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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)

Laceration Vascular

Completely shattered spleen 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 Hcts , 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 nonoperative 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 1. Davis KA, Fabian TC, Croce MA, et al. Improved success in nonoperative management of blunt splenic injuries: Embolization of splenic artery pseudoaneurysms. J Trauma 44:1008, 1998. 2. Schurr MJ, Fabian TC, Gavant M, et al. Management of blunt splenic trauma: Computed tomographic contrast blush predicts failure of nonoperatve management. J Trauma 36:743, 1995. 3. Esposito TJ and Gamelli RL. Injury to the Spleen. p.683. In Mattox KL, Feliciano DV, Moore EE (eds.): Trauma 4th ed. New York, McGraw-Hill, 2000. 4. Rozycki G, Ochsner MG, Jaffin J, et al. Prospective evaluation of surgeons use of ultrasound in the evaluation of trauma patients. J Trauma 34:516, 1993. 5. Pickhard B, Moore EE, Moore FA, et al. Operative splenic salvage in adults: A decade prospective. J Trauma 29:1386, 1989. 6. Cogbill TH, Moore EE, Jurkovich J, et al. Non-operative management of blunt splenic trauma: A multi-center experience. J Trauma 22:1312, 1989. 7. Bee TK, Croce MA, Miller PR, Pritchard FE, Fabian TC. Failures of splenic nonOperative management: is the glass half empty or half full. J Trauma 50:230, 2001. 8. Alonso M, Brathwaite C, Garcia V, et al. EAST Practice Management Guidelines Work Group. EAST practice management guidelines for the nonoperative management of blunt injury to the liver and spleen. http://www.east.org/tpg/livsplenn.pdf