The spleen is the most commonly injured solid organ in blunt abdominal trauma, with over 40,000 adult splenic injuries occurring annually in the United States. [1-2] Management has shifted dramatically toward nonoperative management (NOM), which is now standard for hemodynamically stable patients regardless of injury grade, with success rates of 80–95%. [1-2]
1. History
- Mechanism of injury: blunt abdominal trauma (MVC, falls, bicycle handlebar, contact sports, assault), penetrating trauma (stab, GSW), or atraumatic/spontaneous (splenomegaly, infectious mononucleosis, malaria, hematologic malignancy)
- Characterize force vector, speed, seatbelt use, steering wheel deformity, ejection, height of fall
- Left-sided rib fractures (ribs 9–12) — strongly associated with splenic injury
- Timing: symptoms may be immediate or delayed (delayed splenic rupture can present hours to weeks later) [3]
- Kehr sign: left shoulder pain (referred diaphragmatic irritation from hemoperitoneum)
- Associated symptoms: LUQ pain, diffuse abdominal pain, nausea, lightheadedness, syncope
- Important negatives: loss of consciousness, head strike, chest pain, dyspnea, hematuria, pelvic pain
2. Alarm Features
- Hemodynamic instability (tachycardia, hypotension, poor response to resuscitation) — the primary driver of operative vs. nonoperative decision-making [1][4]
- Peritonitis or rigid abdomen
- Transient responder or non-responder to fluid resuscitation
- Progressive abdominal distension
- Declining hemoglobin despite transfusion (>4 units pRBC or ongoing requirements after initial resuscitation) [4]
- Altered mental status limiting serial abdominal exams
- Coagulopathy (anticoagulant/antiplatelet use) — increases risk of NOM failure and delayed hemorrhage [4]
- Age >55 — independent risk factor for NOM failure [5]
3. Medications
- Relevant contributors: anticoagulants (warfarin, DOACs), antiplatelet agents (aspirin, clopidogrel), NSAIDs — all increase bleeding risk and lower threshold for angioembolization [4]
- Reversal agents: consider 4-factor PCC for warfarin, idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors
- Treatments: tranexamic acid (TXA) within 3 hours of injury per CRASH-2 protocol; blood products per massive transfusion protocol if indicated
- Post-splenectomy: lifelong awareness of infection risk; standby antibiotics (amoxicillin or levofloxacin) for febrile episodes [6]
- DVT prophylaxis: LMWH may be started within 48–72 hours of admission in the absence of active bleeding [2][5]
4. Diet
- NPO on admission (potential for operative intervention)
- Advance diet as clinical status allows once NOM is established and patient is stable
- No specific long-term dietary restrictions related to splenic laceration itself
5. Review of Systems
- Cardiovascular: chest pain, palpitations, syncope, presyncope
- Pulmonary: dyspnea, pleuritic pain (left-sided pleural effusion or hemothorax from associated rib fractures)
- GI: nausea, vomiting, abdominal pain location and radiation, hematochezia
- GU: hematuria (concurrent renal injury), pelvic pain
- MSK: left rib pain, flank pain, shoulder pain (Kehr sign)
- Neuro: headache, LOC, focal deficits (concurrent TBI affects NOM monitoring) [5]
6. Collateral History and Family History
- Collateral from EMS: mechanism details, field vitals, GCS trajectory, fluid administered
- Witnesses to the event (speed, height, weapon)
- Prior splenectomy or known splenomegaly
- Bleeding disorders (hemophilia, von Willebrand disease)
- Medication list from family/pharmacy (anticoagulants, antiplatelets)
- Social context: alcohol/drug use (impairs exam reliability; cirrhosis increases bleeding risk) [5]
7. Risk Factors
- Blunt mechanism: MVC (most common), falls, sports, assault
- Splenomegaly from any cause (infectious mononucleosis, hematologic malignancy, portal hypertension) — lowers threshold for injury
- Age >55: higher NOM failure rates, increased transfusion requirements [4-5]
- Anticoagulation/antiplatelet therapy [4]
- Comorbidities: cirrhosis, HIV, coagulopathy, drug addiction — all risk factors for NOM failure [5]
- High ISS (Injury Severity Score) and polytrauma [5]
- Left lower rib fractures
8. Differential Diagnosis
- Left kidney laceration/contusion — hematuria, flank pain; CT differentiates
- Left hepatic lobe injury — epigastric/LUQ pain; CT differentiates
- Pancreatic injury — epigastric pain, elevated lipase; often delayed presentation
