's hematocrit requires monitoring, and serial CT scans may be required. If the patient is monitored in an outpatient setting, they should be educated on the symptoms of bleeding and the need to urgently go to the nearest emergency room. For those who undergo splenectomy, there is always the risk of sepsis. Hence, the pharmacist should educate the patient on post-splenectomy sepsis. Also, the patient must be told to seek immediate assistance if they spike a fever. Finally, these individuals must be told to avoid traveling to areas where mosquito bites are endemic because, without a spleen, even a minor infection can quickly become life-threatening. Patients who have had their spleen removed must wear a medical alert bracelet. [Level 5]
Today, splenectomy after trauma is rare; it is even rare to perform a splenectomy 24 hours later. After the initial observation of 24 hours, the patient may still require close observation as an inpatient or outpatient for two weeks. The majority of these patients have an excellent outcome in the long run. Further, even in patients who bleed later, selective arterial embolization has replaced splenectomy because it has a very high success rate. [Level 5]
(Click Image to Enlarge)
CT scan of a grade IV-V splenic injury. CXR suggests a left hemidiaphragm rupture.
Contributed by Mark Pellegrini (Public Domain)
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