Splenic Injury


Article Author:
Muhammad Waseem


Article Editor:
Scott Bjerke


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
2/17/2019 9:17:19 AM

Introduction

Injuries to the spleen are one of the most common injuries in abdominal trauma. Unrecognized injury can be a cause of preventable traumatic death. [1][2]

Etiology

The spleen is susceptible to injury if the trauma involves the lower left chest or the upper left abdomen.[3][4]

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

Epidemiology

Each year, an average of 25% (800 to 1200) of admissions are for blunt trauma.

Pathophysiology

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.[5]

The spleen serves the following functions:

Hematologic function

  • Maturation of red cells
  • Extraction of abnormal cells via phagocytosis
  • Remove particulates such as opsonized bacteria, or antibody-coated cells from blood

Immunologic function

  • 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.

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.

Evaluation

Several adjuncts can be used to identify splenic injury.[6][7]

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.

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 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.[8][9][10]

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.

Grade 1

  • Hematoma, subcapsular, less than 10% surface area
  • Laceration, capsular tear, less than 1 cm parenchymal depth

Grade 2

  • 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

Grade 3

  • 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

 Grade 4

  • Laceration, laceration involving segmental or hilar vessels producing major devascularization ( more than 25% of spleen)

Grade 5

  • Laceration, completely shattered spleen
  • Vascular, Hilar vascular injury that devascularizes the spleen

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.[11][12]

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 Management

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 spleen
  • Peritonitis
  • Pseudoaneurysm formation
  • Associated intra-abdominal injuries that require surgical exploration (bowel injuries)

Embolization

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
  • Moderate hemoperitoneum
  • Evidence of ongoing bleeding

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
  • Re-hemorrhage
  • Abscess

Differential Diagnosis

  • Liver laceration
  • Retroperitoneal bleeding
  • Diaphragmatic injury
  • Pancreas injury

Complications

  • Delayed splenic rupture
  • Readmission for bleeding
  • Splenic artery pseudoaneurysm
  • Death

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.

Enhancing Healthcare Team Outcomes

The management of splenic trauma must be multidisciplinary 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.[13][14][15] (Level V)

Outcomes

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. [2][16](Level V)

 


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Splenic Injury - Questions

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A 12-year-old child with a minimal subcapsular splenic tear has received a D5 0.25% normal saline maintenance infusion. After 24 hours, she develops a mild metabolic acidosis and both her hemoglobin and urine output drop. Which action would you NOT consider taking to improve her acidosis?



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A 16-year-old male sustains a right femur fracture and a cerebral concussion in a motor vehicle collision. His initial blood pressure is 75/50 mmHg with a pulse of 90 beats per minute. After giving him 2 liters of Ringers lactate he stabilizes, but his blood pressure falls when he is seen in the emergency room. Which of the following would be the cause of suspected hypotension in this patient?



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A patient presents with left shoulder pain after a fall from a second-floor window while trying to elude police. The patient also describes diffuse aching abdominal pain, abdominal bloating, and weakness. Select a possible cause for the symptoms.



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A 12-year-old boy is brought to the emergency department after sustaining a handlebar injury to his abdomen when he fell from his motorbike. He is complaining of severe abdominal pain. His vital signs are as follows temperature 99.8 degrees F, heart rate 105 beats/minute, respiratory rate 24 breaths/minute, blood pressure 116/78 mmHg, and oxygen saturation 99%. His abdomen is soft; but, there is a diffuse abdominal tenderness with ecchymosis in the left upper quadrant. A primary and secondary survey is completed. His computed tomography scan of both the abdomen and the pelvis shows an intra-parenchymal splenic tear approximately 4 cm in size. What is the best management option for this child?



