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JHSGRJHSGRManagement of Management of
blunt splenic blunt splenic injuriesinjuries
Dr PT Chan /QEHDr PT Chan /QEH
IntroductionIntroduction
Spleen is the most frequently injured Spleen is the most frequently injured organ in blunt traumaorgan in blunt trauma
Spleen plays an important role in Spleen plays an important role in immune functionimmune function Overwhelming Post splenectomy Overwhelming Post splenectomy
Infection (OPSI) 0.05-2%Infection (OPSI) 0.05-2%
Mortality 50%-70%Mortality 50%-70%Takehiro Okabayashi,.World Journal of Gastroenterology 2008
Change in the approach to splenic Change in the approach to splenic injuryinjury Operative splenic preservation achieved Operative splenic preservation achieved
by splenorrhaphy has progressed to the by splenorrhaphy has progressed to the non-operative management. non-operative management.
Etiology and RisksEtiology and Risks TraumaTrauma
Rapid deceleration Rapid deceleration Road Traffic AccidentsRoad Traffic Accidents
Direct forceDirect force Fell from height/ sportsFell from height/ sports
IatrogenicIatrogenic
Risks: Pre-existing illness Risks: Pre-existing illness Splenomegaly due to haematological disease / Splenomegaly due to haematological disease /
malaria/ Infectious mononucleosismalaria/ Infectious mononucleosis
Clinical presentationClinical presentation
Left upper quadrant abdominal painLeft upper quadrant abdominal pain Left shoulder tenderness (referred Left shoulder tenderness (referred
pain from subdiaphragmatic nerve pain from subdiaphragmatic nerve root irritation)root irritation)
Peritoneal sign Peritoneal sign Signs and symptoms of shockSigns and symptoms of shock
e.g. tachycardia, restlessness, e.g. tachycardia, restlessness, tachypneatachypnea
InvestigationInvestigation
USGUSG FAST :Look for any free peritoneal fluidFAST :Look for any free peritoneal fluid
Sensitivity 55%-91%, specificity 97-100%Sensitivity 55%-91%, specificity 97-100% Splenic injuriesSplenic injuries
sensitivity 41-63%, specificity 99%sensitivity 41-63%, specificity 99% CT scanCT scan
Splenic injuriesSplenic injuries Sensitivity 95% , specificity 100%Sensitivity 95% , specificity 100%
AAST Grading of splenic AAST Grading of splenic injuryinjury
Grade 1Grade 1
Subcapsular Subcapsular hematoma of less hematoma of less than 10% of than 10% of surface area.surface area.
Capsular tear of Capsular tear of less than 1 cm in less than 1 cm in depth.depth.
Grade 2Grade 2 Subcapsular Subcapsular
hematoma 10-50% hematoma 10-50% of surface areaof surface area
Intraparenchyml Intraparenchyml hematoma < 5cm hematoma < 5cm diameterdiameter
Laceration of 1-Laceration of 1-3cm in depth and 3cm in depth and not involving not involving trabecular vesselstrabecular vessels
Grade 3Grade 3 Subcapsular >50% Subcapsular >50%
surface area or surface area or expandingexpanding
Ruptured subcapsular or Ruptured subcapsular or intraparenchymal intraparenchymal hematomahematoma
Intraparenchymal Intraparenchymal haematoma >5 cm or haematoma >5 cm or expandingexpanding
Laceration of greater Laceration of greater than 3 cm in depth or than 3 cm in depth or involving trabecular involving trabecular vesselsvessels
Grade 4Grade 4
Laceration Laceration involving involving segmental or hilar segmental or hilar vessels producing vessels producing major major devascularization devascularization (>25% of spleen)(>25% of spleen)
Grade 5Grade 5
Shattered spleen / Shattered spleen / Hilar vascular Hilar vascular injuryinjury
ManagementManagement
Haemodynamic unstableHaemodynamic unstable Surgical interventionSurgical intervention
LaparotomyLaparotomy 4 quadrants packed4 quadrants packed Assess the extent of splenic injuriesAssess the extent of splenic injuries
Only if feasible, may consider conserving the Only if feasible, may consider conserving the spleenspleen
Otherwise, Splenectomy should be performed Otherwise, Splenectomy should be performed Excluded other injuriesExcluded other injuries SplenorrhaphySplenorrhaphy
Parenchymal suture/Fibrin glue/ABC/ Parenchymal suture/Fibrin glue/ABC/ Laser/omental patch/mesh bag/partial Laser/omental patch/mesh bag/partial splenectomysplenectomy
Haemodynamic stableHaemodynamic stable
Non operative management with Non operative management with close monitoringclose monitoring Vital signs, haemoglobin levels Vital signs, haemoglobin levels
Successful rate 80% ~89.2%Successful rate 80% ~89.2%
Jason Smith. Journal of Trauma 2007
Andrew B. Peitzman,.Journal of Trauma 2000.
