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Splenic Injury, Emergency Medicine

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Splenic Injury, Emergency Medicine

Basics

Description

Age-related difficulties in communication, fear-induced uncooperative behavior, or a concomitant head injury make clinical exam less reliable. ‚

All patients with splenic injury require hospitalization for definitive laparotomy or observation with serial abdominal exams, serial hematocrit determinations, and bed rest. ‚

Only asymptomatic patients objectively demonstrated not to have splenic or other traumatic injury may be discharged. ‚

  • The spleen is formed by reticular and lymphatic tissue and is the largest lymph organ.
  • The spleen lies posterolaterally in the left upper quadrant (LUQ) between the fundus of the stomach and the diaphragm.

Etiology

  • The spleen is the most commonly injured intra-abdominal organ:In nearly 2/3 of cases, it is the only damaged intraperitoneal structureBlunt mechanisms are more common
  • Motor vehicle accidents (auto " “auto, pedestrian " “auto) are the major cause (50 " “75%), followed by blows to the abdomen (15%) and falls (6 " “9%)
  • Mechanism of injury and kinematics are important factors in evaluating patients for possible splenic injury.
  • Splenic injuries are graded by type and severity of injury [American Association for the Surgery of Trauma (AAST) criteria]:Grade I:Hematoma: Subcapsular, <10% surface areaLaceration: Capsular tear, <1 cm in parenchymal depthGrade II:Hematoma: Subcapsular, 10 " “50% surface area; intraparenchymal, <5 cm in diameterLaceration: Capsular tear, 1 " “3 cm in parenchymal depth and not involving a trabecular vesselGrade III:Hematoma: Subcapsular, >50% surface area or expanding, ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma, ≥5 cm or expandingLaceration: >3 cm in parenchymal depth or involving the trabecular vesselsGrade IV:Laceration: Involving the segmental or hilar vessels and producing major devascularization (>25% of spleen)Grade V:Laceration: Completely shattered spleenVascular: Hilar vascular injury that devascularizes the spleen
  • In nearly 2/3 of cases, it is the only damaged intraperitoneal structure
  • Blunt mechanisms are more common
  • Grade I:Hematoma: Subcapsular, <10% surface areaLaceration: Capsular tear, <1 cm in parenchymal depth
  • Grade II:Hematoma: Subcapsular, 10 " “50% surface area; intraparenchymal, <5 cm in diameterLaceration: Capsular tear, 1 " “3 cm in parenchymal depth and not involving a trabecular vessel
  • Grade III:Hematoma: Subcapsular, >50% surface area or expanding, ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma, ≥5 cm or expandingLaceration: >3 cm in parenchymal depth or involving the trabecular vessels
  • Grade IV:Laceration: Involving the segmental or hilar vessels and producing major devascularization (>25% of spleen)
  • Grade V:Laceration: Completely shattered spleenVascular: Hilar vascular injury that devascularizes the spleen
  • Hematoma: Subcapsular, <10% surface area
  • Laceration: Capsular tear, <1 cm in parenchymal depth
  • Hematoma: Subcapsular, 10 " “50% surface area; intraparenchymal, <5 cm in diameter
  • Laceration: Capsular tear, 1 " “3 cm in parenchymal depth and not involving a trabecular vessel
  • Hematoma: Subcapsular, >50% surface area or expanding, ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma, ≥5 cm or expanding
  • Laceration: >3 cm in parenchymal depth or involving the trabecular vessels
  • Laceration: Involving the segmental or hilar vessels and producing major devascularization (>25% of spleen)
  • Laceration: Completely shattered spleen
  • Vascular: Hilar vascular injury that devascularizes the spleen
  • Poorly developed musculature and relatively smaller anteroposterior diameter increase the vulnerability of abdominal contents to compressive forces.
  • Rib cage is extremely compliant and less prone to fracture in children but provides only partial protection against splenic injury.
  • Splenic capsule in children is relatively thicker than that of an adult; parenchyma of spleen seems to contain more smooth muscle than in adults.
  • Significant abdominal injury occurs in only about 5% of child abuse cases but is the 2nd most common cause of death after head injury.

Diagnosis

Signs and Symptoms

  • In blunt trauma, note the type and direction (horizontal or vertical) of any deceleration or compressive forces:Injuries are caused by compression of the spleen between the anterior abdominal wall and the posterior thoracic cage or vertebra (e.g., lap-belt restraints).
  • In penetrating trauma, note the characteristic of the weapon (type and caliber), distance from the weapon, or the type and length of knife or impaling object:Injuries result from a combination of the kinetic energy and shear forces of penetration.
  • Injuries are caused by compression of the spleen between the anterior abdominal wall and the posterior thoracic cage or vertebra (e.g., lap-belt restraints).
  • Injuries result from a combination of the kinetic energy and shear forces of penetration.
  • Systemic signs from acute blood loss:Syncope, dizziness, weakness, confusionHypotension or shock
  • Local signs:LUQ abdominal tendernessPalpable tender mass in LUQ (Balance sign)Referred pain to the left shoulder (Kehr sign)Abdominal distention, rigidity, rebound tenderness, involuntary guarding
  • Contusions, abrasions, or penetrating wounds to the chest, flank, or abdomen may indicate underlying spleen injury.
  • Fractures of lower left ribs are commonly seen in association with splenic injuries.
  • Syncope, dizziness, weakness, confusion
  • Hypotension or shock
  • LUQ abdominal tenderness
  • Palpable tender mass in LUQ (Balance sign)
  • Referred pain to the left shoulder (Kehr sign)
  • Abdominal distention, rigidity, rebound tenderness, involuntary guarding