- Mesenteric/bowel injury — peritonitis, free air; cannot-miss diagnosis with splenic trauma [1]
- Left hemothorax/pneumothorax — from associated rib fractures
- Diaphragmatic rupture — left-sided, associated with high-energy mechanism
- Retroperitoneal hemorrhage — pelvic fracture, lumbar spine fracture
- Aortic injury — widened mediastinum, high-energy deceleration
9. Past Medical History
- Prior abdominal surgery (adhesions may complicate operative approach)
- Prior splenectomy (obviously rules out splenic injury)
- Known splenomegaly or splenic pathology
- Bleeding disorders or liver disease
- Chronic anticoagulation
- Prior splenic injury (re-injury risk)
10. Physical Exam
- Vitals: tachycardia (often earliest sign of hemorrhage), hypotension, tachypnea
- Abdomen: LUQ tenderness, guarding, rigidity, distension, seatbelt sign
- Kehr sign: left shoulder pain with supine positioning (diaphragmatic irritation)
- Balance sign: fixed dullness in LUQ with shifting dullness on the right (large perisplenic clot)
- Left lower chest wall: rib tenderness (ribs 9–12), crepitus, ecchymosis
- Pelvis: stability assessment
- Rectal: gross blood (concurrent bowel injury)
- Skin: flank ecchymosis (Grey Turner sign), periumbilical ecchymosis (Cullen sign)
- Serial abdominal exams are essential during NOM monitoring
11. Lab Studies
- CBC with serial hemoglobin/hematocrit: every 8 hours for high-grade injuries (AAST ≥III), every 12–24 hours for low-grade injuries [2]
- Type and screen/crossmatch: essential; activate massive transfusion protocol if needed
- BMP, lactate, base deficit: markers of tissue hypoperfusion and hemorrhagic shock [7]
- Coagulation studies: PT/INR, PTT, fibrinogen — especially if on anticoagulants
- LFTs: AST/ALT elevation may suggest concurrent hepatic injury
- Lipase: rule out pancreatic injury
- Urinalysis: hematuria suggests renal injury
- TEG/ROTEM: if available, guides resuscitation in massive hemorrhage
12. Imaging
- E-FAST (Extended Focused Assessment with Sonography for Trauma):
- First-line in hemodynamically unstable patients; sensitivity 69–98% for free fluid, high specificity [8-9]
- A positive FAST in an unstable patient → OR for exploratory laparotomy
- A negative FAST does not exclude splenic injury — sensitivity for solid organ injury is only ~63% [8][10]
- CT abdomen/pelvis with IV contrast:
- Gold standard for hemodynamically stable patients; sensitivity and specificity near 96–100% [5]
- Identifies laceration depth, subcapsular hematoma, active extravasation (contrast blush), pseudoaneurysm, AV fistula, hemoperitoneum volume
- Arterial phase improves detection of contained vascular injuries [11]
- Used to assign AAST-OIS grade (see Special Tests below)
- Follow-up imaging: contrast-enhanced CT or CEUS at 48–72 hours for AAST Grade ≥III injuries to detect delayed pseudoaneurysm (incidence ~5–15%) [2]
- Imaging is unnecessary for routine post-discharge follow-up in low-grade (I–II) injuries [5]
13. Special Tests
AAST Organ Injury Scale (2018 Revision) — the standard grading system: [12]
Key 2018 revision change: vascular injuries (pseudoaneurysm, AV fistula, active extravasation) now automatically classify as Grade IV or V. [12-13]
WSES Classification integrates AAST grade + hemodynamic status: [5]
- Class I: AAST I–II, hemodynamically stable (minor)
- Class II: AAST III, hemodynamically stable (moderate)
- Class III: AAST IV–V, hemodynamically stable (severe)
- Class IV: Any AAST grade, hemodynamically unstable (severe)
14. ECG
- ECG is not specific to splenic laceration but should be obtained in all trauma patients
- Rule out cardiac contusion (blunt chest trauma), arrhythmia from hemorrhagic shock
- Tachycardia is the most common finding; bradycardia may indicate severe hemorrhage with vagal response or concurrent spinal injury
- Pulseless electrical activity (PEA) in the setting of trauma → consider massive hemorrhage, tension pneumothorax, cardiac tamponade
15. Assessment
Severity stratification is based on hemodynamic status + AAST grade + CT findings + patient factors:
- Hemodynamic status is the single most important determinant of management — stability is a trajectory, not a single measurement [4]
- AAST grade correlates with NOM failure risk but does not dictate management alone [4]
- Specific CT findings that increase concern: contrast blush (active extravasation), pseudoaneurysm, large hemoperitoneum, vascular truncation [4]
- Patient factors modifying risk: age >55, anticoagulation, polytrauma, TBI, cirrhosis [4-5]
