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Management of Splenic Trauma: A Guideline
17
MANAGEMENT OF SPLENIC TRAUMA
A GUIDELINES REVIEW
Vullong K
Overview
OUTLINE
01.
Introduction
02.
Relevant Anatomy
03.
Epidemiology and Mechanism of Injury
04.
Classification and grading of splenic injury
05.
Evolution of Management
OUTLINE
06.
Overview of WSES Guidelines
07.
Overview of EAST Guidelines
08.
An Algorithm for Addenbrooke's
08.
Conclusion
INTRODUCTION
CM, 43yr M.
Assault by group, no weapons, non-penetrating Abd trauma
At admission, CM was Vocal, Clear lung fields, HD stable, Hb 137
Summary of Injuries
- Head and Neck NAD, C-Spine cleared
- Splenic laceration, no active bleeding- for conservative management
- Left flail chest (Rib score 13)- PCA, Lidocaine patch, Paracetamol
- Small apical pneumothorax- monitored
- Mild left Hemothorax- Papworth input
- Fracture Left iliac blade- Ni intervention, can mobilise
- Manibrium fracture with small mediastinal hepatoma- ECG sinus rhythm nad, analgesia
- New (at 48Hrs) moderate left haemothorax with higher attenuation dependent layer- Chest drain inserted (600ml drained)
CT Trauma with contrast @ 5hours
Splenic laceration 18 *9mm at the lower pole (Grade II). Slight arterial blush, concerning of an aneurysm
CT Liver tripple phase @48Hours
Splenic laceration with focal area of arterial density unchanged.
DS, 58yr M. Nil Comobidities
Driver of car v lorry, restrained. Difficult extraction, one hour on scene
Transfused 1U PRBC, 2FFP , Laparotomy + Relook at 48Hrs
Summary of Injuries
- No ICH; Type 3 odontoid PEG # displaced
- Multiple infarcted distal Juvenal/ileal bowel loops, mesenteric tears
- splenic infarcts in anterior pole of spleen, Perisplenic haematoma
- Left abdominal wall muscular injury with haematoma
- L1st 2nd posterior rib fractures, Lidocaine patch, Paracetamol
- Commented left olecranon fracture
- Multiple lumbar transverse process fractures
- Communited displaced fracture Rt fibular with overlapping fragments
CT Liver tripple phase @48Hours
Possible small linear splenic infarcts in anterior pole of spleen (?artefactual) surrounding small perisplenic haematoma
Introduction
1
The management of Splenic trauma has evolved over the last three decades.
2
Epidemiology and mechanism of splenic trauma hint towards a variable range of presentations and outcomes.
AAST splenic injury scale, most recently revised in 2018.
3
EAST and WSES Guidelines provide a working framework
4
A locally relevant set of guidelines becomes imperative
5
Relevant Anatomy
Odd dimensions: 1, 3, 5, 7, 9, 11,
Ar: Splenic branch of Left Celiac trunk
ANATOMY
Central arteriole>> End arterioles (lack wall)
Vv: Splenic vein, IMA, Portal vein...
Gross: White pulp (25%) and Red pulp (75%)
Mechanism of Injury
Penetrating trauma
EPID/MECH OF INJURY
Blunt trauma
Indirect trauma
Clinical Assessment
Clinical Clues
RELEVANT TO MANAGEMENT
Physical examination may be limited by decreased mental status or distracting injuries **
hypovolemic shock manifesting as tachycardia, and hypotension
tenderness in the upper left quadrant; pleuritic left-sided chest pain
generalized peritonitis, or referred pain to the left shoulder (Kehr's sign)
Associated Injuries to other body regions
Comobidities
Worthy of Note to ascertain
- Previous operations including splenectomy
- Liver or portal venous disease
- The use of an anticoagulant agent
- Bleeding tendency
- The use of aspirin or nonsteroidal anti-inflammatory agents.
Grading and Classification
GRADING
Evolution Of Management
Since its introduction in paediatric trauma in the 1960s, Non operative Management (NOM) has been used more commonly, now accounting for up to 60% of cases (Hildebrand et al., 2014)
Data support the safe application of non-operative management to haemodynamically unstable patients
with traumatic splenic injury, particularly in those with low-grade injuries
EVOLUTION
OF MGT.
Prospective research needed to define subgroup appropriate for NOM, and determine long-term outomes of NOM
Options
Management Options
1
Nonoperative Management (NOM)
Angiography/angioembolization (AG/AE)
1b
Operative intervention/ splenectomy
2
Rationale
Approach to decision-making
Laparoscopic splenectomy
CT for blunt splenic injury is ??
(Next slide)
Utility of angiography
Central Tenet...
Correlation of operative and pathological injury grade with computed tomographic grade in the failed nonoperative management of blunt splenic trauma
Overview of WSES Guidelines
WSES
The WSES classification divides spleen injuries into three classes:
- Minor (WSES class I)
- Moderate (WSES classes II and III)
- Severe (WSES class IV)
WSES
Grading + Mgt
(Coccolini et al., 2017)
ALGORITHM
WSES (ADULT)
(Coccolini et al., 2017)
WSES (ADULT AND PAED)
(Coccolini et al., 2017)
EAST OVERVIEW
Based on the review and assessment of the selected references, 3 levels of recommendations
Level I: The recommendation is convincingly justifiable based
on the available scientific information alone.
EAST
Level II: The recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion
Level II: The recommendation is supported by available data, but adequate scientific evidence is lacking
Reccommendations
LEVEL I
One Recommendation:
1. Patients who have diffuse peritonitis or who are haemodynamically unstable after blunt abdominal trauma should be
taken urgently for laparotomy.
I
LEVEL II
Five (5) Recommendations:
A routine laparotomy is not indicated in ...
1
The severity of splenic injury (CT) not contraindications to a trial of NOM in a hemodynamically stable patient.
2
CT is a required to evaluate minor splenic trauma...
3
4
Angiography should be considered for ...
5
NOM is an option where monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy are
Level III
Four (4) Recommendations
1
A number of clinical factorsshould dictate the frequency of and need for follow-up imaging
2
Contrast blush on CT scan alone is not an absolute indication for an operation or angiographic intervention.
3
Angiography: an adjunct to nonoperative management or as an investigative tool
4
Pharmacologic prophylaxis to prevent VTE can be used for patients with isolated blunt splenic injuries
?
Unanswered Questions
Frequency of abdominal examinations
Is there a transfusion trigger after which...
Intensity and duration of monitoring
duration and intensity of restricted activity
Click to edit text
Frequency of Hb g/L
Timing of initiating chemical
(DVT) prophylaxis
Time to reinitiating oral intake
postsplenectomy vaccines?
Optimum length of stay
(ICU)
An Algorith for Addenbrooke's
Addenbrooke's
Conclusion
Conclusion
- Nonoperative management of blunt splenic injuries is now the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury.
- CT imaging remains an invaluable asset in early and long term monitoring of bl splenic trauma patients
- Emergence of Laparoscopic (operative) options amidst utility of adjunct Angiography and TAE provide justification for prospective studies in long-term outcomes of Operative and NOM