Essential Workup

  • History and physical exam are neither specific nor sensitive for splenic injury.
  • Adjunctive imaging studies are required.

Diagnosis Tests & Interpretation

  • No hematologic lab studies are specific for diagnosis of injury to the spleen.
  • Obtain baseline hemoglobin, type and cross-match, and chemistries.
  • Plain abdominal radiographs:Too nonspecific to be of valueCXR findings suggestive for splenic injury:Left lower rib fracture(s)Elevation of left hemidiaphragmMedial displacement of gastric bubble (Balance sign)Left pleural effusion
  • Ultrasound:Routinely performed at bedside in trauma patients as part of focused assessment with sonography (FAST)Primary role is detecting free intraperitoneal blood, which may suggest splenic injuryDoes not image solid parenchymal damage wellTechnically compromised by uncooperative patient, obesity, substantial bowel gas, and subcutaneous air
  • CT scan:Noncontrast CT is procedure of choice in stable patient due to speed and accessibilityDepicts the presence and extent of splenic injury and adjacent organs, including the retroperitoneumProvides the most specific information in patients stable enough to go to the CT scanner
  • MRI:May be applicable to subset of hemodynamically stable patients who cannot undergo CT scan (e.g., allergic to IV contrast)
  • Angiography:Has been added to the diagnostic and treatment options for selected cases
  • Too nonspecific to be of value
  • CXR findings suggestive for splenic injury:Left lower rib fracture(s)Elevation of left hemidiaphragmMedial displacement of gastric bubble (Balance sign)Left pleural effusion
  • Left lower rib fracture(s)
  • Elevation of left hemidiaphragm
  • Medial displacement of gastric bubble (Balance sign)
  • Left pleural effusion
  • Routinely performed at bedside in trauma patients as part of focused assessment with sonography (FAST)
  • Primary role is detecting free intraperitoneal blood, which may suggest splenic injury
  • Does not image solid parenchymal damage well
  • Technically compromised by uncooperative patient, obesity, substantial bowel gas, and subcutaneous air
  • Noncontrast CT is procedure of choice in stable patient due to speed and accessibility
  • Depicts the presence and extent of splenic injury and adjacent organs, including the retroperitoneum
  • Provides the most specific information in patients stable enough to go to the CT scanner
  • May be applicable to subset of hemodynamically stable patients who cannot undergo CT scan (e.g., allergic to IV contrast)
  • Has been added to the diagnostic and treatment options for selected cases
  • Diagnostic peritoneal lavage (DPL):Extremely sensitive for the presence of hemoperitoneum although nonspecific for source of bleeding and does not evaluate retroperitoneumLargely replaced by the FAST exam in most major trauma centers.
  • Extremely sensitive for the presence of hemoperitoneum although nonspecific for source of bleeding and does not evaluate retroperitoneum
  • Largely replaced by the FAST exam in most major trauma centers.

Differential Diagnosis

  • Intraperitoneal organ injury, especially liver
  • Injury to retroperitoneal structures
  • Thoracic injury

Treatment

Pre-Hospital

  • Obtain details of injury from pre-hospital providers.
  • IV access
  • Penetrating wounds or evisceration should be covered with sterile dressings.

Initial Stabilization/Therapy

  • Airway management (including C-spine immobilization)
  • Standard Advanced Trauma Life Support (ATLS) resuscitation measures:Adequate IV access, including central lines and cutdowns, as dictated by the patient 's hemodynamic statusFluid resuscitation, initially with 2 L of crystalloid (NS or lactated Ringer solution), followed by blood products as needed
  • Adequate IV access, including central lines and cutdowns, as dictated by the patient 's hemodynamic status
  • Fluid resuscitation, initially with 2 L of crystalloid (NS or lactated Ringer solution), followed by blood products as needed

