Optimization of selection for nonoperative management of. This varies from institution to institution but usually includes patients with stable hemodynamic signs, stable hemoglobin levels over 1248 hours, minimal transfusion requirements 2 u or less, ct scan injury scale grade of 1 or 2 without a blush, and patients younger than 55 years. The aim of this study was to describe the demographics, mechanisms of injury, management and outcomes in patients who su. An update on nonoperative management of the spleen in adults. Apr 03, 2017 the trend in management of splenic injury continues to favor nonoperative or conservative management. Splenic injury due to infectious mononucleosis im often, an athlete returning to contact sports following infectious mononucleosis are at potential risk of splenic rupture secondary to abdominal trauma. Fernandes tm, dorigatti ae, pereira bmt, cruvinel neto j, zago tm, fraga gp. Objective to analyze national trends in the nonoperative management of pediatric splenic injury design retrospective cohort analysis patients all children and adolescents 18 years or younger from 2 national databases who were hospitalized with pediatric splenic injury setting data from 9 years of the national inpatient sample database 20002008 and 3 years of kids inpatient database.
Review of proximal splenic artery embolization in blunt. Recent nom protocols for splenic injuries debunk the removal of spleen from the equation myth. At present, they are classified according to the anatomy of the injury. This paper aims to provide an update on the treatments and dilemmas of nonoperative management of splenic injuries in adults and to offer suggestions that may improve both consensus and patient outcomes. It includes recommendations for the management of blunt splenic injury in adult trauma pa tients based on literature available since. Spleen injuries are among the most frequent traumarelated injuries. Statement of the problem management of hepatic and splenic injuries has evolved over the past 25 years. Nonoperative management of splenic injury grade iv is safe using rigid protocol. Level ii trauma centers were no more likely to have a failure of nonoperative management adjusted or, 1. Nonoperative management nom has been established as.
A rare mechanism of delayed splenic rupture following the. The admitting hospitals trauma designation level was also associated with the risk of failure of nonoperative management of splenic injuries. Feb 22, 2012 the severity of splenic injury it appears that nom is effective in splenic injuries with an average lesional aast score of 3. Injury to the spleen is most often the result of blunt abdominal trauma. Management of adult blunt splenic trauma2016 updates western. A retrospective study included all splenic injury patients admitted to christchurch public hospital between january 2005 and august 2015. Traumatic splenic injury and management spleniq study spleniq the safety and scientific validity of this study is the responsibility of the study sponsor and investigators. In general, the lower the injury grade the more likely.
The best known splenic grading system is the one created by the american association for the surgery of trauma aast. The spleen is the most easily injured organ in abdominal trauma. The trauma committee of the american pediatric surgical association apsa has established guidelines for inhospital observation, athome care, backtoschool criteria, and resumption of contact activity based on the grade of splenic. The extent to which this practice has been adopted in both trauma centers and nontrauma hospitals has been investigated sporadically.
Hemodynamically normal patient that has not required or has responded quickly to the resuscitation. In rare cases, it may also be caused by spontaneous rupture from an infection or a hematological condition. Ct promoted conservative management by defining the injury and excluding significant vascular or bowel injury. One hundred fifty of 172 consecutive patients 87% with ctdiagnosed splenic injury were stable enough to be considered for nonoperative management. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries.
A diagnostic peritoneal lavage, while not ideal, may be used to evaluate the presence of internal bleeding a person who is hemodynamically unstable. During this period of nonoperative management strict bed rest between 2472 hours with careful monitoring along with a ct 7 days after the injury. Resolution of splenic injury after nonoperative management. In their invited critique, aidlen and luks suggest that rates of nonoperative management can be improved. Trends in operative management of pediatric splenic injury. Because children rarely exsanguinate from trauma to the spleen, splenectomy has been replaced by more conservative management as the. The primary symptom, hemorrhage, presents differently depending on the degree of injury, with the symptoms. Unstable patients undergo laparotomy and splenectomy. Tenyear experience of splenic trauma in new zealand.
