For 90-95% of patients with injuries to the spleen.

1. Page 1
Non-operative management of splenic injuries:
the outline
Raimundas Lunevicius MD, PhD
27 May 2011
King’s College Hospital NHS Foundation Trust
South East London Trauma Network

2. Agenda / Aims
To outline:
main definitions
situations when NOM is safe
a clinical pathway for NOM
Target audience:
Medical students
FY 1, FY2,
Junior Registrars (ST1 – 3)
Others
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3. any intentional / unintentional,
blunt / penetrating damage to the spleen
resulting from acute exposure to
external, mostly mechanical, energy
Definition: injury of the spleen Page 3

4. Grade I Hematoma
Laceration
Subcapsular hematoma < 10% surface area
Capsular nonbleeding tear < 1 cm in parenchymal depth
Grade II Hematoma
Laceration
Subcapsular nonexpanding hematoma 10 – 50%
surface area and/or intraparenchymal hematoma > 2
cm
Active bleeding from capsular tear; 1–3 cm
parenchymal depth which does not involve a trabecular
vessels
Grade III Hematoma
Laceration
Subcapsular hematoma >50% surface area or
expanding intraparenchymal hematoma >2 cm
>3 cm in depth or involving trabular vessels
Grade IV Hematoma
Laceration
Ruptured intraparenchymal hematoma with active
bleeding
Laceration involving segmental or hilar vessels
producing major devascularisation (>25% of spleen)
Grade V Hematoma
Laceration
Hilar vascular injury which devascularizes spleen
Shattered spleen
Definition: *Advance one grade for multiple injuries up to Grade III
(AAST OIS 1994 revision) Page 4

5. Organ Injury Scaling (OIS) and
Abbreviated Injury Scale (AIS)
are different systems
OIS for splenic injuries: Grades I – V
AIS 2005 Update 2008: Grades II – V
AAST and AAAM
(AA for the Surgery of Trauma / Association for the Advancement of Automotive Medicine) Page 5

6. NOM of blunt splenic injuries is the
treatment modality of choice in
hemodynamically stable patients,
irrespective of the grade of injury
Definition: NOM Page 6

7. THE SPLEEN is a critical component of the defense system
The clearance of blood borne bacteria occurs primarily within the spleen
In the adult, the spleen comprises 25% of the reticuloendothelial cell mass
Unique circulation → permits effective splenic phagocytosis because of
more prolonged period within the splenic microcirculation and intensive
perfusion
• 90% of blood enters into the ‘open circulation’
• 10% of the splenic arterial blood empties directly into the venous sinuses
• Perfused 200 mL of blood per minute
Why enthusiasm for NOM of SI continues ? (1) Page 7

8. Rare but often fatal complication known as
‘Overwhelming postsplenectomy infection’ (OPSI)
Encapsulated bacteria:
• Streptococcus pneumoniae,
• Haemophilus influenzae,
• Neiseria meningitidis
Resistant to treatment
Mortality > 50%
Most often: young children / immunocompromised adults
Why enthusiasm for NOM of SI continues ? (2) Page 8

9. When to consider NOM of splenic injury
1. Diagnosis of SI on CT scan
2. Hemodinamically well patient:
- not required fluid administration
- has responded quickly to initial infusion of cristaloids
(!) Consider angiography / embolization before NOM:
in the hemodynamically stable pt who continues to bleed
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10. Page 10
Isolated spleen injury
Grade I – II Grade III – IV
With CT contrast blush
NOM Angiography Operation
Algorithm, Trauma Manual, Moore

11. Indications for angiography / embolization: Grade I – V
Grade I – II: evidence of vascular injury (contrast blush, selective)
Grade III: immediate (evidence of vascular injury)
or semielective action (for every not-shocked injury…)
Grade IV – V:
necessary for every not-shocked injury:
immediate action, asap / stable
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12. NOM: Location / Management
Monitored bed: Grade II, III or higher
ICU bed: Grade IV, V (angiography)
1. Bed rest (no evidence to support this when a pt is stable)
2. NPO status / gradually advanced diet
3. Hydration (hemotransfusion according to current indications)
• Monitoring vital signs hourly / serial examination
• Serial hematocrit and Hb q8hr until stable 2 times
• Refrain from deep palpation during abdominal reassessment
• Ultrasound scanning / monitoring of the peritoneal cavity
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13. NOM: discharge day
(stable, no events - bleeding or pseudoaneurysm)
Grade I – II: may be discharged at 48 hours if ACT is
negative
Grade III: abdo CT in 48-72 hours of admission may be
necessary (no consensus, it should be considered)
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14. After discharge: recommendations for splenic reinjury prevention
1. No school for a week
2. No physical education for appr 6 weeks
3. No major contact sports for appr 3 months (complete
healing should be confirmed by CT documentation)
(ACS Surgery, 6th edition)
INTERVAL OF LIMITED ACTIVITY IS CLINICAL AND DEGREE-DEPENDENT,
RANGING FROM SEVERAL MONTHS TO ONE YEAR
Page 14

15. Follow up
1. Return to clinic in 1-2 weeks
2. Instruct to return to clinic / A&E if LUQ pain
worsens, or dizziness, syncope, or hypotension
develops
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16. Failure of NOM
1. New epizode of hypotension related to splenic bleeding
2. New onset of diffuse peritoneal irritation
Options:
Laparotomy or repeat angiography
Depends on patient’s stability
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17. For splenectomized patients
Vaccination at 2 weeks clinic agains:
• Streptococcus pneumoniae,
• Haemophilus influenzae,
• Neiseria meningitidis
1. Pneumococcus vaccine (Pneumovax)
2. Meningococcus vaccine
3. Haemophilus influenzae vaccine
Page 17

18. NOM of splenic injuries: outcomes
(data of population based study, n = 2303, Washington, USA)
27% - surgery or embolization (610 / 2303)
73% - NOM
62% - successfull NOM (1381)
11% - failed NOM (252)
25% failed later than 2 days (62 pts)
50% (31) failed later than 5 days (rupture of pseudoaneurysm of the artery)
• Being older than 55 years
• having an ISS higher than 25
• admission to a level III or IV trauma hospital were associated with a
significant risk of failure of NOM of splenic injuries
McIntyre, Arch Surg 2005; 140: 263-269
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19. Factors associated with a significant risk of failure of NOM
• Being older than 55 years
• Having an ISS higher than 25
• Admission to a level III or IV trauma hospital
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20. Not predictors of failure of NOM
• Glasgow Coma Scale score
• Associated injuries
• Presenting hemodynamics
McIntyre, Arch Surg 2005; 140: 263-269
Page 20

21. Take – homes
1. NOM : recognized modality / for stable patients – 70%
2. Failure occurs infrequently: appr 10%.... (in in-patients)
3. Observe and judge responsibly:
observation beyond the 3rd day is not necessary
Crowford R et al. Surgery 2007;
142:337-342
An academic health sciences center for London
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22. Literature
McIntyre, Arch Surg 2005; 140: 263-269
Crowford R et al. Surgery 2007; 142:337-342
ACS Surgery, 6th edition
Trauma Manual, Moore, 4th edition.
Clinical Manual, STC, University of Maryland Medicine System
Abbreviated Injury Scale 2005©Update 2008, AAAM
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