Splenic Trauma

 

VBMC TRAUMA CARE SERVICES GUIDELINE

Splenic/Spleen Trauma

Approximately 39,000 adults are admitted to the hospital every year with blunt splenic injury (BSI).¹  Splenectomy was the traditional treatment of choice, however, increased risk of infectious complications led to the development of non-operative management (NOM) strategies.  NOM has become the treatment of choice in hemodynamically normal patients.²  Only 10% of patients with BSI will be treated with urgent splenectomy,¹ and the development of NOM strategies for BSI has led to decreased ICU and total hospital lengths of stay, reduced resource use, and reduced hospital costs without worsening of survival.^3,4

Splenic angioembolization (SAE) has become an adjunct in NOM.²  Use of SAE in both the immediate setting as well as in those failing NOM has reduced the need for operation and has increased splenic salvage rates.⁵  Protocols described in the literature use SAE for patients with signs indicating high risk of NOM failure.  These signs include AAST grades III-V, traumatic pseudoaneurysm, moderate hemoperitoneum, evidence of ongoing splenic bleeding requiring blood transfusion, arteriovenous fistula, and evidence of active extravasation suggested by contrast blush on CT.^4,5,6,7,8,9

All blunt trauma patients undergo workup per the ATLS algorithm, which includes evaluation of hemodynamics, abdominal exam and FAST.  If the patient is unstable with a positive FAST, or is stable but has peritonitis on exam, the patient should be taken emergently to the operating room for celiotomy.  If the patient is unstable but has a negative FAST, the patient should be resuscitated and other causes of shock investigated.  Stable patients and those patients who stabilize after resuscitation should undergo a CT of the abdomen and pelvis with IV contrast as part of the trauma imaging protocol.  Patients with BSI and without another indication for celiotomy are candidates for NOM of BSI.

In evaluating a patient for NOM of BSI, the AAST injury grade should be determined (See Table 1).  Grade I and II injuries do not involve devascularization of the spleen, and therefore operative intervention and SAE are rarely necessary.  AAST and EAST surveys indicate that more than 85% of respondents treat these injuries with observation only.^7,9  A minority (32.3%) of respondents to the EAST survey admitted patients with grade I to a continuously monitored bed, while a majority (75%) of admitted patients with grade II injuries to a monitored bed.⁹  Patients with grade I or II BSI should therefore be admitted at least for observation, to a monitored or non-monitored bed at the discretion of the attending trauma surgeon, and have serial abdominal exams and hemograms drawn at least every 12 hours.

Grade III BSI or greater, involve some form of splenic vascular disruption: Grade III injuries involve laceration of the trabecular vessels; grade IV injuries, laceration of the segmental vessels with devascularization of >25% of the spleen; grade V, laceration of hilar vessels and near complete devascularization of the spleen.  The available data suggests that NOM strategies are more successful in patients with grade III or IV injuries, while patients with grade V injuries are successfully managed nonoperatively in less than 10% of cases.¹⁰  Therefore, stable patients with grade V splenic injuries who do not have other indications for operation should be strongly considered for angiography based on grade alone.

Fu et al., in a series published in 2010 showed that a significant majority of patients with BSI successfully treated by SAE had either grade III or IV injuries.⁸  Therefore, implementation of SAE should focus on this patient population, and stable patients with grade III or IV BSI should be evaluated for candidacy for SAE.  Indications for angiography include evidence of traumatic pseudoaneurysm, arteriovenous fistula, moderate (>1000cc) hemoperitoneum, or evidence of a vascular “blush” on CT scan.  The clinical implications of a vascular blush are controversial, because a high rate of angiograms in patients with vascular blushes will often show no active bleeds.  However, Fu et al. has published data that suggest patients with intraperitoneal contrast extravasation (CE) will exhibit hemodynamic instability at a significantly higher rate than patients with intraparenchymal CE.⁸  Therefore, patients with intraperitoneal CE should undergo SAE.  Patients with intraparenchymal CE can undergo either SAE or observation, at the discretion of the trauma and interventional radiology attendings.

