55.Injuries to the spleen. Clinical presentation and management

Question 1

Injuries to the spleen - Main Points

Answer 1

Spleen protected under ribcage – though it is most commonly affected organ in blunt injury

mortality rate after blunt splenic injury ≈ 9%

Question 2

Injuries to the spleen - mortality rate

Answer 2

After blunt splenic injury ≈ 9%

Question 3

Etiology:

Answer 3

Blunt traumas;

penetrating trauma;

mixed traumas (explosives)

Question 4

Clinical Presentation - Kehr’s sign

Answer 4

LUQ pain – may be referred to left shoulder due to subdiaphragmatic nerve root irritation.

Question 5

Diagnostic Investigations

Answer 5

• Bloods – FBC + Hb levels
• CT in stable pt with contrast
• FAST (focused abdominal sonographic technique) = quick i.d.s presence/absence of peritoneal fluid
• Splenic angiography
• X-ray

Question 6

Staging - American Association for the Surgery of Trauma (AAST) - Grade 1

Answer 6

Grade 1 =
laceration <1cm deep.

Subscapular hematoma <1cm

Question 7

Staging - American Association for the Surgery of Trauma (AAST) - Grade 2

Answer 7

Grade 2 =

laceration 1-3cm. subscapular/central 1-3cm

Question 8

Staging - American Association for the Surgery of Trauma (AAST) - Grade 3

Answer 8

Grade 3 =

laceration 3-10cm. subscapular/central hematoma 3-10cm

Question 9

Staging - American Association for the Surgery of Trauma (AAST) - Grade 4

Answer 9

Grade 4 =

laceration >10cm. subscapular/central hematoma >10cm

Question 10

Staging - American Association for the Surgery of Trauma (AAST) - Grade 5

Answer 10

Grade 5 =

splenic tissue maceration or devascularisation

Question 11

Treatment

Answer 11

• Initial = A,B,C – at this point pt falls into 2 categories: hemodynamically stable or unstable (based on vital signs – bp, HR)
  o Low BP +/- increased HR = unstable – cause most often = bleeding
• If bleeding from spleen = splenectomy
  o Post splenectomy = vaccinations against pneumococcal, meningococcal, H.influenzae
• If H. stable = in ICU, monitored with CT