Splenic trauma
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SPLENIC TRAUMA WITH MANAGEMENT. EMERGENCY MEDICINE.
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Splenic trauma
- 2. HISTORY • Claudius Galen (129-216 AD) described the spleen as “PLENUM MYSTERII ORGANUM” or “the organ full of mystery” • In 1893, Reigner published the first documented successful splenectomy in the German Literature. • Operative mortality rates remained high until the 1950s • In modern English, “to vent one's spleen” means one's anger, eg by shouting (BAD TEMPER).
- 3. ANATOMY • Wedge shaped, Purplish, Plulpy mass. • Development : dorsal mesogastrium. • Largest Lymphoid organ. • Completely encircled by peritonium except at hilum. • It is most commonly injured solid organ in blunt injury abdomen. • Protected by lower thoracic cage.
- 4. 1*3*5*7*9*11 RULE • SIZE 1inch thick 3inch wide 5inch long • WEIGHT 7ounces (200gm approx) • RELATED RIBS 9-11 ribs posteriorly.
- 5. • Posteriorly: Left diaphragm, Lung, costodiaphragmatic recess, 9-11 ribs • Postero-medially: Body & Tail of pancreas. • Antero-medially: Greater curvature of stomach. • Inferiorly: distal transverse colon & splenic flexure. RELATIONS
- 6. BLOOD SUPPLY
- 7. LIGAMENTS • Gastrosplenic: Short gastric & Left gastro omental vessels • Splenorenal: Splenic vessels & tail of pancreas. • Splenocolic: In contact with lower pole of spleen, at danger during splenectomy
- 8. ANATOMICAL VARIATIONS Accessory Spleens: Splenenculi • MC congential anamoly • 20-30% incidence • Found near the hilum >80% • other sites: Gastrocolic lig, Tail of pancreas, Greater omentum, etc.
- 9. PHYSIOLOGY • Acts as filter of Reticulo-endothelial system • Humoral immunity: Produces Ig M, Opsonis, properidin. • Activation of complement system • Source of extramedullary hematopoiesis
- 10. INITIAL ASSESSEMENT • History: Victims sitting in the Left Side of the car. • Type & nature of the weapon. • If weapon is gun: Caliber of the gun is important
- 11. MODES OF INJURY • Blunt trauma: Rapid decelaration (MVA), Direct blow to abdomen ( Domestic voilence, activities such as bicylcling, rowing of boat, etc) • Penetrating trauma: Voilence, Gun shot injuries, etc. • Iatrogenic: Post procedures. • Spontaneous rupture: Malaria, Infectious mononucleosis
- 12. ASSOCIATED INJURIES • Fracture of left lower ribs. • Left lung/diaphragm injury. • Left sided hemothorax • Tail of pancreas injury • Left kidney injury • Left colonic injury
- 13. PRESENTATION • Pain abdomen/Lower part of chest on left side. • Shock. • Wound in left upper quadrant. • Abdominal distention.
- 14. GENERAL EXAMINATION • Tachycardia • Feeble Pulse • Hypotension • Tachypnea • Anemia
- 15. PER ABDOMEN EXAMINATION • External bruise may be seen in the left upper quadrant. • Abdominal distension • Decreased movment of left upper quadrant.(LUQ) • Tenderness in LUQ/ all over the abdomen.
- 16. SIGNS KEHR SIGN: Hans kehr, Germany • Clot collected under left diaphragm irritates it & the phrenic nerve, causing reffered pain in left shoulder after foot end elevation.
- 17. SIGNS • SEAT BELT SIGN: Abdominal wall contusion or hematoma in site of seat belt
- 18. SIGNS BALLANCE SIGN: Charles Alfred Ballance, UK. • Persistent dullness to percussion in the left flank due to coagulated blood. • Shifting dullness to percussion in the right flank due to fluid/blood
- 19. INVESTIGATIONS • In unstable patients : Hemoglobin, Blood grouping & arranging blood. • No specific lab studies specific to splenic injuries.
