Overview
Definition:
Splenic injury refers to damage to the spleen, a vital organ of the immune system located in the upper left quadrant of the abdomen
It is the most commonly injured solid organ in blunt abdominal trauma.
Epidemiology:
Splenic injuries account for approximately 45-55% of solid organ injuries in blunt abdominal trauma
Motor vehicle accidents are the leading cause, followed by falls and assaults
Penetrating injuries are less common but can be more severe.
Clinical Significance:
The spleen plays a crucial role in immune defense, filtering blood, and producing lymphocytes
Significant splenic injury can lead to life-threatening hemorrhage
Understanding grading and appropriate management is critical for patient outcomes and avoiding unnecessary splenectomy, which increases the risk of overwhelming post-splenectomy infection (OPSI).
Clinical Presentation
Symptoms:
Left upper quadrant abdominal pain
Referred pain to the left shoulder (Kehr's sign)
Abdominal distension
Nausea and vomiting
Signs of hypovolemic shock: tachycardia, hypotension, pallor, diaphoresis.
Signs:
Tenderness in the left upper quadrant
Guarding and rebound tenderness
Palpable abdominal mass or distension
Bruising over the left flank (Grey Turner's sign) or around the umbilicus (Cullen's sign) may indicate retroperitoneal hemorrhage, though these are late signs
Signs of shock may be profound in significant hemorrhage.
Diagnostic Criteria:
No specific diagnostic criteria
Diagnosis is based on clinical suspicion in the setting of trauma and confirmed by imaging
The American Association for the Surgery of Trauma (AAST) splenic injury scale is the most widely used grading system for classifying injury severity.
Diagnostic Approach
History Taking:
Mechanism of injury (blunt vs
penetrating)
Force and direction of impact
Speed of vehicle if MVC
Associated injuries
Prior abdominal surgeries or medical conditions affecting the spleen (e.g., mononucleosis, hematologic disorders)
Medications (anticoagulants).
Physical Examination:
Thorough abdominal examination to assess for tenderness, guarding, rebound, and distension
Assess for signs of hypovolemic shock
Examine the entire body for other injuries, especially chest and pelvic trauma.
Investigations:
FAST (Focused Assessment with Sonography for Trauma) exam: rapidly detects free fluid in the abdomen, suggestive of bleeding
CT scan with intravenous contrast: Gold standard for diagnosing and grading splenic injuries
It identifies active extravasation of contrast (a sign of active bleeding), laceration depth, and associated injuries
Hemoglobin and hematocrit levels, coagulation profile (PT/INR, aPTT), blood type and crossmatch
Plain X-rays of chest and pelvis to rule out associated injuries.
Differential Diagnosis:
Gastric perforation
Pancreatic injury
Renal injury
Diaphragmatic rupture
Rib fractures
Left lower lobe pneumonia
Colonic injury.
Splenic Injury Grading Aast Scale
Grade I:
Subcapsular hematoma <10% surface area
Intrasplenic hematoma <1cm.
Grade Ii:
Subcapsular hematoma 10-50% surface area
Intrasplenic hematoma 1-3cm.
Grade Iii:
Subcapsular hematoma >50% surface area
Intrasplenic hematoma >3cm
Laceration depth <1cm parenchymal depth.
Grade Iv:
Laceration with devascularization of 25-50% of spleen
Segmental splenic artery injury.
Grade V:
Completely shattered spleen
Hilum vascular injury with >75% devascularization.
Management
Initial Management:
Hemodynamic resuscitation with intravenous fluids and blood products
Early involvement of trauma surgery
Monitor vital signs closely
Type and screen/crossmatch blood
Consider early operative intervention for hemodynamically unstable patients.
Non Operative Management Nom:
Recommended for hemodynamically stable patients with low-grade injuries (I-III) and no signs of active bleeding on CT
Requires close monitoring in an ICU or step-down unit
Serial abdominal examinations and hemoglobin monitoring
Angioembolization: indicated for active bleeding (blush) on CT, particularly for higher-grade injuries (IV-V) in stable patients, to preserve splenic function
Contraindicated in active, uncontrolled hemorrhage or hemodynamic instability.
Surgical Management:
Splenectomy: Complete removal of the spleen
Indicated for hemodynamically unstable patients with ongoing hemorrhage refractory to resuscitation and embolization, or for completely shattered spleen (Grade V)
Partial Splenectomy or Splenic Repair: Reserved for specific cases, especially in children, to preserve immune function
Techniques include debridement, suturing, and argon beam coagulation
Less commonly performed in adults due to technical difficulty and risk of bleeding.
Supportive Care:
Pain management
Prophylaxis against OPSI (vaccination against encapsulated bacteria: Pneumococcus, Meningococcus, Haemophilus influenzae type b)
Antibiotic prophylaxis post-splenectomy
Monitoring for complications.
Complications
Early Complications:
Hemorrhage (continued bleeding)
Hemoperitoneum
Hemorrhagic shock
Injury to adjacent organs (stomach, colon, diaphragm, kidney).
Late Complications:
Overwhelming post-splenectomy infection (OPSI): a life-threatening sepsis
Pseudoaneurysm formation
Splenic abscess
Splenic cyst
Post-traumatic stress disorder.
Prevention Strategies:
Careful patient selection for non-operative management
Timely angioembolization for active bleeding
Meticulous surgical technique if splenectomy or repair is performed
Strict adherence to OPSI prophylaxis and patient education regarding infection risks.
Prognosis
Factors Affecting Prognosis:
Hemodynamic stability at presentation
Severity of splenic injury (AAST grade)
Presence of active bleeding on CT
Associated injuries
Timeliness and appropriateness of management
Age and comorbidities of the patient.
Outcomes:
Hemodynamically stable patients managed non-operatively have excellent outcomes with preservation of splenic function
Splenectomy is associated with an increased lifetime risk of OPSI
Outcomes are generally good with prompt and appropriate treatment, but severity of injury and associated trauma are significant determinants.
Follow Up:
Regular clinical follow-up to monitor for complications
Patients who have undergone splenectomy require lifelong education on OPSI prevention, including vaccination schedules and prompt medical attention for febrile illness
For non-operatively managed patients, serial imaging may be required depending on the grade and follow-up clinical assessment.
Key Points
Exam Focus:
AAST splenic injury grading scale is crucial
Indications for operative vs
non-operative management
Role of angioembolization
Risks and prevention of OPSI
Management of splenic trauma in children (higher threshold for splenectomy).
Clinical Pearls:
Always suspect splenic injury in blunt abdominal trauma, especially with left-sided thoracoabdominal impact
Hemodynamic stability is the most important determinant for NOM
Active contrast extravasation on CT scan is a key indicator for angioembolization or surgery
Do not miss associated injuries in polytrauma patients.
Common Mistakes:
Delaying definitive management in unstable patients
Over-reliance on FAST alone for diagnosis without CT confirmation
Inadequate monitoring of patients on NOM
Insufficient patient education regarding OPSI risks and prophylaxis post-splenectomy.