Patients undergoing observation should be admitted to a level of care commensurate with the patient’s complete injury burden.  For patients with isolated BSI, this should be related to grade.  Patients with grade I or II injuries should be admitted for observation, with monitoring status left to the discretion of the attending trauma surgeon.  Patients with grade III injuries and greater are at higher risk of failure, and therefore should be admitted to a continuously monitored environment, with strong consideration for ICU admission for grade IV or V injuries.  The literature does not provide evidence for frequency of hemoglobin checks, but these should initially be done at least every 12 hours, with more frequent draws for higher grade injuries.  Serial abdominal exams should also be performed, with development of peritonitis prompting emergent operative intervention given a high rate of hollow viscus injury in patients with isolated solid organ injury on CT scan.⁹  Chemical VTE prophylaxis should not be held longer than 48 hours.¹¹

In addition to development of peritonitis, signs of NOM failure include significant drop in hemoglobin (>4g decrease) with need for transfusion and recurrent hypotension despite adequate resuscitation.  Patients who have failed NOM should undergo SAE.  Patients who are too unstable to undergo angiography should proceed emergently to the operating room for celiotomy.  Patients who have previously undergone SAE and then fail NOM should also undergo celiotomy.

 

1.) Zarzaur, et al.  The splenic injury outcomes trial: An American association for the surgery of trauma multi-institutional study. J Trauma Acute Care Surg. 2015;79:335-342.

2.) Cooney, et al.  Limitations of splenic angioembolization in treating blunt splenic injury. J Trauma. 2005;59:926-932.

3.) Izu, et al.  Impact of splenic injury guidelines on hospital stay and charges in patients with isolated splenic injury (2009). Surgery. 2009;146:787-93.

4.) Hsieh, et al.  non-operative management attempted for selective high grade blunt hepatosplenic trauma is a feasible strategy.  World J Emerg Surg. 2014;9:51

5.) Sabe, et al.  The effects of splenic artery embolization on nonoperative management of blunt splenic injury: A 16-year experience (2009).  J Trauma. 2009;67:565-572

6.)   Fata, et al.  A survey of EAST member practices in blunt splenic injury: A description of current trends and opportunities for improvement. J Trauma.  2005;59:836-842.

7.)  Zarzaur, et al.  A survey of American association for the surgery of trauma member practices in the management of blunt splenic injury. J Trauma. 2011;70:1026-1031.

8.) Fu CY, et al.  Evaluation of need for operative intervention in blunt splenic injury: intraperitoneal contrast extravasation has an increased probability of requiring operative intervention. World J Surg. 2010;34:2745-2751

9.) Stassen, et al.  Selective nonoperative management of blunt splenic injury: an eastern association for the surgery of trauma practice management guideline. J Trauma Acute Care Surg. 2012;73:S294-S300.

10.) Velmahos, et al.  Management of the most severely injured spleen: A multicenter study of the research consortium of New England Centers for Trauma (ReCONECT). Arch Surg. 2010;145(5):456-460

11.) Murphy, et al.  Very early initiation of chemical venous thromboembolism prophylaxis after blunt solid organ injury is safe.  Can J Surg.  2016;59(2): 118-122

 

EAST Guidelines-Blunt Spleen Injury:  Non-operative Treatment

Level 1 recommendation:

·       Patients who have diffuse peritonitis or who are hemodynamically unstable after blunt abdominal trauma should be taken urgently for laparotomy.

Level 2 recommendations:

·       A routine laparotomy is not indicated in the hemodynamically stable patient without peritonitis presenting with an isolated splenic injury

·       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. 

·       In the hemodynamically normal blunt abdominal trauma patient without peritonitis, an abdominal CT scan with IV contrast should be performed to identify and assess the severity of injury to the spleen

·       Angiography should be considered for patients with AAST grade of greater than III injuries, presence of a contrast blush, moderate hemoperitoneum, or evidence of ongoing splenic bleeding.

·       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.

Level  3 recommendations:

·       After blunt splenic injury, clinical factors such as a persistent systemic inflammatory response, increasing/persistent abdominal pain, or an otherwise unexplained drop in Hgb should dictate the frequency of and need for follow-up imaging for a patient with blunt splenic injury.

