Splenic Injury 12-5

what areas of the body does the FAST exam evaluate?

-Morison's pouch (potential space separating liver from right kidney) -spenorenal recess -pelvis -pericardium

How do you diagnose hemodynamically stable splenic injury?

H&P (*nonspecific*) ultrasound - may reveal free intra-abdominal fluid, but can't tell where the fluid is from *CT w/IV contrast* - best for evaluation of extravasation of contrast outside splenic vessels & spleen itself - contrast "blush" = ongoing bleeding

what is the criteria for nonoperative management of blunt splenic injury?

Hemodynamic stability No indication for laparotomy on the basis of physical exam findings or diagnostic tests No transfusion requirement attributed to splenic injury **Constant availability of surgical and critical care resources

what are the general functions of the spleen?

Removal of unwanted elements from the blood Secondary organ of the immune system Source of hematopoietic cells Sequestration of a portion of the formed blood elements

describe overwhelming postsplenectomy infection (OPSI)

Uncommon Sudden onset of symptoms with rapid and fulminating course that often last only 12-18 hours - Patients complain of fever, nausea, vomiting, headache, and altered mental status Infection may occur at any time after splenectomy [years] Overall mortality rate of 50-80% (This is 78% higher than the usual mortality rate in sepsis) Most common bacteria: S. pneumoniae

what is the prophylactic treatment of splenectomized pt's?

Within 2 weeks of splenectomy = Polyvalent Pneumococcal vaccine [PPV-23] = H. influenza type B conjugate vaccine = meningococcal polysaccharide vaccine

Other than the FAST exam what else can be used to diagnose splenic injury in an unstable pt?

diagnostic peritoneal lavage (DPL) Catheter inserted through a small supra- or infra-umbilical incision Peritoneal contents are aspirated and examined Sensitivity 97% [hemoperitoneum] **takes a while, not good in urgent trauma setting

describe the nonoperative management of splenic injury

must be a hemodynamically stable with: *Constant availability of ICU, surgeon*, OR staff Serial abdominal examinations Serial H/H monitoring Repeat CT scan in most cases

is the FAST exam diagnostic of injury to the spleen?

no! just confirms there's fluid in the abdomen

what is the next step in care if a pt w/splenic injury becomes unstable

operate

what is Kehr's sign & what causes it?

pain in the left shoulder - d/t presence of subdiaphragmatic blood often b/c of splenic injury

what arterial vessel supplies the spleen?

splenic artery (large branch of celiac trunk)

what is the criteria for a hemodynamically stable pt?

BP > 90 HR < 120 adequate response to infusion of IV fluids

How do you diagnose splenic injury in a hemodynamically unstable pt?

**FAST** (Focused Assessment for Sonographic [US] evaluation of the Trauma pt) US that assess for free fluid in: -Morison's pouch (potential space separating liver from right kidney) -spenorenal recess -pelvis -pericardium can be rapidly performed for dx hemoperitoneum *Not diagnostic of injury to any specific organ**

what H&P findings should raise suspicion of splenic injury?

*Generalized abdominal pain *Pain that localizes to the left upper quadrant *Pain in the left shoulder [Kehr's sign] *Lower-left rib (9-12) fractures *H&P findings are neither sensitive or specific for Dx*

what is angioembolization?

emerging therapy with varying availablity. Performance by interventional radiology in selected, stable patients with evidence of contrast extravasation has shown a decreased failure rate of nonoperative management.

Describe splenic injury

*most frequently injured intra-abdominal organ in blunt trauma* -almost always blunt trauma causing injury pt's should be managed on basis of their hemodynamic status -> hemo stable (never hypotensive or tachycardic) -> responsive (tachycardia/hyptensive, but resolves w/fluid resuscitation) -> unstable (no response to volume depletion)

what is the management of a pt w/blunt abdominal trauma who is stable?

CT w/IV contrast then: Nonoperative management planned Patient admitted to the ICU; surgical services ready at any time Serial monitoring of H/H Serial abdominal exams Low threshold for taking to the operating room: -Tachycardia -Hypotension -Peritoneal signs -Need for transfusion

what are the sequelae of asplenism?

Increased susceptibility to disseminated infection with *encapsulated* bacteria: *Streptococcus pneumoniae* *Neisseria meningitidis* *Haemophilus influenzae* Group B streptococcus Klebsiella pneumoniae Salmonella typhi

What is the criteria for failure of nonoperative management of blunt splenic injury?

Increasing or persistent fluid requirements to maintain normal hemodynamic status Failed angioembolization of ateriovenous fistula/pseudoaneurysm Transfusion requirement to maintain hematocrit/hemodynamic stability Peritoneal signs/rebound tenderness

what should you do if contrast blush is seen on CT scan in the pt w/blunt abdomen trauma causing splenic injury?

arteriogram/embolization or operate if no interventional radiologist at facility

describe the algorithm for evaluation & management of blunt abdominal trauma

stable = CT w/IV contrast -> further management unstable = FAST exam: if (+) immediate surgical management if (-) -> DPL -> if DPL is (+) = surgery; (-) search for other source of bleeding