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A - MSRA Gastrointestinal [7] > [29] Splenic Rupture > Flashcards

[29] Splenic Rupture Flashcards

1
Q

What is the consequence of the spleen being an extremely vascular organ?

A

Splenic rupture can cause a large intraperitoneal haemorrhage, rapidly leading to fatal haemorrhagic shock

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2
Q

What is splenic rupture secondary to in the majority of cases?

A

Abdominal trauma, particularly blunt trauma

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3
Q

What are the common situations in which the spleen is ruptured?

A

Seat-belt injuries in RTAs

Falls onto the left side

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4
Q

What is the cause of the minority of cases of splenic rupture?

A

Iatrogenic, or secondary to underlying splenomegaly

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5
Q

What can cause underlying splenomegaly?

A

Haemotological malignancy

Infective causes e.g. EBV

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6
Q

How does splenomegaly increase the risk of splenic rupture?

A

The spleen grows in size, and the capsule stretches and thins, becoming more fragile. This puts it at an increased risk of rupture

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7
Q

How is a diagnosis of splenic rupture most commonly made?

A

From investigations of abdominal pain following a history of trauma

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8
Q

What symptoms might splenic rupture present with?

A

Abdominal pain

Clinical features of hypovolaemic shock

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9
Q

What is required to confirm the diagnosis of ruptured spleen?

A

Imaging

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10
Q

What may be found on examination in splenic rupture?

A

Left upper quadrant tenderness and/or peritonism

Kehr’s sign

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11
Q

What can happen to the peritonism as splenic rupture progresses?

A

It can become more generalised as the blood loss increases

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12
Q

What is Kehr’s sign?

A

Radiating left shoulder pain

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13
Q

How can splenic rupture cause Kehr’s sign?

A

Free blood irritates the diaphragm

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14
Q

When is an immediate laparotomy required in splenic rupture?

A

In patients who are haemodynamically unstable with peritonism following trauma, unless proven otherwise

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15
Q

What investigation is required in those who are haemodynamically stable with suspected abdominal injury?

A

Urgent CT chest-abdo-pelvis with IV contrast

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16
Q

What does CT scan allow for in suspected splenic rupture?

A

Identification and assessment of splenic injury, alongside any other abdominal viscera involvement
Also allows for grading of splenic injury

17
Q

What is the importance of grading of splenic injury?

A

It guides further management

18
Q

What can FAST scans in the emergency department reveal in splenic rupture?

A

Free peritoneal fluid

Fluid in the pericardium

19
Q

What needs to be considered when ordering a FAST scan in A&E?

A

It should not delay CT imaging and/or surgical intervention

20
Q

What is the most commonly used system for grading splenic trauma?

A

The American Association for the Surgery of Trauma (AAST) splenic injury scale

21
Q

What is the purpose of the AAST splenic injury scale?

A

It can be used to help guide which patients are likely to benefit from conservative management, and which need surgery

22
Q

What is a grade 1 AAST splenic injury?

A

Capsular tear <1cm parenchymal depth

Subcapsular haematoma <10% surface area

23
Q

What is a grade 2 AAST splenic injury?

A

Capsular tear 1-3 cm parenchymal depth

Subcapsular haematoma 10-50% surface area, or intraparenchymal haematoma <5cm

24
Q

What is a grade 3 AAST splenic injury?

A

Capsular tear >3cm parenchymal depth, or any tear involving trabecular vessels
Subcapsular haematoma >50% surface area, or intraparenchymal haematoma >5cm, or any expanding or ruptured haematoma

25
Q

What is a grade 4 AAST splenic injury?

A

Laceration involving segmental or hilar vessels, devascularising >25% of spleen

26
Q

What is a grade 5 AAST splenic injury?

A

Completely shattered spleen or hilar vascular injury, devascularising the entire spleen

27
Q

How should all patients with a suspected splenic injury be managed initially?

A

They should be assessed, resuscitated, and treated according to ATLS principles

28
Q

Which splenic rupture patients will require an emergency laparotomy?

A

Patients who are haemodynamically unstable, or with a grade 5 injury (a shattered spleen or major hilar vascular injury)

29
Q

What should be done if there is evidence of active extravasation of the contrast during the arterial phase of a CT scan?

A

The patient should undergo embolisation (if locally available) or laparotomy with splenectomy

30
Q

Which patients with splenic rupture can be treated conservatively?

A

Haemodynamically stable patients with grade 1-3 injuries

31
Q

What is involved in the conservative management of splenic rupture?

A

Resuscitation as appropriate
Admitted to high dependancy area for observation
Serial abdominal examinations for evidence of deterioration
Prophylactic vaccinations at discharge

32
Q

What should be done with any evidence of increasing tenderness or peritonitis in splenic ruptures being monitored?

A

There should be a low-threshold for re-imaging and/or laparotomy

33
Q

Why should there be a low threshold for re-imaging and/or laparotomy in patients with splenic rupture and increasing tenderness or peritonitis?

A

As associated injuries such as small bowel injuries are easily missed on initial CT imaging

34
Q

What prophylactic examinations should be given in patients with splenic rupture who are being managed conservatively?

A

Strep Pneumoniae
Haemophilus influenzae B
Meningococcus

35
Q

What are the main complications of conservative treatment or embolisation in splenic rupture?

A

Ongoing bleeding
Splenic necrosis
Splenic abscess formation
Splenic cyst formation

36
Q

What is the pathophysiology behind overwhelming post-splenectomy infection (OPSI)?

A

The spleen is an immunologically active organ, with an active role in destroying encapsulated organisms. Asplenic patients are therefore unable to mount a normal immunological response against these organisms, and infection can lead to overwhelming sepsis

37
Q

Give three examples of encapsulated organisms

A

Pneumooccus
Meningococcus
H. Influenzae

38
Q

How can OPSI be prevented?

A

Any asplenic patient should receive vaccinations against pneumococcus, meningococcus, and H. influenzae.
Prophylactic Penicillin V should be considered

39
Q

When might lifelong prophylactic pencillin V not be required?

A

In low risk patients

A - MSRA Gastrointestinal [7] (44 decks)

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