Splenic Injury Flashcards
Using the rule you know, explain the anatomy of the spleen
If you dont know the rule just put 1
Dimensions of 1x3x5cm
Weighs 7 ounces (200g)
Lies between the 9th and 11th rib
How much should the spleen increase in size for it to become palpable
double
Give 5 functions of the spleen
Immunity: IgM, Opsonin production, Antigen processing
Filtering of macrophages and cellular debris
Iron re-utilization
Platelet pooling
Hematopoiesis in the fetus
Other than the spleen, what is the other most commonly injured solid organ?
What is the most common mechanism of injury? Give 2 examples
What pathogenesis typically increases the risk of injury to these organs?
Liver
Blunt trauma e.g. RTA, falls, contact sports, assaults
Disease of the spleen or liver through infection or hematological abnormalities lead to their enlargement + thinning of capsule (spleen) => more fragile organs
State the causes of Splenomegaly in the adult
1) Infection: Infectious mononucleosis, TB, malaria, congenital infection
2) Storage Disorders: Amyloidosis, Gaucher’s (buildup of fat in organs) (inherited)
3) Autoimmune: Rheumatoid arthritis, SLE
4) Cell proliferation: Leukemia, pernicious anemia, sickle cell
What organism is responsible for infectious mononucleosis?
What is the typical presentation?
In pediatrics, how does this typically happen?
EBV (Epstein Barr virus)
Swollen lymph nodes, sore throat, tonsillitis
Kissing disease (parent to infant) and giving amoxicillin to treat tonsillitis or sore throat)
What is the typical presentation of a patient with splenic trauma?
Hx of trauma to LUQ, left rib cage, left flank
Pain in LUQ/left chest wall, !Left Shoulder! (Kehr’s Sign)
Abdominal wall Ecchymosis (blood pooling similar to AAA in the retroperitoneum), hematoma, contusion )
What is Kehr’s Sign?
Pain referred to left shoulder that !worsens on inspiration! due to irritation of phrenic nerve from blood adjacent to the hemidiaphragm
A patient with a history of trauma to the left flank after an RTA presents to the ED. They are
1) Stable
2) Unstable
What imaging would you perform? What would it show?
How would you grade the injury?
Stable: CT: Should show fluid collections around spleen with !Hypodense regions! indicating the presence of a hematoma in the subscapular or intraperitoneal region
Unstable: FAST US: Hypoechoic (black) rim of subscapular or intraperitoneal hematoma
AAST Criteria:
Instracapsular: Low grade
Grade 1: Subscapular hematoma <10% of size + laceration <1cm
Grade 2: Hematoma 10-50% + laceration 1-3cm
Grade 3: Hematoma >50% +laceration >3cm
Extracapsular: High grade
Grade 4: Laceration involving segmental or hilar vessels with major devascularization of spleen
Grade 5: Shattered spleen, hilar vascular injury with devascularized spleen
What would a negative finding indicate on a FAST US after hx of splenic injury?
Positive finding?
Negative: Does not exclude. Stabilize patient and attempt CT to confirm
Positive: Exploratory laparotomy
A patient with a hx of splenic injury presents to the ED. On imaging, they are found to have a Grade 2 injury. You opt for conservative management. What are the contraindications of the management?
For how long will you monitor the patient?
Conservative management:
Progressive hemorrhage: No progressive hemorrhage => should resolve within 12 hours
Unstable patient
Peritonitis
large hemoperitoneum (hematoma in the peritoneum)
Active extravasation of contrast on IV CT abdomen
Monitor for 3 days (Grade +1)
A patient with a hx of splenic injury presents to the ED. On imaging, they are found to have a Grade 4 injury. You opt for invasive management. What are your 2 options? Explain both management plans along with risks
In both cases, it is an emergency => ABCDE
In both cases, there is hemorrhage => Group and cross match blood
Splenic Embolization: For hemodynamically stable patients Interventional radiology insert a catheter and contrast is administered to occlude damaged portion of spleen => stopping bleeding temporarily
Risk: Splenic infarction, pseudoaneurysm (false aneurysm), bleeding, splenic abscess, contrast-induced nephropathy
Operative: For hemodynamically unstable patients (ongoing bleeding, thats why positive FAST US indicates this). Surgical exploration via laparotomy. Risks of surgery (DVT, pain, hemorrhage, death, infection)
In both cases, if they fail -> Splenectomy
During surgical exploration of splenic injury, you find a small tear. How do you approach that vs large tear?
Small tear: Pressure and suture
Large tear: Omental wrapping (literally wrapping omentum around injury to prevent herniation)
A 12 year old patient suffered a severe RTA and had undergone a splenectomy as it was unable to be saved during operative intervention. What should be communicated to the patient before discharge
Spleen has role in immunity especially vs capsulated bacteria such as Hib => increased risk of infection
Ensure all vaccinations are up to date and receive annual flu and PCV vaccines
Antibiotic prophylaxis (until age 15)
Malaria prophylaxis
Medical jewelry
Medical alert bracelet
A rugby player presents to the ED after receiving a blow to their lower ribs on the left side. The CT scan shows a hypodense region of 2cm and a laceration of 1cm. There is no evidence of hilar involvement nor devascularization of the spleen. What route of management would you use? (only state)
Grade 2 intracapsular splenic injury according to AAST criteria
Conservative management unless contraindications (active bleed, patient unstable, large hemoperitoneum, peritonitis…)