·       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.

·       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.

·       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. 

 

Blunt splenic injury, selective nonoperative management of, EAST. J Trauma 2012. 73(5): S294-S300.

 

Post-Splenectomy Vaccines

 

Patients who have had splenectomy for trauma should be properly immunized (see algorithm) but should also receive information about overwhelming post-splenectomy infection (OPSI). They should be informed that OPSI is rare (0.2-0.4%/year). The best way to prevent OPSI is to be immunized.  Warning signs of OPSI include symptoms of sepsis (acute illness, fever, lethargy) and these symptoms should prompt immediate medical care, at which time they must inform the doctor or provider that they ‘do not have a spleen’. 

Post-splenectomy patients should be:

1.       Immunized according to the guideline

2.       Provided teaching about OPSI

3.       Provided an immunization card to use as their own reminder and an indicator of their asplenic state should they need immediate medical care for symptoms of OPSI

4.       Scheduled for a ‘vaccine-only nurse visit’ in the clinic for follow-up immunization, 8 weeks to 2 months after their initial immunization. This visit is in addition to the postop visit. 

5.       Provided information about ‘vaccine-only nurse visit’ follow-up in their discharge instructions

6. Educated again on OPSI and immunizations in their post-op visit

 

NOTE IN PATIENTS UNDERGOING ANGIOEMBOLIZATION: EAST conditionally recommends AGAINST routine post-splenectomy vaccinations in adult trauma patients who have undergone angioembolization for splenic injury (Freeman, Injury 2022).

 

Post-splenectomy/functional asplenia vaccines

Initial (within 14d splenectomy/functional asplenia)	Dose	Route
Pneumococcal conjugate vaccine, 13-valent (PCV13, Prevar-13)	0.5mL	IM
Quadrivalent meningococcal conjugate vaccine (menACWY, Menactra or Menveo)	0.5mL	IM
Meningococcal group B vaccine (MenB, Bexsero)	0.5mL	IM
Haemophilus influenzae type B (Hib) vaccine (ActHIB, Hiberix, PedvaxHIB)	0.5mL	IM

 

≥8 weeks after initial (clinic follow-up)	Dose	Route
Pneumococcal polysaccharide vaccine, 23-valent (PPSV23, Pneumovax 23)	0.5mL	IM
Quadrivalent meningococcal conjugate vaccine (menACWY, Menactra or Menveo)	0.5mL	IM
Meningococcal group B vaccine (MenB, Bexsero)	0.5mL	IM

 

Every 5 years thereafter	Dose	Route
Pneumococcal polysaccharide vaccine, 23-valent (PPSV23, Pneumovax 23)	0.5mL	IM
Quadrivalent meningococcal conjugate vaccine (menACWY, Menactra or Menveo)	0.5mL	IM
Meningococcal group B vaccine (MenB, Bexsero)	0.5mL	IM

 

Exceptions*:

·Age<18

·Previous known vaccine administration with any of the above vaccines prior to splenectomy or functional asplenia

*call PharmD to assist with determining necessary vaccines to administer

 

 

References
1. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6422a3.htm
2. http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-schedule-bw.pdf
3. http://www.surgicalcriticalcare.net/Guidelines/post%20splenectomy%20vaccines%202015.pdf 4. http://www.cdc.gov/mmwr/volumes/65/wr/mm6504a5.htm <Accessed 12 October 2016> 5. http://www.cdc.gov/vaccines/hcp/acip-recs/recs-by-date.html <Accessed 12 October 2016> 

1.                  Jennifer J. Freeman, Brian K. Yorkgitis, Krista Haines, Deepika Koganti, Nimitt Patel, Rebecca Maine, William Chiu, Thai L. Tran, John J. Como, George Kasotakis, Vaccination After Spleen Embolization: A practice management guideline from the Eastern Association for the Surgery of Trauma, Injury, 2022, ISSN 0020-1383, https://doi.org/10.1016/j.injury.2022.08.006.