BLUNT SPLEEN MANAGEMENT

PROTOCOL

2011

• A. NOTS Blunt Spleen Management Protocol• B. All adult patients with an identified blunt

spleen injury (> 14 years of age)• C. Prehospitital Recommendations: Follow

NOTS triage protocols

D. E.D. Recommendations– Ensure 2 good working IVS – Unstable patients with known spleen injuries or positive

FAST: Should go to OR ASAP, providing cause of hemodynamic instability is related to their abdominal trauma

– Stable Patients:• Abdominal/Pelvis CT indicated for any suspected abdominal

injuries -CT with IV contrast is study of choice to make diagnosis

– If spleen injury is identified at a NON-Trauma Hospital arrange for Transfer – Call Trauma Transfer Center (FCO)

E. Initial Treatment Recommendations

• Treat other identified injuries as indicated• Grade I and II injuries – admit for minimum of > 24 hours with

serial exams and HCTs• Grade III injuries – admit ICU/step down unit, serial HCTS (q 4 -6

hrs) for a minimum of 3 times and until stable • Grade III injuries with moderate to large hemoperitoneum –

Splenic Artery Angio-embolization (SAE) within 2 hours

E. Initial Treatment Recommendations• Treat other identified injuries as indicated• Grade I and II injuries – admit for minimum of > 24 hours with

serial exams and HCTs• Grade III injuries – admit ICU/step down unit, serial HCTS (q 4 -6

hrs) for a minimum of 3 times and until stable • Grade III injuries with moderate to large hemoperitoneum –

– Moderate to Large Peritoneum: defined fluid seen in a least – Splenic Artery Angio-embolization (SAE) ASAP with goal to be within 2

hours

E. Initial Treatment Recommendations• Treat other identified injuries as indicated• Grade I and II injuries – admit for minimum of > 24 hours with

serial exams and HCTs• Grade III injuries – admit ICU/step down unit, serial HCTS (q 4 -6

hrs) for a minimum of 3 times and until stable • Grade III injuries with moderate to large hemoperitoneum -

Splenic Artery Angio-embolization (SAE) ASAP with goal to be within 2 hours

• Grade IV injuries: SAE ASAP with goal to be within 2 hours• Grade V injuries: to OR in most circumstances• Grades I – IV: that show CT evidence of blush/pseudoaneurysm

or extravasation - SAE ASAP with goal to be within 2 hours

F. In-Hospital Recommendations• Patients should be NPO and on bed rest until

HCT stable• Grade 1 and 2: minimum of 1 floor day and 2

total hospital days• Grade 3-5: minimum of 3 hospital days• Splenectomy patients require immunizations

prior to DC from the hospital– H. flu – Meningococcus– Pneumococcus

F. In-Hospital Recommendations• DVT prophylaxis– SCDS upon admission– Stable HCT for 48 - 72 hours and no other

contraindications- Strongly consider starting chemoprophylaxis until DC (Low molecular weight heparin is preferred)

G. Post Discharge Recommendations

• Documentation that patient was seen in “Trauma Clinic” 1– 4 weeks post discharge

• Documentation in the chart of when and if the patient as can return to Normal Activity

• Documentation of need for flu shot and education regarding infections and splenectomy

Initial Mangement of a Hemodymically Stable Patient with a Blunt Spleen Injury

CT scan with IV contrast

Angio-Embolization (within 1-2 hours)

Grade I & II can admit to Floor

Grade III

Moderate/Large hemoperitoneum

ICU/Step-down unit* - q 4- 6 hr HCTs until stable X 3

Dropping HCTs for 24 hours, or need to transfuse blood

Stable HCTs for 24 hours

Can mobilize patient, transfer to floor, and give diet pending other injuries

Consider the following options:OR, angio, Repeat CT scan

No or Small hemoperitoneum

Blush, Extravisation, or Psuedoaneurysm

Floor patients: should be mobilized, diet advance and daily HCTs until stable for two days.Grade 1 and 2: minimum of 1 floor dayGrade 3-5: minimum of 3 hospital daysSplenectomy patients require immunizations

Grade IV

Grade V

References1. The effects of splenic artery embolization on nonoperative management of blunt splenic injury: a 16-year experience.Sabe AA, Claridge JA, Rosenblum DI, Lie K, Malangoni MA. J Trauma. 2009 Sep;67(3):565-72; discussion 571-2.PMID:

19741401 [2. Blunt splenic injuries: dedicated trauma surgeons can achieve a high rate of nonoperative success in patients of all ages.Myers JG, Dent DL, Stewart RM, Gray GA, Smith DS, Rhodes JE, Root HD, Pruitt BA Jr, Strodel WE.J Trauma. 2000 May;48(5):801-5; discussion 805-6.PMID: 10823522 [PubMed -3. Improved outcome of adult blunt splenic injury: a cohort analysis.Rajani RR, Claridge JA, Yowler CJ, Patrick P, Wiant A, Summers JI, McDonald AA, Como JJ, Malangoni MA.Surgery. 2006 Oct;140(4):625-31; discussion 631-2.PMID: 170119104. Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery

pseudoaneurysms.Davis KA, Fabian TC, Croce MA, Gavant ML, Flick PA, Minard G, Kudsk KA, Pritchard FE.J Trauma. 1998 Jun;44(6):1008-13; discussion 1013-5.PMID: 96371565. Use of splenic artery embolization as an adjunct to nonsurgical management of blunt splenic injury.Liu PP, Lee WC, Cheng YF, Hsieh PM, Hsieh YM, Tan BL, Chen FC, Huang TC, Tung CC.J Trauma. 2004 Apr;56(4):768-72; discussion 773.PMID: 151877396. Blunt splenic injury in adults: Multi-institutional Study of the Eastern Association for the Surgery of Trauma.Peitzman AB, Heil B, Rivera L, Federle MB, Harbrecht BG, Clancy KD, Croce M, Enderson BL, Morris JA, Shatz D, Meredith

JW, Ochoa JB, Fakhry SM, Cushman JG, Minei JP, McCarthy M, Luchette FA, Townsend R, Tinkoff G, Block EF, Ross S, Frykberg ER, Bell RM, Davis F 3rd, Weireter L, Shapiro MB. J Trauma. 2000 Aug;49(2):177-87; discussion 187-9.PMID: 10963527 [PubMed - indexed for MEDLINE]

AppendixCT Grading of Splenic Injury

• Spleen injury scale: (advance one grade for multiple injuries, up to grade III)– Grade I:

• Hematoma: subcapsular, < 10% of surface area• Laceration: capsular tear, < 1cm parenchymal depth

– Grade II: • Hematoma: subcapsular, 10-50% surface area; intraparenchymal, <5cm in diameter• Laceration: 1-3cm parenchymal depth which does not involve a trabecular vessel

– Grade III:• Hematoma: subcapsular, >50% surface area or expanding; ruptured subcapsular or

parenchymal hematoma; intraparenchymal hematoma >5cm or expanding• Laceration: >3cm parenchymal depth or involving trabecular vessesls

– Grade IV: • Laceration: laceration involving segmental or hilar vessels producing major devascularization

(>25% of spleen)– Grade V:

• Laceration: completely shattered spleen• Vascular: hilar vascular injury which devascularizes spleen

AppendixSize of Hemoperitoneum

• Small Hemoperitoneum - perisplenic blood or blood in Morrison’s pouch

• Moderate Hemoperitoneum – blood in one or both pericolic gutters

• Large hemoperitoneum – blood in one or both gutters with additional blood in pelvis