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 of the spleen is mainly intraperitoneal.
Because of the immunological functions of the spleen, there is a trend towards salvaging the spleen rather than remove it in traumatic cases. The development of CT scan 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:
The most common cause is motor vehicle accident, followed by direct trauma and fall.
Spleen is commonly injured in blunt abdominal trauma. 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.
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 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. 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 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.
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.
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.
Nonoperative 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:
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:
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.
Post-splenectomy patients should receive vaccinations for encapsulated bacteria before their discharge from the hospital.
Prophylactic antibiotics are also recommended.
Trauma team activation or early surgical service involvement is important
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 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.
The management of splenic trauma must be with an interprofessional team that includes physicians, nurses, radiologist, intensivist 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. ICU nurses play a vital role in the monitoring of splenic injury. The abdomen has to be examined carefully and serial CBC must be followed. Any signs of hemodynamic stability should be reported to the surgeon.
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 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 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. Patients who have had their spleen removed must wear a medical alert bracelet. (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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