- Complications: delayed hemorrhage (main manifestation is new/worsening abdominal pain after leaving ICU), pseudoaneurysm rupture, splenic abscess, overwhelming post-splenectomy infection (OPSI) if splenectomy performed [14]
16. Treatment Plan
Initial Stabilization (all patients):
- ATLS primary survey, 2 large-bore IVs, type and crossmatch
- Massive transfusion protocol activation if indicated (1:1:1 pRBC:FFP:platelets)
- TXA 1g IV bolus within 3 hours of injury, then 1g over 8 hours
- Reverse anticoagulation if applicable
Hemodynamically Unstable / Peritonitis → Emergent Splenectomy: [1][5]
- Unresponsive to resuscitation → OR for exploratory laparotomy
- Splenorrhaphy (splenic repair) may be attempted if feasible, particularly in penetrating trauma [1]
Hemodynamically Stable → Nonoperative Management (NOM): [1-2][5]
- Admission with continuous hemodynamic monitoring (high-grade) or close nursing monitoring (low-grade)
- Serial hemoglobin checks (q8h for Grade ≥III; q12–24h for Grade I–II) [2]
- Serial abdominal exams
- Bed rest initially; mobilization after 24 hours for low-grade injuries, or when 3 successive hemoglobins 8 hours apart are within 10% of each other for high-grade injuries [2]
Splenic Artery Embolization (SAE) — indications: [2][13]
- Arterial blush (active extravasation) on CT, regardless of grade
- AAST Grade IV–V injuries, even without blush
- Grade III with risk factors for NOM failure (age >55, anticoagulation, high ISS, transfusion requirement)
- Both proximal and distal embolization are effective [1]
NOM Failure Triggers — abandon NOM and proceed to OR: [4]
- Persistent transfusion requirements (>4 units total or ongoing after initial resuscitation)
- Hemodynamic deterioration
- Worsening abdominal exam
- Peritonitis
A large cohort study of 12,930 polytrauma patients found that NOM (SAE or observation) was associated with reduced mortality (HR 0.62 for SAE, HR 0.61 for observation vs. splenectomy), fewer complications, and shorter hospital stay, even in patients presenting with hypotension. [15]
Post-Splenectomy Vaccination (if splenectomy performed): [5-6][17-18]
- Pneumococcal: PCV13 → PPSV23 (≥8 weeks later)
- Meningococcal: MenACWY (2-dose series) + MenB
- Haemophilus influenzae type b (Hib) conjugate vaccine
- Annual influenza vaccine (inactivated only)
- Administer ≥14 days post-splenectomy; if discharge anticipated before day 14, vaccinate before discharge [5]
17. Disposition
- All splenic lacerations require hospital admission [2]
- Low-grade (AAST I–II): minimum 1-day admission with close monitoring; floor bed acceptable if stable [2]
- High-grade (AAST III–V): minimum 3-day admission; monitored/ICU setting recommended [2]
- ICU admission: hemodynamic instability, high-grade injury, polytrauma, need for ongoing resuscitation, post-SAE monitoring
- Transfer to trauma center: if institutional capabilities do not support NOM (no 24/7 OR, angiography, blood bank) [4-5]
- Surgical consultation: trauma surgery should be involved for all splenic injuries
18. Follow Up / Return Precautions
Activity Restriction: [5]
- Low-grade injuries: 4–6 weeks
- Moderate-to-severe injuries: 2–4 months
- No contact sports or heavy lifting during restriction period
- Consider imaging (CT or CEUS) before return to major physical activity for Grade ≥III injuries [2]
Follow-Up Imaging: [2][5]
- Routine post-discharge CT is not necessary for Grade I–II injuries
- Grade ≥III: follow-up CT or CEUS at 48–72 hours during admission; outpatient imaging may be considered at 1–2 weeks if high-grade
- Complete healing: ~50% healed at 6 weeks; nearly all grades healed by 3 months [5]
Return Precautions — seek immediate care for: [14]
- New or worsening abdominal pain (main presentation of delayed bleeding after ICU/hospital discharge)
- Lightheadedness, dizziness, syncope
- Fever, chills (especially post-splenectomy — risk of OPSI is lifelong) [6]
- Tachycardia, pallor, weakness
Post-Splenectomy Patients: [6][17]
- Lifelong risk of OPSI (incidence 0.1–8.5%; mortality up to 50% if untreated) [18]
- Carry medical alert identification
- Keep standby antibiotics (amoxicillin 2g or levofloxacin 750mg) for immediate use with any febrile illness if unable to reach medical care within 2 hours [6]
- Ensure primary care provider is aware of asplenic status
- Malaria prophylaxis for travelers to endemic areas [5]
References
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