Splenic Salvage procedures, Trauma

Question 1

What are the advantages of nonoperative management of splenic injuries?

Answer 1

Avoiding immunologic effects and the risks of laparotomy (intraabdominal injuries to pancreas), asplenia (risk of OPSI)

Question 2

What is the prime determinant in operative versus nonoperative management in splenic injury?

Answer 2

Hemodynamic stability

Question 3

What is a grade I splenic injury?

Answer 3

Hematoma with subscapular, <10% surface

Question 4

What is a grade II splenic injury?

Answer 4

Subcapsular hematoma, 10-50% surface area, intraparenchymal hematoma, <5cm;
Laceration: Capsular tear from 1-3cm parenchymal depth

Question 5

What is a grade III splenic injury?

Answer 5

Hematoma - subcapsular >50% surface area or expanding, ruptured or parenchymal hematoma; or intraparenchymal hematoma >5cm or expanding
Laceration >3cm parenchymal depth or involving trabecular vessels.

Question 6

What is a grade IV splenic injury?

Answer 6

Laceration involving segmental or hilar vessels producing major (>25%) devascularization

Question 7

What is a grade V splenic injury?

Answer 7

Completely shattered spleen, or hilar vascular injury with devascularized spleen

Question 8

General indications for angioembolization for splenic injury

Answer 8

Controversial topic, but in general a contrast blush or pooling on CT, a higher grade injury (III +), persistent tachycardia and declining hematocrit are indications

Question 9

Which criteria increase failure rate of angioembolizaion?

Answer 9

Presence of an arteriovenous fistula on CT scan, age >55, hemodynamic instability

Question 10

Criterion for Nonoperative management of blunt splenic injury

Answer 10

Hemodynamic stability, absence of additional injuries requiring operative intervention, transfusion fewer than 2 units

Question 11

At the time of initial injury, should chemical DVT prophylaxis be used in patients undergoing nonoperative treatment for blunt splenic injury?

Answer 11

No, chemical prophylactic anticoagulation is contraindicated.

Question 12

What is the general consensus regarding resuming normal activities after blunt splenic trauma?

Answer 12

After 2-4 months

Question 13

What is the most common cause of failure of nonoperative management?

Answer 13

Bleeding within 4 days on therapy

Question 14

When is repeat imaging recommending for high grade injuries managed nonoperatively? (grades III-IV)

Answer 14

CT scan after 4-6 weeks

Question 15

If a grade 1 or 2 splenic laceration is encountered during abdominal exploration for another indication, what is the preferred method of splenic repair?

Answer 15

Direct application of electrocautery or argon beam coagulator

Question 16

If a grade 3 splenic laceration is encountered, and patient is stable, what are common options for splenorrhapy?

Answer 16

Manual compression, and pledgeted sutures to repair injury or mesh splenorrhapy over injured portions of the spleen.

Question 17

In a patient with an aortic injury and an associated splenic injury, what is the operative approach?

Answer 17

First, splenectomy, then address the more complicated issue.