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Splenic Injury - References

References

Dickinson CM,Vidri RJ,Smith AD,Wills HE,Luks FI, Can time to healing in pediatric blunt splenic injury be predicted? Pediatric surgery international. 2018 Sep 7     [PubMed]
Boyle TA,Rao KA,Horkan DB,Bandeian ML,Sola JE,Karcutskie CA,Allen C,Perez EA,Lineen EB,Hogan AR,Neville HL, Analysis of water sports injuries admitted to a pediatric trauma center: a 13 year experience. Pediatric surgery international. 2018 Aug 13     [PubMed]
Zarzaur BL,Rozycki GS, An update on nonoperative management of the spleen in adults. Trauma surgery     [PubMed]
Yang K,Li Y,Wang C,Xiang B,Chen S,Ji Y, Clinical features and outcomes of blunt splenic injury in children: A retrospective study in a single institution in China. Medicine. 2017 Dec     [PubMed]
Echavarria Medina A,Morales Uribe CH,Echavarria R LG,Vélez Marín VM,Martínez Montoya JA,Aguillón DF, [Associated factors to non-operative management failure of hepatic and splenic lesions secondary to blunt abdominal trauma in children]. Revista chilena de pediatria. 2017     [PubMed]
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Zarzaur BL,Dunn JA,Leininger B,Lauerman M,Shanmuganathan K,Kaups K,Zamary K,Hartwell JL,Bhakta A,Myers J,Gordy S,Todd SR,Claridge JA,Teicher E,Sperry J,Privette A,Allawi A,Burlew CC,Maung AA,Davis KA,Cogbill T,Bonne S,Livingston DH,Coimbra R,Kozar RA, Natural history of splenic vascular abnormalities after blunt injury: A Western Trauma Association multicenter trial. The journal of trauma and acute care surgery. 2017 Dec     [PubMed]
Belli AK,Özcan Ö,Elibol FD,Yazkan C,Dönmez C,Acar E,Nazlı O, Splenectomy proportions are still high in low-grade traumatic splenic injury. Turkish journal of surgery. 2018     [PubMed]
Gaarder C,Gaski IA,Næss PA, Spleen and liver injuries: when to operate? Current opinion in critical care. 2017 Dec     [PubMed]
Hughes J,Scrimshire A,Steinberg L,Yiannoullou P,Newton K,Hall C,Pearce L,Macdonald A, Interventional Radiology service provision and practice for the management of traumatic splenic injury across the Regional Trauma Networks of England. Injury. 2017 May     [PubMed]
Kohler JE,Chokshi NK, Management of Abdominal Solid Organ Injury After Blunt Trauma. Pediatric annals. 2016 Jul 1     [PubMed]
Notrica DM,Eubanks JW 3rd,Tuggle DW,Maxson RT,Letton RW,Garcia NM,Alder AC,Lawson KA,St Peter SD,Megison S,Garcia-Filion P, Nonoperative management of blunt liver and spleen injury in children: Evaluation of the ATOMAC guideline using GRADE. The journal of trauma and acute care surgery. 2015 Oct     [PubMed]
Tugnoli G,Bianchi E,Biscardi A,Coniglio C,Isceri S,Simonetti L,Gordini G,Di Saverio S, Nonoperative management of blunt splenic injury in adults: there is (still) a long way to go. The results of the Bologna-Maggiore Hospital trauma center experience and development of a clinical algorithm. Surgery today. 2015 Oct     [PubMed]
Koo M,Sabaté A,Magalló P,García MA,Domínguez J,de Lama ME,López S, [Multidisciplinary protocol for computed tomography imaging and angiographic embolization of splenic injury due to trauma: assessment of pre-protocol and post-protocol outcomes]. Revista espanola de anestesiologia y reanimacion. 2011 Nov     [PubMed]
Schuster T,Leissner G, Selective angioembolization in blunt solid organ injury in children and adolescents: review of recent literature and own experiences. European journal of pediatric surgery : official journal of Austrian Association of Pediatric Surgery ... [et al] = Zeitschrift fur Kinderchirurgie. 2013 Dec     [PubMed]
Armstrong RA,Macallister A,Walton B,Thompson J, Successful non-operative management of haemodynamically unstable traumatic splenic injuries: 4-year case series in a UK major trauma centre. European journal of trauma and emergency surgery : official publication of the European Trauma Society. 2018 Jun 16     [PubMed]

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