Trauma: Spleen Trauma

Spleen Trauma

General

  • Second Most Common Injured Intraabdominal Organ in Blunt Trauma
  • Most Common Injury Requiring Intervention in Blunt Trauma

AAST Spleen Injury Scale (2018 Revision) Mn

Spleen Injury

Grade II

Grade III 1

Grade IV 2

Grade V 3

Initial Management

  • Unstable: Laparotomy
    • Diffuse Peritonitis Indicates Bowel Injury & Warrants Laparotomy – Diffuse Peritonitis Should Never be Attributed to Solid Organ Injury as Isolated Hemoperitoneum Should Not Cause Diffuse Peritoneal Irritation
  • Transient Responder: Angioembolization
  • Stable: CT
    • Active Extravasation or Pseudoaneurysm: Angioembolization (90% Success Rate)
    • Nonoperative Management Otherwise
  • If Angioembolization Fails: Laparotomy
  • *Historically Severe Traumatic Brain Injury (TBI) & Altered Mental Status (AMS) Were Considered Contraindications to Nonoperative/IR Management – Now Shown to Be Efficient & Safe
    • Was Based on the Fact that Hypotension/Decreased Cerebral Perfusion Pressure is a Significant Risk Factor for Worse Outcomes

Definitive Treatment

  • Nonoperative Management: (Poorly Defined)
    • ICU & NPO for 24-72 Hours
    • Consider Initial Bedrest for 24-48 Hours
      • Previously Defined as Injury Grade + One Day (1999 APSA Guidelines)
    • Strongly Consider Repeat CT After 2-7 Days, Before Discharge
    • Hospital Stay 7-9 Days
    • Activity Restriction 1-4 Months
      • Some Recommend Return to Normal Activity at Injury Grade + 2 Weeks with Longer Contact Sport Restrictions
  • Surgery Management:
    • Stable Subcapsular Hematoma: Leave
    • Small & Minimal Bleeding: Topical Hemostasis
    • Grade II/III: Splenorrhaphy
      • Spleen Does Not Hold Suture Well – Consider Pledgets or Absorbable Mesh
      • Possibly Consider Partial Splenectomy
    • Grade IV/V: Splenectomy
  • *Surgery Solely for Washout of Blood is Generally Not Indicated Unless for Severe Refractory Pain
  • *Start DVT Prophylaxis Early (Within 24-48 Hours) for Solid Organ Injury

Mnemonics

Spleen Injury Grading

  • I/II/III: 1/2/3 cm Depth

References

  1. Lam GY, Chan AK, Powis JE. Possible infectious causes of spontaneous splenic rupture: a case report. J Med Case Rep. 2014 Nov 30;8:396. (License: CC BY-4.0)
  2. Gheju I, Venter MD, Beuran M, Gulie L, Racoveanu I, Carstea P, Iftimie Nastase I, Venter DP. Grade IV blunt splenic injury–the role of proximal angioembolization. A case report and review of literature. J Med Life. 2013;6(4):369-75. (License: CC BY-2.0)
  3. Best IM. Percutaneous repair of a disrupted left renal artery after rapid stabilization. Clin Pract. 2011 Nov 10;1(4):e116. (License: CC BY-4.0)