22 terms

Splenic Injury 12-5

OM3 - Proctor - 1hr
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what arterial vessel supplies the spleen?
splenic artery (large branch of celiac trunk)
what are the general functions of the spleen?
Removal of unwanted elements from the blood

Secondary organ of the immune system

Source of hematopoietic cells

Sequestration of a portion of the formed blood elements
Describe splenic injury
most frequently injured intra-abdominal organ in blunt trauma
-almost always blunt trauma causing injury

pt's should be managed on basis of their hemodynamic status
-> hemo stable (never hypotensive or tachycardic)
-> responsive (tachycardia/hyptensive, but resolves w/fluid resuscitation)
-> unstable (no response to volume depletion)
what H&P findings should raise suspicion of splenic injury?
*Generalized abdominal pain
*Pain that localizes to the left upper quadrant
*Pain in the left shoulder [Kehr's sign]
*Lower-left rib (9-12) fractures

H&P findings are neither sensitive or specific for Dx
what is Kehr's sign & what causes it?
pain in the left shoulder
- d/t presence of subdiaphragmatic blood often b/c of splenic injury
How do you diagnose hemodynamically stable splenic injury?
H&P (nonspecific)
ultrasound - may reveal free intra-abdominal fluid, but can't tell where the fluid is from

CT w/IV contrast - best for evaluation of extravasation of contrast outside splenic vessels & spleen itself
- contrast "blush" = ongoing bleeding
How do you diagnose splenic injury in a hemodynamically unstable pt?
*FAST* (Focused Assessment for Sonographic [US] evaluation of the Trauma pt)
US that assess for free fluid in:
-Morison's pouch (potential space separating liver from right kidney)
-spenorenal recess
-pelvis
-pericardium

can be rapidly performed for dx hemoperitoneum
Not diagnostic of injury to any specific organ*
what areas of the body does the FAST exam evaluate?
-Morison's pouch (potential space separating liver from right kidney)

-spenorenal recess

-pelvis

-pericardium
is the FAST exam diagnostic of injury to the spleen?
no! just confirms there's fluid in the abdomen
Other than the FAST exam what else can be used to diagnose splenic injury in an unstable pt?
diagnostic peritoneal lavage (DPL)
Catheter inserted through a small supra- or infra-umbilical incision
Peritoneal contents are aspirated and examined
Sensitivity 97% [hemoperitoneum]

**takes a while, not good in urgent trauma setting
what is the criteria for a hemodynamically stable pt?
BP > 90
HR < 120
adequate response to infusion of IV fluids
describe the algorithm for evaluation & management of blunt abdominal trauma
stable = CT w/IV contrast -> further management

unstable = FAST exam: if (+) immediate surgical management
if (-) -> DPL -> if DPL is (+) = surgery; (-) search for other source of bleeding
what is the criteria for nonoperative management of blunt splenic injury?
Hemodynamic stability

No indication for laparotomy on the basis of physical exam findings or diagnostic tests

No transfusion requirement attributed to splenic injury

**Constant availability of surgical and critical care resources
What is the criteria for failure of nonoperative management of blunt splenic injury?
Increasing or persistent fluid requirements to maintain normal hemodynamic status

Failed angioembolization of ateriovenous fistula/pseudoaneurysm

Transfusion requirement to maintain hematocrit/hemodynamic stability

Peritoneal signs/rebound tenderness
what is angioembolization?
emerging therapy with varying availablity. Performance by interventional radiology in selected, stable patients with evidence of contrast extravasation has shown a decreased failure rate of nonoperative management.
describe the nonoperative management of splenic injury
must be a hemodynamically stable with:

Constant availability of ICU, surgeon, OR staff
Serial abdominal examinations
Serial H/H monitoring
Repeat CT scan in most cases
what is the next step in care if a pt w/splenic injury becomes unstable
operate
what should you do if contrast blush is seen on CT scan in the pt w/blunt abdomen trauma causing splenic injury?
arteriogram/embolization or operate if no interventional radiologist at facility
what is the management of a pt w/blunt abdominal trauma who is stable?
CT w/IV contrast then:

Nonoperative management planned
Patient admitted to the ICU; surgical services ready at any time
Serial monitoring of H/H
Serial abdominal exams
Low threshold for taking to the operating room:
-Tachycardia
-Hypotension
-Peritoneal signs
-Need for transfusion
what are the sequelae of asplenism?
Increased susceptibility to disseminated infection with encapsulated bacteria:

Streptococcus pneumoniae
Neisseria meningitidis
Haemophilus influenzae
Group B streptococcus
Klebsiella pneumoniae
Salmonella typhi
describe overwhelming postsplenectomy infection (OPSI)
Uncommon

Sudden onset of symptoms with rapid and fulminating course that often last only 12-18 hours
- Patients complain of fever, nausea, vomiting, headache, and altered mental status

Infection may occur at any time after splenectomy [years]

Overall mortality rate of 50-80%
(This is 78% higher than the usual mortality rate in sepsis)
Most common bacteria: S. pneumoniae
what is the prophylactic treatment of splenectomized pt's?
Within 2 weeks of splenectomy
= Polyvalent Pneumococcal vaccine [PPV-23]
= H. influenza type B conjugate vaccine
= meningococcal polysaccharide vaccine
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