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 cemical
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.
Posted 7/1/17 (A Bernard); Reviewed 9/26/24 (A Bernard)