Ed Treatment/Procedures

  • Immediate laparotomy may be appropriate in the acutely injured and hemodynamically unstable patient with presumed hemoperitoneum and splenic injury.
  • Most patients with acute splenic injury either are hemodynamically stable or stabilize rapidly with relatively small amounts of fluid resuscitation.
  • Adjunctive diagnostic procedures supplementing the physical exam should be performed early in the evaluation, followed by laparotomy when indicated by positive diagnostic findings.
  • Gunshot wounds to the anterior abdomen are routinely explored in the OR.
  • Stab wounds can be managed by local wound exploration, followed by US or DPL when intraperitoneal penetration is suspected.
  • Operative vs. nonoperative management:Patients with signs and symptoms of intraperitoneal hemorrhage, those with operative indications based on imaging//diagnostic procedures, and those who fail nonoperative management should undergo laparotomy.Angiographic embolization is an option in hemodynamically stable patientSplenectomy vs. splenic salvage depends on the grade of splenic injury.>70% of all stable patients are currently being treated via nonoperative management:Hemodynamic stabilityNegative abdominal examAbsence of contrast extravasation on CTAbsence of other clear indications for exploratory laparotomyAbsence of associated health conditions that carry an increased risk for bleeding (e.g., coagulopathy, hepatic failure, anticoagulant use, coagulation factor deficiency)Injury grades I " “III
  • Patients with signs and symptoms of intraperitoneal hemorrhage, those with operative indications based on imaging//diagnostic procedures, and those who fail nonoperative management should undergo laparotomy.
  • Angiographic embolization is an option in hemodynamically stable patient
  • Splenectomy vs. splenic salvage depends on the grade of splenic injury.
  • >70% of all stable patients are currently being treated via nonoperative management:Hemodynamic stabilityNegative abdominal examAbsence of contrast extravasation on CTAbsence of other clear indications for exploratory laparotomyAbsence of associated health conditions that carry an increased risk for bleeding (e.g., coagulopathy, hepatic failure, anticoagulant use, coagulation factor deficiency)Injury grades I " “III
  • Hemodynamic stability
  • Negative abdominal exam
  • Absence of contrast extravasation on CT
  • Absence of other clear indications for exploratory laparotomy
  • Absence of associated health conditions that carry an increased risk for bleeding (e.g., coagulopathy, hepatic failure, anticoagulant use, coagulation factor deficiency)
  • Injury grades I " “III
  • Patients >55 yr should be considered for operative management due to decreased physical tolerance to traumatic insult (splenic capsule thins with age) and reduced physiologic reserve.
  • Embolization is relatively contraindicated in patients >55 yr due to higher failure rates in these patients.
  • Nonoperative management of splenic injuries is considered safe:Concerns for overwhelming postsplenectomy infection/sepsis
  • Concerns for overwhelming postsplenectomy infection/sepsis

Follow-Up

Disposition

Additional Reading

  • Bhullar ‚ IS, Frykberg ‚ ER, Siragusa ‚ D, et al. Selective angiographic embolization of blunt splenic traumatic injuries in adults decreases failure rate of nonoperative management. J Trauma Acute Care Surg. 2012;72:1127 " “1134.
  • Gomez ‚ D, Haas ‚ B, Al-Ali ‚ K, et al. Controversies in the management of splenic trauma. Injury. 2012;43:55 " “61.
  • Izu ‚ BS, Ryan ‚ M, Markert ‚ RJ, et al. Impact of splenic injury guidelines on hospital stay and charges in patients with isolated splenic injury. Surgery. 2009;146(4):787 " “791.
  • St Peter ‚ SD, Keckler ‚ SJ, Spilde ‚ TL, et al. Justification for an abbreviated protocol in the management of blunt spleen and liver injury in children. J Pediatr Surg. 2008;43:191 " “194.
  • Tinkoff ‚ G, Esposito ‚ TJ, Reed ‚ J, et al. American Association for the Surgery of Trauma Organ Injury Scale I: Spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg. 2008;207(5):646 " “655.

Codes

ICD9

  • 865.00 Injury to spleen without mention of open wound into cavity, unspecified injury
  • 865.01 Injury to spleen without mention of open wound into cavity, hematoma without rupture of capsule
  • 865.02 Injury to spleen without mention of open wound into cavity, capsular tears, without major disruption of parenchyma
  • 865.09 Other injury into spleen without mention of open wound into cavity
  • 865.03 Injury to spleen without mention of open wound into cavity, laceration extending into parenchyma
  • 865.04 Injury to spleen without mention of open wound into cavity, massive parenchymal disruption
  • 865.0 Injury to spleen without mention of open wound into cavity

ICD10

  • S36.00XA Unspecified injury of spleen, initial encounter
  • S36.029A Unspecified contusion of spleen, initial encounter
  • S36.039A Unspecified laceration of spleen, initial encounter
  • S36.09XA Other injury of spleen, initial encounter
  • S36.020A Minor contusion of spleen, initial encounter
  • S36.021A Major contusion of spleen, initial encounter
  • S36.030A Superficial (capsular) laceration of spleen, initial encounter
  • S36.031A Moderate laceration of spleen, initial encounter
  • S36.032A Major laceration of spleen, initial encounter

SNOMED

  • 23589004 Injury of spleen (disorder)
  • 262820001 Contusion of spleen (disorder)
  • 262822009 Laceration of spleen (disorder)
  • 210180009 Closed injury of spleen (disorder)
  • 262823004 Capsular tear of spleen (disorder)
  • 262824005 Transection of spleen (disorder)
  • 43756009 Traumatic rupture of spleen (disorder)