Spleen

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 LMWH’s 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)

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)

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