SPLENIC INJURY.pptx

In this presentation, I discussed splenic injury- including the mechanism of injury, clinical features, grading, and how to diagnose and treat them.

1. SPLENIC RUPTURE DR.B.SELVARAJ MS;Mch;FICS ; ‘Surgical Educator’ MALAYSIA BLUNT ABDOMINAL TRAUMA

2. SPLENIC RUPTURE Etiology Pathology Clinical features Workup/Investigations Differential diagnosis Splenic CT injury grading Treatment Complications- OPSI Treatment algorithm for Splenic injury LEARNING OBJECTIVES

3. SPLENIC RUPTURE H/O Blunt abdominal or lower thoracic trauma Penetrating trauma to Left Hypochondrium Iatrogenic Spontaneous rupture - Malaria - Leukemia - Infectious mononucleosis ETIOLOGY Injury types Laceration Hilar injury Subcapsular hematoma Injury associated with other organ injuries Mechanism of injury Crushing Deceleration Sudden increase in intra abdominal pressure

4. SPLENIC RUPTURE Classically associated with left lower ribs fracture Delayed rupture is a characteristic feature in Subcapsular hematoma A ruptured spleen can cause life-threatening bleeding into the abdominal cavity. PATHOLOGY

5. SPLENIC RUPTURE H/O Trauma Pain abdomen Occasional distension and vomiting In severe bleeding associated with shock, syncope or dizziness Kher’s sign  Pain over left shoulder joint Fixed dullness to percussion on the left, and shifting dullness on the right (Ballance’s sign). Tenderness all over the abdomen with or without guarding and rigidity Bowel sounds are absent CLINICAL FEATURES

6. SPLENIC RUPTURE Other causes for hemoperitoneum Liver injury Ruptured ectopic pregnancy Ruptured abdominal aortic aneurysm Acute hemorrhagic pancreatitis DIFFERENTIAL DIAGNOSIS

7. SPLENIC RUPTURE INVESTIGATIONS

8. SPLENIC RUPTURE INVESTIGATIONS- CECT CT is the procedure of choice for diagnosis and estimation of the degree of splenic injury in the hemodynamically normal patient. Contrast blush (intraparenchymal hyperdense contrast collection)suggests active hemorrhage and is associated with failure of nonoperative management in all solid organ injuries.

9. SPLENIC RUPTURE INVESTIGATIONS SELECTIVE CELIAC ARTERIOGRAPHY Angiography may be used in patients demonstrating a contrast blush on CT scan to identify and treat a vascular abnormality

10. SPLENIC RUPTURE INVESTIGATIONS DPA/DPL

11. SPLENIC RUPTURE AAST – CT GRADING

12. SPLENIC RUPTURE TREATMENT Nonoperative management Requires ICU monitoring in a dedicated trauma center and immediate ability to convert to operative management should that become necessary Indications Hemodynamic stability Minimal evidence of blood loss, < 2 units packed red blood cells as transfusion requirement Absence of active contrast extravasation on CT scan Absence of other indication for laparotomy Length of intensive care unit (ICU) monitoring is generally 24 to 48 hours initially, with serial hematocrit evaluation and continuous hemodynamic monitoring Blood transfusion is limited to 2 units of packed red blood cells. If the patient has an ongoing transfusion requirement of more than 2 units, operative management should be performed The majority of pediatric splenic trauma is successfully managed nonoperatively. Recovery recommendations include restricted activity in terms of contact sports, running, or similar stresses for 3 months following injury. Angiography is performed in patients who are hemodynamically normal and have a blush on initial CT scan.

13. SPLENIC RUPTURE TREATMENT Operative management Should be performed in those patients demonstrating peritonitis or hemodynamic instability, those failing nonoperative therapy, and those with gunshot wounds to the abdomen Splenectomy i s indicated with significant blood loss (>1000 mL), significant associated injuries, hilar involvement, coagulopathy, or massive splenic disruption Splenic salvage includes splenorrhaphy and partial splenectomy Splenorrhaphy can be performed with absorbable mesh ( Dexon ) Other strategies include the use of topical hemostatic agents, including Surgicel , Avitene , and topical thrombin, as well as the application of mattress sutures to allow tamponade of hemorrhage . Partial splenectomy may be performed for polar injuries. At least 30% of the spleen must be preserved to maintain function.

14. SPLENIC RUPTURE TREATMENT Operative management In stable patient without fecal contamination - Splenic replantation - 15 slices of spleen implanted in greater omentum in three rows  Triple decker omental sandwich

15. SPLENIC RUPTURE COMPLICATIONS Atelectasis which should be treated with aggressive pulmonary toileting Delayed bleeding in subcapsular hematoma Subpherenic abscess Pancreatic injury resulting Pancreatic fistula Thrombocytosis if platelets are > 10,00,000 OPSI- Overwhelming Post Splenectomy Infection

16. SPLENIC RUPTURE OPSI Syndrome consists of rapid development of severe sepsis with hypotension, disseminated intravascular coagulation, respiratory distress, and coma within hours of presentation Incidence. This is a rare complication of splenectomy. 50% to 70% of OPSI occurs less than 2 years after splenectomy. Mortaltiy is 50% to 70% for patients presenting with full-blown OPSI Organisms. S. pneumoniae is responsible for 50% to 90% of infections. Others include N. meningitides, H. influenzae Treatment. Aggressive empiric antibiotic therapy should be initiated awaiting pan-culture/sensitivities . Prophylaxis. Presplenectomy immunization (2 weeks before splenectomy) is optimal but most often impossible for traumatic splenectomy. Immunization for Pneumococcus, Meningococcus, and H. influenzae type B should be administered prior to discharge  Pneumovax . Pneumococcal booster should be considered every 5 to 6 years for high-risk patients.

17. SPLENIC RUPTURE

18. HAND-WRITTEN MINDMAP