EAST Guidelines 2012
1. Patients who have diffuse peritonitis or who are hemodynamically unstable after blunt abdominal trauma should be taken urgently for laparotomy.
1. A routine laparotomy is not indicated in the hemodynamically stable patient without peritonitis presenting with an isolated splenic injury.
2. The severity of splenic injury (as suggested by CT grade or degree of hemoperitoneum), neurologic status, age >55 and/or the presence of associated injuries are not contraindications to a trial of nonoperative management in a hemodynamically stable patient.
3. In the hemodynamically normal blunt abdominal trauma patient without peritonitis, an abdominal CT scan with intravenous contrast should be performed to identify and assess the severity of injury to the spleen.
4. Angiography should be considered for patients with American Association for the Surgery of Trauma (AAST) grade of greater than III injuries, presence of a contrast blush, moderate hemoperitoneum, or evidence of ongoing splenic bleeding.
5. Nonoperative management of splenic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy.
1. After blunt splenic injury, clinical factors such as a persistent systemic inflammatory response, increasing/persistent abdominal pain, or an otherwise unexplained drop in hemoglobin should dictate the frequency of and need for follow-up imaging for a patient with blunt splenic injury.
2. Contrast blush on CT scan alone is not an absolute indication for an operation or angiographic intervention. Factors such as patient age, grade of injury, and presence of hypotension need to be considered in the clinical management of these patients.
3. Angiography may be used either as an adjunct to nonoperative management for patients who are thought to be at high risk for delayed bleeding or as an investigative tool to identify vascular abnormalities such as pseudoaneurysms that pose a risk for delayed hemorrhage.
4. Pharmacologic prophylaxis to prevent venous thromboembolism can be used for patients with isolated blunt splenic injuries without increasing the failure rate of nonoperative management, although the optimal timing of safe initiation has not been determined.
Delayed Rupture of Spleen
J Trauma 36(4):568, April 1994.
Am Surg 63:885, Oct 1997
Splenic management fails due to age>55, major grade (3-5), ISS and quantity of hemoperitineum (Multicenter J Trauma 2000 47;1169)
Meguid AA, Bair HA, Howells GA, et al:, Prospective evaluation of criteria for the nonoperative management of blunt splenic trauma. Am Surgeon 2003;69:238-43. Nonoperative management of blunt splenic injury in hemodynamically stable patients is current standard of care. Two reports from 2000 cautioned that the mortality of such management might be increasing, perhaps due to improper triage. The trauma group at William Beaumont in Michigan reviewed in this paper their most current data from prospectively applied criteria for nonoperative management of blunt splenic injury. These criteria which are indeed those used at most centers are (1) hemodynamic stability on admission after initial resuscitation with up to 2 liters of crystalloid infusion, (2) no physical findings or any associated injuries necessitating laparotomy, and (3) a transfusion requirement attributable to the splenic injury of 2 units or less. Ninetynine patients were treated over six years. Thirty-one underwent splenectomy because of hemodynamic instability. Eight of the 68 patients (12%) who were managed nonoperatively developed hemodynamic instability and underwent splenectomy; all failed nonoperative management in the first 72 hours. No patients died from the splenic injury, and there was no associated morbidity from delayed splenectomy. No significant differences in age, sex, mechanism of injury, ISS, blood pressure or hematocrit on admission, transfusion requirements were found between those successfully managed nonoperatively and those who failed. Those failing had a higher mean CT grade of splenic injury, but 29 of 35 patients with a CT grade of 3 or higher were successfully managed nonoperatively. I think this study strongly supports the current criteria stated above.
Haan J, Ilahi ON, Kramer M, et al: Protocol-Driven Nonoperative Management in Patients with Blunt Splenic Trauma and Minimal Associated Injury Decreases Length of Stay. J Trauma 2003;55:317-322 This is a retrospective study of a screening angiography protocol for all patients with CT evidence of blunt splenic injury. All blunt abdominal trauma patients admitted to the R. Adams Cowley Shock Trauma Center over a 3 year period underwent admission abdominal CT, followed by celiac angiography for all those patients with CT splenic injury grade of 3 or more. When a vascular injury was identified, splenic embolization was performed. Angiography performed selectively for higher grade splenic injuries led to a decreased length of stay, higher therapeutic yield, and decreased use of hospital resources without any increase in the failure rate of nonoperative management. In order to fulfill this protocol, serious commitment on the part of the hospital, surgical staff, and vascular radiology staff are absolutely required.
