Trauma and Critical Care—Splenic Trauma
Concept
Most commonly injured organ in abdominal trauma. Will be in the setting of penetrating or blunt trauma. Gunshot wounds to the abdomen need exploration. Stab wounds can be managed by local wound exploration + DPL. Blunt trauma means CT scan in stable pts, DPL in unstable pts.
Way Question May be Asked?
“14 y/o male is brought into the emergency room after falling off of his bike onto his left side. His chest x-ray shows rib fractures of ribs 10–12. He is tachycardic to the 120s, but not hypotensive. What do you want to do?” May get the sce- nario with pt comatose and have to work through the whole ABC’s and DPL may show gross blood and be faced with splenic injury on ex lap. May get the diagnosis given to you and asked your indications to proceed to the OR.
How to Answer?
In trauma setting, always the ABCs:
Airway and C-spine control (intubate with C-spine control if necessary)
Breathing and Ventilation (does pt need chest tube—place before CXR)
Circulation and IV access Disability (Neuro status)
Don’t skip secondary survey either, or you will miss some key finding!
History should be AMPLE:
Allergies Meds
Past medical history
Last meal
Events surrounding trauma
Physical Exam
Head to toe
Finger/scope in every hole/orifice
Labs/Diagnostic Studies
Full panel including T+C Lateral C-spine
CXR Pelvis x-ray DPL if unstable
CT scan abdomen/pelvis if stable (include head if neuro sx’s)
Resuscitate the Patient
2 large bore peripheral IVs
2 liters crystalloid (20 cc /kg), can repeat once if no response, followed by blood if hemodynamically unstable
Surgical Treatment
To OR when:
(1) Adult pt (the incidence of OPSS is very low) so if there are multiple associated injuries (neuro injuries won’t tolerate hypotension and will pre- clude serial abdominal assessments) or if the pt is unstable or in DIC→ splenectomy
(2) Pediatric pt, don’t transfuse more than 2 units of blood to try to stabilize the pt, if more necessary or pt becomes unstable (some won’t even trans- fuse as risk of transfusion > risk of OPSS)→ operate
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(3) Penetrating trauma will usually bring you to the OR (can try local wound exploration if stab wound, but nothing wrong with ex lap
Nonoperative Management
(1) Blunt trauma→nonoperative management as long as no free blood in abdomen on CT scan
(2) Grade 1, 2, 3 injuries
(3) Pt has minimal other injuries
(4) Will perform serial exams, labs, CT scans and have low threshold for operative management
(1) Pack all four quadrants of the abdomen, suction blood with cellsaver, try to determine source of bleeding (clamp aorta at hiatus if necessary) (2) Mobilize spleen from ligamentous attachments
and inspect
(3) Splenorraphy can be considered for stable pts with Grade 1,2, and 3 injuries
(4) Splenorraphy→
topical agents—fibrin glue (for peripheral injuries) mattress pledgeted sutures (for deeper lacerations) dexon/vicryl mesh wrap (multiple injuries with
out time to repair)
argon beam coagulator (superficial lacera tions/capsular tears)
partial resection if polar injury
(5) Don’t spend time on splenorraphy if pt unsta- ble or multiple other injuries
(6) If doing splenectomy, be careful to ligate short gastrics (not gastric wall), not to injure pancre-
atic tail, and don’t need drain unless suspect pancreatic injury
(7) Do not perform autotransplanation
Common Curveballs
Pt will have other associated injuries (intra and extra abdominal)
Pt will fail nonoperative treatment Splenorraphy will fail
Pt will get OPSS (overwhelming postsplenectomy sepsis) Will be asked how to manage pediatric pt after splenec-
tomy
Abscess in splenic bed post-op
Pt will have bowel injury missed in the nonoperative management until pt becomes septic
Pt will be cirrhotic, be on anticoagulants, have h/o severe CAD
There will be pancreatic or gastric injury during splenectomy
Strikeouts
Not knowing how to manage pt after splenectomy Not knowing techniques for splenorraphy
Not doing adequate trauma work-up
Not having clear criteria for nonoperative management Discussing autotransplantation of splenic fragments Not knowing what OPSS is or what immunizations to
give pt after splenectomy
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