- 20. FAST ADVANTAGES: • Non invasive • Quickily asseses visceral injuries, intra/retro peritoneal fluid collections DISADVANTAGES: • Not reliable if blood <100ml • Not identify injuried hollow viscus
- 21. PLAIN CHEST X-RAY. • Left lower rib fracture. • Left hemidiaphragm elevation, left lower lobe atelectasis & pleural effusion.
- 22. DIAGNOSTIC PERITONEAL LAVAGE • Main diagnostic tool for abdominal trauma in past. • 10ml (blood/stool) +DPL • Senistivity: 97-98% • Complication rate: 1%
- 23. CECT SCAN • Hemoperitoneum • Blood density fluid throughout abdomen • Hypodense regions in region of spleen • Contrast BLUSH
- 24. AAST GRADE I AAST GRADE I
- 25. AAST GRADE II
- 26. AAST GRADE III
- 27. AAST GRADE IV
- 28. AAST GRADE V
- 30. MANAGEMENT SPLENIC TARUMA UNSTABLE STABLE EXPLORATORY LAPROTOMY ARTERIAL EMBOLISATION FAST(+) FAST(-) FAST(+) OBSERVATION CECT GRADE IV & V GRADE III GRADE I & II OBSERVATION EXPLORATORY LAPROTOMY WITH SPLENECTOMY Repeat scan after 72 hrs • Pseudoaneurysm • Contrast blush • Moderate bleed • Unstable • Peritonitis • Failed
- 31. INITIAL NON-OPERATIVE MANAGEMENT • Haemodynamically stable. • Lack of rebound tenderness and gaurding • Blood transfusions <= 4units • Patient is Concious • Age <55yrs
- 32. CONSERVATIVE MANAGEMENT Grade 1-2 (Stable pt): • Hospitalization • Strict bed rest • Vitals monitoring • Serial USG & Ct monitoring • Transfer blood if necessary. • DELAYED SPLENIC RUPTURE: 4% OF PATIENTS. 1. Latent period of Baudet.
- 33. SPLENORRHAPHY
- 34. ADJUNCTS TO SPLENOPRRHAPHY • Hemostatic agents afforded by temporary packs. • Argon lasers for lager splenic tear. • Stapling devices (quicker but cause ischemia or tearing) • Absorbale meshes around the badly injured spleen.
- 35. SPLENECTOMY • Position: Supine. • General Anesthesia. • Incisons: Midline, Left subcostal. • Usually midline laprotomy incision is preffered.
- 36. ...CONTINUED • Incision deepend to access peritoneal cavity • Pack 4 quadrants of peritoneal cavity • Suck out all the free blood and clots • Remove the packs starting from least area of bleeding. • Use your fingers to temporarily sucure hemostasis at the hilum.
- 37. APPROACHES
- 38. ...Continued
- 41. PARTIAL SPLENECTOMY • During Partial splenectomy for extensive injury to splenic segment, transverse intraparenchymal arteries may continue to bleed. • Some transverse spurting vssels can be made hemostatic using electrocoagulation. • Where as other bleeding vessels require 4-0 silk suture placed in a figure-eight manner.
- 42. EMBOLISATION • Tc99/ colloid labeled contrast angiogram. • Presence of blush /Pseudo aneurysm pattern • Transarterial embolisation using polyvinly alcohol/silicone/acrylic embolic spheres. • Reduce post operative hemorrhage
- 43. AUTOTRANSPLANTATION • Multiple 1mm slices of spleen in omentum • Technique is experimental
- 44. COMPLICATIONS INTRAOPERATIVE • Haemorrhage • Pancreatic injury • Bowel injury (stomach/colon) • Diaphragmatic injury
- 45. COMPLICATIONS EARLY POSTOPERATIVE • Hematoma/ Seroma • Wound infection • Subphrenic abscess • Atelectasis • Pneumonia • Pleural effusion
- 47. OVERWHELMING POSTSPLENECTOMY INFECTION • A rapidly fatal infection following removal of spleen. • Mostly occurs during first 2years post splenectomy. • Common Organisms: 1. S.pneumonia (50-90%) 2. H.influeza 3. N.meningitis. Mortality :50-70%
- 48. OPSI • Mechanism: organism with polysaccharide capsules need opsonization with IgG3 or C3b which attaches to special macrophages found in spleen. • Post splenectomy patients have lack of macrophages. • Flu like symptoms, Meningitis or sepsis. • Rapidly progressive in 12-48hrs post onset.