Alejandro KV, Acosta JA, Rodriguez PA, Bleeding manifestations after early use of low-molecular-weight heparins in blunt splenic injuries. Am Surgeon 2003;69:1006-9. Non-operative management of hemodynamically stable patients with blunt splenic injury is the current standard of care. Aggressive prophylaxis against DVT and PE in multiply-injured patients is also the current standard of care. When can low-molecular-weight heparin (LMWH), which is the current prophylaxis of choice, be started when the patient has a splenic fracture? This paper is a retrospective study of all patients with blunt splenic injury managed non-operatively at one institution over 2 years, comparing the outcomes of the 50 patients who received early (during the first 48 hours) LMWH to the 64 who did not. The LMWHs used were enoxaparin 30 mg SQ q.12 hrs. or dalteparin 2500 U SQ qd. The authors found no statistically significant differences in age, gender, ISS, hemodynamic parameters, initial hematocrit, or CT grade of splenic injury between the two groups. They also found that there were no differences in failure of non-operative management (2 of 50 in the early LMWH group vs. 4 of 64 in the no/late LMWH group), number of patients requiring transfusion and mean number of blood units given, morbidity, or mortality. This retrospective study could certainly be flawed by possible selection bias by the attending surgeon as to when to give the LMWH. However, it does strongly suggest that prophylaxis against DVT using LMWH is indeed safe despite the presence of a splenic injury.
abandon non-op management in kids if >20 cc/kg of blood transfusion
observational trial of lmwh in on-op splenic injuries, no increased transfusions or ops (Am surg 2003;69:1006)
vaccinate non-op spleens as it will work better than if you have to give it afterwards. Only really need pneumovax, not all three.
AAST Spleen Injury Score (1994 Revision)
Grade Type Injury Description I Hematoma Subcapsular, <10% surface area Laceration Capsular tear, <1cm parenchymal depth II Hematoma Subcapsular, 10%-50% surface area; intraparenchymal, <5 cm in diameter Laceration Capsular tear, 1-3cm parenchymal depth that does not involve a trabecular vessel III Hematoma Subcapsular, >50% surface area or expanding; ruptured subcapsular or parencymal hematoma; intraparenchymal hematoma > 5 cm or expanding Laceration >3 cm parenchymal depth or involving trabecular vessels IV Laceration Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen) V Laceration Completely shattered spleen VascularHilar vascular injury which devascularizes spleen
Advance one grade for multiple injuries, up to grade III
(Moore EE et al. J Trauma 1995;38:323.)
Use a sheet of vicryl mesh–cut a keyhole shaped slit from one of its sides, wrapping this around back of the freed up spleen or kidney (meaning it is essential that you first free up the organ of the short gastrics and surrounding Gerota’s so it is only up on its vascular pedicle) so that the keyhole slit comes around the pedicle from the back–sew together the slit then so the keyole encompasses the pedicle, suturing so it is tight, then just keep sewing the free corners and edges together so you have a tight wrap, progressively pulling it tighter and tighter to stop any bleeding.–vicryl works well for this because it is stiff and will really tighten up. The tighter the better–once again, no such thing as an organ compartment syndrome. If there is I must be extraordinarily lucky never to have encountered it in 15 years worth of reapired spleens. You cannot choke off the blood supply–take it is true from 15 years of doing this. ERF
Angio/Embolize grade III and above
Review of Angio/Embo (Can J Surg 2008;51(6):464)
Angioembolization For Splenic Injury
Initial nonoperative management of splenic injury is standard in hemodynamically stable patients. Over the past decade, the success rates have climbed by adding angioembolization to the algorithm, according to several published series. However, the objective benefit and specific indications have not been worked out.
A paper published this month by the University of Florida, Jacksonville used the NTRACS registry to try to clarify these issues. They identified 1039 patients undergoing nonoperative management (NOM) over a nearly 10 year period. Patients who died shortly after arrival, those who went directly to OR for hemodynamic reasons, and children were excluded, leaving 539 patients. Only about 1/6 of the patients underwent embolization.
The overall failure rate was about 4%, a little higher in the non-angio patients, a little lower with angio. Incidentally, the angio group had significantly higher injury severity (26 vs 20). Analysis of the lower grade spleen injury group showed no improvement in success rate by adding angio. However, the high grade groups (grades IV-V) did benefit by adding this procedure. Similarly, success improved when performing angio in patients with contrast blush or evidence of slow, ongoing bleeding. If NOM did fail, it usually occurred on day 2.
Bottom line: Although we’ve been adding angio to non-operative management of spleen and liver injury for a decade, here’s the first paper that has been able to define the real indications for doing it. First, all unstable patients go to the OR (don’t even consider nonop management). In the remaining patients, if the CT shows a grade IV or V injury, or a contrast blush, angio is recommended. If neither of these is noted, but the hemoglobin continues to decline “too quickly” (surgeon judgement), then a trip to angio is also warranted. Applying these principles can increase your success rate to about 96%.
Reference: Selective angiographic embolization of blunt splenic traumatic injuries in adults decreases failure rate of nonoperative management. J Trauma 72(5):1127-1134, 2012.