Splenic Trauma - Blunt

exp date isn't null, but text field is

• CT findings of active contrast extravasation or spleen AIS grade 4-5 with large hemoperitoneum:
  • Tx: Fluid resuscitation on IV warmers and external warming device.
  • Consider all of these patients for angiographic embolization unless:
    • Ongoing hypotension despite fluid resuscitation (not tachycardia).
    • Need for exploration for other injuries.
• Hypotension in ED is strongly predictive of failure of non-operative management (NOM)
• Criteria for NOM includes: HD stability, negative abdominal exam, absence of contrast extravasation on CT, absence of other clear indication for exploratory laparotomy, absence of conditions associated with bleeding (coagulopathy, use of anticoagulants, cardiac failure)
• Non-operative Management Protocol:
  • Bedrest algorithm:
    • AIS solid organ score – 1 = days of bed rest, up to a maximum of 3 days of bed rest
    • If embolized, bed rest for 24 hours only.
    • Start Lovenox (if no other contraindication) same day as bed rest restrictions end.
  • For patients with AIS score >3
    • Telemetry monitoring – admit to either stepdown (no vent or pressors) or ICU status for 24 hours of hemodynamic monitoring.
    • Hct check q8 hours x 24 hours
    • Serial abdominal exams x 24 hours
    • A sudden change in hemodynamics, decrease in Hb/Hct or significant change in the abdominal exam should prompt a repeat CT/angio, unless the patient is HD unstable
• 95% of NOM failures happen within 72 hours of injury, regardless of grade.
• Abdominal CT scanning is the gold standard diagnostic test if NOM is to be pursued.
• Splenectomized patients and those who undergo main splenic artery embolization should have vaccines 14 days post splenectomy. If there is any concern for patient follow-up, vaccinate on the day of discharge from the hospital.
  • Vaccines (see med section for details)
    • Pneumococcal vaccine - PPSV23³
    • Meningococcal vaccine - MCV4⁴   (2 – 55 years old),   MPSV4 (>55 years old)
    • Haemophilus influenza type b vaccine - Hib⁵

Table 1. Splenic Injury Scale

Organ, grade *	Injury Type	Description of Injury	AIS
Speen
I	Hematoma	Subcapsular, < 105 Surface area	2
	Laceration	Capsular tear, < 1cm parenchymal depth	2
II	Hematoma	Subcapsular, 10% to 50% surface area; intraperencymal, , 5cm in diameter	2
	Laceration	Capsular tear, 1 to 3 cm parenchymal depth that does not involve a trabecular vessel	2
III	Hematoma	Subcapsular, > 50% surface area or expanding; ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma ≥ 5cm or expanding	3
	Laceration	>3cm parenchymal depth or involving trabecular vessels	3
IV	Laceration	Laceration involving segmental or hilar vessels producing major revascularization (>25% of spleen)	4
V	Hematoma	Completely shattered spleen	5
	Laceration	Hilar vascular injury devascularizes spleen	5

 *Advance one grade for multiple injuries, up to Grade III.

 

Blunt Splenic Injury Algorithm