- 49. OPSI • Other organisms include: Streptococcus species, salmonella, Babesiosis. High risks: • Children <5yrs/ >50yrs old. • Splenectomty for haemoglobinopathies (Thalasemeia, Sickle cell), Myelodysplasia, malignancies.
- 50. OPSI ANTIBIOTIC PROPHYLAXIS: Penicilin V 125mg BD(<3yrs) 250mg BD(3-14yrs), 500mg BD (adults)
- 51. CASE DISCUSSION
- 52. TAKE HOME MESSAGE • Spleen is an important organ, we must try to conserve it. • Clinical examination has vital role in diagnosing & treating splenic injuries • CECT is the Investigation of choice • Hemodynamically unstable patients: directly to be taken to Operation theatre.
- 53. TAKE HOME MESSAGE • Splenic artery embolisation has got definitive role. • Enlarged spleens are more susceptible to injury. • OPSI is devastating sequelae of splenectomy. • Prophylaxis against OPSI is must (in case it is elective).
- 55. NEXT WEEK (26/02/2021) SEMINAR TOPIC : HEPATOBILLIARY TRAUMA. BY: DR. SIDDHARTH HEGDE.
- 56. EAST GUIDE LINES LEVEL 1
- 57. EAST- LEVEL 2
- 58. EAST- LEVEL 2
- 59. EAST LEVEL 3
Editor's Notes
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- It is the most common cause of massive bleeding in blunt abdominal trauma to a solid organ.
- pediatric spleen: implies reduced need of operative intervention. adult: -100-250gms. two ends ANTERIOR of LATERAL END is expanded and us more like a border • POSTERIOR OF MEDIAL END is rounded I rests on upper pole of left kidney Three borders SUPERIOR BORDER us notched near the anterior vend INFERIOR BORDER is rounded INTERMEDIATE BORDER is also rounded and directed to the right T20 swyaces · DIAPHRAGMATIC SURFACE us convex and smooth VISCERAL SURFACE is concave and werequlor Two angles • ANTE ROBASAL ANGLE - It is the junction of superior border with LATERAL Or ANT - It us the most forward projeding part of spleen • POSTEROBASPL ANGLE - junction of inferior borde with lateral or ant end of spleen
- ARTERIAL SUPPLY The spleen us supplied by SPLENIC ARTERY which us the largest branch of the COELIAC TRUNK. - It passes through the leinorenal ligament to reach the hilum where it divides into FIVE OR MORE BRANCHES - These branches enter the spleen to supply it within the spleen, et diuder vrepeatedly eto forn straight Vessels called PENICILi, which further divide into ELLIPSOIDS and arterial CAPILLARIES according to CLOSED THEORY OF SPLENIC CIRWLATION, capillaus are continuous with the venous vaunusoids that lie in the RED PULP • According to OPEN THEORY OF SPLENIC CIRCULATION, capillaris cend by opening unto the red pulp prom where brood envers sinusoids Through uau Others before un a com PROMISE THEORY, Where circulation us open un distendid spleen and closed un contracted spleen SPLENIC VEIN is formed at the hilum of the Spleen - It joins the SUPERIDR MESENTERIC VEIN to form the PORTAL VEIN behind the neck of the pancreas Its tributaries are the SHORT GASTRIC, LEFT CASTROEPIPLOIC, PANCREATIC and INFERIOR MESENTERIC VEINS LYMPHATIC DRAINAGE - splenic lissue has no lymphatics, few lymphatics arise from connective di sues of capsule ancd drain undo PANCREATICOSPLENIC LYMPH NODES Situated along the splenic artery NERVE SUPPLY - Sympathetic fibres are derived from the coeliac plexux: They areVASOMOTOR in nature. They also supply some smooth muscles in the capsule
- type & nature of weapon is important in penetrating injuries.
