Blunt Trauma of the SpleenStephanie Olcese, MS, RN, CCRN

Initial Presentation• 20 y/o male s/p assault with a metal pipe• C/o pain in LUQ of abdomen & L hand• LUQ rebound tenderness, tender to palpation • No penetrating abdominal/chest wall wounds• Ecchymosis over dorsum of L hand• Grade III splenic laceration • Comminuted fx of L 3rd proximal phalanx• Transferred from HCH

Review of Systems Chest discomfort Abdominal discomfortSuperficial & clean abrasion over dorsum of L hand

Past Medical HistoryDenies prior PMH/PSHDenies medicationsNKDA

Physical ExamVS: Afebrile, 98, 138/90, 17, 100% on RAGen: A/Ox3, NADNeuro: GCS 15, A/O x3, motor 5/5 throughout,sensory intact, reflexes 2+ bilaterally, gait deferredCards: RRR, No R/M/G, +2 distal pulsesLungs: Clear bilaterallyAbd: soft, tender to palpation in LUQ, BS+, nondistendedExtr: swelling over L 3rd digit, splint intact

Laboratory Data• H/H: 11.2/32.4

CT Scan on11/25• Grade III splenic laceration• Moderate hemoperitoneum

Days 2 and 3• Doing well, Percocet & IV Dilaudid for

pain • 98.1, 77-91, 146/59, 96% on RA• Mild abdominal pain LUQ, BS+,

nondistended• H/H stable: 11.2/32.6, 10.9/31.7,

10.1/29.6, 10.9/32.3,11.1/31.7• OOB to chair by day 3

Days 4 and 5• VSS, afebrile• Doing well without complaints• H/H stable: 11.8/34.2• Transferred to floor on day 4• Repeat abdominal CT on day 5

CT Scan on 11/29

Management• Continued observation…

Day 6• Recurrent abdominal pain• Mild diaphoresis • Tachycardia 100-115• Remains normotensive (125/79) • Stable SpO2 >95% on RA• H/H: 10.2/29.8• Mild TTP in LUQ• Stat CT scan…

CT Scan on 11/30

Interventions• Selective splenic arteriography• Embolization of distal main splenic

artery • F/u splenic arteriogram

Day 7• Afebrile, 110, 120/75• Mild LUQ abdominal pain• Posthemorrhagic anemia

• 8.2/24.1• 9.4/26.7• 8.8/26.2• 9.4/26.9

Day 8• Remains tachycardic, 110s• Normotensive • Continued posthemorrhagic anemia

•8.1/22.8•8.0/22.1

• Transfused 2Us PRBC

Day 9• Continued tachycardia & posthemorrhagic

anemia• 7.1/20.6

• Persistent mild LUQ abdominal pain• Refused transfusion• Placed on iron supplementation • Continue to monitor H/H q8h• Remained in ICU

Day 10• Doing well• H/H stable for 36 hrs at 7.2/20.6• Transferred to floor

Days 11-13• Clinically stable• H/H on 12/6 8.0/23.6• Repeat CT on 12/7…

CT Scan on 12/7

Outcome• D/C to home• F/U CT at 6 weeks• ORIF of L hand as an outpatient

Source:http://radiopaedia.org/articles/splenic_injury_gradingAmerican Association for the Surgery of Trauma (AAST)

Blunt Spleen Injury

Serial HctMonitor Bed

CT

AE vs. OR

Pseudoaneurysm or Blush

Downgrade

Stable Lac

Repeat CT 24-72h

StableSavage et al., 2008

East Trauma Practice Guidelines

• Level II & III data • NOM in HDS pts is reasonable • Injury severity is NOT a contraindication

to NOM• Abdominal CT MOST reliable method to

assess severity of injury

Alonso et al., 2003

Grade I & II• Duke Trauma Center:

• Monitor Bed• Hct q12h x 48h• Transfuse if Hct < 24• To OR if > 2-4U PRBC• Hct stable d/c after 48h

Duke Trauma Center, 2005; Image from: http://www.trauma.org/index.php/main/image/135/spleen

Grade III• Duke Trauma Center:

• Consider AE• Admit to ICU• Hct q6h x 24h• Hct stable tx to stepdown• Hct q12h x 48h• Hct stable d/c after 72h

Duke Trauma Center, 2005; Image from: http://www.trauma.org/index.php/main/image/136/spleen

Grade IV & V• Duke Trauma Center:

• AE vs. OR• Admit to ICU

Duke Trauma Center, 2005; Image from: http://www.trauma.org/index.php/main/image/544/spleen

References• Alonso M, Brathwaite C, Garcia V, et al. Practice management

guidelines for the nonoperative management of blunt injury to the liver and spleen: EAST Practice Parameter Workgroup for Solid Organ Injury Management. 2003.

• Duke Trauma Center. Splenic Lacerations Management Guideline. 2005. Available at: http://gsresidency.surgery.duke.edu/wysiwyg/downloads/spleen-lacs.pdf

• Peitzman AB, Heil B, Rivera L, et al. Blunt splenic injuries in adults: multi-institutional study of the eastern association for the surgery of trauma. J Trauma. 2000; 49: 177-189.

• Savage SA, Zarzaur BL, Magnotti LJ, et al.The evolution of blunt splenic injury: resolution and progression. J Trauma. 2008; 64: 1085-1092.