Treatment varies depending on severity, but often consists of embolism or splenectomy. Two widely used embolization approaches are proximal and distal. Presentation and management of splenic injury after colonoscopy. Up to 45% of patients with blunt abdominal trauma will have a splenic injury, 1 which may require urgent operative management, angioembolisation, or nonoperative management in the form of active observation. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. The value of injury grade in stratifying patients between operative and nom is not entirely reliable. There are a few studies 34 nallathambi, malangoni, pickhardt, brick, mahon, taylor, jeffrey cit. Selective nonoperative management of blunt splenic injury. Many patients with blunt splenic injury are considered for nonoperative management and, with proper selection, the success rate is high.
Our primary objective was to compare clinical outcomes between operative and nonoperative manage ments in adult patients with blunt splenic injuries. To summarize their institutions experience over the past 50 years. The effects of splenic artery embolization on nonoperative management of blunt splenic injury. The decision to attempt nonoperative management is largely determined by the splenic ct injury grade among other clinical factors, including. Further management of splenic injury depends on the haemodynamic stability of the patient splenic injury is graded i through v depending on the extent and depth of splenic haematoma andor laceration identified on computed tomography scan low grade splenic injuries i, ii, and iii are suitable for nonoperative management, although. Splenic injury, blunt, selective nonoperative management of. The number of patients who did not require surgery increased from 70% to 87%, those requiring blood transfusion decreased from 36% to 23%, and the number undergoing a total splenectomy decreased from. Study type therapy case series level of evidence 4 objective to evaluate incidence, risk factors for, and management of intraoperative splenic injury in our laparoscopic patient cohort. Splenic preservation following trauma has been decisively established as the preferred, safe and feasible therapeutic modality. Because children rarely exsanguinate from trauma to the spleen, splenectomy has been replaced by more conservative management as the treatment of.
Splenic rupture knowledge for medical students and physicians. Splenic injury, blunt, selective nonoperative management. Clinical and radiological presentations and management of blunt. Pdf nonoperative management of high grade splenic injury. Apr 04, 2017 traumatic splenic injury and management spleniq study spleniq the safety and scientific validity of this study is the responsibility of the study sponsor and investigators. The spleen is top of the list of organs most injured in blunt trauma and, if the injury is unrecognized or not skill fully managed, the patient with splenic trauma can. Perforation is the next most common complication, with an incidence of 0.
All splenic injury grades had diagnostic angiography. Time of injury to splenic embolization in hours range options include. The spleen is one of the most frequently injured organs in blunt abdominal trauma. As the use of colonoscopy has increased greatly in recent years, awareness of its complications has become more important. Splenic trauma,blunt trauma abdomen, spleen anatonmy ligaments blood supply accessory spleens, mechanism of injury, presentation symptoms and signs management operative vs non operative imaging techniques for spleen fast ct scan abdomen angiography, grades of splenic injury, criteria for non operative management, surgical management splenectomy vs. Up to 45% of patients with blunt abdominal trauma will have a splenic injury,1 which may require urgent operative management, angioembolisation, or nonoperative management in the form of active observation. Nonoperative management has become the standard of care for hemodynamically stable children with splenic injury from blunt abdominal trauma. Nonoperative management has become the standard of care for the hemodynamically stable patient with a blunt splenic injury. Stable patients with lower grade injuries are treated conservatively. The most accepted grading scale for splenic injury was established by the american association for the surgery of trauma in 1987 and revised in 1997 figure 1. Several studies have demonstrated significant variations in practice patterns. Nonoperative management in blunt splenic trauma emergency. Splenic infarction and splenic vein thrombosis are rare causes of abdominal pain, usually presenting as leftsided abdominal pain associated with fever, nausea or vomiting, and elevated white blood cell count. Review of factors leading to high spleen slavage rate in a level 1 trauma centre.
Splenic rupture knowledge for medical students and. Although their experience is rather limited involving 21 cases in 9 years january 1997 to december 2005, it reflects, to a great extent, the overall practice in the uk. Traumatic splenic injury and management spleniq study. The trauma committee of the american pediatric surgical association apsa has established guidelines for inhospital observation, athome care, backtoschool criteria, and resumption of contact activity based on the grade of splenic laceration as. Two widely used embolization approaches are proximal and. Medical management of grade 12 splenic injuries with active extravasation.
