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<small>'''(d)''' Wound exploration near the inferior costal margin should be avoided if not strictly necessary because of the high risk to damage the intercostal vessels</small>.
<small>'''(d)''' Wound exploration near the inferior costal margin should be avoided if not strictly necessary because of the high risk to damage the intercostal vessels</small>.
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==Pathophysiology==
==Pathophysiology==

Revision as of 16:16, 20 December 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

Rupture of the capsule of the spleen, an organ in the upper left part of the abdomen, is a potential catastrophe that requires immediate medical and surgical attention.

Causes

Life Threatening Causes

Common Causes

Common Causes: [1]

Traumatic causes:

  • Road traffic accidents
  • Contact sports injuries (Hockey and Football)
  • Stab and gunshot wounds
  • Domestic violence
  • Fist fights

Non-Traumatic causes:


Classification

  • American Association for the Surgery of Trauma (AAST) Spleen Trauma Classification: [4]
American Association for the Surgery of Trauma (AAST) Spleen Trauma Classification
Grade Injury description
I Hematoma Subcapsular, < 10% surface area
Laceration Capsular tear, < 1 cm parenchymal depth
II Hematoma Subcapsular, 10–50% surface area
Intraparenchymal, < 5 cm diameter
Laceration 1–3 cm parenchymal depth not involving a perenchymal vessel
III Hematoma Subcapsular, > 50% surface area or expanding
Ruptured subcapsular or parenchymal hematoma
Intraparenchymal hematoma > 5 cm
Laceration > 3 cm parenchymal depth or involving trabecular vessels
IV Laceration Laceration of segmental or hilar vessels producing major devascularization (> 25% of spleen)
V Laceration Completely shatters spleen
Vascular Hilar vascular injury which devascularized spleen
  • WSES Spleen Trauma Classification for adult and pediatric patients:[4]
WSES Class Mechanism of injury AAST Hemodynamix Status (a), (b) CT scan First-line treatment in adults First-line treatment in pediatric
Minor WSES I Blunt/penetrating I - II Stable Yes + local exploration in SW (d) NOM (c) + serial clinical/laboratory/radiological evaluation

Consider angiography/angioembolization

NOM (c) + serial clinical/laboratory/radiological evaluation
Moderate WSES II Blunt/penetrating III Stable Consider angiography/angioembolization
WSES III Blunt/penetrating IV - V Stable NOM (c) All angiography/angioembolization + serial clinical/laboratory/radiological evaluation
Severe WSES IV Blunt/penetrating I - V Unstable No OM OM
SW - Stab wound; GSW - Gunshot wound

(a) Hemodynamic instability in adults is considered the condition in which the patient has an admission systolic blood pressure < 90 mmHg with evidence of skin vasoconstriction (cool, clammy, decreased capillary refill), altered level of consciousness and/or shortness of breath, or > 90 mmHg but requiring bolus infusions/transfusions and/or vasopressor drugs and/or admission base excess (BE) > − 5 mmol/l and/or shock index > 1 and/or transfusion requirement of at least 4–6 units of packed red blood cells within the first 24 h; moreover, transient responder patients (those showing an initial response to adequate fluid resuscitation, and then signs of ongoing loss and perfusion deficits) and more in general those responding to therapy but not amenable of sufficient stabilization to be undergone to interventional radiology treatments.

(b) Hemodynamic stability in pediatric patients is considered systolic blood pressure of 90 mmHg plus twice the child’s age in years (the lower limit is inferior to 70 mmHg plus twice the child’s age in years, or inferior to 50 mmHg in some studies). Stabilized or acceptable hemodynamic status is considered in children with a positive response to fluid resuscitation: 3 boluses of 20 mL/kg of crystalloid replacement should be administered before blood replacement; positive response can be indicated by the heart rate reduction, the sensorium clearing, the return of peripheral pulses and normal skin color, an increase in blood pressure and urinary output, and an increase in warmth of extremity. Clinical judgment is fundamental in evaluating children

(c) NOM should only be attempted in centers capable of a precise diagnosis of the severity of spleen injuries and capable of intensive management (close clinical observation and hemodynamic monitoring in a high dependency/intensive care environment, including serial clinical examination and laboratory assay, with immediate access to diagnostics, interventional radiology, and surgery and immediately available access to blood and blood products or alternatively in the presence of a rapid centralization system in those patients amenable to be transferred

(d) Wound exploration near the inferior costal margin should be avoided if not strictly necessary because of the high risk to damage the intercostal vessels.