Non operative Non operative managementmanagement
How long should be monitored?How long should be monitored? most failure( 95%) occur within 3 most failure( 95%) occur within 3
days(72hrs) of admission.days(72hrs) of admission.
(97% in 5 days, 99 % in 30 days) (97% in 5 days, 99 % in 30 days) Suggested patients to be closely Suggested patients to be closely
monitored for 3-5 days monitored for 3-5 days Highly dependency unit and step down Highly dependency unit and step down
afterwards afterwards Jason Smith. Journal of Trauma 2007
Jason Smith. Journal of Trauma 2007
Successful rate of NOM
Non operative Non operative managementmanagement
Risk factors for failureRisk factors for failure Higher grading of splenic injuriesHigher grading of splenic injuries larger quantity of haemoperitoneumlarger quantity of haemoperitoneum older ageolder age Contrast extravasations in CT Contrast extravasations in CT
Jason Smith.Journal of Trauma 2007
Siriratsivawong K Am Surg 2007
Andrew B. Peitzman. Journal of Trauma 2000.
Non operative Non operative managementmanagement
Andrew B. Peitzman. Journal of Trauma 2000.
Angioembolization Angioembolization
Increased successful rate of non-Increased successful rate of non-operative management in selected operative management in selected policypolicy Increase up to 97%Increase up to 97%
Indications:Indications: Contrast extravasation, Contrast extravasation,
pseudoaneurysm, grade 4 injuriespseudoaneurysm, grade 4 injuries
Ashraf A. Journal of Trauma 2009
Complications of Complications of embolizationembolization
Total splenic infarction (9.5%), Total splenic infarction (9.5%), rebleeding (19%), splenic atrophy rebleeding (19%), splenic atrophy (4.8%), partial infarction (38%), (4.8%), partial infarction (38%), pleural effusion (33%).pleural effusion (33%).
Shih-chi Wu. World journal of surgery 2008
Resolution and Resolution and ProgressionProgression
Time of mobilization?Time of mobilization? No definite guidelines, earlier for low No definite guidelines, earlier for low
grade injuries. grade injuries. 77% mobilization within 72hrs after 77% mobilization within 72hrs after
admissionadmission Day of mobilization was not associated Day of mobilization was not associated
with delayed splenic rupture. with delayed splenic rupture.
London JA.Arch Surg. 2008.
% of patients remained unhealed over time (days)
Stephanie A.Journal of Trauma. 2008
Activity Restriction-Activity Restriction-AthletesAthletes
No consensus on return to play after No consensus on return to play after splenic injurysplenic injury
Acceptable to engage in light Acceptable to engage in light activity for the first 3 months and activity for the first 3 months and then gradually return to full activitythen gradually return to full activity
Elizabeth H.American College of Sports Medicine.2010.
Follow up Follow up
No evidence that routine follow up No evidence that routine follow up serial CT scans without clinical serial CT scans without clinical indications influenced the outcome indications influenced the outcome or management.or management.
