Splenic injury

Background
  • Most commonly injured visceral organ in blunt trauma

Clinical Features
  • LUQ pain
  • Signs of shock
  • Hypotension
  • Left lower rib pain
  • Kehr's sign
    • Acute pain in the tip of the shoulder due to the presence of blood in the peritoneal cavity when a patient's legs are elevated while laying flat.

Differential Diagnosis

Abdominal Trauma

Evaluation
Traumatic rupture of the spleen on contrast enhanced axial CT (portal venous phase).
Splenic hematoma (red arrow) resulting in free abdominal blood (blue arrow).

ATLS Blunt Abdominal Trauma Algorithm
  • Unstable
    • FAST to search for free fluid (vs. DPL if unavailable)
      • Positive: Exploratory laparotomy
      • Negative: CT scan
  • Stable
    • CT scan
      • Exploratory laparotomy, angiographic embolization, conservative management as indicated

AAST Criteria
Grade Hematoma Laceration
I
  • Subcapsular, <10% of surface area
  • Capsular tear <1 cm in depth into the parenchyma
II
  • Subcapsular, 10-50% of surface area
  • Capsular tear, 1 to 3 cm in depth, but not involving a trabecular vessel
III
  • Subcapsular, >50% of surface area OR expanding,
  • Ruptured subcapsular or parenchymal hematoma
  • OR, intraparenchymal hematoma >5 cm or expanding
  • Capsular tear, 3 to 10 cm in depth or involving a trabecular vessel.
IV
  • Subcapsular or central hematoma > 10cm
  • Involving segmental or hilar vessels with major devascularization (i.e. >25% of spleen)
V
  • Shattered spleen
  • Hilar vascular injury which devascularizes spleen.

Management
  • Observation, angiographic embolization, or surgery depending upon:
    • Hemodynamic status of the patient
    • Grade of splenic injury
    • Presence of other injuries and medical comorbidities
  • Operative Management
    • Indicated for diffuse peritonitis or hemodynamic instability after blunt abdominal trauma
    • Not indicated based on injury grade alone[1]
  • Nonoperative management
    • Failure rate of 10-15%
    • Some advocate nonoperative management only if <55yr and CT injury grade less than IV
    • Should only be considered in locations with resources available for urgent laparotomy

Disposition
  • Admit

See Also

References
  1. Stassen N, Bhullar I, Cheng J, 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):s293-s300
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