splenic rupture

Question 1

what are the causes of splenic injury?

Answer 1

usually secondary to abdominal trauma, particularly blunt trauma e.g seat belt injuries in car crash , then fall onto left side

minority of cases or iatrogenic or secondary due to underlying splenomegaly from haematological malignancy or infective causes

in these cases, as the spleen grows, the capsule stretches and things, becoming more fragile and disposable to rupture

Question 2

what are the complications of splenic rupture?

Answer 2

spleen is very vascular so rupture can lead to large intraperitoneal haemorrhage, leading to fatal haemorrhage shock

Question 3

what are the clinical features of splenic rupture?

Answer 3

• abdo pain following trauma
• may have features of hypovolemic shock
• LUQ tenderness
• peritonism
• free blood can irritate diaphragm and cause radiating left shoulder pain (Kehr’s sign)

Question 4

what investigations are done?

Answer 4

• haemodynamically unstable with peritoneum following trauma = have abdominal bleeding until proven otherwise, and need immediate laparotomy
• haemodynamically stable with abdominal injury = urgent CT CAP with IV contrast
• CT allows identification and assessment of splenic injury and any other abdo viscera involvement. can also grade injury to guide management
• FAST scans in ED can reveal free peritoneal fluid or fluid in pericardium. Shouldn’t delay CT/ surgery for however.

Question 5

what is used to grade and treat splenic injuries?

Answer 5

The American Association for the Surgery of Trauma (AAST) splenic injury scale

It is used to help guide which patients are likely to benefit from conservative management and which need surgery.

Question 6

how are haemodynamically stable patients with low grade (1-3) injuries treated?

Answer 6

conservatively

resusitate using permissive hypotension, admit to high dependency area for observation, give serial abdominal exams for any evidence of deterioration

repeat CT scan at 1 week and place on bed rest

any suggestion of increased tenderness or peritonitis, have low threshold for re imaging and/or laparotomy

give prophylactic vaccinations at discharge against Strep Pneumoniae, Haemophilus Influenzae B (HIB) and Meningococcus

Question 7

what are the complications of conservative treatment and embolisation?

Answer 7

• ongoing bleeding
• splenic necrosis
• splenic abscess/cyst
• thrombocytosis

Question 8

what is overwhelming post splenectomy infection (OPSI)?

Answer 8

Spleen is an immunologically active organ. Asplenic patients are unable to mount response against encapsulated organisms e.g pneumococcus, meningococcus and H influenzae.

this can lead to overwhelming sepsis

as a result, asplenic patients should be given vaccinations against these three organisms and prophylactic penicillin V should be considered

Question 9

what bacteria put asplenic patients at risk of sepsis?

Answer 9

encapsulated organisms, such as Pneumococcus, Meningococcus, and H. Influenzae.