Hi everyone!
Welcome back to Trauma Tuesday! Today's POTD will be on splenic injuries, inspired by a question I got wrong on NY ACEP bizz buzz board review. Did you know splenic injuries are the most commonly injured organ in blunt abdominal trauma (BAT)? I didn't. And just like that, my dreams of showing up on the Kahoot leader board were destroyed (though I'm sure all the other questions I got wrong before that didn't help).
Background: In BAT, the spleen is the most commonly injured intraabdominal organ, followed by the liver and kidneys. BAT leads to injury through shearing (rapid deceleration between fixed vs unfixed points of organs; think our aortic friend last week when we covered aortic transection), crushing (organs getting crushed between its neighboring organs, abdominal wall, or bony structures like ribs and vertebrae), and external compression forces (physical force pushing against abdomen leading to rise in intraabdominal pressure).
Workup and initial ED management:
At its core, assessing for splenic injury in blunt abdominal trauma falls under the ATLS algorithm.
ABCs come first, as always. IV x 2, O2, monitor. Rainbow labs, T+S. CXR and PXR. Fluids and blood as needed. Pain control. Though we are talking about BAT, usually force significant enough to cause intraabdominal injury is associated with intracranial, cervical spine, intrathoracic, and extremity injury. Perform your primary survey as normal and resuscitate as usual.
Your EFAST and vitals will determine what happens next to the patient. Unstable vitals and positive free fluid in abdomen? The patient needs the OR. When dealing with a splenic injury, you may note a few findings on your LUQ US during your efast: you may see free fluid in the LUQ, signs of a hematoma, or no findings on LUQ view but positive free fluid in RUQ.
However, a negative eFAST does not exclude splenic injury.
Clues on your physical exam that you may be dealing with a splenic injury include a positive seatbelt sign, tenderness or pain over LUQ, left flank, and kehr sign (referred pain to tip of left shoulder from blood in the peritoneal cavity, performed on supine patient and elevating legs, suggestive of splenic rupture). There may also be no findings on physical exam.
If the patient is stable, next step is CT scan with IV contrast, the results of which allow grading of splenic injury. Splenic injuries can also be graded in the OR if the patient went straight to exlap instead.
American Association for Surgery of Trauma (AAST) Splenic Injury Grading I-V:
https://media.springernature.com/lw785/springer-static/image/prt%3A978-3-642-00418-6%2F19/MediaObjects/978-3-642-00418-6_19_Part_Fig1-517_HTML.gif
Management:
The grade of splenic injury is one of several factors dictating management. There are several options available including operative, embolization, and nonoperative management. Most (up to 80%) of these patients can be managed effectively nonoperatively. As general rules, the patient who is circling the hemodynamic drain, required more than two units of blood, or is showing signs of continued bleeding, requires intervention.
Operative Management:
Used in patients with hemodynamically instability, evidence of peritonitis, pseudoaneurysm formation, and associated intraabdominal injuries requiring operative repair, such as bowel injuries. Goal is to preserve as much spleen as possible, though splenectomy is definitive treatment.
Embolization:
Consider in cases with contrast extravasation on CT scan, moderate hemoperitoneum, signs of ongoing bleeding. Embolization is associated with complications, such as devascularization of spleen defined as infarction in more than 25% of spleen, re-hemorrhage, and abscess formation.
Nonoperative management:
Consider in the hemodynamically stable patient without evidence of bleeding or peritonitis. Usually grade 1-2 injuries, though has been used for patients with higher grade injuries. These patients are admitted with monitoring and serial abdominal exams/CT scans, with urgent exlap possible if needed. Nonoperative management has a failure rate of 10-50%, and these patients continue onto the operative/embolization route.
Be wary of patients returning to ED following an admission for splenic injury/BAT!
*Beware the delayed splenic rupture: Can occur up to 10 days after initial injury. Oftentimes a result of of a small injury not visualized on imaging. Other complications may include rebleeding, pseudoaneurysm formation of splenic artery, abscess, pancreatitis, and infection, especially if patient received splenectomy.
Happy Tuesday!
-SD
Sources:
https://link.springer.com/referenceworkentry/10.1007%2F978-3-642-00418-6_517
https://www.ncbi.nlm.nih.gov/books/NBK441993/
https://wikem.org/wiki/Splenic_trauma
https://www.ncbi.nlm.nih.gov/books/NBK441993/