Pathophysiology

The spleen is an organ in the upper left side of the abdomen that filters the blood by removing old or damaged blood cells and platelets and helps the immune system by destroying bacteria and other foreign substances. It also holds extra blood that can be released into the circulatory system, if needed.

Symptoms

Symptoms of Splenic rupture include: [4] [5] [6] [7] [8]

Prognosis

Splenic rupture permits large amounts of blood to leak into the abdominal cavity which is severely painful and life-threatening. Shock and, ultimately, death can result. Patients typically require an urgent operation, although it is becoming more common to simply monitor the patient to make sure the bleeding stops by itself and to allow the spleen to heal itself. Rupture of a normal spleen can be caused by trauma, for example, in an accident. If an individual's spleen is enlarged, as is frequent in mononucleosis, most physicians will not allow activities (such as major contact sports) where injury to the abdomen could be catastrophic.

Prevention

The spleen is a useful but nonessential organ. It is sometimes removed (otherwise known as a splenectomy) in people who have blood disorders, such as thalassemia or hemolytic anemia. If the spleen is removed, a person must get certain immunizations to help prevent infections that the spleen normally fights.

Related Chapters

Resources

References

  1. Aubrey-Bassler FK, Sowers N (2012). "613 cases of splenic rupture without risk factors or previously diagnosed disease: a systematic review". BMC Emerg Med. 12: 11. doi:10.1186/1471-227X-12-11. PMC 3532171. PMID 22889306.
  2. Fishback SJ, Pickhardt PJ, Bhalla S, Menias CO, Congdon RG, Macari M (2011). "Delayed presentation of splenic rupture following colonoscopy: clinical and CT findings". Emerg Radiol. 18 (6): 539–44. doi:10.1007/s10140-011-0982-3. PMID 21887533.
  3. Guerra JF, San Francisco I, Pimentel F, Ibanez L (2008). "Splenic rupture following colonoscopy". World J Gastroenterol. 14 (41): 6410–2. PMC 2766127. PMID 19009661.
  4. 4.0 4.1 4.2 Coccolini F, Montori G, Catena F, Kluger Y, Biffl W, Moore EE; et al. (2017). "Splenic trauma: WSES classification and guidelines for adult and pediatric patients". World J Emerg Surg. 12: 40. doi:10.1186/s13017-017-0151-4. PMC 5562999. PMID 28828034.
  5. Barone JE, Burns G, Svehlak SA, Tucker JB, Bell T, Korwin S; et al. (1999). "Management of blunt splenic trauma in patients older than 55 years. Southern Connecticut Regional Trauma Quality Assurance Committee". J Trauma. 46 (1): 87–90. PMID 9932688.
  6. Beuran M, Gheju I, Venter MD, Marian RC, Smarandache R (2012). "Non-operative management of splenic trauma". J Med Life. 5 (1): 47–58. PMC 3307080. PMID 22574087.
  7. Pachter HL, Guth AA, Hofstetter SR, Spencer FC (1998). "Changing patterns in the management of splenic trauma: the impact of nonoperative management". Ann Surg. 227 (5): 708–17, discussion 717-9. PMC 1191351. PMID 9605662.
  8. Cadeddu M, Garnett A, Al-Anezi K, Farrokhyar F (2006). "Management of spleen injuries in the adult trauma population: a ten-year experience". Can J Surg. 49 (6): 386–90. PMC 3207549. PMID 17234065.

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