- 1lakh RBC/mm3, 500wbc/mm3, 175IU amylase,bile, bacteria or food.
- Hemoperitoneum – Localized fluid collections around the spleen (especially those with an elevated HU measurement) are highly suggestive of hemoperitoneum. • Briskly bleeding splenic lacerations may establish blood density fluid throughout the abdomen. Hypodensity – Hypodense regions represent areas of Parenchymal disruption, intraparenchymal hematoma or Subcapsular hematoma. Contrast blush or extravasation – Contrast blush describes hyperdense areas within the splenic parenchyma that represent traumatic disruption or pseudoaneurysm of the splenic vasculature. Active extravasation of contrast implies ongoing bleeding and the need for urgent intervention
- tunical media & adventetia cardiac catheterisation. trauma.
- incidence: 15-33%, ' 4-8days after. expanding subcapsular hematoma clot disrutption pseudocyst rupture,
- Once spleen is fully mobilised. For large deep injuries: 2-0 chromic sutures swedged on blunt tip needle. placed 1-2cm from torn margin & passed deep into the wound crevice. Equal tension is achieved on both sides of crevices is obtained with two handed ties. Minor oozing through needle holes are treated by placing dry sponge over spleen & returning the spleen to LUQ for 10mins, while other organs are assessed. If hemostasis appears good when pack is removed, no touch technique applies.
- • Use your fingers to temporarily secure hemostasis at the hilum(to prevent clamping of the tail of pancreas) • Place the left hand on the spleen and draw it down to divide the lieno renal ligament lying posteriorly • Deliver the spleen into the abdominal incision Then a non-crushing clamp is applied at the hilum safeguarding the pancreas • Examine the spleen for grade of injury Ligate and divide; the short gastric arteries, left gastro-epiploic arteries away from the stomach with non absorbable suture.
- elective: lesser sac emergency: leinorenal ligament. • Use your fingers to temporarily secure hemostasis at the hilum(to prevent clamping of the tail of pancreas) • Place the left hand on the spleen and draw it down to divide the lieno renal ligament lying posteriorly • Deliver the spleen into the abdominal incision Then a non-crushing clamp is applied at the hilum safeguarding the pancreas • Examine the spleen for grade of injury Ligate and divide; the short gastric arteries, left gastro-epiploic arteries away from the stomach with non absorbable suture.
- • Use your fingers to temporarily secure hemostasis at the hilum(to prevent clamping of the tail of pancreas) • Place the left hand on the spleen and draw it down to divide the lieno renal ligament lying posteriorly • Deliver the spleen into the abdominal incision Then a non-crushing clamp is applied at the hilum safeguarding the pancreas • Examine the spleen for grade of injury Ligate and divide; the short gastric arteries, left gastro-epiploic arteries away from the stomach with non absorbable suture.
- Gently separate the tail of the pancreas from the splenic Vessels Separately divide and double ligate the splenic artery and Then the vein. • Beware ; tail of the pancreas, splenic flexure of the colon, left kidney and adrenal gland. Complete the splenectomy by dividing the splenocolic liagament • Complete exploratory laparotomy • Meticulous hemostasis • Peritoneal saline lavage Suction drain on splenic bed- to drain the tail of pancreas Closure; abdomen is closed in layers
- Gently separate the tail of the pancreas from the splenic Vessels Separately divide and double ligate the splenic artery and Then the vein. • Beware ; tail of the pancreas, splenic flexure of the colon, left kidney and adrenal gland. Complete the splenectomy by dividing the splenocolic liagament • Complete exploratory laparotomy • Meticulous hemostasis • Peritoneal saline lavage Suction drain on splenic bed- to drain the tail of pancreas Closure; abdomen is closed in layers