Practice management guidelines for the nonoperative management of blunt injury to the liver and spleen i. We read this article on the management of blunt splenic injury with interest. Splenic injury is the leading cause of major bleeding in blunt abdominal trauma bat patients 1. Lee and coauthors analyzed national trends in the nonoperative management of pediatric splenic injury through retrospective analysis of 2 national databases. Unusual complications of colonoscopy include pneumothorax, septicemia, mesenteric tears, and colonic volvulus. The department of pediatrics, bowman gray school of medicine of wake forest university, winstonsalem, north carolina modern technology, specifically the splenic scan, aids in a quick and accurate diagnosis of splenic injury. A rare mechanism of delayed splenic rupture following the nonoperative management of blunt splenic injury in a child toko shinkai, kentaro ono, kouji masumoto, yasuhisa urita and chikashi gotoh abstract background. The approach for diagnosis and management of blunt splenic injury bsi has been considerably shifted towards nonoperative management nom. Pdf spleen injuries are among the most frequent traumarelated injuries. In the past decades, the treatment of patients with blunt splenic injury has. American association for the surgery of trauma spleen injury scale. Management of blunt splenic trauma pubmed central pmc. The spleen is the most frequently injured solid organ following blunt abdominal trauma and it represents around 35% and sometimes up to 50% of all abdominal solid organ injuries.
The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Failure of nonoperative management of splenic injuries. Non operative management can be adopted in majority of patients with blunt isolated splenic injuries but operative management is still indispensable in certain instances. Trauma is a major cause of morbidity and mortality. The management of splenic injuries has evolved over the. Nonoperative management of high grade splenic injury.
It is important that individuals who have been recently diagnosed with im meet with their doctor for clearance to return to sports. In one highvolume trauma center, of those who fail nonoperative management, 75% fail within 2 days, 88% within 5 days, and 93% within 7 days of injury. The trend in management of splenic injury continues to favor nonoperative or conservative management. Management of isolated splenic injuries after blunt trauma. Blunt splenic trauma occurs when a significant impact to the spleen from some outside source i. The management of splenic injuries has evolved over. Wed like to understand how you use our websites in order to improve them. Results most of the current guidelines support the nom or minimally approaches in hemodynamically stable patients. Apr 11, 2009 splenic trauma,blunt trauma abdomen, spleen anatonmy ligaments blood supply accessory spleens, mechanism of injury, presentation symptoms and signs management operative vs non operative imaging techniques for spleen fast ct scan abdomen angiography, grades of splenic injury, criteria for non operative management, surgical management splenectomy vs splenorrahphy partial. An update on nonoperative management of the spleen in. A and b, portal venous phase a and renal excretory phase b axial maximumintensityprojection mdct images show active bleeding arrowheads into peritoneum from splenic injury. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology. Nonoperative management of splenic injury can be considered when all of the following conditions have been met.
Blunt aortic injuries accompany hepatic and splenic lesions in 1520% of cases fabian, hunt cit. Santaniellos study states that 33% of the patients with blunt aortic injury have associated simultaneous hepatic splenic lesions. Splenic rupture is usually evaluated by fast ultrasound of the abdomen. The spleen is the most commonly injured organ in blunt abdominal trauma. We used the keywords traumatic splenic injury, blunt splenic trauma, management between december 1954 and november 2014. Prospective trial of angiography and embolization for all grade iii to v blunt splenic injuries. The spleen is delivered to the midline by means of blunt and sharp dissection of the areolar plane between the kidney and the pancreas. With the spleen retracted medially, the phrenicocolic ligament is. Selective nonoperative management of pediatric blunt splenic injury became the standard of care in the late 1980s. With the increasing use of colonoscopy, radiologists are more likely to encounter the unusual complications of this procedure. Hemorrhage is the most common complication, with an incidence of 12%. Splenic arterial embolization has been proposed to reduce the risk of nonsurgical management failure in both adults and children. Management of intraoperative splenic injury request pdf. Abdominal pain is a common complaint among all ages of patients.
Listing a study does not mean it has been evaluated by the u. Pdf presentation and management of splenic injury after. Splenic trauma by doctor saleem linkedin slideshare. Bjui management of intraoperative splenic injury during. Sep 01, 2007 nonoperative management has become the standard of care for hemodynamically stable children with splenic injury from blunt abdominal trauma. However, there should be a predetermined transfusion threshold typically 2 units for isolated splenic injuries beyond which surgery should be done to prevent morbidity and mortality. Surgery is usually performed in patients who have traumatic injuries to.