Trauma: Spleen Trauma

Initial Management

• Unstable: Laparotomy
  • Diffuse Peritonitis Indicates Bowel Injury & Warrants Laparotomy – Diffuse Peritonitis Should Never be Attributed to Solid Organ Injury as Isolated Hemoperitoneum Should Not Cause Diffuse Peritoneal Irritation
• Transient Responder: Angioembolization
• Stable: CT
  • Active Extravasation or Pseudoaneurysm: Angioembolization (90% Success Rate)
  • Nonoperative Management Otherwise
• If Angioembolization Fails: Laparotomy
• *Historically Severe Traumatic Brain Injury (TBI) & Altered Mental Status (AMS) Were Considered Contraindications to Nonoperative/IR Management – Now Shown to Be Efficient & Safe
  • Was Based on the Fact that Hypotension/Decreased Cerebral Perfusion Pressure is a Significant Risk Factor for Worse Outcomes

Definitive Treatment

• Nonoperative Management: (Poorly Defined)
  • ICU & NPO for 24-72 Hours
  • Consider Initial Bedrest for 24-48 Hours
    • Previously Defined as Injury Grade + One Day (1999 APSA Guidelines)
  • Strongly Consider Repeat CT After 2-7 Days, Before Discharge
  • Hospital Stay 7-9 Days
  • Activity Restriction 1-4 Months
    • Some Recommend Return to Normal Activity at Injury Grade + 2 Weeks with Longer Contact Sport Restrictions
• Surgery Management:
  • Stable Subcapsular Hematoma: Leave
  • Small & Minimal Bleeding: Topical Hemostasis
  • Grade II/III: Splenorrhaphy
    • Spleen Does Not Hold Suture Well – Consider Pledgets or Absorbable Mesh
    • Possibly Consider Partial Splenectomy
  • Grade IV/V: Splenectomy
    • Vaccinations: *See Spleen: Splenectomy
• *Surgery Solely for Washout of Blood is Generally Not Indicated Unless for Severe Refractory Pain
• *Start DVT Prophylaxis Early (Within 24-48 Hours) for Solid Organ Injury