[29] Splenic Rupture Flashcards
What is the consequence of the spleen being an extremely vascular organ?
Splenic rupture can cause a large intraperitoneal haemorrhage, rapidly leading to fatal haemorrhagic shock
What is splenic rupture secondary to in the majority of cases?
Abdominal trauma, particularly blunt trauma
What are the common situations in which the spleen is ruptured?
Seat-belt injuries in RTAs
Falls onto the left side
What is the cause of the minority of cases of splenic rupture?
Iatrogenic, or secondary to underlying splenomegaly
What can cause underlying splenomegaly?
Haemotological malignancy
Infective causes e.g. EBV
How does splenomegaly increase the risk of splenic rupture?
The spleen grows in size, and the capsule stretches and thins, becoming more fragile. This puts it at an increased risk of rupture
How is a diagnosis of splenic rupture most commonly made?
From investigations of abdominal pain following a history of trauma
What symptoms might splenic rupture present with?
Abdominal pain
Clinical features of hypovolaemic shock
What is required to confirm the diagnosis of ruptured spleen?
Imaging
What may be found on examination in splenic rupture?
Left upper quadrant tenderness and/or peritonism
Kehr’s sign
What can happen to the peritonism as splenic rupture progresses?
It can become more generalised as the blood loss increases
What is Kehr’s sign?
Radiating left shoulder pain
How can splenic rupture cause Kehr’s sign?
Free blood irritates the diaphragm
When is an immediate laparotomy required in splenic rupture?
In patients who are haemodynamically unstable with peritonism following trauma, unless proven otherwise
What investigation is required in those who are haemodynamically stable with suspected abdominal injury?
Urgent CT chest-abdo-pelvis with IV contrast
What does CT scan allow for in suspected splenic rupture?
Identification and assessment of splenic injury, alongside any other abdominal viscera involvement
Also allows for grading of splenic injury
What is the importance of grading of splenic injury?
It guides further management
What can FAST scans in the emergency department reveal in splenic rupture?
Free peritoneal fluid
Fluid in the pericardium
What needs to be considered when ordering a FAST scan in A&E?
It should not delay CT imaging and/or surgical intervention
What is the most commonly used system for grading splenic trauma?
The American Association for the Surgery of Trauma (AAST) splenic injury scale
What is the purpose of the AAST splenic injury scale?
It can be used to help guide which patients are likely to benefit from conservative management, and which need surgery
What is a grade 1 AAST splenic injury?
Capsular tear <1cm parenchymal depth
Subcapsular haematoma <10% surface area
What is a grade 2 AAST splenic injury?
Capsular tear 1-3 cm parenchymal depth
Subcapsular haematoma 10-50% surface area, or intraparenchymal haematoma <5cm
What is a grade 3 AAST splenic injury?
Capsular tear >3cm parenchymal depth, or any tear involving trabecular vessels
Subcapsular haematoma >50% surface area, or intraparenchymal haematoma >5cm, or any expanding or ruptured haematoma
What is a grade 4 AAST splenic injury?
Laceration involving segmental or hilar vessels, devascularising >25% of spleen
What is a grade 5 AAST splenic injury?
Completely shattered spleen or hilar vascular injury, devascularising the entire spleen
How should all patients with a suspected splenic injury be managed initially?
They should be assessed, resuscitated, and treated according to ATLS principles
Which splenic rupture patients will require an emergency laparotomy?
Patients who are haemodynamically unstable, or with a grade 5 injury (a shattered spleen or major hilar vascular injury)
What should be done if there is evidence of active extravasation of the contrast during the arterial phase of a CT scan?
The patient should undergo embolisation (if locally available) or laparotomy with splenectomy
Which patients with splenic rupture can be treated conservatively?
Haemodynamically stable patients with grade 1-3 injuries
What is involved in the conservative management of splenic rupture?
Resuscitation as appropriate
Admitted to high dependancy area for observation
Serial abdominal examinations for evidence of deterioration
Prophylactic vaccinations at discharge
What should be done with any evidence of increasing tenderness or peritonitis in splenic ruptures being monitored?
There should be a low-threshold for re-imaging and/or laparotomy
Why should there be a low threshold for re-imaging and/or laparotomy in patients with splenic rupture and increasing tenderness or peritonitis?
As associated injuries such as small bowel injuries are easily missed on initial CT imaging
What prophylactic examinations should be given in patients with splenic rupture who are being managed conservatively?
Strep Pneumoniae
Haemophilus influenzae B
Meningococcus
What are the main complications of conservative treatment or embolisation in splenic rupture?
Ongoing bleeding
Splenic necrosis
Splenic abscess formation
Splenic cyst formation
What is the pathophysiology behind overwhelming post-splenectomy infection (OPSI)?
The spleen is an immunologically active organ, with an active role in destroying encapsulated organisms. Asplenic patients are therefore unable to mount a normal immunological response against these organisms, and infection can lead to overwhelming sepsis
Give three examples of encapsulated organisms
Pneumooccus
Meningococcus
H. Influenzae
How can OPSI be prevented?
Any asplenic patient should receive vaccinations against pneumococcus, meningococcus, and H. influenzae.
Prophylactic Penicillin V should be considered
When might lifelong prophylactic pencillin V not be required?
In low risk patients
