Splenic injury

Background

  • Most commonly injured visceral organ in blunt trauma

Clinical Features

  • LUQ pain
  • Signs of shock
  • Hypotension
  • Left lower rib pain
  • Kehr's sign
    • Acute pain in the tip of the shoulder due to the presence of blood in the peritoneal cavity when a patient's legs are elevated while laying flat.

Differential Diagnosis

Abdominal Trauma

Evaluation

ATLS Blunt Abdominal Trauma Algorithm

  • Unstable
    • FAST to search for free fluid (vs. DPL if unavailable)
      • Positive: Exploratory laparotomy
      • Negative: CT scan
  • Stable
    • CT scan
      • Exploratory laparotomy, angiographic embolization, conservative management as indicated

AAST Criteria

Grade Hematoma Laceration
I
  • Subcapsular, <10% of surface area
  • Capsular tear <1 cm in depth into the parenchyma
II
  • Subcapsular, 10-50% of surface area
  • Capsular tear, 1 to 3 cm in depth, but not involving a trabecular vessel
III
  • Subcapsular, >50% of surface area OR expanding,
  • Ruptured subcapsular or parenchymal hematoma
  • OR, intraparenchymal hematoma >5 cm or expanding
  • Capsular tear, 3 to 10 cm in depth or involving a trabecular vessel.
IV
  • Subcapsular or central hematoma > 10cm
  • Involving segmental or hilar vessels with major devascularization (i.e. >25% of spleen)
V
  • Shattered spleen
  • Hilar vascular injury which devascularizes spleen.

Management

  • Observation, angiographic embolization, or surgery depending upon:
    • Hemodynamic status of the patient
    • Grade of splenic injury
    • Presence of other injuries and medical comorbidities
  • Operative Management
    • Indicated for diffuse peritonitis or hemodynamic instability after blunt abdominal trauma
    • Not indicated based on injury grade alone[1]
  • Nonoperative management
    • Failure rate of 10-15%
    • Some advocate nonoperative management only if <55yr and CT injury grade less than IV
    • Should only be considered in locations with resources available for urgent laparotomy

Disposition

  • Admit

See Also

  • Abdominal Trauma
  • Splenic Infarction

References

  1. Stassen N, Bhullar I, Cheng J, et al. Selective nonoperative management of blunt splenic injury: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012; 73(5):s293-s300
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