Splenic trauma

Background

• Most commonly injured visceral organ in blunt trauma

Clinical Features

• LUQ pain
• Signs of shock
• Hypotension
• Left lower rib pain
• Kehr's sign
  • Acute pain in the tip of the shoulder due to the presence of blood in the peritoneal cavity when a patient's legs are elevated while laying flat.

Differential Diagnosis

Abdominal Trauma

• Abdominal compartment syndrome
• Diaphragmatic trauma
• Duodenal hematoma
• Genitourinary trauma
• Liver trauma
• Pelvic fractures
  • Acetabular pelvic fractures
  • Open book pelvic fracture
  • Straddle pelvic fracture
  • Pelvic avulsion fracture
• Retroperitoneal hemorrhage
• Renal trauma
• Splenic trauma
• Trauma in pregnancy
• Ureter trauma

Diagnosis

ATLS Blunt Abdominal Trauma Algorithm

• Unstable
  • FAST to search for free fluid (vs. DPL if unavailable)
    • Positive: Exploratory laparotomy
    • Negative: CT scan
• Stable
  • CT scan
    • Exploratory laparotomy, angiographic embolization, conservative management as indicated

AAST Criteria

Grade	Hematoma	Laceration
I	Subcapsular, <10% of surface area	Capsular tear <1 cm in depth into the parenchyma
II	Subcapsular, 10-50% of surface area	Capsular tear, 1 to 3 cm in depth, but not involving a trabecular vessel
III	Subcapsular, >50% of surface area OR expanding, ruptured subcapsular or parenchymal hematoma OR intraparenchymal hematoma >5 cm or expanding	>3 cm in depth or involving a trabecular vessel.
IV		Involving segmental or hilar vessels with major devascularization (i.e. >25% of spleen)
V	Shattered spleen	Hilar vascular injury which devascularizes spleen.

Management

• Observation, angiographic embolization, or surgery depending upon:
  • Hemodynamic status of the patient
  • Grade of splenic injury
  • Presence of other injuries and medical comorbidities
• Nonoperative management
  • Failure rate of 10-15%
  • Some advocate nonoperative management only if <55yr and CT injury grade less than IV

See Also

• Abdominal Trauma
• Splenic Infarction