The following are three mechanisms of injury:
Each year, an average of 25% (800 to 1200) of 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 opsonization of encapsulated organisms.
The spleen serves the following functions:
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.
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.
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 to 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 which is contained may have few symptoms.
One should evaluate for 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 who were initially thought to have an isolated organ 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. 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.
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.
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.
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 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.
This CT grading may not always correlate with the grading of the injury as identified on 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 rupture of the spleen 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, careful selection of patients should be performed and make sure that one closely monitors these patients, and a serial abdominal examination should be performed.
Nonoperative 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. 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:
Splenic embolization requires specialized imaging facilities and a vascular interventionist. The following are guidelines for embolization, in spleen trauma patients:
The complication rate is up to 35%. The following are common complications:
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.
The management of splenic trauma must be an interprofessional involving physicians, nurses and laboratory personnel. One must at all times 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. Besides regular physical exams, the patient's hematocrit has to be monitored and serial CT scans may be required. If the patient is monitored in an outpatient setting, he or she should be educated on the symptoms of bleeding and the need to urgently go to the nearest emergency room. For those who undergo a splenectomy, there is always the risk fo sepsis. Hence the pharmacist should educate the patient on post-splenectomy sepsis. Also, the patient must be told to seek immediate assistance if he or she spikes a fever. Finally, these individuals must be told to avoid travel to areas where mosquito bites are endemic, because, without a spleen, even a minor infection can quickly become life-threatening. (Level V)
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 2 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 V)
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