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Management of Splenic Injury Brian Tiu, PGY 4 June 26, 2014 SUNY Downstate
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Case Presentation • • • • •
60 yo ♀, GSW left chest, 5th IC space, PAL Speaking, airway protected Equal bilateral breath sounds BP 155/65, P128 GCS 15
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Case Presentation • CXR • FAST – negative • Labs – CBC 6.75> 10.3/33.1 10.3/33.1 3 cm parenchymal depth – involving trabecular vessels
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Assessment – Grade IV • Laceration – involving segmental or hilar vessels producing major devascularization (>25% of spleen)
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Assessment – Grade V • Laceration – Shattered Spleen
• Vascular – Hilar vascular injury with devascularized spleen
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Management – EAST Guidelines • Level I – peritonitis, unstable = OR
• Level II – CT scan for stable patient – Consider angio for grade III or higher – For the stable patient, grade does not dictate OR
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Management – EAST Guidelines • Level III – Consider rescanning with change in status – Blush alone is not an indication for IR – Angiography as adjunct
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Management: Non-operative • Hemodynamically stable • No diffuse peritonitis – Serial abdominal exams
• Qualified center • Hematocrit • +/- Interventional radiology
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• • • • •
Retrospective review Level I trauma center 4 years, 174 Patients Blunt trauma, clinically stable grade III and less splenic injury
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• • • • •
Prospective trial Level I trauma center 3 years, 168 patients Blunt trauma, clinically stable grade III and greater splenic injury
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Management: Operative • Grade I – pack – Hemostatic agents
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Management: Operative • Grade II or III – Hemostatic agents – Argon beam – Splenorrhaphy
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Management: Operative • Grade II or III – Partial splenectomy
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Management: Operative • Grade IV – Splenectomy – immunizations
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Summary – Hemodynamically stable patient may be observed – Splenic injury grading system guides treatment – IR/Angiogram/embolization as an adjunct
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References •
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Barrios, C. et al. Computed Tomography Blush and Splenic Injury: Does It Always Require Angioembolization? The American Surgery. 2013 OCT; 79: 1089-92 Hassan, R. et al. Computed Tomography of Blunt Spleen Injury: A Pictorial Review. Malays J Med Sci. 2011 Jan-Mar; 18(1): 60–67. Miller, P. et al. Prospective Trial of Angiography and Embolization for All Grade III to V Blunt Splenic Injuries: Nonoperative Management Success Rate Is Significantly Improved. J Am Coll Surg. 2014 APR; 218(4): 644-648 Stassen, A. et al. Selective nonoperative management of blunt splenic injury: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012; 73(5): 294-300 Wesson, H. and Stevens, K. Splenic Salvage Procedures: Therapeutic Options. Cameron: Current Surgical Therapy, 11th ed. Philadelphia, PA: Saunders; 2013 Wisner DH. Chapter 30. Injury to the Spleen. In: Mattox KL, Moore EE, Feliciano DV. eds. Trauma, 7e. New York, NY: McGraw-Hill; 2013.
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Question Which indications for splenectomy are associated with the lowest susceptibility of OPSI? a. b. c. d. e.
Spherocytosis Elliptocytosis Leukemia Trauma ITP
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Question Which indications for splenectomy are associated with the lowest susceptibility of OPSI? a. b. c. d. e.
Spherocytosis Elliptocytosis Leukemia Trauma ITP
