FRCA Notes

Splenic Injury

Splenectomy for ITP was an SAQ in 2017, although the bulk of the marks were on the perioperative implications of ITP.

Other marks were for knowing the vaccinations required post-splenectomy, including their timing, and for the conservative management of traumatic splenic injury.

Resources

  • Up to 45% of those experiencing blunt abdominal trauma will have associated splenic injury
  • Other modes of injury can occur e.g. iatrogenic from abdominal surgeries, from malignancy or infection (e.g. EBV)

Grade Degree of sub-capsular haematoma Laceration
1 <10% surface area <1cm
2 10 - 50% surface area 1-3cm
3 >50% (or intraparenchymal haematoma) >3cm
4 Splenic vascular injury or active bleeding
5 Shattered spleen


Primary survey

  • Essentially the same as any primary survey, though with a focus on management of major haemorrhage from splenic injury
  1. Immobilise C-spine and manage airway
  2. Administer oxygen and ensure adequate ventilation
  3. Management of major haemorrhage
    • Wide bore IV access x 2
    • Bloods including cross-match
    • Activation of major haemorrhage protocol
    • TXA etc.
  4. Standard neurological assessment, neurovascular limb assessment and analgesia
  5. Input from general surgeons

Investigations

  • FAST: hypoechoic rim around the spleen ± fluid in Morrison's pouch (hepatorenal space)
  • CT abdomen: hemoperitoneum | hypodense areas in the spleen representing parenchymal disruption | contrast extravasation

Conservative

  • Standard management of the trauma patient and of major haemorrhage, as above
  • Haemodynamically stable patients with Grade 1 - 3 injuries may be suitable for:
    • HDU admission
    • Serial surgical reviews
    • Repeat CT scan at 1 week interval

Interventional

  • IR-guided embolisation of the splenic artery
  • Laparotomy and (partial/total) splenectomy

  • From 2 weeks post-traumatic splenectomy:
    • Pneumococcal vaccine
    • Haemophilus influenzae B vaccine
    • Meningococcal C vaccine
  • Lifelong penicillin V (or clarithromycin if penicillin allergic)