Splenic Injury and Rupture

Background

• Spleen injury can occur from traumatic or nontraumatic causes.
• Up to 45% of patients with blunt abdominal trauma may have splenic injury.

Evaluation

• Suspect splenic injury in a patient with left upper quadrant pain, left shoulder tip pain, or diffuse abdominal pain with a history of trauma (in particular to left lower thorax, left upper abdomen, rib cage, diaphragm, pancreas, or bowel).
• Consider diseases associated with splenomegaly (mononucleosis, leukemia, malaria) that may lead to splenic injury or pain.
• Use focused abdominal sonography for trauma (FAST) in hemodynamically unstable patients as the initial diagnostic tool to identify a need for emergent laparotomy (Strong recommendation).
• Perform abdominal computed tomography (CT) with IV contrast in hemodynamically stable patients with blunt abdominal trauma without peritonitis to identify severity of splenic injury.
• The severity of splenic injury can be graded using the American Association for Surgery of Trauma (AAST) grade or the Baltimore CT grading system.
• Consider follow-up imaging for a patient with blunt splenic injury indicated by clinical factors, such as (Weak recommendation):
  • persistent systemic inflammatory response
  • increasing or persistent abdominal pain
  • an unexplained drop in hemoglobin

Management

• Perform surgical exploration in (Strong recommendation):
  • hemodynamically unstable patients with positive focused abdominal sonography for trauma (FAST) scan
  • patients with diffuse peritonitis or who are hemodynamically unstable after blunt abdominal trauma
• Consider nonoperative management in patients who are hemodynamically stable with low grade splenic injuries who can be monitored and are available for serial clinical evaluation so that urgent laparotomy can be performed if necessary.
• Consider angiography for patients with ≥ 1 of:
  • American Association for Surgery of Trauma (AAST) grade > III injuries
  • contrast blush
  • moderate hemoperitoneum
  • ongoing splenic bleeding
• Use angiography and embolization for patients that are hemodynamically stable with active blush.