Imaging maybe considered if patient Imaging maybe considered if patient has a high grade of injury/ still has a high grade of injury/ still experiencing symptomsexperiencing symptoms
Thaemert BC. Journal of Trauma 1997
Prevention of InfectionPrevention of Infection
VaccinationVaccination Pneumococcal , then booster after 5 Pneumococcal , then booster after 5
yearsyears Hamemophilus influenza BHamemophilus influenza B Meningococcal every 3 -5 yearsMeningococcal every 3 -5 years Two weeks after emergency Two weeks after emergency
splenectomysplenectomy EducationEducation Bracelet/CardBracelet/Card
Guidelines from the Centers for Disease Control and Prevention
Shatz DV .Journal of trauma 2002, 1998
Antibiotic prophylaxisAntibiotic prophylaxis No clinical trials in adultsNo clinical trials in adults ““StandbyStandby”” antibiotics antibiotics Some suggest 2-5 years prophylaxisSome suggest 2-5 years prophylaxis Long term prophylaxis not generally Long term prophylaxis not generally
recommendedrecommended
DC. The Netherlands Journal of Medicine 2004
SummarySummary Operation if haemodynamic unstableOperation if haemodynamic unstable Only stable patient are admitted for observation for Only stable patient are admitted for observation for
3-5 days3-5 days CT for assessing degree of injuriesCT for assessing degree of injuries
Grade 5 injuries need operationGrade 5 injuries need operation Majority of grade 4 splenic injuries are unstable and likely Majority of grade 4 splenic injuries are unstable and likely
need to be operatedneed to be operated Angio/embolization can be considered for stable Angio/embolization can be considered for stable
patients with contrast extravasation or patients with contrast extravasation or pseudoaneurysmpseudoaneurysm
Advise activity restriction according to the grade of Advise activity restriction according to the grade of injuriesinjuries
Vaccination /education for infection prophylaxis Vaccination /education for infection prophylaxis Follow up CT scan should be considered in selected Follow up CT scan should be considered in selected
patientspatients
ManagementManagement
Thank YouThank You
Latent pseudoaneurysm may present Latent pseudoaneurysm may present ~ 24-48 hrs after injury (2.2%) ~ 24-48 hrs after injury (2.2%)
Computed Tomography Identification of Latent Pseudoaneurysm after blunt splenic injury : Pathology or Technology
Hunter B.Long-Term Follow up of Children with nonoperative management of blunt spenic trauma. Journal of Trauma 2010.
SplenorraphySplenorraphy
Grade 1: haemostatic agentGrade 1: haemostatic agent
Grade 2 : 43% + suture/meshGrade 2 : 43% + suture/mesh
Grade 3 : 100% + suturing /parenchymal Grade 3 : 100% + suturing /parenchymal suturesuture
Grade 4: anatomical resectionGrade 4: anatomical resection
Grade 5: splenectomyGrade 5: splenectomy
PickhardtB, Operative splenic salvage in adults: a decade perspectives. Journal of Trauma 1989
Paediatric patientsPaediatric patients Mechanism of injury:Mechanism of injury:
More fall or sports than RTAMore fall or sports than RTA Elastic ribs readily change contour and cause rapid flexion of Elastic ribs readily change contour and cause rapid flexion of
organs along its axis -> lacertions are more oriented to the organs along its axis -> lacertions are more oriented to the larger segmental vesselslarger segmental vessels
Thicker and more fibrous splenic capsuleThicker and more fibrous splenic capsule Tolerate higher grade of injuries with non operative Tolerate higher grade of injuries with non operative
managementmanagement ComplicationsComplications
Very low incidenceVery low incidence For delayed splenic rupture (0 case in one metaanalysis 1083 For delayed splenic rupture (0 case in one metaanalysis 1083
patient vs 5-6% in adult)patient vs 5-6% in adult) Most pseudoaneurysm will spontaneously resolve or self Most pseudoaneurysm will spontaneously resolve or self
tamponadetamponade
Non-operative management is the standard for all grades of Non-operative management is the standard for all grades of splenic injuries in all haemodynamic stable patients (75-93% splenic injuries in all haemodynamic stable patients (75-93% successful rate)successful rate)
Peditric blunt splenic trauma: a comprehensive review
Pediatr Radiol (2009)39:904-916
Andrew B. Peitzman, Blunt Splenic Injury in Adults: Multi-institutional Study of the Eastern Association for the surgery of Trauma. Journal of Trauma 2000.
Activity RestrictionActivity Restriction
Light activityLight activity Light housework, office work, low Light housework, office work, low
impact aerobic activityimpact aerobic activity Strenuous activityStrenuous activity
Running, lifting over twenty pounds, Running, lifting over twenty pounds, cosntruction work, manual laborcosntruction work, manual labor
Full activity (contact sport)Full activity (contact sport)
Fata P.A survey of EAST member practices in blunt splenic injury; a description of current trends and opportunities for improvement. Journal of Trauma 2005
Late complication of Late complication of splenic injuriessplenic injuries
Non operative Non operative Delayed rupture spleen 1%Delayed rupture spleen 1% Splenic Pseudocyst Splenic Pseudocyst Splenic necrosis/abscessSplenic necrosis/abscess
SplenectomySplenectomy Overwhelming postsplenectomy Overwhelming postsplenectomy
Infection (OPSI)Infection (OPSI)
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